Asthma Flashcards
Asthma History?
P: when was it diagnosed? Symptoms
R: FH, Occupational exposures, Smoking, Hayfever, Atopy, Triggers (seasonal, cold, dust, exercise, occupational, virus)
I: Spirometry, PFT, methacholine challenge, have you seen allergy specialist? (RAST or skin prick).
Compliance: how often you do peak flow (usual reading, variability - PF before & after bronchodilator), missing meds / appointments?
M: current regime, Home O2, Home nebs, asthma action plan
Complications: ABPA/Pseudomonas, Hospitalisations, ICU, intubation, steroid side effects (ICS + oral), how is it impacting you? (jobs, daily life), baseline ET
P: exacerbation last 12 months, current symptoms, unusual use of bronchodilators, understanding of own prognosis (insight), Advanced Care Plan
Asthma examination? (things to present)
SOB/tachypnoa/accessory muscle use at rest
Steroid features (ecchymosis, cushingoid, striae)
Tremor due to beta-agonists
Cyanosis
Polyphonic wheeze
FET
What is your approach in investigating this patient with suspected Asthma exacerbation?
T: confirm the dx (PFT, ask for previous metacholine challenge test), peak-flow (review patient’s chart - day-time/post bronch variability), spirometry (FEV1, reversibility), sputum MCS (?eosinophils or neutrophils)
E: CXR (pneumonia or infiltrate - ABPA), septic work up, CT chest if ABPA or PE suspected. Consider other alternative diagnosis (anaemia, HF..etc)
S: blood for inflammatory markers, ABG for RF
Screen complications: ABPA - eosinophils, IgE, aspergillus precipitins, Bronchiectasis (CT), Cor-pulmonale / pulmonary HTN (TTE), Steroids - DyDy the FAT HIPPO
What should in in an “Asthma self-management plan”? (5)
Individualised PEF readings (stable, exac, severe exac)
Medication / inhaler doses in each of above
Instructions to when to increase/decrease oral steroids
When to seek medical help
Contact details for GP/Pharm/ED
What is your approach in managing this patient’s asthma which is not well controlled currently?
Goals: control / minimise exacerbation, maximise function, prevent complications
Confirm Dx: PFT (obstructive/reversibility), metacholine challange, ascertain current status (PEF, Spirometry)
A: screen & treat associated conditions - GORD, infection, depression (poor compliance), smoking. Eosinophil, IgE (for biological therapy)
sputum culture - ABPA, bronchiectasis
T: Non-pharm
- Educate - importance of disease control in preventing life-threatening complications. Asthma educator
- Manage adherence & check inhaler technique
- Avoiding triggers & smoking cessation
- Adjust asthma management plan according to current status
- Vaccination, hygiene to minimise infection
T: Pharm
- Consider escalating to next ladder
- Increase PRN SABA, increase ICS dose or add LABA
- Consider oral steroids, LTRA
Involve family & GP for continued support and monitoring of adherence and inhaler techniques
F/U and review for progress & complications
- Again, PEF, spirometry, PFT - consider stepping down if disease well controlled
- ABPA work-up, TTE, CT (bronchiectasis), DEXA (OP)…ETC
What complications of Asthma would you screen for in a routine follow-up? (5)
Poor disease control
Pulmonary HTN / Cor-pulmonale
Bronciectasis
ABPA
Steroids-related complications, especially osteoporosis / infection
What are the treatment options for poorly controlled asthmatics despite maximal ICS, LABA and LTRA and still requiring frequent steroids and exacerbations?
Addition of LAMA (e.g. tiotropium)
Anti-IgE: omalizumab (SC), if evidence of sensitivity to allergens (allergy skin test, specific IgE or serum IgE significantly raised 30-700)
IL5 monoclonal Abs (Mepolizumab - SC, Resilzumab- IV)
IL5 receptor-alpha Abs (Benralizumab - SC)
IL-4 receptor-alpha Abs (Dupilimab - SC)
- IL4/IL5: require peripheral eosinophils level to be at least 150 / microL
Injections are 2-4 weekly
Bronchial thermoplasty (catheter via scope - burn off bronchial walls to impair smooth muscle contractility - debated)
What defines poorly controlled asthma? (5)
Not well controlled (very poorly controlled) - GINA
Symptoms >2 day/ week (throughout day)
Night time awakenings 1-3/week (≥4 / week)
Some limitation of normal activity (extremely limited)
SABA use >2 days / week (several times / day)
FEV1 60-80% (<60%)
5 steps of GINA strategy for Asthma treatments?
Step 1: ICS prn
- or, use PRN low dose ICS + Formoterol (rapid onset of action and long-acting, up to 12h)
Step 2: Regular low dose ICS
Step 3: Low-dose ICS-LABA
- Can use LAMA instead if LABA is contraindicated (but require 2 separate inhalers)
- or add LT (Montelukast) to low dose ICS (but less effective)
Step 4: Medium-dose ICS-LABA
Step 5: High-dose ICS-LABA, refer for phenotypic assessment for add on therapy (IgE, IL4/5 mabs…etc)
Consider LTRA, LAMA or Biologics add on.
Do you think this patient’s asthma is active?
She experiences SOB at least a number of times per weak, requiring the use of PRN salbutamol.
She also has nocturnal dyspnoea and reports that she can’t get as much work during the day.
So not under the control
Asthma monitoring?
History: nocturnal symptoms, how many times/wk (symptoms), impacting on work/life, frequent SABA use, hospital admissions or steroid use.
Exam: Respiratory + look for steroids side effects (e.g. oral candida)
Spirometry or PEF (spirometry is preferred, as PEF does not reliably distinguish between obs vs res)
Inhaler technique spiel? (5)
90% of MDI users or 50% of DPI (dry powder drugs) users have an incorrect technique
The inadequate technique results in poor disease control and consequent sub-optimal adherence
Involve educators
I would teach the patient inhaler technique: address common errors including not shaking the device before use, not breathing out, holding it horizontally (otherwise drug can escape), ensure to hold the breath for few seconds
- For MDIs: requires slow-steady inhalation
- For DPIs: requires a quick + deep inhalation
- Failing to do above increases the risk of drug impacting in mouth/throat
If the patient is using a spacer for pMDIs → ensure patient inhale straightaway - as the drugs only stay suspended in the spacer for a short amount of time
