My name is dr faisal respiratory physician from ukmc and today we’ll be talking mainly about a small heavy disease reaching extra benefit in asthma and copd all right first of all how do you diagnose uh asthma okay is it enough to hear wheezing to diagnose asthma right as you all know that there are many causes of wheezing okay it can be asthma it could be
Because of copd it could be because of a hyposensitivity pneumonitis right to a more rare diseases such as just trout syndromes loftless syndromes and so on so um if you the most important thing is you have to go back to history right history to different shape between asthma copd and any other causes so if you ask uh in a typical respiratory cleaning if you
Ask elderly gentlemen most of them will say that they have asthma but it is our job actually to to ascertain whether this patient is purely asthmatic or this patient have any other diseases such as copd so you have to go back to the history history is very important as you can see over here yeah these are the features to suggest patient asthma and these are the
Features who suggest that this patient has copd generally copd they are elderly right they have a significant smoking history and so on while patients with asthma they tend to be younger age group right they are non-smokers and they have associated atop such as allergic rhinitis allergic conjunctivitis and skin eczema but most importantly is to do a lung function
Test because lung function tests can differentiate this patient whether they are having asthmatic or copd so let me give you a case scenario a 23 year old man with background history of allergic rhinitis on ever miss nasal spray and monte lucas presented to the respiratory clinic with cough for more than one month and he has history of atop and there was no
History of childhood asthma and his chest x-ray was normal so this is actually the spirometry so if you are familiar with spirometry all right this is the uh baseline spirometry pre-bronchodilator and this is a spirometric post bronchodilator and see what can you see obviously over here all right can you see any difference between a pre bonco director and post
Bronchodilator okay it is important to calculate the bronchodilator response so how do you calculate bronchodilator response so a lot of mistakes done by medical officers is that the minus post bronchodilator of 78 minus 65 percent and that value they say that that’s uh more than two percent it’s associated with positive quadratic response but that’s not the
Correct way of measuring so the correct way of measuring is you have to calculate the post fev 1 1.76 minus your pre fe 1 1.45 that value divided by 3 f ev1 1.45 times 100 that’s the correct way of calculating a low quality response and over here they calculated for you that is 21 so what does that indicate so if there’s an increment of everyone by more than
12 percent and 200 mils is indicate that this patient has a positive bronchodilator response in other words that this patient has asthma but there are in many other ways to diagnose asthma majority of the cases we may pick up from a positive brain quadratic response but in some cases sometimes we have to we have to do further tests you know to demonstrate uh
Increment of fev1 for example in the malaysian gina guidelines sorry malaysian cpg guidelines on asthma they mentioned that an increase in everyone of more than 12 and 200 mils from a baseline after four weeks of inhaled corticosteroid is also a positive test all right sometimes what you need to do is you have to do an opposite test to uh demonstrate there is
A bronchoconstriction right so we call the test as metacalling provocation test so if there is a fall of 20 then that is actually positive to suggest that this patient has bronchial asthma so there are many ways right but for medical officers it’s very important for you to know uh that improvement in everyone of more than 12 percent and 200 meals is a positive
Bronchodilator reversibility so that indicates asthma so what’s next so after you’ve diagnosed that this patient has asthma so you need to know what medications to start all right i’m sure all of you have already familiar with this gina guidelines so every year they’ve been updating we have step one until step five and um if you look at medications there are many
Medications available in the market until someone’s a bit confused so which medication to start if you look at the different uh preparation of medications we have mdi emitted those inhaler we have dry powder inhalers so among dry powder hinges we have various uh medication for example is your turbo halo all right your acute healer your ellipta sorry it’s a handy
Healer and inhaler for thiotropium are we getting it right so we know that ics laba improved asthma control right but it is still not optimal because there was a study that was done in europe a cross-sectional survey of patients that reported to have asthma control in the past five years majority of them are still not well controlled so what do you do in this
Kind of patient so first of all as a doctors we need to know whether are they using the correct medications are they using the correct um are they are they uh using the correct technique okay do they have poor morbidities such as good okay bronchitis allergic rhinitis and so on so if you have tackled all these issues and they still have poor asthma control then
You might think that you know they might have a small heavy disease so there was a study done actually shows that the prevalence of small heavy disease in adult asthma is about 65 percent that was study done by professor usmani and how do you diagnose this small iv disease so a simple spirometry may not be enough to diagnose more every disease you probably need
