Avril (Asthma diagnosis and Guidelines) Flashcards
Diagnosis
Important to treat acute symptom if patient is presenting unwell -i.e. if they come in with breathlessness give inhaler.
Take a structured clinical history.
Presence of more than one variable symptoms of wheeze, cough, breathlessness, a chest tightness.
Three questions to assess control
- Have you have difficulty sleeping because of asthma symptoms?
- Have you had your usual asthma symptoms during the day?
- Has your asthma interfered with usual daily activities?
Yes to any implies uncontrolled asthma
Occupational or family history?
Occupational asthma- may be suggested by adult onset asthma, where symptoms improve when not at work. High risk occupations include laboratory work, baking, animal handling, welding, and paint spraying. Can ask if symptoms are better on days away from work or when on holiday.
Family history- check history for asthma or other atopic conditions
Diagnostic tests
FeNO test- breathe into a machine that measures the level of nitric oxide in your breath (sign of inflammation in the lungs).
Spirometry- blow into a machine that measures how fast you can breathe out and how much air you can hold in your lungs.
Fraction exhaled Nitric Oxide testing (FeNO)
Used to confirm eosinophilic airway inflammation to support an asthma diagnosis.
May be available in some primary care practices or may require referral to a specialist.
A FeNO level of 40 parts per billion or higher is considered a positive result.
Approximately 1 in 5 people with a negative result will have asthma.
Approximately 1 in 5 people with a positive result will not have asthma.
Spirometry
Should be offered to all symptomatic people over the age of 5. The FEV1/FVC ratio is normally greater than 70%. Any value less than this suggests airflow limitation.
Bronchodilator reversibility (BDR) can also help to confirm a diagnosis.
Aim of treatment
No daytime symptoms.
No nighttime wakening due to asthma.
No need for rescue medication.
No asthma attacks.
No limitations of activity, including exercise.
Normal lung function.
Minimum side effects of medication.
Approach to management
Start treatment at the level most appropriate to initial severity.
Achieve early control.
Maintain control by
- increasing treatment as necessary
- decreasing treatment as necessary (to reduce any side effects)
Intermittent reliever therapy
Inhale short acting beta agonists (SABA) as required.
This step only manages symptoms and does not control underlying inflammation.
SABAs work more quickly and with fewer side effects than the alternatives e.g. tablets or syrups.
Anyone prescribed more than 1 SABA a month should be identified and have their asthma assessed urgently as asthma control is poor.
NICE guidelines
Offer a SABA as reliever therapy to adults with newly diagnosed asthma.
Consider this treatment alone in patient who have infrequent, short lived wheeze and normal lung function.
If SABA alone isn’t working the offer a low dose ICS as first line maintenance therapy.
NICE pathway (step-up/step-down)
With step-up step-down always review within 4-8 weeks.
1. SABA
2. Low dose ICS and SABA
3. Low dose ICE plus LTRA with SABA
4. Low dose ICS plus LABA, with or without LTRA, with SABA.
5. MART therapy- combination of ICS and LABA, no longer need SABA
6. Increase dose of ICS to moderate, plus LABA (in MART regimen) or change to SABA
7. High dose ICS plus LABA with a SABA
8. Seek advice from specialised healthcare professional
Do not give LABA without ICS.
LTRA- leukotriene receptor antagonist- oral therapy.
BTS/GINA guidelines do not use LTRA and go straight to LABA in their step-up step-down chart whereas NICE do use LTRA as they consider cost.
MART- maintenance and reliever therapy. Both ICS and LABA treatment in one inhaler.
Regular preventer therapy
Inhaled corticosteroids (ICS) control underlying inflammation but can take several weeks to achieve maximal effects.
Patients need to understand that they use inhaler regularly even when well.
Before initiating therapy check inhaler technique and eliminate trigger factors.
Doses
In adults 100micrograms 2 puffs BD is an appropriate starting dose. (Can get 200 microgram inhalers but 2*100 is better if patients technique is incorrect).
In children 5-16 years old 50 micrograms 2 puffs BD is an appropriate starting dose.
Inhaled corticosteroids side effects
Hoarseness, dysphonia, throat infections and oral candidiasis. (Can deposit in mouth and affect biodiversity of the bacteria in the mouth causing oral thrush. Advise to use inhalers before they clean their teeth or wash mouth out after use).
Higher doses reduce bond density, skin thinning, bruising.
Increased risk of pneumonia.
Spacers
The spacer should be compatible with the pMDI being used.
The drug should be administered by repeated single actuations of the MDI into the spacer followed by inhalation.
There should be minimal delay between pMDI actuation and inhalation.
Spacer should be cleaned monthly rather than weekly as internal protective coat may be damaged. Let divide air dry.
Less likely to get oral thrush.
Correct amount of medication reaches lung.
Easier for children who can’t master the breathing technique.
Use one puff at a time. Do not do both together.
Can be bought or prescribed- make sure patient has one in case they need one.
