Asthma Flashcards
Approach to asthma management for 6-11 year olds, as per GINA guideline?
Step 1: SABA prn is generally what we do, but for GINA, they make an off label recommendation of SABA-ICS prn. (In general, GINA’s emphasis on no SABA only treatment is a much stronger recommendation for adults/adolescents; they don’t make as strong of a statement for this age group)
Step 2: this is the step where you start daily therapy with daily low dose ICS
Step 3: GINA gives the option of low ICS-LABA or medium dose ICS
Step 4: medium dose ICS/LABA
Approach to asthma management for 6-11 years olds, as per CTS guidelines?
Step 1: SABA prn
Step 2: low dose ICS
Step 3: medium dose ICS
Step 4: medium ICS with LABA or LTRA (so at this step, CTS gives an option. GINA seems to be more pro LABA)
What are the differences between GINA and CTS for managing asthma in 6-11 years of age?
- Step 1 is mostly similar, though GINA technically mentioned ICS prn with SABA
- Step 2: GINA gives an option of adding LABA versus medium dose ICS, but CTS does not
- Step 3: CTS gives option of either adding LABA or LTRA to medium dose ICS
Medium dosing for various ICS in 6-11 years and >12 years of age?
For 6-11 years, in general 201-400 is medium dose for qvar, flovent, alvesco, except for budesonide (which is twice as potent) so 401-800 is medium dose.
For >12 years, it’s the same dosing range for budesonide and ciclesonide, except for qvar and flovent, which have a dosing range of 251-500.
For mometasone, they only give a dosing range for >=12 years, which is similar to budeonisde. So 401-800 is medium dose
What are the common colors of inhalers?
Qvar: brown
Flovent: orange
Alvesco: red
What are side effects of ICS?
- Local: thrush, dysphonia
- Adrenal insufficiency: hypoglycemia, altered mental status, fatigue, weakness, anorexia, Cushingoid features, growth failure, or weight loss. (There have been cases of pediatric death related to adrenal crisis from flovent, ? stopping flovent)
- Height: Height: decreased growth velocity in prepubertal children in first 1-2 years of treatment, but this is not progressive or cumulative. Final result of 0.7% decrease in adult height
More relevant for adults:
- Cataract - uptodate says that adults taking regular ICS should be monitored with regular eye exams
- accelerated decline in bone mineral density
When should patients with asthma be tested for adrenal insufficiency?
- Symptoms of adrenal insufficiency like fatigue, poor growth, weakness, anorexia, altered mental status, cushingoid, growth failure
- High dose ICS, especially with low BMI, for >=3 months
When should you screen an asthma patients for adrenal insufficiency in the absence of them having any symptoms?
- exceeding threshold ICS dose for >= 3 months
- ICS of any dose in combination with CYP3A4 inhibitor (eg. HIV drugs, anti fungal agents, some antidepressants) for >3 months
Threshold doses corresponds to the upper limit of medium dose range for everything except, flovent:
- Flovent >=400 mcg for 4-11 years, but >=500 mcg for 12 years and up
How do you screen for adrenal insufficiency?
- AM cortisol
- Patients needs to stop glucocorticoid for 24 hours prior to test
- testing should be repeated every 3 months for patients at threshold dose of ICS
Describe technique for using MDI
- Shake cannister x 5 seconds
- Attach cannister to spacer
- Patient exhales normally to FRC
- Place mouthpiece in mouth and close lips
- Begin slow inspiration and complete inhalation over several seconds (4-5 seconds)
- Activate cannister
- Hold breath x 10 seconds
- Wait 30-60 seconds in between doses to repeat steps above (pitfall: should NOT be dispensing several doses at once)
- (Need to make sure that there are doses left)
- Infant: 5-10 tidal breaths per puffer dose
How would you escalate acute asthma therapy beyond back to back ventolin and atrovent?
Steroids- either oral (eg. Dexamethasone) or IV (methylpred 1-2 mg/kg to maximum of 125 mg) - both are equivalent. (key reason for IV steroids would be inability to tolerate oral therapy, can give IV steroids every 24 hours)
- MgSO4
- Continuous ventolin (0.15 mg/kg/hour to max of 15 mg)
- Subcutaneous/IM epinephrine (0.01 mg/kg to max of 0.3 mL)
- IV ventolin
- ipratroprium 500 mcg every 4-6 hours (in Kendig’s, not in CPS statement)
Less typical:
- Heliox
- Theophylline
Complications of MgSO4?
