Asthma Flashcards
1
Q
What are 7 clinical features of asthma?
A
- Episodic, diurnal symptoms
- Cough
- Wheeze
- Breathlessness
- Chest tightness
- Symptoms triggered by exercise, viral infection, exposure to cold air, allergens (emotion and laughter in children, NSAIDs and beta blockers in adults)
- Expiratory polyphonic wheeze on auscultation
2
Q
What are 7 things that can trigger asthma symptoms?
A
- Exercise
- Allergen/ irritant exposure
- Changes in weather e.g. cold
- Viral respiratory infections
- Emotion/ laughter (children)
- Beta blockers (adults)
- NSAIDs (adults)
3
Q
What are 9 risk factors for asthma?
A
- Personal or family history of atopic disease
- Male sex for pre-pubertal asthma, female sex for persistence from childhood to adulthood
- Respiratory infections in infancy
- Exposure (including prenatally) to tobacco smoke
- Premature birth and associated low birth weight
- Obesity
- Social deprivation
- Exposure to inhaled particulates
- Workplace exposure including flour dust and isocyanates from paint
4
Q
What is the typical prognosis of asthma in children under 2 years?
A
Males more likely to grow out of asthma in transition to adulthood
Earlier the onset, better prognosis: most children who present <2y become asymptomatic by 6-11 years of age
However, in atopic children earlier onset my suggest worse prognosis
5
Q
What are 6 respiratory complications of asthma?
A
- Irreversible airway changes
- Pneumonia
- Pulmonary collapse: atelectasis caused by mucus plugging of airways
- Respiratory failure
- Pneumothorax
- Status asthmaticus (repeated asthma attacks without respite, or non-response to appropriate treatment)
6
Q
What are the 5 things that can be used to make a clinical decision as to whether to diagnose asthma?
A
- Presence of more than one variable symptom of wheeze, cough, breathlessness, chest tightness
- Personal/family history of other atopic conditions
- Results of fractional exhaled nitric oxide (FeNO) testing
- Results of objective tests to detect airway obstruction, when person is symptomatic
- spirometry
- bronchodilator reversibility
- variable PEF
- Results of direct bronchial challenge test with histamine or methacholine
7
Q
What suggests occupational asthma and what are 5 examples of high-risk occupations?
A
Adult-onset asthma, where symptoms improve when not at work (on holidays, days off)
- Laboratory work
- Baking
- Animal handling
- Welding
- Paint spraying
8
Q
How is fractional exhaled nitric oxide (FeNO) testing used to diagnose asthma?
A
Should be used where possible to confirm eosinophilic airway inflammation to support an asthma diagnosis in people aged 17 and older (available in primary care in some places, sometimes needs specialist referral)
Consider in 5-16 year olds if diagnostic uncertainty after initial assessment, and either normal spirometry or obstructive spiromatry with negative bronchodilator reversibility
9
Q
What is a positive result from FeNO testing in adults (17y+)?
A
FeNO level >40 parts per billion (ppb)
10
Q
What is a positive result from FeNO testing in 5-16 year olds?
A
>35ppb
11
Q
What can influence the accuracy of results of FeNO tests?
A
Empirical treatment with inhaled corticosteroids
12
Q
What are the 3 tests to detect airway obstruction, when person is symptomatic?
A
- Spirometry
- Bronchodilator reversibility (BDR)
- Variable expiratory peak flow readings
13
Q
Which patients should be offered spirometry?
A
All symptomatic people over age of 5
14
Q
What value from spirometry suggests asthma and what should you bear in mind if the patient is aymptomatic?
A
FEV1/FVC ratio normally >70%, any value less suggests airflow limitation
Normal spirometry when asymptomatic does not rule out asthma
15
Q
When should tests of bronchodilator reversibility (BDR) be offered?
A
Offer to adults 17y and over, and consider in children 5-16y with obstructive spirometry (FEV1/FVC<70%)
16
Q
What level of bronchodilator reversibility is regarded as a positive result in 1) adults and 2) children?
