Asthma Flashcards
What is acute asthma?
Acute asthma is nearly always seen in patients who’ve got a history of asthma.
What are the features of acute asthma?
Worsening dyspnoea, wheeze and cough that is not responding to salbutamol. It may be triggered by a respiratory tract infection.
How are patients with acute severe asthma stratified?
Patients are stratified into moderate, severe, or life-threatening categories.
What are the characteristics of moderate acute asthma?
PEFR 50-75% best or predicted, speech normal, RR < 25/min, pulse < 110 bpm.
What are the characteristics of severe acute asthma?
PEFR 33-50% best or predicted, can’t complete sentences, RR > 25/min, pulse > 110 bpm.
What are the characteristics of life-threatening acute asthma?
PEFR < 33% best or predicted, oxygen sats < 92%, silent chest, cyanosis or feeble respiratory effort, bradycardia, dysrhythmia or hypotension, exhaustion, confusion or coma.
What does a normal pCO2 indicate in an acute asthma attack?
A normal pCO2 indicates exhaustion and should be classified as life-threatening.
PEFR, speech, RR, pulse
What are the categories of acute asthma according to the British Thoracic Society (BTS)?
The categories are moderate, severe, and life-threatening.
What are the characteristics of moderate acute asthma?
PEFR 50-75% best or predicted, speech normal, RR < 25/min, pulse < 110 bpm.
What are the characteristics of severe acute asthma?
PEFR 33-50% best or predicted, can’t complete sentences, RR > 25/min, pulse > 110 bpm.
What are the characteristics of life-threatening acute asthma?
PEFR < 33% best or predicted, oxygen sats < 92%, ‘normal’ pC02 (4.6-6.0 kPa), silent chest, cyanosis, or feeble respiratory effort, bradycardia, dysrhythmia, or hypotension, exhaustion, confusion, or coma.
What should be done if a patient has any life-threatening features?
They should be treated as having a life-threatening attack.
What is ‘Near-fatal asthma’ characterized by?
‘Near-fatal asthma’ is characterized by a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.
What does the BTS recommend for further assessment in patients with oxygen sats < 92%?
Arterial blood gases should be assessed.
When is a chest x-ray recommended?
A chest x-ray is recommended for life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.
What is the admission criteria for patients with life-threatening asthma?
All patients with life-threatening asthma should be admitted to the hospital.
What should be done for hypoxaemic patients?
Start supplemental oxygen therapy.
What is the initial oxygen therapy for acutely unwell patients?
Start on 15L of supplemental oxygen via a non-rebreathe mask, titrated down to maintain SpO2 94-98%.
What is the recommended bronchodilation treatment for acute asthma?
High-dose inhaled SABA (e.g., salbutamol, terbutaline).
How should SABA be administered in patients without life-threatening features?
SABA can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer.
What is the recommended treatment for patients with life-threatening exacerbation of asthma?
Nebulised SABA is recommended.
What corticosteroid should all patients receive?
All patients should be given 40-50mg of prednisolone orally daily for at least five days.
What additional treatment can be considered for severe or life-threatening asthma?
Nebulised ipratropium bromide may be used if there is no response to beta-agonist and corticosteroid treatment.
What does the BTS say about IV magnesium sulphate?
The evidence base is mixed, but it is commonly given for severe/life-threatening asthma.
What should be done for patients who fail to respond to treatment?
They require senior critical care support and should be treated in an appropriate ITU/HDU setting.
What are the criteria for discharge from the hospital?
Patients must be stable on discharge medication for 12-24 hours, inhaler technique checked, and PEF > 75% of best or predicted.
What SpO2 level indicates a severe asthma attack in children?
SpO2 < 92%
Unlike in adults, SpO2 < 92% may be consistent with a ‘severe’ attack in children.
What is the PEF range for a severe asthma attack in children?
PEF 33-50% best or predicted
What are the signs of a severe asthma attack related to communication?
Too breathless to talk or feed
What is the heart rate threshold for a severe asthma attack in children over 5 years?
Heart rate >125
What is the heart rate threshold for a severe asthma attack in children aged 1-5 years?
Heart rate >140
What is the respiratory rate threshold for a severe asthma attack in children over 5 years?
Respiratory rate >30 breaths/min
What is the respiratory rate threshold for a severe asthma attack in children aged 1-5 years?
Respiratory rate >40 breaths/min
What physical sign indicates a life-threatening asthma attack?
Use of accessory neck muscles
What is the PEF level for a life-threatening asthma attack?
PEF <33% best or predicted
What are some signs of a life-threatening asthma attack?
Silent chest, Poor respiratory effort, Agitation, Altered consciousness, Cyanosis
What SpO2 level indicates a severe asthma attack in children?
SpO2 < 92%
Unlike in adults, SpO2 < 92% may be consistent with a ‘severe’ attack in children.
What is the PEF range for a severe asthma attack in children?
PEF 33-50% best or predicted
What are the signs of a severe asthma attack related to communication?
Too breathless to talk or feed
What is the heart rate threshold for a severe asthma attack in children over 5 years?
