Asthma Flashcards
What is Asthma?
Asthma is a chronic inflammatory condition of the airways that causes episodic exacerbations of bronchoconstriction.
In asthma, there is reversible airway obstruction that typically responds to ________ such as _________
bronchodilators, salbutamol
What causes bronchoconstriction in asthma?
Airway hypersensitivity
What are some typical asthma triggers?
- Infection
- Nighttime or early mornings
- Exercise
- Animals
- Cold, damp, or dusty air
- Strong emotions
What are some patient presentations that could suggest a diagnosis of asthma?
- Episodic symptoms
- Diurnal variability. Typically worse at night
- Dry cough with wheeze and shortness of breath
- History of other atopic conditions such as eczema, hayfever, and food allergies
- Family history
- Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
What are some patient presentations that could suggest a diagnosis other than asthma?
- Wheeze related to coughs and colds more suggestive of viral-induced wheeze
- Isolated or productive cough
- Normal investigations
- No response to treatment
- Unilateral wheeze suggesting a focal lesion or infection
According to the BTS/SIGN guidelines from 2016, when should you make a clinical diagnosis for asthma?
When there is a high clinical suspicion of asthma
According to the BTS/SIGN guidelines from 2016, when should you conduct testing for asthma?
When there is an intermediate or low clinical suspicion of asthma
What do the NICE 2017 guidelines suggest regarding asthma diagnosis?
They advise against making a diagnosis without definitive testing
What are the BTS/SIGN guidelines on asthma diagnosis when there is a high probability of asthma treatment?
Try treatment
What are the BTS/SIGN guidelines on asthma diagnosis when there is an intermediate probability of asthma treatment?
Perform spirometry with reversibility testing
What are the BTS/SIGN guidelines on asthma diagnosis when there is a low probability of asthma treatment?
Consider referral and investigating for other causes
List the key treatments for long-term management of asthma.
- Short-acting beta 2 adrenergic receptor agonists
- Inhaled Corticosteroids (ICS)
- Long-acting beta 2 agonists (LABA)
- Long-acting muscarinic antagonists (LAMA)
- Leukotriene Receptor Antagonists (LTRA)
- Theophylline
- Maintenance And Reliever Therapy (MART)
An example of SABA includes
Salbutamol
How do Short-acting beta 2 adrenergic receptor agonists work?
- They work quickly but the effect only lasts for an hour or two
- Adrenalin acts on the smooth muscles of the airways to cause relaxation resulting in dilatation of bronchioles
When are Short-acting beta 2 adrenergic receptor agonists used?
Used as “reliever” or “rescue” medication during acute exacerbations of asthma when the airways are constricting.
An example of ICS includes
Beclometasone
What do Inhaled Corticosteroids (ICS) do?
Reduce inflammation and reactivity of the airways
When are Inhaled Corticosteroids (ICS) used?
Used as “maintenance” or “preventer” ‘medications and are taken regularly even when well
An example of LABA includes
Salmeterol
How do Long-acting beta 2 agonists (LABA) work?
They work in the same way as SABA’s but have a much longer action
An example of LAMA includes
Tiotropium
How do Long-acting muscarinic antagonists (LAMA) work?
They block the acetylcholine receptors that are stimulated by the parasympathetic nervous system causing the bronchial smooth muscles to contract. Blocking these receptors leads to bronchodilatation.
An example of LTRA includes
Montelukast
What are leukotrienes?
Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction, and mucus secretion in the airways.
How do LTRA’s work?
By blocking the effects of leukotrienes
How do theophyllines work?
By relaxing bronchial smooth muscles and reducing inflammation
What is the therapeutic window of theophyllines?
It has a narrow therapeutic window and can be toxic if used in excess, so monitoring plasma theophylline levels in the blood is required.
How frequently should plasma theophylline levels be monitored when on theophylline treatment?
5 days after starting treatment and 3 days after each dose changes
What is MART?
It is a combination inhaler containing a low-dose inhaled corticosteroid and a fast-acting LABA. This replaces all other inhalers and the patient uses this single inhaler regularly as a preventer and as a reliever when symptoms show.
Both BTS/SIGN and NICE guidelines start with __________ followed by ___________
SABA; low dose inhaled corticosteroid
After the first-line treatment, what medication is provided in the next step?
LTRA or an inhaled LABA
List the principles of using the stepwise ladder.
- Start at the most appropriate step for the severity of the symptoms
- Review at regular intervals based on severity
- Step up and down the ladder based on the symptoms
- Aim to achieve no symptoms or exacerbations on the lowest dose and number of treatments
- Always check inhaler technique and adherence at review
List out the steps in the BTS/SIGN 2016 guidelines stepwise ladder
- Add a SABA as required for infrequent wheezy episodes
- Add a regular low dose ICS
- Add LABA inhaler and continue ONLY if the patient has a good response
- Consider a trial of an oral LTRA, oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA
- Titrate the ICS up to high dose. Combine additional treatments from step 4. Refer to a specialist.
- Add oral steroids at the lowest dose possible to achieve good control.
List out the steps in the NICE 2017 guidelines stepwise ladder
- Add a SABA as required for infrequent wheezy episodes
- Add a regular low dose ICS
- Add an oral LTRA
- Add LABA inhaler and continue ONLY if the patient has a good response
- Consider changing to a MART regime
- Increase the inhaled corticosteroid to a ‘moderate dose’
- Consider increasing the ICS dose to “high dose” or oral theophylline or an inhaled LAMA
- Refer to a specialist
Additional management for patients with asthma include
- Each patient should have an individual asthma self-management programme
- Yearly flu jab
- Yearly asthma review
- Advise exercise and avoid smoking
