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Primary Care > Asthma > Flashcards

Asthma Flashcards

1
Q

Define Asthma.

A
  • Chronic inflammatory disorder of the airways characterized by variable and reversible airflow obstruction due to bronchial hyper-responsiveness
  • Characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough
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2
Q

What are the 2 key defining features of asthma? (GINA)

A
  1. A history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity AND
  2. Variable expiratory airflow limitation
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3
Q

What % of the population has asthma?

A
  • ~7%
    • May develop at any age, although less common as get older
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4
Q

What is a differential diagnosis (15) for a cough?

A
  • Upper Airway Disorders
    • Foreign-body aspiration
    • Tracheomalacia
    • Angioedema and anaphylaxis
    • Vocal cord paralysis
    • Laryngotracheal mass
  • Lower Airway Disorders
    • Asthma
    • Bronchiolitis
    • COPD
    • Bronchiectasis
    • Cystic fibrosis
    • Pneumonia
  • Other (often cough predominant)
    • CHF
    • GERD
    • PE – consider CT if not improving on treatment
    • Churg-Strauss syndrome
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5
Q

What is the classic triad on history for asthma?

A
  • Episodic dyspnea
  • Cough
  • Wheezing
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6
Q

At what age can children reliably cough up sputum?

A
  • +9 years old
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7
Q

What are 5 important symptoms to ask about in a patient presenting with asthma?

A
  • Wheezing – high-pitched whistle sound
    • Cough variant asthma do not wheeze
    • If poor air entry, then cannot wheeze (Status Asthmaticus)
  • Cough worse at night
    • May be only symptom
    • Before age 9 cannot reliably cough up sputum
  • Dyspnea – stops from participating in activities that peers can do
    • Subjective SOB does not correlate with the FEV1 or severity of disease
  • Chest tightness, heavy – rarely sharp
  • Rhinosinusitis 80% associated
    • Treating PND helps with asthma
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8
Q

What are 7 potential asthma triggers? (GINA)

A
  • Exercise
  • Cold air
  • Viral URIs – fever
  • Domestic and Occupational Allergens
    • House dust mite
    • Pollens
    • Cockroach
  • Smoking and 2nd hand smoke
  • Stress
  • Drugs
    • Beta-blockers
    • ASA
    • NSAIDs
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9
Q

What is commonly seen in patients with aspirin-exacerbated respiratory disease? (GINA)

A
  • Severe asthma
  • Nasal polyposis
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10
Q

What is important to ask on family history in a patient presenting with asthma?

A
  • History of Atopy
    • Eczema
    • Asthma
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11
Q

What is important to ask an asthma patient about regarding their asthma control?

A
  • Prior ER visits
  • Doses of prednisone per year
  • ICU admission
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12
Q

What are 9 criteria to measure asthma control? (CTS)

A
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13
Q

Which age group has the highest rate of emergency department visits and hospital admissions for asthma symptoms? (CTS)

A
  • Preschoolers (1-5 years)
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14
Q

In which preschool (1-5 years) children should the diagnosis of asthma be considered? (CTS)

A
  • Frequent (≥8 days/month) asthma-like symptoms OR
  • Recurrent (≥2) exacerbations (episodes with asthma-like signs)
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15
Q

What is required for the diagnosis of asthma in preschoolers? (CTS)

A
  • Objective documentations of signs (or convincingly reported symptoms) of airflow obstruction
    • Personal atopy (e.g. eczema, food allergy) or family history of asthma increase suspicion but are not necessary for diagnosis
  • Reversibility of airflow obstruction
    • Documented response to SABA (with or without OCS) by health care professionals during an acute exacerbation
    • In children with NO objective signs of airflow obstruction (i.e. only symptoms) then can be determined by either:
      • 3-month therapeutic trial of medium dose inhaled corticosteroids (200 ug to 250 ug) with SABA prn OR SABA prn
  • Absence of an alternative diagnosis
    • Recurrent URTIs with postnasal drip
    • Croup
    • Bronchiolitis (1st episode usually <1 year of age)
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16
Q

What is the preferred diagnostic method for asthma in preschoolers? (CTS)