Heart rate >125
What is the heart rate threshold for a severe asthma attack in children aged 1-5 years?
Heart rate >140
What is the respiratory rate threshold for a severe asthma attack in children over 5 years?
Respiratory rate >30 breaths/min
What is the respiratory rate threshold for a severe asthma attack in children aged 1-5 years?
Respiratory rate >40 breaths/min
What physical sign indicates a life-threatening asthma attack?
Use of accessory neck muscles
What is the PEF level for a life-threatening asthma attack?
PEF <33% best or predicted
What are some signs of a life-threatening asthma attack?
Silent chest, Poor respiratory effort, Agitation, Altered consciousness, Cyanosis
Assessment of acute attacks in children aged 2-5, and in > 5: moderate, severe, life-threatening
Pred doses in children
What should be done for children with severe or life-threatening asthma?
They should be transferred immediately to hospital.
What are the indicators of a moderate asthma attack in children aged 2-5?
SpO2 > 92% and no clinical features of severe asthma.
What are the indicators of a severe asthma attack in children aged 2-5?
SpO2 < 92%, too breathless to talk or feed, heart rate > 140/min, respiratory rate > 40/min, use of accessory neck muscles.
What are the indicators of a life-threatening asthma attack in children aged 2-5?
SpO2 < 92%, silent chest, poor respiratory effort, agitation, altered consciousness, cyanosis.
What should be attempted for children greater than 5 years of age during an asthma attack?
Attempt to measure PEF in all children aged > 5 years.
What are the indicators of a moderate asthma attack in children aged > 5?
SpO2 > 92% and PEF > 50% best or predicted with no clinical features of severe asthma.
What are the indicators of a severe asthma attack in children aged > 5?
SpO2 < 92%, PEF 33-50% best or predicted, can’t complete sentences in one breath or too breathless to talk or feed, heart rate > 125/min, respiratory rate > 30/min, use of accessory neck muscles.
What are the indicators of a life-threatening asthma attack in children aged > 5?
SpO2 < 92%, PEF < 33% best or predicted, silent chest, poor respiratory effort, altered consciousness, cyanosis.
What is the treatment for children with mild to moderate acute asthma?
Bronchodilator therapy using a beta-2 agonist via a spacer, with 1 puff every 30-60 seconds up to a maximum of 10 puffs.
What should be done if symptoms are not controlled in children with acute asthma?
Repeat beta-2 agonist and refer to hospital.
What steroid therapy should be given to children with an asthma exacerbation?
Steroid therapy should be given for 3-5 days.
What is the usual prednisolone dose for children aged 2-5 years?
20 mg od or 1-2 mg/kg od (max 40mg).
What is the usual prednisolone dose for children older than 5 years?
30 - 40 mg od or 1-2 mg/kg od (max 40mg).
What organizations produced joint guidelines on asthma management in 2024?
NICE, the British Thoracic Society, and SIGN.
What are the first-line investigations for suspected asthma in adults according to NICE?
Measure the eosinophil count OR fractional nitric oxide (FeNO).
When can asthma be diagnosed without further investigations in adults?
If eosinophil count is above the reference range or FeNO is ≥ 50 ppb.
What is the criterion for diagnosing asthma using bronchodilator reversibility (BDR) in adults?
FEV1 increase is ≥ 12% and 200 ml or more from the pre-bronchodilator measurement, or FEV1 increase is ≥ 10% of the predicted normal FEV1.
What should be measured if spirometry is not available for adults suspected of asthma?
Measure peak expiratory flow (PEF) twice daily for 2 weeks.
What indicates asthma diagnosis based on PEF variability in adults?
PEF variability (amplitude percentage mean) is ≥ 20%.
What should be done if asthma is still suspected in adults after initial tests?
Refer for consideration of a bronchial challenge test.
What is the first-line investigation for suspected asthma in children aged 5 to 16?
Measure the fractional nitric oxide (FeNO).
When can asthma be diagnosed in children aged 5 to 16 based on FeNO?
If FeNO is ≥ 35 ppb.
What should be done if FeNO testing is not available for children aged 5 to 16?
Measure bronchodilator reversibility (BDR) with spirometry.
What indicates asthma diagnosis based on PEF variability in children aged 5 to 16?
PEF variability (amplitude percentage mean) is ≥ 20%.
What tests can be performed if asthma is not confirmed in children aged 5 to 16?
Perform skin prick testing to house dust mite OR measure total IgE level and blood eosinophil count.
What indicates asthma diagnosis based on sensitization in children aged 5 to 16?
Evidence of sensitization OR a raised total IgE level and eosinophil count > 0.5 x 10^9/L.
What should be done if there is doubt about asthma diagnosis in children aged 5 to 16?
Refer to a paediatric specialist for a second opinion.
What is the guideline for investigating asthma in children under 5?
Treat with inhaled corticosteroids and review regularly.
When should objective tests be attempted for children under 5?
If they still have symptoms at age 5.
What is the recommendation for preschool children with frequent wheeze?
Refer to a specialist respiratory paediatrician.
What role do eosinophils play in asthma?
Eosinophils are involved in type 2 inflammation and airway inflammation.
