3. Asthma Flashcards
Medical emergency in Community
Respiratory
Acute asthma
Anaphylaxis
Severe Croup
What is asthma
Asthma is caused by swelling (inflammation) of the breathing tubes that carry air in and out of the lungs. This makes the tubes highly sensitive, so they temporarily narrow. It may occur randomly or after exposure to a trigger.
Asthma
Symptoms
wheezing (a whistling sound when breathing)
breathlessness
a tight chest – it may feel like a band is tightening around it
coughing at night & early morning
Asthma
Step 1
REGULAR PREVENTERS
Low dose ICS
Start at BD then OD if good control
Memetasone Fluticasone Beclomethasone Budesonide Ciclesonide
ALTERNATIVELY
🟢 leukotriene receptor antagonist (Montelukast) 🟢theophylline 🟢inhaled sodium cromoglicate 🟢inhaled nedocromil
Give a drug name
leukotriene receptor antagonist
Montelukast
To be taken ON
Montelukast
MHRA warning on SE
Can cause:
neuropsychiatric reactions
sleep disturbances,
depression and agitation (1 in 100)
disturbances of attention /memory (up to 1 in 1,000)
very rarely, hallucinations and suicidal behaviour (up to 1 in 10,000 people).
ICS
SE
Headache;
oral candidiasis;
pneumonia (in patients with COPD); taste altered;
voice alteration
Uncommon Anxiety; bronchospasm paradoxical; cataract; vision blurredpp
Asthma
Step 2
ADD to initial Tx (low dose ICS)
LABA:
Formoterol
Salmeterol
LABA
SE
Arrhythmias; cardiovascular disease; diabetes (risk of hyperglycaemia and ketoacidosis, especially with intravenous use); hypertension; hyperthyroidism; hypokalaemia; susceptibility to QT-interval prolongation
Cautions, further information
Hypokalaemia
Potentially serious hypokalaemia may result from beta2 agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, diuretics, and by hypoxia.
Asthma
Step 3
A) LABA not effective: STOP and increase dose ICS
B) LABA effective but asthma not adequately controlled : continue LABA & increase ICS to medium
C) LABA effective but asthma not controlled adequately: continue LABA and trial:
Montelukast (LTRA) Or Toitropium (LAMA) Or SR theophylline
Asthma
Step 4
Persistent poor control
ADD:
A) Oral drug:
Montelukast
SR theophylline
MR beta2 agonist (bambuterol)
Tiotropium bromide
B) ⬆️ dose ICS + spacer
2000mcg beclomethasone or equivalent
Still no control?
Specialist
Asthma
Step 5
ADD
Regular oral
Corticosteroids: prednisolone OM
Continue taking ⬆️dose ICS
Specialist referral if still poor control
What do
beta 2 agonists do
List a few
Bronchodilators of the bronchi
salbutamol
salmeterol
formoterol
vilanterol
Difference between
salmeterol
And
salbutamol
duration of action.
Salmeterol lasts 12 hours LABA
salbutamol lasts about 4–6 hours SABA
Salbutamol
(blue inhaler)
A SA bronchodilator, reliever
Usual dosage ?
Up to QDS prn
SABA
Short Acting beta2 agonist
Name 2
Salbutamol
Or
Terbutaline
Onset 5mints
Duration:4-6hrs
When to refer pt to Gp if no relief on a SABA
How many hours?
If SABA fails to relief for atleast 3 hours
LABA
Long Acting Beta-2 agonists
List
ASTHMA
Salmeterol
Formoterol
Most common used in asthma
LABA
Long Acting Beta-2 agonists
List
COPD
Formoterol
Indacaterol
Olodaterol
Vilanterol
SABA
&
LABA
SE
Arrhythmias; headache; hypokalaemia (with high doses); muscle spasms; nasopharyngitis; nausea; palpitations; rash; tremor
SABA
monitoring
In severe asthma, plasma-potassium concentration should be monitored (risk of hypokalaemia).