A
  • Recurrent (≥2) episodes of asthma-like symptoms AND WHEEZING ON PRESENTATION
  • Direct observation of improvement with inhaled bronchodilator (with or without OCS) by a physician or trained health care practitioner confirms the diagnosis
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17
Q

Why is a minimum 3-month trial of moderate dose ICS suggested to diagnose asthma in preschoolers? (CTS)

A
  • Onset of action within 1-4 weeks
  • Efficacy within 3-6 months
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18
Q

Which ICS is recommended for preschoolers with suspected asthma and why? (CTS)

A
  • Fluticasone
    • Studied most effectively along with budesonide
    • Budesonide only available for use by nebulization in Canada in children
    • MDI preferred route
    • Fluticasone shows less effect on growth than budesonide at equivalent dose
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19
Q

What should be monitored in preschoolers to assess response to a 3-month trial of ICS in suspected asthma? (CTS)

A
  • Asthma Diary
    • Daytime and nighttime symptoms
    • Rescue SABA use
    • Effort limitation
    • Absenteeism from usual activities
    • Exacerbations requiring unscheduled medical visits
    • Oral corticosteroids and/or hospital admission
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20
Q

What should be done for preschoolers in whom there is an unclear response to a trial of ICS for suspected asthma? (CTS)

A
  • Dechallenge – stopping therapy for a period of observation of 3-6 months or until recurrence of symptoms, whichever occurs first
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21
Q

What are 5 reasons to refer to an asthma specialist for consultation or comanagement in preschoolers? (CTS)

A
  • Diagnostic uncertainty or suspicion of comorbidity
  • Repeat (≥2) exacerbations requiring rescue OCS or hospitalization or frequent symptoms (≥8 days/month) despite moderate (200 ug to 250 ug) daily doses of ICS
  • Life-threatening event such as an admission to the ICU
  • Need for allergy testing to assess the possible role of environmental allergens
  • Other considerations (parental anxiety, need for reassurance, additional education)
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22
Q

What % of children with asthma become asymptomatic by the age of 6? (CTS)

A
  • 60%
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23
Q

What is the normal FEV1/FVC ratio in adults and children? (GINA)

A
  • Adults > 0.75-0.80
  • Children > 0.90
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24
Q

What is the gold standard for diagnosis of asthma?

A
  • PFTs – Reversible Obstruction
    • FEV1/FVC <0.8
    • >12% (and 200 mL improvement in adults) with bronchodilators
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25
Q

What are 3 methods to diagnose asthma? (CTS)

A

***GINA = average daily diurnal PEF variability is >10% (in children, >13%)

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26
Q

Distinguish between bronchiolitis, croup and foreign body aspiration from asthma and how they would be managed?

A
  • Bronchiolitis
    • First episode of wheezing in contact of respiratory infection (RSV)
    • Treatment
      • Reassure, hydration, monitor respiratory status
      • SABA or Epinephrine if moderate symptoms
      • No antibiotics
      • Unless atopic child or recurrent, do NOT use prednisone
  • Croup
    • Upper respiratory wheezing – stridor
    • Parainfluenza virus
    • Febrile, non-toxic, barking cough
    • Treatment
      • Blow-by humidified oxygen, Dexamethasone
  • Foreign body aspiration
    • History of playing with small object
    • No atopy
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27
Q

In a patient with cough as the only respiratory symptom, what is the differential diagnosis? (GINA)

A
  • Cough variant asthma
  • Chronic upper airway cough syndrome (‘post-nasal drip’)
  • Chronic sinusitis
  • GERD
  • Vocal cord dysfunction
  • Eosinophilic bronchitis
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28
Q

What is the most frequent finding on physical examination in patients with asthma? (GINA)

A
  • Wheezing on auscultation (especially on forced expiration)
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29
Q

What is the recommended maintenance therapy and matching step-up therapy for preschoolers, children and adults (12 and over)?

