When to step up asthma treatment? If the inhaler fails and one of the below applies: 1. asthma attack more than (...) a WEEK 2. Waking up at (...) because of an asthma attack 3. Poorly controlled asthma with a (...) alone

1. asthma attack more than 3 times a WEEK 2. Waking up at night because of an asthma attack 3. Poorly controlled asthma with SABA alone

NICE asthma guidelines (\< 5y) If the inhaler fails and one of the below applies: 1. asthma attack _more than_ 3x a WEEK 2. Waking up at night because of an asthma attack 3. Poorly controlled asthma with SABA alone 4. using a (..) in a MONTH step-up treatment

Step 1 - NICE asthma guidelines (\<5y) If the inhaler fails and one of the below applies: 1. asthma attack more than (...) a WEEK 2. Waking up at (...) because of an asthma attack 3. Poorly controlled asthma with SABA alone 4. using a full inhaler in a MONTH (200 doses in 28 days) step-up treatment Note: 4 step up points for paeds different to those aged 5-16 and 17y+

Respiratory Flashcards by Robby A

What are the signs/symptoms of asthma?

cough, wheeze & chest tightness (with SOB)

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In the NICE adult treatment guidelines for asthma, “adults” are considered to be those aged (…) and over

aged 17 years and over

The KPOP boyband ‘seventeen’ sang a song called very nice

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In the BTS/SIGN adult treatment guidelines, “adults” are considered to be those aged (…) and over

aged 12 years and over

there are twelve zodiac signs

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What is MART (maintenance and reliever therapy)?

MART is a combination of a ICS + LABA in one inhaler

The LABA component is fast acting. F for Formoterol.

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Give TWO examples of a MART inhaler

MART inhalers: keep in the fridge

Fostair (Beclomethasone + F)
Symbicort (Budesonide + F)

F is the fast-acting LABA called Formoterol.

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Give an example of a leukotriene receptor antagonist (LTRA)

leuk = Monteleukast

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Give an example of a long-acting muscarinic receptor antagonist (LAMA)

U TAG

LAMA end with the letter M = Tiotropium**

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NICE guidelines for adults (17y+)

Step 1?

Examples?

SIM LABA MART INCREASE2 LAMAT

S = SABA prn

Examples: Salbutamol & Terbutaline

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When to step up asthma treatment?

If the inhaler fails and one of the below applies:

asthma attack more than (…) a WEEK
Waking up at (…) because of an asthma attack
Poorly controlled asthma with a (…) alone

asthma attack more than 3 times a WEEK
Waking up at night because of an asthma attack
Poorly controlled asthma with SABA alone

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NICE guidelines for adults (17y+)

Step 2?

Max doses?

SIM LABA MART INCREASE2 LAMAT

I = ICS (low-dose)

Max for low dose ICS in adults
Beclomethasone 500mcg daily
Budesonide 400mcg daily

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NICE guidelines for adults (17y+)

Step 3 (options)?

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Step 3 - add on options?

Using NICE asthma guidelines (17y and over)

Consider the following scenerio: 20y-old patient with asthma prescribed salbutamol, budesonide 400mcg, montelukast and Salmeterol; after a medication review their GP concludes that their asthma is not well controlled & the LTRA is NOT showing benefit anymore.

use MART inhaler (low dose ICS + LABA)

NB - MART @ any point can change to 2 separate inhalers as ICS dose slowly increases; Patient may still be on LTRA if it still shows some benefits.*
****

If this doesn’t help INCREASE2 = increase ICS dose to moderate then to high if needed

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What is next?

NICE asthma guidelines (17y +)

SABA
SABA + low ICS
SABA + low ICS + LTRA
SABA + low ICS + LABA +/- LTRA
SABA + low MART +/- LTRA
SABA + mod MART +/- LTRA
SABA + high MART +/- LTRA
(…)
Refer to specialist

SIM LABA MART INCREASE2 LAMAT

Add LAMA (Tiotropium) or Theophylline

NB - @ any point MART can be separated back to ICS and LABA.
NB - LTRA may be stopped on continued depending on if providing benefit

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NICE asthma guidelines (<5y)

