Asthma Flashcards
Asthma Adults Symptoms (4)
Variable respiratory symptoms: SOB Wheeze Cough Chest tightness
How to diagnose asthma is adolescents/adults and children
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
What is “good control” in asthmatic adults/adolescents
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
What is “partial control” in asthmatic adults/adolescents?
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
What is poor control in asthmatic adults/adolescents?
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
How to titrate asthma medications in adults/adolescents
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
How to titrate asthma meds in children 1-5
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
when to start asthma preventer in children 6-11d
Consider when mild flare ups more than 6 weekly or
> 2 moderate flare ups requiring oral corticosteroids in last year
Define infrequent intermittent asthma in children =>6 not taking a preventer
Symptom free for at least 6 weeks at a time (flare ups up to once every 6 weeks on average but no symptoms between)
Define frequent intermittent asthma in children =/>6 not taking reliever
Flare ups more than once every 6 weeks but no symptoms between flare ups
Persistent asthma Mild in children =/6 not taking reliever
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
Define Persistent asthma moderate in children >/=6 not taking reliever
Any of:
- FEV1 <80% predicted
- Daytime symptoms daily
- Night time symptoms >1x per week
- Symptoms sometimes restrict activity or sleep
Define Persistent severe asthma in children >/6 not taking preventer
Any of:
- FEV1< 60% predicted
- daytime symptoms continual
- night time symptoms frequent
- Flare ups frequent
- symptoms frequently restrict activity or sleep
Should I start a preventer for infrequent intermittent asthma in children?
This means flare ups 6 weekly and fine between
Start preventer if moderate-severe flare up (need corticosteroid or ED >2x in past year)
Should I start a preventer for children with Frequent intermittent asthma
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)
Should I start preventer for Persistent asthma in children
= day time symptoms > once a week, or night time symptoms >2x 啊 month our symptoms restrict activity or sleep
Yes
Define mild/moderate acute asthma in adults
Can walk and speak whole sentences in one breath
Define Severe asthma attack in adults
Any of:
- unable to speak in sentences
- visibly breathless
- increased work of breathing
- oxygen saturation 90-94%
define life-threatening asthma attack in adults
Any of
- drowsy
- collapsed
- exhausted
- cyanosis
- poor respiratory effort
- oxygen says < 90%
how to treat mild/moderate asthma exacerbation in adults
- 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
HOw to manage severe asthma exacerbation
- 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
HOw to manage adult life threatening asthma exacerbation
- 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
How to manage mild/moderate asthma exacerbation in child
- 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
Management of severe asthma exacerbation in children
- 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
How to adjust medications in an asthma action plan if on SABA only
- 5 days 37.5mg - 50mg pred OR
- start regular ICS for at least 2-4 weeks (budesonide turbuhaler 400microg)
- check use of device
How to adjust medicine in asthma action plan if on ICS preventer
- 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
How to adjust medicine in written asthma action plan if on ICS/LABA budesonide/formoterol maintenance and reliever regimen
- 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
How to adjust medication in asthma action plan if patient is on fluticasone+ LABA
- replace with highest strength formulation for 7-14 days
What is spirometry criteria for COPD
Persistent airflow limitation post bronchodilator FEV1/FVC <0.7%
Symptoms of COPD (3)
Exertional breathlessness
Cough
Sputum
What is chronic bronchitis
Daily sputum production for at least 3 months of 2 or more consecutive years
Risk factors for COPD (7)
- smoking
- parental smoking
- genetic factors including alpha1 antitrypsin deficiency
- asthma
- low SES
- environmental - dusty occupations, air pollution
- nutrition
What investigations might you do to confirm or exclude other conditions with a similar presentation to COPD
- spirometry
- CXR
- haematology
- biochemistry
- exercise stress testing
- ECG
- echo
Define mild, moderate and severe COPD (spirometry)
FEV1
Mild 60-80% predicted
Moderate 40-59% predicted
Severe < 40% predicted
Non-pharmacological treatment for COPD (3)
- smoking cessation
- pulmonary rehabilitation (includes exercise training)
- regular physical activity
When to refer COPD patient?
- 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
When to refer COPD patient for O2 therapy
<92% (persistent)
How to treat COPD exacerbation?
- 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
What to follow up post COPD exacerbation
- 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
What is stepwise management of COPD Optimise function
- 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
COPD pharmacological interventions step by step
SABA or LAMA prn (ventolin)
Add LAMA or LABA (tiotropium - spiriva)
Change to combination LAMA/LABA
Consider adding ICS (triple therapy)
