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GINA Flashcards

1
Q

4 asthma phenotypes

A
  1. allergic asthma
  2. non-allergic asthma
  3. asthma w persistent airflow limitation
  4. asthma w obesity
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2
Q

characteristics 1. allergic asthma

A
  • childhood onset;
  • PMH/FHx eg eczema, allergic rhinitis;
  • induced sputum: eosinophilic ariway inflam
  • respond well to ICS
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3
Q

characteristics 2. non-allergic asthma

A
  • less short term response to ICS

- sputum profile: paucigranulocytic/neurotph/eosino

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4
Q

characteristics 3. asthma w persistent airflow limitation

A

airway remodelling in chronic asthma; irreversible airflow limitation

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5
Q

characteristics 4. asthma w obesity

A

little eosinoph inflam; obese pt w resp symp

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6
Q

4 Patterns of respiratory symptoms suggestive of asthma

A
  1. > 1 : wheeze, SOB, cough +/- chest tightness
  2. at night/early morning
  3. vary over time & intensity (Reversible)
  4. symptoms triggered by infection/allergen/exercise etc
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7
Q

5 Symptoms that make asthma diagnosis less likely

A
  1. exercise induced noisy inspiration
  2. chest pain
  3. SOB w dizziness/lightheadedness/paraesthesia
  4. isolated cough
  5. chronic sputum prdn
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8
Q

Diagnostic criteria of asthma in persons > 5 yr old

A
  1. pattern respiratory symptom
  2. documented expiratory airflow limitation AND
  3. documented excessive variability in lung function
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9
Q

What is documented expiratory airflow limitation?

A

FEV1 reduced– so FEV1/FVC reduced

normal adult >0.75-0.8
normal child>0.9

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10
Q

what is documented excessive variability in lung function?

A

positive bronchodilator reversibility test: 15 min after 200-400mcg salbutamol
- increase FEV1 >12% or >200ml from baseline

*withhold bronchodilator: SABA ≥4; BD LABA 24h; OM LABA 36hr

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11
Q

which test is more reliable in assessing variability in lung function?

A

FEV1 in spirometry > Peak expiratory flow

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12
Q

when should variability in lung function be assessed?

A
  1. at diagnosis/ before treatment started as otherwise lung function will improve
  2. after 3-6 tx
  3. every 1-2 yr after exacerbation
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13
Q

how to diagnose asthma in pt already on controller treatment

A

x

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14
Q

tests to exclude asthma

A

bronchial provocation test
eg inhaled methacholine– negative excludes asthma
but +ve cannot diagnose asthma

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15
Q

pt already on controller treatment– steps in confirming diagnosis

A

x box1-3 pg 26,27

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16
Q

when to consider differential diagnosis in asthma

A

normal/near normal FEV1 w frequent resp symptoms

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17
Q

in elderly workup of asthma

A
  1. consider CHF – sob at night/exertion – do ECG, CXR BNP, echo TRO
  2. hx of smoking– consider COPD
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18
Q

in workup of occupational asthma

A
  • ask if symptoms improve when away from work

PEF monitoring at and away from work

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19
Q

if there is only persistent nonproductive cough, consider…

A
  1. ACEi – dry cough
  2. post nasal drip= chronic upper airway cough syndrome
  3. GERD
  4. cough variant asthma
20
Q

in smokers/elderly

A

consider Asthma-COPD overlap
~copd= post bronchodilator FEV1/FVC <0.7 + chronic resp symp+ exposure risk + bronch reversibility >12%

*hx dx chronic asthma w persistent airflow limitation vs COPD

21
Q

Asthma chronic history taking–need to ascertain?

A
  1. control= symptom mx (APGAR)+ risk for exacerbation

2. severity

22
Q

Symptom control assesed using APGAR?

A

*past 2-4 weeks
Activities
1. symptoms interfered w activities

Persistence

  1. daytime– used rescue inhaler
  2. night – woken up/use rescue inhaler
  3. SABA reliever > x2/week

triGgers– do you know what makes asthma worse//can you avoid the things

Asthma medications– ora/inhaler/nasal; how many times have you taken?

Response to medication– after meds how do you feel?

