scholarly journals PENANGANAN PERIOPERATIF PADA ASMA

2013 ◽  
Vol 5 (1) ◽  
Author(s):  
Christina Suhartono ◽  
Harold F Tambajong ◽  
Diana Ch. Lalenoh
Keyword(s):  
Perioperative Management ◽  
Smooth Muscles ◽  
Special Treatment ◽  
Asthma Symptoms ◽  
Asthma Attack ◽  
Asthma Patients ◽  
Post Operation ◽  
Laboratory Examinations ◽  
Keywords Asthma ◽  
Selection Of

Abstract: The management of a patient with asthma during surgery requires a special treatment based on thorough clinical and laboratory examinations to reduce complications during surgery and the post-operative state. Asthma is characterized by a difficulty in breathing due to spastic contractions of bronchiolar smooth muscles, which partially block the bronchioles’ airways. The evaluation of asthma patients before anesthesia and surgical procedures is essential to prevent or control the occurence of asthma attacks during intra-operation and post-operation. Patients with histories of chronic asthma or frequent exacerbations of asthma have to be treated to achieve an optimal condition or a condition in which asthma symptoms are minimal. Patients with frequent bronchospasms should be treated. The selection of drugs and anesthetic procedures should be considered meticulously to avoid a stimulation of  bronchospasm or an asthma attack. Keywords: asthma, perioperative management, patient.   Abstrak: Pengelolaan pasien dengan penyakit asma selama pembedahan membutuhkan penanganan khusus berdasarkan pemeriksaan klinis dan laboratorium yang saksama untuk mengurangi komplikasi selama dan pasca pembedahan. Asma adalah kesukaran bernapas yang ditandai dengan kontraksi spastik otot polos bronkiolus, yang menyumbat bronkiolus secara parsial. Evaluasi pasien asma sebelum tindakan anestesia dan pembedahan sangat penting untuk mencegah atau mengendalikan kejadian serangan asma, baik selama pembedahan maupun pasca pembedahan. Pasien dengan riwayat asma berulang atau kronis memerlukan pengobatan hingga tercapai kondisi yang optimal untuk dilakukan operasi atau kondisi dimana gejala-gejala asma sudah minimal. Pasien dengan  bronkospasme berulang harus diobati terlebih dahulu. Pemilihan obat-obatan dan tindakan anestesia perlu dipertimbangkan dengan cermat untuk menghindari terjadinya bronkospasme atau serangan asma. Kata kunci: asma, penanganan perioperatif, pasien.

scholarly journals Structural alterations and markers of endothelial activation in pulmonary and bronchial arteries in fatal asthma

2019 ◽  
Vol 15 (1) ◽  
Author(s):  
Renata Calciolari Rossi ◽  
Raquel Anonni ◽  
Diogenes Seraphim Ferreira ◽  
Luiz Fernando Ferraz da Silva ◽  
Thais Mauad
Keyword(s):  
Adhesion Molecules ◽  
Adhesion Molecule ◽  
Pulmonary Arteries ◽  
Endothelial Activation ◽  
Bronchial Arteries ◽  
Activation Markers ◽  
Asthma Attack ◽  
Collagen Iii ◽  
Asthma Patients ◽  
Fatal Asthma

Abstract Background There is interest in better understanding vessel pathology in asthma, given the findings of loss of peripheral vasculature associated with disease severity by imaging and altered markers of endothelial activation. To date, vascular changes in asthma have been described mainly at the submucosal capillary level of the bronchial microcirculation, with sparse information available on the pathology of bronchial and pulmonary arteries. The aim of this study was to describe structural and endothelial activation markers in bronchial arteries (BAs) and pulmonary arteries (PAs) of asthma patients who died during a fatal asthma attack. Methods Autopsy lung tissue was obtained from 21 smoking and non-smoking patients who died of an asthma attack and nine non-smoking control patients. Verhoeff–Masson trichrome staining was used to analyse the structure of arteries. Using immuno-histochemistry and image analyses, we quantified extracellular matrix (ECM) components (collagen I, collagen III, versican, tenascin, fibronectin, elastic fibres), adhesion molecules [vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1)] and markers of vascular tone/dysfunction [endothelin-1 (ET-1) and angiotensin II type 2 receptor (AT2)] in PAs and BAs. Results There were no significant differences in ECM components, ICAM-1, ET-1 or AT2 between asthma patients and controls. Smoking asthma patients presented with decreased content of collagen III in both BA (p = 0.046) and PA (p = 0.010) walls compared to non-smoking asthma patients. Asthma patients had increased VCAM-1 content in the BA wall (p = 0.026) but not in the PA wall. Conclusion Our data suggest that the mechanisms linking asthma and arterial functional abnormalities might involve systemic rather than local mediators. Loss of collagen III in the PA was observed in smoking asthma patients, and this was compatible with the degradative environment induced by cigarette smoking. Our data also reinforce the idea that the mechanisms of leukocyte efflux via adhesion molecules differ between bronchial and pulmonary circulation, which might be relevant to understanding and treating the distal lung in asthma.