A
- Improvement in FEV1 12% or more, together with increase in volume of at least 200ml in response to beta-2 agonists or corticosteroids.
- Improvement of greater tan 400ml is strongly suggestive of asthma
- Improvement in FEV1 of 12% or more
17
Q
When is peak expiratory flow used to help make an asthma diagnosis? Consider adults and children
A
- If variable, can support an asthma diagnosis if diagnostic uncertainty after initial assessment, an FeNO test, and/or objective tests to detect airway obstruction:
- In adults, offer if person has normal spirometry, or obstructive spirometry and positive BDR, with FeNO of 39ppb or less.
- Consider monitoring peak flow variability if person has obstructive spirometry and negative BDR and FeNO between 25-39ppb
- Children: offer if normal spirometry or obstructive spirometry, irreversible airways obstruction and a FeNO of >35ppb
18
Q
What is regarded as a positive result for asthma from peak expiratory flow?
A
Value of more than 20% variability after monitoring at least twice daily for 2-4 weeks
19
Q
How is peak flow variability calculated?
A
Difference between highest and lowest readings expressed as a percentage of average PEF. Recorded over 2-4 weeks
20
Q
What should you remember about how helpful PEF variability is?
A
PEF charting when asthma inactive is unlikely to confirm variability
21
Q
Where is a direct bronchial challenge test with histamine or methacholie performd?
A
Requires specialist referral
22
Q
What is considered a positive result from direct bronchial challenge testing with histamine or methacholine?
A
a PC20 value (provocative concentration causing 20% drop in FEV1) or 8mg/ml or less is regarded as a positive result
23
Q
When should you offer direct bronchial challenge testing?
A
- Spirometry normal, FeNO positive, PEF negative
- Spirometry normal FeNO negative, variable PEF
- Spirometry obstructive, no bronchodilator reversibility, FeNO 25-39 (neg), PEF negative
ie if the other tests don’t clearly give diagnosis of asthma
24
Q
When and how should a diagnosis of asthma be reviewed? For adults and children
A
Review after 6-10 weeks (adults) by repeating spirometry and objective measures of asthma control, and reviewing symptoms
Review after 6 weeks for child by repeating any abnormal tests and reviewing symptoms
25
When should you refer a child who is being tested for asthma for specialist assessment?
If there is obstructive spirometry, negative bronchodilator reversibility and a FeNO level of 34ppb or less (i.e. normal)
26
How should you diagnose asthma in a child who is less than 5 years old?
* Use clinical judgement based on any positive objective test results and noted signs and symptoms to determine the likelihood of asthma
* If cannot perform a particular test, attempt to perform at least 2 other objective tests
* When child reaches 5 years, carry out objective tests
27
What are 7 red signs and symptoms that suggest an alternative diagnosis and should prompt immediate referral to respiratory physician?
1. Prominent systemic features e.g. myalgia, fever, weight loss
2. Unexpected clinical findings e.g. crackle, finger clubbing, cyanosis, evidence of cardiac diease, monophonic wheeze, stridor
3. Persistent, non-variable breathlessness
4. Chronic sputum production
5. Unexplained restrictive spirometry
6. Chest X-ray shadowing
7. Marked blood eosinophilia
28
What are 8 red flag symptoms suggesting an alternative diagnosis to asthma in children?
1. Failure to thrive
2. Unexplained clinical findings (such as focal signs, abnormal voice or cry, dysphagia, and/or inspiratory stridor)
3. Symptoms that are present from birth
4. Excdssive vomiting or posseting
5. Evidence of severe upper respiratory tract infection
6. Persistent wet or productive cough
7. Family history of unusual chest disease
8. Nasal polyps
29
What are the 7 things that define complete control of asthma?
1. No daytime symptoms
2. No night-time waking due to asthma
3. No need for rescue medication
4. No asthma attacks
5. No limitations on activity including exercise
6. Normal lung function (FEV1 and/or PEF \>80% predicted or best)
7. Minimal side effects from medication
30
How can baseline asthma status be assessed?
