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Asthma > GINA guidelines > Flashcards

GINA guidelines Flashcards

1
Q

2 key defining features of asthma

A
  1. history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough
  2. variable expiratory airflow limitation
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2
Q

evidence of variable expiratory airflow limitation

A
  1. FEV1/FVC ratio is below lower limit of normal
  2. FEV1 increases after inhaling bronchodilator by >200ml and >12% of pre-bronchodilator value; average diurnal PEF variability is >10% in children; FEV1 increases by >12% and 200ml from baseline after 4 weeks of anti-inflammatory treatment
  3. the greater the variation, the more confident you are that it is asthma
  4. testing may need to be repeated in the early morning, during symptoms or after withholding bronchodilator medications
  5. significant bronchodilator reversibility may be absent during severe exacerbations or viral infections
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3
Q

characterised by cough and airway hyperresponsiveness, and documenting variability in lung function is essential to make the diagnosis

A

Cough variant asthma

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4
Q

How to assess a patient with asthma:

Asthma control

A

Assess both symptom control and risk factors

  1. assess symptom control over the last 4 weeks
  2. Identify modifiable risk factors for poor outcomes
  3. measure lung function before starting treatment, 3-6 months later and then periodically
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5
Q

How to assess a patient with asthma:

Are there any comorbidities?

A

rhinitis, chronic rhinosinusitis, GERD, obesity, OSA, depression and anxiety

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6
Q

How to assess a patient with asthma:

Treatment issues

A

ask about side effects
watch the patient using inhaler to check their technique
empathic discussion about adherence
check if there is an action plan
ask about the goals and preferences for asthma treatment

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7
Q

What are the symptoms to be asked to asthma patients?

A

In the past 4 weeks, has the patient had:

  1. daytime symptoms more than 2x a week?
  2. any night waking due to asthma?
  3. SABA reliever needed more than 2x a week?
  4. Any activity limitation due to asthma?
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8
Q

In the past 4 weeks, has the patient had:

  1. daytime symptoms more than 2x a week?
  2. any night waking due to asthma?
  3. SABA reliever needed more than 2x a week?
  4. Any activity limitation due to asthma?

none of the above symptoms is called

A

well controlled

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9
Q

In the past 4 weeks, has the patient had:

  1. daytime symptoms more than 2x a week?
  2. any night waking due to asthma?
  3. SABA reliever needed more than 2x a week?
  4. Any activity limitation due to asthma?

patient has 1-2 of the above symptoms

A

partly controlled

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10
Q

In the past 4 weeks, has the patient had:

  1. daytime symptoms more than 2x a week?
  2. any night waking due to asthma?
  3. SABA reliever needed more than 2x a week?
  4. Any activity limitation due to asthma?

Patient has 3-4 of the above symptoms

A

Uncontrolled

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11
Q

When should we measure FEV1 in patients with asthma?

A

start of treatment
after 3-6 months for personal best lung function
periodically or ongoing risk assessment

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12
Q

asthma that can be controlled by with reliever alone or low dose ICS

A

Mild asthma

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13
Q

asthma that requires high-dose ICS-LABA

A

severe asthma

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14
Q

long term goals of asthma management

A

risk reduction and symptom control

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15
Q

GINA now recommends that every adult and adolescent should receive

A

ICS-containing controller medication to reduce risk of serious exacerbations even in patients with infrequent symptoms

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16
Q

SABA only treatment is associated with

A

increased risk of exacerbations and lower lung function

Regular use of SABA increases allergic responses and airway inflammation and reduces bronchodilator response to SABA when needed

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17
Q

patient has troublesome asthma symptoms on most days; waking asthma >/= to once/week

A

start at step 3 (maintenance and reliever therapy with low dose ICS-Formoterol)

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18
Q

patient presents with severely uncontrolled asthma at presentation or initial presentation is during exacerbation

A

start regular controller treatment at step 4

medium dose ICS-Formoterol maintenance and reliever therapy

19
Q

consider stepping down if asthma symptoms are controlled for

A

3 months

However, in adults and adolescents, ICS should not be completely stopped

20
Q

preferred approach recommended by GINA to adults and adolescents

A

TRACK 1 (reliever is as needed low dose ICS-Formoterol)

  1. When a patient at any treatment step has asthma symptoms, they use low-dose ICS-Formoterol in a single inhaler for symptom relief
  2. In steps 3-5, patients also take ICS-Formoterol as regular daily treatment. this is called Maintenance and reliever therapy
21
Q

what is track 2 in asthma management in adults and adolescents

A

alternative when track 1 is not possible or not preferred by by a patient who has no exacerbations on their current therapy

  1. In step 1, patient takes a SABA and low dose ICS together for symptom relief when symptoms occur, either in combination inhaler or with ICS taken right after SABA
  2. In steps 2-5, SABA alone is used for symptom relief and the patient takes ICS-containing controller medication regularly every day
22
Q

