Asthma pre-work (+COPD) Flashcards
Draw the lung volume graph and label
What is spirometry?
- Forced expiration
- Breathing out as quickly as possible from maximum inspiratory level
Define spirometry values
- FVC - volume breathed out during forced expiration
- FEV1 - volume breathed out during first second
- FEV1/FVC - proportion of FVC that is breathed out in the first second
- PEFR - peak expiratory flow rate - gradient of the graph at time 0, corresponds to the highest rate of flow of air from lungs
Four patterns of spirometry
- Normal - normal FEV1, FVC and FEV1/FVC ratio
- Restrictive - reduced FVC but with normal FEV1/FVC ratio
- Obstructive - normal FVC but reduced FEV1 so reduced FEV1/FVC ratio, PEFR also reduced
- Mixed - FVC reduced AND FEV1/FVC is reduced
Bronchodilator reversibility and spirometry
- Involves repeating spiro testing 20-30 mins after administering dose of bronchodilator (eg salbutamol 2x 200mcg puffs ideally via large volume spacer)
- If reversible - improvement in FEV1/FVC ratio
What is PEFR?
- PEFR measures the maximum flow of air during expiration
- Happens at the beginning of expiration
- Is the gradient of the spirometry volume-time graph at time 0
How often do we ask patients to do peak flow with asthma?
- Twice daily for 2-4 weeks initially while diagnosing
- Then asked to check regularly to monitor asthma
How to do peak flow
- Set the arrow to 0
- Hold with fingers at edge of device, not obstructing the arrow
- Take the deepest breath in you can
- Seal mouth around mouthpiece
- Blow out as hard as fast as you can
- Note the reading where the arrow is pointing
- Record in peak flow diary - available at asthma.org website
What is FENO?
- Newer test used in primary care
- Fraction exhaled nitric oxide test
- Measures nitric oxide exhaled in breath
- These levels are elevated when inflammation within lungs (eg in asthma)
What can affect FENO?
- Smoking
- Inhaled corticosteroids
- Not always raised in people with asthma - NICE says 1 in 5 people with positive result will not have asthma, 1 in 5 with a negative result will have asthma
Specialist tests for asthma
Direct bronchial challenge - used if there is doubt of diagnosis
How to do spirometry?
- Sit comfortably
- Wear a clip on your nose to make sure all the air from your lungs goes into the mouthpiece.
- First do a relaxed breath - it is often described as a big sigh into the machine.
- Then take a deep breath in and breathe out as fast and as hard as you can, for as long as you can, through the mouthpiece.
- You will need to blow a few times, and put as much effort into the test as you can, to get an accurate result.
Advice for before FeNO test
Leave enough time to get to your appointment, so you’re not rushed and tired before the test.
* You should avoid too much physical activity or exercise for at least an hour before the test.
* If you smoke, avoid smoking at least an hour before the test.
* Hot drinks, caffeine and alcohol can all affect the result, so avoid these at least an hour before the test.
* Foods such as green leafy vegetables and beetroot can also affect the result, because they are rich in nitrates. Avoid eating these for at least three hours before the test.
* You can take your regular medicines as usual before the test. But let the person doing the test know about any medicines you’ve taken.
How to do FeNO test?
- breathing into a mouthpiece attached to a hand-held monitor. The reading shows up on the monitor screen .
- First, you need to breathe in deeply, with your mouth open.
- Then you’ll be asked to breathe out slowly and steadily into the mouthpiece until your lungs are empty.
- May need to do a few times
3 different types of inhaler
- MDI’s - pressurised metered dose inhalers, generates aerosol which is inhaled
- DPI’s - dry powder inhaler, dry powder is inhaled
- SMI’s - soft mist inhalers, soft mist is inhaled
5 drug groups of inhaler
- ICS
- SABA - agonist
- LABA - agonist
- SAMA - antagonist
- LAMA - antagonist
Combination inhalers
- ICS + LABA (used in asthma and COPD)
- LABA + LAMA (mainly COPD)
- ICS + LABA + LAMA (COPD)
When should spacers be considered?
- In anyone struggling with inhaler
How to use pMDI?
