Asthma Flashcards
MOA of beta agonists
- Bind to g protein coupled receptors and activate adenylyl cyclase resulting in cAMP
- This activates PKA leading to phosphorylation and muscle relaxation (bronchodilation)
- Non-bronchodilation actions: increased mucociliary clearance, protect epithelium against bacteria, suppress microvascular permeability, inhibit cholinergic transmission, primes glucocorticoid receptors leading to enhanced nuclear translocation and some mild anti inflammatory effects
List adverse effects of B-agonists
- Tremor
- Tachycardia
- Prolonged QT
- Hyperglycemia
- Hypokalemia
- Hypomagnesemia
- Densensitization
What is cromolyn sodium?
- Cromolyn sodium is a mast cell stabilizer, available as an inhalation or opthalmic drop - pregnancy category B
- Requires QID dosing
- works by inhibiting IgE-mediated calcium channel activation, which prevents mast cell release of histamine, leukotrienes, and cytokines (therefore blocks activation of eosinophils, inhibits neutrophil activation, chemotaxis and mediator release, and inhibits IgE production)
- commonly used in allergic eye disease and in the treatment of GI symptoms in mastocytosis
Approval criteria for Xolaire in asthma
Asthma
- Age 6+
- Moderate to severe asthma inadequately controlled with ICS
- Allergic sensitization by SPT or RAST to a perennial allergen
- Total serum IgE 30-700 IU/mL for >12s, and 30-1300 for 6- 12 years old
CRSwNP
- add on therapy for adults age 18+ with CRSwNP not adequately controlled on INCS
CSU
- Patients age 12+ with CSU who remain symptomatic despite anti histamine therapy
MOA of Xolaire:
- Omalizumab binds to the third constant domain of the IgE heavy chain (Cε3), which is the same site at which IgE normally binds to both high and low affinity IgE receptors on mast cells, basophils, and other cell types
- Omalizumab forms complexes with free IgE and prevents its interaction with these receptors. The omalizumab-IgE complexes are subsequently cleared by the hepatic reticuloendothelial system
- The antibody is specific to IgE and does not bind to IgG or IgA. An important property of omalizumab is that it cannot bind to IgE receptors or to IgE already attached to FcεRI, and therefore does not interact with cell-bound IgE or activate mast cells or basophils by interacting with FcεRI.
Adverse effects of Xolair
- anaphylaxis (0.2%); FDA recommendations: should be observed for xolair injections X 60 minutes for first three and then X 30 minutes after and have epipen for 24 hours after each injection.
Unclear associations: CSS, cardiovascular disease, susceptibility to parasitic infection.
Xolair dosing
0.016 mg/kg per IU IgE/mL per month. Cost about $10,000 per year.
Efficacy of Xolair in asthma
Reduction in ICS, decreased exacerbations, decreased hospitalizations. Smaller reduced FEV1 upon acute allergen exposure (such as cat). Duration of therapy not determined - if respond, generally continue for long-term.
Management of asthma in pregnancy
- Follow spirometry Qmonthly
- avoid asthma triggers, don’t smoke
- if on AIT can continue if on maintenance but otherwise stop.
- ICS preferred controller therapy; if moderate persistent asthma can use either medium dose ICS or ICS/LABA.
- Unusual to have asthma attack during labor/delivery but should stay on meds. If recently on OCS should be stress dosed.
Discuss the mechanism of theophyllines
Theophylline inhibits PDE resulting in elevated cAMP and also acts as an adenosine receptor antagonist (may account for s/e of CNS stimulation, gastric hypersecretion, diuresis).
Clinical effects: increases IL10, increases apoptosis of inflammatory cells (eos, T lymphocytes), increases histone deacetylase activity (synergy with CS), prevents nuclear translocation of NFKB (anti-inflammatory). Is both bronchodilator and anti-inflammatory.
Decreased clearance with macrolides, CHF, liver disease, older age, high CHO diet.
Increased clearance with young age, high protein diet, ETOH, smoking, antiepileptics.
