Asthma Flashcards
Pt presents with cough, but no other symptoms. Has raised FeNO but no airway hyper-responsiveness. What is most likely diagnosis?
Eosinophilic bronchitis
- chronic cough but no lower airway symptoms (wheeze/SOB)
- raised FeNO and sputum Eos
- no airway hyper-responsiveness
–> treat with steroids and will always respond
Pt presents with cough, but no other symptoms. Has raised FeNO but no airway hyper-responsiveness. What is best treatment
Steroids
Eosinophilic bronchitis
- chronic cough but no lower airway symptoms (wheeze/SOB)
- raised FeNO and sputum Eos
- no airway hyper-responsiveness
–> treat with steroids and will always respond
Pt presents with throat tightness while exercising. What is most likely diagnosis?
Intermittent laryngeal obstruction
- Exercise-induced and symptoms at peak of exercise
- With exercise asthma, get 20mins after
- Can also be triggered by irritant, emotional stress
Clues: sudden onset, throat tightness, inspiratory noise
Treat: avoidance, SLT
Pt present with sudden onset throat tightness when stressed. What is best treatment?
Trigger avoidance and SLT.
Intermittent laryngeal obstruction
- Exercise-induced and symptoms at peak of exercise
- With exercise asthma, get 20mins after
- Can also be triggered by irritant, emotional stress
Clues: sudden onset, throat tightness, inspiratory noise
Pt presents with SOB, cough and wheeze. Found to have 52% of tracheal lumen collapse on review . What is diagnosis?
Excessive dynamic airways collapse (EDAC)
- posterior tracheal membrane collapse >50% lumen
- often co-exist with asthma/COPD
- symptoms: SOB, cough, wheeze
Treat: CPAP +/- stent (but response poor)
Pt presents with SOB. Gets score of 23 on Nijmengen score. What is diagnosis?
Breathing-pattern disorder
- Nijmengen score 23+/64
Treat: PT
Can asthma cause fixed airflow obstruction?
Yes if chronically untreated eosinophilic asthma as get airway remodelling
Pt has wheeze and SOB. What PEFR would be considered suggestive for asthma?
Variable of >10% when measured over 2 readings a day for at least 2 weeks. Each reading is best of 3.
What factors on spirometry suggestive of asthma?
FEV1/FVC <0.7 + increased by 12% and 200ml with bronchodilator (after 15mins)
What tests are there for bronchial hyper-responsiveness and what is positive?
Histamine or Metacholine challenge.
PC20 ≤8mg/ml considered positive
PC20 16mg/ml considered normal
(PC20 = mg/ml of metacholine required to give drop of FEV1 of 20%) nb. for mannitol, use 15%
What is considered a positive FeNO test?
> 40
25-39 intermediate and may warrant testing of bronchial hyperresponsiveness
What factors can artifically lower FeNO?
Smoking, steroids, leukotriene receptor antagonists, caffeine
What cause high FeNO?
Asthma
Allergic rhinitis
Eosinophilic bronchitis
(COPD, OSA, ILD)
What is FeNO measuring?
Indirect marker of Th2 inflammation i.e. IL4/13. Therefore won’t be reduced by IL5 inhibition
What are risk factors for dying from asthma?
Overuse of SABA for >1month
Underuse of ICS
Use of oral steroids
ED/hospital admissions
Previous near fatal asthma (ITU)
Psychosocial
What are risk factors for future asthma attacks?
Older age
Female
Reduced lung function
Obesity
Smoking
Depression
Pt with asthma takes PRN salbutamol. Still getting symptoms >3/week. What is next best appropriate therapy? When should this be reviewed?
Add low dose ICS. Review 4-8 weeks after
Also consider alternative diagnoses, poor adherence, inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal & environmental factors
Asthma pt taking salbutamol and beclametasone. Waking at night wheezing. What is next best treatment?
Add LABA. Review 4-8 weeks after
NICE says LRTA
Also consider alternative diagnoses, poor adherence, inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal & environmental factors
Pt with asthma taking SABA, ICS and LABA. Having to use SABA every day. What is next best treatment option?
Medium dose ICS or leukotriene-receptor antagonist. Review 4-8 weeks after
Also consider alternative diagnoses, poor adherence, inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal & environmental factors
What is MART therapy in asthma?
Single maintenance and reliever therapy - only licensed for SABA and low dose ICS (although higher doses often used in reality)
When should you consider referral to a specialist in asthma?
Not controlled on moderate dose ICS
Diagnosis unclear
Suspect occupational
Poor response to treatment
Severe/life-threatening attack
Pt with well-controlled asthma becomes pregnant. What should they be told? Should any changes be made to asthma therapy?
- Peak exacerbation in 3rd trimester
- Leukotriene RA shouldn’t be stopped without careful consideration
- Theophylline safe for preg and BF (but more monitoring as lower levels from increased metabolism and protein binding)
- Tiotropium (LAMA) best avoided
- if >7.5mg pred in 2 weeks before labour then give 100mg hydrocortisone qds during labour
What is definition of severe asthma for biologics consideration?
Needing high dose ICS + LABA or leukotriene/theophylline
OR 4xoral steroids is past year
OR steroids for >50% year
What is Omalizumab and what are indications?
Anti-IgE (helps stop allergic p/w)
Criteria:
- Confirmed allergic-medicated severe asthma (perennial aeroallergens i.e. not seasonal)
- ≥4 pred in 12/12
- FEV1 <80%
- Symptoms
- Already on high dose ICS and LABA
–> dose based on weight and total IgE
What are GINA treatment steps for asthma?
