CLINICAL- ASTHMA Flashcards
What is the first line investigation used for asthma in adults and children over 5?
Spirometry
Work out the FEV1 to FVC ratio
(Forced expiratory volume in 1 second vs Forced vital capacity)
A ratio of less than 70% is a positive result for obstructive airway disease
Bronchodilator reversibility test showing improvement in FEV1 would show positive for asthma
What is asthma?
A chronic INFLAMMATORY disease characterised by recurrent attacks of breathlessness and wheezing
It’s caused by airways inflammation (controlled by ICS) and airway smooth muscle dysfunction (controlled by LABA: dilates the airway)
Asthma is more inflammatory than COPD therefore more responsive to what type of medication?
ICS (inhaled corticosteroids)
Asthmas inflammatory characteristic is driven by which inflammatory cell infiltrates?
Eosinophils
Lymphocytes
Neutrophils
(COPD is predominately neutrophil driven. Less response to ICS)
Which disease, COPD or asthma, results in airway remodelling, bronchial hyperactivity and mucosal oedema?
Asthma
But remember mucus is not present in asthma: patients don’t have a chronic productive cough (but may have a cough) or sputum production!
What two types of inhalers used synergistically (together) tackle both smooth muscle dysfunction and airway inflammation that leads to symptoms and exacerbations in asthma?
LABAs (for smooth muscle dysfunction)
And ICS (for airway inflammation)
If symptoms are worse at night, what’s it more likely to indicate- COPD or asthma??
Asthma
If someone’s spirometry results are Normal and they’re free of symptoms, does this exclude asthma?
No
If a patient is experiencing Voice disturbance, what would this indicate?
Probably not asthma
How do we confirm asthma diagnosis after it is deemed that a patient has a high probability that they have asthma??
We trai them on treatment
If we see a response: asthmas diagnosis is confirmed
If we don’t see a response: assess inhaler technique, reconsider the diagnosis
What can we use to assess how well a patient is controlling their asthma with their medication?
The Asthma Control Test
Asks patients how they have found certain things over the past 4 weeks
Once a patient has persistently good asthma control (e.g for 3 months), what should we consider?
Consider stepping down to the lowest dose of ICS that maintains symptom control.
Note: there is limited evidence of increasing ICS dose to over 800mcg of BDP per day or equivalent actually improves asthma control.
ALL METERED DOSE INHALERS SHOULD BE ADMINISTERED USING A _______
SPACER
(New guidance)
Spacers avoid deposition in the lungs
They’re quite big! So some bag sized spacers are now coming out
What does new guidance recommend is now used at stage 3 asthma treatment?
Combination devices consisting of ICS combined with LABA.
Eg. Symbicort: Budesonide plus Formeterol
Seretide: fluticasone propionate plus salmeterol
There are now 6 of these combination inhalers available!
How much Fluticasone propionate is equivalent to 1000 mcg Beclometadone Dipropionate per day?
The ratio is 2:1 beclo: fluticasone
So it’s equivalent to 500mcg per day or 250mcg BD of FP
A magic number in the asthma treatment plan in 800 mcg per day of Beclometasone Dipropionate when talking about ICS.
What is this equivalent to for fluticasone propionate?
400 mcg per day FP or 200 mcg BD
The ratio is 2:1 beclo: fluticasone
Relvar Elliptar is an inhaler containing fluticasone furoate and vilanterol. There are 2 strengths available: 92:22 and 184:22 micrograms.
One strength can be used in both asthma and COPD, the other can only be used in asthma.
Which one is which?
92: 22 can be used in both asthma and COPD
184: 22 can be used in asthma only
Relvar is a preventer, but it was blue in colour, now changed to yellow as people thought it was a reliever.
What is Symbicort SMART?
Symbicort inhaler contains a combination of ICS and a LABA
It can be used alone as BOTH maintenance (preventer) and reliever medication- so patients don’t have to use two inhalers blue and brown.
Patient takes a fixed maintenance dose each day, with additional puffs as reliever of symptoms as needed. Very convenient for patients as they only need one inhaler!
We now use these combination inhalers at step 3 of the asthma treatment plan as it will IMPROVE PATIENT COMPLIANCE
One of the aims of asthma therapy is to achieve normal lung function. This is classed as over what percentage (FEV1)?
Over 80%
Difficult to treat asthma (I.e. Asthma where symptoms are present despite maximal treatment) causes a high rate of __________ co-morbidities
Psychological co morbidity
Eg. Depression
Anxiety
Stress
We quite often have to question: is it actually difficult to treat asthma? As it could just be more psychological and the patient just panicky and stresses which worsens the asthma
As it’s hard for patient to cope and have a good QoL
What medical conditions could aggregate difficult to treat asthma?
Rhinosinusitis, allergic rhinitis Allergy Nasal polyps Depression or anxiety Gastro-oesophageal reflux disease (GORD) Relation to the menstrual cycle
What DRUGS CAN AGGREVATE/ SHOULD NOT BE USED IN ASTHMA?
