Asthma: diagnosis, monitoring and chronic asthma management

Question 1

Asthma description

Answer 1

Asthma is a chronic respiratory condition usually associated with airway inflammation and hyper-responsiveness.”

Question 2

asthma causes?

Answer 2

exact cause unknown

however people with asthma have been found to have swollen (inflamed) and “sensitive” airways that become narrow and clogged with sticky mucus in response to certain triggers

Genetics, pollution and modern hygiene standards have been suggested as causes, but there’s not currently enough evidence to know if any of these do cause asthma

Question 3

some asthma triggers

Answer 3

exercise,
* strong emotion,
* allergen or irritant exposure,
* or viral respiratory tract infections.

pets, pollen, bugs, chemical fumes, cold air, smoking, stress, strong odours..etc could all fall under the aforementioned

Question 4

why is asthma still fatal?

Answer 4

poor patient management

missed warning signs, due to inadequacy in monitoring and recognition of deterioration

Healthcare Gaps, i.e lack of personalised asthma action plans

Overuse of SABA (Short-acting beta-2 agonists). they are taken to relieve symptoms, and are aka rescue medicines, but overuse can be fatal

SABAs opens the airway

Question 5

some recommendations for asthma management to reduce fatalities

Answer 5

regular asthma reviews

PAAP(personalised asthma action plans ) for all

Avoiding excessive SABA use

promoting ICS(inhaled corticosteroids) adherence

Post attack follow-ups

Specialist reviews

Question 6

what questions to ask in assessing someone with suspeected asthma

Answer 6

The nature and pattern of symptoms
impact on daily activities
risk factors; atypical symptoms
comorbidities
occupation (and whether symptoms improve away from work)
family history
environmental exposures
Medications and previous treatment(s) or admission(s).

Question 7

what other ways can we assess someone with suspected asthma

Answer 7

Assessment for signs of expiratory polyphonic wheeze

An expiratory polyphonic wheeze is a loud, musical wheeze that occurs during exhalation. It’s made up of many different frequencies that start and end together. it indicates narrowing of the airways

Question 8

name some tests use to confirm asthma diagnosis

these tests vary depending on what factor

Answer 8

Tests include measuring** blood eosinophil count**, fractional exhaled nitric oxide (FeNO), bronchodilator reversibility with spirometry (or peak expiratory
flow variability if spirometry is unavailable), or skin prick testing/total IgE level (in children)

varies depending on the person’s age (over 5 years )

Question 9

the order of tests for confirming asthma diagnosis in children aged 5-16years with history suggesting asthma

Answer 9

FeNO(if available)-> Bronchodilator reversibility(BDR) with spirometry->Peak expirotory flow variability-> skin prick test or total IgE and blood eosinophils

Question 10

order of tests for confirming asthma diagnosis in adults and young people (over 16yrs)

Answer 10

Blood eosinophils or FeNO-> Bronchodilator respiratory(reversibility) with spirometry ->Peak expiratory flow variability-> Bronchial challenge test

Question 11

why is asthma diagnosis in those under 5 years old hard

Answer 11

it is difficult to do the tests and there are no good reference standards

Question 12

recommendations for treatment of asthma in those under 5years of age

Answer 12

For children under 5 with suspected asthma, treat with inhaled corticosteroids in line with the recommendations on medicines for initial management in children under 5, and review the child on a
regular basis. If they still have symptoms when they reach 5 years, attempt objective tests

always provide spacer device for any age, if patients find inhaler difficult to coordinate

Question 13

aims of asthma management

Answer 13

to minimise or eliminate the occurence of symptoms

maximise lung functions

to prevent exacerbations

minimise the need for medication

minimise the adverse effects of treatments

provide info and support to facilitate self-management

promote medications adherence

Question 14

pharmacological treatments for quick relief of asthma

Answer 14

SABA (short acting beta-2 agonist) , and should be taken as required

note that SABAs are relievers, as they act quickly at the onset of symptoms to relieve bronchoconstriction

use in combination with ICS

Question 15

examples of SABA drugs and their usual doses

Answer 15

Salbutamol (Ventolin®) MDI 100mcg/metered inhalation – 1-2 puffs up to QDS/PRN

• Terbutaline (Bricanyl®) DPI 500mcg/metered inhalation – 1 puff up to
  QDS/PRN

Question 16

main counselling points of SABAs

Answer 16

Proper Use and Administration:

Inhaler Technique: Ensure patients are trained in the correct use of their inhaler devices to maximize drug delivery to the lungs.

Dosage: Typically, one or two puffs are taken as needed for symptom relief, but patients should follow their prescribed regimen.

