Asthma Flashcards by yeswanth AKULA

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

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Medications which may trigger asthma symptoms

NSAIDs

Beta-blockers

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Examples of high-risk occupations which may be associated with asthma

Lab work
Baking
Animal handling
Welding

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Why is family/personal history important in asthma diagnosis

To check for atopic eczema/dermatitis and/or allergic rhinitis

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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

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Which tests can be used to detect airway obstruction, when a person is symptomatic

Spirometry
Bronchodilator reversibility
variable peak expiratory flow readings

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Normal spirometry reading

FEV1/FVC ratio is normally greater than 70%

Any value less than this suggests airflow limitation

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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

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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

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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

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Which tool can be used to assess an individual’s baseline asthma status

Asthma control questionnaire or asthma control test

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Which psychiatric conditions are more associated with asthma

Anxiety

Depression

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What should asthmatics regularly measure

Their peak flow regularly with their own peak flow meter

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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

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Which other class of meds has to be co-prescribed with LABAs in asthma management

Inhaled corticosteroids

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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

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Common side effects of beta-2 agonists

Fine tremor
Palpitations
Headache
Seizure

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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

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What should be monitored with use of SABAs alongside corticosteroids, diuretics or xanthine derivatives

Potassium levels

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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

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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