A
  • Can try intermittent high dose (750 mg Flovent) for children with recurrent viral associated wheezing (if persistent, trial daily therapy)
    • Low-medium dose is not effective
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30
Q

Name 11 potentially modifiable independent risk factors for asthma exacerbations? (GINA)

A
  • Uncontrolled asthma symptoms (e.g. daytime symptoms, night waking, reliever needed >2x/week, activity limitation)
  • ICS not prescribed; poor ICS adherence; incorrect inhaler technique
  • High SABA use (with increased mortality if >1x200-dose canister/month)
  • Low FEV1, especially <60% predicted
  • Major psychological or socioeconomic problems
  • Exposures: smoking, allergen exposure if sensitized
  • Comorbidities: obesity; rhinosinusitis; confirmed food allergy
  • Sputum or blood eosinophilia
  • Pregnancy
  • Ever being intubated or in ICU for asthma
  • Having 1 or more severe exacerbations in the last 12 months
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31
Q

Define an asthma flare-up or exacerbation and what terminology is preferred. (GINA)

A
  • An acute or sub-acute worsening in symptoms and lung function from the patient’s usual status
  • ‘Flare-up’ is preferred
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32
Q

How would acute management in the ER differ for mild, moderate, severe and near death asthma attacks and how would they present?

A

Assessment

Clinical

Treatment

Mild

  • Exertional SOB/cough
  • Nocturnal symptoms
  • Increased SABA use with good response
  • Speaks in sentences
  • FEV1 >60% predicted
  • PEF >300L/min
  • Oxygen
  • SABA
  • Consider steroids

Moderate

  • SOB at rest
  • Cough
  • Partial relief from SABA
  • SABA use >8x/day
  • Chest tightness
  • Speaks in phrases
  • FEV1 40-60% predicted
  • PEF 200-300L/min
  • Oxygen
  • SABA
  • Anticholinergics
  • Steroids

Severe

  • Laboured breathing
  • Difficulty speaking
  • Agitated
  • Diaphoretic, Tachycardic
  • No relief from SABA
  • Speaks in words
  • O2 sat <90%
  • FEV1 <40% predicted
  • PEF <200L/min
  • 100% O2
  • Continuous SABA
  • Anticholinergics
  • IV Steroids
  • IV 2g Magnesium sulfate as a last ditch
  • IV SABA
  • Telemetry, O2 sat, ABG, CXR
  • Consider BI-PAP, must be awake, monitor for barotrauma and hypotension
  • Consider Inubation
  • Consider IM Epi

Near Death

  • Exhausted
  • Confused
  • Diaphoretic, cyanotic
  • Failing heart rate
  • Near death
  • Can’t speak
  • O2 sat <90%
  • FEV1 and PEFR not appropriate
  • Ventolin 4-8 puff or 2.5-5mg (0.15mg/kg/dose, min 2.5mg) in 3cc neb q20min x3
  • Atrovent 4-8 puffs or 250-500mcg (<2 years 125mcg/dose) in same neb q20min x3
    • Delayed effect. No benefit to greater than 3 treatments.
  • Prednisone 50mg or 1mg/kg x 3-10 days. First dose within the hour at the ER. No taper needed with doses less than 10 days
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33
Q

What steroid is best for the treatment of pediatric asthma exacerbations and why? (TFP)

A
  • 1-2 doses (2 days) dexamethasone 0.6 mg/kg (safe and effective, no difference in relapse rates as 5-day course of prednisone)
  • NNT = 20 for reduced vomiting compared to prednisone
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34
Q

What finding on examination would be most concerning for an asthma exacerbation and how should it be treated? (GINA)

A
  • Silent chest
    • Inhaled SABA
    • Inhaled Iptratropium bromide
    • Oxygen
    • Systemic corticosteroids
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35
Q

What criteria would allow a patient with asthma to be discharged home from the ER after an asthma attack?

A
  • Ventolin longer than q4h
  • Never had a prior ICU admission
    • Must be admitted regardless
  • No recurrent ER visits or admissions
  • PEF > 300, or >70%, never if less than 200 or 40%
  • Improvement on steroids
    • If not improvement by 6h, unlikely to occur
  • Nothing trumps clinical judgement
  • Use Ventolin q4h for 48h with aerochamber and steroids
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36
Q

What investigations would you consider performing in a patient with an asthma attack in the ER?