3 causes of cough
chronic cough = >4 weeks (children), >8 weeks (adults)
1. Upper airway cough syndrome (UACS) prev known as post-nasal drip syndrome most common cause of chronic cough may be attributed to combination of upper airway inflammation, nasobronchial reflex, cold dry air stimulation, central and peripheral neuroplasticity 2. Asthma 3. GERD
Risk factors for AR
- AAAAI 2008 PP Risk factors for allergic rhinitis:
- family hx of atopy
- serum IgE >100 before age 6
- higher SES
- presence of a positive SPT- Unknown effect:
- early childhood infections (might reduce atopy)
- early childhood exposure to animals (might reduce atopy)
- secondary tobacco smoke exposure (might increase atopy)
- Unknown effect:
MOA of INCS
- reduce influx of inflammatory cells into the nasal mucosa in response to allergic stimuli
- this reduces the release of inflammatory mediators and the development of nasal hyperresponsiveness
- block the synthesis and release of cytokines and chemokines from T cells, epithelial cells, eosinophils, and mast cells
Who is suitable for step 1 of GINA guidelines?
(Age 12+)
Step 1: As needed low dose ICS- formoterol (Age 12+)
patients with symptoms less than twice a month, and no exacerbation risk factors
<12 years is PRN SABA or ICS whenever PRN saba is taken
What is step 2 of GINA guidelines? (Age 12+)
sx more than 2x a month, but less than daily
- daily low dose ICS and PRN SABA
- PRN ICS-formoterol
What is step 3 GINA guidelines? (Age 12+)
low dose ICS- fom maintenance and reliever or low dose ICSLABA and PRN SABA Med dose ICS and PRN SABA Low dose ICS and LTRA
reasons to go to step 3
- sx most days
- waking more than once per week
step 2
- >2 x per month, but less than daily
What is step 4 of GINA guidelines? (Age 12+)
medium dose ICS-LABA maintenance and PRN
Other options: high dose ICS, add on tiotropium or add on LTRA
if HDM - do SLIT if FEV>70%
What is step 5 of GINA guidelines? (Age 12+)
high dose ICS-LABA
Refer for phenotypic assessment
add on therapy like tiotropium, anti IgE, anti IL5/5R, and anti IL4R
What is the modified asthma predictive index and compare it to the original asthma predictive index
Modified API
4 episodes of wheeze with 1 MD confirmed episode AND
1 Major OR 2 minor
Major:
- Parental history of asthma
- MD dx atopic derm
- Allergic sensitization to at least 1 aeroallergen
Minor
- allergic sensitization to milk, egg or peanuts
- wheezing unrelated to colds
- blood eos > 4%
Original API Major - Parental asthma - MD dx atopic derm Minor - AR - wheezing unrelated to colds - blood eos >4%
Absolute contraindications for bronchoprovocation testing
- FEV1 <50% predicted or 1.0L
- ACS within 3 months
- Severe Htn (>200 sBP or >100dBP)
- cerebral or aortic aneurysm
Relative contraindications
- inability to perform spirometry
- pregnant or nursing
- hypoxemia
- recent resp infection
Medications to stop before methacholine challenge
Inhaled bronchodilators
- salbutamol (8 hours)
- ipratropium (24 hours)
- salmeterol/formoterol (48 hours)
- tiotropium (1 week)
Oral bronchodilators - theophylline (24 hours)
Inhaled/oral steroids (2-3 weeks)
mast cell stabilizers (cromolyn 8 hours)
antihistamines (72 hours)
LTRA (24hours)
Name the three types of bronchoprovocation testing
- Specific airway irritants
- allergens and occp. exposures - Non specific pharmacological agents
- methocholine - Indirect stimuli
- exercise, cold air, mannitol
What type of hypersensitivity reaction is APBA
It is a combo of type 1 and type 3 responses (IgE and IgG)
Describe the immunology of ABPA
Increase in th2 response
generation of cytokines IL-4, IL-5 and IL-13
this causes increase in eosinophilia and IgE
Diagnosis of ABPA ISHAM Criteria
Obligatory criteria
- total IgE elevated >1000 IU/mL
- skin test positive or specific IgE to aspergillus elevated
Other criteria 2 of
- precipitating serum antibodies to A.fumigatus
- radiographic pulmonary opacities consistent with ABPA
- total eos count of >500
Beclamethasone is…?
QVAR
Category C for pregnancy
List 5 mechanisms where cytokines contribute to clinical asthma
Th2 lymphocytes release IL-3, IL-4, IL-5, IL-13 and GM- CSF
IL-3 is a survival factor for eosinophils and basophils
IL-4 promotes T cells to become Th2, B cells to class switch to IgE, endothelial cells to express VCAM-1 which promotes eos, baso, and t cell recruitment
IL-5 regulates eos production and survival
IL-13 contributes to airway eos, mucous glad hyperplasia, airway fibrosis and remodeling
GM- CSF- survival factor for eos
What is the role of eosinophils in asthma?