Validated questionnaire e.g. **Asthma Control Questionnaire** or **Asthma Control Test**, and/or lung function tests such as spirometry or peak expiratory flow (if not already done)
31
What should you do if occupational asthma is suspected?
Arrange specialist referral
32
What are 9 things to do when a new diagnosis of asthma is made?
1. Provide self-management education and personalised asthma action plan (available from Asthma UK)
2. Ensure up to date with **vaccinations** (childhood, influenza)
3. Advice about sources of info and support e.g. **British Lung Foundation, Asthma UK**
4. Advise to avoid **trigger** factors
5. Advice on weight loss and smoking cessation
6. Assess for presence of **anxiety/depression** (more common in people with asthma)
7. Ensure has **own peak flow meter** and measure regularly
8. Initiate drug treatment as appropriate level
9. Explain when and how to use inhalers. Demonstrate correct technique
33
What is the first step of treatment for patients who have symptomatic asthma?
Short-acting beta-2-agonist to all people with symptoms, reliever therapy as required (salbutamol, terbutaline)
34
When should SABA use prompt urgent asthma control/ symptom assessment and measures to improve control?
Anyone prescribed more than one SABA inhaler per month
35
What are 4 conditions when you should add an inhaled corticosteroid (ICS) to the initial SABA?
1. All people who use inhaled SABA **three** times a week or more
2. All people who have asthma symptoms **three** times a week or more
3. Are woken at night by asthma symptoms **once** weekly or more
4. Consider if have had asthma attack requiring treatment with oral corticosteroids in past 2 years
36
How many times a day should an ICS be used for asthma?
Twice daily (little evidence for using it more, bar ciclesonide = once daily)
Once good control established, one-daily at same daily dose can be considered as maintenance therapy
37
Which group of people may need a higher than usual dose of ICS for asthma control?
Smokers - smoking reduces effectiveness
38
What dose of daily ICS should be used as maintenance therapy for asthma?
Low dose then adjust over time, aiming for lowest dose required for effective asthma control
39
After SABA plus low-dose ICS, what are the next 6 steps which can be taken for asthma control in adults?
1. Add leukotriene-receptor antagonist (LTRA), review after 4-8 weeks
2. if uncontrolled with ICS and LTRA, offer LABA in combo with ICS. decide whether to continue LTRA
3. If still uncontrolled, change ICS+LABA to maintenance and reliever therapy (MART) used as maintenance AND as required
4. If still uncontrolled, increase ICS to moderate maintenance dose - either continuing MART or changing to a fixed-dose of ICS and LABA with SABA as reliever therapy
5. If still uncontrolled, trial of additional drug e.g. muscarinic receptor antagonist or theophylline OR higher maintenance dose of ICS
6. In addition to step 5, specialist may also recommend continuous or frequent use of oral steroids (usually prednisolone) or additional steroid tablet-sparing treatments
40
After beginnig with salbutamol and low paediatric dose ICS in children aged 5-16, what are the next 5 steps to take if asthma is uncontrolled?
1. Consider offering leukotriene receptor antagonist (LTRA) in addition to low dose ICS and review response in 4-8 weeks
2. If uncontrolled, consider stopping LTRA and offer LABA in combination with ICS
3. If sitll uncontrolled, consider changing ICS and LABA maintenance to MART regimen with low maintenance ICS dose
4. If still uncontrolled on MART, increase ICS to moderate dose (either continuing MART regimen or change to fixed dose ICS and LABA with SABA as reliever)
5. If still uncontrolled, seek advice from asthma expert health professional. Increasing ICS to high or trial theophylline - usually done under specialist supervision
41
What is MART? Give 4 examples
Maintenance and reliever therapy: a fast-acting LABA and ICS in same inhaler, used as both reliever and maintenance therapy
1. **Symbicort** (budesonide + formoterol)
2. **Fostair** (beclametasone + formoterol)
3. DuoResp Spiromax (budesonide +formoterol)
4. Fobumix Easyhaler (budesonide +formoterol)
42
What is the first next step after a child **\<5 years old** with suspected asthma has tried using salbutamol as a reliever?
