Asthma Flashcards
Define asthma. (1)
Chronic respiratory disease characterised by reversible airway inflammation and hyper responsiveness.
What are the s/s of asthma? (4)
Coughing (nocturnal/early morning)
Wheezing
Dyspnoea
Chest Tightness
What are the differentials of s/s between asthma, COPD, HF, Anaemia? (4)
Asthma: Dry cough (nocturnal/early morning), wheezing, breathlessness, chest tightness, variable symptoms.
COPD: Chronic cough, breathlessness, frequent chest infections, sputum production, persistent symptoms.
HF: Breathlessness, peripheral oedema, reduced exercise tolerance, orthopnea, persistent symptoms.
Anaemia: Breathlessness, pallor, fatigue/malaise, blood loss, persistent symptoms
What are the triggers for asthma? (11)
Animal allergens
Exercise
Genetic links
House dust mites
Viral infections
Occupational agents in workplace
Pollen
Medications
Smoking (current/passive)
Weather
State the importance of performing a physical exam for diagnosing asthma. (1)
Looking for main polyphonic wheezing.
What does a structured clinical assessment consist of in chronic asthma? (6)
Reported wheezing, noisy breathing, coughing, breathlessness and chest tightness.
Variation in symptoms.
Personal/family Hx of atopic disease
Known triggers
S/s suggesting alternative diagnosis.
When should asthma not be diagnosed? (1)
Unless the clinical Hx is suggestive with a supporting objective test.
Provide an overview of diagnostic process for asthma. (1)
If a px presents acutely unwell but has no formal asthma diagnosis, tx acute presentation and perform diagnostic tests together. Can perform diagnostic tests once recovered if needed.
What objective tests are carried out for diagnosing asthma in adults and children > 16 yrs? (4)
1st line: Blood eosinophils counts OR fractional exhaled nitric oxide (FeNO):
- If eosinophils raised = Asthma
- If FeNO level is 500ppb or higher = asthma
2nd line: Spirometry:
- FEV1 >= 12% and increased by 200ml = Asthma
- FEV1 increase > 10% of predicted normal FEV1 = Asthma
3rd line: Peak expiratory flow (PEF):
- If variability > 20 = Asthma.
4th line: Bronchial hyperresponsivess.
What objective tests are carried out for diagnosing asthma in adults and children 5-16 yrs? (4)
1st line: Fractional exhaled nitric oxide (FeNO):
- If FeNO level >= 35ppb = Asthma
2nd line: Spirometry
- If Spirometry showes reversibility of 12% = Asthma
- May be unsuitable for all this age range = move to PEF.
3rd line: Peak Expiratory Flow (PEF):
- Variability > 20% = Asthma
4th line: If asthma isn’t confirmed by any of the above but is still suspected can perform skin prick testing or measure IgE / Eosinophils.
Explain the diagnostic process for children < 5 years old. (2)
Treated based on clinical judgement and reviewed regularly.
If still symptomatic when 5 years old, run objective tests.
State the key features of eosinophils. (4)
WBC
High Eosinophils = allergic conditions.
When body is exposed to trigger = inflammatory response.
Normal eosinophils range from= 0-300cells/mcl
State the key features of FeNO. (4)
Measures amount of nitric oxide in your breath.
High levels = asthma
Raised eosinophils have potential for steroid responsiveness.
FeNO and eosinophils correlate if eosinophils have potential for steroid responsiveness so can FeNO.
Explain the key features of Spirometry. (3)
Main form of lung function tests and marker for obstructive or restrictive lung diseases.
Performed at single point in time and a negative result doesn’t rule out asthma. Need full clinical picture and alternative diagnostic tests.
Adults and children 5-16 yrs can have Spirometry performed but some children may not be able to perform the test as required high levels of expiratory force.
Explain the process of Spirometry. (3)
- Perform 3 separate breaths into a spirometer to general 3 different readings. The best of these readings is recorded.
- Px takes 2 puffs of a rapid acting bronchodilators e.g. salbutamol.
3, Px repeats step 1.
Px are advised to stop any existing bronchodilators prior to testing.
What results can be obtained from spirometry? (3)
FVC (Forced vital capacity) - total volume of air the px can exhale in one breath.
FEV1 (Forced expiratory volume in 1 second) - total volume of air exhaled following deep inspiration and forced expiration.
FEV1/FVC ratio
What is the FEV1/FVC ratio for assessing obstructive airways disease? (1)
Pre-bronchodilators FEV1/FVC < 0.7 (Asthma/COPD)
What is the FEV1/FVC ratio and FEV1 value for diagnosing asthma? (2)
Asthma using spirometry diagnosis:
- FEV1/FVC ratio < 0.7 pre-bronchodilator + FEV1 improvement of 200ml + improvement of 12% of baseline.