Beta blockers: these constrict airways (but dilate blood vessels so good in HTN, AF)
Aspirin
NSAIDS!!! E.g. Ibuprofen in an asthmatic: had this in 3rd year dispensing
ACEinhibitors
Patients with difficult to treat asthma have persistent and frequent exacerbations despite treatment at step 4/5. They usually have oral corticosteroids either intermittently or long term. What can this cause??
Steroid related adverse effects
Osteoporosis
Cushings
Diabetes! (A symptom of cushings)
What co-existing LUNG related conditions could worsen asthma??
Dysfunctional breathing Bronchiectasis: airways become too wide and excess mucus builds up: prone to infection Severe COPD (some patients are unfortunate enough to have both) Vocal cord dysfunction
What modifiable factors could aggravate Asthma?
Adverse drug effects: NSAIDS, beta blockers Allergy Cigarette smoking Obesity Occupational factors: may be a trigger
What is difficult to treat asthma?
Patient has Persistent and frequent exacerbations despite treatment at step 4/5 of the BTS guidelines.
What pharmacological options are there for difficult to treat asthma?
Anti Ig E : OMALIZUMAB
Tumour necrosis factor alpha : ETANERCEPT
Others: the following are to decrease the use of oral steroids in asthma.
Ciclosporin
Methotrexate
Gold
Terbutaline injection (monitor heart rate, not recommended long term)
The higher the concentration of Ig__, the greater the likelihood of an individual having asthma.
IgE
A relationship between serum IgE and asthma have been shown in adults
This is why we can use anti-IgE therapy OMALIZUMAB in difficult to treat asthma. This drug mops up IgE, therefore it reduces allergic inflammation and prevent asthma exacerbations and reduces symptoms
The newer anti IgE therapy is only licensed in patients meeting certain criteria, what are these?
Must be at step 4/5 asthma FEV1 under 80% predicted Over 2 severe exacerbations Positive skin prick test IgE level over 50
OMALIZUMAB is a monoclonal antibody that binds to free ___. Serum free IgE concentrations are reduced by _____ within a few days. In addition, omazulimab decreases the concentration of sputum ______, the presence of these correlates to asthma severity and risk of exacerbations.
Free IgE
95-99%
Sputum eosinophils
What is the role of methotrexate, Ciclosporin and oral gold in asthma treatment?
They are immunosupressants to minimise use of oral steroids as long term oral steroids are bad news. Even reducing steroid dose by 1mg is worth it to reduce risk of some of the complications we can get from using them!!
Continuous IV terbutaline infusion can also be used
What medication used in asthma treatment would require a PICC line?
Terbutaline
As it’s an IV infusion
It is only used in difficult to treat asthma to avoid long term oral steroid therapy
Problems with infection in these lines
We can get steroid induced diabetes mellitus from long term steroids in asthma which can lead to eye problems and kidney problems.
We can also get steroid induced osteoporosis
Can also get steroid induced depression (or this may be from the chronic asthma)
These are all symptoms of cushings!!
What TWO things do doctors now need to use to diagnose asthma?
Symptoms
AND
History of atopic disorders
If there is some benefit from the treatment but a low probability of asthma then what should we suspect?
another condition e.g. COPD
There are now two salts of fluticasone available. Fluticasone propionate and fluticasone furoate. These are not bioequivalent. What are their steroid equivalence ratios compared to Beclometasone Dipropionate?
Fluticasone propionate ratio: 2:1 (BP: FP)
Fluticasone furoate: 10:1 (BP:FP)
What is symbicort a combination of?
A LABA and an ICS
By combining a LABA with the ICS you can use less of the ICS which is good!!! Want to minimise steroid use
LABA: Formoterol fumarate
ICS: Budesonide
What is the steroid equivalence ratio of Budesonide?
1:1 with Beclometasone Dipropionate
In order to be classed as acute severe asthma, what must Respiratory rate and Heart rate be classified as?
RR over/ equal to 25
HR over/ equal to 110
A patient is unable to complete their sentences in one breath and their PEF is 33-50% of best predicted. What does this indicate?
Acute severe asthma
What does SpO2 have to be for asthma attack to be classed as life threatening?
Under 92%
In Pka, What does PaO2 have to be for asthma to be classed as life threatening?
Under 8Pka- remember this!
What signs and symptoms is someone having a life threatening asthma attack likely to have?
Silent chest
Cyanosis (blue)
Exhaustion
Hypotension
What’s the PEF likely to be in someone having a life threatening asthma attack?
Likely to be under 33%
Note: their PaCO2 is likely to be in the normal range
What is the steroid equivalence of Beclometasone Dipropionate QVAR inhaler?
2:1, so 400mcg BP is equivalent to 200mcg BP-QVAR!!!
Other BP inhalers such as Clenil Modulite, Beclo easyhaler are all 1:1
What’s the steroid equivalence ratio of Budesonide?
1:1
What is the steroid equivalence ratio of Ciclesonide?
2.5:1
