Module 2.1.2 (Asthma Management) Flashcards
What are the key features of asthma?
Asthma is a chronic inflammatory disorder involving the airways
Inflammation results in asthma symptoms:
- Wheezing
- Breathlessness
- Chest tightening
- Coughing
- Airways hyper-responsiveness
Symptoms are often worse at night or early in the morning
Airway obstruction is usually reversible
What are the symptoms of asthma in an acute attack?
- Acute attack – a sudden worsening of symptoms
- Severe wheezing when breathing in and out
- Coughing that won’t stop
- Very rapid breathing
- Chest tightness or pressure
- Tightened neck and chest muscles (retractions)
- Difficulty talking
- Feelings of anxiety or panic
- Pale, sweaty face
- Blue lips of fingernails (cyanosis)
- Confusion, lethargy, loss of consciousness
- Worsening symptoms despite medication use
What are some risk factors for developing asthma?
- Genetics
- Allergic rhinitis
- Use of broad-spectrum antibiotics
- Use of paracetamol during pregnancy and infancy
- Some childhood infections
- Exposure to cigarette smoke and maternal smoking during pregnancy
- Delivery by caesarean section
Factors associated with reduced risk of developing asthma?
- Breastfeeding and diet
- Consumption of unpasteurised cow’s milk
- Exposure to farm environments and contact with farm animals
- Diets rich in oily fish
- Childhood viral and bacterial infections
- Regular long-term low dose aspirin use by adults
Provide examples of triggers in these different sub-categories for asthma;
A) Allergic
B) Non-allergic
C) Certain drugs
D) Some foods/wine
A)
- Dust mites, moulds, pollens, animals
B)
- Respiratory tract infection
- Exercise-induced bronchoconstriction
- Cold air
- Irritants such as tobacco smoke, air pollutants, and occupational dusts, gases, and chemicals
- Air temperature changes
- Stress and anxiety
C)
- Certain drugs such as aspirin
- see attached image
D)
- Some foods/wines (also low incidence)
For asthma diagnosis in children;
A) Is there a reliable test for diagnosis
B) Are spirometry tests problematic in children under 7 years of age?
C) Why is it difficult to diagnose children aged 0 to 5 years?
D) How should a diagnosis NOT be made?
A)
No single reliable test for diagnosis
> No standardised diagnostic criteria for asthma
B)
- Yes
C)
- Wheezing and cough are common in children under 3 years
- Spirometry is not feasible to use
- Many will respond to bronchodilator treatment but will not go on to have asthma later in childhood
D)
- A diagnosis of asthma should not be made if cough is the only or predominant respiratory symptom and there are no signs of airflow limitation.(e.g. wheeze, breathlessness)
What is the definition of childhood wheeze?
A continuous musical, high pitched sound heard emanating from the chest during expiration
- It is not possible to predict whether children with a wheeze will go on to have asthma
True or false: After pre-school age, most children with recurrent wheeze are likely to have asthma.
What factors make asthma diagnosis more likely in children?
True
asthma diagnosis more likely if symptoms are:
- Recurrent or seasonal
- Worse at night or early in the morning
- Triggered by viral infections, exercise, irritants/allergens, cold air
- Rapidly relieved by short-acting bronchodilator
- Family history of asthma
- Family history of allergies (atopic profile)
What is the diagnosis of asthma in adults based on? Is there a reliable test and standard diagnostic criteria?
- History
- Physical examination
- Considering alternate diagnoses
- Documenting variable airflow limitation
> No single reliable test & no standard diagnostic criteria
What are the clinical features that increase the probability of asthma? Provide at least FIVE reasons.
More than one of the following symptoms
- Wheeze, breathlessness, chest tightness, cough—particularly if these:
> Are worse at night and in the early morning
> Occur in response to exercise, allergen exposure or cold air
> Occur after taking aspirin or beta blockers
- History of atopic disorder, e.g. allergic rhinitis, atopic dermatitis
- Family history of asthma and/or atopic disorder
- Widespread wheeze heard on auscultation of the chest
- Otherwise unexplained low FEV1 or PEF (historical or serial readings)
- Otherwise unexplained peripheral blood eosinophilia
What are the clinical features that LOWER the probability of asthma? Provide at least FIVE reasons.
- Prominent dizziness, light-headedness, peripheral tingling
- Chronic productive cough in the absence of wheeze or breathlessness
- Repeatedly normal physical examination of chest when symptomatic
- Voice disturbance
- Symptoms with colds only
- Significant smoking history (more than 20 pack years)
- Cardiac disease
- Normal spirometry or PEF when symptomatic
What are some alternate diagnoses to asthma?
- Vocal cord dysfunction
- Bronchitis
- Foreign bodies
- Congestive cardiac failure
- Gastro-oesophageal reflux
- COPD
- Chronic sinusitis
- Pulmonary embolism
For spirometry;
A) What does it measure?
B) What measurements are obtained from spirometry?
C) What is peak expiratory flow (PEF)?
D) What are the 3 main patterns it shows?
