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competency 10/11 > respi: asthma > Flashcards

respi: asthma Flashcards

1
Q

low, med, high ICS doses: beclometasone diproprionate, standard particles

A

Beclo-asma
low: 200-500
med: 500-1000
high: >1000

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2
Q

low, med, high ICS doses: beclomethasone dipropionate, extrafine

A

Beclomet easyhaler
low: 100-200
med: 200-400
high: >400

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3
Q

low, med, high ICS doses: budesonide

A

Symbicort, Pulmicort
low: 200-400
med: 400-800
high: >800

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4
Q

low, med, high ICS doses: fluticasone fuorate

A

Relvar Ellipta
low, med: 100
high: 200

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5
Q

low, med, high ICS doses: fluticasone proprionate

A

Flixotide, Flutiform
low: 100-250
med: 250-500
high: >5001

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6
Q

asthma is characterised by

A

chronic airway inflammation

defined by a history of respiratory symptoms:
- wheeze
- sob
- chest tightness
- cough

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7
Q

pathophysiology of asthma

A

reduction in airway diameter due to contraction of smooth muscle, vascular congestion, thick secretions
> increased airway resistance, hyperinflation of lungs and increased work of breathing

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8
Q

histologic changes in asthma

A
  • hypertrophy or airway smooth muscle
  • increased airway wall thickness and edema
  • mucous gland hypertophy and hypersecretion
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9
Q

classic triad of chronic asthma

A

dyspnea, wheezing, cough

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10
Q

exercise-induced bronchoconstriction

A

acute airway narrowing that occurs as a result of exercise
- occurs in pt w or without asthma
- defined as a >= 10% decrease in FEV1 from pre-exercise value

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11
Q

frequent sob, cough, wheezing symptoms but normal FEV1

A

cardiac disease? lack of fitness?

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12
Q

few sob, cough, wheezing symptoms but low FEV1

A

poor perception? restriction of lifestyle?

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13
Q

low ___ is an independent predictor of exacerbation risk

A

FEV1

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14
Q

FEV1

A

volume of air exhaled forcefully in the first second of maximal expiration

normal: >= 80%

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15
Q

FVC

A

maximum volume of air that can be exhaled after full inspiration

reported in liters and % predicted
- normal adults can empty 80% of air in < 6 seconds

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16
Q

FEV1/FVC

A

differentiates between obstructive and restrictive disease

normal: within 5% of predicted range, which varies with age, usually 75-80% in adults

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17
Q

in asthma, reversibility is shown by

A

an increase in FEV1 of >= 12% after SABA

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18
Q

FEV1/FVC is ______ in obstructive disease (asthma, copd)

A

decreased, < 75%

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19
Q

risk factors for poor asthma control

A
  • uncontrolled asthma sx
  • high SABA use (>= 3 canisters/year)
  • having >= 1 exacerbation in the last 12 months
  • low FEV1, higher bronchodilator reversibility
  • incorrect inhaler technique and/or poor adherence
  • smoking
  • obesity, chronic rhinosinusitis, pregnancy, blood eosinophilia
  • ever intubated for asthma
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20
Q

risk factors for fixed airflow limitation include

A
  • no ICS treatment
  • smoking
  • occupational exposure
  • mucus hypersecretion
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21
Q

categories of asthma severity: mild

A

well-controlled with steps 1 or 2

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22
Q

categories of asthma severity: moderate

A

well-controlled with step 3

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23
Q

categories of asthma severity: severe

A

requires step 4/5 or remains uncontrolled despite this treatmetn

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24
Q

medications that may worsen asthma

A

NSAID, BB

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25
Q

non-pharmacological interventions

A
  • avoidance of tobacco smoke exposure
  • physical activity
  • occupational asthma
  • avoid medications that may worsen asthma
  • remediation of dampness or mould in homes
  • sublingual immunotherapy
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26
Q

higher use of SABA is associated with

A

adverse clinical outcomes
- patients with apparently mild asthma are at risk of serious adverse events (do not see the need for additional treatment due to the rapid relief of sx)

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27
Q

formoterol

A

selective beta2-adrenergic agonist that produces relaxation of bronchial smooth
muscle in patients with reversible airways obstruction.
- bronchodilating effect sets in rapidly,
within 1-3 minutes after inhalation, and has a duration of 12 hours after a single dose.

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28
Q

Acute overdose with budesonide, even in excessive doses, is not expected to be
a clinical problem. When used chronically in

A

excessive doses, systemic
glucocorticosteroid effects, such as hypercorticism and adrenal suppression,
may appear.

