Management of Asthma Flashcards
Making a diagnosis of asthma in children
- Does the child present with symptoms of cough wheezing breathlessness and chest tightening
High probability: Structural and clinical assessment looking at history
- Reoccouring episodes of symptoms
- Symptom variability
- Absence of symptoms and symptoms and alternative diagnosis
- Observations of wheezing
- Personal history of atopy
- Historical record of PEF and FEV
Good response
Initiation of treatment after high probability asthma
- Response is assessed objectively - Lung function validated symptom score
- Definate asthma adjustment and maintainance of dose arrange ongoing review
Poor score on Assess response objectively (lung function and validated score system)
- Intermediate probability of asthma
- Test for airway disruption by spiromitry and bronchodialator
Test to investigate airways obstruction
- Reversibility
- PEF charting
- Challenge tests
- FeNO
- Eosinophils
- Skin prick test and IgE
- Wait till good response
Low probability asthma diagnosis
- Investigate and treat other more likely diagnosis
- If other diagnosis unlikely test forairways obstruction
Adults and >17
Suspected asthma treatment
- Concider monitored initiation of treatment with low ICS
Adults and >17
Regular preventer asthma diagnosed
- Low dose ICS used
adult
Initial add on therapy for diagnosed asthma
- Add inhaled LABA to ICS use fixed dosage
adult
Additional controller therapy
- Concider icreasing ICS to medium dose or addin LTRA
- If no response to LABA concider stopping
- Additionally refer to specialist care
Child
Treatment control therapy
- Last resort continue pediatric moderate dose of ICS with trial of additional drug
Uncontrolled asthma
- Asthma that has a impact on persons quality of life
- 3 or more days a week with symptoms
- 3 or more days required use of SABA for symptomatic relief
- 1 or > nights a week with awakening due to asthma
Maintainance and reliever therapy (MART)
- One preventer and one reliever inhaler
- Inhaled steroid + long acting brochodialator with fast onset action
Usage of MART inhaler
- Daily maintainance and relief inhaler
- Appropriate for low dose ICS step 2 & 3 and medium dose step 4
- Person with personalised asthma action plan
- Person that is able to self manage & compliant with treatment
- Only treatment that is uncontrolled with ICS, LABA and SABA as a reliever
Maintainance and reliever therapy with other inhalers
- Total dose of ICS shouldnt be decreased
- Patient Taking regular once a day
- rescue doses of the combination inhaler
- Seperate SABA eliever inhaler not required
- Counselling required
Fostair MART
- Beclametasone/Formoterol 100/6 (Meter dose inhaler)
- > 18 licence
- One puff twice a day additional puff if symptoms persist
- Max 8 puffs in 24hrs
Symbicort SMART
- Turbohaler with budesonide/formoterol 100/6 or 200/6
- 12yrs and over
- 100/6 take 2 puffs daily can increase to 200/6 strength two puff daily or two puff twice daily for some
- Not >6 puff at once with max 8 puff in day
DuoResp Spiromax
- Busonide/fomoterol 160/4.5 equal to 200/6 symbicort
- > 18 yrs 2 puffs daily increase to 2 puff twice day for some
- No more than 6 in one go and 8 in 24 hrs
Importance of inhaling slowly
- Contains ICS possiblity of developing candisis due to hitting the back of throat
Short acting High risk selective B2-agonist
- Inhaled short risk agonist used for immediate relief asthma symptoms
- 3-5 duration
- Salbutamol and terbutaline
Long acting B2 agonist
- Combination with ICS for prophylatic treatment
- Duration of 12 hrs
- Salmeterol and formoterol used for COPD
Monitoring of Beta 2 agonist
- Plasma potassium concentration in severe asthma
- Blood glucose in diabetes
MHRA advice on pMDI
- Risk of airways obstruction from aspiration of loose objects
CHM advice on LABA’s
Long acting bronchodialating inhaler
- Added if regular use of ICS has failed to work
- Not been initiated in patients with rapidly deteriorating asthma