* Offer **8 wk trial paediatric moderate dose ICS** if symptoms indicate maintenance therapy needed (3x week or more, waking at night, uncontrolled with SABA)
* After 8 weeks, stop ICS treatment and continue to monitor symptoms
* If did not resolve during trial, consider alternative diagnosis
* If resolve then recurred within 4 weeks of stopping ICS, restart ICS as **maintenance therapy**
* If symptoms resolved by recurred beyond 4 weeks after stopping ICS treatment, repeat **8 week trial** of moderate dose ICS
43
What are the next 2 steps in a child under 5 years with suspected asthma after salbutamol and low dose ICS maintenance therapy are used?
1. Consider LTRA in addition to ICS
2. Stop LTRA and refer to healthcare pro with asthma expertise
44
How is asthma diagnosed in children \<5y?
Should be confirmed when child is old enough/ able to undergo objective tests
45
What are 4 alternatives to ICS maintenance therapy if contraindicated or not tolerated?
1. LTRA for children under 5
2. Sodium cromoglicate, adults and children \>5y
3. Nedocromil sodium, adults and children \>5y
4. Theophyllines, all age groups
46
What is the suggested self-management for when asthma control deteriorates?
With self-management programme, consider increased dose of **ICS for 7 days** for those using ICS in single inhaler
Consider **quadrupling** regular dose
Do not exceed maximum licensed daily dose
47
What is recommended for people whose asthma is exacerbated by exercise? 3 things
1. Review regular treatment as can indicate poor control
2. Consider use of LTRA, LABA, sodium cromoglicate or nedocromil sodium
3. Advise SABA immediately prior to exercise
48
When can you consider decreasing maintenance therapy for asthma?
Once person's asthma well controlled with current maintenance therapy for at least **3 months**
49
How should you go about decreasing maintenance therapy in well-controlled asthma?
* stop or reduce medicines in order that takes into account clinical effectiveness when introduced, side effects and person's preference
* reductions in ICS dose should be slow: **25-50%** each time, **every three months**
* decide with person how effects of decreasing meds will be monitored and reviewed
50
Does management of asthma change in pregnant women?
No, advise to continue all meds including systeic corticosteroids if applicable
51
What follow up should there be for patients with asthma?
At least annual follow up
Closer if poor lung function and/or history of asthma attack within last year, people undergoing treatment adjustment, and those at risk of poor outcomes
52
What are the 2 key delivery systems for inhaled asthma medications?
1. Dry-powder inhalers (DPIs)
2. Pressurised metered-dose inhalers (PMDIs)
53
What delivery system is recommended for adults?
PMDI with or without spacer (some may prefer DPI)
54
What delivery system is recommended for children 5-12y?
PMDI with spacer; face mask required until child can breathe reproducibly using spacer mouthpiece
55
What delivery system is recommended for children \<5y?
No evidence - specialist advice if uncertainty
56
What type of inhaler can be used with a spacer?
PMDIs (pressurised metered-dose inhaler)
57
What is the benefit of spacers?
Increase proportion of drug delivered to the airways and reduce amount of drug deposited in the oropharynx (reduce local adverse effects and reduce systemic absorption)
58
What are 9 things to monitor at an asthmareview in everyone?
1. Monitor asthma control if iver 5 using either spirometry or peak flow variability testing
2. Observe and give evidence on inhaler technique
3. Monitor number of asthma attacks
4. Monitor oral corticosteroid use
5. Time off school/ nursery/ work due to asthma
6. Nocturnal symptoms
7. Adherence
8. Possession of/ use of self-management plan/ written eprsonalised action plan
9. Exposure to tobacco smoke
59
In chidren what are 4 additional points for monitoring at the asthma?
