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The Patient > Asthma (Therapeutics) > Flashcards

Asthma (Therapeutics) Flashcards

1
Q

What is asthma?

A

A chronic inflammatory disorder of the airways

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2
Q

What does asthma lead to an increase in?

A

Airway hyperresponsiveness

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3
Q

What are some of the symptoms of asthma?

A

Recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or early in the morning

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4
Q

What are episodes of asthma associated with physiologically?

A

Widespread, variable airflow obstruction that is often reversible, spontaneously or with treatment

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5
Q

How is asthma usually mediated?

A

By IgE

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6
Q

Which cells produce mucus?

A

Goblet cells

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7
Q

What can occur if asthma is poorly managed over a period of years?

A

Airway remodelling

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8
Q

Does asthma have a cause?

A

Factors are no longer referred to as ‘causes’ of asthma, but environmental and genetic factors that contribute to its development

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9
Q

What are some of the factors that contribute to the development of asthma?

A

Family history or other atopic conditions (e.g. eczema, hay fever)
Bronchiolitis in childhood
Exposure to tobacco smoke, especially if mother smokes during pregnancy
Premature birth
Low birth weight
Occupational exposure to plastics, agricultural substances and volatile chemicals
A BMI>30kg/m2
Bottle feeding
Changes in housing, air pollution levels and a more hygienic lifestyle (reducing exposure to allergens)

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10
Q

Is asthma more common in prepubescent girls or boys?

A

More common in prepubescent boys but boys are also more likely to grow out of their asthma during adolescence

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11
Q

What is a phenotype?

A

A set of observable characteristics of an individual resulting from the interaction of its genotype with the environment

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12
Q

What is phenotyping?

A

The process of predicting an organism’s phenotype using only genetic information collected from genotyping or DNA sequencing

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13
Q

What is the relevance of phenotyping in asthma?

A

Variations in genes that code for beta-adrenoceptors have been linked to differences in how cells respond to beta-agonists
Potential to tailor treatment to individuals in the future

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14
Q

What are some of the possible triggers of asthma?

A 
Common cold
Allergens (e.g. dust mites, pollen)
Exercise
Exposure to hot or cold air
Medicines (e.g. NSAID's)
Emotions (e.g. anger, anxiety or sadness)
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15
Q

What is the cause of wheezing and coughing in asthma?

A

Wheezing that occurs as a result of bronchoconstriction and coughing are likely to be caused by stimulation of sensory nerves in the airways

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16
Q

What signs may be present/absent in an acute exacerbation of asthma?

A

Wheeze may be absent and chest may be silent on listening
In such cases, other signs such as cyanosis (bluish cast to the skin and mucous membranes) and drowsiness may be present
The patient may be unable to complete sentences

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17
Q

What are some of the clinical features that lower the probability of asthma?

A

Symptoms only when patient has a cold
Isolated cough with no wheeze or difficulty breathing
History of moist cough (in children)
Chronic productive cough with no wheeze or difficulty breathing
Prominent dizziness and peripheral tingling
Repeated normal physical examination of chest when symptomatic
Normal PEV or spirometry when symptomatic
Cardiac disease
Voice disturbance
History of smoking >20 pack years
In such cases, it is likely another disease, not asthma, is present

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18
Q

How is asthma diagnosed?

A

Based on medical history, physical examination, lung function testing and response to medication
No ‘gold standard’ test

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19
Q

How is diagnosis altered if patient has a high probability of asthma?

A

Usually start with a treatment trial and response is assessed using spirometry

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20
Q

How is diagnosis altered if patient has a intermediate probability of asthma?

A

Lung function tests are conducted first such as spirometry, peak flow and airway responsiveness

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21
Q

Do normal spirometry findings exclude a diagnosis of asthma?

A

No, not if the patient is well at the time of testing

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22
Q

What are some of the spirometric measures used?

A

FVC
FEV1
FEV1/FVC ratio

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23
Q

What is FVC?

A

The total volume of air expelled by a forced exhalation after maximal inhalation

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24
Q

What is FEV1?

A

The volume of air expelled in the first second of a forced exhalation after maximal inhalation

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25
Q

A FEV1/FVC ratio of…

A

Less than 0.7 suggests airway obstruction, which can increase the probability of asthma but also be caused by other conditions such as COPD

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26
Q

How do you take a peak expiratory flow (PEF) measurement and what does it measure?

A

Use a peak flow meter to measure the resistance in the airway

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27
Q

Which is more accurate, spirometry or peak expiratory flow measurements?

A

Spirometry

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28
Q

What are PEF measurements particularly useful for?

