asthma management

Question 1

signs of asthma on history

Answer 1

Hx atopy
worse in morning or at night
triggered by cold air or allergens
recurrent/seasonal

Question 2

diagnosis of asthma on examination

Answer 2

expiatory wheeze
there may be no abnormality on examination

Question 3

what would you not expect to see on examination for asthma

Answer 3

crackles

Question 4

what does asthma look like on spirometry

Answer 4

obstructive pattern
FEV1/FVC is below the lower limit (usually below 70% but less in older people)

Question 5

two key features of asthma

Answer 5

obstruction and reversibility (improved with bronchodilator)

Question 6

technique of spirometry

Answer 6

seated, good seal, good effort, all the way out, no coughing
normal spirometry doesn’t exclude asthma

Question 7

if there is obstruction but no reversibility

Answer 7

you might have COPD
fixed airway limitation due to long term asthma
patient has already administered maximal bronchodilator

Question 8

good control of asthma

Answer 8

all of:
daytime symptoms <2 days per week
need for reliever <2 days per week (not including SABA prophylactically before exercise)
no limitation of activities
no symptoms during night or waking

Question 9

partial control of asthma

Answer 9

one or two of:
daytime symptoms >2 days per week
need for reliever >2 days per week (not including SABA prophylactically before exercise)
any limitation of activity
any symptoms during night or waking

Question 10

poor control of asthma

Answer 10

three or more of:
daytime symptoms >2 days per week
need for reliever >2 days per week (not including SABA prophylactically before exercise)
any limitation of activity
any symptoms during night or waking

Question 11

releivers

Answer 11

usually this means short acting beta agonists (SABA): salbutamol, terbutaline (largely interchangeable)

Question 12

preventers

Answer 12

inhaled corticosteroids (ICS)
beclomethasone, budesonide, fluticasone, ciclesonide
also for kids: oral montelukast (LTRA)

Question 13

symptom controllers

Answer 13

long acting beta agonists LABA
formoterol (faster), salmeterol (slower), vilanterol

Question 14

formoterol might be used

Answer 14

might be used as a releiver as well because its fast

Question 15

ICS/LABA combination preparations

Answer 15

Symbicort (budesonide/formoterol)
seretide (fluticasone/salmeterol)
breo (fluticasone/vilanterol)

Question 16

typical symptoms of asthma

Answer 16

dyspnoea
tightness
wheeze
cough

Question 17

especially likely to be asthma if presenting with

Answer 17

worse at night
triggered by RTIs/exercise/cold air/allergens
relieved by bronchodilator
recurrent / seasonal
Fix asthma / personal or FHx atopy

Question 18

what does obstructive look like on spirometry

Answer 18

Question 19

what does restrictive pattern look like on spirometry

Answer 19

Question 20

reversibility

Answer 20

there should be a 12% improvement in FEV1

Question 21

reproducibility of spirometry

Answer 21

less than 150ml difference in FVC

Question 22

does normal spirometry exclude asthma

Answer 22

no

Question 23

good technique for spirometry

Answer 23

seated, good seal, good effort, all the way out, no coughing (esp. in first second of test)

Question 24

severity of asthma

Answer 24

mild
moderate
severe
difficult-to-treat
severe treatment resistant asthma (severe refractory asthma)

Question 25

guidelines for treatment levels for asthma

Answer 25

Question 26

MART

Answer 26

maintenance and reliever therapy in the same inhaler different approach of using ICS-formoterol prn like a reliever as well as a preventer to maximum of 12 puffs total daily from dry powder inhaler

Question 27

MART is indicated in patients with

Answer 27

- frequent asthma symptoms despite ICS or ICS/LABA - good at perceiving airway obstruction - don't overuse SABAs

Question 28

SABA relievers

Answer 28

Question 29

LABA medications

Answer 29

Question 30

ICS preventers

Answer 30

Question 31

non-steroidal preventer

Answer 31

Question 32

ICA/LABA

Answer 32

Question 33

spacers

Answer 33

use with MDIs not with dry powder inhalers wash plastic ones before use with dish washing detergent and drip dry (do not wipe)

Question 34

DPIs and MDIs

Answer 34

equally efficacious DPIs may not be suitable for for young children (<6) and people with severe asthma with limited inspiratory capacity

Question 35

most patients will need

Answer 35

Question 36

some patients will need

Answer 36

Question 37

few patients will need

Answer 37

Question 38

obstructive picture

Answer 38

concave obstruction of flow butno reestriction of volume

Question 39

restrictive picture

Answer 39

Question 40

mixed picture

Answer 40

Question 41

two SABAs examples

Answer 41

salbutamol and terbutaline

Question 42

inhaled corticosteroids examples

Answer 42

beclomethhasone, budesonide, fluticasone, ciclesonide

Question 43

three LABAs examples

Answer 43

formoterol, salmeterol, vilanterol

Question 44

symbiccort contains

Answer 44

formoterol and budesonide

Question 45

seretide contains

Answer 45

fluticasone and salmeterol

Question 46

SMART theraapy

Answer 46

symbicort maintenance and. reliever therapy

Question 47

6steps of asthma management

Answer 47

assess severity achieve best lung function maintain best lung function (identify and avoid triggers) optimise medications action plan educate and rreview regularly

Question 48

very few patients will be well managed on

Answer 48

SABA alone it is safer to add a steroid, so few patients fall into this category where they are okay on SABA alone

Question 49

most patients will be well managed on

Answer 49

regular daily ICS (low dose)+ SABA prn OR budesonide(ICS)/formoterol(LABA) single inhaler prn (symbicort)

Question 50

patients who need more than ICS+SABA or symbicort

Answer 50

need to add LABA either by: MART therapy or regular ICS+LABA with prn SABA

Question 51

patients who need more than MART or added LABA

Answer 51

increase MART dosage or increase ICS-LABA dosage

Question 52

patients who are still not controlled on medium dose MART or medium-high dose ICS+LABA with SABA

Answer 52

consider specialist treatment

Question 53

where should you start with most people

Answer 53

symbicort (good because its practical - patients only take it s needed) OR regular low dose ICS + SABA

Question 54

what about kids under 5

Answer 54

Question 55

what should you advise patients to do after they've used their steroid inhaler

Answer 55

rinse mouth out to prevent oral candidiasis

Question 56

when do you use pek expiratory flow for asthma

Answer 56

basically never might play a role for poor perceivers of symptoms