It is my pleasure and privilege to present one of my action plans
for this year, revised Asthma Training Module (ATM) and a book on
Asthma By Consensus (ABC). The prevalence of bronchial asthma varies
from country to country and in thesame country varies from state to
state. The largest study group who conducted a study on prevalence
of bronchial asthma is the ISAAC study group [1]. They studied the
prevalence of bronchial asthma in 56 countries with the study
population of 4.5 lakhs. As the principal investigator of this study
from the state of Kerala, the data from Ettumanoor block area of
Kottayam district showed the prevalence of 32.2% in children 13 – 14
years and 25 % in children 6 – 7 yrs (ISAAC Phase 1). Bronchial
asthma is an iceberg disease [2]. Classical presentation with cough,
wheeze, dyspnea and chest tightness is the tip of the iceberg and is
seen only in 30% and remaining 70% present with atypical features.
Patient education, along with pharmacotherapy is an integral part of
asthma management [3].
Why Education is Important in Management of Asthma?
Education helps children and their families to
develop the necessary knowledge, attitudes, beliefs and skills to
manage asthma effectively. No treatment regime is likely to be
effective unless it is followed properly, so patient education is
central component in current asthma guidelines. It starts from the
basic communication skills. The lack of attention paid to parents’
fears and concerns about their child’s illness results in
dissatisfaction with the consultation. Clear-cut explanations about
the disease avoiding medical jargon are always valued by patients.
It is recommended that clinicians teach patients and their families,
essential information concerning the disease process, medication
skills, self-monitoring techniques and environmental controls
[4-11]. The major goals of communication to the family of a child
with asthma include the following:
1. Make them accept the diagnosis
2. Understand the trigger factors and avoid
them
3. Drug therapy
(a) Concept of controllers and relievers
(b) Proper use of the drug delivery
system
4. Likely prognosis in individual cases
5. Adjuvant
(a) Lifestyle modification
(b) Weight reduction
6. Consider the psychosocial aspects of asthma
Make Them Accept the Diagnosis
When there is family history of asthma and when
child gets recurrent episodes of wheezing and breathlessness, it is
probably easy for them to understand the concept of asthma. This is
not the case when child presents only with nocturnal or exercise
induced symptoms or has a cough variant asthma. Many people do not
want their child to be labeled as ‘asthmatic.’ It will be easier for
them to understand and accept the diagnosis if we do a bit of
explanation on the pathophysiology, of course, in non-medical terms.
They may understand better if explanation is done with the help of a
few drawings. Explain the following questions – What is asthma? What
causes asthma? Why my child got asthma? Is asthma same as allergy?
Understand Trigger Factors and Avoid Them
The importance of environmental control should be
explained in great deal. Triggers may be different in different
individuals. We can make the parents aware of the common allergens
which may act as trigger in asthmatic children and instruct them to
observe and find out the specific precipitants in the individual
child. It is found that food is the least important trigger for
asthma, but food restriction is the easiest to implement on the
child, so many people practice various food restrictions. The
important and avoidable triggers are tobacco smoke, smoke from fire
wood in kitchen, incense sticks, mosquito coils, perfumes, body
sprays, talc, odor of cleaning agents, house dustmites, cockroach
debris, moulds, stuffed dolls, pets at home, pollens around certain
food items, and additives.
Drug Therapy
Make the parents understand at least the
following facts regarding medications. There are two kinds of
medications in the treatment of asthma. (a) controllers - for
prevention of future attacks (b) relievers - for relief of
present attack.
Controller medications: These medicines are
for long term control of asthma. They help to reduce the
inflammation in the lungs that is behind each asthma attack. These
medications should be administered daily irrespective of whether the
child is having asthma symptoms or not. The commonly used
controllers are inhaled corticosteroids and monteleukast. It is
rather easy to start monteleukast which is an orally administered
drug, but we may have to spend a little more time discussing about
the need of inhaled corticosteroids. This is because many people are
prejudiced against corticosteroids as well as use of inhaled devices
use. The common belief is once a child is started on an inhaled
medication, he becomes dependent on it. We should make them
understand that some patients need these medicines for a longer
duration due to the chronic or continuing nature of the disease.
Also you can tell them that since child has problem only in his
lungs, medicines administered directly to that part will be more
effective than a medicine given orally which will be distributed
throughout the body and hence likely to produce unwanted side
effects in other parts of body. Another point which we can explain
is the reduction in dose of drug when you use the inhalation route.
It comes to a few micrograms whereas orally given drugs are in
milligrams.
Reliever medications: These are medications,
to be administered once asthma symptoms like cough and wheeze begin.
These stop the current attack only. They have no effect in the
inflammatory changes of airways and also they won’t prevent future
attacks. Long term use of relievers do more harm than good as they
can reduce the perception of bronchospasm by the patient and can
lead to more severe and difficult to treat attacks.
Asthma Training Module (ATM)
The concept and idea of ATM was started in 2000
by the Respiratory chapter of IAP under the Chairmanship of Dr TU
Sukumaran, Dr SS Kamath, Secretary; Dr Swati Y Bhave, Advisor; and
Dr RP Khubchandani, Convener. The first TOT on ATM was conducted at
Hyderabad and trained 100 pediatricians as master trainers all over
the country. The first revision of ATM was conducted at Bangalore by
Dr Suresh Babu, Dr Mahesh Babu and Dr Nagabhushana in 2005. Now we
are launching the 3rd revised
ATM. With this aim, a national level TOT was conducted successfully
at Bangalore on 7th and 8th of May. We are planning to conduct 35
workshops on ATM throughout the country this year.
Asthma By Consensus (ABC of Asthma)
Respiratory chapter of IAP published the first
edition of ABC of Asthma in 2003 under the chairmanship of Dr RP
Khubchandani. Even though the revision of ABC started in 2005 by Dr
Suresh Babu, Dr Mahesh Babu and later on 2008 by Dr Gautam Ghosh and
Dr KK Ghosh it could not be materialized. This year we are
publishing the second edition of ABC and are planning to distribute
one copy of this book to all IAP members. We had a successful
national consultative meeting on ABC at Hyderabad on 26th
& 27th March 2011. My thanks to Dr YK Amdekar, Dr Swati Bhave, Dr
Krishan Chugh, Dr H Paramesh, Dr N Somu, Dr L Subramaniam, Dr RP
Khubchandani, Dr Varindar Singh, Dr Suresh Babu, Dr Mahesh Babu, Dr
Nagabhushana, Dr A Balachandran, Dr D Vijayasekaran, Dr SK Kabra, Dr
GR Sethi, Dr Gautam Ghosh, Dr KK Ghosh, Dr Deepak Ugra, Dr Rohit
Agrawal and Dr Tanmay Amladi for their advice and guidance for
preparing this module. I acknowledge the help of Dr P Jayasree,
Asstt. Professor of Pediatrics, PIMS Thiruvalla for preparing this
article.
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