M103 T4 L7 Flashcards
When does asthma most commonly present?
in childhood or in middle age
Which three factors cause airflow obstruction?
Bronchoconstriction
Bronchial secretions and plugs of mucus
Oedema of the bronchial wall
What causes bronchial secretions and plugs of mucus?
inflammation of the bronchial wall
What causes oedema of the bronchial wall?
inflammation the lining mucosa of the bronchial wall
How can asthma be identified in patients?
skin prick test
measure igE atby levels
often associated hay fever / eczema in the personal family history
blood test (in conjunction with other tests - rarely done by itself for asthma)
What are the symptoms of asthma?
Cough
Wheeze
Breathlessness
Chest tightness
Time wise how do asthma symptoms take effect?
occurs in episodes with periods of no / minimal symptoms
diurnal variability
What would you look at to better diagnose asthma?
History Symptom free periods Past medical history family history (of any atopic disease) social history (occupation, pets) alternative diagnosis is unlikely Physical examination may be normal except during an attack
What are examples of features in a past medical history that could help indicate asthma?
previous wheezing illness
hay fever
eczema
What three investigations can be conducted to indicate asthma?
Tests done by GP
Tests done by GP/Hospital
Skin prick / blood tests may confirm allergies
Which investigations can be done by the GP alone to help diagnose asthma?
Peak flow monitoring
Spirometry may show airflow obstruction, but may be normal between attacks
Which investigations can be done by the GP or the hospital to help diagnose asthma?
CXR, eosinophil count, FeNO
CXR often normal, but may show hyperinflation
ec increased
Which investigations can be done by the hospital only to help diagnose asthma?
skin prick
blood test
How often is peak flow monitored by the GP?
twice day for two weeks
What causes hyperinflated lungs?
trapped air - can’t exhale / push out all of the air that’s in the lungs
the air gets trapped and takes up space
can make it harder to get fresh air into the body
the lungs try to fix this by taking in more and more air
How can eosinophilic asthma be identified from other asthmas?
patient will have an increased eosinophil count in the blood
count will be greater than 0.3
What value indicates airflow obstruction?
when the FEV1 / FVC ratio is greater than 0.7
Reversible airflow obstruction is when the asthma is not present all the time. What test can we do to indicate the presence of asthma in these conditions?
patient performs spirometry
measure their FEV1
give them a bronchodilator to see if the value improves
How can salbutamol be administered to an asthma patient?
inhaler via a spacer
sometimes nebuliser
In what circumstance can salbutamol be administered as a nebuliser?
only if the patient has severe asthma or COPD / acute exacerbation of their asthma
How can salbutamol be administered to an asthma patient?
a spacer device containing an inhaler
tablets, capsules or syrup (for people who cannot use an inhaler very well)
nebuliser
How is PEFR monitored independently by the patient?
they should take a PEFR three times so that an average value can be calculated
should be standing up at the time
What does a positive FeNO value look like and what does it indicate?
a positive test is more than 40ppb - supports diagnosis of asthma
Where is FeNO used?
can be done in GP and hospital clinics
How are asthma patients symptoms / QoL improved by non-physiological means?
stop smoking
lose weight
What four factors do corticosteroids reduce?
ease swelling
itching
redness
allergic reactions
Why are asthma patients never administered a single asthma treatment by itself?
one medication only is associated with increased deaths a bronchodilator (e.g.) only treats the symptoms - is short term relief doesn't do anything about the cause - doens't treat the inflammation
What is the function of long acting b2 agonists?
to relax smooth muscle and cause bronchodilatation
What are two examples of long acting b2 agonists?
salmeterol
formoterol
How long do LABAs last for and how often should they be administered per day?
12 hours (longer lasting than others) twice a day
What are the two oral treatments of asthma? (LAM Theo)
leukotriene antagonist-montelukast
theophyllines
When might an asthma patient be put on low dose long-term oral steroids?
chronically poorly controlled asthma
patients who keep having recurrent courses of high doses of steroids
Give an example of a low dose longterm oral steroid
prednisolone
Give an example of an oral leukotriene antagonist
montelukast
What is the function of short acting beta agonists?
relieves symptoms when the patient becomes symptomatic in certain situations e.g. exercise
What are two examples of short acting beta agonists?
Salbutamol
Terbutaline
After salbutamol treatment, what would indicate improvement?
FEV1 value improves to 15% and 200 ml compared to baseline
What is a benefit of Maintenance and reliever therapy?
tackles airway inflammation and bronchoconstriction
What is the next step of prescription if LABA isn’t that effective (since it’s only short term)?
then LABA combined with a specific ICS
What is the dosage for specific ICS / LABA combinations taken as additional doses?
4/day for 2-3 days
to rapidly treat any worsening asthma symptoms
What are the benefits of using certain specific ICS / LABA combinations?
can be used as relievers as well as preventers
they aim to address and treat the inflammatory aspect of disease
What are the lines of treatment for asthma?
1st LoT: low dose ICS
2nd LoT: 1st + inhaled LABA
3rd LoT: 2nd + LTRA or medium dose ICS (if no response to LABA, discontinue)
4th LoT: refer patient for specialist care
What are the main two types of inhalers?
dry powder inhalers
pressurised metered dose inhalers
Which two drugs is MART a combination of?
