STEPWISE TREATMENT IN ASTHMA  

Dr. George Mothi Justin

MD DNB (Respiratory Diseases)

Consultant Pulmonologist

Medical Trust Hospital 

Definition of Asthma

n A chronic inflammatory disorder of the airways

n Many cells and cellular elements play a role

n Chronic inflammation leads to an increase in airway hyper responsiveness with recurrent episodes of wheezing, coughing, and shortness of breath

n Widespread, variable, and often reversible airflow limitation

 

Asthma Diagnosis

 

Six Part Asthma Management Programme

1. Educate Patients

2. Assess and Monitor Severity

3. Avoid Exposure to Risk Factors

4. Establish Medication Plans for Chronic   Management:  Adults and Children

5. Establish Plans for Managing Exacerbations

6. Provide Regular Follow-up Care

 

WHY SHOULD AN INHALER BE USED REGULARLY

 

n      There is an ongoing process of bronchial inflammation &  hyperresponsive airways even in the asymptomatic state

n      Regular use of inhaled  steroids controls inflammation &  protects the airways from going into spasm.

 

Role of Allergen-specific Immunotherapy

 

n      Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

n        A number of questions must be addressed regarding the role of specific immunotherapy in asthma therapy

n        Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

n        Perform only by trained physician

 

 

Stem cell transplantation - An overview

DR. N V Ramaswamy MD, DNB,DM (Clinical Haematology)

Medical Trust Hospital

 

It is a victory of optimism over pessimism. Animal studies led  the way for human trials. First successful human bone marrow transplantation was done by Dr. Donall Thomas in 1970 for which he was awarded Nobel Prize in 1990. The principle behind transplantation is myeloablation and immunosuppression which is achieved by preparative ( conditioning ) regimens. Sources of stem cells are bone marrow, peripheral blood , umbilical cord blood and fetal liver.

For an allogenic transplant six antigens of HLA-A, B, DR matching is required. Partially matched related donors and matched unrelated donor can also be considered in absence of an HLA identical sibling. Matched unrelated donor list can be obtained from NMDP ( United States ) and Asian Indian Donor Marrow Registry

 ( AIIMS, India).

Autologous   transplantation is done for malignant and some autoimmune disorders. It is based on the principle of linear dose- response relation of high dose chemotheraphy on malignant cells and followed by stem cell rescue.

 

PROCEDURE :

Bone marrow transplant : 700 1200 ml of blood is aspirated from posterior iliac crest and transfused intravenously after processing ( if required ).

Peripheral blood stem cell transplant : Growth factors and or high dose chemotheraphy mobilized stem cells are collected by cell separator.

Umbilical cord blood : Cryopreserved cord blood from the cord blood bank is cooled, thawed and then transfused. This is useful mainly for paediatric patients as the stem cell counts may not be adequate for an adult engraftment.

Transplantation is done in a specially designed sterile room. Post transplant patient is supported with antibiotics, TPN and irradiated blood products. Prophylaxis for graft versus host disease( GVHD ) is given in allogenous transplant. Engraftment depends on stem cell dose and HLA matching and is assessed by chimerism analysis.

Acute  complications due to preparatory regimen include mucositis, infection, myocarditis, venoocclusive disease , renal failure  and haemorrhagic cystitis. Late complications include relapse, sterility, cataract and secondary malignancy.

 

INDICATIONS :

Non malignant conditions :- Severe aplastic anaemia, Fanconi anaemia, beta thalasemia, sickle cell anaemia , immunodeficiency & autoimmune disorders.

Malignant conditions :- CML, ALL, AML, MM, MDS, HD, NHL and solid tumors like breast, ovary, renal cell cancers, neuroblastoma and germ cell tumors.

 

            Non myeloablative stem cell transplant( Mini transplant ) is useful for elderly and co morbid patients who cannot tolerate myeloablative preparatory regimens.

            Great progress in transplant technology with concomitant improved survival rates has made stem cell transplantation a practical reality.