A
  • CXR if not improving, moderate to severe symptoms or comorbidities
  • Potassium – can get low with repeated dosing of Ventolin
  • PEF pre and post treatment
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37
Q

Why should regular daily controller treatment be initiated as soon as possible after the diagnosis of asthma is made? (GINA)

A
  • Early treatment with low dose ICS leads to better lung function than if symptoms have been present for more than 2-4 years
  • Patients not taking ICS who experience a severe exacerbation have lower long-term lung function than those who have started ICS
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38
Q

For which patients (3) is regular low dose ICS recommended? (GINA)

A
  • Asthma symptoms more than 2x per month
  • Waking due to asthma more than 1x per month
  • Any asthma symptoms plus any risk factor(s) for exacerbations (e.g. needing OCS for asthma within the last 12 months; low FEV1; ever in ICU for asthma)
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39
Q

What are 5 lifestyle management suggestions for the chronic management of asthma?

A
  • Reduce allergen exposure – animal dander, dust, pollen, mold, pollution
  • No smoking
  • ASA induced, nasal polyps and rhinosinusitis triad
    • Avoid NSAIDs – blocking PG synthesis shifts the pathway towards bronchoconstrictors
  • Immunizations – Flu and Pneumococcal
  • Inhaler technique
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40
Q

When would you consider stepping down asthma treatment and what is NOT advised? (GINA)

A
  • Symptoms controlled for 3 months + low risk for exacerbation
  • Ceasing ICS is NOT advised
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41
Q

How should ICS dose be stepped down when asthma is well controlled? (GINA)

A
  • Reduce ICS dose by 25-50% at 2-3 month intervals
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42
Q

Should LABAs be used as monotherapy for asthma in any age group? (CTS)

A
  • NO
43
Q

If low-dose ICS is not adequate to maintain asthma control, what is the next step in children 6-11 years old and adults 12+ years? (CTS)

A
  • 6-11 – Increase to Medium-dose ICS
  • 12+ - Add a LABA to low-dose ICS
44
Q

If medium-dose ICS is not adequate to maintain asthma control, what is the next step in children 6-11 years old? (CTS)

A
  • Addition of either a LABA or LTRA
45
Q

If LABA+ICS is not adequate to maintain asthma control, what is the next step in adults 12+ years? (CTS)

A
  • Consider addition of LTRA
  • Consider referral to specialist
46
Q

What is the recommended controller therapy by age? (CTS/DFCM)

A

6-11 years old

>12 years old

First-line

Low dose ICS

Low dose ICS

Second-line

Medium dose ICS

Low dose ICS + LABA

Third-line

Medium dose ICS + LABA

OR

Medium dose ICS + LTRA

Medium dose ICS + LABA

OR

Medium dose ICS + LABA + LTRA

47
Q

What would management options be for asthma in patients < 6 years old?

A
  • Can only suspect diagnosis and confirm based on response to treatment
  • Same management as ages 6-11, but consider referral 1 step before
  • Use lowest effective dose
48
Q

What would management options be for asthma in patients 6-11 years old?

A
  • Lifestyle management – decrease allergens, no humidifier, action plans
  • Intermittent asthma
    • SABA prn
      • QID standing with viral respiratory illness for 24h
  • Persistent daily asthma
    • Low dose ICS
      • Second line LTRA if allergic component
    • Medium dose ICS – consult if not controlled
    • Add LABA or LTRA
    • Prednisone
49
Q

What would management options be for asthma in patients >12 years old?

A
  • Lifestyle management – decrease allergens, no humidifier, action plans
  • Intermittent asthma
    • SABA prn
      • QID standing with viral respiratory illness for 24h
  • Persistent daily asthma
    • Low dose ICS
      • Second line LTRA if allergic component
    • Add LABA – consult if not controlled
    • Add LTRA if not done already
    • Anti IgE (Omalizumab) or Prednisone
50
Q

For purely seasonal allergic asthma, how should ICS be prescribed? (GINA)

A
  • Start ICS immediately and cease 4 weeks after end of exposure
51
Q

What is the 5-step approach for adjusting asthma treatment? (GINA)

A
  • Step 1 – as-needed SABA with no controller
    • Symptoms are rare, no night waking due to asthma, no exacerbations in the last year
    • Normal FEV1
  • Step 2 – regular low dose ICS plus as-needed SABA
  • Step 3 – low doses ICS/LABA either as maintenance treatment plus as-needed SABA, or as ICS/formoterol maintenance and reliever therapy
  • Step 4 – low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as maintenance plus as-needed SABA
  • Step 5 – refer for expert investigation and add-on treatment
52
Q

What would management options be for asthma in patients >18 years old?