To do a further test such as your full lung function so basically as a summary there are few indications to suggest that this patient have a small every disease for example uh if you have um increase in residual volume based on your full lung function if it’s more than 120 percent you may suggest that this patient might have a small heavy disease if your rv tlc
Ratio is more than 120 also means sorry more than 35 it may suggest that this patient has small heavy disease all right and we can look at other parameters including impulse oscillometry okay most hospitals they have this impulse oscillator machine that can also suggest that these patients have a small heavy disease okay so what is small heavy disease so if you
Imagine that our bronchial anatomy is like a bronchial tree it’s just like a branch of three all right so the large airway is has a diameter of 2 to 18 more than 2 mm while small a disease have a diameter of less than 2 mm so imagine that if you take some inhalers so most of some of the inhalers might not reach your distal airway because of the diameter of less
Than 2 mm so you might need a medication with the low molecules okay low diameter to reach the distal area so the large airway actually has a small surface area compared to your small airway which has a higher surface area all right and also the small airway has a high corticosteroid receptor density as well as high beta-2 adenosine receptors density so if
You imagine that again that this is actually your bronchial tree so any it’s a diameter of less than 2 mm indicates that this patient has actually small heavy disease generally after the generation of 8 and 9 so that’s considered as a small heavy disease okay inflammation some of the studies done shows that inflammations are present uh in both your large and small
Airways so it is very important to detect patients with small airway disease so as you can look over here is that a lot of cells are present in the small airway your t cells your major basic protein activated use you know fills your muscles these are all better physiology of asthma so in order to target a small heavy disease right you need to give medications that
That can penetrate your small heavy disease so this is actually a histological uh pictorial to show that in small highway disease they have a lot of inflammation going on all right you can see over here there’s a lot of eusinophils and so on so what about the small every manifesto all right uh various guidelines have actually recommended that we should target a
Small airway so small area plays a key role in the pattern of asthma and copd it’s more away can be targeted to ensure disease control and better outcomes and small particle inhale formulations are beneficial in question with asthma and copd especially those with predominant small airway disease so what is actually a small particle size inhaler so so when you
Prescribe some patients with inhaler you need to also know what is their particle size so generally uh a particle size between one two three are considered a small particle size okay particles has more than five large particle size less than one is considered the most useful particles is between one to three because anything less than one it will actually floats
In the lung and can be expelled out all right so if you have a particle size between one two three it can deposit in your distal airways and it can give you beneficial response so small away disease also correlates with the patient’s outcome all right there was a study done over here looking at a small heavy disease those who have small heavy disease have more
Exacerbation so how they did the study is that they they do a single breath nitrogen wash out so the higher the single bright natural washout the higher uh possibility of the patient to have small heavy disease so those with actually a smaller disease have more than two exhibitions per year especially with asthma okay and cyclosanite so probably some of us have
Prescribed cyclonic in the past this is a very quite old medication it’s actually single inhale corticosteroids that has small particle size so this is a study done by gohan that was published in 2008 found that if you prescribe a patient with asthma recycles a night so after four weeks when they they measure the uh fractional exhale nitro nitrogen uh oxide
They found that there is a reduction of a phenol level after treatment with cyclonic after four weeks all right so phenol is actually one of the marker to suggest that this patient might have small heavy disease so phenol might also be useful if if the levels are high it may indicate that this patient may have eustonophilic inflammation and may respond to inhaled
Corticosteroids sometimes we do a phenol level to assess the response to inhale corticosteroids so if there is a significant reduction of phenol level after treatment of ics that indicates a positive response so there was another study actually uh by david price at all in 2010 it’s actually a real life study uh looking at odds ratio for uh asthma control and rate
Ratios for exhibition so they compared between extra fine and b chrometason all right versus frutical sound so both are actually inhaled corticosteroids and of similar potency however the one in the bichlorometer zone they’re using extra fine particles so theoretically if you use extra front particles it can deposit further distally in your lungs so what they
Found that those who receive extra fund bichromethasone actually favors better in terms of better asthma control all right less usage of saba and less change of therapy compared to those with fluticason group and there was another study so this is a study comparing between laba ics okay lava in one arm was a foster former trophy chrometason and the other arm
