29a. Asthma Management in Adults and Children Flashcards by Callum Anderson

What has an enormous effect on the flow resistance in the airways?

Radius (R^4)

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What is the prevalence of asthma in the UK?

~ 10% population (5.5m patients in UK)

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What percentage of hospital admissions for asthma are avoidable?

75%

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How many people die every six hours from Asthma?

One person every six hours

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What percentage of deaths are preventable?

90%

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What is a basic definition of Occupational asthma?

Symptoms related to work exposure

No prior history of Asthma

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What is a basic definition of Work-exacerbated Asthma?

Symptoms related to work exposure

Prior history of Asthma

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What are the investigations for Asthma?

Peak flow monitoring
Spirometry 
Bronchodilator reversibility
Blood tests (Eosinophils, IgE)
Allergy tests (skin, blood)
Bronchial hyper-responsiveness
Exhaled NO
CXR in some patients
Challenge testing

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What are the two types of asthma?

Acute Asthma Attack

Chronic Asthma

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What are the Non-pharma techniques for treating acute asthma attack?

ITU/HDU
Ventilation
ECCO2R
Chest drain if pneumothorax

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What are the main drug techniques for treating acute asthma attack?

Bronchodilator:
Oxygen
Magnesium

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What are the main drug techniques for treating chronic asthma?

Anti-inflammatory:
Leukotriene RAs
Monoclonal Abs

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What are the main drug techniques for treating both acute asthma attack and chronic asthma?

Bronchodilators:
- β2 agonists
- Anti-muscarinics
- Theophyllines
Anti- inflammatory:
- Steroids

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What are the Non-pharma techniques for treating chronic asthma?

Asthma Action Plan
Weight loss if ˄BMI
Vaccines – flu &amp; pneum
Allergen avoidance
     (inc. occup. Asthma)
Physiotherapy
Smoking Cessation
Bronchial Thermoplasty

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What drugs should be avoided in asthma management?

β-blockers
NSAIDS / Aspirin
Sedatives/strong opiates (unless in critical care)

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What is the main way of chronic asthma management and why?

Mainly inhalers

Small dose of drugs
Delivery directly to the target organ (airways and lung)
Onset of effect is faster
Minimal systemic exposure
Systemic adverse effects are less severe and less frequent

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What are the facts about pMDI (Metered Dose Inhalers)?

DEVICE GENERATES AEROLSOL - low insp. flow
Needs co-ordination
Elderly, young children, unwell can’t use effectively

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What are the facts about pMDI (Metered Dose Inhalers) with spacers?

Low oro-pharyngeal deposition of aerosol
Reduced speed of the aerosol
Decreases bad taste associated with oral deposition
Reduced the risk of oral candidiasis and dysphonia with steroids
Reduced “cold-Freon effect” in some

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What are the facts about Dry powder inhalers (DPI)?

PATIENT GENERATES AEROSOL – high insp flow
Less coordination required
Similar issues with deposition

What is the complete control of Asthma defined as?

No daytime symptoms 
No night-time awakening due to asthma 
No need for rescue medication 
No asthma attacks 
No limitations on activity including exercise &amp; normal lung function (in practical terms FEV1 and/or PEF>80% predicted or best)
Minimal side effects from medication.
- BTS/SIGN 2016

What are two Short acting beta 2 agonists (SABA) - Relievers?

Salbutamol
- MDI
- DPI
Terbutaline
- DPI

What are the adverse effects of Beta2-stimulants?

Tremor 
Cramp
Headache
Flushing
Palpitations
Angina

What are the inhaled coricosteroids (ICS) - Preventers?

Beclomethasone
Budesonide
Fluticasone 
Ciclesonide
Mometasone

When do you start ICS?

Using inhaled β2 agonist (“Reliever”) x3/week or more
Waking one night a week or more due to asthma
Requiring oral steroid for an exacerbation in the past 2 years
Symptomatic x3/week or more

What are the the advantages of the inhaled route of corticosteroids?

``` Low dose Delivered to the site of action Minimal side effects - No adrenal suppression - No bone problems - Normal growth in children ```

What are the long term steroid side effects taken orally?

