Notes Flashcards
What is asthma
Chronic respiratory condition associated with airway inflammation and hyper-responsiveness
Is asthma irreversible or reversible
Reversible
What are the 4 physiological changes associated with asthma
- Bronchoconstriction
- Bronchial hyperreactivity
- Mucosal oedema
- Excess mucus production
Chronic asthma can lead to…
Airway remodelling
What are some of the medicinal triggers of asthma
NSAIDs
Non selective beta blockers - propanolol, labetalol, timolol
X ray constrast material
What are some environmental triggers of asthma
Dust mites
Dander
Animal fur, urine and salvia
Cockroaches
Sudden changes in temperature
Pollen
Mould
What are some dietary triggers of asthma
Food additives
Frozen food
Dairy, eggs, nuts, chocolate
What are some of the causes of asthma
• Ethnicity
• Genetic predisposition
• Women
• Airway hypersensitivity
• Age = puberty
• Allergens
• Obesity
• Pollutants/ tobacco
• Low birth weight
• Occupation
• Diet
• Emotions
• Infections
• Premature
What are the diagnostic criteria for asthma
Peak flow [PEF]:
Spirometry [FEV1/FVC]:
FeNO:
+3
Chest examination and auscultation
History of atopic disorders -eczema and hay fever
Widespread wheeze
Peak flow [PEF]: more than 20%
Spirometry[FEV1/FVC]: less than 80%
FeNO: over 40 ppb
What can be done to find out if there are any complications from asthma
X ray
What is normal oxygen saturation
95-100%
In what age group can asthma not be diagnosed and why
Under 5 years old
Due to the frequency of bronchitis and the development of the immune system
Medical records should say ‘suspected asthma’
Which type of asthma is inflammatory
Eosinophillic
Which type of asthma is allergic to
Extrinsic
Which type of asthma is non-allergic
Intrinsic
What are the 7 risks and complications of asthma
Pneumonia
Pulmonary failure
Respiratory failure
Fatigue
Underperformance in school
Time off work
Death
What are the 6 aims of managing asthma
No daytime symptoms
No night waking
No need for rescue medication
No exacerbations
No limitations on activity
Normal lung function
4 Non pharmacological management of asthma
Weight loss
Smoking cessation
Exercise
Decrease allergens by vaccuming, ventilation, air filtration and ionisers
What drug classes are bronchodilators
4
SABA - salbutamol, tertubaline
LABA- Formoterol, salmeterol
Xanthines - theophylline
Antimuscarinics - Tiotropium
What 4 drug classes are anti inflammatories and so are used as preventers
Leukotriene antagonist - montelukast
Corticosteroids - prednisolone
Mast cell stabiliser - sodium cromoglicate
Monoclonal antibodies- -lizumab
What active ingredient is in pulmicort
Budesonide
What active ingredient is in Alvesco
Ciclesonide
What active ingredient is in Fixotide
Fluticasone
What active ingredient is in Asmanex twisthaler
Mometasone
What is MART therapy
Maintenance and reliever therapy
Containing a LABA/ICS
Fostair and Seretide is MART therapy, what are their active ingredients
Fostair - Beclometasone and Formoterol
Seretide - Fluticasone and Salmeterol
Which drug class is not recommended as standalone therapy and why
LABA
They are linked to increased asthma deaths and serious ADE
Which drug class activates b2 adrenoceptors in the lungs result in smooth muscle relaxation of bronchial smooth muscle
SABA and LABA
Which drug class blocks M3 receptors on smooth muscles cells of the bronchi and blocks muscarinic cholinergic receptors resulting in a decrease in formation of cGMP leading to decreased contractibility of smooth muscle
SAMA and LAMA
Which drug class is cautioned in cardiac patients
SAMA and LAMA
Which drug class is immunosuppressive
Glucocorticoids/ corticosteroids
Which drug class increases the risk of pneumonia in COPD
Glucocorticoids/ corticosteroids
What is triple therapy and give an example
Triple therapy is an inhaler that contains Beclometasone, Formoterol and glycopyrronium [ICS/LABA/LAMA] combined
What are the side effects of prolonged use of corticosteroids
Crushing syndrome
Osteoporosis
Retradation of growth
Thinning of skin
Immunosuppression
Cataracts and glaucoma
Oedema
Suppression of hypothalamic pituitary axis
Teratogenic
Emotional disturbances - depression, irritability, anxiety
Raised BP and heart failure
Obesity
Increased body hair growth (hirstuism)
Diabetes mellittus
Striae (red/purple stretch marks)/ Stomach ulcers
How can thrush be minimised when on steroids
Rinse the mouth after inhaler use
Use a spacer
How can indigestion/peptic ulcers be minimised when on steroids
Take tablets with breakfast or milk
How can cataracts be minimised when on steroids
Apply a good seal around the mouthpiece of inhaler or mask