A
  • In moderate to severe asthma, can monitor sputum eosinophilia as a measure of asthma control
53
Q

What should patients with asthma be educated about?

A
  • Consider allergy testing if appear to be predominant feature
  • Make a trigger log and avoid triggers
  • Progressive decline in lung function if not controlled and can be minimized if start effective treatment
  • YouTube videos for inhaler technique
  • No beta-blockers
54
Q

How often should PFTs be performed to monitor patients with asthma? (GINA)

A
  • FEV1 at start of treatment
  • FEV1 after 3-6 months of controller treatment to record personal best lung function
  • Periodically for ongoing risk assessment
55
Q

What should be included in a written asthma action plan? (GINA)

A
  • The patient’s usual asthma medications
  • When and how to increase medications and start OCS
  • How to access medical care if symptoms fail to respond
56
Q

How should patients be told to increase their controller in written asthma action plans? (GINA)

A
  • Rapid increase in ICS component up to max 2000 mcg BDP equivalent
  • Type of ICS Controller

Dose Increase

ICS

At least double dose

Maintenance ICS/formoterol

Quadruple maintenance ICS/formoterol dose (max formoterol dose 72 mcg/day)

Maintenance ICS/salmeterol

Step up at least to higher dose formulation; consider adding separate ICS inhaler to achieve high ICS dose

Maintenance and reliever ICS/formoterol

Continue maintenance dose; increase as-needed ICS/formoterol (maximum formoterol 72 mcg/day)

57
Q

How should patients be told to increase OCS in the written asthma action plans? (GINA)

A
  • Adults – prednisolone 1 mg/kg/day up to 50 mg, usually for 5-7 days
  • Children – 1-2 mg/kg/day up to 40 mg, usually for 3-5 days
  • Tapering not needed if treatment has been given for less than 2 weeks
58
Q

For children being given OSA, what should practitioners ensure the child is immunized against? (CTS)

A
  • Chickenpox
59
Q

How would you educate patients with asthma on using a MDI, Diskus, Turbuhaler and Handihaler?

A
  • MDI (require SPACER)
    • Shake and then attach aerochamber – take at least 6 breaths if can’t hold their breath or are children
    • Breathe out all the way, press MDI, then breathe in and breathe several breaths through aerochamber – repeat in 5 min
    • Must wait 1 min between puffs
    • Must prime dose with 1 puff (if not used in the last few days)
    • Must reshake MDI after 2 puffs
  • Diskus and Turbuhaler
    • Do NOT require spacer
    • <6 years CANNOT generate required inspiratory force necessary to use
    • When breathing out, do so away from the inhaler
  • Handihaler (Spiriva)
    • Must inhale 2x for each dose
60
Q

What should be included in an action plan for patients with asthma?

A
  • When symptoms increase:
    • Allow patients to self-titrate medications with worsening symptoms
    • Give patients clear indications of when to seek help
61
Q

When would you consider a referral for a patient with asthma?

A
  • < 6 years – not controlled on low dose ICS
  • < 12 years – not controlled on moderate ICS
  • ≥12 years – not controlled on ICS/LABA
  • Frequent oral steroids
62
Q

At what age are children unlikely to have the required inspiratory force to use inhalers other than an MDI?

A
  • < 6 years
63
Q

What forms does salbutamol come in and at what dose?

A
  • Ventolin HFA (MDI) – 100 mcg
  • Ventolin Diskus – 20 mcg
64
Q

What are potential adverse effects of salbutamol use?

A
  • Tachycardia
  • Nervousness
  • Headache
  • Dizziness
  • Tremor
  • Palpitations
  • Increased QT
  • Decreased K
  • Tachyphylaxis
  • Hyperglycemia in DM
65
Q

How would you prescribe salbutamol for acute and chronic asthma in adults and children <12?