State the key features of peak flow. (3)
Peak expiratory flow rate (PEFR)
Best used to give variability estimation.
Multiple readings taken over 2 weeks:
- 3 readings twice a day (record best of each)
- Average calculated over 28 readings
- Difference between best/worse calculated as % of average.
- Uper limit for diagnosis is 20%
Difficulties:
- px ability to provide consistent breaths.
- lack of specificity/selectivity.
Explain the process of peak flow. (8)
Deep breath in
Hold breath for 2 seconds
Rapidly breathe out
Record value
Do this 3 times morning and night and record best from each.
Repeat BD for 2 weeks.
Take average of all best readings from daytime and evening.
Take highest and lowest readings and calculate express these % of average. 20% difference between values = asthma.
What are the 2 types of Beta agonists? (2)
Short-acting beta agonists (SABA) e.g. salbutamol, terbutaline. Used in old guidelines for symptom relief and for children with new diagnosis.
Long-acting beta agonists (LABA) e.g. salmeterol, olodaterol, indacterol and vilanterol. Prevents symptoms.
Formoterol is long acting beta agonists but has a rapid onset, similar to salbutamol can be used as both reliever and preventer simultaneously. Onset 5-10mins enables use as a reliever. DofA = 12 hrs (preventer)
What are the common s/e of Beta agonists? (2)
Hypokalaemia
Tachycardia
Due to oversuse/IV/nebulised.
When reviewing a patient on old asthma guidelines, what needs to be identified? (1)
Identify number of SABA inhalers in the past 12 months.
What medication combination should never be used in chronic asthma? (1)
LABA not used without concomittant ICS.
- Always given in a combination inhaler.
- High risk of mortality of LABA without ICS.
- Should have formoterol-ICS at each step (new guidelines)
What are the key features of ICS? (5)
Prevention. All asthma px given ICS.
E.g. Beclometasone dipropionate, Budesonide, fluticasone fumarate.
ICS given in a combination inhaler = Beclometasone/budesonide only ICS with formoterol.
Brand prescribing: Beclometasone monotherapy (ICS monotherapy first line in children under 12 yrs. May also be seen in adults.)
What is a common s/e of ICS? (1)
Oral thrush: Rinse mouth out and use of spacers (pMDI)
What are the key features of LTRA? (5)
Leukotriene receptor antagonist:
- Used later in asthma management if initial tx is ineffective (preventer)
- E.g. Montelukast, roflumilast.
Montelukast:
- Given OD at night
- 10mg in adults
- 5mg children 6-14 yrs (chewable tablets)
- 4mg children 6m-5 yrs (chewable tablets)
- Main px counselling: Neropsychiatric reactions
- Useful if FeNO = very high
- Useful if allergen induced symptoms / exercise-induced.
What are the key features of LAMA? (4)
E.g. Tiotropium
- Given as one dose in the morning (5mcg)
- Often given as a Respimat device
- Main s/e = dry mouth.
What are the key features of Theophylline? (5)
Not in new guidelines but can be seen in old guidelines.
High risk medication - narrow therapeutic index (10-20mg/L):
- Metabolised by CYP450 enzymes prone to enzyme induction and enzyme inhibition interactions = fluctuating concentrations.
- Concentration also affected by viral disease, HF, smoking.
Plasma levels needed upon initiation (5 days after starting)
Plasma levels needed after every dose change (3 days after)
What are the s/s of Theophylline overdose? (6)
Hyperglycaemia
Tachycardia
Hypokalaemia
Dilated Pupils
Restlessness
Agitation
What are the treatment aims of chronic asthma management? (7)
No:
- Daytime symptoms
- Night time awakening due to asthma
- Need for rescue medication
- Asthma attacks
- Activity limitations including exercise
Normal lung function
Minimal s/e from medications.
Explain the aims of using preventers in chronic asthma management. (4)
Main management strategy
Prevents asthma symptoms including regular dosing i.e. BD.
Each preventative regimen must has a baseline ICS.
When using new guidelines, ICS always given in a combination inhaler with a LABA.
May also use PTRA or lAMA as adjunctive therapy depending on control.
Explain the aims of using relievers in chronic asthma management. (5)
Acute symptoms management:
- Aims to relieve symptoms when present e.g. new onset SOB, coughing, wheezing.
Used prn throughout the day.
Under new guidelines, choice of reliever is formoterol and given with ICS.
What are the patient difficulties in understanding relievers and preventers? (3)
Does px known the difference between preventer and reliever?
Px may take preventer only when they feel symptomatic - not appropriate. Preventers are for regular use.
Px may take reliever regularly even if not symptomatic - not appropriate. Reliever for prn use.
