Asthma in Adults

Question 1

What is reversible airway obstruction?

Answer 1

In asthma there is reversible airway obstruction that typically responds to bronchodilators such as salbutamol.

Question 2

What are the typical triggers of asthma?

Answer 2

Infection
Symtoms worse at night time or early morning
Exercise
Animals
Cold/damp
Dust
Strong emotions

Question 3

Signs of asthma

Answer 3

Tachypnoea

Hyperinflated chest

Hyper-resonance on chest percussion

Decreased air entry (sign of severe illness: silent chest)

Wheeze on auscultation

Question 4

Signs of a severe asthmatic attack:

Answer 4

Inability to speak in complete sentences, respiratory rate >25, peak flow 33-50% predicted

Question 5

Signs of a severe asthmatic attack:

Answer 5

Inability to speak in complete sentences, respiratory rate >25, peak flow 33-50% predicted

Question 6

Signs of a life-threatening attack

Answer 6

Silent chest, confusion, bradycardia, cyanosis, exhaustion

Question 7

Investigations in chronic asthma

Answer 7

The following investigations and their associated results point to a diagnosis of asthma.

Peak flow: variability >20%
Fractional exhaled nitric oxide (FeNO): >40 ppb in adults or >35 ppb in children
Spirometry: FEV1/FVC <0.7 (obstructive spirometry)

Question 8

Non-pharma management of chronic asthma

Answer 8

Smoking cessation
Avoidance of precipitating factors (eg. known allergens)
Review inhaler technique

Question 9

Pharma management of chronic asthma - BTS guideline

Answer 9

1. Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
2. Add a regular low dose corticosteroid inhaler.
3. Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
4. Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA (i.e. tiotropium).
5. Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist.
6. Add oral steroids at the lowest dose possible to achieve good control.

Question 10

Pharma management of chronic asthma - NICE

Answer 10

1. Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
2. Add a regular low dose inhaled corticosteroid. (beclometasone)
3. Add an oral leukotriene receptor antagonist (i.e. montelukast).
4. Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
5. Consider changing to a maintenance and reliever therapy (MART) regime.
6. Increase the inhaled corticosteroid to a “moderate dose”.
7. Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
8. Refer to a specialist.

Question 11

Describe the following in relations to long term asthma management:

Short acting 2 beta adrenergic receptor agonist

Answer 11

For example salbutamol.

These work quickly but the effect only lasts for an hour or two. Adrenalin acts on the smooth muscles of the airways to cause relaxation.

This results in dilatation of the bronchioles and improves the bronchoconstriction present in asthma.

They are used as “reliever” or “rescue” medication during acute exacerbations of asthma when the airways are constricting.

Question 12

Describe the following in relations to long term asthma management:

Inhaled Corticosteroids (ICS)

Answer 12

Inhaled corticosteroids (ICS), for example beclometasone. These reduce the inflammation and reactivity of the airways.

These are used as “maintenance” or “preventer” medications and are taken regularly even when well.

Question 13

Describe the following in relations to long term asthma management:

LABA

Answer 13

Long-acting beta 2 agonists (LABA), for example salmeterol. These work in the same way as short acting beta 2 agonists but have a much longer action.

Question 14

Describe the following in relations to long term asthma management:

LAMA

Answer 14

Long-acting muscarinic antagonists (LAMA), for example tiotropium. These block the acetylcholine receptors. Acetylecholine receptors are stimulated by the parasympathetic nervous system and cause contraction of the bronchial smooth muscles. Blocking these receptors leads to bronchodilation.

Question 15

Describe the following in relations to long term asthma management:

Leukotriene receptor antagonists

Answer 15

Leukotriene receptor antagonists, for example montelukast. Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in the airways. Leukotriene receptor antagonists work by blocking the effects of leukotrienes.

Question 16

Describe the following in relations to long term asthma management:

Theophylline

Answer 16

This works by relaxing bronchial smooth muscle and reducing inflammation.

Unfortunately it has a narrow therapeutic window and can be toxic in excess so monitoring plasma theophylline levels in the blood is required.

This is done 5 days after starting treatment and 3 days after each dose changes.

Question 17

Describe the following in relations to long term asthma management:

Maintenance and Reliever Therapy

Answer 17

Maintenance and Reliever Therapy (MART).

This is a combination inhaler containing a low dose inhaled corticosteroid and a fast acting LABA.

This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.

Question 18

Examples of:

Short acting beta 2 adrennergic receptor agonists

Answer 18

Salbutamol and terbutaline

Question 19

Examples of: Inhaled corticosteroids (ICS)

Answer 19

Beclometasone

Question 20

Examples of LABA

Answer 20

Salmeterol

Question 21

Example of LAMA

Answer 21

Tiotropium

Question 22

Example of: Leukotriene receptor antagonists

Answer 22

Montelukast and zafirlukast

Question 23

Additional management

Answer 23

Each patient should have an individual asthma self-management programme
Yearly flu jab
Yearly asthma review
Advise exercise and avoid smoking