1) PRN SABA
2) Add low dose ICS (400-800)
3) Add LABA then if needed, increase ICS to 800 and consider LABA/leukotriene/theophylline/oral LABA
4) Increase ICS up to max of 2000, consider the other things from step 3
5) Refer to specialist care. Add oral steroids and lowest dose possible to maintain control
What are SEs of omalizumab?
SE: headache, fatigue, muscle aches, local rash (nb. systemic rash unlikely)
Risk of anaphylaxis: need to give epipen
Nb. no need to stop during infections and IgE very specific to allergy pathway
How monitor omalizumab?
Review at 16 weeks and consider stopping if no effect
How is omalizumab given?
S/c every 2-4 weeks
What is Mepolizumab and what are indications?
Anti-IL5
Severe asthma
+ [≥4 pred/yr + EP >0.3) OR [EP >0.4 + ≥3 pred]
Nb. EP >0.4 + ≥3 pred is same criteria as for benralizumab and reslizumab
Nb2. EP needs to be within last year (as gets suppressed by steroids)
How should Mepolizumab be monitored?
Need clinically meaningful response at 1 year. Assess every year
- clinically meaningful reduction in exacerbations
- or clinically meaningful reduction in oral steroids
How is Mepolizumab given?
S/c 1/12. Fixed dose.
What are SE of Mepolizumab?
SE: headache, fatigue, muscle aches, local rash (nb. systemic rash unlikely)
Specific: shingles
What is Reslizumab and what are indications for use?
Anti-IL5
Severe asthma
+ EP >0.4 + ≥3 pred
Nb. EP needs to be within last year (as gets suppressed by steroids)
What are SE of Reslizumab?
SE: headache, fatigue, muscle aches, local rash (nb. systemic rash unlikely)
How is Reslizumab given?
IV (only one that can be given this way). Weight-based dose
What is Benralizumab and what are indications?
Binds NK cells and EP (causes apoptosis)
Severe asthma
+ [≥4 pred/yr + EP >0.3) OR [EP >0.4 + ≥3 pred]
Nb. EP needs to be within last year (as gets suppressed by steroids)
How is Benralizumab given?
Month 1, 2, 3 then every other month
What are criteria for continuing Benralizumab?
Need clinically meaningful response at 1 year. Assess every year
- clinically meaningful reduction in exacerbations
- or clinically meaningful reduction in oral steroids
Nb. all 1 year except Omalizumab which is 16 weeks
Can macrolides be used in asthma?
Limited evidence that decrease exacerbations and increase QOL
- 50-70 years
- symptoms despite high dose ICS
- ≥1 oral steroids/year
Why do you have to monitor asthma biologics yearly?
Can generate Ab to them therefore stop working
What is bronchial thermoplasty and what is its role?
Heat treatment to reduce smooth muscles in airways. Dont’ really know who it will help.
Can be used in severe asthma not controlled with drugs. FEV1 >50% and no bronchiectasis
What are diagnostic criteria for EGPA?
Score of 6+:
EP >1 = +5
Obstructive airways disease = +3
Nasal polyps = +3
PR3 ANCA (cANCA) = -3 (as pANCA most common)
Extravascular eosoinophilic-predominant inflammation = +2
Mononeuritis multiplex/motor neuropathy not due to radiculopathy = +1
Haematuria = -1
What is mononeuritis multiplex?
Damage to at least 2 different areas of peripheral nervous system
What is biggest cause of death in patients with EGPA?
Cardiomyopathy - recommend echo
What is EGPA? What are symptoms?
Small to medium vessel vasculitis. Necrotising granulomatous disease (central eosinophilic core)
Constitutional: fatigue, wt loss, fever, muscle aches
Asthma
Paranasal sinusitis
Allergic rhinitis
Cough/haemoptysis
Athralgia
Peripheral neuropathy
GI - diarrhoea, colitis
Rash
What is the treatment for EGPA?
1mg/kg pred if organ/life-threatening
+/- cyclophosphamide or rituximab
Low dose steroid if mild/mod disease
Remission/maintenance: methotrexate, azathioprine
What is definition of moderate acute asthma exacerbation?
Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe
Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence
Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort
Near-fatal:
- increased pCO2
- mechanical ventilation
What is severe acute asthma exacerbation?
Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe
Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence
Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort
Near-fatal:
- increased pCO2
- mechanical ventilation
What is life-threatening acute asthma exacerbation?
Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe
Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence
Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort
Near-fatal:
- increased pCO2
- mechanical ventilation
When do you need ABG in acute asthma exacerbation?
If SATS<92% or features of life-threatening
Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe
Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence
Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort
Near-fatal:
- increased pCO2
- mechanical ventilation
When need CXR in acute asthma exacerbation?
- if suspect PNX or consolidation
- life-threatening
- failure to respond to treatment
- need ventilation
When can you discharge pt with acute asthma exacerbation?
if moderate/severe exacerbation and PEFR >75% after 1 hour treatment
Admit if life-threatening or near fatal
How treat acute asthma?
O2 to get SATS 94-98
High dose B2 agonist (neb is severe + consider continuous delivery)
Pred 40-50mg for 5d
Ipatropium 4-6hrly if severe of haven’t responded to previous treatment
Consider Iv Mg if poor response to above (NOT nebulised)
Abx not routine
When inform GP after asthma exacerbation?
Within 24 hours of d/c
What is considered ‘difficult asthma’
Symptoms/frequent attacks despite:
- high dose ICS
- medium dose ICS + additional therapy
- continuous/frequent PO steroid
Need to assess:
- diagnosis
- adherence
- psychosocial factors
- consider sputum EP monitoring to guide steroid treatmnet
