2- primary care management of asthma

Question 1

what are presenting symptoms of asthma?

Answer 1

• breathlessness
• wheeze
• cough

→diagnosis tricky as all of these can be caused by lots of things

Question 2

what can exacerbate asthma symptoms?

Answer 2

• can be worse in morning, after exercise, in cold air, at certain times of year like hayfever if atopic
• symptoms can be triggered like emotion or laughter in kids and non-steroidal anti-inflammatory drugs & beta blockers in adults

Question 3

what can be heard in clinical examination for asthma?

Answer 3

• can hear expiratory polyphonic history heard in lots of different areas of lungs
  
  • polyphonic = multiple tones

Question 4

why can occupation (job) matter for asthma diagnosis?

Answer 4

because asthma can be caused by work with bakeries, dust, smoke, pets etc - hint is if gets better on holiday or away from work

Question 5

what test can you do if you’re unsure if person has asthma? (and it’s not like urgent problem)

Answer 5

do peak flow charting - send patient with peak flow meter and make chart

Question 6

what are some tests for eosinophils? (to test for inflammation or atopy)

Answer 6

• exhaled FeNO not very accessible, very suggestive of asthma but normal FeNO doesn’t rule out
• sputum eosinophils = counting them is laborious and and getting sputum from asthmatic patients tricky
• skin prick test = good for allergy but don’t directly test for asthma

Question 7

what is asthma drug treatment? (what are the steps)

Answer 7

1. start with low dose inhaled corticosteroid
2. then add SABA
3. then add LABA
4. add leukotriene receptor antagonist, LAMA or theophylline

Question 8

what are first line inhaled corticosteroids?

Answer 8

start with ICS (beclometasone 1st choice)
can have:
- kelhale (MDI) + use spacer = extrafine particle beclomethasone
- use QVAR easi- breathe = breath actuated (powder inhaler)

Question 9

what are 1st lines short acting beta 2 agonist?

Answer 9

1st choice salbutamol. 2nd choice terbutaline

can use with spacer or powder

Question 10

how should long acting beta 2 agonists (LABA) be given and what ones are first line?

Answer 10

= used in combination inhaler (also steroid) which is called maintenance & reliever therapy

1st line = luforbec (extra fine particle beclometasone (BDP) & formoterol (beta agonist - fast acting)
→delivered 2 puffs twice a day - use with spacer
*changed to luforbec as more cost effective but fostair just as effective 2nd choice

2nd line reliever is dried powder inhaler (DPI) = fluticasone furoate & vilanterol (relvar@ or ellipta)
→1 puff once a day, powder inhaler, low carbon footprint

Question 11

what is a 1st choice leukotriene receptor antagonist?

Answer 11

Montelukast 10 mg once a day - good for allergy phenotypes & exercise induced asthma
(nightmares common side effect)

Question 12

what is 1st line long acting muscarinic antagonist?

Answer 12

Tiotropium (respimat@
- if breathless with no allergy or inflammation then good to maximally bronchodilate airways
- breathless patients benefit most

Question 13

what add on is best for allergic or exercise induced asthma?

Answer 13

montelukast

Question 14

what is best add on for asthma that has breathlessness without allergy or inflammation?

Answer 14

tiotropium

Question 15

what is the respimat inhaler used for tioropium?

Answer 15

it’s a reusable inhaler that can be used for tiotropium (LAMA) - lasts 6 months and has low carbon footprint

Question 16

who makes asthma action plan?

Answer 16

chronic disease nurses - involves a yearly review

Question 17

why are flu vaccines good for helping asthma?

Answer 17

• reduce flu rates
• reduce admissions
• reduce severity of flu

*but has poor uptake (used to get way more done)

Question 18

what treatment needed if asthma gets worsening symptoms (beyond day-day variations) - after last add ons?

Answer 18

• can increase inhaled corticosteroids
• oral steroid 40mg once a day (but contraindication in bacterial infection)
• consider antimicrobials

Question 19

what is criteria for people being admitted for asthma?

Answer 19

admit if:
- life threatening asthma exacerbation
- if any feature of severe asthma attack persisting after initial bronchodilator treatment
- if moderate asthma exacerbation with worsening symptoms despite initial bronchodilator treatment &/or who have had previous near fatal attack

Question 20

how should you manage a life threatening or severe asthma acute episode in primary care?

Answer 20

give salbutamol via oxygen driven nebulizer (5 mg to all people aged over 5 years, and 2.5 mg to children aged 2–5 years).

*if nebulizer not available use pressurized meter dose inhaler with large volume spacer

if poor response to salbutamol, consider adding nebulized ipratropium bromide (500 micrograms for adults and 250 micrograms for children aged 2–12 years, do not repeat within 4 hours)
- also consider quadrupling inhaled corticosteroids (ICS) at onset of attack