31. Asthma Management in Adults Flashcards
1
Q
What are the bronchiole walls and smooth muscle like in an asthmatic airway that is not suffering from an attack?
A
- relaxed smooth muscle
- walls inflamed and thickened
2
Q
What are the bronchiole walls and smooth muscle like an an asthmatic airway that is suffering from an asthma attack?
A
- tightened smooth muscle (air trapped in alveoli) which is more likely to contract
- walls inflamed and thickened
3
Q
What cells are stimulated when bronchiole walls are inflamed? (3)
A
- TH2 response and cytokines
- mast cells
- eosinophils
4
Q
What two things restrict blood flow to alveoli in asthmatics?
A
- mucus in narrowed airways
2. smooth muscle overreaction and contracting around bronchioles
5
Q
How prevalent is asthma in the UK?
A
~10% of population
6
Q
What percentage of asthma deaths are preventable?
A
around 90%
7
Q
How much does asthma cost NHS?
A
£1 billion a year
8
Q
What investigations are needed for asthma diagnosis? (9)
A
- peak flow monitoring
- spirometry
- bronchodilator reversibility
- blood tests (eosinnophils, IgE)
- allergy tests (skin, blood)
- bronchial hyper-responsiveness
- exhaled NO
- chest x ray in some patients
- challenge testing
9
Q
Does occupational asthma have links with previous asthma history?
A
No, usually only related to work exposure
10
Q
Does work-exacerbated asthma have links with previous asthma history?
A
Yes, symptoms are related to work exposure but there is also prior history of asthma (already has asthma)
11
Q
What bronchodilator drugs are given to treat both acute and chronic asthma? (4)
A
- B2 agonists
- anti-muscarinics
- theophylline
- magnesium and oxygen
12
Q
What anti-inflammatory drugs are given to treat both acute and chronic asthma? (2)
A
- leukotriene RAs
- Monoclonal antbodies
13
Q
What non-pharma methods are there to treat acute asthma attack? (4)
A
- ITU/HDU (intensive therapy or high dependency units)
- ventilation
- ECCO2R
- chest drain if pneumothorax
14
Q
What are non-pharma methods that treat chronic asthma? (7)
A
- asthma action plan
- weight loss if high BMI
- vaccines (flu and pneumonia)
- allergen avoidance (esp. in occupational asthma)
- physiotherapy
- smoking cessation
- bronchial thermoplasty
15
Q
What drugs to ALWAYS avoid in treating any form of asthma? (3)
A
- Beta blockers
- NSAIDS/ aspirin (non-steroid anti-inflammatory drugs)
- sedatives/ strong opiates unless in critical care
16
Q
What are advantages to using inhalers? (5)
A
- small dose of drugs administered
- delivery directly to target organ (airways and lung) since avoids liver metabolism
- onset of effect is faster
- minimal systemic exposure
- systemic adverse effects are less severe and less frequent
17
Q
What are 2 types of inhalers?
A
- pMDI (metered dose inhalers)
2. dry powder inhalers (DPI)
18
Q
How do pMDI inhalers work?
A
they generate aerosol (low inspiratory flow) and need coordination with pressing canister and inhaling
19
Q
What groups of people should not be administered with a pMDI inhaler?
A
elderly and young children who can’t use it effectively
20
Q
What can be added to a pMDI to allow easier use of inhaler especially elderly and children?
A
a spacer
21
Q
What are main advantages of using a spacer? (5)
A
- low oro-pharyngeal deposition of aerosol
- reduced speed of the aerosol
- decreases bad taste associated with oral deposition
- reduced risk of oral candidiasis and dysphonia with steroids
- reduced “cold-Freon effec”t in some
22
Q
How do DPI inhalers work?
A
- high inspiratory flow
- less coordination required
- non-propellenat based and contains solid particles
- patient controls inhalation (but lung function might affect deposition)
23
Q
What types of inhalers contain Salbutamol;SABA? (short acting beta agonists)
A
MDI and DPI
24
Q
What are the 2 SABA drugs used as relievers? (act short term)
A
- Salbutamol
- Terbutaline
25
What types of inhalers contain Terbutaline; SABA?
only DPI
26
What are some of the adverse side effects of Beta 2 agonists? (6)
- tremor
- cramp
- headache
- flushing
- palpitations
- angina
27
Are adverse side effects of Beta 2 agonists more common in oral or inhaled drugs?
