Asthma Management Flashcards
What are the goals of asthma treatment?
- “Minimal” symptoms during day and night
- Minimal need for reliever medication
- No attacks (exacerbations)
- No limitation of physical activity
-Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best) - NOT A PRIORITY
Is there a cure for asthma?
No cure for asthma, only palliation or spontaneous resolution
Is FEV1 an indicator for asthma?
NOT ALWAYS!!
How do you measure asthma control?
SANE - find out of poorly controlled
S - Short acting beta agonist/week (>2 times a week)
A - Absence school/nursery
N - Nocturnal symptoms/week (1 night a week)
E - Excertional symptoms/week
What medication change should you make if the asthma is well controlled?
No change
Reduce
What medication change should you make if the asthma is poorly controlled?
Not taking treatment - don’t change treatment
Not taking treatment correctly - don’t change treatment
Not asthma - stop treatment
None of the above - increase treatment
Asthma treatment has a step up and step-down approach. How do you begin?
Low dose ICS
When do you review after first treatment?
Review after 2mo
- No routine test to monitor progress (?)
- No change easier than down
- Need an inhaler holiday to confirm diagnosis (Easter) - as coughs and colds are less common in easter
What are the classes of asthma medications
Short acting beta agonists Inhaled corticosteroids (ICS) Long acting beta agonists* Leukotriene receptor antagonists* Theophyllines* Oral steroids - uncommon * “add ons”
What is the stepwise approach to asthma treatment?
BTS/SIGN
How do the child BTS/SIGN guidelines differ from those for adults?
Max dose ICS 800 microg (<12 yo) No oral B2 tablet LTRA first line preventer in <5s No LAMAs Only two biologicals
When do you introduce a regular preventer (step 2 in old guidelines)?
Diagnostic test
B2 agonists > two days a week - GIVEN TO ALL ASTHMATICS
Symptomatic three times a week or more, or waking one night a week
Exacerbations of asthma in the last two years
What with? - not important
Start very low dose inhaled corticosteroids (or LTRA in <5s)
What are the benefits of ICS?
Very useful for diagnosis Very effective (when taken) Very safe (when prescribed correctly)
What are the adverse effects of ICS?
Height suppression Potentially: -Oral candidiasis -Adrenocortical suppression* (particularly with fluticasone) NOT: -HTN -Cataracts
What is the next step after ICS?
LABA - long-acting beta agonist
What 2 things must you remember when using a LABA?
Do not use without ICS
Use as fixed dose inhaler
What is another add-on preventer?
LTRA - Leukotriene receptor antagonist
What are pros of LTRA therapy?
Better adherence
Granules for reluctant toddlers
What are the causes of severe asthma?
50% psychological issues
>50% compliance issues
How is severe asthma treated?
Experimental medicine
Role of biologics unproven
What is the rule of thirds with LTRAs?
One third great benefit, one third get a bit of a benefit and in one third, there’s no benefit.
What is the best next step after ICS?
LABA
Add on LABA or LTRA (BTS/SIGN)
Add on LTRA (NICE)
Increase ICS dose (GINA)
How best should you manage asthma?
1) Treat “with” and not “to”
2) Recognise individuality - lifestyle and response to treatment
3) Objective PFT (sometimes random and unhelpful)
4) Adherence measured
5) Link Rx to 3 and 4
What are the two types of delivery systems?
MDI/spacer
Dry powder device
How does spacer affect deposition?
<5% lung deposition without spacer
≤20% lung deposition with spacer
MDI/spacer = 4x MDI
What maintenance should be carried out with inhaler and spacer?
Shake inhaler between puffs
Wash spacer monthly reduce static
Shake=2x no shake
Wash = 2 x no wash
How does lung deposition change with inhalation?
Children should quietly inhale with appropriately fitted mask and not crying
Who can use dry powder devices?
Licensed in over 5s, under 8s cannot use them
WORK BETTER IN GIRLS
How effective are dry powder devices?
Achieve 20% lung deposition
When are nebulisers indicated?
Not for day to day use
What makes an MDI/spacer better than a nebuliser?
Quieter Quicker Valve mechanism Don’t break down Portable Cheaper
What are non-medicinal interventions for asthma?
Stop tobacco smoke exposure
Remove environmental triggers
-Cat, Dog
-HDM?? - dust mites
Not proven:
Diet – evidence negative
Alter humidity – no evidence
-Air ionisers increase cough
Weight reduction – no evidence