- When first get or not used for 5 days or more, need to test it
- Take cap off, shake well, point away from you and press cannister to release puff into air - how many test sprays depends on inhaler, check instructions
- If dose counter, check not empty
- Take cap off, check nothing inside mouthpiece
- Shake well
- Sit or stand up straight
- Tilt chin up slightly
- Breathe out gently and slowly away from inhaler until lungs empty and ready to breathe in
- Lips around mouthpiece to make tight seal
- Breathe in slowly and steadily
- Press cannister on inhaler once at same time
- Breathe in slowly until lung feel full
- Hold breath off mouthpiece for up to 10seconds or as long as can
- Breathe gently away from inhaler
- If need 2 puffs, wait 30s, shake inhaler and repeat
- Replace cap
- If steroids, rinse mouth out and spit it out
Using spacer with pMDI - two techniques
- Single breath and hold
- Tidal breathing/multiple breath
Using spacer with pMDI technique
- Remove cap and shake inhaler well, check mouthpiece is clean and nothing in it
- If spacer has valve, check this is facing upwards
- Put inhaler into hole at back of spacer
- Take cap off spacer if it has one
- Sit or stand straight and slightly tilt chin up
- Breathe out gently and slowly away from spacer until empty lungs
- Put lips around spacer mouthpiece and create tight seal
- Press cannister on inhaler once
- Breathe in slowly and steadily untul lungs feel full
- Hold breathe up to 10s or as long as comfortable
- Breathe out slowly
- Spacers can make noise if breathing in too fast
- If second puff needed, wait 30s to 1 minute, shake inhaler and repeat
- Replace caps
- If steroid containing, rinse mouth with water and spit out
Good videos for inhaler technique
Asthma and Lung UK
Spacer and tidal breathing/multiple breathe technique technique with pMDI
- Used in asthma attack or if cannot hold breath for 5 seconds after inhaler
- Can have spacer with mouthpiece/mask if cannot get tight seal
- Hold inhaler upright and take cap off, check mouthpiece is empty
- Shake well
- If spacer has valve, check is upwards
- Put inhaler into hole at back of spacer
- If mouthpiece is capped, remove this
- Sit or stand up straight
- Slightly tilt chin up
- Lips around mouthpiece and tight seal
- Press cannister on inhaler once
- Breathe in and out slowly and steadily into spacer 5 times
- Remove inhaler and spacer from mouth
- If need second puff, wait 1 minute, shake inhaler and rpt
- Some make whistling sound if breathing in too fast
- Can use with large volume spacer too
- Valve should make clicking noise with tidal breathing as it opens and closes
- Remove inhaler from spacer and replace caps
- If steroid containing, rinse with water and spit out
How to use turboinhaler
- Dry powder device
- When first get, need to get ready to use
- Twist off cover and hold upright with coloured base at bottom
- Turn coloured base as far as it will go in one direction and then all the way back again
- Doesn’t matter which way you turn it first
- Should hear click on one of these turns
- Do this once more
- You won’t need to do this again - it is now ready to use
- To use, twist off top cover
- Check mouthpiece is clean
- Check dose counter isn’t empty - when 20 doses, red strip will appear in window, when to bottom of window is empty
- Twist coloured base as far to right as will go and then to left until you hear a click
- Dose is now ready
- Sit or stand up straight and slighty tilt chin up
- Breathe out gently and slowly away from inhaler iuntul lungs empty
- Hold inhaler horizontally - not upside down as powder can fall out
- Create tight seal around mouthpiece
- Inahler quickly and deeply
- Hold breath up to 10s or as long as can
- Breathe out gently away from inhaler.
- Repeat if need 2nd puff
- Replace cover
Pathophysiology of asthma
- Chronic respiratory condition
- Airway inflammation
- Hyperresponsiveness
- Heterogenous - varies between people
- Cough, wheeze, chest tightness, SOB, variable expiratory airflow limitation
- Can vary over time and intensity
- Acute asthma exacerbation is onset of severe asthma symptoms - can threaten life
Symptoms to suspect asthma
- Wheeze
- Cough
- Chest tightness
- Breathlessness
- Episodic and diurnal (worse night or early morning)
- NSAIDs, beta blockers can trigger in adults
- Emotions and laughter can trigger in children
Clinical findings asthma
- Expiratory polyphonic wheeze on auscultation of chest (lots of different pitches and tones)
- Eczema, dermatitis, allergic rhinitis
- FeNO test 40 parts per billion or higher
- FEV1/FVC less than 70% with bronchodilator reversibilty of 12% or more and increase in at least 200ml volume, increase of 400ml of FEV1 = asthma
- More than 20% variability of PEFR
Risk factors of asthma
- Personal or family history of atopy - esp atopic eczema, dermatitis, allergic rhinitis
- FH asthma
- Viral resp infections in childhood
- Occupational exposure
- Smoking
- Air pollution
- Obesity
Spirometry adults (18 and over) vs children aged 5-17 years
- Offer spiro in everyone over 5 years
- Any value FEV1/FVC below 70% suggests obstruction
Reversibility adults vs children aged 5-17
- Adults - improvement in FEV1 of 12% or more, together with an increase in volume of at least 200 mL in response to beta-2 agonists or corticosteroids is regarded as a positive result. An improvement of greater than 400 mL in FEV1 is strongly suggestive of asthma.