- mediate smooth muscle contraction
- cause damage to airway epithelium and nerves
- may be involved in airway remodeling and fibrosis
Effects of tobacco smoke on asthma?
- May cause development of asthma in some studies
- May cause more severe symptoms
- May cause an accelerated decline in lung function
- may impair short term therapeutic response to corticosteroids
Name the 4 tachykinins that contribute to asthma
- Substance P
- Neurokinin A
- Calcitonin
- Gene related peptide
These neurotransmitters effect the airways by initiating bronchoconstriction, causing mucous secretion, causing vasodilation and plasma exudation, and leading to inflammatory cell recruitment
Name 5 features that suggest the diagnosis of asthma in a 3 years old after trying low dose ICS x 2 months and SABA PRN (CTS)
- Reduction in daytime and nocturnal symptoms
- Reduction in the use of rescue SABA
- No acute care visits
- No hospital admissions for asthma exacer.
- No use of rescue OCS
Diagnosis of pre-schooler asthma
- MD documented airflow obstruction
(alt: convincing parental report of wheeze) - MD documented reversibility of obstruction
(alt: convincing parental reports of response to SABA) - No evidence of other diagnosis
4 reasons a teen has poorly controlled asthma
- Non compliance
- not using device properly
- smoking
- allergy triggers
- insufficient dose
Name 6 elements that would indicate well controlled asthma control
- Daytime sx < 2 days a week
- nighttime <1 night/ week
- Physical activity normal
- exacerbations mild and infrequent
- absence from work - none
- Need for SABA < 2 doses per week
- FEV1 or PEF >90% of personal best
- PEF diurnal variation <10-15%
- sputum eosinophils <2-3%
How does the mannitol test work?
bronchoconstriction by increasing the osmolarity of the airway surface resulting in release of mast cell mediators –> the mast cell mediators (prostaglandins and leukotrines E4) in turn cause broncho constriction
Diagnostic criteria for Churg Strauss/ EGPA
ACR
Presence of 4 or more of these criteria had a sens. of 85% and spec. of 99.7% for EGPA
- Asthma
- Greater than 1% eosin of the differential
- Mononeuropathy or polyneuropathy
- Migratory or transient pulm. opacities
- paranasal sinus abnormality
- Biopsy containing a blood vessel should accumulation of eos in extravascular areas
Treatment for EGPA
- Prednisone 0.5-1.5 mg/kg OD for 6-12 weeks than slow taper (mainstay of treatment)
- Consider azathioprine for maintenance
In a child age 6-11 years who is on maintenance ICS, what is their yellow zone step up therapy? (CTS)
- First choice: None
2. 2nd chocie: Oral Prednisone 1 mg/kg x 3-5 days
In a child age 12+ who is one ICS for maintenance therapy, what is their yellow zone step up therapy? (CTS)
- Increase ICS to 4 x dose for 7-14 days
2. 2nd choice: Pred 30 -50 mg for 5 days
In a child age 12+ who is one ICS/LABA for maintenance therapy, what is their yellow zone step up therapy? (CTS)
- Increase to 4 inhalation BID or 8 inhalation max daily if Bud/Form is their reliever
- Pred 30-50 mg for 5 days
What are the criteria for hypereosinophilia?
- absolute eosinophil count of >1.5 x 109 on peripheral smears on 2 occasions separated by at least 1 month and
- pathologic confirmation of tissue HE
AND - eosinophil mediated organ damaged and/or dysfunction, provided other causes for damage is excluded
Stages of ABPA
Stage 1. Acute - upper lobe or middle lobe involvement with elevated IgE
Stage 2. Remission - No infiltrates, off prednisone with elevated or normal IgE
Stage 3. Exacerbation - upper lobs or middle with markedly elevated IgE
Stage 4- Steroid dependant asthma - infiltrates absent or only intermittent with elevated or normal IgE
Stage 5 - End stage - fibrotic, bullous, or cavitary lesions and IgE may be normal
Name 3 Categories of hypersensitivity pneumonitis
acute
subacute
chronic
What 5 features suggest asthma in a patient who has been on ICS x 2 months and beta agonists PRN? (CTS 2012)
- reduction in daytime nocturnal sx of asthma
- reduction in the use of SABA
- No acute care visits
- No hospital admissions
- No use of PO Pred
Name some non specific stimuli used in asthma testing (3)
- methacholine
- histamine
- cold air
Name a direct test in asthma dx
- Methacholine challenge
Name an indirect agent used in asthma testing
- inhaled mannitol
causes bronchoconstriction by increasing osmolarity of the airway surface –> release of mast call mediators –> bronchoconstriction - exercise provocation
- eucapnic voluntary hyperpnea
what is the eucapnic voluntary hyperpnea test?