- hypotension
- Headache
- Weakness (think hypotonia). Adverse effects on neuromuscular function can happen in patients with neuromuscular disease
- Hypermagnesemia –patient with renal disease are at higher risk for this and hypermagenesemia can cause cardiac arrhythmia, respiratory failure to due to severe muscle weakness, sudden cardiopulmonary arrest
- Bradycardia
4 x H’s = hypotension, headache, hypotonia, hypermagnesemia
Complications of IV ventolin?
- Tachycardia
- Arrhythmia
- Myocardial injury
- (The use of IV ventolin is considered a non-standard therapy)
- Hypokalemia
What are the complications of intubation for asthmatic?
- hypotension
- hypoxemia
- challenges related to ventilation, such as dynamic hyperinflation
- laryngoscopy can precipitate bronchospasm
Ventilator strategy for an asthmatic?
Goals:
- minimize hyperinflation and barotrauma (overall, you are mimizing the amount of pressure and volume that you are shoving in the lung)
- permissive hypercapea
- Slow ventilator rate so more time in exhalation–>you basically want the lower respiratory rate
- I:E ratio of 1:3 or more (since airflow obstruction is worse on exhalation)
- Low tidal volume since there is already hyperinflation (about 4-6 mL/kg)
- Low PEEP (PEEP should be lower than auto-PEEP)
Other:
- plateau pressure <30 (this is just the same idea as minimizing tidal volume)
Additional info from Kendig:
* At risk for hypotension with intubation since auto-PEEP decreases systemic venous return:
* Adequate hydration before intubation * avoid excessive positive pressure ventilation immediately after * Permissive hypercapnea-->you don't need to normalize ventilation * The goals: treat hypoxemia, relieve work of breathing (muscle fatigue) * Principles of ventilation: * Volume ventilation--lowest volume and flow to minimize peak pressure and volume damage * Maximize expiratory time * Respiratory rate should be low (Eg. 8-10 breaths/min) * Low tidal volume (eg. 6-8 mL/kg) * prolonged expiratory time * Can tolerate a pH as low as 7.2 * Continue all regular medications, including bronchodilator. MDI can be given through the endotracheal tube
Reason for hypoxemia in asthma?
V/Q mismatch causes intra-pulmonary shunt (atelectasis) and dead space (due to airway over distension)
What is the key change in GINA 2019 guidelines?
Key change is in management of mild asthma, in particular for adolescent and adult age group. Mild asthma tends to managed in a symptom driven fashion, previously with SABA prn. But SABA prn has been associated with increased risk of exacerbations and death. So, GINA advises that for the mild group where treatment is symptom drive, it should be ICS/formoterol or SABA/ICS.
Key point: patient with mild asthma are still at risk for severe or fatal exacerbations so it makes to sense to have ICS on board. As well, it’s challenging to get patients with mild asthma (symptoms<2x per month) to take ICS regularly so then they are basically just on SABA only treatment
(This is directly in contrast with CTS 2012 which specifically said they favour in SABA prn instead of ICS/LABA prn in the mild asthma patients who are on no maintenance medication)
After severe exacerbation leading to hospital admission, how soon should follow up be arranged?
Within 2 days (eg. family doctor) and again 3-4 weeks
What are the diagnostic criteria for asthma, as based on GINA? Based on CTS?
- Want to try and make a diagnosis BEFORE starting treatment. Once you start, there may be less variability in lung function.
- Combination of symptoms + objective testing
- Variable respiratory symptoms + variable expiratory airflow limitation/obstruction
- Key symptoms: cough, SOB, wheeze, tightness. These symptoms vary over time, within same day and with particular triggers
- Objective testing: expiratory airflow limitation + excessive variability in lung function:
- Airflow obstruction/limitation: when FEV1 is reduced, FEV1/FVC is also reduced. Normal ratio is children >0.9
- Variability in lung function:
- Positive BD reversibility/responsiveness (more likely if BD has been witheld): increase in FEV1 by >=12% and >=200 mL from baseline in adults, and just >=12% in children. (This definition is different than ATS definition, which says either increased in FEV1 or FVC by both >=200 mL and >=12%)
- Excessive variability in twice daily PEF >=13% for children, >10% for >=12 years
- Positive exercise challenge test
- Positive methacholine challenge, while acknowledging lower specifity
CTS is very similar to GINA. I actually like the layout of their tables better.