Use the lowest effective
How can osteoporosis be minimised when on steroids
Take calcium supplements
How can adrenal suppression be minimised when on steroids
Use lowest effective dose
Give steroid card
How can crushing syndrome be minimised when on steroids
Use lowest effective dose
Give steroid card
Name the 7 drug groups that interact with prednisolone
Anticonvulsants
Antidiabetics
Antihypertensives
Diuretics
Vaccines
Anticoagulants
Cyclosporin
How does prednisolone interact with anticonvulsants
Anticonvulsants decrease the effects of steroids
How does prednisolone interact with antidiabetics
Prednisolone decreases the hypoglycaemic effect of antidiabetics
How does prednisolone interact with antihypertensives
Prednisolone decreases hypotensive effect of antihypertensives
How does prednisolone interact with diuretics
Prednisolone reduces diuretic effect
How does prednisolone interact with vaccines
Prednisolone decrease immune response
How does prednisolone interact with anticoagulants
Prednisolone increases the activity of anticoagulants
How does prednisolone interact with Cyclosporin
Cyclosporin increases the steroid effect of prednisolone
What drug is used for asthma and seasonal allergic rhinitis
Montelukast
Which drug class blocks cytLT1 receptor for leukotriene c4, d4, and e4
Leukotriene receptor antagonists
Drug class useful for people with atopic disorders
LTRA - montelukast
What drug/drug class is an adenosine receptor antagonist that inhibits phosphodiesterase which raises cAMP levels leading to the relaxation of smooth muscle of bronchial airways
Xanthines - Theophylline
Toxicity is a risk with which drug class
Xanthines - theophylline
Which drug interacts with alcohol and smoking
Theophylline
How does theophylline interact with alcohol and cigarettes
Alcohol and cigarettes increase the clearance of theophylline
What are the symptoms of an acute exacerbation [8]
Hunched forward and breathless at rest
Speaks in words not sentences due to exhaustion
Cyanosis, agitation, confusion, drowsiness
Tachypnea
Tachycardia
High pitched wheeze
PEFR [Peak flow] : below 33%
Oxygen saturation : less than 92%
What is the clinical presentations of an acute exacerbation
Tachypnea
Tachycardia
Peak flow (PEFR)
Oxygen saturation
Respiratory rate = more than 25 [normal 14-17]
Heart rate = more than 110/ min
Peak flow = less than 33%
Oxygen saturation = less than 92%
What is the 3 treatments of acute exacerbation of asthma
Nebulised salbutamol(2.5 or 5mg) or ipratropium
If not in a medical facility: Inhaled high dose bolus of SABA - 10 puffs via spacer with 30-60 seconds between each and call ambulance
In primary care :40mg of prednisolone stat then 40-50mg od for 5 days
What is difficult asthma
Asthma requires high dose treatment to control symptoms
What is severe asthma
Asthma where symptoms are hard to control even with high doses of medication that is diagnosed and treated by specialists
What is eosinophilic asthma
Asthma caused by high levels of eosinophils in the airways causing inflammation
What is eosinophilic asthma treated with
Biological therapy
What causes eosinophilic asthma
Type 2 inflammation [linked to cytokines]
What is the referral criteria for severe/difficult asthma [4]
No response to medium or High dose ICS plus LABA/other controllers
History of exacerbations in the previous year
High blood eosinophil counts
High FeNO levels
IMPORTANT AS THESE INCREASE THE RISK OF SEVERE EXACERBATIONS
How is biological therapy given out and why
It’s reserved and given to patients that meet the criteria as it is expensive
What 7 things need to be looked at before referring a patient for severe/difficult asthma
Include figures for blood eosinophils, FeNO, sputum eosinophil
Inhaler technique
Poor adherence
If they’re on high dose ICS
Blood eosinophils above 1.5
FeNO is more than 20ppb
Sputum eosinophil more than 2
Asthma is clinically allergen driven
1st line Treatment for severe/ difficult asthma
And counselling
High dose prednisolone with a LABA
- Use the lowest effective dose for short term use
- If repeated exacerbations and on frequent low dose oral corticosteroids they need to carry a steroid card as its considered as high dose
2nd line for severe/difficult asthma
Trial of montelukast , stop if its not helpful after a few weeks
3rd line of severe/difficult asthma
Add a LAMA [Tiotropium]
to high dose prednisolone with LABA and montelaukast (if effective)
4th line treatment for severe/difficult asthma
Trial of theophylline by a specialist
5th line treatment for severe/difficult asthma
Biological treatment
What is the mechanism of action of Biologic therapy