1. Symptoms score best assessed using Childhood Asthma Control Test or Asthma Control Questionnaire
2. Ask 'do you use blue inhaler (reliever) every day'?
3. Ask children about own symptoms
4. Growth (height and weight centiles)
60
What are 6 additional things to do at an asthma review specific to adults?
1. Symptomatic asthma control using Royal College Physicians 3 Questions or Asthma Control Test or Astham Control Questionnaire
2. Closed questions such as how many days a week do you use blue inhaler
3. Lung function
4. Bronchodilator overuse, especially more than 12 SABA inhalers per year
5. Smoking status
6. Possibility of occupational asthma
61
What is one factor asociated with greatly increased risk of future asthma attacks in adults?
Previous asthma attacks
62
What are 2 factors asociated with moderately increased risk of future asthma attacks in adults?
1. Poor control
2. Inappropriate or excessive use of SABAs
63
What are 6 factors associated with slightly increased risk of future asthma attacks in adults?
1. Older age
2. Female
3. Reduced lung function
4. Obesity
5. Smoking
6. Depression
64
What are 2 factor asociated with greatly increased risk of future asthma attacks in children?
1. Previous asthma attacks
2. Persistent asthma symptoms
65
What are 4 factors associated with moderately increased risk of future asthma attacks in children?
1. sub-optimal regimen
2. Comorbid/atopic allergic disease
3. Low-income family
4. Vitamin D deficiency
66
What are 4 factors associated with slightly increased risk of future asthma attacks in children?
1. Younger age
2. Exposure to environmental tobacco smoke
3. Obesity
4. low parental education
67
What are 5 things that you should offer monitoring of for poeple on long term steroid tablets (\>3 months)?
1. BP
2. Urine or blood sugar
3. Cholesterol
4. Bone mineral density
5. Vision (assess for cataracts and glaucoma)
68
After how long should you review the response to treatment if medication is adjusted?
4-8 weeks
69
Who should be offered prophylactic treatment for asthma to reduce possibility of exacerbation frequency?
People 50-70y, ongoing symptoms despite high-dose inhaled steroids, who have suffered one exacerbation requiring oral steroids in previous year
70
What is the suggested oral antibiotic therapy for people 50-70 whose asthma is uncontrolled on high dose steroids?
Azithromycin 500mg 3x a week for minimum 6-12 months
71
What are 5 things you should do before commencing oral macrolide therapy for asthma?
1. Referral to respiratory specialist or specialist asthma service
2. Ensure optimisation of other asthma therapies, including establishing good adherence to inhaled therapies
3. ECG to assess QTc interval should be performed
4. Perform baseline liver function tests
5. Counsel about potential adverse effects including GI upset, hearing and balance disturbance, cardiac effects, microbiological resistance
72
What monitoring should be carried out when prescribing oral macrolides for asthma? 2 things
1. Liver function after 1 month then every 6 months
2. ECG to assess QTc prolongation 1 month after treatment
73
What is the Royal College of Physicians 3 Questions tool for asthma follow up in adults?
Answering no to all three questions is consistent with controlled asthma. They are:
1. Have you had difficulty **sleeping** because of your asthma symptoms (including cough)?
2. Have you had your usual asthma symptoms during the **day** (e.g. cough, wheeze, chest tightness, breathlessness)?
3. Has your asthma interfered with your **usual** **activities** (e.g. housework, work, school)?
74
What are 7 things to do as the management of an acute exacerbation of asthma in primary care?
1. Determine severity grade
2. Review person's history - compliance, previous exacerbations
3. Consider need for hospital admission
4. While awaiting admission (if indicated) give O2, SABA etc.
5. If do not require hospital admission, give appropriate treatment
6. Follow up within 48 hours of presentation if not admited
7. Follow up all people admitted to hospital within 2 working days of discharge
75
What are 7 things to look at when assessing severity of an asthma exacerbation?
