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Respiratory RACGP > Asthma > Flashcards

Asthma Flashcards

1
Q

Asthma Adults Symptoms (4)

A 
Variable respiratory symptoms:
SOB
Wheeze
Cough
Chest tightness
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2
Q

How to diagnose asthma is adolescents/adults and children

A

Spirometry pre-bronchodilator and 10-15 mins post 4 puffs 100mcg/actuation salbutamol MDI via spacer

FEV1/FVC reduced for age at a time when FEV1 is lower than predicted

bronchodilator response = FEV1 increases by >200ml and >12% (>12% in children)

If criteria not met give 4-6 weeks low dose ICS and PRN salbutamol then repeat test

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3
Q

What is “good control” in asthmatic adults/adolescents

A

Day time symptoms =/< 2 days / wk

Need for SABA reliever =/<2 days/week

No night time symptoms/symptoms on waking

No limitations of activities

Note: control is based on symptoms over the previous 4 weeks

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4
Q

What is “partial control” in asthmatic adults/adolescents?

A

One or 2 of:

Day time symtoms > 2 day /wk

Need for SABA reliever >2d/wk

Any limitation of activities

Any symptoms during night or on waking

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5
Q

What is poor control in asthmatic adults/adolescents?

A

Three or more of:

Day time symptoms >2 days/wk

Use of SABA reliever >2 days/wk

Any limitation of activities

Any symptoms during night or on waking

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6
Q

How to titrate asthma medications in adults/adolescents

A

SABA PRN

Most - Low-dose preventer e.g. Budesonide 200-400mcg/day (pulmicort turbuhaler) needed if symptoms 2x in last month/any waking due to asthma in past month/flare up in last year

Low dose combination - budesonide/formoterol 100mcg/6mcg (Symbicort Turbuhaler). Use 2 doses/day and for reliever. Use up to 6 actuations at a time and no more than 12 in one day.

Medium dose budesonide/formoterol (400mcg/12mcg) bd maintenance and low dose as reliever therapy. Consider referral

Review in 6-8 weeks. When asthma is stable and well controlled for 2-3 months no flare in prev 12 mo consider stepping down unless already on low dose ICS

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7
Q

How to titrate asthma meds in children 1-5

A

Mild flare ups less than every 4 months - no preventer. Moderate flare-ups need preventer
SABA

ICS low dose (budesonide 200mcg) or Montelukast

ICS low dose + Montelukast or ICS high dose

Need mask for 1-2 yo

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8
Q

when to start asthma preventer in children 6-11d

A

Consider when mild flare ups more than 6 weekly or

> 2 moderate flare ups requiring oral corticosteroids in last year

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9
Q

Define infrequent intermittent asthma in children =>6 not taking a preventer

A

Symptom free for at least 6 weeks at a time (flare ups up to once every 6 weeks on average but no symptoms between)

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10
Q

Define frequent intermittent asthma in children =/>6 not taking reliever

A

Flare ups more than once every 6 weeks but no symptoms between flare ups

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11
Q

Persistent asthma Mild in children =/6 not taking reliever

A

FEV1 =/> 80% predicted and at least one of:

  • daytime symptoms more than once per weeks but not every day
  • Night time symptoms more than 2x per month but not every week
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12
Q

Define Persistent asthma moderate in children >/=6 not taking reliever

A

Any of:

  • FEV1 <80% predicted
  • Daytime symptoms daily
  • Night time symptoms >1x per week
  • Symptoms sometimes restrict activity or sleep
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13
Q

Define Persistent severe asthma in children >/6 not taking preventer

A

Any of:

  • FEV1< 60% predicted
  • daytime symptoms continual
  • night time symptoms frequent
  • Flare ups frequent
  • symptoms frequently restrict activity or sleep
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14
Q

Should I start a preventer for infrequent intermittent asthma in children?

