Airways disease, obstructive Flashcards
Lifestyle changes include:
weight loss, stopping smoking and breathing exercise programmes (as an adjuvant to drug treatment) to improve quality of life + reduce symptoms.
NICE guidance >17 years:
SABA (salbutamol or terbutaline) as intermittent reliever therapy
- Refer if using >1 SABA inhaler in 1 month
1) Low dose ICS if patient using SABA >3x weekly, symptomatic >3x weekly, night take awakeness due to asthma
2) LTRA + low dose ICS. Review in 4-8 weeks
3) LABA + low dose ICS, remove LTRA if necessary
4) Consider above as MART regimen
5) Moderate dose ICS
6) High dose ICS or LAMA/theophylline
BTS/SIGN guidance >12 years:
SABA as required unless using MART
1) Low Dose ICS
2) Add LABA to low dose ICS (fixed or MART)
3) Increase ICS to medium dose, consider addign LTRA, if no response to LABA stop LABA and consider ICS alone
4) Refer to specialist
Management of Chronic asthma (Adults and children over 5 years)
1st Line: Inhaled short-acting beta2 agonist (e.g. Salbutamol) used as required.
When to move from step 1 treatment to step 2
If patient presents with any one of the following: using inhaled beta2 agonist 3 times a week or more, being symptomatic 3 times a week or more, waking at night due to asthma at least once a week or had an asthma attack in the last 2 years MOVE TO STEP 2
Management of Chronic asthma (Adults and children over 5 years) - step 2
ADD a Low dose ICS (e.g. Beclometasone, Budesonide, Fluticasone, Mometasone).
- Fluticasone and Mometasone provide equal clinical activity to Beclometasone and Budesonide at HALF the dosage
- ICS should be taken initially TWICE daily, however the same TOTAL dose can be taken ONCE daily if good control is established.
In children, administration of high doses of ICS may be associated with
growth failure, reduced bone mineral density and adrenal suppression.
Management of Chronic asthma (Adults and children over 5 years) - step 3
ADD a Long-acting beta2 agonist (LABA) such as formoterol or salmeterol to be used in conjunction with the ICS.
- If the patient is gaining some benefit from addition of LABA but control is inadequate, then continue LABA and dose of ICS to medium dose.
- If there is no response to the LABA, discontinue and dose of ICS.
- If control is still INADEQUATE, start a trial of either a leukotriene receptor antagonist (e.g. Montelukast),
Management of Chronic asthma (Adults and children over 5 years) - step 4
modified-release Theophylline, or modified-release oral beta2 agonist. Leukotriene receptor antagonists are the preferred option in children.
- Before proceeding to Step 5, refer patients with inadequately controlled asthma to specialist care
• STEP 5:
ADD a regular oral corticosteroid (Prednisolone as a single daily dose) at lowest dose to provide adequate control
- Continue high dose ICS
Management of Asthma in Pregnancy and Breastfeeding
- When good control of asthma is achieved, it has no important effects on pregnancy, labour or on the fetus.
- Drugs for asthma should preferably be administered by inhalation to minimise exposure to the fetus.
- All drugs can be taken as normal during pregnancy, however there is limited information on the use of leukotriene receptor antagonists, but they can be taken if the benefit outweighs the risk.
- Drugs for asthma including corticosteroid tablets can be used in line with the manufacturer’s recommendation in breast feeding.
Exercise-induced asthma
If exercise is a specific problem in patients already taking ICS who are otherwise well controlled consider adding either a Leukotriene receptor antagonist, LABA, an oral beta2 agonist, sodium cromoglicate/nedocromil sodium or Theophylline.
drug of choice before exercise
An inhaled short-acting beta2 agonist used immediately
Moderate-acute asthma
- Increasing symptoms
- Peak flow >50-75% of best/predicted
- No features of Severe-acute asthma
Severe-acute asthma (any one of the following)
- Peak flow 33-50% of best/predicted
- Respiratory rate >25 breaths/min
- Heart rate >110 beats/min
- Inability to complete sentences in one breath
Life-threatening acute asthma (any one of the following)
• Peak flow <33% of best/predicted
- Exhaustion
• Partial arterial pressure of oxygen (PaO2) <8kPa
• Altered conscious level
- Cyanosis
• Arterial oxygen saturation (SpO2) <92% - Hypotension
• Normal PaCO2 (4.6-6kPa)
- Silent chest
- Arrythmia
Near-fatal acute asthma
• Raised PaCO2 requiring mechanical ventilation with raised inflation pressures or both
• First-line treatment for acute asthma
a high-dose inhaled short-acting beta2 agonist (Salbutamol) given as soon as possible.
- If the patient is non-life threatening a pMDI with a spacer is preferred.
- If the patient is life-threatening a beta2 agonist administered by an oxygen-driven nebuliser is recommended.
• Supplementary oxygen
• Supplementary oxygen should be given to all hypoxemic patients with acute-severe asthma to maintain SpO2 levels between 94 - 98%.
• If the response to the initial dose of short-acting beta2 agonist is POOR, consider
continuous nebulisation with a nebuliser.
In all cases of acute asthma, patients should be prescribed
an adequate dose of oral prednisolone ONCE daily for 5 days (3 days in children) or until recovery.
- Take PO as single dose in morning to reduce disturbance to circadian cortisol secretion
If patient cannot take PO prednisolone, consider
parenteral hydrocortisone or IM methylprednisolone
acute-severe or life-threatening asthma or those with a poor initial response to beta2 agonist.
• Nebulised Ipratropium bromide may be combined with a nebulised beta2 agonist in patients with acute-severe or life-threatening asthma or those with a poor initial response to beta2 agonist.
- The combination provides greater BRONCHODILATION.
may also be used (senior medical staff).
• Magnesium sulfate (bronchodilator) + Aminophylline
Bronchodilators examples
SABA: Salbutamol, Terbutaline.
LABA: Formoterol, Salmeterol, Indacaterol, Olodaterol, Vilanterol
Short-acting beta2 agonists
- Inhalation of a selective SABA (Salbutamol) can rapidly treat mild-moderate symptoms of asthma.
Long-acting beta2 agonists
- LABA’s have a role in the long-term management of asthma + can be useful in nocturnal asthma.
Salmeterol should not be used for an asthma attack due to its slower onset of action. Formoterol is licensed for short-term symptom relief and for the prevention of exercise-induced bronchospasm. - Combination inhalers that contain a LABA + Corticosteroid (e.g. Fostair) reduce the flexibility to adjust dose of each component.
Oral beta2 agonists
- Oral preparations are useful for patients who cannot manage the inhaled route.
But inhaled beta2 agonists are more effective and the have fewer side effects.