scholarly journals Efeito de imunodulador glutamina e probiótico pool de Lactobacillus na atenuação dos sintomas e crises de asma em crianças

2020 ◽  
Vol 34 (4) ◽  
pp. 346-354
Author(s):  
Michele Honicky ◽  
João Paulo Zattar ◽  
Mariana Saciloto ◽  
Mariana Abe Vicente Cavagnari ◽  
Claudia Nodari ◽  
...  
Keyword(s):  
Prevention And Control ◽  
Clinical Characteristics ◽  
Glutamine Supplementation ◽  
Control Group ◽  
Beneficial Effects ◽  
Asthma Symptoms ◽  
Asthma Attack ◽  
Asthma In Children ◽  
And Control

Introduction: Immunomodulator glutamine and probiotic Lactobacillus at certain doses have beneficial effects by modulation of the immune system and may assist in the integrity of therespiratory system. However, studies about the effects of glutamine or Lactobacillus pool on the prevention and control of asthma in children are still scarce. The aim of study was to evaluate the effect of the use of glutamine and Lactobacillus pool on the attenuation of clinical asthma symptoms in children. Methods: Longitudinal study, 45 children with medical diagnosis of asthma distributed in three groups: control group (C), glutamine group (G), Lactobacillus group (L). Group G was supplemented with L-glutamine powder (0.3 g/kg/day). Group L used a pool of Lactoba- cillus (Lactobacillus casei, paracasei, rhamnosus, acidophilus and Bifidobacterium lactis) (2 g/day). Group C received no glutamine or Lactobacillus pool. Clinical characteristics and symptoms of respiratory diseases were assessed by study-specific anamnesis and ISSAC Questionnaire (to obtain diagnostic scores and asthma symptoms) for 4 months. To test for differences between groups, the ANOVA test with Tukey post-hoc test was used. It was considered significant p <0.05. Results: Initial ISSAC score was (C=8.67±1.77, L=7.80±1.52 and G=8.00 ± 1.46, p=0.31). At the first follow-up, the ISSAC score indicated that group G had improvement in the clinical characteristics of asthma (C=6.47±2.29, L = 5.07±2.28, G = 4.00±1.73, p <0.05), as also occurred in the following months until the last follow-up (C=5.93±2.28, L=5.13±2.13, G=4.00±1.96, p<0.05). After supplementation, group G presented lower mean duration of asthma attack (p=0.01), lower number of asthma attack (p<0.05), lower prevalence of typical asthma symptoms, as cough and wheezing (p<0.05). Conclusion: Glutamine supplementation attenuated the typical asthma symptoms, while the use of Lactobacillus pool did not attenuate the symptoms. Glutamine may be a new strategy for prevention and control of asthma in children.

scholarly journals Tiotropium add-on therapy is safe and reduces seasonal worsening in paediatric asthma patients

2019 ◽  
Vol 53 (6) ◽  
pp. 1801824 ◽  
Author(s):  
Christian Vogelberg ◽  
Stanley J. Szefler ◽  
Elianne J.L.E. Vrijlandt ◽  
Attilio L. Boner ◽  
Michael Engel ◽  
...  
Keyword(s):  
Unmet Need ◽  
Comprehensive Analysis ◽  
Double Blind ◽  
Once Daily ◽  
Safety Database ◽  
Treatment Groups ◽  
Asthma Symptoms ◽  
Paediatric Patients ◽  
Asthma Patients ◽  
Symptomatic Asthma

