Asthma Flashcards
Asthma is defined by the presence of both of the
following:
1
2
- excessive variation in lung function
* respiratory symptoms (
What is meant by excessive variation in lung function
(‘variable airflow limitation’ i.e. variation in expiratory
airflow that is greater than that seen in healthy
people)
In young children in whom lung function testing
is not feasible, including most preschool children,
asthma is defined by the___________
presence of variable respiratory symptoms.
BA
It has an unacceptable mortality rate of
approximately________of the population.
5 per 100 000
BA
It tends to develop between the ages of _______ but can develop at any age
2 and 7 years,
Key test for BA
Spirometry is the key investigation
New aerosols, notably _________
have non-CFC propellants leading to increased
lung deposition and thus requiring overall lower
dosage.
hydrofluoroalkanes,
Pathophysio of BA
- infiltration of the mucosa with_______
- _________
- intermittent airway narrowing (due_______
inflammatory cells (especially eosinophils) and cellular elements
airway hyper-responsiveness
to bronchoconstriction, congestion or oedema of
bronchial mucosa or a combination of these)
About 90% of children with atopic symptoms
and asthma demonstrate ________
responses to dust mite extract
positive skin-prick
Classic Sx of BA
- wheezing
- coughing (especially at night)
- tightness in the chest
- breathlessness
Auscultation findings of BA
diffuse, high-pitched wheezes throughout inspiration and most of expiration, which is usually prolonged
If wheeze
is not present during normal tidal breathing it may
become apparent during a ______
forced expiration
Spirometry: a value of________ for FEV 1 /VC ratio
indicates obstruction. It is the more accurate test
and recommended for those who can perform it
(i.e. most adults and children >6 years).
<75%
Measurement of peak expiratory flow rate
(PEFR) or spirometry before and after SA β A: has
a characteristic_________
improvement >15% in FEV 1 and
PEFR.
__________ airway reactivity is
tested in a respiratory laboratory to inhaled
histamine, methacholine or hypertonic saline.
Sometimes useful to confirm diagnosis
Inhalation challenge tests:
Other tests for BA
Mannitol inhalation test.
An exercise challenge may also be helpful.
Significant advances in the management of asthma
The realisation that asthma is an inflammatory
disease. Therefore the appropriate first- or secondline
treatment in moderate to severe asthma
is ____ or _________
inhaled sodium cromoglycate (especially in
children) or inhaled corticosteroids (ICS).
Significant advances in the management of asthma
2 The regular use of _________
3 The use of spacers attached to_______
4 Improved and more efficient inhalers.
5 Combined________
spirometry.
inhalers/puffers.
long-acting relievers and preventers including combinations of long-acting β -agonists
(LA β A) and ICS—the fixed-dose inhalers.
Patients with moderate to severe chronic asthma
require regular measurement of ______ which is more
useful than subjective symptoms in assessing asthma
control
PEFR,
Goal of measuring PEFR
This allows the establishment of a baseline
of the ‘patient’s best’, monitors changes, and allows
the assessment of asthma severity and response to
treatment
______ are not a substitute for spirometry
Peak flow meters
Some people who have trouble using metered dose
inhalers (MDIs) can have a special________fitted onto
the mouthpiece of the inhaler
‘spacer’
Children under 5–6 years and/or 20 kg can use an
MDI and a ______
small volume valved spacer (AeroChamber,
Breath-A-Tech) with a face mask.
Goals of BA Tx
• absent or minimal _________
• maintain best possible lung function at all
times—keep asthma under control
daytime symptoms and no nocturnal symptoms; restore normal airway function (>80% of predicted)
Definition of good BA control
• Minimal symptoms day and night
• No nocturnal waking due to asthma
• No limitation of normal or physical activity
• Minimal need for reliever medication
• No exacerbation
• Normal lung function (FEV 1 and/or PEFR >80%
predicted or best)
• No side effects of medication
• Near or near-normal lung function (i.e. >80%
predicted)
These medications are directed towards the
underlying abnormalities—bronchial hyperreactivity
and associated airway inflammation
‘Preventer’ drugs or anti-inflammatory
agents
Treatment with a ‘preventer’ is recommended if asthma
episodes are ______ or those who use SA β A____
> 3/week
>3 times a week
ICS types
- beclomethasone
- budesonide
- ciclesonide (single daily dose)
- fluticasone
Dose range of ICS
• 400–1600 mcg (adults); aim to keep below 500
mcg children and 1000 mcg (adults)
SE of ICS
• oropharyngeal candidiasis, dysphonia (hoarse voice)—less risk with once daily\_\_\_\_\_\_\_ • bronchial irritation: cough • \_\_\_\_\_\_\_\_\_ (doses of 2000 mcg/daily; sometimes as low as 800 mcg)
ciclesonide
adrenal suppression
Intermittent BA
Status before treatment
Lung function FEV1 or PEFR (% predicted)
Episodic Symptoms
Intermittent BA
Recommended β-agonist
Estimated starting daily dose range of ICS
required to achieve good control
SAβA prn
Regular ICS not required Add preventer if ≥3 SAβA/week
Mild persistent
Status before treatment
Lung function FEV1 or PEFR (% predicted
Symptoms >weekly, not every day Night symptoms >2 per month Symptoms regularly with exercise
≥ 80%
Mild persistent
Recommended β-agonist
Estimated starting daily dose range of ICS
required to achieve good control
SAβA prn
<250 mcg beclomethasone <400 mcg budesonide <250 mcg fluticasone <160 mcg ciclesonide Increase dose if >2 SAβA 2–3 times daily
Moderate persistent
Status before treatment
Lung function FEV1 or PEFR (% predicted
Symptoms every day Night symptoms >weekly
Several known triggers apart from exercise
60–80 %
MOd persistent
Recommended β-agonist
Estimated starting daily dose range of ICS
required to achieve good control
LAβA + SAβA prn
250–400 mcg beclomethasone 400–800 mcg budesonide 250–500 mcg fluticasone 160–320 mcg ciclesonide
Severe persistent
Status before treatment
Lung function FEV1 or PEFR (% predicted
Symptoms every day Wakes frequently at night with cough/ wheeze, Chest tightness on waking, Limitation of physical activity
<60%
Severe persistent
Recommended β-agonist
Estimated starting daily dose range of ICS
required to achieve good control
LAβA + SAβA prn
>400 mcg beclomethasone >800 mcg budesonide >500 mcg fluticasone >320 mcg ciclesonide
ICSs have a________ curve so it may not
be necessary to prescribe above ICS doses considered
high
flat dose–response
________ is used mainly for exacerbations. It
is given with the usual inhaled corticosteroids and
bronchodilators
Prednisolone
Dose of Prednisolone
• up to 1 mg/kg/day for 1–2 weeks
These are sodium cromoglycate (SCG) and nedocromil
sodium
Cromolyns
AE for Cromolyns
local irritation may be caused by the dry powder. Systemic
effects do not occur.
_______is used for frequent episodic asthma
in children over 2 years of age for the prevention of
exercise-induced asthma and the treatment of mildto-
moderate asthma in some adults
Nedocromil
These drugs, which include montelukast and
zafirlukast, are very useful for seasonal asthma and
aspirin-sensitive asthma and reduce the need for
inhaled steroids or
Leucotriene antagonists
Montelukast is taken as a _________
5 or 10 mg chewable tablet once daily
Indications for preventive therapy
Guidelines for introducing preventive asthma therapy
in adults and children include any of the following:
- requirement of β 2 -agonist _______
- symptoms (non-exercise______
- spirometry showing ______
> 3–4 times each week or >1 canister every 3 months (excluding preexercise)
> 3–4 times per week between attacks
reversible airflow obstruction during asymptomatic phases
Indications for preventive therapy
Guidelines for introducing preventive asthma therapy
in adults and children include any of the following:
• asthma significantly interfering with physical
activity despite appropriate pre-treatment
• asthma attacks_______
• infrequent asthma attacks but ________
> every 6–8 weeks
severe or lifethreatening
The three groups of bronchodilators are
1
2
3
• the β 2 -adrenoceptor agonists ( β 2 -agonists)—
short acting (SA β A) and long acting (LA β A)
• methylxanthines—theophylline derivatives
• anticholinergics
These drugs ‘stimulate’ the β 2 adrenoreceptors and
thus relax bronchial smooth muscle. The inhaled
route of delivery is the preferred route
β 2 -agonists
Onset of B2 agonist
The inhaled drugs produce measurable
bronchodilation in 1–2 minutes and peak effects
by 10–20 minutes
The traditional agents such as _______are short-acting
preparations. The new longer acting agents (LA β A)
include____
salbutamol and terbutaline
salmeterol, eformoterol and vilanterol.
These oral drugs may have complementary value
to the inhaled agents but tend to be limited by side
effects and efficacy
Theophylline derivatives
This anti-IgE agent is marketed for SC injection in
patients >12 years with moderate to severe allergic
asthma treated by ICS and who have raised serum IgE
levels
Omalizumab
This term is reserved for those medications that are
taken prior to known trigger factors, particularly for
exercise-induced asthma
Prophylactic agents
Meds of exercise induced asthma
β 2 -agonist inhaler (puffer): two puffs 5 minutes
immediately before exercise last 1–2 hours. LA β A
such as salmeterol and eformoterol are more
effective
Other drugs for exercise induced asthma
• SCG or nedocromil, two puffs.
• Combination β 2 -agonist + SCG (5–10 minutes
beforehand).
• Montelukast 10 mg (less in children ≥ 2 years)
(o) daily or 1–2 hours beforehand
What are the 3 steps in BA control
Step 1: Assess asthma symptom control and
identify the patient’s risk factors
Step 2: Treat and adjust to achieve good control.
Step 3: Review response and monitor to maintain
control
For breakthrough asthma or persistent poorly
controlled asthma with poor compliance switch
to _________
combined medication (e.g. Seretide MDI Accuhaler, or Symbicort).
Techniques on how to use MDI
The open-mouth technique and the closed-mouth
technique are the main methods, and both are effective
but the _________ is preferred
closed-mouth technique
The usual dose of standard MDI is _____
one or two
puffs (adult) every 3–4 hours for an attack (four
puffs in children
The _______ is a breath-activated MDI which can
improve lung deposition in patients with poor inhaler
technique.
Autohaler
The _______ is a dry powder delivery system that
is widely used as an alternative to the MDI. It is a
breath-activated device
Turbuhaler
People who have experienced one or more of the
following are more likely to have severe attacks:
• previous severe asthma attack
• previous hospital admission, especially admission
to intensive care
• hospital attendance in the past 12 months
• long-term oral steroid treatment
• carelessness with taking medication
• night-time attacks, especially with severe chest
tightness
• recent emotional problems
• frequent SA β A use
Dangerous sign (pulse) associated with BA
Pulsus paradoxus
T or F
This is a good sign in BA
Chest becoming ‘silent’ with a quiet wheeze, yet
breathing still laboured
f
Patients who are sensitive to________
need to be reminded that salicylates are present in
common cold cure preparations and agents such as
Alka-Seltzer
aspirin/salicylates
The non-steroidal medications, ______, ________ or _________ by inhalation, are
the prophylactic drugs of choice in childhood chronic
asthma of mild-to-moderate severity.
montelukast (oral)
and SCG and/or nedocromil sodium
ICS in children
Any dose equal to or greater than _______ in children can have side effects, including growth suppression and
adrenal suppression
400 mcg