A

Demonstrating variability of lung function throughout the day
Measurements should be taken in the morning and evening (as a minimum) and recorded in a diary to see if there is diurnal variability
Best of three expiratory blows should be recorded (dependent on technique and effort)
More useful for monitoring those with an established asthma diagnosis rather than for making an initial diagnosis

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29
Q

How can airway responsiveness be measured?

A

Using inhaled mannitol or methacholine

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30
Q

When is this airway responsiveness test used?

A

To diagnose patients who have a baseline FEV1 <70% of population data

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31
Q

How does the airway responsiveness test work?

A

Both drugs induce bronchospasm

A fall in FEV1 of >15% following the test is a specific indicator for asthma

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32
Q

An airway responsiveness test is particularly useful for doing what?

A

Distinguishing asthma from other common conditions often confused with asthma (rhinitis, gastro-oesophageal reflux, heart failure and vocal cord dysfunction)

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33
Q

What does a treatment trial involve?

A

Being prescribed a 6-8 week trial of inhaled beclomethasone or prednisolone

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34
Q

What do the results from a treatment trial indicate?

A

An improvement in FEV1 of 400ml or more is strongly suggestive of asthma

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35
Q

When should spirometry be carried out after a treatment trial?

A

Spirometric assessment after a trial is more effective for patients with known airway obstruction and less helpful for patients who had near normal lung function between the trial

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36
Q

What other tests aside from spirometry, peak expiratory flow, airway responsiveness and treatment trials can be carried out to help guide a diagnosis of asthma?

A

Non-invasive testing of sputum eosinophils and exhaled NO concentration
Not routinely used in general practice

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37
Q

What do the results from this additional test indicate?

A

A raised eosinophil count (>2%) is seen in the majority of patients with uncontrolled asthma
An exhaled NO level of >25 parts per billion supports a diagnosis of asthma

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38
Q

Which conditions could the results from the additional test also indicate?

A

Patients with COPD or a chronic cough may exhibit similar results and so should not be used for a definite diagnosis

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39
Q

How is asthma management defined?

A

No day time symptoms or night time waking due to asthma
No need for rescue medication
No exacerbations
No limitations on activity including exercise
Normal lung function (in practical terms FEV1 and/or PEF >80% of predicted or best)
Minimal side effects from treatment

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40
Q

What are some non-pharmacological asthma management strategies?

A

Allergen and trigger avoidance (e.g. pollen, dust mites)
Stop smoking
Lose weight if obese
Avoid exercise in cold air
Minimise occupational stimuli
Avoid NSAID’s and β-blockers (inc. eye drops)
Holistic remedies such as immunotherapy, breathing techniques
Breast feeding
Air ionisers

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41
Q

Who produces guidance on asthma management?

A

British Thoracic Society (BTS)
Scottish Intercollegiate Guidelines Network (SIGN)
NICE

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42
Q

Which guidelines do the BNF and other sources mainly refer to?

A

BTS

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43
Q

Do guidelines differ and how?

A

NICE guidelines differ greatly to traditional BTS/SIGN and are more conservative with using ICS

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44
Q

How do paediatric guidelines differ?

A

Do not advocate regular oral steroids and ICS doses are lower

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45
Q

Describe briefly the steps of asthma management.

A

Step 1 - inhaled SABA to be used as required
Step 2 - add ICS
Step 3 - add LABA
Step 4 - consider increasing ICS doses or adding in a 4th agent (leukotriene receptor antagonist, SR theophylline, oral β2-agonist)

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46
Q

What are SABA’s used for?

A

To provide short term relief for mild and intermittent asthma

47
Q

What is increasing use of a SABA a marker of?

A

Uncontrolled asthma and indicates that the patient should be escalated to the next step

48
Q

Patients using high doses of SABA’s are more likely to…

A

Experience side effects such as tremor, cramps, palpitations and headache

49
Q

What should be checked before a step up in therapy is initiated?

A

Adherence to inhaled therapy and inhaler technique

50
Q

How often should patients be reviewed?

A

Every 3-6 months with a view to stepping down treatment

51
Q

When is addition of an ICS indicated?

A

For patients who,
Have had an exacerbation in the previous 2 years
Experience asthma symptoms 3 or more times a week
Are woken up at night with asthma symptoms on 1 or more occasions a week

52
Q

Name 3 examples of inhaled corticosteroids.

A

Beclomethasone, budesonide, ciclesonide

53
Q

ICS are classified as…

A

Either low, medium or high doses

54
Q

What is the recommended starting dose of Beclomethasone for adults?

A

400µg equivalence per day

55
Q

What are some of the long term side effects of ICS therapy?