Explain the management of chronic asthma in patients aged 12 and over. (4)
Initial management: Low dose ICS / formoterol combination inhaler:
- Taken as needed for symptom relief (AIR = anti-inflammatory reliever)
- DuoResp Spiomax 160/4.5mcg (budesonide/formoterol): 1 puff to be inhaled prn up to max 8 puffs per day (12+)
- Symbicort Turbohaler 100/6mcg (Budesonide/formoterol); 1 puff to be inhaled prn up to a max 8 puffs per day (12+)
Only recommended when px is newly diagnosied and mild symptoms.
Only budesonide/formoterol containing inhalers are currently licensed for AIR therapy. Others are unlicensed.
If px newly diagnosed with asthma is highly symptomatic, can move straight to low dose MART.
What is considered as highly symptomatic? (4)
Nocturnal symptoms.
Frequent daytime symptoms
Recent acute attack
Impacted QofL.
Explain the process of medication sequencing in chronic asthma management in patients aged 12 yrs and over. (3)
Applicable to px who are 12+ and previously on low dose ICS-formoterol prn and still poorly controlled. On diagnosis, highly symptomatic.
New tx consists of low dose MART regimen.
If control continues to be poor despite low dose MART regime = Increase to moderate dose MART regime.
Give e.g. of low-dose MART. (3)
DuoResp Spiromax 160/4.5mcg (Budesonide-formoterol): 1 puff in the morning and night for prevention and 1 puff prn for relief (max 8 puffs/24 hrs).
Symbicort Turbohaler 100/6mcg (budesonide-formoterol): 1 puff in morning and at night for prevention AND 1 puff prn for relief (max 8 puffs in 24 hrs)
Symbicort Turbohaler 200/6mcg (budesonide-formoterol): 1 puff in morning and at night for prevention AND 1 puff prn for relief (max 8 puffs in 24 hrs)
Give e.g. of a moderate-dose MART. (3)
DuoResp Spiromax 160/4.5mcg (budesonide/formoterol): 2 puffs in morning and at night for prevention and 1 puff prn for relief (max 8 puffs in 24 hrs)
Symbicort Turbohaler 200/6mcg (budesonide/formoterol): 2 puffs in morning and at night for prevention and 1 puff prn for relief (max 8 puffs in 24 hrs).
Fostair 100/6mcg evohaler/NEXThaler (budesonide/formoterol): 1 puff in morning and at night for prevention and 1 puff prn for relief (max 8 puffs in 24 hrs)
- Extra-fine particles -> more potent -> higher doses.
Explain the use of MART regimens in chronic asthma management in patients aged 12 and over. (2)
One inhaler used as both reliever (PRN use) and preventer (BD use)
MART regimes contain LABA and ICS but LABA must be rapid acting so it can act as a reliever (formoterol).
What are the requirements to Rx MART? (5)
12+ (budesonide inhalers) - DuoResp 160/4.5, Symbicort 100 or 200/6.
18+ (Beclometasone inhalers) - Fostair 100/6
Failed initial tx or highly symptomatic px.
Must have the right dose for right step of asthma pathway.
High dose of Beclometasone and budesonide aren’t used for MART.
What is the benefit of MART regimens? (4)
Keeps inflammation in airways to min. Every PRN dose also comes with a dose of ICS.
Gives ongoing symptom relief e.g. breathlessness or chest tightness.
Acts quickly to manage symptoms and reduce risk of developing an asthma attack and reduces risk of hospital admission.
As px uses more extra reliever doses, the requirements will reduce with time due to extra antiinflammatory effects of ICS and provides longer term control of asthma.
Explain the use of ongoing sequencing in chronic asthma management in patients 12 years and over. (4)
If px in moderate dose MART and remains poorly controlled:
- Check FeNO +/or blood eosinophils. If raised = specialist.
- If FeNO +/or eosinophils aren’t raised = add on therapies.
Add in Montelukast 10mg once at night (LRTA) or add in LAMA e.g. tiotropium.
If despite adding LTRA or LAMA px remain poorly controlled, add in other.
A px count be taking concurrently:
- Moderate dose MART
- LTRA
- LAMA
What is poor control? (5)
Asthma attack in the last 2 years.
Using reliever inhalers 3x/week or more.
Symptomatic 3x/week or more.
Waking 1 night/week
Asthma affecting daily activities.
What are the main differences between old and new guidelines? (2)
Shift to using ICS-formoterol combination inhalers from point of diagnosis for both relief and prevention in adults and children > 12 yrs.
New diagnosis for asthma in adults and children > 12 yrs, no longer given ICS monotherapy for prevention and SABA for relief.
- ICS (prevention) and SABA (relief) key to managing children.
Outline how to manage px on the previous asthma guideline. (5)
Px may still be using inhaler regimens in accordance to previous set of guidelines.
