Management of Asthma in Adults Flashcards
What is the aim of the treatment in asthma?
No daytime symptoms, no night time wakening, no need for rescue medication, no asthma attacks, no limitations on activity, minimal side effects from medications.
What are non-pharmacological ways to manage asthma?
Patient education and self management plans, exercise, smoking cessation, weight management, physiotherapy, vaccines, allergen avoidance, bronchial thermoplasty
What are inhalers?
Small dose of a drug, it allows it to be delivered directly to the target organs. The onset is very quick and there are very little systemic side effects.
What are the two main types of inahlers?
Metered dose inhalers (with spacers)
Dry powder inhalers
What are short acting beta agonist relievers examples?
Salbutamol - MDI, DPI
Terabutaline - DPI
What are the main symptoms of using salbutamol?
Tremor and increased heart rate.
What are the main examples of oral therapy?
Leukotriene receptor antagonist
Theophylline
Prednisolone
What are specialist options of treatment for asthma?
Omalizumab (Anti-IgE)
Mepolizumab (Anti-interleukin)
Bronchial thermoplasty
Only prescribed by specialists in the respiratory clinic
What is an acute asthma attack?
There is an increase in inhaler use, they may be given an oral steroid, you need to treat the trigger, you need to make sure that there is an early follow up, and you need to have a back up plan just in case.
What should you do with a severe asthma attack?
The patient should be in hospital.
They are now using nebulisers, Oral or IV steroids (faster onset), IV magnesium (doesnt make patients feel great), IV amophylline, trying to treat the triggers,
Complication (people who breath hard and hyperventilate are at a risk of getting pneumothorax.)
Level 2/3 care
What is the contrast between COPD and asthma?
Both have airways inflammation and irritability of the smooth muscle causing increased contraction and narrowing of the airways.
Aim of treatment is reducing the number of exacerbations they have.
Patients of asthma tend to be younger whereas some patients with COPD are smokers and they tend to be in the 50s and over.
However non pharmacological interventions tend to be the same
What cells are responsible for the effects of asthma?
Th2 Cytokines, Eosonophils, mast cells
What is the major contributor of the air resistance of a tube?
The radius
What is the difference between occupational asthma and work exacerbated asthma?
Occupational has no prior history of asthma.
What are the drugs used to treat acute asthma attack and chronic asthma?
B2 agonist, steroids, anti-muscarinic, Theophyllines, Magnesium, Oxygen, Leukotriene RAs, Monoclonal Abs.
What are the drugs to avoid during the treatment of asthma?
NSAIDS/Aspirin, Sedatives/strong opiates (unless in critical care)
- What are the non-pharma methods of treatment of acute asthma attack?
ITU/HDU, Ventilation, ECCO2R, Chest drain if pneumothorax
- What are the benefits of inhalers?
Small dose of drugs, Delivery directly to the target organ (airways and lung), Onset of effect is faster, Minimal systemic exposure, Systemic adverse effects are less severe and less frequent
What are the problems associated with metered dose inhalers?
Needs co-ordination, Elderly, young children, unwell can’t use effectively
What are the benefits of spacers?
Low oro-pharyngeal deposition of aerosol, Reduced speed of the aerosol, decreases bad taste associated with oral deposition, reduced the risk of oral candidiasis and dysphonia with steroids, Reduced “cold-Freon effect” in some
What are the benefits associated with dry powder inhalers?
Less coordination required, Similar issues with deposition
When do you start ICS?
Using inhaled β2 agonist (“Reliever”) x3/week or more, Waking one night a week or more due to asthma, Requiring oral steroid for an exacerbation in the past 2 years, Symptomatic x3/week or more
What are the long term side effects of inhaled long term steroids?
Dysphonia -difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords, Oropharyngeal Candidiasis
When do you move up the steps from SABA to ICS?
If it is being used more than three times a week.
What does SABA stand for?
Short acting beta agonists.
What are regular preventers?
Low dose ICS, Beclomethasone, Budesonide, Fluticasone, Ciclesonide, Mometasone.
What is the next step of asthma management after administration of ICS?
Add inhaled low dose ICS
What should you do if there is no response to LABA?
Stop it and consider using an increased dose of ICS
What should you do if there is a benefit from LABA but control is still inadequate?
Continue LABA and increase ICS to medium dose, Or continue LABA and ICS and consider LRTA, SR Theophylline, LAMA.
What are the possible high dose therapies?
Increasing the ICS up to high dose, Addition of a fourth drug - LRTA, SR theophyline, beta agonist tablet, LAMA
Give examples of Leukotrine receptor antagonists?
Montelukast, Zafirlukast
What is theophylline?
Phosphodiesterase inhibitor, Adenosine receptor antagonist, Weak bronchodilator
What are the downsides to using Theophylline?
Many side effects, narrow therapeutic window, unpredictable metabolism, Side effects: anorexia, headache, Nausea, Malaise, Vomiting, Nervousness, Abdominal discomfort, Insomnia, Tachycardia, Tachyarrhythymias, Convulsions
Give an example of an inhaled long acting anti-muscarinic?
Tiotropium Bromide
What is the effect of LAMA?
Antagonises muscarinic acetylcholine receptor in bronchial smooth muscle, Some limited evidence of benefit in asthma when added to ICS/LABA
What are the side effects of LAMA?
Dry mouth, GI upset, Headaches, Can rarely precipitate angle-closure glaucoma- emergency
What is the very last stage of asthma treatment?
Daily steroid tablets, Maintain high dose ICS, Consider other treatments to minimise the use of steroids
Give an example of a long term steroid.
Prednisolone
What dose is recommended for long term oral steroids?
Lowest oral dose that controls symptoms.
What is the result of abrupt cessation of oral steroid if on for over 3 weeks?
Acute adrenal insufficiency (failure of adrenal glands to produce endogenous glucocorticoid - can be fatal)
What is the function of Omalizumab?
Monoclonal antibody against IgE, For IgE mediated severe allergic asthma
What is the cytokine that is responsible for driving the hypersensitivity in asthma?
Interleukin - 5
What is the effect of Mepolizumab?
Monoclonal antibody against interleukin 5
Who is mepolizumab given to?
People with poor asthma control (it is an injection), Long term steroid use or frequent use, Blood eosinophilia
What is defined as moderate asthma?
Increasing symptoms, PEF >50-75% best or predicted, No features of acute severe asthma.
What is defined as acute severe asthma?
Any one of: PEF 33-50% best or predicted, respiratory rate > 25 min, heart rate > 110 inability to complete sentences in one breath
What is defined as life-threatening asthma?
Any one of: Altered conscious level, Exhaustion, Arrythmia, Hypotension, Cyanosis, Silent chest, poor respiratory effort, PEF < 33% best or predicted, SpO2 < 92%, PaO2 < 8kPa, normal PaCO2
What is described as near fatal asthma?
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures (504-507)
What is the treatment of acute asthma - mild/moderate?
Oral prednisolone for 7 days, SABA - more frequently, Upto 2 hourly. In some cases, increase ICS/LABA dose as well, Assess within 24 hours. Advice immediate medical help if deteriorating.
What is the treatment for acute asthma - severe?
Ipratropium is a short acting muscarinic drug, Consider IV MgSo4 if no response, Antibiotics if there is pneumonia / bacterial infection, CXR – pneumothorax + asthma = bad. Needs chest drain if unwell, Involve senior medical staff including ITU if life threatening features, May need anaesthesia, intubation and ventilation in ITU, In extreme cases ECCO2R may be life saving (Extra cocorial CO2 removal (ECCO2R))