ICS
LABA
How do dry powder inhalers work?
the powdered drug is dispersed into particles by inspiration
How do pressurised metered dose inhalers work?
the drug is dissolves in propellant HFCs
a pressure valve system delivers a metered dose
When are dry powder inhalers beneficial to use?
when the patients know how to use them
when the patient has good dexterity
when the patient has a good enough inspiratory effort - can take a deep enough breath in to trigger activation
What should pressurised metered dose inhalers always be used in conjunction with and why?
a spacer device
to provide correct co-ordination so that enough gets in the lungs
What is a disadv of pressurised metered dose inhalers?
contain HCFs - bad for the environment
What are the side effects of some asthma-treating drugs from inhalers?
thrush (caused by ICS),
tremor (caused by SABA / LABA)
tachycardia (caused by SABA / LABA)
What are the three key questions to ask asthma patients?
Have you had difficulty sleeping because of your asthma symptoms (including cough)?
Have you had your usual asthma symptoms during the day?
Has your asthma interfered with your usual activities?
When are specialised treatments used for asthma patients (4th LoT)?
used for a very small number of patients with difficult asthma at a hospital
What are specialised treatments for asthma?
using monoclonal antibodies
bronchial thermoplasty
What are the two types of monoclonal antibody specialist treatments for asthma?
anti-IgE injections
anti IL-5 treatment
Why are monoclonal antibody treatments only reserved for specialist treatment?
much more expensive
given as injections
What are five factors that may result in unintentional lack of treatment compliance / adherance?
misunderstanding (continuation of previous inhalers in addition to new ones) poor inhaler technique language barrier / medical terminology forgetfulness stress
What are five factors that may result in intentional lack of treatment compliance / adherance?
concern about side-effects
denial
cost (have to pay for prescription drugs in inhaler)
What are the requirements for a self management and a personal asthma action plan (PAAP) to lower the rate of asthma deaths?
List daily medication to take and explain why
List which asthma triggers to avoid and importance of smoke free environment
List what to look for signs of deterioration of asthma/ values for PEFR
List names and doses of medication to be taken to treat worsening asthma
List indicators of how and when to seek medical attention
Easy to understand, 2-3 action points, traffic light colour coded leaflets
What is the importance of using personal asthma action plans?
Improves asthma control
Reduces emergency contacts with GP
Reduces hospital admissions
Why should all patients should see the asthma nurse at the GP practice regularly?
it gives an opportunity for a health care professional to actually see what the asthma control is like
review inhaler technique
review asthma education
either step up or step down treatments
What is the PEFR, respiration rate and pulse of patients with acute severe asthma?
PEFR: 33-50% of best
Respirations: x≥25 breaths/min
Pulse: x≥110 beats/min
What are life threatening features of acute severe asthma?
PEFR <33% of best or predicted
SpO2 <92% (regardless of air or oxygen)
What are the seven symptoms of life threatening acute severe asthma? (All Arrows Can Exhaust Fierce Soldier Hate)
altered consciousness arrhythmia cyanosis exhaustion feeble respiratory effort silent chest hypotension
What is a symptom of acute severe asthma?
Can’t complete sentences in one breath
What 1LoT drug types are used to treat acute severe asthma?
corticosteroids and nebulised bronchodilators
What might be required for asthma treatment in exceptional circumstances?
intubation
ventilation
What are the requirements for discharging an asthma patient from hospital?
their inhaler technique should be checked and recorded
a written PAAP follow up
After discharging an asthma patient from the hospital, what follow up meetings should they attend?
GP / nurse within 2 working days
respiratory clinic within 4 weeks
When are IgE antibodies produced?
allergic reaction
Is there a large number of eosinophils in circulation in a normal healthy patient?
no
What device is used to measure the peak expiratory flow rate?
peak flow meter
What are two oral long term treatments for asthma?
theophyllines
leukotriene receptor antagonists
How do leukotriene receptor antagonists treat long term asthma?
it prevents exercise induced bronchoconstriction
treats seasonal allergic rhinitis
What terms is a leukotriene receptor antagonist otherwise known as?
antileukotriene
leukotriene modifier
What is a feature of breath-actuated inhalers that might make usage either easier or more difficult to use during an asthma flare?
they typically require a quick, forceful inhalation
What’s an advantage of dry powder inhalers?
they allows medicine to get deep into the lungs
What is the FeNO test used to diagnose and how?
dx breathing conditions (certain types of asthma) via airway inflammation
When are FeNO tests used?
to diagnose breathing conditions
to check if any medication being taken is working
Are FeNO tests used independently?
no, other tests are needed (spirometry and a peak flow test)
What quantity of salbutamol is delivered via an inhaler?
100 mcg
What quantity of salbutamol is delivered via an nebuliser?
2.5mg (high dose)
What are the aims for acute severe asthma treatment?
to correct oxygen levels
to administer medication correctly
normal target saturations
What is the 2LoT for acute severe asthma?
iv MgSO4 or iv aminophylline
What corticosteroid is used to treat acute severe asthma?
prednisolone 40-60 mgs (oral)
What nebulised bronchodilators are used to treat acute severe asthma?
salbutamol + ipratropium bromide
What are the medical requirements for discharging an asthma patient from hospital?
patient must have been on discharge medication for 24hrs
What medication do asthma patients need to have for home administration IOT be discharged from hospital?
oral and inhaled steroids
bronchodilators
What equipment do asthma patients need to have for home administration IOT be discharged from hospital?
PEFR meter
What must an asthma patients’ PEFR be to be discharged from hospital?
PEFR >75% (of best or predicted)
What must an asthma patients’ PEFR diurnal variability be to be discharged from hospital?
x<25%