breath dry hypercapnic air for 6 minutes at a RR of 300 x the FEV1
spirometry is performed prior to the test and at 5, 10 and 15 minutes after completion
positive if FEV1 decreases by 10% or more
what is the exercise provocation test?
exercise for 6-8 minutes at 20-25C while breath dry air at 80-90% of max HR
then measure FEV1 at 5, 10, 15 and 30 minutes
drop in FEV1 by 10% is diagnostic
Give some examples of low molecular weight agents, what type of reaction are they likely to cause?
- dust mite, cleaning products, platinum salts, wood acids
2. likely to cause late or dual responses in bronco-provocation testing
Give examples of high molecular weight agents, wha type of reaction do they cause?
- animals, fish, flours, latex
2. immediate reaction in broncho provocation testing
What is reactive airway dysfunction syndrome?
- new asthma occurring as the aftermath of an acute inhalation injury, caused by a single high dose exposure (corrosive gas, vapour, fumes)
- dx criteria :
1. absence of prior resp sx
2. onset of sx after a single irritant exposure
3. exposure to high conc. of irritant chemical
4. sx onset within 24 hrs
5. methacholine +
6. exclusion of other types of lung disease
7. documented airflow obstruction
What is Churg strauss vasculitis?
multi system granulomatous vasculitis of the small and medium sized arteries, characterized by
- asthma
- rhinosinusitis
- blood eosinophilia
what are the 3 phases of EGPA?
- Prodromal - atopic diseases, AR and asthma
- Eosinophilic - eos infiltration of multiple organs
- Vasculitic - pot. life threatening phase of systemic vasculitis
diagnosis of EGPA
- lung biopsy is gold standard but not practical ACR (need 4/6) - paranasal sinus abnormality - asthma - migratory or transient pulm opacities - mononeuropathy - >10% eos on the diff - biopsy with vessel showing eos
name the 3 categories of hypersensitivity pneumonitis
- acute: pts exposed to a culprit antigen and produce IgG, subsequent exposure leads to immune complex formation and influx of neutrophils
- subacute: CD4 Th1 lymphocyte mediated delayed hsn causing granuloma formation
- chronic: development of fibrosis, increase of CD4, CD8 T cells
Name some precipitants of hypersens. pneumonitis
- mold
- birds
- feathers
- isocyanates
- pesticides
dx of HP:
- known exposure to offending agent
- compatible HRCT findings
- BAL lymphocytosis
- positive inhalation challenge
lung biopsy in HP shows?
non caseating granulomas
mononuclear infiltrate
fibrosis
How to confirm occupational asthma?
confirm reversible airflow obstruction using spiro pre and post OR non specific bronchoprovocation challenge to the sensitizing agent at that work place
main allergen in western red cedar?