A

This means flare ups 6 weekly and fine between

Start preventer if moderate-severe flare up (need corticosteroid or ED >2x in past year)

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15
Q

Should I start a preventer for children with Frequent intermittent asthma

A

This means flare ups more than 6 weekly but fine between

Consider preventer and indicated if moderate-severe flare ups (>2 in past year requiring ED or oral corticosteroid)

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16
Q

Should I start preventer for Persistent asthma in children

A

= day time symptoms > once a week, or night time symptoms >2x 啊 month our symptoms restrict activity or sleep

Yes

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17
Q

Define mild/moderate acute asthma in adults

A

Can walk and speak whole sentences in one breath

18
Q

Define Severe asthma attack in adults

A

Any of:

  • unable to speak in sentences
  • visibly breathless
  • increased work of breathing
  • oxygen saturation 90-94%
19
Q

define life-threatening asthma attack in adults

A

Any of

  • drowsy
  • collapsed
  • exhausted
  • cyanosis
  • poor respiratory effort
  • oxygen says < 90%
20
Q

how to treat mild/moderate asthma exacerbation in adults

A
  • Give 4-12 puffs salbutamol 100microg/actuations) via pMDI + spacer then reassess severity
  • In non-acute care settings arrange immediate transfer if no improvement
  • Repeat dose every 20-30 mins for first hour if needed or sooner as needed
  • within first hour give 37.5 - 50mg prednisone orally and continue for 5 days

If poor response add IV magnesium sulfate 10mmol iv infusion

At 1 hour - perform spirometry, repeat oximetry, check for dyspnoea while supine. 
If dyspnoea resolved observe for >1 hour
Prior to d/c
- ensure can manage asthma at home
- Provide oral prednisone for 5 days
- Check has regular inhaled corticosteroid and enough SABA
- Check inhaler technique
- provide spacer if needed
- provide interim action plan
- arrange follow up
Ambulance if no improvement or worsens
21
Q

HOw to manage severe asthma exacerbation

A
  • salbutamol 12 puffs via spacer
  • Ipratropium 8 puffs (21mcg/actuation) via pMDI plus spacer
    OR if can’t breathe through space
  • 5mg nebule salbutamol with 500mg nebule ipratropium added
  • start oxygen aim for 93-95%
  • repeat dose every 20 minutes for first hour or sooner as needed
  • if poor response add IV magnesium sulfate
  • within 1st hour start 37.5-50mg oral prednisone for 5 days
  • at 1 hour perform spirometry, repeat pulse oximetry, check for dyspnoea while supine
  • observe for more than 1 hour after dyspnoea resolved.
  • if persisting dyspnoea, inability to lie flat without dyspnoea or FEV1 <60% predicted -> ambulance
22
Q

HOw to manage adult life threatening asthma exacerbation

A
  • Salbutamol 2x5 mg nebule via continuous nebulisation
  • Ipratropium 500mcg added to solution
  • titrate oxygen to 93-95%
  • Call ambulance
  • continuous nebulisation until dyspnoea improves, consider changing to mdi + spacer if improves
23
Q

How to manage mild/moderate asthma exacerbation in child

A
  • Salbutamol (100mcg per actuation) via pMDI and spacer (plus mask if 2 or under)
    6 years and over 4-12 puffs
    1-5 years 2-6 puffs
  • reassess. If no improvement in non-acute care setting arrange transfer
  • repeat dose every 20-30 minus for first hour if needed (or sooner as needed)
  • if poor response add IV magnesium sulfate
  • within first hour Start prednisolone 1mg/kg max 50mg orally for 3-5 days (for children 1-5 years avoid systemic corticosteroids if responses to initial bronchodilator treatment)
  • At 1 hour reassess - spirometry and pulse oximetry
  • if ok - observe for >1hour after breathing difficulty resolves
  • Discharge
  • ensure can manage at home
  • provide oral pred for 3 days
    -ensure has regular inhaled preventer if indicated
  • check inhaler technique
  • interim asthma action plan
  • arrange review
24
Q

Management of severe asthma exacerbation in children

A
  • salbutamol
    6-11 years 12 puffs
    1-5 years 6 puffs
  • ipratropium 21 mcg/actuation via spacer
    6-11 years 8 puffs
    1-5 years 4 puffs
    OR if can’t breathe through spacer:
  • salbutamol via intermittent nebulisation driven by oxygen
    6-11 years 5mg nebule salbutamol + ipratropium 500microg
    1-5 years 2.5mg nebule salbutamol + 250microg ipratropium
  • titrate to o2 says 95%
  • repeat above 20 minutely for 1st hour or sooner if needed
  • Start prednisolone 1mg/kg max 50mg within 1st hour
  • If no improvement call ambulance
  • After 1 hour check spirometry and sats, if ok observe for > 1hour
  • Discharge
  • ensure can monitor and manage at home
  • provide oral pred for 3 days
  • ensure has regular inhaled preventer and SABA
  • check inhaler technique
  • provide spacer if needed
  • provide interim asthma action plan
  • arrange follow up
25
Q

