Introduction

Asthma is an important chronic disorder of the airways with significant morbidity and mortality. Around 300 million people in the world currently have asthma. It is estimated that there may be an additional 100 million people with asthma by 2025.

According to First National Asthma Prevalence Study (NAPS) 1999, in Bangladesh about 7 million people (5.2% of the population) are suffering from current asthma (at least three episodes of asthma attack in last 12 months). More than 90% of them do not take modern treatment. Unfortunately, majority of these patients are in 1-15 years of age group, that is, 7.4% of the total pediatric population of our country is suffering from asthma. The following points have been noted from the said study:

Asthma is more prevalent in children than in adults
Asthma and all other allergic conditions are more prevalent in male children than in females
Other atopic diseases (allergic rhinitis, allergic conjunctivitis and atopic dermatitis) are more common in older children than younger ones
Asthma is more frequent in coastal and rural areas than in urban areas

The disease causes physical, emotional and financial sufferings for patients leading to a deleterious effect on the overall socio-economic structure of the country. Asthma accounts for about 1 in every 250 deaths worldwide, although modern management, which obviously includes patient education, can prevent 80% of such death. The economic cost of asthma is considerable both in terms of direct · medical costs (such as hospital admissions and cost of pharmaceuticals) and indirect medical costs (such as loss of work-time and premature death).

Due to advances in the field of medicine, great progress has been achieved in the treatment of asthma. Latest scientific concepts about asthma pathogenesis and management have revolutionized its treatment. With the combination of pre venter, reliever and protector drugs and patient education we can offer an almost normal life to an asthma patient.

It is very much interesting that 11% of US athletes participating in Los Angeles Olympic games in 1984 were identified as having exercise induced asthma; 41 of those athletes won medals. In the 1998 Winter Olympics in Nagano, Japan, out of 196 US athletes who participated, 44 (22.4%) had diagnosed asthma. Of them, 11 .4% (5 athletes) won medals. Among the athletes without asthma medal-winning rate was slightly higher (17.8%).

It is a point of immense regret that when asthmatics of the developed world are taking part in world-class sports and even winning, our patients are suffering enormously and even dying of untreated asthma.

There are many false beliefs among the people of our country regarding asthma and its various management aspects. Being part and parcel of the community, many physicians also have such misconceptions. A study conducted among the health care providers of Bangladesh, from qualified consultants down to quacks, regarding perception and practice of asthma management revealed a disappointing picture. The study found that Chest x-ray was the only investigation advised to support the diagnosis of asthma. Spirometry and pulse oximetry were almost non-existent. For acute asthma management, use of nebulizer was limited to the consultants and physicians working at medical colleges. Use of rescue course of oral corticosteroids was bare minimum. Antibiotics use was found in large number of cases. There was rampant use of oral salbutamol, injectable aminophylline and ketotifen in the management of asthma. Use of inhalers by the patients was found to be low and limited only to salbutamol and beclomethasone. The technique of inhalation was very poor. Asthma education was merely confined to advising 'avoidance of trigger factors', which was often injudicious and incomplete.

It is obvious that clinical course of asthma differ from one country to another due to variation in the environmental trigger factors and allergens. There are various guidelines published in different countries to meet their patient's demand. Keeping in mind the need of the patients in our country we took this initiative to develop guidelines for asthma management. The aim of this book is to simply explain the basic facts and modern management concepts of asthma to all medical professionals, so that they can serve the community more scientifically and with greater confidence and satisfaction.

A fundamental premise of this guide is "patient education" for adults and children with asthma and parents of asthmatic children. We emphasize on the development of asthma management skills, and stress the fact that asthma can be controlled. Patient education must include:

Providing basic information about asthma
Developing a partnership between the physicians in one side and the patient or parents and family on the other side
Involving the patient and family in decision making about the management of asthma, including the development of a workable treatment plan and discussing problems in taking medications as prescribed as well as for environmental control measures
Demonstrating asthma management appliances to the patient, such as how to use inhalers, nebulizers, and peak flow meters
Examining the patient's skill practically and correcting it if necessary
Giving special attention to vulnerable groups, such as pregnant women and elderly people

There had been outbreaks of bronchiolitis in Bangladeshi children in the year of 2001-2002 and again in 2003-2004. It has been proved to be mainly due to respiratory syncytial virus (RSV). Though large numbers of infants in this country are the victims of viral bronchiolitis, they are often misdiagnosed as pneumonia. Any young child presenting with fast breathing and chest indrawing is erroniously diagnosed as pneumonia and indiscriminately treated with so-called "high-powered" costly antibiotics (e.g. ceftriaxone). It is important to consider the diagnosis of bronchiolitis in a child with wheeze and runny nose. We also need to practice rationale use of antibiotics in children with respiratory distress. Frequent administration of antibiotics in childhood may lead to development of asthma in later life. Recently conducted "Asthma Risk Factor Study" of Asthma Association and some other published reports suggest that, in a genetically prone infant, exposure to bronchiolitis strongly correlates with development of asthma in future. With this background a brief guideline for the management of bronchiolitis has been incorporated in this book.

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of death and disability throughout the world. Cigarette smoking is the major risk factor responsible for development COPD. While there is not yet a cure for COPD, its progress can be slowed and its effects may be minimized. With proper medications, appropriate supplementation, consistent physical activity and the right attitude, most patients can regain some lung function and enjoy a happier and more productive life.

It is of great concern that often COPD is misdiagnosed as bronchial asthma and vice versa. It is necessary to differentiate between COPD and asthma, because the two diseases differ in their etiology and pathogenesis and they respond differently to treatments. A concise guideline has been provided for diagnosing and treating COPD in a more confident way.

We believe that these guidelines will be helpful for all health professionals including doctors, nurses, medical students (under-graduate and post-graduate), pharmacists, paramedics, and even for the patients as well.

It is our appeal to everybody who is going through the book to read and follow the guidelines entirely. We shall fail to achieve our desired objectives if piecemeal implementation is practiced. We believe, with appropriate management, we can alleviate the sufferings of millions of asthma patients and make "effortless easy breathing" possible for them. Inshallah we hope to achieve our goal: “প্রশান্তি ভরা শ্বাস, আমাদের প্রয়াস।