Frequency of Use:

SABAs are intended for immediate symptom relief. Frequent use (e.g., more than three inhalers per year) may indicate poorly controlled asthma and necessitates a medical review.

Potential Side Effects:

Common side effects include tremors, palpitations, and headaches. These are usually mild and transient.

Drug Interactions:

Caution is advised when using SABAs with other medications, such as beta-blockers, which may reduce their effectiveness.

Monitoring and Follow-Up:

Advise patients to seek medical attention if they find themselves needing to use their inhaler more frequently, as this may indicate worsening control of their respiratory condition

Question 17

are inhaled corticosteroids preventers or relievers of asthma

Answer 17

they are regular preventers. they are taken consistently even when the patient feels well

Question 18

ICS examples

Answer 18

Beclomethasone, Fluticasone, Budesonide, Ciclesonide

Question 19

how ICS works to prevent asthma

Answer 19

Anti-inflammatory and reduce airway hyperresponsiveness

Improve lung function, reduce symptoms, improve quality of
life

Reduce frequency and severity of exacerbations

Question 20

initial adult daily dose for the various ICS that are equipotent to each other

equipotent means the dose required for the various drugs to exert the same effect

Answer 20

Beclomethasone= 400mcg

Budesonide=400mcg

Fluticasone=200mcg

Mometasone= 200mcg

Ciclesonide= 200-300mcg

Question 21

Should SABAs be used alone with asthma of any age

give a reason for your answer

Answer 21

no they should not

Every patient prescribed a SABA for asthma should also receive an ICS.

This is because SABA’s provide quick symptom relief but do not address the underlying airway inflammation in asthma. so over-reiliance on them can lead to exacerbations and even asthma-related death

ICS (e.g., beclometasone, budesonide, fluticasone) reduce airway inflammation, which is essential for long-term asthma control.

Question 22

in asthma, when are LABAs used

Answer 22

they are used as initial add-on therapy, where they are added to an inhaled corticosteroid (ICS) when a patient’s symptoms are not well managed with ICS alone.

Question 23

examples of LABAs

Answer 23

** Salmeterol**(brand name Serevent); Evohaler (MDI): 25 mcg per metered inhalation, 2 puffs twice daily (BD)
**Accuhaler (DPI): **50 mcg per blister, 1 blister BD

Formoterol (Oxis®)
Turbohaler (DPI): 6 or 12 mcg per metered inhalation
6–12 mcg, 1–2 times/day, up to 24 mcg BD

Question 24

examples of** LABA+ICS** combination inhalers and their constituents

Answer 24

seretide(Salmeterol + Fluticasone)

symbicort (Formoterol + Budesonide)

fostair (Formoterol + Beclomethasone)

flutiform(Fluticasone + Formotero)

Question 25

differences between an evohaler, accuhaler, and turbohaler

Answer 25

**1. Inhaler Type** Evohaler → Metered Dose Inhaler (MDI) Accuhaler → Dry Powder Inhaler (DPI) Turbohaler → Dry Powder Inhaler (DPI) **2. Activation Mechanism** Evohaler → Press & Inhale (coordination needed) Accuhaler → Slide Lever & Inhale (breath-activated) Turbohaler → Twist Base & Inhale (breath-activated) **3. Breath Coordination Needed?** Evohaler → Yes (better with a spacer) Accuhaler → No (breath-activated) Turbohaler → No (breath-activated) **4. Spacer Needed?** Evohaler → Yes, recommended Accuhaler → No Turbohaler → No **5. Medication Form** Evohaler → Pressurized spray (propellant-based) Accuhaler → Blister of dry powder Turbohaler → Reservoir of dry powder **6. Ease of Use** Evohaler → More difficult (requires coordination) Accuhaler → Easier (lever + inhale) Turbohaler → Easier (twist + inhale) **7. Inhalation Strength Required** Evohaler → No (propellant delivers dose) Accuhaler → Yes (needs strong inhalation) Turbohaler → Yes (needs strong inhalation)

Question 26

MDIs (Metered Dose Inhalers) description

Answer 26

A pressurized inhaler that delivers a measured dose of aerosolized medication with each actuation. Requires pressing the canister while inhaling to deliver the medication.