plicantic acid
allergen in glues
abietic acid
allergen in paint
isocyanates
cytokines that contribute to asthma (4)
IL-1b, TNF-a, IL-6, IL-4, IL-13, TGF-b
What do eos do in asthma? (3)
- smooth muscles contraction
- airway damage
- airway remodeling
effects of tobacco on asthma
- development of asthma
- accelerated decline in lung function
- impaired short term response to steroids
discuss some immunological mechanisms of asthma (4)
- Upregulation of adhesion molecules
- arachidonic acid metabolite production (LTB4)
- chemokine synthesis (IL-8)
- Cytokine secretion (IL-1b, YNF-a, IL-6)
Name some mediators in the pathogenesis of asthma
- histamine
- PGD2
- Leukotrines
- TNf-a
- eosinophils
with allergen exposure, bronchoconstriction occurs within minutes due to release of the above mast cell mediators
name 4 tachykinins
- substance P
- neurokinin A
- neurokinin B
- gene related peptide (GRP)
- calcitonin
airway nerve endings contain these tachykinins and then have effects on the airways like bronchoconstriction, mucous secretion, leads to vasodilation and inflammatory cell recruitment
MOA of Ipratropium bromide
antagonize the actions of the Ach at the parasympathetic cell junction by competing with Ach for M3 receptor sites –> leads to SM relaxation and bronchodilation
GINA 2020 on azithromycin
- add on azithromycin for adults with persistent sx asthma despite moderate to high dose ICS/LABA reduced asthma exacerbations in eosinophilic and non-eos asthma and improved QOL
- tx for 6 months suggested
GINA 2020 on Cromolyn sodium
favourable safety profile, but low efficacy
the inhalers require burdensome daily washing to avoid blockage, no recommended for routine use
5 mechanisms where steroids help in asthma
- activate anti inflammatory genes
- switching off inflammatory gene expression
- inhibiting inflammatory cells
- enhancement of B2 adrenergic signalling by increasing B2 receptor expression and function
- decreasing mucous secretion
SE of ICS
- dysphonia
- topical candidiasis
- contact hypersensitivity (budesonide)
- cough and throat irritiation
- adrenal suppression
- growth deceleration
dosing of beclomethasone diproprionate
QVAR
Peds < 200 ug daily
adult <250 ug (low), 250-400 ug (med), > 400 ug is high
Leukotrines role in asthma
Cys- LTs are produced within mins of exposure to an allergen
asthmatics produce a high levels of cys-Lts and levels of sputum Cys-Lts correlate with asthma severity
Cys- Lts cause smooth muscle contraction and bronchoconstriction, increase permeability leading to bronchovascular leakage and mucous gland secretion and cause fibroblasts to proliferate leading to airway remodelling
Cys-LT1 receptor antagonists role in asthma
Monteleukast
- block the cyst-LT1 receptor which are on inflammatory cells like eos, mast, lympho, and macs
mAPI
Major criteria
- parent with asthma
- atopic derm (MD dx)
- allergic sensitization to at least 1 aero allergen
Minor criteria
- elevated eos > 4%
- wheezing unrelated to colds
- allergic sens to egg, milk, or peanuts
GINA guidelines diagnosis of asthma
- Documented airflow obstruction
- Objective excessive variability in lung function using one or more of the tests below
A. bronchodilator test: >12% or >200 mls 10-15 mins after bronchodilator challenge
B. Excessive variability in twice daily PEF over 2 weeks
- adults variability is >10%, kids >15%
C. significant increase in lung function after 4 weeks of anti inflammatory treatment
- increase of 12% of 200 mls
D. Positive exercise challenge
- decrease in FEV by 10% or 200 mls, kids is 12% or PEF 15%
E. Positive bronchial challenge
- fall in FEV1 >20% with methacholine/ histamine or >15% fall with hyperventilation/ hypertonic saline/mannitol
F. excess variation in lung function between visits
- adult > 12% or 200 mls between visits
- kids >12% FEVB1 or 15% PEF between visits
when should you do PEF?
when spirometry is not available
not rec. for dx of asthma in children
Name two indirect challenges for asthma
mannitol and exercise
Name two direct asthma challenges
methacholine and histamine
QVAR
Beclomethasone
kids, approved for > 5 y.o
low dose 50 ug bid
med dose 100 ug bid
adult
low 50- 100 ug bid
med >100 ug bid
high >200 ug
Pulmicort
Budesonide
DPI not rec. for kids <6 years adult 6-18: low 100 ug bid med 200-400 ug bid high > 400 ug bid
Alvesco
Ciclesonide
kids:
100 ug OD - low
200 ug OD - med dose
adults
100 ug OD - low
200-400 ug OD is med
> 400 ug is high
Advair
fluticasone/salmeterol
approved > 4 y.o
dosing
- comes in 125/25 ug or 250/25 2 puffs BID MDI
- 100/50 ug, 250/50, 500/50 ug diskus 1 puff BID
Breo elliptica
fluticase furoate/vilanterol
DPI 100/25 ug/day or 200/25 ug/day
not indicated for < 18 years old
Zenhale
approval age
dosing
Mometasone/formeterol approved for >12 years old low dose is 50/5 2 puffs bid med dose 100/5 ug 2 puffs bid high dose 200/5 2 puffs bid
Name a LAMA
Tiotropium (spiriva respimate)
not indicated for <18 years of age
1.25 ug 2 puffs BID
Name the 3 Anti IL5 therapies and dosing
- Mepolizumab (Nucala) - 100 mg SC Q4 weeks
- Benralizumab (Fasenra) - 3 mg/kg IV Q4 weeks
- Reslizumab (Cinqair) - 3 mg/kg IV Q4 weeks
none are indicated for < 18 years of age right now
Xolair dosing kids vs adults
kids - 150-375 mg SC Q2-4 weeks based on weight and pre tx serum IgE
adults 75-375 mg SC Q2-4 weeks based on weight and pre tx serum IgE
What is theophylline?