In patients with diabetes, monitor blood glucose (risk of hyperglycaemia and ketoacidosis, especially when beta2 agonist given intravenously).
Long Acting Muscarinic Antagonist (LAMA)
List
Tiotropium OD
Glycopyrronium bromide OD
Aclidnium BD
LAMA
SE
Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea, blurred vision, glaucoma
Short Acting Muscarinic Antagonist (SAMA)
List
Ipratropium
Asthma & COPD
SAMA
DURATION
Onset: within 20 mints
Duration 4 hrs
SAMA
SE
Most common
Dry mouth 💋
Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea
Bambuterol
Indication
Long acting bronchi dilator
Used in asthma step 4
To be taken ON
LABA + ICS
Not to be used :
Alone
In rapidly deteriorating asthma
Best to be used in nocturnal asthma
LABA
Inhalers containing
Formoterol therefore can be used as a reliever
(4)
Fostair
DuoResp
Spiromax
Symbicort
LABA
SABA
Can cause cardiovascular events therefore what has to told to pt or on RX
The dose frequency
And MAX dose puffs in 24hrs
Usually when hyperglycaemia is present ….. is also present
HypOkalaemia
Hypoxia can cause
HypOkalaemia
HypOkalaemia
Symptoms
Weakness and Fatigue.
Muscle Cramps and Spasms Muscle cramps are sudden contractions of the muscles Digestive Problems Heart Palpitations Muscle Aches and Stiffness Tingling and Numbness Breathing Difficulties Mood Changes
Most common
ICS
List & dosing
Beclometasone
Budesonide
Fluticasone
All Taken BD
Except
Ciclesonide OD
Mometasone BD or OD
ICS
How do they work
Preventers
Take 3-4 weeks to work
Beclometasone available
As DRY powder inhaler (DPI)
Brands include:
Pulvernal
Beclometasone easy haler
Beclometasone available as
CFC-free inhalers
Must be prescribed by brand name sue to potency
List both
QVAR is twice as potent as
Clenil Modulite
Potency of inhalers
Put them in Oder of most potent :
QVAR
Fostair
CFC containing beclometasone inhalers
Clenil module
- Fostair
- QVAR
- Clenil module
- CFC containing beclometasone inhalers
Minimum age
For
Beclometasone easyhaler
18+
Minimum age
For
QVAR
12 +
Minimum age
For
High dose Clenil Modulite 200 or 250
12+
An indication of incorrect inhalation technique
List 2
Hoarse voice
Sore throat
Oral thrush
What is
Oropharyngeal deposition
Drugs in mouth or back of throat due to poor inhalation technique
NICE recommends
Using a spacer with pressurised metered dose inhalers
for patients under…… years.
15
What is
Paradoxical bronchospasm
And they can be caused by what?
Paradoxical bronchospasm is the unexpected constriction of smooth muscle walls of the bronchi that occurs in the setting of an expected bronchodilatory response
ICS
It it does happen, stop and use alternative
Mild
(Paradoxical)bronchospasm
Can be avoided by:
By using SABA before an ICS
Transferring from pMDI to a dry powder inhaler
Smoking and ICS
increase or decrease dose?
Increase dose
Do patients on ICS need a steroid card?
Only if they are on HIGH doses; especially those on unlicensed high doses
Leukotriene receptor antagonists
Montelukast
Or
Zafirlukast
Indication
Withdrawal side effect with on Corticosteroids
Chronic asthma
Systematic relief of hayfever in asthma
SE: churg strauss syndrome
What is
Churg strauss syndrome
Churg-Strauss syndrome
is a disease characterized by inflammation of the blood vessels.
Churg-Strauss syndrome occurs in patients with a history of asthma or allergy.
Symptoms of Churg-Strauss syndrome include fatigue, weight loss, nasal passage inflammation, numbness, and weakness
It occurs on withdrawal or reduction of an concomitant ORAL corticosteroids
Zafirlukast
SE
Hepatotoxic
Pts have to report symptoms of liver toxicity
Abdominal Pain, itch, N+V, jaundice
What is theophylline
Given to who?