1. Degree of agitation and consciousness. May be sign of hypoxia in child
2. Signs of exhaustion - inability to complete sentences
3. Cyanosis - blue lips/ extremities
4. Use of accessory muscles at rest
5. Examine chest, record resp rate, pulse, BP
6. Record PEFR (if old and well enough to comply) and use best of three recordings compared to their best in past 2 years or predicted value
7. Measure oxygen sats in room air
76
What are the 3 grades of asthma exacerbation severity?
1. Moderate
2. Acute severe
3. Life-threatening
77
What are 3 features that puts an asthma exacerbation in the moderate category?
1. PEFR more than 50-75% best or predicted (at least 50% in children)
2. Normal speech
3. Noo features of acute severe or life-threatening asthma
78
What are 7 features that puts an asthma exacerbation in the acute severe category?
1. PEFR 33-50% best or predicted (less than 50% in children) OR
2. RR at least 25 in people over age of 12, 30 in children 5-12y, 4- in children 2-5
3. HR \>110 in \>12y, \>125 in 5-12y, \>140 in children 2-5y OR
4. Inability to complete sentences in one breath or
5. Accessory muscle use OR
6. Inability to feed (infants)
7. with O2 \>92
79
What are 10 features that puts an asthma exacerbation in the life-threatening category?
1. PEFR \<33% best or predicted OR
2. O2 sats \<92
3. Altered consciousness
4. Exhaustion
5. Cardiac arrhythmia
6. Hypotension
7. Cyanosis
8. Poor respiratory effort
9. Silent chet
10. Confusion
(only need 1)
80
What are the 4 criteria for admitting an acute asthma exacerbation?
1. **All** people with features of life-threatening asthma exacerbation
2. Admit people with any feature of severe asthma attack **persisting after initial bronchodilator treatment**
3. Moderate with **worsening symptoms** despite initial bronchodilator treatment and/or have had **previous near-fatal asthma attack**
4. Moderate with factors that warrant **lower threshold** for admission
81
What are 11 factors that warrant a lower threshold for admission and would result in admission in moderate asthma exacerbations?
1. \<18y
2. Poor treatment adherence
3. Living alone/social isolation
4. Psychological problems such as depression, and alcohol or drug misuse
5. Physical or learning disability
6. Previous severe asthma attack
7. Exacerbation despite adequate dose of oral corticosteroids before presentation
8. Presentation in afternoon or at night
9. Recent nocturnal symptoms
10. Recent hospital admission
11. Pregnancy
82
What are 6 things to do while a patient is awaiting admission to hospital?
1. Give controlled supplementary oxygen
2. Treat with SABA
3. Consider ipratropium nebs if life-threatening or severe and poor response to salbutamol
4. Consider advising quadrupling ICS at onset
5. If quadrupled ICS not suitable, give first dose of course of prednisolone. IM methylprednisolone if can't swallow
6. Monitor PEFR and O2 sats to assess response
83
What is the pathophysiology of asthma?
**Type 1 IgE-mediated hypersensitivty** reaction resulting in contraction of smooth muscle in airways
84
How is controlled supplementary oxygen given to a patient with an asthma attack awaiting hospital admission?
Use face mask, Venturi mask or nasal cannulae. Adjust flow rates as necessary to maintain oxygen saturation **94-98%** but do not delay oxygen administration in the absence of pulse oximetry
85
How should a short-acting beta-2 agonist be given for life-threatening or severe asthma in the community if awaiting hospital admission?
* **Nebulised** salbutamol **5mg** if \>5y, 2**.**5mg to children 2-5y
* Ideally **oxygen drive: 6L/min** to avoid worsening hypoxia
* Deliver by air-driven neb if oxygen-driven neb unavailable
* **Continuous** nebulisation preferred in severe obstruction
* If intermittent nebulisation, repeat salbutamol every 20-30 minutes. If continuous nebuliser, give dose over 30-60 minutes
86
When should ipratropium bromide be given when a patient is awaiting hospital admission for an asthma exacerbation?
