Adult Asthma Management Flashcards
What investigations can be carried out in the diagnosis of asthma?
- Peak flow monitoring
- Spirometry
- Bronchodilator reversibility
- Blood tests
- Allergy tests
- Bronchia; hyper-responsiveness
- Exhaled NO
- CXR in some patients
- Challenge testing
What is occupational asthma?
- Symptoms related to work exposure
- No prior history of asthma
What is work exacerbated asthma?
- Symptoms related to work exposure
- Prior history of asthma
What non-pharmacological management is there for acute asthma attack?
- ITU/HDU
- Ventilation
- ECCO2R
- Chest drain if pneumothorax
What non-pharmacological management is there for chronic asthma?
- Asthma action plan
- Weight loss if high BMI
- Vaccines
- Allergen avoidance
- Physiotherapy
- Smoking cessation
- Bronchial thermoplasty
What drugs should be avoided in asthma?
- Beta blockers
- NSAIDs/aspirin
- Sedatives/ strong opiates unless in critical care
What bronchodilators are used in asthma management?
- B2 agonists (b)
- Anti-muscarinincs (b)
- Theophyllines (b)
- Magnesium (a)
What anti-inflammatories are used in asthma management?
- Steroids (b)
- Leukotriene RAs (c)
- Monoclonal Abs (c)
Why are inhalers used in chronic asthma management?
- Small doses
- Delivery directly to the target organ
- Onset of effect is faster
- Minimal systemic exposure
- Systemic adverse effects are less severe and less frequent
Describe the use of pMDI.
- Needs co-ordination
- Elderly, young children and the unwell can’t use effectively
- Generates aerosol: low inspiratory flow
What are the advantages of using pMDI with a spacer?
- Low oro-pharnygeal 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
Describe the use of DPI.
- Patient generates aerosol: high inspiratory flow
- Less coordination required
- Similar issues with deposition
What is 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 limitation on activity and normal lung function
- Minimal side effects
What forms do SABA relievers come in?
- Salbutamol as MDI or DPI
- Terbutaline as DPI
What are the adverse effects of oral B2 agonists?
- Tremor
- Cramp
- Headache
- Flushing
- Palpitations
- Angina
What ICS preventers are there?
- Beclomethasone
- Budesonide
- Fluticasone
- Ciclesonide
- Mometasone
When should ICS be started?
- Using inhaled B2 agonist 3x or more per week
- Waking 1x or more a week due to asthma
- Requiring oral steroid for an exacerbation in the past 2 years
- Symptomatic 3x or more a week
What are the advantages of ICS?
- Low dose
- Delivered to the site of action
- Minimal side effects
What are the long term effects of inhaled steroids?
- Dysphonia
- Oropharyngeal candidiasis
What are the long term effects of oral steroids?
- Red cheeks
- Fat pads
- Thin skin
- Hypertension
- Thin limbs
- Moon face
- Bruisability ecchymoses
- Red striations
- Pendulous abdomen
- Osteoporosis
- Poor wound healing
What ICS and LABA combinations are there?
- Fostair (pMDI + DPI)
- Symbicort (DPI)
- DuoResp SpiroMax (DPI)
- Flutiform (pMDI)
- Seretide (pMDI + DPI)
- Relvar Ellipta (DPI)
What LTRA are there?
- Montelukast
- Zafirlukast
What is important about LTRA?
- More effective in those highly allergic
- Response is difficult to predict
- Worth a 6-12 week trial in some patients
What is theophylline?
- Non specific phosphodiesterase inhibitor and adenosine receptor antagonist
- Weak bronchodilator
What are the side effects of theophylline?
- Anorexia
- Headache
- Nausea
- Malaise
- Vomiting
- Nervousness
- Abdominal discomfort
- Insomnia
- Tachycardia
- Tachyarrhythmias
- Convulsions
What are the disadvantages of theophylline?
- Narrow therapeutic window
- Unpredictable metabolism- interact with many drugs
What is the most common form of LAMA?
Tiotropium bromide via Spiriva Respimat device
What do LAMAs do?
Antagonise muscarinic acetylcholine receptor in bronchial smooth muscle
What are the side effects of LAMAs?
- Dry mouth
- GI upset
- Headaches
- Can rarely precipitate angle-closure glaucoma
What is the main long term oral steroid?
Prednisolone
What can happen if prednisolone is suddenly stopped after 3+ week use?
-Acute adrenal insufficiency
What is omalizumab?
Monoclonal antibody against IgE
What is mepolizumab?
Monoclonal antibody against interleukin-5
When is mepolizumab usually started?
Poor asthma control with blood eosinophilia
What examples of immune suppressive drugs are there?
- Methotrexate
- Ciclosporin
- Oral gold
Why are immune suppressive drugs often used as a last resort?
They can have significant side effects
What non-pharmacological measures are there?
- Patient education and self management plans
- Inhaler technique
- Smoking cessation
- Flu/ pneumococcal vaccinations
- Allergen avoidance
- Bronchial thermoplasty
What non-pharmacological management is there for occupational asthma?
Prompt removal from inhalation exposure
What is the management for mild/moderate acute asthma?
- Oral prednisolone (0.5mg/kg/day) for 7 days
- SABA up to 2 hourly
- Increase ICS/LABA dose
- Assess within 24 hours
- Advice immediate medical help if deteriorating
What is the management for severe acute asthma?
- Admission to hospital
- Oral/ IV steroids
- Nebulised bronchodialators- SABA/SAMA
- Oxygen
- Consider IV MgSo4 if no response
- Antibiotic is infection
- CXR
- May require ITU, intubation and ventilation or ECCO2R