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29
Q

after starting treatment, patients should preferably be seen

A

1-3 months
then 3-12 months after that
in pregnancy, must be reviewed every 4-6 weeks
after an exacerbation, review visit within 1 week

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30
Q

step 1

A

sx less than twice a month
- track 1: PRN low-dose ICS-formoterol
- track 2: take ICS whenever SABA taken, PRN ICS-SABA or SABA

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31
Q

step 2

A

sx more than twice a month but less than 4-5 days a week
- track 1: PRN low-dose ICS-formoterol
- track 2: low-dose maintenance ICS, PRN ICS-SABA or SABA

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32
Q

step 3

A

sx most days, or waking with asthma once a week or more
- track 1: low-dose maintenance ICS-formoterol, PRN low-dose ICS-formoterol
- track 2: low-dose maintenance ICS-LABA, PRN ICS-SABA or SABA

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33
Q

step 4

A

daily sx or waking with asthma once a week or more and low lung function
- track 1: medium-dose maintenance ICS-formoterol, PRN low-dose ICS-formoterol
- track 2: medium/high dose ICS-LABA, PRN ICS-SABA or SABA

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34
Q

step 5

A

refer to phenotypic assessment +/- biologic therapy
- add on LAMA
- consider high-dose ICS/formoterol or ICS-LABA

PRN ICS-formoterol or other ICS-SABA or SABA

35
Q

exercise-induced bronchoconstriction

A

acute airway narrowing that occurs as a result of exercise
- occurs in pt with or wo asthma
- defined as a >= 10% decr in FEV1 from pre-exercise value

36
Q

treatment of exercise-induced bronchoconstriction

A
  • SABA, 15mins before exercise
  • for pt w sx despite SABA before exercise, long-term use of ICS may improve underlying disease which may decrease the frequency of EIB
  • alt: LTRA (approx 2hr before exercise or once every 24hrs) or mast-cell stabilisers
  • stop the activity, usually resolves in 20-30mins
37
Q

________ dose ICS provides most of the clinical benefit of ICS for most patients with asthma

A

low

38
Q

stepping up asthma treatment: sustained step-up

A

for at least 2-3 months
- important: first check for common causes (sx not due to asthma, incorrect inhaler technique, poor adherance)

39
Q

stepping up asthma treatment: short-term step up

A

for 1-2 weeks eg. with viral infection or allergen
- may be initiated by patient with written asthma action plan

40
Q

stepping up asthma treatment: day-to-day adjustment

A

for patients prescribed low-dose ICS-formoterol MART
- approved only for PRN low-dose beclo/bude-formoterol

41
Q

stepping down asthma treatment

A

consider after good control maintained for 3 months
- find each patient’s minimum effective dose that controls symptoms and minimises risk of exacerbations
- reduce the ICS dose by 25-50% at intervals of 2-3 months

42
Q

is it recommended to stop ICS completely?

A

no! risk of exacerbations

43
Q

acute asthma exacerbation

A

flare-up, acute or sub-acute worsening of symptoms and lung function compared with the patient’s usual status

44
Q

patients at risk of asthma-related death

A
  • any history of near-fatal asthma requiring intubation and ventilation
  • hospitalisation or emergency care for asthma in the last 12 months
  • not currently using ICS, or poor adherance with ICS
  • currently using or recently stopped using OCS
  • overuse of SABAs, especially if more than 1 canister per month
  • lack or written asthma action plan
  • history of psychiatric disease or psychosocial problems
  • confirmed food allergy in a patient w asthma
45
Q

magnesium sulfate: place in therapy

A

not for routine use, may have a role in patients with moderate-severe asthma who fail to respond to B-agonists +/- systemic steroids
- adult: 1.2-2g IV infusion over 20-30mins
- children: 25-100mg/kg

46
Q

written asthma action plans should include

A
  • pt’s usual asthma meds
  • when/how to incr reliever/controller or start OCS
  • how to access medical care if sx fail to respond
47
Q

add OCS if needed, dose?

A

prednisolone 1mg/kg/day, up to 50mg, usually 5-7 days

48
Q

tapering of OCS dose is needed if taken

A

for less than 2 weeks

49
Q

common OCS side effects

A

sleep disturbance, incr appetite, reflux, mood changes

50
Q

SABA moa

A

rapidly relax bronchial smooth muscle from the trachea to the bronchioles through action on the b2-receptors

51
Q

SABA adr

A

palpitations, tachycardia, tremor, headache

52
Q

SABA

A

salbutamol, terbutaline

53
Q

LABA

A

salmeterol, formoterol, bambuterol

54
Q

LABA: place in therapy

A

recommended only in combi with inhaled steroid
- data showing incr risk of asthma-related deaths and life-threatening events when used as monotherapy
- use of LABA alone without long-term asthma control meds such as ICS is c/i

55
Q

inhaled corticosteroids moa

A
  • reduce the initial inflammatory response by decreasing the formation and release of many inflammatory mediators such as histamine, leukotrienes and cytokines
  • reduce vasoconstriction and subsequent serum production, swelling and discomfort
  • produce an immunosuppressive state that limits the body’s hypersensitivity reaction, which in turn may limit bronchospasm and other associated sx

BUT do not cure asthma!

