Asthma: diagnosis, monitoring and chronic asthma management Flashcards
Asthma description
Asthma is a chronic respiratory condition usually associated with airway inflammation and hyper-responsiveness.”
asthma causes?
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
some asthma triggers
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
why is asthma still fatal?
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
some recommendations for asthma management to reduce fatalities
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
what questions to ask in assessing someone with suspeected asthma
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).
what other ways can we assess someone with suspected asthma
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
name some tests use to confirm asthma diagnosis
these tests vary depending on what factor
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 )
the order of tests for confirming asthma diagnosis in children aged 5-16years with history suggesting asthma
FeNO(if available)-> Bronchodilator reversibility(BDR) with spirometry->Peak expirotory flow variability-> skin prick test or total IgE and blood eosinophils
order of tests for confirming asthma diagnosis in adults and young people (over 16yrs)
Blood eosinophils or FeNO-> Bronchodilator respiratory with spirometry ->Peak expiratory flow variability-> Bronchial challenge test
why is asthma diagnosis in those under 5 years old hard
it is difficult to do the tests and there are no good reference standards
recommendations for treatment of asthma in those under 5years of age
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
aims of asthma management
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
some pharmacological treatments for asthma
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
examples of SABA drugs and their usual doses
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
main counselling points of SABAs
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
are inhaled corticosteroids preventers or relievers of asthma
they are regular preventers. they are taken consistently even when the patient feels well
ICS examples
Beclomethasone, Fluticasone, Budesonide, Ciclesonide
how ICS works to prevent asthma
Anti-inflammatory and reduce airway hyperresponsiveness
Improve lung function, reduce symptoms, improve quality of
life
Reduce frequency and severity of exacerbations
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
Beclomethasone= 400mcg
Budesonide=400mcg
Fluticasone=200mcg
Mometasone= 200mcg
Ciclesonide= 200-300mcg
Should SABAs be used alone with asthma of any age
give a reason for your answer
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.
in asthma, when are LABAs used
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.
examples of LABAs
** 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
examples of** LABA+ICS** combination inhalers and their constituents
seretide(Salmeterol + Fluticasone)
symbicort (Formoterol + Budesonide)
fostair (Formoterol + Beclomethasone)
flutiform(Fluticasone + Formotero)
differences between an evohaler, accuhaler, and turbohaler
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)
MDIs (Metered Dose Inhalers) description
A pressurized inhaler that delivers a measured dose of aerosolized medication with each actuation.
Requires pressing the canister while inhaling to deliver the medication.
how do we manage newly-diagnosed or
suspected asthma
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
initial pharmacological management of newly diagnosed asthma in people aged 12 and over
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. (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
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.
pharmacological management of asthma in children aged 5-11years old
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
MART stands for maintenance and reliever therapy
if children aged 5-11years are unable to manange the MART regimen, then how do we treat their asthma
they are given a LTRA (Leukotriene receptor antagonist) to a twice daily 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
refer to specialist if still uncontrolled after all that
how do we monitor asthma control in a patient
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
asthma control monitoring should be carried out at every review/ patient visit
describe PAPs for asthma
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