- Children - improvement of FEV1 of 12% or more = positive
PEFR variability testing adults vs children 5-17 (twice daily over at least 2 weeks)
Adults offer if:
* Normal spiro OR
* Obstructive spiro, with BDR but FeNO of 39ppb or less OR
* Consider if obstructive spiro + negaive BDR and FeNO of 25-39ppb
Children:
* Normal spiro OR
* Obstructive, negative BDR and FeNO of 35ppb or more
FeNO adults vs children 5-17
- Use where possible in people aged 17 or older
- If steroid naive, 40ppb or more = +ve
Consider in people aged 5-16 if:
* diagnostic uncertainty and either normal spiro OR
* obstructive spiro with negative BDR
FeNO of 35ppb or more = +ve in this group
What do in children under 5 as they cannot be tested?
- Use clinical judegement based on any +ve tests and noted signs/symptoms and determine likelihood
- If person cannot perform particular test, attempt to perfom at least 2
- When child reaches 5 carry out tests
Aims of asthma management
- No daytime symptoms
- No night waking due to asthma symptoms
- No limitation to exercise/activity
- No need for rescue medication
- No asthma attacks
- Normal lung function FEV1/PEFR 80% of predicted/best or more
- Minimal side effects from medication
Key aspects at initial review at diagnosis for asthma
- Assess baseline status using validated questionaire eg Asthma Control Questionaire or Asthma Control Test +/- lung function tests eg spiro or PEFR if not already done
- Arrange specialist referral if occupational asthma is suspected
- Provide self management education and asthma action plan (Asthma UK)
- Ensure up to date routine vaccinations - childhood and annual flu
- Advice - sources of info from Asthma UK and British Lung Foundation
- Weight loss and smoking cessation
- Anxiety or depression?
- Need own peak flow meter - measure for action plan
- Initiate drug treatment at level appropriate to severity
- Explain how and when to use inhalers
Follow up general for asthmatic?
- At least annually
- Closer monitoring of poor lung function/history of asthma attack within last year
- Also if treatment adjustment and people at risk of poor outcomes (eg due to non-adherance, psychosocial problems)
Asthma step wise treatment
- SABA
- Add low dose ICS (if using SABA or symptomatic 3x per week or more or waking up at night due to symptoms) (BD)
- Add LTRA/(eg montelukast), review in 4-8 weeks, OR BTS recommend add on LABA before LTRA (MART with ICS or seperate)
- Switch to LABA if LTRA no benefit, or if still not offer MART with low dose ICS inside
- Have MART with moderate dose ICS inside
- Options are: increase ICS to high dose (seperate to LABA), trial additonal drug eg LAMA (tiotropium) or seek advice from specialist
Step wise pharmacological management asthma LLR
What is a personalised asthma action plan?
- Contains infromation about daily inhalers
- What do do if peak flows get to certain levels eg taking increased doses of preventer or calling 999
Follow up of newly diagnosed asthmatic?
- At least annually
- May be more often when first diagnosed to check adherance and inhaler technique
Adults - when is SABA / ICS used
- Prescribe an inhaled short-acting beta-2 agonist (SABA) to all people with symptomatic asthma, to be used as reliever therapy as required.
Give ICS if:
* Use an inhaled SABA three times a week or more, and/or
* Have asthma symptoms three times a week or more, and/or
* Are woken at night by asthma symptoms once weekly or more.
* ICS should be considered for adults and children over the age of 5 years who have had an asthma attack requiring treatment with oral corticosteroids in the past two years.