- Preferred: spirometry showing reversible airway obstruction either with bronchodilator or course of controller therapy so: decreased FEV1/FVC with BD reversibility–>increase in FEV1 by >=12% in children. For adults: >=12% and >=200 mL.
- Alternate: Peak expiratory flow variability after bronchodilator, with a course of controller therapy or diurnal variation. (They don’t provide the option of diurnal variation for 6-11 years). –>the threshold for definition of diurnal variation is all over the place: >8% based on twice daily readings, >20% based on multiple daily readings, >10-15% when using PEF to assess control
- Alternate: positive challenge test with methacholine or exercise.
Methacholine: PC20 <4 mg/mL
Exercise: >=10-15% decrease in FEV1 post exercise
What is the role of FeNO in diagnosis of asthma?
- FeNO correlates with serum and sputum eosinophilia
- Associated with type 2 airway inflammation, but also: eczema, allergic rhinitis, eosinophilic bronchitis
- Not elevated in neutrophilic asthma
May predict ICS responsiveness, but there are no studies examining safety of with-holding ICS on basis of FeNO (GINA)
How do you confirm a diagnosis of asthma in a patient already on ICS?
Few options in relation to symptoms and variable expiratory flow limitation:
- Option 1: ongoing symptoms + expiratory flow limitation –>confirm asthma, optimize treatment
- Option 2: ongoing symptoms but no expiratory flow limitation. Key question: is this asthma as main cause of symptoms or something else?
- If safe to do bronchial challenge (FEV1>70%)–>bronchial challenge
- If it’s not safe, then escalate asthma treatment and reassess symptoms
- Option 3: no symptoms and no expiratory flow limitation. key question: either asthma that is well controlled or not a diagnosis of asthma. Plan: wean ICS and repeat spirometry
Practically, I think the index of suspicion for a diagnosis of asthma, affects the willpower to proceed with trying to prove the diagnosis. It’s important to rule out alternate diagnoses and asssess for co-morbidities
(GINA, keeping in mind this is more of an adult based guideline)
If you did want to prove a diagnosis of asthma in a patient referred to you on controller treatment who is asymptomatic with no evidence of variable airflow limitation, how would you wean controller?
- Decrease ICS dose by 25-50% or stop second controller treatment (eg. LABA, LTRA)
(GINA, more of an adult based guideline)
How is asthma severity defined?
It’s defined based on the retrospective treatment to control symptoms
What are the key things to assess when seeing a patient regarding their asthma management? (Things you would evaluate on a follow up visit)
4 things to assess for asthma patients at every visit:
- Control, as assessed retrospectively over the past 4 weeks
- Risk factors for adverse outcomes (persistent air flow limitation), exacerbation, side effects
- Treatment utilization: adherence, technique, action plan
- Co-morbidities
(It’s important to separately assess control and risk factors for adverse outcomes. Although control is intuitively linked to exacerbations, they are not perfectly correlated and there are independent risk factors for exacerbations. Hence, even individuals with mild asthma can have severe exacerbations and death)
After the diagnosis of asthma, how often should spirometry be repeated?
- 3-6 months after diagnosis and then periodically therefter
What are the asthma control criteria as per GINA?
These criteria are actually more strict than CTS
- Retrospective assessment over the last 4 weeks
- Daytime symptoms > 2 days per week (3 days or greater)
- Any night time symptoms
- Reliever use >2 times per week (not including pre-exercise)
- any activity limitation due to asthma (this a a very important question b/c for any respiratory disease, the patient can limit symptoms by limiting physical activity
- Based on the above, patients can be classified as well controlled, partly controlled or not controlled
What are the risk factors for an exacerbation, as per GINA? (Of note, these risk factors should be assessed at diagnosis and periodically, especially for patients who are having exacerbations)
- Poor asthma control
- Low lung function (FEV1<60%)
- High BD reversibility
- > = 1 severe exacerbation in the last 12 months (as per CTS, severe exacerbation is where oral steroids are needed)
- Ever being intubated or in ICU for asthma
- high blood eosinophils
- elevated FeNO
- comorbiities: GERD, food allergy, pregnancy
Risk factors for developing persistent airflow limitation?
- Preterm birth
- Low birth weight
- Tobacco exposure
- Lack of treatment with ICS
- Low initial FEV1
Risk factors for asthma medication side effects?