A
  • Adults
    • Acute
      • 4-8 puffs q20min MDI for up to 4 hours, then q1-4h
      • 2.5-5 mg neb q20min for 3 doses, then 2.5-10mg q1-4h
    • Chronic
      • 1-2 puffs QID prn MDI or 1 puff QID prn Diskus
  • Children (< 12)
    • Acute
      • 4-8 puffs q20min MDI x3 doses, then q1-4h
      • 0.15 mg/kg (2.5mg minimum) neb q20min x3 doses, then 0.15-0.30 mg/kg (10 mg maximum) q1-4h
66
Q

What is another type of SABA that can be prescribed for asthma and what is the advantage of it?

A
  • Terbutaline (Bricanyl Turbuhaler)
  • 1 inhalation, if not effective after 5 minutes may repeat dose
  • Max is 6 inhalations in a 24-hour period
67
Q

What is the difference between salbutamol and terbutaline in regards to age of starting treatment? (DFCM)

A
  • Salbutamol ≥4-years
  • Terbutaline ≥6-years
68
Q

What is considered regular use of a SABA necessitating adjunct therapy for asthma? (CTS)

A
  • >3 doses per week
69
Q

Should LABA be used as monotherapy for asthma? Why or why not? (TFP)

A
  • LABA should NOT be used without ICS
  • Increased risk of serious adverse events
    • FDA meta-analysis of 110 trials found 2.8 extra events (asthma-related death, intubation and hospitalization) per 1000 asthmatic patients treated with LABA inhalers (NNH = 358)
  • No clear increased risk of adverse events with ICS+LABA
    • Not statistically significant (NNH = 3,334)
70
Q

What is a FABA and is it recommended as a reliever for asthma? (CTS)

A
  • Fast-acting beta2-agonist (FABA) – SABA or fast-acting LABA (e.g. Formoterol)
  • Use of formoterol alone (without an ICS) as a reliever in asthma is NOT recommended and it is not approved for this indication in Canada
71
Q

What is recommended as reliever therapy for asthma in all patients with mild asthma? (CTS)

A
  • SABA
    • Including individuals not on controller therapy and those on ICS monotherapy)
72
Q

When would BUD/FORM (budesonide/formoterol) be considered as a reliever therapy for asthma? (CTS)

A
  • Adults (12+ years) with poor controlled on maintenance ICS/LABA
73
Q

What forms does fluticasone come in and at what dose?

A
  • Flovent HFA (MDI) – 50, 125 and 250 mcg
  • Flovent Diskus – 50, 100, 250 and 500 mcg
74
Q

What are potential adverse effects of fluticasone use?

A
  • Thrush (Oropharyngeal Candidiasis) – rinse after each use
  • Short-term growth deceleration – achieve adult height but takes longer
  • Dysphonia, cough at time of inhalation, sore throat
  • With high dose – osteoporosis, adrenal suppression, cataracts, glaucoma
  • Flovent Diskus has lactose in it – caution with lactose allergy but not intolerance
75
Q

What can be done to reduce the local adverse effects of ICS? (GINA)

A
  • Rinse mouth with water and spit out after inhalation
76
Q

What are 3 important points to tell patients when prescribing fluticasone?

A
  • Need to give 2 puffs BID to achieve required dose
  • Takes 4 weeks to achieve maximal effect
  • If stable, can decrease by 25% q3months if desired
77
Q

What dose should you prescribe fluticasone for asthma based on age?

A

<12 years old

>12 years old

Low

Medium

Low

Medium

<200

200-400

<250

250-500

78
Q

What is the combination of fluticasone (ICS) and salmeterol (LABA) called?

A
  • Advair (Purple)
79
Q

What doses does Advair come in and how should it be prescribed?

A
  • Advair HFA (MDI) – 125/25 and 250/25 mcg
    • Max 2 puffs BID for maintenance
  • Advair Diskus – 100/50, 250/50 and 500/50 mcg
    • Max 1 puff BID for maintenance
80
Q

Is Advair suitable as an on demand reliever for asthma?

A
  • No
81
Q

What is the max dose that children 4-11 years can use Advair for asthma?

A
  • 200/100 per day
82
Q

What are side effects of LABAs to warn patients taking Advair for asthma?

A
  • Elevated BP
  • Tachycardia
  • Hypokalemia
  • Caution if epilepsy due to CNS stimulation
83
Q

What forms does budesonide come in and at what dose?