There remains an unmet need for effective, well-tolerated therapeutic options in paediatric patients with not fully controlled asthma, for whom safety is of paramount importance.Data were pooled from five randomised, double-blind, placebo-controlled studies evaluating tiotropium 5 or 2.5 µg versus placebo add-on therapy in patients with symptomatic asthma aged 1–17 years. Analysis included adverse events (AEs) and serious AEs (SAEs) reported throughout and for 30 days following treatment.Of 1691 patients treated, 1119 received tiotropium. Reporting of AEs was low and comparable across all groups: tiotropium 5 µg (51%), tiotropium 2.5 µg (51%) and placebo (54%). Reporting of drug-related AEs, those leading to discontinuation and SAEs was also low and balanced between treatment groups, irrespective of age, disease severity or sex. The number of AEs related to asthma symptoms and exacerbations was lower with tiotropium (5 µg) than with placebo, particularly during the seasonal peaks of these AEs.This comprehensive analysis of a large safety database allowed subgroup analyses that are often impractical with individual trials and provides further support for the safety of once-daily tiotropium Respimat add-on therapy in paediatric patients with symptomatic asthma.

scholarly journals Efektivitas Pemberian Oksigen Posisi Semi Fowler Dan Fowler Terhadap Perubahan Saturasi Pada Pasien Asma Bronkial Persisten Ringan

JKEP ◽  
2019 ◽  
Vol 4 (1) ◽  
pp. 31-43
Author(s):  
Syamsul Firdaus ◽  
Misbachul Munirul Ehwan ◽  
Agus Rachmadi
Keyword(s):  
Oxygen Saturation ◽  
Bronchial Asthma ◽  
Oxygen Therapy ◽  
Sampling Technique ◽  
T Test ◽  
Low Oxygen ◽  
Asthma Attack ◽  
Asthma Patients ◽  
The Difference ◽  
Persistent Bronchial Asthma

Mild persistent bronchial asthma is a chronic inflammatory airway that cause the low oxygen saturation value (91-95%). Administering oxygen therapy, setting the position of the semi fowler and fowler can reduce the risk of a decreased chest configuration. This research aims to assess the difference of effectiveness of administering oxygen at semi fowler with fowler position to the saturation changes in mild persistent bronchial asthma patients in Ratu Zalecha Martapura Hospital. This research method is quasy Experiment. The population research are all patients who experience mild persistent bronchial asthma attack, the sample of this research are 20 respondents with purposive sampling technique and analyzed with independent T test. The results is at semi fowler position the average of oxygen saturation before the treatment is 93.10%, after administering oxygen therapy with semi fowler position the average saturation is 98.00%. At the fowler position the average of oxygen saturation before the treatment is 92.60%, after administering oxygen therapy with fowler position the average saturation is 98.00%. The independent T-test result showed no difference of effectiveness of administering oxygen at semi fowler with fowler position to the saturation changes in mild persistent bronchial asthma patients,so teh patients can be given both positions.

scholarly journals ADHERENCE TO THERAPY AND ITS IMPACT ON THE CONTROL OF ASTHMA SYMPTOMS IN CHILDREN

2020 ◽  
pp. 419-426
Author(s):  
R.M. FAYZULLINA ◽  
◽  
V.V. VIKTOROV ◽  
R.R. GAFUROVA ◽  
A.V. SANNIKOVA ◽  
...  
Keyword(s):  
Bronchial Asthma ◽  
Clinical Laboratory ◽  
Symptom Control ◽  
Treatment Compliance ◽  
Specific Ige ◽  
Asthma Symptoms ◽  
Treatment And Prevention ◽  
Age Of Diagnosis ◽  
Male Patients ◽  
Keywords Asthma