For those with life-threatening and severe asth,a and with a poor initial response to salbutamol
87
What dose of ipratropium bromide should be given in the community to those awaiting hospital admission who are eligible? Adults + children 2-12y
1. Adults: 500 micrograms
2. Children 2-12y: 250 micrograms
don't repeat within 4 hours
88
When should you consider quadrupling ICS while awaiting hospital admission for an asthma exacerbation?
At onset of asthma attack
89
When should a course of oral prednisolone be started in patients awaiting hospital admission for an asthma exacerbation?
For those people who are **not** suitable for quadrupled ICS
90
What dose of oral prednisolone should be initially given in patients awaiting hospital admission for an asthma exacerbation? Adults, \>5y, 2-5y, \<2y
* 40-50mg for adults
* 30-40mg for children over 5 years
* 20mg for children 2-5 years
* 10mg for children under 2 years
91
What route and doses of alternatives to oral prednisolone can be given during an asthma exacerbation awaiting hospital admission, if medication can't be swallowed? Adults, \>5, 2-5y
1. IM methylprednisolone 160mg adults
2. IV hydrocortisone 100mg in people \>5y
3. IV hydrocortisone 50mg in children 2-5y
92
What are 7 points for management if a person has an acute asthma exacerbation but does **not** require hospital admission?
1. SABA via large spacer
2. Consider quadrupling ICS at onset and for up to 14 days
3. If unsuitable for increased ICS consider prescribing short course of oral prednisolone
4. Do not prescribe antibiotics routinely, unless symptoms and signs suggest bacterial infection
5. Once symptoms have subsided advise return to SABA as required up to 4x daily, not exceeding 4 hourly
6. Advise to monitor PEFR and symptoms
7. Consider initiating montelukast in children \>2 with mild asthma exacerbation early after onset of symptoms
93
How should a SABA be given to patients with an exacerbation of asthma who do not need to be admitted to hospital? Adult + child
* SABA via large-volume spacer
* Adult: 4 puffs initially followed by 2 pufs every 2 minutes according to response, **up to 10 puffs**
* Child: puff every 30-60 seconds, **up to 10 puffs**
* Each puff one at a time and inhaled with 5 tiadl breaths
* **Repeat every 10-20 minutes** according to clinical response
(note in hosp can give back to back salbutamol nebs, max 5 in a row, given over 30min)
94
When would you consider referral to a respiratory physician based on asthma attacks?
If person has experienced 2 asthma attacks within 12 months
95
When should you follow up a patient who has had an acute asthma exacerbation, based on whether or not they were admitted to hospital?
If admitted - within 2 working days of discharge
If not admitted - within 48 hours of presentation
96
What are 10 things to consider at a follow up following an acute asthma exacerbation?
1. Relieve symptoms and check PEF
2. Check inhaler technique
3. Consider stepping up treatment by increasing ICS or adding new preventive therapy
4. Address potentially preventable contributors e.g. triggers, non-compliance
5. Lifestyle advice, vaccines, diet, exercise, smoking
6. Advise how to recognise poor asthma control, early signs of exacerbation, what to o at early signs, seeking help
7. Consider prescribing supply of oral corticosteroids for person to keep at home and provide written info advising to start during early exacerbation, and contact primary care if start treatment
8. ensure they have self management info
9. if \>18, can use LABAL/ICS como as relieer therapy when replied in addition to regular preventer
10. consider referral to resp physician if 2 attacks in 12 months
97
Why is the diagnosis of asthma in young children difficult?
Common for them to develop wheeze when they have a virus (viral-induced wheeze)
98
What happens to FEV1, FVC and FEV1/FVC in asthma?
* FEV1 = significantly reduced
* FVC = normal
* FEV1/FVC = \<70% ie. obstructive
99
Why can FeNO be used to help diagnose asthma?
Levels of a certain type of NO tend to rise in inflammatory cells, particularly eosinophils; levels therefore correlate with levels of inflammation
100
What s a key side effect of SABAs e.g. salbutamol?
Tremor
101
What are 2 side effects of ICSs?