More common in oral (it's very rate in inhaled)
28
When are SABA administered to patients?
When they need fast relief (e.g. feeling wheezy after a run)
29
What is the next step of asthma management after SABAs?
Inhaled corticosteroids (preventers)
30
What are some examples of (preventer) inhaled corticosteroids used to prevent asthma? (5)
- beclomethasone
- budesonide
- fluticasone
- ciclesonide
- mometasone
31
When to start patient on inhaled corticosteroids? (5)
- more for long-term management
- when using inhaled B2 agonist (reliever) 3x a week or more
- waking 1 or more nights a week due to asthma
- requiring oral steroid for an exacerbation in the past 2 years
- if patient symptomatic for 3x a week or more
32
What are advantages for using inhaled corticosteroids?
1. low dose
2. delivered to the site of action
3. minimal side effects (normal growth in children ,no bone problems and no adrenal suppression at usual doses)
33
What are some side effects of oral corticosteroids? (6)
- poor wound healing
- high BP
- thin arms and legs
- moon face and red cheeks
- red marks and bruisability
- osteoporosis compressed vertebrae
34
What are some side effects of inhaled corticosteroids? (2)
1. dysphonia (hoarse voice)
| 2. oropharyngeal candidiasis (oral thrush)
35
What is the next asthma management step if corticosteroids don't work?
corticosteroids + LABA (long acting beta agonist)
36
In which inhalers is LABA found in?
Both: pMDI and DPI
37
What is the next form of treatment if corticosteroids + LABA don't work?
high dose of ICS + 4th additional drug (e.g. LTRA, SR theophylline, beta agonsist tablet and LAMA)
38
What are leukotrienes?
One of the cytokines driving the allergic reaction in the airways
39
What are 2 types of LTRAs? (leukotriene receptor antagonist) which are additional drugs to high dose of ICS
1. montelukast
| 2. zafirlukast
40
What is the main advantage of using LTRAs?
They are more effective in those who are highly allergic (but response is difficult to predtict)
41
What is the trial length for s LTRA trial?
Worth a 6-12 week trial
42
What type of medicine is theophylline?
Non-specific phosphodiesterase inhibitor and adneosine receptor agonist
43
What are the disadvantages of using theophylline? (4)
- weak bronchodilator
- many strong side effects
- narrow therapeutic range
- unpredictable metabolism; interacts with many drugs
44
What are some side effects from theophylline? (12)
- anorexia
- headache
- nausea
- malaise
- vomiting
- nervousness
- abdominal discomfort
- insomnia
- tachycardia
- tachyarrhythmias
- convulsions
45
What is LAMA?
- (inhaled) long acting anti-muscarinic
| - tiotropium bromide (via spiriva respimat device)
46
What does LAMA anatgonise?
M3 muscarinic acetylcholine receptor in bronchial smooth muscle (parasympathetic ANS is responsible for constriction so antagonist will stimulate dilation needed for asthma)
47
Using LAMA with what shows little evidence of benefit when treating asthma with it?
Using LAMA when added to ICS/LABA to benefit asthma
48
What are some side effects of using LAMA?
- dry mouth
- GI upset
- headaches
- can rarely precipitate angle-closure glaucoma (ophthalmological emergency)
49
What is the next step of treatments if high dose of ICS + 4th drug doesn't work?
Continuous or frequent use of oral steroids ( high dose ICS _ daily steroid tablet in lowest dose to provide adequate control of symptoms)
50
What is the main steroid name for the oral steroid treatment?