A

Diabetes, skin thinning and bruising, cataracts

56
Q

High does of ICS have the potential to…

A

Induce adrenal suppression

57
Q

What should all patients taking ICS be given?

A

Steroid card

58
Q

What are some of the local side effects associated with ICS?

A

Dysphonia (difficulty in speaking)

Oral candidiasis

59
Q

How can local side effects of ICS be minimised?

A

Spacer device

Rinsing mouth with water after each use, but do not swallow water

60
Q

How should patients be taken off ICS?

A

Discontinuation can worsen clinical outcomes significantly, patients need to be weaned off treatment

61
Q

Which agent should not be used as single therapy for asthma treatment, and should only be used alongside ICS?

A

LABA

62
Q

What effect do LABA’s have on airway inflammation?

A

They have no effect

Induce bronchodilation, do not affect inflammation

63
Q

What are some of the adverse effects of LABA’s?

A

CV stimulation
Anxiety
Tremor

64
Q

Name 2 leukotriene receptor antagonists (LTRA’s).

A

Montelukast and zafirlukast

65
Q

How do LTRA’s work?

A

Interfere with the pathway of leukotriene mediators which are released from mast cells, eosinophils and basophils

66
Q

How are LTRA’s administered?

A

Orally

67
Q

What are some of the side effects of LTRA’s?

A 
Abdominal pain
Headache 
Thirst 
Rash 
Sleep disturbances 
CNS effects
68
Q

Give 2 examples of methylxanthines and how they are administered.

A

Oral theophylline

IV/oral aminophylline

69
Q

Why are SR preparations of methylxanthines used?

A

Have a narrow therapeutic index
SR preparations are used to give a more predictable effect
The brand must remain constant

70
Q

What effects does a subtherapeutic dose of methylxanthine have?

A

Nausea, diarrhoea, nervousness, headache

71
Q

What effects does an overdose of methylxanthine have?

A

Vomiting, insomnia, arrhythmias

72
Q

What effects does a serious overdose of methylxanthine have?

A

Hyperglycaemia, arrhythmia, convulsions, death

73
Q

How are methylxanthines cleared?

A

CYP450 metabolism

74
Q

What impact does the clearance of methylxanthines have on their use?

A 
ADR's as CYP450 is a common route of drug metabolism 
Enzyme inhibition (decreased clearance, increased concentration, overdose) e.g. by cimetidine, erythromycin, allopurinol, ciprofloxacin 
Enzyme induction (increased clearance, decreased concentration, subtherapeutic dose) e.g. carbamazepine, rifampicin, phenytoin, smoking
75
Q

How does Theophylline work to treat asthma?

A

Promotes bronchial smooth muscle relaxation, increase mucocilliary transport and contractility of the diaphragm, and acts as a central respiratory stimulant

76
Q

What are some of the side effects of Theophylline?

A 
Tachycardia 
Palpitations
Headache 
Insomnia 
Nausea
GI disturbance
77
Q

What can be said about the side effects of Theophylline?

A

More common than with alternative treatments

78
Q

How are oral β2-agonists formulated?

A

As slow release tablets

79
Q

What is the only licensed LAMA for asthma?

A

Tiotropium

80
Q

What is meant by ‘maintenance and reliever therapy’?

A

An approach for those who struggle using multiple inhalers
Employs the use of combination products that contain a LABA and an ICS to provide maintenance and reliever therapy without the need for an additional SABA
Patient receives a maintenance dose of ICS/LABA in the morning and at night

81
Q

When should you consider reviewing a patients ‘maintenance and reliever therapy’?

A

If the patient is using the inhaler one or more times during the day on a regular basis in addition to their maintenance dose

82
Q

When is oral corticosteroid maintenance therapy required?

A

For a small number of patients who have severely uncontrolled asthma

83
Q

What is the most commonly used oral corticosteroid?

A

Prednisolone

84
Q

What are some of the side effects of long term oral corticosteroids?

A 
Hypertension
Diabetes 
Hyperlipidaemia 
Osteoporosis 
Obesity
Cataracts 
Glaucoma 
Skin thinning and bruising 
Muscle weakness
85
Q

How can you minimise the side effects of long term oral corticosteroid use?

A

Use the lowest dose possible

86
Q

What is Omalizumab?

A

A humanised anti-immunoglobulin E (IgE) monoclonal antibody

87
Q

How is Omalizumab given?

A

Administered by SC injection

88
Q

Name 3 immunosuppressants used in asthma.

A

Methotrexate
Ciclosporin
Liquid gold

89
Q

Why are immunosuppressants used in asthma?