When to offer ICS/SABA children 5-17?
Same as adults
When to offer ICS/SABA for children under 5?
Consider an 8-week trial of ICS:
* asthma-related symptoms three times a week or more
* experiencing night-time awakening at least once a week
* or suspected asthma that is uncontrolled with a short-acting beta2 agonist alone.
After 8 weeks, stop and assess symptoms
When are adults offered additional add on therapy to SABA+ low dose ICS?
- If uncontrolled add LTRA and reassess in 4-8weeks
- Alternatively can add on LABA - can be as seperate fixed dose or as a MART regime
- Also consider MART if on fixed dose ICS/LABA seperately or history of asthma attacks on moderate dose ICS alone
Inital add on therapy for children aged 5-17
- Add LTRA
- BTS recommend LABA instead if over 12 - MART or seperate
- If 5-12 can habe LABA/LTRA added to very low dose ICS
Initial add on therapy children under 5 to SABA and ICS
- LTRA
- If still not controlled on this, refer to asthma specialist
Additional therapies for adults already on SABA + ICS + initial add on
- LABA +/- LTRA THEN
- Offer to change LABA + ICS to MART regime THEN
- Increase ICS to moderate (as part of MART or not) THEN
- Increase ICS to high (fixed dose, seperate with SABA as reliever) OR trial additonal drug OR seek help from specialist
Children aged 5-17 additonal controller therapies after SABA + ICS + initial add on
- Discontinue LTRA, replace with LABA THEN
- Change to MART regime
- Increase dose of ICS to moderate (continue as MART or switch to fixed dose) THEN
- Seek advice from specialist OR increase ICS dose to high (fixed dose) OR trial theophylline
Additonal controller therapies children under 5 (after SABA + ICS + initial add on therapy)
- Refer to specialist
How to determine severity of asthma attack?
- Note agitation/consciousness
- Look for signs of exhaustion eg inability to complete sentenses
- Examine chest and record RR, pulse and BP
- Record PEFR
- Measure O2 sats
Severity of asthma exacerbation
Moderate:
* PEFR more than 50-75% predicted
* Normal speech
* No features of acute/LF asthma
Acute severe:
* PEFR 33-50% predicted
* RR at least 25 in people over 12 (30 in 5-12 and 40 2-5)
* HR 110 or more (125 5-12, 140 2-5)
* Inability to complete sentences
* Accessory muscle use
* Inability to feed
* O2 sats of at least 92%
Life threatening:
* PEFR less than 33% best/predicted
* O2 sats less than 92%
* Altered conc
* Exhaustion
* Arrhythmia
* Hypotension
* Cyanosis
* Poor resp effort
* Silent chest
* Confusion
What to do whilst waiting for transfer if someone needs admission for asthma attack?
- Give controlled supplementary O2 - aim for 94-98% sats (but do not delay if no pulse oximetry)
- LF/severe - nebulised salbutamol O2 driven, continious is good but if not rpt every 20-30 mins, if continious, give dose over 30-60 mins
- If no neb use pressurised MDI with large volume spacer
- Adult - 4 puffs initially followed by 2 every 2 mins up to 10 puffs, rpt every 10-20 mins if needed
- Child - puff every 30-60s up to 10 puffs
- LF/Severe or not responding to salbutamol - consider addition of neb ipratropium bromide
- Give first dose pred
- Monitor PEFR
Treatments for someone not being admitted with asthma attack
- SABA via large volume spacer
- Adult 4 puffs initially then 2 puffs every 2 mins up to 10 puffs
- Child puff every 30-60s up to 10 puffs
- Each puff taken with 5 tidal breaths
- Adults - short course of oral prednisolone
- No abx routinely
- Once symptoms subsided advise to use SABA prn again (do not exceed 4hrly)
- Monitor PEFR
- Conside montelukast in children over 2 with mild asthma exacerbaton early after onset of symptoms
When to f/u someonwe with asthma exacerbation not attending hosp?
- Within 48hrs - review asthma management, inhaler technique, lifestyle etc
- Also f/u those discharged from hospital within 2 working days
- Consider oral steroids to keep at home to take during early signs of exacerbation (tell them to increase SABA too if notice exacerbation)
- If 2 asthma attacks within 12 months conside resp referral
Safety netting asthma attack
Seek help if symptoms worsen or PEFR reduces