- Frequent oral steroids
- High dose ICS, especially if with CYP450 inhibitor
- Local side effects for high dose ICS or poor inhaler technique
How is diurnal variation in PEF calculated?
- Diurnal PEF measurements:
- PEF is done twice daily x 2 weeks
- (Day’s highest - day’s lowest)/(mean of day’s highest and lowest)x100 —>average with other values over 1-2 weeks
After confirming a diagnosis of asthma, is it necessary to with-hold controller medication?
No, you care more about where their lung function is at on treatment. If they still have BD reversibility while on treatment, then you know that they are high risk for an exacerbation. Likely uncontrolled and either non-adherent or need an escalation in treatment.
How does FEV1 change in response to asthma therapy?
- Improves in first 2 months, then plateaus
What is the role of PEF in long term monitoring of asthma?
- PEF can be used for long-term monitoring or short-term monitoring.
- Short term:
- identify occupational or domestic triggers
- monitor recovery post exacerbation or after a change in treatment
- if excessive symptoms and you want objective evidence
Long-term monitoring:
ONLY for severe asthma and individuals with poor perception of symptoms
- Earlier perception of exacerbations in patients with poor perception or sudden severe exacerbation
How is asthma severity defined?
- Severity is defined based on treatment required to control symptoms, after spending several months figuring out the ideal treatment regimen. (Key point: we can’t make this determination when seeing a patient for the first time. It depends on where they stabilize out to)
- Mild asthma: step 1 (symptom driven therapy with ICS-formoterol) or step 2 (same as step 1 or daily low dose ICS)
- Moderate asthma: needing LABA
- Severe: high dose ICS-LABA and above so step 5
What is the relationship between asthma control and risk of exacerbation?
There is not a 1:1 relationship between symptom control and risk of exacerbation.
There is more a relationship for mild asthma, but for severe asthma it’s not uncommon to have a patient with mild symptoms, who is an exacerbator.
What is the role of sputum eosinophils in asthma management?
Minimal role for children
- in adults, use of sputum eosinophils has been shown to decrease exacerbations, though similar to control with traditional management
- On a population scale, sputum eosinophils is NOT recommended (GINA)
- CTS: recommend considering use of sputum eosinophils in adults with moderate to severe asthma who are being followed in a specialized centre
What is the role of FeNO in asthma management?
- Using FeNO is better than traditional management in terms of exacerbations, but similar for daily asthma control
- Complementary
- Withdrawing treatment on the basis of low FeNO is NOT recommended (though it may make sense to not escalate treatment in patients with low FeNO)
- On a population scale, FeNO is not recommended (GINA)
- CTS: insufficient evidence to use FeNO in any way (either as adjunctive or on it’s own)
- GINA emphasizes how guideline based recommendations are made on a population scale
What threshold level of FeNO level in children is associated with eosinophilic inflammation and ICS responsiveness?
FeNO > 35
What is the big change in the GINA 2019 guideline?
- The big change is in the management of mild asthma, which is typically through symptom drive driven and historically with SABA prn.
- For adults and adolescents, they do not recommend SABA alone prn therapy.
- As needed low-dose ICS formoterol compared to SABA prn reduces risk of exacerbations by 2/3.
- Although this is also part of the diagram in approach to children, the strength of this recommendation is much more so for >12 years of age. (we actually don’t see as many patients on just symptom drive therapy)
For adult/adolescent who has poor control on low dose ICS, what is the next step as per GINA? (step 3 options?)
- the preferred step 3 is low dose-ICS/LABA with SABA prn
- But for frequent exacerbators, it’s better to do ICS/LABA as maintenance and reliever since there will be fewer exacerbations.
For child 6-11 years who has poor control on low dose ICS, what is the next step as per GINA? (step 3 options?)
- Medium dose ICS or low dose ICS/LABA with SABA prn
- Either of these options is preferable
When should step down of asthma therapy be considered?
when patients have been stable for 3 months
- step down the dose to find the lowest dose, which would effectively manage symptoms. (At this point, patients could be classified based on severity)
Dry cough differential diagnosis? (think about this differential in patients presenting for asthma evaluation, but with only cough as the symptoms.
- GERD
- Rhinitis
- Cough variant asthma (main symptom of asthma is just cough)
- ACE inhibitor
What are the options for initiating asthma treatment for adult/adolescent with symptoms <2x per month?