A

Reduce the need for long term oral corticosteroids

90
Q

What are Cromones?

A

Mast cell stabilisers used as preventer therapy in 5-12 year olds

91
Q

Give an example of a Cromone.

A

Nedocromil

92
Q

How do Cromones work?

A

Inhibit mediator (histamine) release from mast cells

93
Q

What are some of the side effects of Cromones?

A

N&V
Bitter taste
Dyspepsia

94
Q

What is a bronchoplasty?

A

A procedure involving the delivery of radio frequency energy to the airway wall to heat the tissue and remove smooth muscle present

95
Q

Novel therapies are…

A

Invasive, expensive and often associated with a higher level of risk

96
Q

What is a ‘reliever’ in terms of asthma therapy? Give an example.

A

Produces quick symptom relief
Usually dosed PRN
SABA’s e.g. Salbutamol

97
Q

What is a ‘preventer’ in terms of asthma therapy? Give an example.

A

Act on underlying inflammation
Usually dosed BD
Corticosteroids e.g. Beclomethasone

98
Q

What is a ‘controller’ in terms of asthma therapy? Give an example.

A

Slow onset and long acting
Usually dosed BD
LABA’s e.g. Salmeterol

99
Q

Inhalers were traditionally defined by…

A

Colour i.e. blue for reliever, but this is often not the case now

100
Q

What are nebulisers do?

A

Vaporise aqueous solution of drug to a mist for inhalation through a mask or mouthpiece

101
Q

When and where are nebulisers used?

A

Used to delivery high doses and are particularly useful in acute or chronic/severe asthma since coordination is not needed
Used a lot in hospital settings

102
Q

What is ‘difficult asthma’?

A

Patients who have persistent symptoms, frequent exacerbations, or both, despite treatment at steps 4 or 5 are described as having ‘difficult asthma’

103
Q

What is ‘difficult asthma’ a result of?

A

Often a result of poor adherence, incorrect inhaler technique, environmental factors, psychological issues or co-existing conditions

104
Q

What is ‘severe refractory asthma’?

A

Patients who have difficult asthma but remain uncontrolled despite resolution of contributing factors are described as having ‘severe refractory asthma’

105
Q

Why are personalised asthma action plans (PAAP’s) used?

A

To help patients recognise the deterioration of their asthma control and to provide tailored advice on how they can treat their exacerbations at an early stage (detailing when and how they should modify their medicines in response to worsening asthma and when to see a HCP)

106
Q

What should a patients PAAP include?

A

Instructions on how to recognise signs of worsening asthma
Advice on the prompt use of SABA’s and oral corticosteroids
Monitoring of response to medicines
Contact information/telephone numbers
Follow up to assess asthma control

107
Q

What are the 4 features determining ‘severe’ asthma?

A

PEF<50% of normal/best
Ability to talk
RR>25
HR>110

108
Q

What are the additional features present in ‘life threatening’ asthma?

A 
Silent chest
Cyanosis 
Bradycardia 
Confusion
Exhaustion 
Coma 
Difficulty speaking full sentences 
PEF<33% of normal/best
109
Q

What should be immediately prescribed in an acute asthma attack?

A

Oxygen - highest possible concentration (40-60%), aim for arterial oxygen saturation 94-98%
β-agonist - nebuliser or multiple doses (10-20 puffs) via spacer
Corticosteroid - oral prednisolone or IV hydrocortisone

110
Q

What else could be prescribed for an acute asthma attack for immediate treatment?

A

Ipratropium nebuliser
Single dose IV magnesium sulphate (stabilises T-cells and mast cells)
IV aminophylline/salbutamol

111
Q

What monitoring requirements are there for a patient experiencing an acute asthma attack?

A 
PEF 
O2 saturation (aim 94-98%)
Arterial blood gases 
HR and RR (tachycardia/ponea)
CRP
WCC (if infection is suspected)
Theophylline levels (if continued >24 hours)
Serum K+ (if taking nebuliser SABA)
Glucose 
Hydration 
Blood pH ~7.4 (risk of acidosis)
112
Q

What symptoms indicate the patient requires a transfer to ITU?

A 
Deteriorating PEF
Persistent hypoxia 
Hypercapnia 
Exhaustion and drowsiness 
Coma and respiratory arrest
113
Q

Whilst the patient is hospitalised, the following should be done/put in place…

A 
IV to nebuliser to inhaler transition 
Oral steroid 40-50mg 5/7 depending on severity of exacerbation 
Restart steroid inhaler 
Discharge criteria 
Action plan 
Check inhaler technique

The Patient (17 decks)

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