How to adjust medications in an asthma action plan if on SABA only

A
  • 5 days 37.5mg - 50mg pred OR
  • start regular ICS for at least 2-4 weeks (budesonide turbuhaler 400microg)
  • check use of device
26
Q

How to adjust medicine in asthma action plan if on ICS preventer

A
  • increase dose by 4 for 7-14 days OR

- start prednisolone 37.5 - 50mg mane for 5-10 days in addition to usual dose of ICS

27
Q

How to adjust medicine in written asthma action plan if on ICS/LABA budesonide/formoterol maintenance and reliever regimen

A
  • take extra doses of budesonide/formoterol prn to relieve symptoms up to 72 micro formoterol/day (12 actuations of 100/6mcg or 200/6 dry powder inhaler or 24 actuations of 50/3 or 100/3 micrograms MDI). No more than 6 actuations at one time OR
  • prednisolone 37.5-50mg orally mane for 5-10 days in addition to usual budesonide/formoterol
28
Q

How to adjust medication in asthma action plan if patient is on fluticasone+ LABA

A
  • replace with highest strength formulation for 7-14 days
29
Q

What is spirometry criteria for COPD

A

Persistent airflow limitation post bronchodilator FEV1/FVC <0.7%

30
Q

Symptoms of COPD (3)

A

Exertional breathlessness
Cough
Sputum

31
Q

What is chronic bronchitis

A

Daily sputum production for at least 3 months of 2 or more consecutive years

32
Q

Risk factors for COPD (7)

A
  • smoking
  • parental smoking
  • genetic factors including alpha1 antitrypsin deficiency
  • asthma
  • low SES
  • environmental - dusty occupations, air pollution
  • nutrition
33
Q

What investigations might you do to confirm or exclude other conditions with a similar presentation to COPD

A
  • spirometry
  • CXR
  • haematology
  • biochemistry
  • exercise stress testing
  • ECG
  • echo
34
Q

Define mild, moderate and severe COPD (spirometry)

A

FEV1
Mild 60-80% predicted
Moderate 40-59% predicted
Severe < 40% predicted

35
Q

Non-pharmacological treatment for COPD (3)

A
  • smoking cessation
  • pulmonary rehabilitation (includes exercise training)
  • regular physical activity
36
Q

When to refer COPD patient?

A
  • diagnostic uncertainty
  • particular indications such as assessment for o2 therapy
  • haemoptysis
  • rapid decline
  • persistent symptoms
  • frequent chest infections (>annually) to assess preventable factors and rule out co-existing bronchiectasis
  • ankle oedema - assess for cor pulmonale
  • oxygen saturation < 92
  • Bullous lung disease on CT or CXR
  • COPD < 40 years
37
Q

When to refer COPD patient for O2 therapy

A

<92% (persistent)

38
Q

How to treat COPD exacerbation?

A
  • salbutamol 4-8 puffs via spacer 3-4 hourly
  • prednisolone 30-50mg for 5 days then stop
  • if features of infection - increased volume and change in colour of sputum or fever
  • amoxicillin 500mg 8 hourly OR
  • doxycycline 100mg daily for 5 days
  • change antibiotic if no improvement and sputum culture grows resistant organism (not routine)
  • O2 for SpO2 88-92%
  • once resolved refer for pulmonary rehab
39
Q

What to follow up post COPD exacerbation

A
  • level of physical activity
  • referral for pulmonary rehab
  • spirometry
  • medicine adherence and device use
  • influenza and pneumococcal status
  • smoking cessation
  • persistent CXR finding should be reviewed 4-6 weeks post discharge
  • r/v action plan
40
Q

What is stepwise management of COPD Optimise function

A
  • reduce risk factors - smoking, air pollution, flu and pneumococcal vaccine
  • optimise function - regular exercise, nutrition, education, GPMP and action plan
  • Optimise treatment of co-morbidities
  • refer symptomatic patients for pulmonary rehab
  • initiate advanced care planning
41
Q

COPD pharmacological interventions step by step

A

SABA or LAMA prn (ventolin)

Add LAMA or LABA (tiotropium - spiriva)

Change to combination LAMA/LABA

Consider adding ICS (triple therapy)

Respiratory RACGP (9 decks)

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