- Low dose and discontinued in absence of benefit
Caution with selective B2 agonist
- Arrhythmias
- Cardiovascular disease and prolonged QT interval
- Risk of hyperglycemia in diabetes
- Hypokalemia due to corticosteroids
Inhaled corticosteroids
- Reduce airways inflammation and redue oedema and secreation of mucus in airways
- Beclametasone dipropinate
- Budesonide
- Mometasone furoate
Monitoring of ICS
- Weight and height of children reciving prolonged treatment annually
- Slowed growth refer to peads
MHRA info on ICS
- pMDI risk of airway obstruction from aspiring loose objects
MHRA advice on beclametasone inhalers
- Not interchangeable must be prescribed by brand
- Qvar twice as potent as clenil
MHRA risk CSC
- Rare risk of central serous chorioretinopathy as well as local systemic administeration
Cautions of ICS
- Systemic absorption may follow inhaled administeration
- Candidiasis - risk reduction from using a spacer and rinse mouth with water after inhaling
- Paradoxical bronchospasm - bronchodialator beforehand ICS should be discontinued
Adult >17
ICS dose
- 400mcg busonide dose would be low dose
- 400-800mcg is moderate dose
- > 800mch is a high dose
Children <16
ICS dose
- <200mcg concider low pead dose
- 200-400mcg moderate pead dose
- > 400mcg concider high dose
Theophylline
- Narrow theraputic drug 10-20 mg/L
- Sampe should be taken every 4-6 hrs after oral dose
Pharmacokenetics Theophylline
- Dose adjustments may be necessary if soking started or stopped during treatment
- Plasma conc decrease in smokers, alcohol consumption and enzyme inducer
- Plasma conc increased cause heart failure, hepatic impairment and viral infection
Overdose symptoms of Theophylline
- Due to narrow theraputic index
- Severe vomiting
- Agitation
- Restlessness
- Dialated pupils and sinus tachycardia
- Hyperglycemia and convulsions
- Severe hypokalemia
Cautions with Theophylline
- Cardiac arrhithmyas and cardiac disease
- Elderly
- Epilepsy
- Hypertention
- Peptic ulcer
Leukotrine receptor antangonist
- Monotekulast
- MHRA advice risk of neuropsychatric reaction
- Eosinophilic granulomatosis with polyangiitis - Look out for eosinophilic rash worsening pulmonary systems and cardiac
- Avoid pregrancy unless essential
COPD treatment guideline
- Look at spirometrically confirmed diagnosis
- Assess air flow limitation
- Assess symptoms risk and exacebation
- <70 then issue
- Post brochodialator FEV1/FVC gold 1 >80 and <40 is gold 4 for improve
Dypeanea
- LABA/LAMA or LABA +ICS
- LABA+LAMA OR LABA+ICS+LAMA
- Consider switch of inhaler if not working
Exacerbations
- LABA/LAMA or LABA +ICS
- LABA+LAMA concider if eos >100
- LABA+ICS+LAMA
- If eos is <100 then roflumilast FEV <50% chronic brochitis
- Azithomycin if former smoker
eos - eoseniphil blood count
LAMA examples
Tiotropium
Umeclidinium Glycopyronnium
MHRA Inhaled antimuscarinics
- Inhalation of capsule if placed in the mouthpiece of the inhaler
- bladder outflow obstruction
- Constipation and arrhythmias
Management of exacerbation
- Short acting require higher dosage
- Increase in dyspnea, increased sputum volume
- Hydrocortisone for life threatening asthma
- Predisolone used as a short course
- Antibiotics when there is a sign of infection
According to gold standard what would give patient in group A
- A SABA (Salbutamol) inhaler or a SAMA (e.g. ipratropimum) inhaler as inly 0-1 exacerbation
- mMRC 0-1 CAT score <10
According to gold standard what would give patient in group B
- LABA Famoterol or samoterol or LAMA (Tiatropium) - long lasting BA or MA
- Moderate exacebation 0-1
- mMRC >2 CAT score >10
According to gold standard what would give patient in group C
- LAMA (Tiatropium) - long lasting MA
- > 2 Moderate exacebation OR >1 hospitalization
- mMRC 0-1 CAT score <10
According to gold standard what would give patient in group D
- LAMA or LABA + LAMA or ICS + LABA
- Asthma regualtion due to receptors
- ICS used due to high esinophil levels if COPD patient
- Do not need ICS using may cause pneumonia