Objective: To assess the level of adherence to medical prescriptions and recommendations by patients with bronchial asthma (BA), in order to achieve control over the symptoms of the disease; to identify the most common factors of low adherence to BA therapy; to suggest strategies for optimizing treatment compliance. Methods: 92 children with a verified diagnosis of BA were examined. All patients underwent a general clinical, laboratory and instrumental examination, as well as an additional screening test with a mixture of respiratory allergens – the ImmunoCapPhadia® 250 method. The control of BA symptoms was assessed using ACT and ACQ tests. Adherence to BA therapy was assessed using a questionnaire. Results: Analysis of gender differences revealed that the proportion of male patients was 58%; female – 42%. The median age was 11 years. The average age of diagnosis of BA in children was 9 years. All patients were hospitalized during the period of exacerbation of the disease, the proportion of children with an attack of moderate BA – 87%; severe – 13%. An intermittent course of BA was observed in 28%; a persistent course in 72%. Analysis of ImmunoCap Phadia®250 data revealed that in 17.2% of cases class V sensitization prevailed, and the average values of allergen-specific IgE antibodies were 69.82 kU/L. Assessment of the level of control over asthma symptoms and the use of AST and ACQ tests revealed that partially controlled the course of BA was noted by 56% and uncontrolled over 46% of children. Analysis of the «Questionnaire of adherence to treatment of bronchial asthma (BA) in children», differences were found in the response to questions: «Do you experience difficulties in using the inhaler?» (χ2=8.952; p=0.003), «Was there any reluctance to take medications?» (χ2=4.715; p=0.03); «Does it happen that you forget to take drugs one/several days?» (χ2=5.093; p=0.025), «Are you satisfied with the prescribed therapy for BA?» (χ2=5.093; p=0.025). Conclusions: In order to achieve success in long-term control of the symptoms of BA in a patient, a comprehensive approach to the treatment and prevention of exacerbation of BA is required with an individual approach to each child, both from the doctor and from an adult who participates in the conduct and adherence to doctors appointments. Keywords: Asthma, children, adherence, compliance, symptom control.

scholarly journals Bronchospasm during Anesthesia Induction in A Patient with Undiagnosed Asthma

2020 ◽  
Vol 8 (6) ◽  
Author(s):  
Bo Sung Kim ◽  
Jae Chan Choi
Keyword(s):  
Allergic Rhinitis ◽  
Vital Signs ◽  
Good Control ◽  
Anesthesia Induction ◽  
Current Case ◽  
Asthma Symptoms ◽  
Asthma Patients ◽  
Life Threatening ◽  
Undiagnosed Asthma ◽  
Pathophysiologic Mechanisms

In large study of 9287 children undergoing general anesthesia, the incidence of perioperative bronchospasm is 2.1 percent. During anesthesia in patients with well-controlled asthma, airway complications such as bronchospasm are rare. However, poorly controlled asthma is closely related to the pathophysiologic mechanisms of nonallergic and allergic bronchospasm. More than 80% of asthma patients have allergic rhinitis, and 10-40% of allergic rhinitis patients have asthma.    We report a case of a 10-year-old male with undiagnosed asthma who developed bronchospasm during induction of anesthesia. This patient had been treated for allergic rhinitis before surgery. Unexpected bronchospasm occurred immediately after induction of anesthesia and was treated with salbutamol nebulizer and intravenous dexamethasone. In addition, a massive hypotension-suspected anaphylactic reaction occurred and was treated with intravenous epinephrine, after which airway pressure and vital signs improved. For safety, the operation was canceled, anesthesia was discontinued, and the patient was discharged without specific complications. Asthma was diagnosed upon further evaluation two weeks after discharge.   Because this patient had been treated for allergic rhinitis before surgery, asthma should have been diagnosed before surgery. If asthma symptoms before anesthesia were well-controlled using a bronchodilator, steroid, etc., bronchospasm could have been prevented during anesthesia in the current case.   This case suggests that, when possible, asthma should be diagnosed before surgery in allergic rhinitis patients. This case also suggests that anesthesia should be performed after good control of asthma symptoms before surgery to prevent life-threatening perioperative events.

scholarly journals HUBUNGAN INDEKS MASSA TUBUH (IMT) DENGAN RASIO VOLUME EKSPIRASI PAKSA SATU DETIK PERTAMA PER KAPASITAS VITAL PAKSA (VEP1/KVP) PADA PASIEN ASMA STABIL DI RSUD KOTA MATARAM 2019

2021 ◽  
Vol 6 (2) ◽  
pp. 152
Author(s):  
Prasetya Angga Firmansyah ◽  
Risky Irawan ◽  
Dian Rahadianti ◽  
Fachrudi Hanafi
Keyword(s):  
Body Mass Index ◽  
Quality Level ◽  
P Value ◽  
Medical Clinic ◽  
Cross Sectional ◽  
Fundamental Limit ◽  
Medical Issues ◽  
Asthma Patients ◽  
Clinical Records ◽  
Keywords Asthma