- ICS/formoterol as needed (preferred) or ICS/SABA prn
(with very infrequent symptoms, we are taking a symptom drive approach) - there are not very many patients we see who would fall into this category
What are the options for initiating asthma treatment for adult/adolescent with symptoms >=2x per month?
Either low dose ICS with SABA prn or ICS/formoterol prn
- Preferred option is low dose ICS daily since there is better symptom control and improved FEV1, but if patient won’t take treatment consistently, then it’s better to use ICS/formoterol prn and at least have some ICS on board
Second line: LTRA–>not first line since not as effective in terms of exacerbations, but consider for patients with allergic rhinitis or who don’t want take ICS
How would you initiate asthma treatment on adult/adolescent with troublesome asthma symptoms most days or waking due to asthma?
Start with ICS/LABA either with SABA prn or as maintenance and reliever therapy
- If frequent exacerbations, then maintenance and reliever therapy is better as there will be fewer exacerbations
How would initiate asthma treatment on adult/adolescent who presents with severe uncontrolled asthma or with acute exacerbation?
Oral steroids + controller with high dose ICS or medium dose ICS/LABA
(Practically, keep this in mind for hospital consults. I’ve seen patients started on this more intense treatment and then seen in followup to wean therapy) .
GINA mentions using this increased controller dose for 2-4 weeks
When should allergen immunotherapy be considered in children with asthma?
- Allergic rhinitis, especially if ongoing symptoms in spite of environmental control/drug treatment or if they can’t tolerate drug treatment
- At step 2 (daily low dose ICS) or above, with allergic rhinitis and FEV1>70% and sensitization (such as house dust mite (GINA)
- Consider it in patients with new onset allergic rhinitis and asthma because the immunotherapy can be disease modifying for asthma (studies have shown that immunotherapy for allergic rhinitis has decreased development of asthma)
- Recall that there are certain burdens of therapy - subcutaneous versus oral, duration of therapy: 3 years (Kendigs)
What dose of ICS do most patients need to be on for response?
- Low dose
- Some patients will need medium dose, but the majority respond to low dose
Is ICS-formoterol on a purely prn basis for mild asthma recommended for children <12 years of age?
No
Is formoterol as effective as SABA for acute symptom relief? What about exercise symptoms?
Yes to both!
For what age groups is symbicort approved?
- approved by health canada for ages 12 and older
- approve by FDA for >= 6 years of age
When should ICS-formoterol maintenance and reliever therapy be considered?
GINA:
>= 12 years (though I have seen it used off label)
- >=1 exacerbation in the last year
- Exacerbator
CTS:
- exacerbation prone individual 12 years of age and older who is having poor control on fixed-dose ICS/LABA. Reliever dose at same maintenance ICS dose
- on ICS/LABA fixed dose, but poor control/persistent symptoms. Can switch to formoterol maintenance and reliever therapy as an alternative to increasing ICS dose.
- so i would practically think about this at step 3/4 if poor symptom control. makes sense to try this before tiotropium or biologic
For what ages is spiriva approved?
6 years and older
Before labelling someone as having severe asthma, what do you need to consider? (Basically want to differentiate between uncontrolled asthma due to severe asthma versus uncontrolled asthma due to suboptimal management)
- Consider alternate diagnosis. It can be hard to prove the diagnosis of asthma in severe asthma since patients might not safely be able to withold medications for methacholine or exercise challenge or with longstanding disease in adults, they may have fixed obstruction. Try and look for old PFTs.
- Medication adherence and technique–look for old pharmacy records. Review technique
- Co-morbidities: rhinitis, GERD, obesity, OSA, psychiatric
- Persistent environmental exposure or allergen. (Don’t forget to ask kids about smoking, vaping, NSAID use)
Predominant cell type in children with severe asthma?
- Eosinophil
in contrast to neutrophils being predominant in adult severe asthma
What are the broad phenotypes of preschool and childhood asthma?
- Preschool asthma: episodic viral wheeze (neurophilic) versus multitrigger wheeze (eosinophilic)
- Childhood asthma: atopic (eosinophil) versus non-atopic (neutrophil)
Dose of prednisone for asthma exacerbation? When does the dose need to be tapered?
CTS: 1 mg/kg/day x at least 3 days (maximum dose of 40 mg)
Dose does not need to be tapered if used for <2 weeks
Can a LTRA be used as monotherapy for asthma?
