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Systems: Resp. WK > 31. Asthma Management in Adults > Flashcards

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

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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
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3
Q

What cells are stimulated when bronchiole walls are inflamed? (3)

A
  • TH2 response and cytokines
  • mast cells
  • eosinophils
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4
Q

What two things restrict blood flow to alveoli in asthmatics?

A
  1. mucus in narrowed airways

2. smooth muscle overreaction and contracting around bronchioles

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5
Q

How prevalent is asthma in the UK?

A

~10% of population

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6
Q

What percentage of asthma deaths are preventable?

A

around 90%

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7
Q

How much does asthma cost NHS?

A

£1 billion a year

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8
Q

What investigations are needed for asthma diagnosis? (9)

A
  1. peak flow monitoring
  2. spirometry
  3. bronchodilator reversibility
  4. blood tests (eosinnophils, IgE)
  5. allergy tests (skin, blood)
  6. bronchial hyper-responsiveness
  7. exhaled NO
  8. chest x ray in some patients
  9. challenge testing
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9
Q

Does occupational asthma have links with previous asthma history?

A

No, usually only related to work exposure

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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)

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11
Q

What bronchodilator drugs are given to treat both acute and chronic asthma? (4)

A
  • B2 agonists
  • anti-muscarinics
  • theophylline
  • magnesium and oxygen
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12
Q

What anti-inflammatory drugs are given to treat both acute and chronic asthma? (2)

A
  • leukotriene RAs

- Monoclonal antbodies

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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
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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
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15
Q

What drugs to ALWAYS avoid in treating any form of asthma? (3)

A
  1. Beta blockers
  2. NSAIDS/ aspirin (non-steroid anti-inflammatory drugs)
  3. sedatives/ strong opiates unless in critical care
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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
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17
Q

What are 2 types of inhalers?

A
  1. pMDI (metered dose inhalers)

2. dry powder inhalers (DPI)

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18
Q

How do pMDI inhalers work?

A

they generate aerosol (low inspiratory flow) and need coordination with pressing canister and inhaling

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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

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20
Q

What can be added to a pMDI to allow easier use of inhaler especially elderly and children?

A

a spacer

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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
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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)
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23
Q

What types of inhalers contain Salbutamol;SABA? (short acting beta agonists)

A

MDI and DPI

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24
Q

What are the 2 SABA drugs used as relievers? (act short term)

A
  • Salbutamol

- Terbutaline

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25
Q

What types of inhalers contain Terbutaline; SABA?

A

only DPI

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26
Q

What are some of the adverse side effects of Beta 2 agonists? (6)

A
  • tremor
  • cramp
  • headache
  • flushing
  • palpitations
  • angina
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27
Q

Are adverse side effects of Beta 2 agonists more common in oral or inhaled drugs?

A

More common in oral (it’s very rate in inhaled)

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28
Q

When are SABA administered to patients?

A

When they need fast relief (e.g. feeling wheezy after a run)

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29
Q

What is the next step of asthma management after SABAs?

A

Inhaled corticosteroids (preventers)

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30
Q

What are some examples of (preventer) inhaled corticosteroids used to prevent asthma? (5)

A
  • beclomethasone
  • budesonide
  • fluticasone
  • ciclesonide
  • mometasone
31
Q

When to start patient on inhaled corticosteroids? (5)

A
  • 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
Q

What are advantages for using inhaled corticosteroids?

A
  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
Q

What are some side effects of oral corticosteroids? (6)

A
  • poor wound healing
  • high BP
  • thin arms and legs
  • moon face and red cheeks
  • red marks and bruisability
  • osteoporosis compressed vertebrae
34
Q

What are some side effects of inhaled corticosteroids? (2)

A
  1. dysphonia (hoarse voice)

2. oropharyngeal candidiasis (oral thrush)

35
Q

What is the next asthma management step if corticosteroids don’t work?

A

corticosteroids + LABA (long acting beta agonist)

36
Q

In which inhalers is LABA found in?

A

Both: pMDI and DPI

37
Q

What is the next form of treatment if corticosteroids + LABA don’t work?

A

high dose of ICS + 4th additional drug (e.g. LTRA, SR theophylline, beta agonsist tablet and LAMA)

38
Q

What are leukotrienes?

A

One of the cytokines driving the allergic reaction in the airways

39
Q

What are 2 types of LTRAs? (leukotriene receptor antagonist) which are additional drugs to high dose of ICS

A
  1. montelukast

2. zafirlukast

40
Q

What is the main advantage of using LTRAs?

A

They are more effective in those who are highly allergic (but response is difficult to predtict)

41
Q

What is the trial length for s LTRA trial?

A

Worth a 6-12 week trial

42
Q

What type of medicine is theophylline?

