Asthma Flashcards
Common features of asthma symptoms
Episodic
Diurnal(worse at night or in the early morning)
+/- triggered or exacerbated by exercise,
viral infection, and exposure to cold air or allergens
Medications which may trigger asthma symptoms
NSAIDs
Beta-blockers
Examples of high-risk occupations which may be associated with asthma
Lab work
Baking
Animal handling
Welding
Why is family/personal history important in asthma diagnosis
To check for atopic eczema/dermatitis and/or allergic rhinitis
Which test should be used to confirm eosinophilic airway inflammation to support an asthma diagnosis
Fractional exhaled nitric oxide(FeNO) testing
In steroid-naive adults, a FeNO level of 40 parts per billion or higher is considered a positive result
Which tests can be used to detect airway obstruction, when a person is symptomatic
Spirometry
Bronchodilator reversibility
variable peak expiratory flow readings
Normal spirometry reading
FEV1/FVC ratio is normally greater than 70%
Any value less than this suggests airflow limitation
When are variable peak expiratory flow readings used to diagnose asthma
Diagnostic uncertainty after initial assessment, a FeNO test, and/or objective tests to detect airway obstruction
What is considered a positive variable peak expiratory flow readings test
A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks
What is complete control of asthma defined as
No daytime symptoms No night-time waking No need for rescue meds No asthma attacks No limitations on activity Normal lung function
Which tool can be used to assess an individual’s baseline asthma status
Asthma control questionnaire or asthma control test
Which psychiatric conditions are more associated with asthma
Anxiety
Depression
What should asthmatics regularly measure
Their peak flow regularly with their own peak flow meter
First line medication for new diagnosis of asthma
Short-acting beta-2 agonist
Anyone prescribed more than one SABA per month should be reassessed urgently
Which other class of meds has to be co-prescribed with LABAs in asthma management
Inhaled corticosteroids
In which conditions should beta-2 agonists be used with caution
Hyperthyroidism
Diabetes mellitus
Cardiovascular disease(including hypertension)
Susceptibility to Q-T interval prolongation
Hypokalaemia
Convulsive disorders
Common side effects of beta-2 agonists
Fine tremor
Palpitations
Headache
Seizure
Which condition has been reported in people using nebulised SABA and how can the risk of this be reduced?
Acute angle-closure glaucoma
A mouthpiece rather than a mask should be used to minimise exposure of the eyes to the drug
What should be monitored with use of SABAs alongside corticosteroids, diuretics or xanthine derivatives
Potassium levels
When should an ICS be added to asthma treatment
Use of inhaled SABA x3 a week or more
Asthma symptoms x3 a week or more
Woken at night by asthma symptoms once weekly
When might a higher dose of ICS be required in management of asthma
Previous or currently smokers as smoking reduces the effectiveness of ICS therapy
How often should ICS initially be used
Twice daily initially
Once good control is established, once-daily ICS at the same daily dose can be considered as maintenance therapy
What should be checked before trialling add-on therapy in asthma management
Adherence
Inhaler technique
Elimination of trigger factors
What is the next option after trial of ICS with SABA in management of asthma
LABA in addition to low dose ICS
When is LTRA taken
Oral therapy only taken at night
What is the next option after trial of SABA + ICS + LTRA
LABA in combination with ICS
Use clinical judgement to continue treatment with LTRA
What is the next option if asthma is uncontrolled on a low dose of ICS and a LABA with/without LTRA
Offer to change ICS and LABA to a maintenance and reliever therapy (MART) regimen with a low maintenance ICS dose
What is MART
MART consists of a single inhaler containing both ICS and a fast-acting LABA, which is used for both daily maintenance therapy and the relief of symptoms as required
Which additional drug can be used if asthma is uncotrolled on a moderate ICS dose with a LABA(either as MART or fixed-dose)
Muscarinic receptor antagonist or theophylline
When should maintenance therapy for asthma be reduced
If the person’s asthma has been controlled with their current maintenance therapy for at least 3 months
Purpose of spacers
Increase the proportion of the drug delivered to the airways and reduce the amount of drug deposited int he oropharynx(thereby reducing local adverse effects and reducing the amount of systemic absorption)
How often should people with asthma be followed up
At least annually to determine whether treatment needs to be changed
Factors should be monitored in all patients with asthma
Number of asthma attacks(time off work due to asthma)
Nocturnal symptoms
Adherence
Possession of asthma action plan
Exposure to tobacco smoke
What should patients on long-term steroid tablets be monitored for
Blood pressure Urine or blood sugar(HbA1c) Cholesterol Bone mineral density Vision(to assess for cataracts and glaucoma)
Which medication may be considered in asthmatics who have ongoing symptoms, despite high-dose inhaled steroids
Prophylactic oral macrolide therapy to reduce possibility of exacerbation frequency
What should be done before commencing prophylactic oral macrolides
Specialist referral Optimisation of other treatments ECG to assess QTc interval Baseline LFTs Counselling about adverse effects
Definition of moderate acute exacerbation of asthma
PEFR more than 50-75% best or predicted (at least 50% best or predicted in children) and normal speech, with no features of acute severe or life-threatening asthma
Definition of acute severe acute exacerbation of asthma
PEFR 33-50% best or predicted or resp rate of least 25/min in people over age of 12 years
Definition of life-threatening acute exacerbation of asthma
PEFR less than 33% best or predicted, or oxygen sats of less than 92%, or altered consciousness, or exhaustion, or cardiac arrhythmia, or hypotension, or cyanosis or silent chest or confusion
Which factors may warrant a lower threshold for admission in acute exacerbation of asthma despite only being moderate
Age under 18 yrs Poor treatment adherence Pregnancy Psychological problems Previous severe asthma attack
Management of acute exacerbation of asthma while awaiting admission to hospital
Controlled supplementary oxygen if hypoxic Nebulised SABA Consider nebulised ipratropium bromide Consider ICS Monitor peak expiratory flow rate
Management of acute exacerbation of asthma if hospital admission not required
SABA via large-volume spacer ICS(consider quadrupling dose) Check adherence to ICS Monitor peak expiratory flow rate Consider montelukast in children aged over 2 yrs
How often should a SABA be used once asthma symptoms have subsided after an acute exacerbation
As required
Up to 4 times a day(not exceeding 4 hourly)
When should a person be followed up after an acute exacerbation of asthma
Within 48 hours of presentation, if not admitted to hospital
Follow-up all people admitted to hospital within 2 working days of discharge
What should be done as follow up for asthmatics after an acute exacerbation of asthma
Review symptoms and checked peak expiratory flow Check inhaler technique Consider stepping up ICS Advice regarding avoiding triggers Vaccinations Personalised asthma action plan
Definition of forced expiratory volume in 1s(FEV1)
The volume exhaled in the first second after deep inspiration and forced expiration, similar to PEFR.
Definition of FVC
the total volume of air that the patient can forcibly exhale in one breath
Typical spirometry findings in obstructive lung disease
Reduced FEV1 (<80% of the predicted normal) Reduced FVC (but to a lesser extent than FEV1) FEV1/FVC ratio reduced (<0.7)
How long should bronchodilator therapy be stopped prior to spirometry
Short-acting beta-2-agonists should be stopped 6 hours prior to testing.
Long-acting beta-2-agonists should be stopped 12 hours prior to testing.
Causes of obstructive lung disease
COPD Asthma Emphysema Bronchiectasis Cystic fibrosis
Typical spirometry findings in restrictive lung disease
FVC decreased
FEV1 decreased or normal
Absolute FEV1/FVC > 0.7