A
  • Pulmicort Turbuhaler – 100, 200, 400 mcg
84
Q

What dose should you prescribe fluticasone for asthma based on age?

A

<12 years old

>12 years old

Low

Medium

Low

Medium

<400

400-800

<400

400-800

85
Q

What is the combination of budesonide (ICS) and formoterol (LABA) called?

A
  • Symbicort
86
Q

What doses does Symbicort come in and how should it be prescribed?

A
  • Symbicort Turbuhaler – 100/6 and 200/6
    • Maintenance 1-2 puffs BID
    • Maximum 8 puffs daily
87
Q

What is the max dose that children 5-11 years can use Symbicort for asthma?

A
  • Max 4 inhalations per day (Symbicort 80/4.5)
88
Q

What is SMART for asthma?

A
  • Symbicort Maintenance and Reliever Therapy
    • Can be used for maintenance and reliever therapy
    • Maintenance: 1-2 puffs BID or 2 puffs once daily
    • Reliever: 1 additional inhalation as needed, may repeat if not relief for up to 6 inhalations total (maximum: 8 inhalations/day)
89
Q

What is recommended for reliever therapy in exacerbation-prone individuals 12 years of age and over with moderate asthma and poor control on a fixed-dose maintenance ICS/LABA combination? (CTS)

A
  • Budesonide/Formoterol
90
Q

What leukotriene receptor antagonist (LTRA) can be prescribed for asthma or for allergic rhinitis?

A
  • Montelukast (Singulair)
  • 10 mg tablet once daily
91
Q

At what age can patients with asthma use LTRAs as an acceptable, second-line, daily monotherapy? (CTS)

A
  • Children 6+
92
Q

When would montelukast be used first line for asthma?

A
  • Allergy-related – if always allergic trigger
93
Q

What dose of montelukast would you prescribe for asthma based on age?

A
  • 2-5 years – 4 mg
  • 6-14 years – 5 mg
  • >15 years – 10 mg
94
Q

What should you monitor on patients started on montelukast (Singulair)?

A
  • Monitor baseline and periodic LFTs
95
Q

When should the maximum effect be seen with montelukast (Singulair)?

A
  • Maximum effect within 6 weeks
  • Starts within 2 days
96
Q

How do LTRAs compare to ICS and ICS+LABAs for treating pediatric asthma? (TFP)

A
  • Inferior to ICS monotherapy
    • NNH = 21 for extra exacerbation
  • Inferior as add-on to ICS compared to ICS+LABAs
97
Q

What subgroups of asthma has LTRAs demonstrated some benefit? (TFP)

A
  • Allergic rhinitis
  • Exercise induced bronchospasm
  • Specific genotypes
98
Q

What is the benefit of adding Tiotropium as add-on therapy for patients with moderate-severe asthma already on an ICS or ICS+LABA? (TFP)

A
  • Addition of Tiotropium prevents exacerbations for 1 in 18-36 patients over 4-52 weeks
99
Q

What delivery system is recommended for Tiotropium in asthma and what is the potential concern with this? (TFP)

A
  • Respimat (aqueous solution soft mist inhaler)
  • Possibility of increased mortality with tiotropium delivered via the Respimat inhaler in COPD (particularly those with cardiovascular disease and arrhythmias)
100
Q

How would you prescribe prednisone for asthma exacerbations?

A
  • 50 mg OR 1-2 mg/kg x3-10 days
  • Watch for acute bone necrosis and glaucoma, osteoporosis, immunosuppression
101
Q

How would you manage pregnant patients with asthma?

A
  • Treat as needed
  • SABA and ICS safe
  • Less data on LABA and LTRAs – use only if needed
  • Systemic steroids are safe but…
    • Increased risk of pre-eclampsia, hemorrhage, low birth weight, preterm birth and hyperbilirubinemia
102
Q

How often should pregnant patients with asthma be reviewed? (GINA)

A
  • Every 4-6 weeks
103
Q

What type of preschool children are more likely to have their asthma resolve in childhood?

A
  • Non-atopic child with minimal symptoms
104
Q

What are 3 symptoms that would make you consider a diagnosis of asthma in the elderly?

A
  • Dyspnea
  • Wheezing
  • Nocturnal cough

Primary Care (12 decks)

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