A

Non-specific phosphodiesterase inhibitor and adneosine receptor agonist

43
Q

What are the disadvantages of using theophylline? (4)

A
  • weak bronchodilator
  • many strong side effects
  • narrow therapeutic range
  • unpredictable metabolism; interacts with many drugs
44
Q

What are some side effects from theophylline? (12)

A
  • anorexia
  • headache
  • nausea
  • malaise
  • vomiting
  • nervousness
  • abdominal discomfort
  • insomnia
  • tachycardia
  • tachyarrhythmias
  • convulsions
45
Q

What is LAMA?

A
  • (inhaled) long acting anti-muscarinic

- tiotropium bromide (via spiriva respimat device)

46
Q

What does LAMA anatgonise?

A

M3 muscarinic acetylcholine receptor in bronchial smooth muscle (parasympathetic ANS is responsible for constriction so antagonist will stimulate dilation needed for asthma)

47
Q

Using LAMA with what shows little evidence of benefit when treating asthma with it?

A

Using LAMA when added to ICS/LABA to benefit asthma

48
Q

What are some side effects of using LAMA?

A
  • dry mouth
  • GI upset
  • headaches
  • can rarely precipitate angle-closure glaucoma (ophthalmological emergency)
49
Q

What is the next step of treatments if high dose of ICS + 4th drug doesn’t work?

A

Continuous or frequent use of oral steroids ( high dose ICS _ daily steroid tablet in lowest dose to provide adequate control of symptoms)

50
Q

What is the main steroid name for the oral steroid treatment?

A

Prednisolone

51
Q

What should patients have with them if they are on oral steroids?

A

steroid alert card

52
Q

When should abrupt cessation of oral steroids happen?

A

if on steroids for> 3 weeks

53
Q

What can occur if oral steroids are abruptly stopped?

A

acute adrenal insufficiency (failure of adrenal glands to produce endogenous glucocorticoid) which can be fatal or result in unconsciousness

54
Q

Why are oral steroids the LAST therapeutic method that should be used to treat asthma?

A

because its side effects are very bad

55
Q

What are side effects of inhaled long term oral steroids? (2)

A
  1. dysphonia (difficulty in speaking)

2. oropharyngeal condidiasis (oral thrush)

56
Q

What are some side effects of oral long term steroids? (9)

A
  • 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
Q

What is an anti-IgE injection used for IgE mediated severe allergic asthma? (difficult asthma clinics)

A

Omalizumab (anti-IgE) which is a monoclonal antibody (mab) against IgE

58
Q

What is an anti-interleukin-5 injection used for poor asthma control patients in difficult asthma clinics?

A

Mepolizumab (anti-interleukin-5) which is a monoclonal antibody (mab) against inter-leukin 5

59
Q

What needs to be elevated in patients to be administered mepolizumab (anti-interleukin 5)?

A

elevated blood eosinophilia (patients have poor asthma control and are on long term steroid or frequent steroid)

60
Q

What are “steroid-sparing” drugs used in patients to treat asthma? What are some examples?

A

Immune suppressive drugs (more often used in rheumatoid arthritis and in organ transplant recipients)
eg. methotrexate, ciclosporin and oral gold

61
Q

Why are steroid-sparing drugs used as a last resort?

A

can have significant side effects and are not favourable options

62
Q

What are some non-harmacological approaches to managing asthma? (8)

A
  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
Q

If a patient doesn’t get better once treatment is administered, what must always be checked before trying therapies with more serious side effects?

A

always check patient’s inhaler technique before changing treatment plans

64
Q

What are common co-morbidities associated with asthma? (3)

A
  1. obesity
  2. allergic rhinitis
  3. GORD (gastro-oesophageal disease)
65
Q

What is considered to be moderate asthma? (3)

A
  1. increasing symptoms
  2. peak exp. flow> 50-75% best or predicted
  3. no features of acute severe asthma
66
Q

What is considered to be acute severe asthma? (4)

A

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
Q

What is considered to be life-threatening asthma? (7)

A

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
Q

What are the treatment steps for acute asthma-mild/moderate asthma? (5)

A
  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
Q

What are the treatment steps for acute asthma-sevee asthma?

A
  1. admission to hospiral
  2. oral/ IV steroids
  3. nebulised bronchodilators- Salbutamol (SABA)/ Ipratropium (SAMA)
  4. oxygen (target saturation (94-98%) consider ABG
70
Q

Why are NEBULISED bronchodilators used?

A

to help patients administer medication even when they find it difficult to breathe

71
Q

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?

A

Consider IV MgSO4 if no response

72
Q

If patient with asthma suffers from pneumonia/bacterial infection, what is administered?

A

antibiotics

73
Q

What investigation is needed if patient with asthma is experiencing a pneumothorax? (2)

A

chest x ray and chest drain if unwell (severe condition)

74
Q

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?

A
  • may need anaesthesia, intubation and ventilation in ITU

- in extreme cases, ECCO2R may be life saving (extracorporeal CO2 removal)

Systems: Resp. WK (40 decks)

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