2.4 Chronic Asthma

Question 1

What are the atopic conditions?

Answer 1

Asthma, eczema, hay fever, food allergies.

Question 2

What happens in asthma?

What are some triggers?

Answer 2

Chronic inflammatory airway disease. Variable airway obstruction. Hypersensitve smooth muscles give bronchoconstriction.

Triggers:
Dust (house dust mites)
Animals
Cold air
Exercise
Smoke
Food allergens (e.g. peanuts, shellfish or eggs)

Question 3

Presentation suggesting asthma?

Answer 3

• Episodic symptoms with intermittent exacerbations
• Diurnal variability, typically worse at night and early morning
• Dry cough with wheeze and shortness of breath
• Typical triggers
• A history of other atopic conditions such as eczema, hayfever and food allergies
• FHx of asthma or atopy
• Bilateral widespread “polyphonic” wheeze
• Symptoms improve with bronchodilators

Suggest not asthma:

• Wheeze only related to coughs and colds, more suggestive of viral induced wheeze
• Isolated or productive cough
• Normal investigations
• No response to treatment
• Unilateral wheeze suggesting a focal lesion, inhaled foreign body or infection

Question 4

How do you diagnose asthma?

Answer 4

Usually not until 2 or 3 yo.

Clinical on Hx and Ex…

Intermediate / high probability: start treatment and see if things improve.

Intermediate or some doubt:

• spirometry with reversibility if over 5yo
• bronchial challenge get with histamine or metacholine
• FeNO
• peak flow variability in a diary for 2 to 4 week TDS

Low probability then refer to a specialist

Question 5

Medical management of asthma in under 5s and 5-12yo?

Answer 5

UNDER 5:

1. SABA
2. ICS or LTRA (i.e. oral montelukast)
3. Add the other option from step 2.
4. Refer to a specialist.

5-12 YEARS:

1. SABA
2. ICS
3. LABA; continue salmeterol only if the patient has a good response.
4. Titrate up the corticosteroid inhaler to a medium dose. Consider adding:
   - Oral leukotriene receptor antagonist (e.g. montelukast)
   - Oral theophylline
5. Increase the dose of the inhaled corticosteroid to a high dose.
6. Referral to a specialist. They may require daily oral steroids.

Question 6

Medical therapy for asthma for adults?

Answer 6

ADULTS:

1. SABA (reliever)
2. low ICS (preventer)
3. LABA; continue salmeterol only if the patient has a good response.
4. Increase ICS to medium or trial oral leukotriene receptor antagonist (i.e. montelukast), oral theophylline or an inhaled LAMA (i.e. tiotropium).
5. Increase ICS to high. Combine additional treatments from step 4, including the option of an oral beta 2 agonist (i.e. oral salbutamol). Refer to specialist.
6. Add oral steroids at the lowest dose possible to achieve good control under specialist guidance.

Question 7

ICS in children and worried parents?

Answer 7

SE:
- can slow growth velocity and reduce final adult height by up to 1cm when used >12months. Dose dependent.

Context:

• poorly controlled asthma leads to attacks and higher oral steroids being given
• poor controlled asthma impacts growth and development
• regular reviews will check that they are on minimum dose and are growing well

Question 8

Explain MDI inhaler technique with and without a spacer

Answer 8

This focuses on the technique used for the typical salbutamol metered dosed inhaler (MDI). There are also dry powder inhalers that require the patient to inhale quickly and deeply to draw the powder into the lungs.

Without spacer:

1. Remove the cap
2. Shake the inhaler (depending on the type)
3. Sit or stand up straight
4. Lift the chin slightly
5. Fully exhale
6. Make a tight seal around the inhaler between the lips
7. Take a steady breath in whilst pressing the canister
8. Continue breathing for 3 – 4 seconds after pressing the canister
9. Hold the breath for 10 seconds or as long as comfortably possible
10. Wait 30 seconds before giving a further dose
11. Rinse the mouth after using a steroid inhaler

With spacer:

1. Assemble the spacer
2. Shake the inhaler (depending on the type)
3. Attach the inhaler to the correct end
4. Sit or stand up straight
5. Lift the chin slightly
6. Make a seal around the spacer mouthpiece or place the mask over the face
7. Spray the dose into the spacer
8. Take steady breaths in and out 5 times until the mist is fully inhaled

Alternatively exhale fully before putting making a seal with the spacer, spray the dose and take one deep breath in to inhale the mist in one breath before holding for 10 seconds.

Spacers should be cleaned once a month. Avoid scrubbing the inside and allow them to air dry to avoid creating static. Static can interact with the mist and prevent the medication being inhaled.