Management of Asthma in Adults Flashcards
What cells are responsible for the effects of asthma?
Th2 Cytokines - (IL-5, LT)
Eosinophils
Mast cells
What is the major contributor for the ari 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 is non-pharma management of chronic asthma?
Asthma Action Plan
Weight loss if ˄BMI
Vaccines – flu & pneum
Allergen avoidance
(inc. occup. Asthma)
Physiotherapy
Smoking Cessation
Bronchial Thermoplasty
What are the drugs used to treat acute asthma attack and chronic asthma?
What are the drugs to avoid during the treatment of asthma?
**β-blockers**
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
Requires high inspiratory flow
What is defined as the complete control of asthma?
- no daytime symptoms
- no night-time awakening due to asthma
- no need for rescue medication
- no asthma attacks
- no limitations on activity including exercise & normal lung function (in practical terms FEV1 and/or PEF>80% predicted or best)
- minimal side effects from medication.
–BTS/SIGN 2016
What does SABA stand for?
Short acting beta 2 agonists
Where do you find salbutamol?
MDI
DPI
Where do you find terbutaline?
DPI
What are the adverse side effects of beta 2 stimulants?
What are regular preventers?
Low dose Inhaled Corticosteroids (ICS) - Preventers
•Beclomethasone
•
•Budesonide
•
•Fluticasone
•
•Ciclesonide
•
•Mometasone
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 advantages of inhaled ICS?
What are the side effects of Long term oral cortical steroid use?
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 three times a week
What is the next step of asthma management after administration of ICS?
Add inhaled low-dose ICS (normally as inhaled combination)
What are the ICS long acting beta 2 agonists?
What should you do if there is no response to LABA?
Stop using it and consider 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 - interacts with many drugs
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 oral 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 are other steroid sparing drugs?
What are the non-pharmacological methods of asthma management?
Patient education and self-management plans
Inhaler technique
Smoking cessation
Vaccinations (flu/pneumococcal)
Allergen avoidance - removal needed if occupational asthma
Bronchial thermoplasty - heating parts of the airway with a heater probe
What is defined as moderate asthma?
What is defined as acute severe asthma?
What is defined as life-threatening asthma?
What is defined 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?
What is 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))