and oral bronchodilator with modest anti inflam. effects reserved fro those >12 years who are intolerant to or continue to be sx despite other therapies
What makes a good flow loop curve
- meeting a good start of test criteria
- sharp rise in flow - meeting a good end of test criteria
- pt exhaled to complete RV
- exhalation of > 6 secs - absence of artifacts
- determine whether the repeatability or between-maneuver criteria are met
pathophysiology of hypersensitivity pneumonitis
- prolonged exposure to offending agents leads to T cell mediated damage.
- antigens trigger the inflammatory process mediated by T cells and immune complexes
- primarily a th1 response which develops into th2 when fibrosis develops
ABPA Criteria
Presence of asthma or CF and 2 obligatory criteria 1. IgE> 1000 2. sIgE or SPT to aspergillous 2 of the other criteria - eos > 500 - serum antibodies to a. fumigatus - pulmonary opacities
ABPA management
- steroids
- antifungals - voriconazole and intraconazole
- Xolair being used in CF patients
RFs for asthma
- male gender
- perinatal infections - prematurity, maternal diet
- atopy and allergens
- pollution
- resp infection
- rhinitis
- smoking and tobacco exposure
most common cause for occupational asthma
- flour
2. diisocyanates (from polyurethane foam)
pathogenesis of EGPA
- overproduction of TH2 cytokines IL-4, IL-5, IL-13
- ANCA detected in 40-60% of people
- unclear mechanism
definition of chronic cough
persistent cough > 8 weeks in adults and >4 weeks in children
most important causes of chronic cough
- asthma
- UACS
- NAEB (non asthmatic eosinophilic bronchitis)
- GERD
diagnostic criteria for CF
- clinical sx consistent with CF in at least one organ system AND
- Evidence of CFTR dysfunction (any of)
a. elevated sweat chloride
b. presence of two disease causing CFTR mutations- one from each parental allele
c. abnormal nasal potential difference
absolute CI to bronchoprovocation testing
- ACS within 3 months
- FEV1 <50%
- known brain or aortic aneurysm
- severe HTN
Meds to stop before methacholine challenge
- salbutamol - 8 hours
- ipratropium - 24 hours
- salmeterol/formoterol - 24 hours
- tiotropium - 1 week
- oral bronchodilators (theophylline) - 24 hrs
- inhaled or PO steroids - 2-3 weeks
- AH - 72 hours
what drugs cause pulmonary eosinophilia
- NSAIDs
- Phenytoin
- Antibiotics - sulfa, amp, daptomycin, minocyclin, nitrofurantoin
GINA 6-11 years
STEP 1
sx < than 2 a month
low dose ICS whenever SABA taken
alt: low dose daily ICS
STEP 2 GINA age 6-11
sx > 2 a month but less than daily
tx - low dose ICS + PRN SABA
alt: low dose ICS taken when SABA taken
daily LTRA
STEP 3 age 6-11
sx most days
sx waking more than1 x a week
tx - MART with very low dose Bud-form (100/6 mcg)
low dose ICS/LABA + PRN SABA
Med ICS + SABA
low dose ICS + LTRA
STEP 4 age 6-11
- med dose ICS/LABA +PRN SABA+ refer to expert
- low dose bud-form (200/6) MART
- med dose ICS/LABA + tiotropium or LTRA
STEP 5 for age 6-11 GINA
- refer for phenotypic assessment and higher dose ICS LABA or add on therapy ie. anti IgE
alt: add on anti IL5 or add on low dose OCS but consider SEs
Name some questionnaires used in asthma
the ATAQ - asthma therapy assessment questionnaire for children and adolescents
ACQ - asthma control questionnaire
MESNA trial
- mepo tx in severe asthma
- eos > 150 at screening or > 300 in past year qualified
- asthma exac reduced by 47%
biomarkers for biologics in asthma
- IgE
- FeNO
- Periostin
- Eosinophils
scoring system for rhino sinusitis
SNOT 22 - sino nasal outcome test (quality of life score)
Polyp score
visual analog score
what was the success of Asteria I and II
- reduced itch severity score by 52%
- 66% reduction in asteria II