Oral candidiasis and stunted growth in children
102
What is a key example of a long-acting muscarinic antagonist (LAMA), used in the highest stages of controlling adult asthma?
Tiotropium
103
What constitutes high, moderate and low dose ICS for adults?
* Low: **\<400 micrograms budesonide** or equivalent
* Moderate: **400-800** micrograms budesonide or equivalent
* High: **\>800** micrograms budesonide or equivalent
104
What diagnostic tests should all patients with suspected asthma who are 17 years or older have to diagnose asthma?
1. Spirometry with bronchodilator reversibility test
2. FeNO
(clinical judgement used less, objective tests now better in NICE's guideliens)
105
What tests can be done to help diagnose occupational asthma?
Serial measurements of PEF at work and away from work
106
What should you do if a patient has suspected occupational asthma?
Referral to respiratory specialist
107
What is a fourth category of severity of asthma exacerbations, in addition to moderate, acute severe and life threatening?
Near-fatal
108
What are 2 features that define near-fatal asthma?
1. Raised pCO2 (upper and middle airway obstruction blocking alveolar ventilation leading to CO2 retention) and/or
2. Requiring mechanical ventilation with raised inflation pressures
109
In secondary care what are 2 parts of further assessment of an acute asthma exacerbation?
1. ABG if blood saturation \<92%
2. Chest x-ray ONLY if life-threatening asthma, suspected pneumothorax or failure to respond to treatment
110
What are the only 3 situations when you would request a chest x-ray in an acute exacerbation of asthma?
1. Life-threatening asthma
2. Suspected pneumothorax
3. Failure to respond to treatment
111
What is the suggested oxygen management of an acute exacerbation of asthma in secondary care?
If hypoxaemic and acutely unwell, start on 15L supplemental via non-rebreate mask, which can be titrated down to a flow rate where they are able to maintain sats 94-98%
112
How should a SABA be given in secondary care in an acute asthma exacerbation?
* Salbutamol 5 mg nebulised via oxygen-driven nebuliser
* Can give salbutamol ‘back to back’ if severe. This means running 5mg ampoules through the nebuliser one after another.
* You can do this up to 5 times in row. It takes approximately 6 minutes for one ampoule to go through so this takes approx 30 minutes (5×6).
113
What steroids should be given to a patient with an acute asthma exacerbation in secondary care?
* 40-50mg prednisolone orally od for at least 5 days or until patient recovers
* also continue normal medication routine including inhaled corticosteroids
114
What type of drug is ipratropium bromide?
Short-acting muscarinic antagonist
115
When should a patient who has been admitted with an acute asthma exacerbation be given nebulised ipratropium bromide?
* if severe or life-threatening
* in patients who have not resonded to beta-gonist and corticosteroid treatment
116
In a patient admitted with an acute asthma exacerbation, when is magnesium sulfate given and how?
Commonly given for severe/life-threatening asthma; IV magnesium sulfate
117
What must you do before prescribing aminophylline for a patient admitted with an acute asthma exacerbation?
Following consultation with senior medical staff
118
What should you do if patients fail to respond to all the recommended medication when admitted with an acute asthma exacerbation?
They require senior critical care support: should be traeted in appropriate ITU/HFU setting
119
What are 2 types of treatment that may be given to a patient with an acute asthma exacerbation who needs to be managed in ITU/HDU?
1. Intubation and ventilation
2. Extracorporeal membrane oxygenation (ECMO)
120
What are 3 criteria for discharge from hospital for a patient admitted with an acute asthma exacerbation?
1. Been stable on discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
2. Inhaler technique checked and recorded
3. PEF\>75% of best or predicted
121
What may trigger an acute asthma exacerbation?
Respiratory tract infection
122
What is the mnemonic to remember the management of an acute asthma exacerbation?
OSHITME
* oxygen
* salbutamol nebs/ inhaler
* hydrocortisone/prednisolone (oral pred)
* ipratropium nebs
* IV aminophylline (a theophylline)
* IV magnesium sulphate
* escalate
