1. The document provides information on evaluating and managing asthma and COPD. It compares the pathophysiology and characteristics of the two conditions. 2. Key differences include that COPD typically affects larger airways through destruction and fibrosis, while asthma affects smaller airways through bronchial hyperresponsiveness and mucus plugs. COPD is usually caused by smoking and leads to irreversible airway obstruction. 3. Management of both involves reliever medications for acute symptoms and controller medications like inhaled corticosteroids and bronchodilators. Lifestyle changes such as smoking cessation and pulmonary rehabilitation are also important aspects of COPD management.

1. 1
EVALUATION GUIDELINE ASTHMA & COPD
Asthma COPD Obstructive
Asthma & COPD
Pathophysiology COPD Asthma
COPD Asthma
Airways affected  Alveolar
 Destruction(Emphysema)
 Bronchiolitis
 Fibrosis
 Large and small
 No emphysema
 Mucus plugs
 Bronchial Hyper
Responsiveness
Inflammatory Cells  Neutrophils
 Macrophages
 CD8,Tcells
 Eosinophils
 Mast cells
 CD4,T cells
Mediators  IL-8, TNF alpha,LTB4
 Reactive Oxygen species
 IL-4,IL-5,cysLTs
 Histamine
Airway Obstruction  Irreversible  Reversible
COPD Asthma
COPD Asthma
 Onset in mid-life
 Symptoms slowly progressive
 Long history of tobacco smoking
 Dypnea during exercise
 Largely irreversible airflow
limitation
 Onset early in life (often
childhood)
 Symptoms vary from day to day
 Symptoms at night / early morning
 Allergy, rhinitis, and or eczema
also present
 Family history of asthma
 Largely reversible airflow limitation

2. 2
ASTHMA
1.
2.
3.
(noctural asthma)
4.
5. atopy skin eczema
6.
7. wheeze
1.
2.
3.
4.
5.
6.

3. 3
- COPD
- Acute pulmonary edema
- Foreign body aspiration
- Gastro-esophageal reflux
- Bronchiectasis
- Upper airway obstruction
(Spirometry)
Reversible airflow obstruction FEV1(forced expiratory
volume in one second) 12
FEV1 200ml. PEF 60
/ 20 Reversible airflow obstruction
Spirometry
Spirometry
20
,Aspirin induced asthma Spirometry
COPD
Spirometry
COPD

4. 4
(variable) PEF
1-2
20
PEF variability = (PEFmax-PEFmin)x100
½(PEFmax + PEFmin)
PEF variability PEF
1
PEF PEF
PEFmin x100
PEFmax
variability
(bronchial hyper responsiveness)
FEV 1 methacholine
(methacholine challenge test)
1. (allergen)
2.
3.
4. NSAIDs (aspirin) B-blockers

5. 5
5.
6.
7.
8.
Allergic rhinitis
1.
corticosteriod
I
ntermittent Persistent asthma
Spi
rometry
1
Intermittent
1
PEF
2
PEF
FEV1
≥80%
PEF
variability
<20%
2
1
1 2
PEF
FEV1
≥80%

6. 6
Mild persistent PEF
variability
< 20%-
30%
3
Moderate
persistent
1
PEF
FEV1
60%-80%
PEF
variability
>30%
4
Severe
persistent
PEF
FEV1
≤ 60%
PEF
variability
>30%
2.
(controller)
Asthma Control Test(ACT) Asthma Control Questionnaire(ACQ)
3
(controlled)

7. 7
(Relivers)
(Partly
controlled) (uncontrolled)
Controlled
( )
Partly
Controlled
(
)
Uncontrolled
2 2
Partly
controlled
3
Partly
controlled
3
Partly
controlled
3
Reliver/rescue 2 2

8. 8
treatment Partly
controlled
3
(
PEF or FEV1)
80%pre
dicted or
personal best
Partly
controlled
3
(Exacer
bation)
1 1
Controller Medications
Inhaled
Glucocortico
steroids
-Beclomethasone
-Budesonide
-Fluticasone
propionate
inflammat
ory cell
mic
rovascular
leakage
2-
agonists
Local side effect
-Oropharyngeal
-candidiasis(Oral
thrush)
-Dysphonia
-Cough
Systemic side
effect( )
-
-Osteoporosis
-
first
choice
persistent
asthma
inflammat
ion
spacer
Leukotriene
modifiers
LT-receptor
antagonist
-Montelukast
-Zafirlukast
5-lypoxygenase
Headache,fatique aspi
rin-sensitive
asthma
I
CS