GINA guidelines on asthma treatment for 12 years old and above

A

RELIEVER: as needed low dose ICS-Formoterol

CONTROLLER:
Steps 1-2: as needed low dose ICS-Formoterol

Step 3: low dose maintenance ICS-Formoterol

Step 4: medium dose maintenance ICS-Formoterol

Step 5: refer

23
Q

GINA guidelines on asthma treatment for 12 years old and above controller and alternative reliever

A

ALTERNATIVE RELIEVER: as needed short acting B2 agonist

CONTROLLER:
Step 1: takeICS whenever SABA taken

Step 2: low dose maintenance ICS

Step 3: low dose maintenance ICS-LABA

Step 4: medium/high dose maintenance ICS-LABA

Step 5: add on LAMA; refer for phenotypic assessment

24
Q

Child with asthma 12yrs old and above with symptoms less than 4-5 days a week

A

Steps 1-2: as needed low dose ICS-Formoterol

25
Q

Child with asthma 12 years old and above with symptoms on most days or waking with asthma once a week or more

A

Step 3: low dose maintenance ICS-Formoterol

26
Q

Child 12 years old and above with daily symptoms of asthma or waking with asthma once a week or more, and low lung function

A

Step 4: medium dose maintenance ICS-Formoterol

27
Q

Children 6-11 years with asthma:

Preferred controller to prevent exacerbations and control symptoms

A

RELIEVER: as needed SABA

PREFERRED CONTROLLER:
Step 1: low dose ICS taken whenever SABA taken

Step 2: daily low dose inhaled corticosteroids (ICS)

Step 3: Low dose ICS-LABA or medium dose ICS or very low dose ICS-Formoterol maintenance and reliever (MART)

Step 4: medium dose ICS-LABA or low dose ICS-Formoterol maintenance and reliever (MART); refer for expert advise

Step 5: refer for phenotypic assessment

28
Q

In children 6-11 years: symptoms less than 2x a month

A

Step 1: low dose ICS taken whenever SABA taken

29
Q

In children 6-11 years: symptoms 2x a month or more but less than daily

A

Step 2: daily low dose inhaled corticosteroids (ICS)

30
Q

In children 6-11 years:

symptoms most days or waking with asthma once a week or more

A

Step 3: Low dose ICS-LABA or medium dose ICS or very low dose ICS-Formoterol maintenance and reliever (MART)

31
Q

In children 6-11 years:

symptoms most days or waking with asthma once a week or more and low lung function

A

Step 4: medium dose ICS-LABA or low dose ICS-Formoterol maintenance and reliever (MART); refer for expert advise

32
Q

Adults and adolescents ICS

A 
BDP 200-500mcg
Budesonide 200-400mcg
Ciclesonide 80-160mcg
Fluticasone furoate 100mcg
Fluticasone proprionate 
Mometasone furoate
33
Q

usual dose of as needed Budesonide-Formoterol is one inhalation of

A

200.6mcg taken whenever needed for symptom relief

34
Q

maximum recommended dose of Budesonide-Formoterol in a day

A

total of 72mcg Formoterol

in mild asthma, average usage is 3-4 inhalations per week

35
Q

taken as needed and before exercise showed similar benefit as daily ICS

A

ICS-Formoterol

*suggests that patients prescribed with as needed ICS-Formoterol do not need to be prescribed a SABA for pre-exercise use

36
Q

maximum recommended dose of ICS-Formoterol in a single day is total of

A

48mcg formoterol for BDP-Formoterol (36mcg delivered dose)

72mcg formoterol for budesonide-Formoterol (54mcg delivered dose)

37
Q

non-pharmacological strategies and interventions

A

smoking cessation
physical activity: encourage to engage in regular physical activity because of general benefits
investigation for occupational asthma
identify aspirin-exacerbated respiratory disease

38
Q

In patients with asthma who will undergo surgery, when should we give intra-operative Hydrocortisone to reduce risk of adrenal crisis?

A

patients on long term high dose ICS or having more than 2 weeks’ OCS in the past 6 months

39
Q

written asthma action plan should incude:

A

patient’s usual asthma medications
when and how to increase medications and start OCS
how to access medical care if symptoms failed to respond

40
Q

management of patients with signs of severe exacerbation, confused, has silent chest

A

immediately give inhaled SABA, inhaled Ipratropium bromide, oxygen and systemic corticosteroids

41
Q

talks in phrases, prefers sitting to lying, not agitated; RR increased, accessory muscles not used, PR 100-120bpm, 90-95% O2 sat, PEF >50%

A

mild or moderate asthma

42
Q

talks in words, sits hunched forward, agitated; RR >30/min, accessory muscles in use, PR >120, O2 sat <90%, PEF <50%

A

severe asthma

43
Q

management of mild to moderate asthma

A

SABA 4-10 puffs by pMDI + spacer repeat every 20 mins for 1 hour

Prednisolone: adults 40-50mg, children 1-2mg/kg, max 40mg

controlled oxygen (if available): target saturation 93-95% (children 94-98%)

assess response at 1 hour or earlier

44
Q

these patients with mild to moderate exacerbations can be discharged

A

symptoms improved; not needing SABA
PEF improving and >60-80% of personal best or predicted
O2 sat >94% at room air
resources at home adequate

Asthma (3 decks)

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