non acute management of asthma

Question 1

How do we test for asthma>

Answer 1

You don’t really
Spirometry, peak flow monitoring & allergy testing are often done but not reliable/definitive

Trial for 2 monhts with low dose ICS –> Gets better = asthma

Question 2

What is needed to diagnose Asthma?

Answer 2

Chronic
Episodes of wheeze, cough & SOB at rest
Variable/Reversible
Responds to asthma meds

It can help to look for a h/o or FH/o asthma & atopic conditions e.g. hayfever, eczema or food allergy

Question 3

What is the summary of asthma treatment in under 5s?

Answer 3

1) SABA (salbutamol)
2) Add a LTRA (oral montelukast)
3) Add Inhaled LABA
5) Dose adjustments, theophylline & biologics

Question 4

What is the summary of asthma treatment in over 5s?

Answer 4

1) SABA (salbutamol)
2) Add Low Dose ICS
3) Add Inhaled LABA
4) Add LTRA (oral montelukast)
5) Dose adjustments, theophylline & biologics

Question 5

When do you go to step 2?

Answer 5

IF using the B2 agonists >2days/wk

If symptomatic >3x/wk

Or if Waking >1night/wk

Question 6

adverse affects of ICS?

what do they not cause?

Answer 6

Height suppression
Oral candidiasis
Adrenocortical suppression- Particularly with fluticasone

DO NOT CAUSE:
Hypertension
Cataracts

Question 7

Rulse for using a LABA?

Answer 7

Do not use without ICS

Use as fixed dose inhaler

Question 8

what LTRA is used?

Answer 8

Montelukast only

Question 9

What’s different about childhood to adult asthma treatment?

Answer 9

Kids have lower max ICS doses

Use LTRAs early in <5yrs

No LAMAs in kids

Question 10

What non-medical things actually help with asthma?

Answer 10

Stopping smoke exposure
Removing environmental triggers e.g. cat or dog

Diet, humidity, wt & hypoallergic duvets etc don’t help

Question 11

What mnemonic can you use to assess how well the child’s asthma is controlled

Answer 11

SANE:

• SABA /wk
• Absence from school/nursery
• Nocturnal symptoms /wk
• Exertional symptoms /wk

Question 12

What’s first line for treating asthma?

Answer 12

SABA as required e.g. salbutamol

Question 13

What’s second line for Asthma?

Answer 13

A low dose ICS or if <5yrs a LTRA (Montelukast)

Question 14

What’s third line for childhood asthma?

Answer 14

inhaled LABA or LTRA (low dose ICS in under 5s?)

Question 15

How do you deliver inhaled drugs in kids?

Answer 15

MDI Spacer- shake, wash and use a spacer!

Dry powder inhaler, only start using it properly when they’re about 8

Question 16

why are mdi with spacer so much more effective than just mdi?

Why you gotta shake?
why you gotta wash?

Answer 16

<5% lung deposition without spacer
≤20% lung deposition with spacer

4x MDI
Shake=2x no shake
Wash = 2 x no wash

Question 17

how much lung deposition in dry inhalers?

Answer 17

20% lung deposition

Question 18

use of nebuliser?

Answer 18

Rubbish.

don’t use a nebuliser day to day use

Question 19

Medical Therapy Aged Over 12 Years (Same as Adults)

Answer 19

1. Start a short-acting beta 2 agonist inhaler (e.g. salbutamol) as required
2. Add a regular low dose corticosteroid inhaler
3. Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
4. Titrate up the corticosteroid inhaler to a medium dose. Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral theophylline or an inhaled LAMA (i.e. tiotropium).
5. Titrate the inhaled corticosteroid up to a high dose. Combine additional treatments from step 4, including the option of an oral beta 2 agonist (i.e. oral salbutamol).

Refer to specialist.
Add oral steroids at the lowest dose possible to achieve good control under specialist guidance.