9. 9
inhibitor
-Zileuton
LABA
Long-acting
inhaled β2-
agonists
-Salmeterol
-
Formoterol(
duration
)
-
stero
ids
-
mucocilia
ry clearance
- vascular
permeability
-CVS stimulants
(Tachycardia)
-Hypokalemia
Skeleton muscle
tremor
ICS ICS
Long-acting
oral
β2-agonists
-Salbutamol(slow
release
formulation)
-Terbutaline(Slow
release
formulation)
-Bambuterol
-
stero
ids
-
mucocilia
ry clearance
- vascular
permeability
IC
S
Theophylline
SR
Theophylline
SR
Th
eophylline
mucoc
illary
clearance
Arrythmia
Tachycardia
Seizures
(10-20
mcg/ml.)meta
bolite
Cyp1A2
Cyp1A2
inhibitor
Cimetidine
Erythromycin

10. 10
Ciprofloxacin
Cyp1A2
inducer
Rifampicin
Phenytoin
Carbamazepi
ne
Phenobarbital
Systemic
glucocorticoi
ds
-Prednisolone
-Methyl
prednisolone
-Hydrocortisone
-Dexamethasone
inflammat
ory cell
mic
rovascular
leakage
2-
agonists
Fluid retention
HPA axis
Osteoporosis
(
3-
10 )
(>2
)
Anti-IgE Omalizumab monoclo
nal antibody
IgE
Pain and bruising
Anaphylaxis
12
SC
ICS
Cromones Sodium
cromoglycolate
mild
persistent

11. 11
Reliver Medication
Rapid-acting
inhaled
β2-agonists
-Salbutamol
-Terbutaline
-Fenotero
-Procaterol
-Formoterol
Lo
ng acting
inhaledβ2-
agonists
steroids
mucocilary
clearance
vascular
permeability
Long acting
inhaled β2-
agonists CVS
stimulants
Hypokalemia
Skeleton
muscle tremor
duration
(Re
gular
controller)
ICS
Short acting oral
β2-agonists
-Salbutamol
-Terbutaline
-Procaterol
Lo
ng acting
inhaledβ2-
agonists
steroids
mucocilary
clearance
vascular
permeability
Inhaled -Ipratropium

12. 12
anticholinergics bromide vagal tone (bitter taste) inhaled β2-
agonists
Short acting
theophylline
-Theophylline
Anhydrous
-Aminophyline
anhydrous
-Aminophyline
dihydrate
respiratory
drive
2-agonists
Arrhythmia
Tachycardia
Seizures
-
Theophylline
100%
-
Theophylline
86 %
-
Theophylline
79%
Systemic
glucocorticosteroid
s
Prednisolone
inflammatory
cell
microv
ascular
leakage
2-
agonists
Fluid retention
HPA axis
Osteoporosis
40-
50mg.
5-10
Easyhaler Beclomet Easyhaler
inhalation powder
Beclomethasone dipropionate
200mcg/dosex200 doses
Turbuhaler Pulmicort turbuhaler Budesonide100mcg/dosex200doses
Budesonide200mcg/dosex100doses

13. 13
Turbuhaler Symbicort Forte
turbuhaler
Budesonide320mcg,Formoterol
fumarate 9 mcg/dosex60doses
Turbuhaler Symbicort turbuhaler Budesonide160mcg,Formoterol
fumarate
dihydrate4.5mcg/dosex60doses
Turbuhaler Symbicort turbuhaler Budesonide80mcg, Formoterol fumarate
dihydrate4.5mcg/dosex60doses
Evohaler Flixotide evohaler Fluticasone
propionate125mcg/dosex120doses
Fluticasone
propionate250mcg/dosex60doses
Evohaler Seretide25/125
evohaler
Salmeterol 25mcg,Fluticasone
propionate 125mcg/dosex120dose
Evohaler Seretide25/250
evohaler
Salmeterol 25mcg,Fluticasone
propionate 250mcg/dosex120dose
Evohaler Seretide25/50
evohaler
Salmeterol 25mcg,Fluticasone
propionate 50mcg/dosex120dose
Accuhaler Seretide50/100
accuhaler
Salmeterol50mcg,Fluticasone
propionate 100mcg/dosex60dose
Accuhaler Seretide50/250
accuhaler
Salmeterol50mcg,Fluticasone
propionate 250mcg/dosex60dose
Evohaler Ventoline evohaler Salbutamol sulfate 100mcg/1
inhalationx200doses
Evohaler Combivent metered
aerosol
Salbutamol sulphate120mcg,Ipratropium
Bromide
monohydrate21mcgx200doses/10mlx1”s
Turbuhaler Bricanyl turbuhaler Terbutaline
sulfate0.5mg/1dosex200doses
Evohaler Berodual metered
dose inhaler
Fenoterol HBr 0.05mg,Ipratropium
Br0.02mgx200puff/10ml.

14. 14

15. 15
1 As
need
reliever
medicatio
n
Rapid acting β2-agonist ( )
2
Reliever
medicatio
n plus
single
controller
Rapid acting β2-agonist + Low dose ICS
3
Reliever
medicatio
n plus
one or
two
controller
Rapid acting β2-agonist + Low dose ICS + Long actingβ2-agonist
Steroids
( dose steroids medium or high)
Rapid actingβ2-agonist+Medium or high dose
ICS (
Long actingβ2-agonist)
4
Reliever
medicatio
n plus two
or more
controller
Rapid acting β2-agonist+ Medium or high dose ICS+Long acting
β2-agonist
5
Reliever
medicatio
n plus
additional
controller
options
( 4)oral glucocorticoid (lowest dose) / anti-
IgE treatment

16. 16
1.
2.
NSAIDs beta blockers
3.
4. peak flow
meter
5.