A)
- Spirometry measures how much air you can breathe in and out
- It also measures how fast you can blow air
B)
- Forced vital capacity (FVC) = total amount of air exhaled during the FEV test
- Forced expiratory volume in 1 second (FEV1) = FEV1 is the volume of air that can forcibly be blown out in the first 1 second, after full inspiration
- (FEV1/FVC) is the ratio of FEV1 to FVC expressed as a percentage
C)
- Peak expiratory flow (PEF) is the maximal expiratory flow rate
D)
- Normal
- An obstructive pattern
- A restrictive pattern
For reversibility testing;
A) What should the FEV1 reading be 10-15 minutes post bronchodilator
B) At least ….% change in FEV1 with repeated measurement over time
C) What should the FEV1 reading be after exercise
D) What should the FEV1 be reading after a trial of 4 or more weeks with an ICS
E) Peak flow of diurnal variability (fluctuations during the day) of >… %
F) What should the decrease in lung function be during a laboratory test for airway hyper-responsiveness
A)
- Increase in FEV1 of at least 200ml and 12% from baseline 10-15 minutes post bronchodilator
B)
- 20%
C)
- A decrease in FEV1 of at least 200ml and 12% after exercise
D)
- Increase in FEV1 of at least 200ml and 12% from baseline after trial of 4 or more weeks with an inhaled corticosteroid
E)
- > 10%
F)
- 15-20% decrease in lung function depending upon the test
Who writes asthma action plans? What benefits does it provide?
GPs develop and write plans - other health care professionals review and reinforce plans
Benefits
- Increase in asthma control
- Decrease in exacerbations
- A decrease in hospitalisation, ED visits, emergency GP visits
- Decrease in days off work or school
What are the goals of treatment?
- Achieve and maintain symptom control
- Maintain activity level
- Maintain lung function
- Prevent exacerbations
- Avoid adverse effects
- Prevent mortality
The variability of asthma requires ongoing clinical monitoring and treatment should be adjusted accordingly
Provide the answer to the following situations for the initial treatment of adults in asthma;
A) Symptoms less than twice per month and no flare-up in previous 12 months
B) Newly diagnosed asthma with mild symptoms occurring twice per month or more often
C) Patient who has woken due to asthma symptoms at least once during the last month
D) Patient with infrequent symptoms (on average < 2x per month) who has required oral corticosteroids due to flare up within last 2 years
E) Patient who has ever received artificial ventilation or been admitted to intensive care due to acute asthma
F) Patient with newly diagnosed asthma whose symptoms are severely uncontrolled or very troublesome
A)
- SABA as needed
B)
- Regular ICS starting at low dose plus SABA as needed
C)
- Regular ICS starting at low dose plus SABA as needed
- If frequent daytime symptoms consider medium to high dose ICS plus SABA as needed OR combination ICS/LABA
D)
- Regular ICS starting at low dose plus SABA as needed
E)
- Regular ICS starting at a low dose plus SABA as needed
- Frequent monitoring required
F)
- Regular ICS plus SABA as needed
- For very uncontrolled asthma at presentation (i.e. frequent night waking, low lung function) consider high dose ICS (then titrate down when symptoms improve) or short course of oral corticosteroids in addition to ICS.
Provide the answer to the following situations for selecting and adjusting medications in asthma;
A) Newly diagnosed asthma
B) Good recent asthma symptom control
C) Partial recent asthma symptom control
D) Poor recent asthma symptoms control
E) Difficult to treat asthma
F) Patients with risk factors
A)
- Consider low dose ICS plus SABA as needed
- If symptoms severe at initial presentation consider:
> Short-course oral corticosteroid (plus ICS) OR Short initial period of high dose ICS then step down OR Combination ICS/LABA
B)
- If maintained for 2 to 3 months, no flare up in previous 12 months and low risk for flare-ups step down where possible
C)
- Review inhaler technique and adherence – correct if suboptimal
- If no improvement, consider increasing treatment by one step and reviewing (if still no improvement, return to the previous step, review diagnosis, and consider referral)
D)
- Review inhaler technique and adherence – correct if suboptimal
- Confirm that symptoms are due to asthma
- Consider increasing treatment until good asthma control is achieved then step down again where possible.
E)
- Consider referral for assessment or add-on options
F)
- Tailor treatment to reduce individual risk
Provide the answer to the following situations for the initial treatment for children >6years;
A) Infrequent intermittent asthma
B) Frequent intermittent asthma
C) Mild persistent asthma
D) Moderate to severe persistent asthma
A)
- Regular preventer treatment NOT recommended
B)
- Consider a treatment trial with montelukast 5mg once daily, assess response after 2 to 4 weeks (NB a cromone can be trialled as an alternative)
C)
- Consider a treatment trial with montelukast 5mg once daily, assess response after 2 to 4 weeks
- If inadequate response after checking adherence consider treatment trial with inhaled corticosteroid (NB a cromone can be trialled as an alternative)
D)
- Consider a treatment trial with regular inhaled corticosteroid (low dose); assess response after 4 weeks
Divide good control, partial control, and poor control of asthma in CHILDREN in 3 different sections
see attached image
stepped approach to adjusting asthma medication in children
see attached image