As long as the px is well controlled, it’s not necessary to transfer them to the new guidelines.
Only consider moving them to the new guidelines if px is poorly controlled.
Old guidelines:
- ICS monotherapy given BD for prevention and salbutamol given prn for relief: Clenic Modulite (Beclometasone) + salbutamol, Pulmicort (Budesonide) + salbutamol.
- LABA/ICS combination therapy given BD for prevention and salbutamol given prn for relief: Fostair 100/6 or 200/6 + salbutamol, Seretide 250/25 + salbutamol, DuoResp 160/4.5 or 320/9 + salbutamol.
Explain the management of chronic asthma in children aged 5-11 years. (7)
Offer BD paediatric low dose ICS given BD as preventative tx: e.g. Clenil modulite (Beclometasone dipropionate) 500mcg/puff 1-2 puffs BD.
Offer prn SABA as relief: e.g. salbutamol 100mcg/puff: 2 puffs prn.
If poor control consider:
- Using a paediatric low dose MART regime (off label) OR
- Montelukast trialled for 8-12 weeks with SABA followed by addition of low dose LABA/ICS with SABA if poor control.
What are the safety risks associated with SABA? (2)
Overuse of SABA:
- Deterioration = higher mortality.
- Well controlled px = 3 Rx/year
- If px use excessive salbutamol = step up tx.
Salbutamol pMDI: no dose counter
- Empty = no drug
- Residual propellant in device
- High mortality of using when no medication present.
- Advice in usage and monitoring of usage essential.
What should be checked during an asthma review? (10)
Adherence
Frequency of reliever doses
Inhaler technique
Symptoms (daytime/nighttime/activities)
Asthma control questionnaire
Triggers/ smoking status
Acute asthma frequency
Does px have a PAAP
Consider FeNO
Is px aware they can increase reliever dose when symptoms acutely deteriorate?
When would you consider decreasing therapy in asthma? (5)
Well controlled px who are eligible for deprescribing.
If decreasing therapy, do so in order that takes into consideration effectiveness of tx at time of introduction.
Consider px preference.
Don’t reduce anymore frequently than every 8-12 weeks.
Only decrease if satisfied the px has complete control and stable long-term.
Give e.g. of devices used in asthma. (3)
PMDI (standard/easi-breathe):
- Salbutamol evohaler/breath-actuated
- Fostair evohaler (formoterol/beclometasone), seretide evohaler (salmeterol/fluticasone)
- Standard pMDI suitable for use with spacer devices.
Soft mist (Respimat):
- Spiriva Respimat (Tiotropium)
Dry Powder Inhalers:
- Turbohaler - Symbicort (Formoterol/budesonide), Pulmicort (budesonide)
- Breath actuated - DuoResp (formoterol/budesonide)
- NEXThaler - Fostair (formoterol/beclomethasone)
- Accuhaler - seretide (salmeterol/fluticasone)
- Ellipta - Incruse (umeclidinium)
- Breezehaler (Sebring (glycopyrrinium)
- Genuair (Eklira (aclidinium)
Rightbreathe
State the importance of inhaler technique. (6)
Poor inhaler technique associated with poor control.
Must review technique annually.
Manage px expectations.
Determine specific px problems with using inhalers: perceived lack of benefit, dexterity issues, are, difficulty handling, improper inhalation technique etc.
Needed px centred approach.
What do you need to consider when selecting devices? (4)
Common brands, active ingredients, types of inhaler regimens.
Inhaler choice based on technique, lowest environmental impact, px inspiratory effort and px preference.
If px on multiple inhalers, maintain same device type.
For children, preferred to have them on pMDI can be used with spacers also can use Easi/breathe forms.
Explain the use of spacer devices. (7)
Aero chamber plus
Volumetric with/without paediatric mask.
Works with pMDI inhalers only
Useful for those:
- With difficulty using pDMI due to technique problems.
- Who experience oral thrush regularly with ICS .
Replaced every 6-12 months.
Cleaned once per month (Warm soapy water must be left to air dry.)
What should be given to px to support self-management of asthma? (6)
All px given a personalised asthma action plan:
- Written instructions on how to improve control during short term deterioration. Aims to prevent deterioration of acute asthma.
- Based on PEFR, Symptom control.
- Clearly outlines px specific triggers
- Annually reviewed
Explain the use of the asthma action plan.
Explain the management of chronic asthma in patients < 5 yrs. (4)
Diagnosis difficult in objective testing.
8-12 weeks trial of low-dose ICS BD with prn SABA.
Can increase to moderate paediatric ICS dose if remains poorly controlled.
Can add it paediatric dose of Montelukast if symptoms remain poorly controlled, trailled for 8-12 weeks.