Yes, it can be used in children >=6 years of age, but it would be second line. ICS is first line. In general, LTRA will be less effective in terms of symptoms of preventing exacerbations.
(may consider LTRA by itself if there is steroid phobia or allergic rhinits. But with new black box recommendation, parents may be less keen on this option)
As per CTS, if there is poor asthma control on low dose ICS, what is the next step?
12 years and older: low dose ICS-LABA
6-11 years: medium dose ICS
Child who is 6-11 years with inadequate control on medium dose ICS?
CTS presents addition of LABA or LTRA as equivalent options.
Describe the findings of the sygma studies?
- Patients >=12 years of age
- Randomized, double blind trial
- Assigned either to terbutline prn, budesonide-formoterol prn or bid low dose budesonide + SABA prn
- Findings:
- Exacerbations:
- More exacerbations and worse symptom control with SABA prn alone compared to budesonide-formoterol prn
- Symbicort prn compared to regular low dose budesonide: non-inferior with respect to exacerbations
- Regular low dose budesonide was better than symbicort prn in terms of symptom control
Symptom control: low dose daily budesonide > symbicort prn > SABA prn
Exacerbations: low daily budesonide = symbicort prn > SABA prn
What is a severe asthma exacerbation?
Exacerbation requiring oral steroids
What does CTS recommend regarding intermittent ICS?
- Intermittent ICS (just initiated at the start of an exacerbation) is not recommended
- For individuals with mild asthma who are not therapy at baseline, you could consider committing them to regular ICS
What does CTS recommend regarding escalating ICS dose during exacerbation?
- 6-11 years: they do NOT recommend increasing ICS dose
- Adults who have had an exacerbation requiring oral steroids in the last year: ICS dose can be increased 4-5 times x 7-14 days. (this recommendation is a bit confusing throughout the statement. in some places, age cut off seems like 12 years or 16 years of truly adult; i will just remember that this more of an adult recommendation)
- doubling of dose is not recommended for any age category
What are the components of symbicort?
Symbicort 100 or 200
100: 100 mcg/puff budesonide and 6 mcg of formoterol
200: 200 mcg of budesonide and 6 mcg formoterol
What are 3 different ways that symbicort can be used?
- purely PRN (CTS2012 does not acknowledge this option)
- Daily maintenance therapy with SABA prn
- Maintenance and reliever therapy
Why is LABA monotherapy not recommended?
Increased risk of asthma related death
Ongoing research if concurrent use of ICS decreases this risk - as per CTS 2012
Is doubling the ICS dose at start of an asthma exacerbation recommended?
No
(there are subgroups of adults of age in whom a 4 or 5x increase in dose is recommended)
(CTS)
In children <12 years with asthma, when should you consider oral steroids as part of management in the yellow zone?
Yellow zone is the zone where you are considering controller step up therapy
- Only consider having oral steroids for yellow zone if: recent severe exacerbation (=need for oral steroids) and suboptimal response to SABA.
(They don’t define what a recent severe exacerbation is)
(CTS)
In a child >12 years with asthma on symbicort (either as maintenance with prn SABA or as maintenance and reliever therapy), how can dose be changed in the yellow zone? (CTS)
Symbicort 4 puffs bid x 7-14 days or SMART (max 8 inahalations/day)
- They present either of these as options for patients on some form of regular symbicort
Asthma control criteria as per CTS?
- Severe asthma statement has the most comprehensive control criteria:
- Poor control as per CTS criteria or standardized questionnaire, such as ACQ
CTS control criteria:
History:
Daytime symptoms <4 days per week (daytime symptoms >3 days per week)
No night time symptoms
SABA doses <4 doses per week (>3 doses per week)
No physical activity limitation
Not missing any work or school
Mild, infrequent exacerbations
Objective testing:
FEV1>=90% of personal best
Diurnal variation of PEF <10-15% (recall that diurnal variation is not recommended for diagnosis of asthma in children, but maybe it’s ok for control follow up?)
Sputum eosinophils <2-3%
Also:
- Frequent severe exacerbations: 2 or more times of needing systemic steroids in the last year
- Severe exacerbations, requiring hospitalization, ICU or mechanical ventilation
- Airflow limitation - FEV1<80% of personal best after bronchodilator withold (this is more strict than above)
State the dosing ranges for ICS
Look at CTS guideline
ICS/LABA on a prn basis whether purely prn or in maintenance/reliever approach, what is the age cut off?
12 years