Prednisolone
51
What should patients have with them if they are on oral steroids?
steroid alert card
52
When should abrupt cessation of oral steroids happen?
if on steroids for> 3 weeks
53
What can occur if oral steroids are abruptly stopped?
acute adrenal insufficiency (failure of adrenal glands to produce endogenous glucocorticoid) which can be fatal or result in unconsciousness
54
Why are oral steroids the LAST therapeutic method that should be used to treat asthma?
because its side effects are very bad
55
What are side effects of inhaled long term oral steroids? (2)
1. dysphonia (difficulty in speaking)
| 2. oropharyngeal condidiasis (oral thrush)
56
What are some side effects of oral long term steroids? (9)
- red cheeks
- moon face
- bruisability ecchymoses
- red striation on skin
- pendulous abdomen
- poor wound healing
- thin arms and legs
- high BP
- fat pads (buffalo hump)
57
What is an anti-IgE injection used for IgE mediated severe allergic asthma? (difficult asthma clinics)
Omalizumab (anti-IgE) which is a monoclonal antibody (mab) against IgE
58
What is an anti-interleukin-5 injection used for poor asthma control patients in difficult asthma clinics?
Mepolizumab (anti-interleukin-5) which is a monoclonal antibody (mab) against inter-leukin 5
59
What needs to be elevated in patients to be administered mepolizumab (anti-interleukin 5)?
elevated blood eosinophilia (patients have poor asthma control and are on long term steroid or frequent steroid)
60
What are "steroid-sparing" drugs used in patients to treat asthma? What are some examples?
Immune suppressive drugs (more often used in rheumatoid arthritis and in organ transplant recipients)
eg. methotrexate, ciclosporin and oral gold
61
Why are steroid-sparing drugs used as a last resort?
can have significant side effects and are not favourable options
62
What are some non-harmacological approaches to managing asthma? (8)
1. patient education and self management plans
2. inhaler technique
3. smoking cessation
4. flu/pneumococcal vaccinations
5. co-morbidities
6. stepping down treatment when controlled
7. allergen avoidance (occupational asthma)
8. bronchial thermoplasty
63
If a patient doesn't get better once treatment is administered, what must always be checked before trying therapies with more serious side effects?
always check patient's inhaler technique before changing treatment plans
64
What are common co-morbidities associated with asthma? (3)
1. obesity
2. allergic rhinitis
3. GORD (gastro-oesophageal disease)
65
What is considered to be moderate asthma? (3)
1. increasing symptoms
2. peak exp. flow> 50-75% best or predicted
3. no features of acute severe asthma
66
What is considered to be acute severe asthma? (4)
Any one of:
1. PEF 33-50% best or predicted
2. resp. rate >=25/min
3. heart rate >=110/ min
4. inability to complete sentences in one breath
67
What is considered to be life-threatening asthma? (7)
Any one of:
1. altered conscious level (PEF <33% best or predicted)
2. exhaustion (SpO2<92%)
3. arrhythmia (PaO2<8kPa)
4. hypotension (normal PCO2; 4.6-6kPA)
5. cyanosis
6. silent chest
7. poor respiratory chest
68
What are the treatment steps for acute asthma-mild/moderate asthma? (5)
1. oral predisolone (0.5mg/kg.day) for 7 days
2. SABA (relievers), more frequently and up to 2 hours
3. in some cases, increases in ICS/LABA dose as well
4. assess within 24 hours
5. advice immediate medical help if detoriarating
69
What are the treatment steps for acute asthma-sevee asthma?
1. admission to hospiral
2. oral/ IV steroids
3. nebulised bronchodilators- Salbutamol (SABA)/ Ipratropium (SAMA)
4. oxygen (target saturation (94-98%) consider ABG
70
Why are NEBULISED bronchodilators used?
to help patients administer medication even when they find it difficult to breathe
71
If patient with severe asthma has no response to oral/IV steroids, oxygen or any other bronchodilators on admission to hospital, what can be considered?
Consider IV MgSO4 if no response
72
If patient with asthma suffers from pneumonia/bacterial infection, what is administered?
antibiotics
73
What investigation is needed if patient with asthma is experiencing a pneumothorax? (2)
chest x ray and chest drain if unwell (severe condition)
74
What is done at the Intensive Therapy unit (ITU) in hospital with senior medical staff involved if patient's asthma is life threatening in serious circumstances?
- may need anaesthesia, intubation and ventilation in ITU
| - in extreme cases, ECCO2R may be life saving (extracorporeal CO2 removal)
