29b. Asthma Management in Adults and Children

Question 1

What is the medical treatment of asthma?

Answer 1

There is no cure for asthma, only palliation or spontaneous resolution

Question 2

What are the goals of treatment?

Answer 2

“Minimal” symptoms during day and night 
Minimal need for reliever medication 
No exacerbations 
No limitation of physical activity 
Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best)

Question 3

How do you measure control?

Answer 3

SANE

Short acting beta agonist/week
Absence school/nursery
Nocturnal symptoms/week
Excertional symptoms/week

Question 4

What are the classes of medications?

Answer 4

Short acting beta agonists
Inhaled corticosteroids (ICS)
Long acting beta agonists*
Leukotriene receptor antagonists*
Theophyllines*
Oral steroids
* “add ons”

Question 5

What did treatment for children used to be like?

Answer 5

5 steps for 5-12 yrs
4 steps for <5s
Step 3 was rather confusing

Question 6

What is the stepwise approach to the treatment?

Answer 6

One figure for all children
ICS doses overlap with adults
- Very low
- Low
- Medium 
- High
Acknowledges areas of uncertainty when ICS are not sufficient

Question 7

What is the step up step down approach to treatment?

Answer 7

Start on low dose ICS
- Severe may respond to minimal treatment
Review after 2mo
- No routine test to monitor progress
- Stepping up easier than down
Remember natural rise and fall of asthma
When is it safe to stop treatment?

Question 8

What is the contrast with adults treatment?

Answer 8

Max dose ICS 800 microg
No oral B2 tablet
LTRA first line preventer in <5s

Question 9

What is step 1?

Answer 9

SABA as required
Short acting beta agonists
Inhaled (not oral)
Spacer/MDI or Dry Powder Inhaler

Question 10

What is step 2?

Answer 10

Regular preventer
When?
- using inhaled B2 agonists three times a week or more
- symptomatic three times a week or more, or waking one night a week.
- exacerbations of asthma in the last two years
What with?
- Start very low dose inhaled corticosteroids (or LTRA in <5s)

Question 11

What is step 3?

Answer 11

Add on preventer
Gets complicated
- Add on LABA
- Add on LTRA (NICE)
- Increase ICS dose (USA)

Question 12

What is the better option for step 3 LABA or LTRA?

Answer 12

Add on LABA but keep an open mind!
Additional add-on therapies
- Increase ICS (this is the first add on in many countries!)
- LTRA (this is likely to be the first add on recommended by NICE!!)

Question 13

What are the facts about High dose therapies?

Answer 13

BIG difference!!
Under 5s, refer for confirmation of diagnosis
Over 5s, increase to medium dose ICS and consider referral

Question 14

What do you need to do if on continuous or regular oral steroids?

Answer 14

Refer

Question 15

What are the facts about inhaled corticosteroids?

Answer 15

Very useful for diagnosis
Very effective (when taken)
Very safe (when prescribed correctly)

Question 16

What Is the dose response for ICS?

Answer 16

Postive effects increase as Total daily dose of BUD increases
2 BUD : 1 FDP

Question 17

What also happens as ICS is increased?

Answer 17

Adverse effects increase

Question 18

What are the adverse effects of ICS?

Answer 18

Height suppression
Oral candidiasis
Adrenocortical suppression*
Hypertension
Cataracts
*Particularly with fluticasone
Go brown!

Question 19

What are the two things two remember about Long acting beta agonists?

Answer 19

Do not use without ICS

Use as fixed dose inhaler

Question 20

What are the facts about Leukotriene receptor antagonist?

Answer 20

Montelukast only (licensed in kids)
Rule of thirds (works for 3rd of people)
Better adherence
Granules for reluctant toddlers

Question 21

What is step 6?

Answer 21

Experimental medicine
50% psychological issues
>50% compliance issues
Question the diagnosis
**Minority with genuine severe disease**
Role of biologics unproven

Question 22

What is significant about the respiratory tract?

Answer 22

Designed to expel/repel

Question 23

What air the two types of treatment that should be given to children?

Answer 23

MDI/spacer

Dry powder device

Question 24

What should always be used with an MDI?

Answer 24

A spacer

Question 25

What is the difference between lung deposition with and without a spacer?

Answer 25

<5% lung deposition without spacer

≤20% lung deposition with spacer

Question 26

What reduces static and increases delivery by 100%?

Answer 26

Washing spacer

Shake=2x no shake
Wash = 2 x no wash
MDI/spacer = 4x MDI

Question 27

What shouldn’t be used in primary school children?

Answer 27

Dry powder devices

Use MDI/spacer

Question 28

Should nebulisers be used?

Answer 28

No

Question 29

What is the differences between MDI and Nebuliser?

Answer 29

Quieter
Quicker
Valve mechanism
Don’t break down
Portable
Cheaper

Question 30

What do you do with acute asthma?

Answer 30

Start treatment and reassess in 1 hour

Step up or down as appropriate

Question 31

What is used in chronic/maintenance treatment?

Answer 31

Inhaled steroids

Question 32

What is used in acute treatment?

Answer 32

Oral steroids

Question 33

What are the starters for Asthma? MILD

Answer 33

SABA via spacer

SABA via spacer + pred

Question 34

What are the main treatments for asthma? MODERATE

Answer 34

SABA via ned + pred

SABA + ipsa via ned + pred

Question 35

What are the special treatments for asthma? SEVERE

Answer 35

IV salbutamol
IV aminphylline
IV magnesium (neb)
IV hydrocortisone
Intubate and ventilate

Question 36

How do you choose where to start on patient?

Answer 36

Look at the patient

• Respiratory rate
• Work of breathing
• Heart rate
• Oxygen saturations
• Ability to complete sentences
• Confusion
• Air entry

Question 37

No wheeze =

Answer 37

No asthma