Antimuscarinic
Xanthine bronchodilator
Acute and chronic asthma
Chronic COPD
What are the ingredients in
Aminophylline
Theophylline
+
Ethylenediamine
Given by injection as it’s 20 x more soluble give IV
Not given IM as it’s irritating: AVOID
Therapeutic range
Of theophylline
10-20m/L (55-110 mmol/L)
Sample 4-6hrs after dose
Theophylline
Warning signs
(Report STAT to dr)
Toxicity
(Vomiting, dilated puplis,arrhythmia, restless, agitation, hyperglycaemia)
Symptoms of uncontrolled asthma
(Cough,wheeze,tight chest)
Frequent courses of antibiotics and corticosteroids
(Shows poor asthma control)
Theophylline
Pregnancy
Benefit outweighs risk
Continue taking as normal with monitoring
Theophylline
Branding
MR preps have to be prescribed as brand
as different brands have different bioavailability
(If brand not specified contact prescriber)
Theophylline
Monitoring
2
Potassium
Theophylline concentration
Normal potassium level
3.5 and 5.5mmol/L
In healthy patients
Theophylline
Cautions
Cardiac arrhythmias or other cardiac disease; elderly (increased plasma-theophylline concentration) (in adults); epilepsy; fever; hypertension; peptic ulcer; risk of hypokalaemia; thyroid disorder
Theophylline
SE
Anxiety; arrhythmias; diarrhoea; dizziness; gastrointestinal discomfort; gastrooesophageal reflux disease; headache; hyperuricaemia; nausea; palpitations; seizure; skin reactions; sleep disorders; tremor; urinary disorders; vomiting
Side-effects, further information
Potentially serious hypokalaemia may result from beta2-agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, and diuretics, and by hypoxia. Plasma-potassium concentration should therefore be monitored in severe asthma.
Severe asthma
Theophylline
Monitoring potassium level is essential!
Major SE hypokalaemia
Theophylline
Medicine causing
Increased plasma concentration
7
Diltiazem
Verapamil
Cimetidine
Ciprofloxacin
Erythromycin
Clarithromycin
Fluvoxamine
Oestrogen
Theophylline
Conditions that cause increase plasma concentration of theophylline 4
Elderly
HF
Viral infection
Hepatic impairment
Enzyme inhibitors
Theophylline
Reduce plasma concentration
8
Alcohol Smoking Enzyme inducers Carbamazepine Primidone Phenobarbital Phenytoin Ritonavir
Theophylline
And
smoking
Decreases theophylline concentration
Dose adjustment may be necessary
Inform dr if you want to start or stop smoking
Continue smoking while on theophylline
Theophylline
+
What drug classes (4)
causes:
HypOkalaemia
As major SE
Loop diuretics
Thiazides diuretics
Corticosteroids
Beta2 agonist
Theophylline
+
?
Increased risk of seizures
Ciprofloxacin
Main Tx acute asthma
Short acting bronchodilators
&
Oral Corticosteroids
Tx
acute asthma (ALTERNATIVE)
Short-acting beta-agonists (SABAs)
Salbutamol/terbutaline
Salbutamol by nebuliser (better drug delivery to the lungs 🫁 (O2 driven as BA have a SE atrial hypoxia)
If symptoms persist after 12-30 mints
999
A short course of oral corticosteroids given as a single dose OM
Beta 2 agonist
SE
Atrial hypoxia
Acute Asthma
12 year old on oral corticosteroids
Max days?
And for adults?
Up to max 3 days
Adults? Atleast 5 days 40-50mg OM
Prednisolone for acute asthma
When is gradual withdrawal required?
Can be stopped abruptly
Gradual withdrawal only required if used oral corticosteroids arte taken for more than 3 weeks
After acute attack
Asthma meds have to be reviewed