Saat ini asma masih menjadi salah satu masalah kesehatan utama baik di negara maju maupun di negara berkembang. Diperkirakan terdapat 300 juta penduduk di dunia menderita asma. Prevalensi asma di Indonesia sendiri pada tahun 2018 sebesar 2,4%. Provinsi Nusa Tenggara Barat (NTB) berada di peringkat ke 7 dengan angka kejadian mencapai 2,5%. Asma adalah penyakit heterogen dengan berbagai proses penyebab yang mendasarinya. Salah satu penyebab asma yang telah diidentifkasi adalah asma dengan obesitas. Gold standart  dalam pemeriksaan penyakit asma adalah spirometri. Parameter yang dinilai dalam pemeriksaan spirometri untuk menilai derajat obstruksi pasien asma adalah VEP1/KVP. Perubahan pada IMT baik overweight maupun underweight akan menyebabkan perubahan mekanik dan kimiawi sistem pernapasan yang nantinya berperan sebagai faktor yang berpengaruh dan memperberat nilai VE1/KVP pada pasien asma. Tujuan dalam penelitian ini mengetahui hubungan indek massa tubuh dengan rasio volume ekspirasi paksa satu detik pertama per kapasital vital paksa pada pasien asma stabil di RSUD Kota Mataram 2019. Penelitian ini merupakan analitik observasional, dengan rancangan cross sectional. Sumber data yang digunakan dalam penelitian ini berupa data sekunder dari rekam medik pasien asma yang menjalani rawat jalan di RSUD Kota Mataram 2019 berupa data berat badan dan tinggi badan serta nilai VEP1/KVP. Sampel pada penelitian ini berjumlah 118 orang. Analisis data menggunakan rank spearman dengan bantuan software SPSS versi 25. Hasil analisis didapatkan nilai p-value 0,000 (p-value ≤0,05), yang berarti terdapat hubungan antara IMT dan VEP1/KVP pada pasien asma stabil. Terdapat hubungan antara Indeks Massa Tubuh dengan rasio VEP1/KVP pada pasien asma stabil di RSUD Kota Mataram 2019.Kata Kunci: Asma, indeks massa tubuh, VEP1/KVP.ABSTRACTRight now, asthma is as yet one of the principle medical issues in both created and non-industrial nations. The highest quality level in inspecting asthma is spirometry. The boundary evaluated in the spirometry assessment to survey the level of impediment in asthma patients was FEV1/FVC. Changes in BMI both overweight and underweight will cause mechanical and synthetic changes in the respiratory framework which will later go about as an impacting factor and bother the VE1/KVP esteem in asthma patients. The reason for this examination to decide the connection between weight file and the proportion of constrained expiratory volume of the first second per constrained fundamental limit in stable asthma patients at Mataram City Clinic 2019. This examination was an observational scientific contemplated, with a cross sectional plan. This examination utilizing optional information from clinical records of asthma patients as weight and tallness information just as VEP1/KVP esteems. The patients are going through outpatient at the Mataram City Medical clinic in 2019. The example in this investigation added up to 118 individuals. Information examination utilized position spearman with the assistance of SPSS form 25 programming The aftereffects of the investigation utilizing Rank Spearmen acquired a p-value of 0.000 (p-value ≤0.05), which implies that there is a connection among BMI and FEV1/FVC in stable asthma patients at Mataram City Clinic 2019.Keywords: Asthma, body mass index, FEV1/FVC.

ВАРИАБЕЛЬНОСТЬ ОТВЕТА НА СТАНДАРТНУЮ ФАРМАКОТЕРАПИЮ У ПАЦИЕНТОВ С БРОНХИАЛЬНОЙ АСТМОЙ

2019 ◽  
Author(s):  
K.S. Pavlova ◽  
D.S. Mdinaradze ◽  
O.M. Kurbacheva
Keyword(s):  
Ipratropium Bromide ◽  
Tiotropium Bromide ◽  
Bronchial Obstruction ◽  
Asthma Phenotype ◽  
Basic Therapy ◽  
Asthma Symptoms ◽  
Asthma Patients ◽  
High Doses ◽  
Long Acting ◽  
Basic Treatment

Актуальность. Основанием для проведения данного исследования послужило наличие группы пациентов с бронхиальной астмой (БА), которые предпочитают для купирования приступов удушья использовать короткодействующие антихолинергические препараты (КДХП). Цель. Изучение возможной низкой эффективности длительно действующих Р2-агонистов (ДДБА) у пациентов с БА, не имеющих достаточного ответа на КДБА, а также вероятности уменьшения бронхиальной обструкции с помощью длительно действующих антихолинергических препаратов (ДДХП) у этих пациентов. Материалы и методы. В исследовании приняли участие 12 взрослых некурящих пациентов с БА средней степени тяжести (III-IV ступень по GINA), получавшие в качестве базисной терапии ИГКС в средних или высоких дозах в сочетании с ДДБА, при этом характеризовались отсутствием или неполным контролем над симптомами БА. В первую (n7) группу были определены пациенты с клинически и инструментально подтвержденной эффективностью сальбутамола, которые в то же время имели хороший ответ на ипратропия бромид (КДБАКДХП). Во вторую группу (n5) вошли пациенты с низким ответом на саль-бутамол и положительным тестом с ипратропия бромидом (КДБА-КДХП). Пациентам проводили серию исследований функции внешнего дыхания (ФВД) до и через 5, 10, 15, 30, 60, 120 и 240 мин после ингаляции бронхолитического средства (салметерола 50 мкг, формотерола 12 мкг и тиотропия бромида 18 мкг). Результаты. Было показано, что пациенты с БА и фенотипом КДБА-КДХП имеют низкий ответ на ДДБА: максимальный прирост ОФВгпосле ингаляции сальметерола составил 7,641,67 и 156,0116,03 мл, а после формотерола 9,435,84, 166,71103,14 мл (в сравнении с группой КДБАКДХП, где ответ на сальметерол составил 20,812,42 и 551,4393,94 мл, а на формотерол 30,216,75 и 718,57140,78 мл), и хороший ответ на ДДХП (13,735,78 и 250,0361,61). Заключение. Результаты исследования дают основание к выделению отдельного фенотипа БА с низкой обратимостью бронхиальной обструкции в ответ на КДБА и достаточной обратимостью в ответ на КДХП (КДБА-КДХП). Этой группе пациентов в качестве базисной терапии следует рассматривать сочетание ИГКСДДБА и ДДХП (тиотропия бромида).Background. The aim of this study was to analyse the group of patients with asthma, who prefer to use short-acting anticholinergics (SAMA) for relief of asthma attacks. At the same time, these patients are prescribed inhaled glucocorticosteroids (ICS) in combination with long-acting P2-agonists (LABA) as a basic therapy according to the standards. Tha aim. To study the cause of low efficacy of LABA in patients with asthma who do not have a sufficient response to SABA, as well as the probability of reducing of bronchial obstruction with LAMA. Materials and methods. 12 non-smoking adults with moderate to severe asthma (III-IV stage of GINA), receiving medium or high doses of ICS in combination with LABA as a basic therapy without adequate control over asthma symptoms were included in the study. First group of patients showed the efficacy of salbutamol (FEV1reversibility was more than 12 and more than 200 ml after 400 g of salbutamol) and ipratropium bromide (SABASAMA). Second group included patients with low response to salbutamol and positive test (FEVtreversibility) with ipratropium bromide (SABA-SAMA). Spirometry was performed at baseline point and in 5, 10, 15, 30, 60, 120 and 240 min after inhalation of bronchodilator (salmeterol 50 g, formoterol 12 g and tiotropium bromide 18 g in the different days). Results. It was shown that SABA-SAMA phenotype asthma patients demonstrated low response to LABA: FEV1increased up to 7.641.67, 156.016.0 ml after salmeterol inhalation and up to 9.45.8, 166.7103.1 ml after formoterol inhalation (compared with a group of SABASAMA, where the response to salmeterol was 20.812.42, 551.4393.94 ml and the response to formoterol was 30.216.75, 718.57140.78 ml, p0.05), and a good response to LAMA (13.75.8 and 250.061.6). Conclusion. The results of the study allowed to define asthma phenotype with low bronchial obstruction reversibility to SABA and sufficient reversibility to SAMA (SABA-SAMA). This group of asthma patients need the basic treatment with the combination of ICS and LABA and LAMA (tiotropium bromide).

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