Asthma management adults

Question 1

An adult presents with symptoms generally suspicious of asthma

What are these symptoms?

Answer 1

wheeze
cough
breathlessness
chest tightness

Question 2

If a patient presents with suspicious symptoms, what aspects of the History of PC would help a diagnosis?

Answer 2

Recurrent episodes of symptoms

Symptom variability

Absence of symptoms of alternative diagnosis

Question 3

Apart from a history, what else would you consult for evidence towards a diagnosis of asthma?

Answer 3

Previous medical records of:

Recorded observation of wheeze

History of atopy

Historical record of variable PEF or FEV1

Question 4

Before a diagnosis of asthma is made, the patient may be prescribed something. What is this and why?

Answer 4

Monitored treatment with low dose ICS

Key feature of asthma is it’s reversibility - if the obstructions ceases with the test inhaler then it shows this

Question 5

What are the features of ‘moderate acute asthma’?

Answer 5

Increasing symptoms

PEF >50–75% best or predicted

No features of acute severe asthma

Question 6

What are the features of ‘acute severe asthma’?

Answer 6

Any one of:

PEF 33–50% best or predicted
Respiratory rate ≥25/min
Heart rate ≥110/min
Inability to complete sentences in one breath

Question 7

What are the features of life threatening asthma?

Answer 7

In a patient with severe asthma any one of:

PEF <33% best or predicted
SpO2 <92%
PaO2 <8 kPa
Normal PaCO2 (4.6–6.0 kPa)

Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion
Altered conscious level 
Hypotension

Question 8

What are the features of Near fatal asthma?

Answer 8

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Question 9

What is the inhaler for an initial diagnosis of asthma presenting with infrequent, short lived wheeze?

Answer 9

SABA - Salbutamol

Symptom relief as required

Question 10

If a patient has:

Had an asthma attack in the past 2 years
Symptomatic ± used their SABA 3 or more times per week
Has night symptoms

What is their recommended treatment?

Answer 10

SABA & low dose ICS

ICS - 100 μg : 2

(100μg:2 = 100 micrograms 2 puffs per day)

Question 11

If a patient is on SABA and Low dose ICS but symptoms are failed to be controlled, what is the next step?

Answer 11

SABA

Low dose ICS

Inhaled LABA

Question 12

How is an inhaled LABA often added to a treatment regime?

Answer 12

Low dose ICS and LABA often given as a combination inhaler

Question 13

A patient uses a SABA and a combination inhaler (Low dose ICS + LABA) but is failing to control their symptoms

The addition of a LABA does not seem to be making a difference

How do you change their treatment?

Answer 13

Stop LABA and increase dose of ICS ‘beclometasone’ to 200μg:2

• If no response to LABA then stop the combination inhaler and just give them a medium dose ICS

Question 14

A patient uses a SABA and a combination inhaler (low dose ICS + LABA) but is failing to control their symptoms

The addition of a LABA has improved symptoms but overall control is still inadequate

How do you change their treatment?

Answer 14

Continue LABA and increase dosage of ICS ‘beclometasone’ to 200μg:2

or

Consider adding another therapy such as:
LTRA or
SR theophylline or
LAMA

Question 15

A patient requires high dose therapy as their current management; a SABA, LABA and medium dose ICS is not working

What do you do

Answer 15

Increase ICS ‘beclometasone’ to high dose of 200μg:4

or

Adding 4th* drug to therapy - either an LTRA, SR theophylline, beta agonist tablet or LAMA

You definitely would also refer patient for specialist care

Question 16

What is the final stage change to a patient’s therapy for asthma?

Summarise the overall therapy regime for this patient

Answer 16

• Final stage is adding daily steroid tablet

SABA
High dose ICS
LABA 
LTRA or other '4th drug' 
Daily steroid tab 

Patient referred to/receiving specialist care