Asthma CUE CARDS

Question 1

What is Asthma?

Answer 1

> Chronic inflammatory disorder of the airways in which many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of: wheezing, breathlessness, chest tightness and coughing

Question 2

What are Asthma Episodes associated with?

Answer 2

> Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment

Question 3

What are the signs of an acute asthma attack?

Answer 3

> Severe - any of: unable to speak in full sentences, visibly breathlessness, increased work of breathing

> Life Threatening - any of: collapsed, exhausted, cyanotic, poor respiratory effort

Question 4

Describe a brief overview of the lung function in asthma

Answer 4

> At time of diagnosis, lung function is poor
Early on, lung function is variable, sometimes it’s better than others = variability (characteristic of asthma)
Initiate treatment; as treatment takes effect: improved lung function and less variability
At times, asthma may be less well controlled for no reason or less compliant = gradual loss of airway control
Acute exacerbation: respiratory tract infection - decline in lung function
Acute attack: can go from being well controlled to very quickly having asthma attack - severe, sudden SOB

Question 5

What is the diagnosis of asthma based on?

Answer 5

History and Supportive Diagnostic Testing

Question 6

Diagnosis of asthma based on: Describe Hx

Answer 6

> Characteristic symptoms in a pattern of coming and going
Wheeze, chest tightness, SOB, cough
Particularly if symptoms are recurrent or seasonal, worse at night, early in morning, obviously triggered by exercise, irritants, allergies, infections

Question 7

Diagnosis of asthma based on: Supportive Diagnostic testing

Answer 7

> Accurate measurement of respiratory function is necessary to access and manage asthma (diagnose airflow limitation, demonstrate presence and reversibility of airflow limitation, monitor effects of treatment)
Spirometry, peak expiratory flow

Question 8

Discuss FEV1, FVC and FEV1/FVC

What measurement is used more in asthma?

Answer 8

> FEV1: volume of air forced out in one second after taking deep breath (most important measure in asthma)

> FVC: total volume forcefully expired from a maximum inspiratory effect

> FEV1/FVC: indicates nature of airways disease

Question 9

What is important about FEV1?

Answer 9

> Need good technique

> Not good technique in young children so diagnosis based on symptoms and history

Question 10

Describe the severity/classification in asthma in adults

Answer 10

> Good control: symptoms <2 days per week, no limitations of activities, no symptoms during night or on waking, need for SABA reliever <2 days per week

> Partial control: one or two of - day time symptoms >2 days/week, limitations of activities, symptoms during night or on waking, need for SABA reliever > 2 days/week

> Poor control = 3 or more of partial control

Question 11

If a child isn’t old enough for spirometry what do you do?

Answer 11

> Diagnose based on variability/episodic nature of symptoms/looking for other potential causes

> If it looks like asthma - treat it as asthma and if it gets better then it’s asthma

Question 12

Airflow limitation is judged to be reversible if?

What does reversible refer to?

Answer 12

> The effect of bronchodilators on airway function as measured by spirometry

> Airway constriction in asthma is reversible by use of bronchodilators, where reversibility of constriction is defined by specific numbers

> If you give bronchodilation, you see a significant change in lung function as assessed by spirometry

Question 13

What are the treatment aims in asthma?

Answer 13

> Manage symptoms/acute attacks when they occur (all patients require rapid acting beta 2 agonists for prn - reliver - rapid relief of symptoms)

> Obtain good asthma control (minimal symptoms during day and night - minimal need for reliever medication, no exacerbations, no limitation of physical activity, normal lung function)

Question 14

What can patients avoid to assist their asthma?

Answer 14

> There’s a strong association between allergy and asthma
Inhaled allergens: major triggers for asthma and wheezing
Allergen/triggers avoidance may benefit (pets, pollens, tobacco smoke, RTIs)

Question 15

Discuss medication and asthma triggers

Answer 15

> Some meds may exacerbate asthma so only use when drug has clear benefits that outweigh risks (patient hx significant)
Closely monitor airway response
Beta blockers (avoid non-selective beta blockers)
If needed, use a b1 selective and be cautious with dose
Choose rate limiting CCB where possible
Cholinergic agents
NSAIDs
Complementary medications (e.g. royal jelly)

Question 16

What is important in drug management and assessing control?

Answer 16

> Compliance and technique: using inhalers wrong or don’t use - not good outcome
Assessing control: do they know how to use it?

Question 17

Describe the role of ICS in asthma

Answer 17

> Few patients should have a SABA (only those with infrequent symptoms)
Most patients (adults) mainstay management should be ICS
Patients seem to be inappropriately treating themselves with salbutamol

Question 18

Describe management strategies in asthma

Answer 18

> Conservative: Start low, uptitrate according to response, response may take longer, adverse events minimised

> Aggressive: Start high, down titrate according to response, may achieve rapid control, may experience adverse reactions

Question 19

What should be reviewed regularly?

Answer 19

> Asthma control should be reviewed regularly
Important to assess patients compliance and technique
Limited evidence as the best way to step down treatment: Consider after 8-12 weeks of good control, Individualised according to patient’s hx

Question 20

What happens when patients become less well controlled?

Answer 20

> Move to the next level
Requires patients to recognise that they’re not well controlled (symptoms more often)
Asthma action plans: educated on what initiates asthma isn’t well controlled and knowing what to do

Question 21

What is SMART Therapy?

Answer 21

> Using budesonide with formeterol (can’t be salmeterol)
Use this one product bd everyday as their regular ICS + LABA and then use the same product as their reliever (when they get symptoms0
Formeterol although long acting, has a rapid onset of action
Effectively uptitrating steroid in response to symptoms that aren’t being well enough controlled

Question 22

What does exacerbation refer to?

Answer 22

> Relative rapid decline in lung function
Acute or subacute deterioration in symptom control and lung function (compared with usual level of variation)
Sufficient to cause distress or risk to health (increased risk of acute attack during an exacerbation)
Commonly triggered by RTIs

Question 23

Acute exacerbations are recognised by?

Answer 23

> Increased symptoms (increased use of SABA)

> Reduction in PEF (or increased variability)

Question 24

How is exercised induced asthma treated?

Answer 24

Most commonly the preemptive use of SABA prior to exercise