How is fractional exhaled nitric oxide (FeNO) measured?
By having the patient exhale into a handheld device that analyzes nitric oxide concentration in ppb.
What does bronchodilator reversibility (BDR) testing evaluate?
The degree of airflow limitation that improves after bronchodilator administration.
What does peak expiratory flow (PEF) variability reflect?
Diurnal changes in airway calibre, a hallmark of asthma.
What role does immunoglobulin E (IgE) play in allergic asthma?
IgE mediates hypersensitivity reactions leading to airway inflammation.
Why is skin prick testing for house dust mite performed?
It identifies a common trigger for asthma in atopic individuals.
What does the bronchial challenge test assess?
Airway hyper-responsiveness characteristic of asthma.
Adult with a history suggesting asthma -diagnosis objective tests
Children with a history suggesting asthma -diagnosis objective tests
What do the 2024 NICE guidelines represent in asthma management?
A major step change in the management of asthma diagnosis and treatment.
What was the traditional treatment approach for asthma?
Starting with a short-acting beta-2 agonist (SABA) inhaler before stepping up to a regular inhaled corticosteroid with SABA as needed.
What do the new guidelines advocate for reliever therapy?
The use of combined inhalers (ICS + long-acting beta-2 agonist) as reliever therapy or regularly, depending on severity.
What is the first step in managing adults aged ≥ 12 years with newly diagnosed asthma according to NICE?
A low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief.
This is termed anti-inflammatory reliever (AIR) therapy.
What should be done if a patient presents with severe exacerbation or regular nocturnal waking?
Start treatment with low-dose MART (maintenance and reliever therapy) and treat acute symptoms appropriately.
What does MART stand for?
Maintenance and reliever therapy.
What is the second step in asthma management according to NICE?
A low-dose MART for daily maintenance therapy and relief of symptoms as needed.
What is the third step in asthma management?
A moderate-dose MART.
What should be checked at step 4 of asthma management?
The fractional exhaled nitric oxide (FeNO) level and the blood eosinophil count.
What action should be taken if FeNO or eosinophil count is raised?
Refer to a specialist in asthma care.
What should be considered if neither FeNO nor eosinophil count is raised?
A trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) in addition to moderate-dose MART.
What should be done if control has not improved after trying LTRA or LAMA?
Stop the LTRA or LAMA and start a trial of the alternative medicine.
When should a patient be referred to a specialist in asthma care?
When asthma is not controlled despite treatment with moderate-dose MART and trials of an LTRA and a LAMA.
What is the new treatment for patients previously on SABA as required only?
Low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy).
What should be done for patients on SABA as required + regular low-dose ICS?
Switch to a regular low-dose ICS/formoterol combination inhaler (MART therapy).
What is the new treatment for patients on a high-dose ICS?
Refer to a respiratory specialist.
Pharmacological treatment 12yrs+
What year did NICE, the British Thoracic Society, and SIGN produce joint guidelines on asthma management?
2024
What is the new recommended reliever therapy for asthma management?
Combined inhalers (ICS + long-acting beta-2 agonist) depending on the severity of asthma.
What does MART stand for in asthma management?
Maintenance and reliever therapy.
What is the first step in managing asthma for children aged 5 to 11?
Twice-daily paediatric low-dose inhaled corticosteroid (ICS) + short-acting beta2 agonist (SABA) as needed.
What is the MART pathway for children whose symptoms are not controlled on the first step?
Paediatric low-dose MART + SABA as needed.
What should be added if symptoms are still not controlled in the conventional pathway?
A leukotriene receptor antagonist (LTRA) to twice daily paediatric low-dose ICS plus SABA as needed.
What is the next step if symptoms are still not controlled after adding LTRA?
Switch to a twice daily paediatric low-dose ICS/LABA combination inhaler plus SABA as needed.
What should be done if children’s asthma symptoms are still not controlled despite treatment?
Refer to a respiratory specialist.
What is the initial management for children under 5 with asthma?
8 to 12 week trial of twice-daily paediatric low-dose ICS as maintenance therapy + SABA as required.
What should be considered after the 8 to 12 week trial for children under 5?
Stopping ICS and SABA treatment if symptoms are resolved, with a review after a further 3 months.
Stepwise treatment - existing and new
Pharmacological management 12yrs+
Pharmacological management 5-11yrs
Pharmacological management under 5s
MART for children
What do the British Thoracic Society (BTS) guidelines recommend regarding stepping down asthma treatment?
The BTS guidelines recommend considering stepping down treatment every 3 months or so.
Do the BTS guidelines advocate a strict move from one treatment step to another?
No, the guidelines do not advocate a strict move from one step to another but advise considering duration of treatment, side-effects, and patient preference.
How should the dose of inhaled steroids be reduced according to the BTS?
The BTS advises reducing the dose of inhaled steroids by 25-50% at a time.
How often may patients with stable asthma have a formal review?
Patients with stable asthma may only have a formal review on an annual basis.
What is likely for patients who have recently had an escalation of asthma treatment?
It is likely that they would be reviewed on a more frequent basis.
