asthma management Flashcards
signs of asthma on history
Hx atopy
worse in morning or at night
triggered by cold air or allergens
recurrent/seasonal
diagnosis of asthma on examination
expiatory wheeze
there may be no abnormality on examination
what would you not expect to see on examination for asthma
crackles
what does asthma look like on spirometry
obstructive pattern
FEV1/FVC is below the lower limit (usually below 70% but less in older people)
two key features of asthma
obstruction and reversibility (improved with bronchodilator)
technique of spirometry
seated, good seal, good effort, all the way out, no coughing
normal spirometry doesn’t exclude asthma
if there is obstruction but no reversibility
you might have COPD
fixed airway limitation due to long term asthma
patient has already administered maximal bronchodilator
good control of asthma
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
partial control of asthma
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
poor control of asthma
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
releivers
usually this means short acting beta agonists (SABA): salbutamol, terbutaline (largely interchangeable)
preventers
inhaled corticosteroids (ICS)
beclomethasone, budesonide, fluticasone, ciclesonide
also for kids: oral montelukast (LTRA)
symptom controllers
long acting beta agonists LABA
formoterol (faster), salmeterol (slower), vilanterol
formoterol might be used
might be used as a releiver as well because its fast
ICS/LABA combination preparations
Symbicort (budesonide/formoterol)
seretide (fluticasone/salmeterol)
breo (fluticasone/vilanterol)
typical symptoms of asthma
dyspnoea
tightness
wheeze
cough
especially likely to be asthma if presenting with
worse at night
triggered by RTIs/exercise/cold air/allergens
relieved by bronchodilator
recurrent / seasonal
Fix asthma / personal or FHx atopy
what does obstructive look like on spirometry
what does restrictive pattern look like on spirometry
reversibility
there should be a 12% improvement in FEV1
reproducibility of spirometry
less than 150ml difference in FVC
does normal spirometry exclude asthma
no
good technique for spirometry
seated, good seal, good effort, all the way out, no coughing (esp. in first second of test)
severity of asthma
mild
moderate
severe
difficult-to-treat
severe treatment resistant asthma (severe refractory asthma)
guidelines for treatment levels for asthma
MART
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
MART is indicated in patients with
- frequent asthma symptoms despite ICS or ICS/LABA
- good at perceiving airway obstruction
- don’t overuse SABAs
SABA relievers
LABA medications
ICS preventers
non-steroidal preventer
ICA/LABA
spacers
use with MDIs not with dry powder inhalers
wash plastic ones before use with dish washing detergent and drip dry (do not wipe)
DPIs and MDIs
equally efficacious
DPIs may not be suitable for for young children (<6) and people with severe asthma with limited inspiratory capacity
most patients will need
some patients will need
few patients will need
obstructive picture
concave
obstruction of flow butno reestriction of volume
restrictive picture
mixed picture
two SABAs examples
salbutamol and terbutaline
inhaled corticosteroids examples
beclomethhasone, budesonide, fluticasone, ciclesonide
three LABAs examples
formoterol, salmeterol, vilanterol
symbiccort contains
formoterol and budesonide
seretide contains
fluticasone and salmeterol
SMART theraapy
symbicort maintenance and. reliever therapy
6steps of asthma management
assess severity
achieve best lung function
maintain best lung function (identify and avoid triggers)
optimise medications
action plan
educate and rreview regularly
very few patients will be well managed on
SABA alone
it is safer to add a steroid, so few patients fall into this category where they are okay on SABA alone
most patients will be well managed on
regular daily ICS (low dose)+ SABA prn
OR
budesonide(ICS)/formoterol(LABA) single inhaler prn (symbicort)
patients who need more than ICS+SABA or symbicort
need to add LABA either by:
MART therapy
or
regular ICS+LABA with prn SABA
patients who need more than MART or added LABA
increase MART dosage
or
increase ICS-LABA dosage
patients who are still not controlled on medium dose MART or medium-high dose ICS+LABA with SABA
consider specialist treatment
where should you start with most people
symbicort (good because its practical - patients only take it s needed)
OR
regular low dose ICS + SABA
what about kids under 5
what should you advise patients to do after they’ve used their steroid inhaler
rinse mouth out to prevent oral candidiasis
when do you use pek expiratory flow for asthma
basically never
might play a role for poor perceivers of symptoms