17. 17
COPD
(Chronic Obstructive Pulmonary Disease)
COPD
(usually progressive) noxious agent
(abnormal inflammation)
noxious agent
Allergen Atopy
COPD 2
(Chronic bronchitis) (emphysema)
Emphysema ( )

18. 18
alveoli
Chronic bronchitis ( )
3
1 2
COPD
1.Gene 1-antitrypsin
Protein Neutrophils esterase
Neutrophils Neutrophil esterase 1-
antitrypsin Neutrophils esterase elastin
2.Exposure to particles
 Tobacco smoke
 Occupational dusts,organic and inorganic
 Indoor air pollution from heating and cooking with biomass
in poorly vented dwellings
 Outdoor air pollution
 Lung growth and development
 Oxidative stress
 Gender
 Age
 Respiratory infection

19. 19
 Previous tuberculosis
 Bronchial hyperesponsiveness


20. 20

21. 21

22. 22

23. 23
Figure 2 Spirometric Classification of COPD Severity Based on Post-Bronchodilator
FEV1
Stage I : Mild FEV1/FVC < 0.70
FEV1 ≥ 80% predicted
Stage II : Moderate FEV1/FVC < 0.70
50% ≤ FEV1 < 80% predicted
Stage III : Severe FEV1/FVC < 0.70
30% ≤FEV1<50% predicted
Stage IV: Very Severe FEV1/FVC <70%
FEV1 < 30% predicted or FEV1 < 50%
Predicted plus chronic respiratory failure
Spirometry
0.5,1,2
3
Spirometer Spirogram

24. 24
FVC(forced vital capacity)
(TLC=total lung capacity)
FEV1 (forced expiratory volume time)
(TLC) 1,2,3
FEV1 FEV2 FEV3
FEV1/FVC % FEV1 FVC
FEV1/FVC%,FEV2/FVC%,FEV3/FVC%
COPD
1.
2.
3.
4.
5.
6.
COPD
Bronchodilator
steroids FEV1

25. 25
Bronchodilator 2-agonist,anticholinergic,theophylline combination
side effect onset side effect

26. 26
 2-agonist
Short acting : Salbutamol,Terbutaline,Fenoterol=duration 4-6
prn.

27. 27
Long acting : Salmeterol,Formoterol,Bambuterol =duration 12
bid.
 Anticholinergic ( COPD )
Short acting : Ipratopium bromide = duration 6-8 qid
Long acting : Tiotropium bromide = effect 72 =
DPI theophylline

1.Influenza vaccine Pneumococcal vaccine
2.Alpha1-antitrypsin
3.Mucolytic
4.Antibiotic
5.Oxygen treatment O2
long term ( 15 )
6.Antioxidant N-acetylcysteine
ROS( steroids)

1. (Pulmonary rehabilitation)
 spirometry




28. 28


1. (endurance
exercise) exercise perfomance
20
3
70 ( 220- )


pursed-lip 5


29. 29

8
(6-minute walk test) performance score
2.
15
lung mechanics
PaO2 60 mmHg.
SaO2 90%
1
(Smoking cessation)
FEV1
5 ”5A”
1.Ask about tobacco use ( )

30. 30
2.Advise to quit( )
3.Assess willingness to quit
( )
2-
3
5R”s
 Relevance
 Risks
 Rewards
 Roadblocks
 Repetition
4.Assist in quit attempt( )

31. 31
nicotine
dopamine
dopamine
 Nicotine replacement therapy
 Bupropion Sustained-
release
norepinephrine,serotonin dopamine
5.Arrange follow up
Pressure metered-dose inhaler (PMDI)
1.
2. 4-5
3. 2
MDI 2 MDI 4
4. MDI 1-
2 aerosol

32. 32
30l./min. 3-
5
5. MDI
10
6. 1-2
7.
8.
9. 4
Turbuhaler
1. Turbuhaler
2. 1 dose
“ ”
3. Mouthpiece Turbuhaler
4. Mouthpiece Turbuhaler

33. 33
5. Turbuhaler
6.
7. 4
Accuhaler
1. accuhaler
2.
“ ”
accuhaler
3. accuhaler
accuhaler
4. accuhaler

34. 34
“ ”
6.
7. 4
Handihaler
1= Mouthpiece Handihaler

35. 35
2=Mouthpiece
3= Handihaler
4=
5= capsule
1. 1 Handihaler Mouthpiece
2.
3. Mouthpiece “ ”
4.

36. 36
5. Mouthpiece
Handihaler
6. Mouthpiece
handihaler

37. 37