23
Q

indicators of risk of future exacerbations?

non-modifiable
modifiable

A

non-modifiable:

  1. uncontrolled asthma symptoms
  2. history of ≥1 exacerbation in the previous year
  3. intubation/ICU for asthma

modifiable:
1. medications:
- high SABA ≥1 x 200/dose/month (>=3/yr increase mortality)
- poor adherence/inhaler technique
2. exposures: smoking
3. lung function: low FEV1 <60%
4. PMH: obesity, GERD,
5. other tests type 2 inflam: blood eosinophilia

24
Q

risk factors for medication side effects

A
  1. systemic: frequent use + LT, high dose/potent ICS+ P450 inhibitor
  2. local: high dose/potent ICS + poor inhaler technique
25
Assessment of treatment response
peak expiratory flow
26
how to assess asthma 2. severity
1. mild: well-controlled w step 1&2= ICS-formoterol 2. moderate: well-controlled w step3&4 3. severe: - uncontrolled despite high dose ICS-LABA or - requiring high dose from preventing uncontrolled asthma
27
management of poor symptom control/ exacerbation of treatment
1. check inhaler technique & adherence 2. confirm asthma diagnosis - 1/2 ICS+ lung fn using spirometry 3. remove potential risk factors + manage co-morbids eg GERD 4. treatment step up 5. specialist referral after 3-6 months if uncontrolled after high dose ICS-LABA
28
2 treatment tracks for adults & adolescents
Track 1. low dose ICS-formoterol PRN or daily maintenance Track 2. salbutamol (if track 1 is not possible) - Step 1: SABA+ low dose ICS - Step 2-5: SABA alone PRN + ICS-controller daily
29
what to check before initiating treatment
1. dx confirmation 2. lung fn (Symptom control) &modifiable risk factors 3. comorbids 4. inhaler technique & adherence 5. pt preferences & goals
30
1. what to check before stepping up treatment? | 2. types of adjustment
1. inhaler technique, adherence, persistent trigger exposure, cormorbids 2. - day to day - short term (For 1-2 weeks eg seasonal allergy/viral) - sustained step up (≥1-2 months): review pt in 2-3 months; if no tx response, tx shld step down & consider alternatives
31
when to step down treatment?
good control achieved & maintained for about 3 months; do not withdraw ICS completely
32
Track 1 | symptom presentation & step differentiation
- step 1&2: symptoms <4-5 days/week - step 3: symptomatic most days + ≥ 1 night waking - step 4: daily symptoms + low lung fn + ≥ 1 night waking - step 5: severely uncontrolled
33
Track 1 management based on steps *MART= maintenance and reliever therapy
- step 1 & 2: PRN low dose ICS-formoterol 200/6mcg max F 72mcg/day - step 3: low dose maintenance ICS-F (MART) - step 4: medium dose maintenance ICS-F - step 5: LAMA + referral for + consider high dose ICS-F 1) phenotype assessement 2) +/- anti IgE, IL5/5R, IL4R 3) azithromycin if sputum cultured shows atypical (+ reliever ICS-F for all steps)
34
Track 2 | symptom presentation & step differentiation
- step 1: symptom <2x/month - step 2: ≥2x/month but <4-5x/month step 3-5 same as track 1
35
Track 2 | management based on steps
- step 1: ICS+SABA PRN - step 2: low dose maintenance ICS - step 3: low dose maintenance ICS+SABA - step 4: medium/high dose maintenance ICS - step 5: same* as track 1 (+reliever is SABA) -- do not prescribe SABA for pre-exercise; use PRN ICS-F
36
Low Medium High dose of ICS (budesonide)
Low 200-400 Medium >400-800 High >800mcg
37
Step 1: what about the use of inhaled anti-cholinergics eg ipratropium what should not be used orally?
can be used for routine symptomatic relief of asthma but slower onset than iSABA oral SABA & theophylline
38
Step 2: what alternatives can be considered?
Montelukast but shown to be less effective than ICS and in reducing exacerbations *note blackbox warning of neuropsych symptoms
39
who can be considered in add-on (when uncontrolled step 4/5): anti-IgE anti-IL5/5R anti-IL4R low dose oral CS
anti-IgE: ≥6 years with moderate or severe allergic asthma anti-IL5/5R: severe eosinophilic step 4/5 - subQ mepolizumab ≥6 years - IV reslizumab ≥18 - subQ benralizumab ≥12 anti-ILR4: severe type 2 asthma - subQ dupilumab ≥12 OCS: ≤7.5 mg/day prednisone - add on step 5 ensuring gd technique/adherence & after other biologics - caution SE & monitored osteoporosis, adrenal insufficiency, ≥3 months education to minimise SE
40
Switching therapy from MART to ICS-LABA + PRN SABA may...
increase exacerbations
41
how often should asthma review be?
1-3 months after starting tx every 3-12 months thereafter
42
alternative strategies for adjusting treatment
1. blood esinophil levels | 2. blood FeNO
43
non-pharmaco advice for pt at clinic...
1. influenza vaccinations/year for mod-severe pt 2. stop smoking (>10 pack years- COPD KIV) 3. exercise: low dose ICS-F 4. know triggers: NSAIDs/eyedrop
44
referral indications
x
45
how to improve adherence?
factors affecting adherence: 1. medication eg burdensome regime, difficulties in using inhaler eg arthritis 2. intentional: denial/SE 3. non-intentional

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