Target key cells and mediators that drive inflammatory responses in the lungs and blocks specific inflammatory pathways
What’s good about biologic therapy
Long duration of action so require infrequent doses
It is well tolerated with side effects
What’s an example of Biologic therapy
Omalizumab
-lizumab
How frequently are biologic therapy given
Every 2-4 weeks
What are the 7 pieces of information need to be taken from a patient before referral if severe asthma is suspected
Current and previous medication history
Any exacerbations in the last 12 months
FeNO test results
Full blood count - eosinophils and neutrophils
Allergy history
Inhaler technique
Modifiable risk factors such as smoking, weight, alcohol, exercise
Asthma is older patients is …
Usually late onset asthma that is diagnosed as a child then is dormant then reactivates
In older patients who is asthma most common in
Women around menopause
Why is asthma harder to diagnose in older adults
Symptoms are different and there is an assumption by healthcare professionals that it is COPD
TRUE OR FALSE : Late onset asthma is harder to control so add on treatments like LTRA and LABA are needed for extra support
TRUE
What 5 things need to be considered in managing asthma in older patients
Interactions
Co-morbidities
Inhaler technique And ability to
Fraility
Obstructive sleep apnoea
How does reduced fitness and weight gain/loss affect management of asthma in older patients
Reduced fitness and weight loss/gain is more prevalent with age.
Being less mobile results in weight gain and increasing symptoms
These are modifiable risk factors so can be changed
What age group is ‘younger patients’ when considering asthma
0– 11 years [under 12]
When taking a structured clinical history of a child with suspected asthma [5]
Involve the child
Symptoms and when during the day
Any triggers
Personal or family history of asthma or allergic rhinitis
Any symptoms that suggest alternative diagnosis
What objective tests should be done in younger patients with suspected asthma
Chest examination
Oxygen saturation
Blood eosinophils
FeNO test
What is the order of objective tests for diagnosing asthma in children aged 5-16 with a history suggesting asthma
- FeNO
- Bronchodilator reversibility with spirometry
- Peak flow
- Skin prick test / total IgE and blood eosinophils
Why is diagnosis difficult in younger patients
There is no good reference standards and its difficult to do tests
A child with suspected asthma that is 4 years old needs medication, what do you give
If under 5 yrs, give ICS and review regularly
If symptoms are still there when they reach 5 then do objective tests
If objective tests at 5 are unable then try again every 6-12 months
What age are most inhalers licensed for
Over 12
So any inhaler prescribed under 12 =off label prescribing
What should be given to a child aged 5-11yrs who is not controlled on paediatric low-dose-ICS plus SABA as needed
Consider paediatric low-dose MART if they have the ability to manage MART regimen
What formulation of MART should be given in children aged 5-11
Dry powder inhaler
Example of paediatric low dose MART
100mg of Beclometasone, budesonide and fluticasone with 6mg of Formoterol
E.g. symbicort 100/6 turbohaler 1 puff bd [budesonide/formoterol]
Example of paediatric moderate dose MART
Beclometasone[standard particle] and budesonide - 300-400mcg /day
Beclometasone[fine particles] and fluticasone - 150-200mcg/day
What do you give to an child on twice daily paediatric low dose ICS plus SABA who’s asthma is uncontrolled and cannot manage the MART regimen
LTRA trial for 8-12 weeks
Dose of montelukast for under 5 years
4mg od in the evening
Dose of montelukast for child aged 6-14 years
5mg od at night
Dose of montelukast for child aged 15 -17 years
10mg od in the evening
When do you refer a child with asthma to a specialist
Asthma is uncontrolled on paediatric moderate dose MART or paediatric moderate dose ICS/LABA
What key considerations need to taken into account when assessing, managing and treating asthma in adolescents
- Smoking and vaping = they need to stop
- Hormonal changes =oestrogen
- Future career choices = highlight occupations that increase susceptibility to work-related asthma symptoms
- School and social situations = consider factors that affect inhaler use in real life such as embarrassment
How do you monitor asthma control in children [5]
Use validated questionaire
E.g. asthma control test or the childhood asthma control test
Ask additional about :
Time off school due to asthma
Amount the reliever is used
Number of courses of oral corticosteriods
Any admissions or attendance to hospital or A&E