Question 27

how do we manage newly-diagnosed or suspected asthma

Answer 27

by; Providing advice about sources of information and support. * Advising about self-care measures and managing modifiable risk factors like; ✓ weight management, ✓stopping smoking, ✓and vaccination

Question 28

initial pharmacological management of newly diagnosed asthma in people aged 12 and over

Answer 28

1st line is a low-dose combination of inhaled corticosteroids (ICS) and formoterol to be taken as needed for everyone aged 12 and over with newly diagnosed asthma to reduce inflammation as well as relieve symptoms. **(as- needed AIR therapy)** Not prescribing short-acting beta2 agonists (SABA), the most widely used blue ‘reliever’ inhaler/medication, without inhaled corticosteroids, to anyone diagnosed with asthma -evidence showed using the** combined ICS and formoterol inhalers **when required led to people suffering fewer severe asthma attacks. If the person needing asthma treatment presents highly symptomatic (**for example, regular nocturnal waking) or with a severe exacerbation, start treatment with low-dose MART (maintenance and reliever therapy) **in addition to treating the acute symptoms as indicated (**oral corticosteroids may be needed**). Consider stepping down to as-needed AIR therapy using a low-dose ICS/formoterol inhaler at a later date if their asthma is controlled ## Footnote AIR therapy, or anti-inflammatory reliever therapy, is a combination inhaler used to treat asthma. It contains a steroid to reduce inflammation and a fast-acting medicine to open airways.

Question 29

pharmacological management of asthma in children aged 5-11years old

Answer 29

initially, offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with a shortacting beta2 agonist (SABA) as needed if the asthma is not controlled after that, then, consider the MART pathway(thus a** paediatric low-dose MART **, **as long as they are assessed to have the ability to manage a MART regimen**) Escalate to** moderate dose MART** if low dose not efficient/working ## Footnote MART stands for maintenance and reliever therapy

Question 30

if children aged 5-11years are unable to manange the MART regimen, and their asthma is uncontrolled, then how do we treat their asthma

Answer 30

they are given a **LTRA (Leukotriene receptor antagonist)** twice daily plus paediatric low-dose ICS for a trial period of 8 to 12 weeks, with SABA as needed if still uncontrolled then, Offer a twice daily paediatric low-dose ICS/LABA combination inhaler plus SABA as needed ## Footnote refer to specialist if still uncontrolled after all that

Question 31

how do we monitor asthma control in a patient

Answer 31

ask about any symptoms they are experiencing(new/ old) ask about; time off work or school due to asthma ✓amount of reliever inhaler used, including a check of the prescription record ✓number of courses of oral corticosteroids ✓any admissions to hospital or attendance at an emergency department due to asthma ## Footnote asthma control monitoring should be carried out at every review/ patient visit

Question 32

describe PAPs for asthma

Answer 32

PAPs (Personalized Asthma Action Plans) are essential written guides that help patients effectively manage their condition by outlining routine medication, actions for worsening symptoms, and emergency protocols. includes; How to recognise signs of worsening asthma Prompt use of SABA and oral corticosteroids How to monitor response to medication Allergen/trigger avoidance Asthma nurse contact details

Question 33

in MART therapy, the LABA drug always remains the same, true or false

Answer 33

true the LABA drug is always formeterol

Question 34

what is MART

Answer 34

it is an asthma treatment plan where you use one combination inhaler instead of two separate preventer and reliever inhalers. contains a steroid preventer(ICS ) to prevent or reduce inflammation, and the fast-acting LABA , formeterol, to **relieve** symptoms of asthma

Question 35

can patients on MART therapies use SABA

Answer 35

usually no, but not all MART combinations sufficiently relieve asthma symptoms, so some patients may be provided SABAs

Question 36

Beclometasone inhaler should be prescribed by brand, why is this the case

Answer 36

Beclometasone dipropionate CFC-free pressurised metered-dose inhalers (Qvar® and Clenil Modulite®) are **not interchangeable** and should be prescribed by brand name; Qvar® has extra-fine particles, is more potent than traditional beclometasone dipropionate CFC-containing inhalers, and is approximately twice as potent as Clenil Modulite ## Footnote clenil modulate and Qvar are the two main brands of Beclometasone

Question 37

important thing to remember when switching a patient with well controlled asthma from another ICS to QVAR ## Footnote note that qvar is twice as potent as beclometasone dipropionate

Answer 37

When switching a patient with well-controlled asthma from another corticosteroid inhaler,** initially a 100-microgram metered dose of Qvar® should be prescribed for 200–250 micrograms of beclometasone dipropionate or budesonide and for 100 micrograms of fluticasone propionate**

Question 38

important thing to remember when switching someone with a poorly controlled asthma from another inhaled corticosteroid to QVAR

Answer 38

When switching a patient with poorly controlled asthma from another corticosteroid inhaler, initially a 100-microgram metered dose of Qvar® should be prescribed for 100 micrograms of beclometasone dipropionate, budesonide, or fluticasone propionate; the dose of Qvar® should be adjusted according to response. ## Footnote so fundamentally the dose is doubled