Chronic asthma Flashcards
Symptoms
- Dyspnoea
- Chest tightness
- Wheezing
- Cough
- Symptoms typically happen more at night when asleep
Triggers
- Infection
- Hay fever
- Dust
- Pets
- Smoking
- Chemicals
- Medication: NSAID + Beta blocker
Treatment: BTS/SIGN guidelines: adults + 12+
Offer SABA prn
→ Regular preventer: low dose ICS
→ Initial add on therapy: LABA (fixed dose or MART)
→ Additional controller therapies:
- (if no response to LABA consider stopping)
- Medium dose ICS OR
- LTRA
→ Refer patient for special care (oral steroid, theophylline)
Reasons to step up treatment: BTS/SIGN guidelines: adults + 12+
- Taking 3 doses a week/more
- Night time waking once a week
- Asthma attack that needed oral steroids in the last 2 years
URGENT assess if >1 inhaler a month
Low dose ICS: adults
- Beclometasone: 200-400mcg
- Budesonide: 400mcg
- Fluticasone: 200mcg
- Mometasone: 400mcg
- Ciclesonide: 160mcg
Drugs
- SABA: salbutamol, terbutaline
- LTRA: montelukast
- LABA: formoterol, salmeterol
- Oral steroid prednisolone
Low dose ICS: children
- Beclomethasone: 200-400mcg
- Fluticasone: 200mcg
SABA: MOA
Acts on B2-adrenoreceptor on bronchi = bronchodilation for 3-5H
SABA: indication
reliever inhaler
- Asthma
- COPD
SABA: Dose
2 puffs QDS PRN
- Counsel: take dose immediately before exercise to prevent symptoms
- Counsel: see doctor if dose fails to provide relief <3H
SABA: Side effect
Hypokalaemia
- Caution: diuretics, hypoxia
- Monitor:
- Potassium: severe asthma + COPD
- Glucose: diabetes
Hand tremors
CVS effects
LABA: MOA
Acts on B2-adrenoreceptors on bronchi = bronchodilation for 12H
LABA: drugs
- Formoterol (BD: short onset reliever (fostair - fridge))
- Salmeterol (BD: long onset)
- Vilanterol (OD: combination inhaler with fluticasone)
- Olodaterol + indacaterol (OD: COPD only)
LABA: indication
not used alone, taken with ICS
Asthma (w regular ICS)
- Add only if ICS fail
- Stop if no benefit, step down when good control
- Not for exercise induced asthma unless on regular ICS
- Do not start in rapidly deteriorating asthma
COPD
LABA: combination inhalers rationale
- Stable dose
- Minimise no. of inhalers
- Improves compliance
- Guarantees ICS
LABA: dose
Twice daily (+ reliever doses if MART)
- Counsel: report any deterioration after starting a LABA
ICS: MOA
local anti-inflammatory effects in bronchi, Takes 7 to 14 days to work
ICS: drugs
- Beclometasone
- Budesonide
- Ciclesonide (OD)
- Mometasone (OD/BD)
ICS: dose
Twice daily
MHRA: beclometasone CFC free inhalers: brand prescribed:
- Qvar is twice as potent as clenil modulite because it has extra fine particles, which means more is delivered to the lungs
- Beclomethasone - Fostair is more potent than other CFC free inhalers
ICS: age restriction
- Easyhaler: 18+
- Qvar + clenil 200/250: 12+
ICS: side effect
Oral candidiasis
- Counsel: Spacer, rinse mouth + brush teeth, technique
Hoarse voice + sore throat
Bronchospasm - Stop, if mild: SABA before use or DPI
Leukotriene receptor antagonist: MOA
blocks leukotriene receptors in lungs = bronchodilation + anti-inflammatory
Leukotriene receptor antagonist: indication
- Asthma
- Hay fever
Leukotriene receptor antagonist: dose
At night (oral)
Leukotriene receptor antagonist: side effect
Neuropsychiatric reaction
- MHRA: reminder: speech impairment + obsessive compulsive symptoms
- Seek immediate medical attention if speech + behaviour changes