Was a submetrol fluticason so what happened over here is that they’ve found out that even after two weeks of treatment extra fine foster provides faster or greater improvement in lvc compared to your submetro fluticason and another study actually comparing between uh three arms okay one is one arm is foster which is for motorola bikromitas on the other arm is
A formulator buddhisoni and the third arm is a samatrophilicazon again that this study actually shows that those who patients will receive some foster for motorola micrometer so they have actually a better asthma control right compared to the other arms okay now what about copd so small airway is not only uh in asthma right small airway can there are various
Causes of small heavy disease it can be because of copd it can be because of intellectual lung disease and so on so small areas are also present in uh in copd right so this is actually a study again that was published in new england journal showed that in the copd patients with small heavy diseases there’s a lot of inflammation going on so these are actually a
Potential target for treatment so again i’m sure that all of you are aware of gold guidelines your goal a b c and d right i think the latest work guidelines suggest that you know you to use ics in certain cohort operations in goldie so again out of all these gold guidelines small every diseases are prevalent in patients with copd even in gold a up to 49 right
Will be about 88 percent and gold b of patients 96 percent of them have small heavy diseases so small away disease also correlate with the present also correlates with the uh uh impacts the patient’s health status yeah of copd so if you look over here patients with the small heavy disease have more symptoms right they have more cough okay they have more flames
More chest tightness right they are more breathlessness and so on so so it is very important if you have a patient with copd who’s not properly controlled you should actually look for small heavy disease right you should refer them for a body practice tomography to look for any evidence of small heavy disease because there are certain medications they can target
Yeah digital airway so back in goal 2017 now we have goal 2020. back in goal 2017 they have already mentioned in the guidelines that extra fine is able to deposit more in the peripheral airway so if you can i can read the paragraph over here for drug delivery to lower respiratory tract and lungs particle size can be 5 2 5 or extra 5 less than 2 which influences
The total respirable fraction particles and the amount inside of drug depositions more peripheral deposition with extra fine particles so these are some of the medications available in the market and you can look over here what is the fractional size all right for example for motorola because on yeah it’s about 1.5 all right so they have a mdi they have also
Dpi all right it’s 1.5 as well so other medications for example your formation of buddhism buddhisonite have a particle size of a 3.0 so these are considered as extra fine and this part inhalers are considered as fine particles and if you look if you do a lung synthrophy this is actually a lung symptom graphic those with extra fine particles tend to have more
Lung deposition compared to those with fine particle size so is there any studies in copd all right comparing uh between extra fine and other inhalers so this is actually a study um done by zany at all in 2011 so we’re comparing between foster mdi as well as some metro fruiticason so please note over here that the dose of uh daily dose of summer chocolate cousin
Was 500 100 okay 500 100. so i mean they’re using uh 250 50 one puff bd so the treatment period was for 12 weeks and what they found was that those who receive the pink color is actually foster from author of the chromatin have reduction in your residual volume all right that means there’s less hyperinflation so the normal residual volume is about 80 to 120
So anything more 120 indicates hypo inflation so those who receive uh um foster actually have reduction in your original volume they have also reduction in your tlc all right and also there’s improvement in your fbc as well so which is actually a positive response so if you have you managed to reduce the hyperinflation you manage to reduce the air traffic the
Symptoms will get better so what about this study so this study is comparing between foster mdi versus summertroll fluticasone at the higher dose right one thousand slash one hundred bear in mind that this study was done in 2014 right now this we don’t use a very high dose of summation of fructica sun because of the risk of pneumonia so again um after 12 weeks
What they found was that there was a significant improvement in your um changing functional impairment all right so for those who who receive foster okay they have uh improvement your your disney index they have changed in your magnitude effort as well as magnitude of task so better uh response in those who receive extra fine foster right and as well as improvement
In your sense just respiratory questionnaire so whatever that i mentioned earlier all right uh about using lava ics in copd you must always go back to your guidelines so this is actually the gold guidelines so when do you start labor ics in copd because there’s no doubt that lava is significant but in copd all right please bear in mind that you only use it in
Patients with goldie those will go the uh with even in goldie that’s significant so those sweet actually has a raise in use in the field value so consider using uh lava ics if your original free value is more than 300 or more than 100 and two or more exacerbations then only you consider them using ics otherwise go back to your background treatment which is your
Laba lama or combination of lava llama all right so i think that’s my last slide okay i welcome any questions with regards to small every disease
Transcribed from video
Formoterol and Beclomethasone for small airway diseases (COPD & Asthma) By MMED
