asthma- andrew Flashcards by Niamh Walsh

what is asthma?-WHO

It is a disease characterised by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day.

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what are the symptoms of asthma?

–variable and reversible airway obstruction
–airway inflammation
–bronchial hyper-responsiveness to various stimuli

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what is the pathophysiology of asthma?

Chemical mediators are released by mast cells in airways: which cause:
1- bronchoconstriction
2- mucosal oedema
3-hypersecretion of mucus

overall this stops air getting to alveoli and into blood

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what are the signs and symptoms of asthma?

Breathlessness
Tightness in the chest
Coughing
Wheezing

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what are the most common causes and triggers of asthma?

Genetic links - not absolute
–House dust mite
–Animal allergens- e.g.cats
–Pollens e.g.grass, trees
–Infections - particularly viral
–Occupational agents in workplace

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what triggers asthma?

Drugs–3-5% of asthma population get severe bronchoconstriction after taking aspirin/NSAIDs
passive smoking-childhood
emotion/stress
exercise/extreme cold weather

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how do you diagnose asthma?

clinical examination and full history- no certain blood tests you can do
some other investigations- FEV1/ peak flow can influence

it is important to compare the results when the patient is symptomatic and asymptomatic

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what do you look out for in a structured clinical assessment for asthma?

HIGH PROBABILITY

recurrent epsoides of symptoms/
symptom variaility
absense of symptoms of alternse diagnosis

LOW PROBABILITY OF ASTHMA

wheeze?
history of atopy
variable PEV/FEV1

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What is the test for airway obstruction?

spirometrey and bronchodilator reversibility

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what happens in a structured clinical assessment?

Episodic symptoms
•Wheeze confirmed by a HCP on auscultation
•Evidence of diurnal variability
•Atopic history
•Absence of symptoms, signs or clinical history to suggest alternative diagnoses

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what result of a spirometry test would suggest the presence of asthma?

Obstructive spirometry with positive reversibility increases probability of asthma
–Positive result: improvement in FEV1of ≥ 12% with an increase in volume of 200ml
–Improvement in FEV1of ≥ 400ml – strongly suggests asthma

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what would be a positive result of a peak flow test to indicate that a person has asthma?

more than 20% variability- not a straight line

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how does a peak flow work?

it is comapred to predicted peak flow based on persons diameters

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what are the aims of management of asthma?

–Reduce inflammation
–Encourage brochodilatation
- control disease

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what is complete control defined as?

–No daytime symptoms
–No night time awakening due to asthma
–No need for rescue medication
–No asthma attacks
–No limitations on activity including exercise 
–Normal lung function
–Minimal side-effects from medication

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what guidelines is BTS governed by?

NICE and BTS

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What does the BTS approach suggest?

Start at the level most appropriate to initial severity
•Achieve early control
•Maintain control by:–Increasing treatment–Decreasing treatment

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what are the types of drug treatment for asthma?

relievers and preventers

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what are relivers?

Bronchodilators relax smooth muscle walls of airways e.g. salbutamol, ipratropium, theophylline

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what are preventers?

anti inflammatory drugs which reduce inflammation in the airways
-orticosteroids, leukotriene receptor drugs

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what are the differnces between NICE and BTS?

NICE–Introduction of LTRA after ICS

BTS/SIGN continues view that low-dose ICS should be followed by addition of long-acting beta-agonists (LABA)

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what is the most effective combination?

Efficacy – ICS/LABA combination is most effective

•BUT…..generic LTRA now are ‘cost effective’ …role of NICE

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what do bronchodilators (SAB2A) DO?

Relieve symptoms–Activation of β2-receptors results in relaxation of smooth muscle - widening of the airway

what should all symptomatic patients of asthma be prescribed?

All patients with symptomatic asthma should be prescribed inhaled SAB2A.- e.g. salbutamol
good to treat exacerbation but nit preventor

how fast do SAB2A act?

Act within 5 -10 mins–Last 4 - 6 hours

are the bronchodilators selective?

Selective but ß2receptors present in cardiac tissue. | -So overuse(oral forms) – cardiac s/e- tachycardia- dilation of blood vessels

what is the max number of SAB2A you should be prescribed per month?

1- if more need to be assessed

what do the anticholenergic bronchodilators do?

Block acetylcholine receptors in the respiratory tree Used mainly as add on therapy to B2agonists •Example: ipratropium

what are the s/e of anticholergics?

dry mouth & large doses systemic side effects

what kind of drugs are corticoid steroids?

anti-inflamatory

how do corticosteroids work?

Thought to inhibit mediators involved in airway inflammation | •Examples: –Inhaled: Beclometasone, budesonide–Oral: prednisolone (severe attack)

what are the low dose s/e of ICS?

oral thrush –hoarseness–rinse mouth with water after dose, use spacer device

What allerts regrowth in children?

CSM alert re growth in children

when are corticoidsteroids used?

Recommended preventer drug to achieve overall treatment goals

when do you consider using Corticosteroids?

Asthma attack in the last 2 years –Using inhaled SAB2A 3 times per week or more –Symptomatic 3 times per week or more –Waking 1 night per week

how do you prescribe ICS?

start at low dose- appropriate for the severity | use the lowest dose for effective control

when is ICS more effective?

when taken twice daily

what should be avoided in ICS prescribing?

Generic prescribing of inhalers should be avoided – brand prescribing- as they are not interchangable

who usually needs a higher dose?

smokers/ ex-smokers

when should LAB2A be used?

Added to short acting B2agonists & ICS–Improves lung function and symptoms–Decreases asthma attacks e.g. salmeterol

what must LAB2A be used in comb with?

ICS

why do we use combination inhalers?

less devices- better compliance more practical No difference in efficacy to separate inhalers

what are some examples of combination inhalers?

Beclometasone/formoterol: Fostair –Budesonide/formoterol: DuoResp, Symbicort –Fluticasone propionate/salmeterol: Seretide –Fluticasone furoate/vilanterol: Relvar

what types of add on therapys can you use?

Leukotriene receptor antagonists- Methylxanthines-oral Tiotropium

what do Leukotriene receptor antagonists do?

Block leukotriene mediators in airways | •Examples: montelukast

what do Methylxanthines-oral do?

``` Mode of action unclear•Example: theophylline Drug interactions common •Narrow therapeutic window – Pxby brand •Monitor blood levels •Side effects- GI ```

what does Tiotropium do?

Fewer exacerbations of asthma –Improved lung function –Benefits to asthma control

why would you decrease therapy?

cautious about long term s/e | When good control is established

how would you decrease therapy?

–ICS: stable patients, consider reducing dose by 25 – 50% every 3 months

what are the common therapeutic problems associated with asthma?

Under diagnosed •Failing to avoid / reduce exposure to allergens •Lack of patient knowledge about condition and its management •When to start ICS Tx •Taking ICS “prn” •Missing signs of deteriorating asthma control •Poor technique – poor compliance

how do you differenciate betweem the different types of asthma?

look at the oxygen sat/ speach/ pulse | /respiration/pef

how would you clasify acute asthma?

``` PEF> 50-70% oxygen >92% normal speach resp <25 breaths/min pulse<110 bpm ```

what is the treatment for acute asthma?

Oxygen–Steroids–SAB2A–SAMA–Magnesium sulphate

what is supported self- managment?

Education– Disease– Symptom recognition– Review– Compliance/Inhaler technique

what type of non-pharmacological managment is there?

Avoid known allergens and triggers• Difficult, expensive, time consuming– Stop smoking, exposure to passive smoking– Breathing exercises– Ideal body weight

what else can the pharmacist to to help the patient manage their asthma?

action plan leafelet