- MHRA: reminder: sleep disorders, hallucinations, anxiety, depression
Churg-strauss syndrome - inflammation of blood vessels → restrict blood flow to organs and tissues, sometimes permanently damaging them
Theophylline: MOA
- xanthine bronchodilator
- aminophylline: mixture that contains theophylline (injected in medical emergencies)
→ prescribe by BRAND
Theophylline: dose
Every 12H (oral)
Theophylline: therapeutic index
10-20MG/L
- Monitor 4-6H after dose
- Regular monitoring isn’t needed once a patient is on a stable dose
- INC levels: HF, viral infection, elderly, liver impairment
- RED levels: smoker alcohol
Theophylline: signs of toxicity
- Convulsions
- Hypokalaemia
- HypERglycaemia
- Arrhythmias
- Tachycardia
- Vomiting (severe haematemesis)
Theophylline: interaction
- Enzyme inhibitors → INC theophylline levels = toxicity
- Enzyme inducers → RED theophylline levels = therapeutic failure
- Betablockers → bronchospasm
- Ciprofloxacin → seizures
- Diuretic, corticosteroids, beta2 agonist → hypokalaemia
- Drugs that prolong QT interval → torsade de pointes
Pressurised metered dose inhaler (pMDI)
Slow + steady
- Oropharyngeal deposition + coordination problems
- Use Spacer
MHRA: obstruction from aspiration of loose objects: fully remove cover, shake device +check mouthpiece, store with cover
Counsel: after dose used up inhaler will still actuate but with propellant base only which affects the environment, use dose counter or gauge when likely to be empty
Dry powder inhaler (DPI)
Fast + deep
- Alt to pMDI
- Can cause coughing
- Suitable for 5+ year old
Who should use a spacer?
Children under 5:
- ICS, SABA/LABA (+ face mask)
Children 5-12years : ICS
- Poor inhaler technique, nocturnal asthma, oral candidiasis, high dose ICS
How to use a spacer
- Inhale ASAP after single dose actuation, tidal breathing as effective
- Not interchangeable, replace every 6-12M
- Clean once a month with warm water, mild detergent + air dry
Peak flow diary
Peak expiratory flow - how quickly you can blow air out of your lungs after taking a deep breath. Repeated 3 times and highest measurement is recorded as the peak flow score
- PEF >80%: good control
- PEF <80%: quadruple ICS dose
- PEF <60%: start oral steroids, same day medical advice
- PEEF <50%: urgent medical advice
Acute asthma (medical emergency): treatment
Salbutamol pMDI + spacer
- 2-10 puffs every 10-20mins or PRN
→ Prednisolone tablets
- Children 11 + under: upto 3 days
- Adult + child 12+: at least 5 days (40-50mg OD)
→ Hospital: unresponsive, severe + life threatening, under 2
Treatment: BTS/SIGN guidelines: children
(LTRA can be added at any step in children under 5 who can’t take corticosteroid or LABA bc isn’t licenced in this age group)
Offer SABA prn
→ Regular preventer: low dose ICS OR LTRA (under 5)
→ Initial add on therapy: LABA OR LTRA (under 5)
→ Additional controller therapies:
- (if no response to LABA consider stopping)
- Inc to low dose ICS OR
- LABA OR
- LTRA
→ Refer patient for special care (oral steroid, theophylline)
What classifies as moderate asthma?
PEF >50-75%
SpO2 >92%
Normal speech
Respiration <25
Pulse <110
What classifies as acute severe asthma?
PEF 33-50%
SpO2 >92%
Can’t complete sentence
Respiration >25
Pulse >110
What classifies as life threatening asthma?
PEF <33%
SpO2 <92%
Silent
Arrhythmia
Exhausted