56
Q

fluticasone 2butx vs

A

budesonide and beclomethasone

57
Q

relief of sx with use of ICS

A

1-2 weeks
max effects seen in 4-8 weeks

58
Q

relief of sx with use of IV/oral corticosteroids

A

4-6 hours in acute exacerbations

59
Q

oral pred dose

A

acute: 0.5-2mg/kg/d (adults = 30-40mg/d)
chronic: 5-10mg/d (step 5)

60
Q

methylprednisolone/hydrocortisone dose

A

40-125mg q6h

61
Q

systemic corticosteroids adr

A

osteoporosis, htn, diabetes, hpa axis suppression, obesity, cataracts, glaucoma, skin thinning, cutaneous striae, easy bruising, muscle weakness

62
Q

ICS adr

A

local - cough, dysphonia, oral thrush

63
Q

LABA as an add-on therapy to ICS

A
  • relaxing bronchial smooth muscle
  • inhibit the release of hypersensitivity mediators from mast cells for up to 12hrs through action on the b2 receptors
64
Q

Seretide

A

salmeterol + fluticasone

65
Q

Symbicort

A

formoterol + budesonide

66
Q

Dulera, Zenhale

A

formoterol + mometasone

67
Q

Flutiform

A

formoterol + fluticasone

68
Q

Foster

A

formoterol + beclometasone

69
Q

Relvar

A

vilanterol + fluticasone

70
Q

tiotropium: place in therapy

A

LAMA - induces bronchodilation via inhibition of the muscarinic receptor on airway smooth muscle
- adjunctive therapy in pt on ICS+LABA
- step 4 or 5 and still uncontrolled

71
Q

tiotropium dose

A

2.5mcg OD (respimat)

72
Q

tiotropium adr

A

bronchitis, cough, pharyngitis, sinusitis

73
Q

mast-cell stabilisers (chromones)

A

cromolyn sodium < nedocromil
- stabilise membranes of mast cells and inhibit release of mediators of inflammation
- max clinical effect after 2-6 weeks

no longer recommended for routine use as monotherapy, not as effective as inhaled steroids

alt for exercise-induced asthma

nausea, headache, diarrhea
nedocromil has an unpleasant taste

74
Q

leukotriene modifiers moa

A
  • interfere with the pathway that allows mast cells, eosinophils and basophils to release leukotriene mediators that participate in the slow phase reaction of anaphylaxis
  • reduce sx associated with the inflammatory allergic component of asthma, including swelling of the airway and smooth muscle constriction
75
Q

LTRA

A

montelukast
- adults: 10mg on
- children > 6yo: 5mg on
- children 2-5yo: 4mg on

76
Q

LTRA ddi

A

warfarin, phenytoin, carbamazepine
- metabolised by cyp450 enzymes

77
Q

LTRA adr

A

headache, nausea, neuropsychiatric events (based on post-marketing reports: agitation, depression, suicidal behaviour, insomnia, restlessness)

78
Q

theophylline serum conc monitoring

A

therapeutic range: 5-20mg/L

79
Q

theophylline adr

A

gi: n/v
cardiac: tachycardia, arrhythmias
cns: insomnia, headache, seizures

80
Q

theophylline moa

A

multifactorial:
- induces sm relaxation
- resulting in bronchodilation
- inhibiting the body’s reaction to external allergic stimuli

81
Q

omalizumab

A

recombinant monoclonal antibody against lgE
- binds free lgE and prevents binding of lgE to receptors on mast cells and basophils

approved for treatment of adults and children >12yo with severe allergic asthma who are not controlled by high-dose ICS-LABA (step 5)

82
Q

IL-5 receptor antagonists

A

monoclonal antibodies that bind to the IL-5 receptor on the surface of eosinophils and basophils
> lessen the inflammatory response to allergic triggers
- severe persistent asthma as adjunctive maintenance therapy for >12yo who have an eosinophilic phenotype
- benralizumab, mepolizumab, reslizumab

83
Q

IL-4 receptor antagonists

A

binds to IL-4 receptor alpha, blocking both IL-4 and IL-13 signalling
- dupilumab

84
Q
A

competency 10/11 (31 decks)

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