``` Red cheeks Moon face Fat pads (Buffalo hump) Thin skin High B.P. Thin arms and legs Osteoporosis Poor wound healing Pendulous abdomen Red Striation Bruisability ecchymoses ```

What are the long term steroid side effects that are inhaled?

Dysphonia | Oropharyngeal candidiasis

What are the ICS + Long acting beta2 agonists (LABA)?

``` Fostair (pMDI & DPI) - Beclomethasone with formoterol Symbicort (DPI) - Budesonide with formoterol DuoResp SpiroMax (DPI) - Budesonide with formoterol Flutiform (pMDI) - Fluticasone propionate with formoterol Seretide (pMDI & DPI) - Fluticasone propionate with salmeterol Relvar Ellipta (DPI) - Fluticasone fumarate with vilanterol ```

What are the LTRA (Leukotriene Receptor Agonists)?

Montelukast | Zafirlukast

What are the facts about LTRAs?

More effective in those highly allergic Response is difficult to predict Worth a 6-12 week trial in some patients

What are the facts about Theophylline?

Non-specific phosphodiesterase inhibitor and adenosine receptor antagonist Weak bronchodilator Narrow therapeutic window Unpredictable metabolism- Interacts with many drugs

What are the side effects of Theophylline?

``` Anorexia Headache Nausea Malaise Vomiting Nervousness Abdominal discomfort Insomnia Tachycardia Tachyarrhythmias Convulsions ```

What are the facts about Inhaled Long-acting Anti-muscarinic (LAMA)?

Tiotropium Bromide - via Spiriva Respimat device Antagonises M3 muscarinic Acetylcholine receptor in bronchial smooth muscle – some limited evidence of benefit in asthma when added to ICS/LABA

What are the side effects of Inhaled Long-acting Anti-muscarinic (LAMA)?

Dry mouth GI upset Headaches Can rarely precipitate angle-closure glaucoma (ophthalmological emergency)

What are the facts about long-term oral steroids?

Prednisolone is main drug used Aim for lowest oral dose that controls symptoms Should have a “steroid alert card”

What could happen after abrupt cessation of oral steroid if on long-term oral steroids for >3 weeks?

Acute Adrenal Insufficiency (failure of adrenal glands to produce endogenous glucocorticoid – can be fatal)

What are the facts about Omalizumab (Anti- IgE)?

Monoclonal Antibody (mab) against IgE IgE mediated severe allergic asthma Usually started by Specialist centres (Difficult asthma clinics)

What are the facts about Mepolizumab (Anti-Interleukin-5)?

``` Monoclonal Antibody (mab) against Interleukin-5 Poor asthma control (long term steroid or frequent steroid) with blood eosinophilia Usually started by Specialist centres (Difficult asthma clinics) ```

What are other steroid sparing drugs and what is significant about them?

Immune suppressive drugs (more often used in conditions such as Rheumatoid Arthritis, and in organ transplant recipients), eg: - Methotrexate - Ciclosporin - Oral Gold These agents can have significant side effects and are often tried as a ‘last resort’

What are the non-pharmacological solutions for asthma?

``` Patient Education and Self management plans Inhaler technique Smoking cessation Flu/Pneumococcal vaccinations Co-morbidities Obesity Allergic Rhinitis GORD Stepping down treatment when controlled Allergen avoidance Bronchial Thermoplasty ```

What is the solution for asthma in occupational asthma?

Prompt removal from inhalational exposure is the definitive cure

What are the signs of moderate asthma?

Increasing symptoms PEF >50-75% or predicted No features of acute severe asthma

What are the signs of acute severe asthma?

``` Any one of: PEF 33-55% best or predicted Respiratory rate >/= 25/min Heart rate >/= 110/min Inability to complete sentences in one breath ```

What are the clinical signs of Life-threatening asthma?

``` Altered conscious level Exhaustion Arrhythmia Hypotension Cyanosis Silent chest Poor respiratory effort ```

What are measurements of Life-threatening asthma?

PEF <33% best or predicted SpO2 <92% PaO2 < 8 kPa 'normal' PaCO2 (4.6-6.0 kPa)

What are the clinical signs of near-fatal asthma?

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures