Asthma Flashcards
Normal expiration:inspiration ratio should be ?
2:1
Differentials
COPD (less daily/diurnal variation and in smokers)
HF
CHD
Malignancy
GORD
Vocal cord dysfunction
Fibrosis
Recurrent PE
TB
How often should asthma be reviewed?
At least annually
What should be asked at an asthma review?
Questions:
- Do they have difficulty sleeping? (incl cough)
- Do they have Sx during the day
- Does it interfere with ADL
- Any exacerbations in the last year- use of oral steroids and time off work.
Peak flow/spirometry
Inhaler technique
Check adherence and reliance on bronchodilators
Smoking
Flu jab annually
Depression screen
Patient ownership and use of action plan - review and update this if necessary.
What amount of bronchodilator use indicates poor control?
> 2 cannisters/month or 10-12 puffs per day indicates poor control, high risk.
What are the four aims of asthma management?
Symptom control
Reduce exacerbations and need for rescue meds
Achieve best lung function
Reduce SEs
What are the steps of asthma management?
- SABA PRN
- regular preventer: SABA + ICS
- initial add on
- additional add on
- high dose
- continuous or frequent use of oral steroids
> ? doses SABA suggests they might need to step up the ladder?
3 per week
What is involved in step 3 initial add on?
Keep SABA and ICS
Add LABA (often combination inhaler)
What is involved in step 4 additional add on
SABA
LABA didn’t work- stop and consider increasing dose ICS
LABA worked but still inadequate-
a) continue and increase ICS to medium dose
b) continue all and consider trialling others- LTRA, SR theophylline, LAMA
What is involved in step 5 high dose therapies?
Trial increasing ICS to high dose or adding a fourth drug e.g. LTRA, SR theophylline, LAMA, beta agonist tablet.
Refer
What is involved in step 6 continuous or frequent use of oral steroids?
Use daily steroid tablet in the lowest dose providing adequate control. Maintain high dose ICS. Consider other Rx to minimise use of steroids.
Refer
Complications of asthma
Pneumonia
Pneumothorax
Pneumomediastinum
Resp failure and arrest
What is involved in step 2 regular preventer?
200-800micrograms e.g. beclametasone
Give an example of a LTRA
Montelukast
Give an example of a LABA
Salmetrol
Is there a diagnostic test for asthma?
No, tests just increase probability
How to diagnose asthma?
Clinical assessment to determine probability
What is involved in a clinical assessment to determine asthma probability?
a) history of recurrent episodes of symptoms (ideally corroborated with variable peak flow)
b) symptoms of wheeze, cough, breathlessness, chest tight
c) wheeze recorded by health professional in notes (and variable PEFR or FEV1)
d) personal or FHx atopy
e) no suggestion of alternative diagnosis
What is the purpose of spirometry?
Demonstrate obstruction
Give baseline to assess response to treatment
Exclude alternative diagnosis
Does normal spiro in asymptomatic rule out asthma?
No
What should you do if the pt has a high probability of asthma?
Record this (code as susp asthma) and start treatment (6w ICS)
Assess response objectively with lung function or a validated symptom questionnaire and ideally FEV1/home PEFR
If good response- confirm diagnosis
If poor- check technique and adherence, further tests/alt diagnosis.
What should you do if the patient has a medium probability of asthma?
Test for airway obstruction (spiro and bronchodilator reversibility)
Investigation options:
- Test for variability (reversibility, PEFR charts, challenge tests)
- Test for inflammation/atopy (FeNO- exhaled nitric oxide-, blood eosinophils, skin-prick test, IgE)
If suspected asthma- watchful waiting if asymptomatic, or commence treatment and assess response objectively
Poor response- investigate other diagnosis.
What if someone has a low probability of asthma?
Investigate/treat for more likely diagnosis