The THREE main inhaler classes used are…

SIM = SABA, ICS, Montelukast

Notes say SIT but it is wrong should be SIM!*
Trial the ICS for 8 weeks. If improvement but an asthma attack occurs within a month of use re-initiate ICS but at a low dose for 8 weeks. If the same thing occurs again after stopping use a moderate dose for 8 weeks. If that fails, step-up treatment.*
Use Montelukast if the child cannot use ICS for any reason. Note Mometasone is not suitable for <5y olds.*

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NICE asthma guidelines (<5y)

Step 1 involves starting the child on a SABA inhaler to be delivered with the use of a (…)

spacer

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NICE asthma guidelines (< 5y)

If the inhaler fails and one of the below applies:

asthma attack more than 3x a WEEK
Waking up at night because of an asthma attack
Poorly controlled asthma with SABA alone
using a (..) in a MONTH

step-up treatment

Step 1 - NICE asthma guidelines (<5y)

If the inhaler fails and one of the below applies:

asthma attack more than (…) a WEEK
Waking up at (…) because of an asthma attack
Poorly controlled asthma with SABA alone
using a full inhaler in a MONTH (200 doses in 28 days)

step-up treatment

Note: 4 step up points for paeds different to those aged 5-16 and 17y+

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NICE asthma guidelines (<5y)

What strength of ICS should be added to SABA when stepping up from step 1 to step 2? How many weeks’ work is given and why?

PAEDIATRIC moderate dose ICS
Give 8 week’s worth as a trial period

After 8 weeks, stop the ICS and monitor child’s symptoms. If it doesn’t improve then it may not be asthma, could be something else. If symptoms get better but come back within 4 weeks of stopping the ICS, start the ICS again at a PEDIATRIC low dose ICS 8-week trial. If the same thing happens then start a PEDIATRIC moderate dose ICS 8-week trial.

If for any reason the child can’t have ICS use LTRA instead and see how they get on as part of the SIM

NICE asthma guidelines (<5y)

Consider this: a child is prescribed a SABA + PAEDIATRIC moderate dose ICS (after appropriate trials have taken place) but their asthma is still NOT controlled.

What should be added?

add Montelukast

If Montelukast fails refer to the specialist. NB - if ICS cannot be used in step 2 opt for LTRA instead.

NICE asthma guidelines (5-16)

Step 3?

SIM LABA MART INCREASE2 T

M = Montelukast (LTRA)

NB - pretty much the same as NICE adults (17y+) except NO use of LAMA and at step 4 you stop the Montelukast (LTRA) instead of just reviewing it.

How often should asthma treatment be reviewed when stepping down asthma treatment?

Review every 3 months when stepping down

Consider reducing ICS by 25-50% every 3 months

NICE asthma guidelines (<5y)

Step 1?

When to step up?

SABA PRN

Consider moving to step 2 if the child needs SABA more than 3x per week, is woken at night once a week, asthma not controlle with SABA alone, using one full inhaler in one month ….or….had an exacerbation in the last 2 years

NICE asthma guidelines (<5y)

Step 2?

8 week trial of ICS

SIM = SABA, ICS, Montelukast

Which ICS is not recommended in children under 12y?

Mometasone

According to BTS and NICE guidelines, in what situations would a patient need a regular preventor?

asthma attack in the last (…) years

NB - other criteria on previous flashcards

2 years

BTS asthma guidelines in adults: If a patient is on a regular **low dose** ICS and SABA yet symptoms are not being controlled, what would the next step up be? How can this regimen be introduced?

Add LABA (either as MART or separate inhalers) ## Footnote * NB - if MART is used stop the SABA* * For BTS children those \<5y should be started on Montelukast (LTRA) only at step 3 for them. If that fails refer to a specialist. For children 5-12y you can give them a LABA if that fails try the LTRA before considering referral.*

BTS asthma guidelines in adults: Patient's regular meds = a LABA was added to the patient's low dose ICS and SABA but there is no response to the LABA. What should the next step be?

**_Stop_** the LABA; increase to **medium dose** ICS or keep the patient on low dose ICS and start an LTRA ![]()

BTS asthma guidelines in adults: Patient's regular meds on Low dose ICS and LABA combination and SABA. If the patient is benefitting from the LABA yet symptoms are still not being controlled, what would the next step be?

Add an **LTRA** or...Increase to **medium dose** ICS ![]()

BTS asthma guidelines in adults: The patient is on a **medium dose** MART regimen and an LTRA (Montelukast) but still needs step-up treatment? What comes next?

Refer to specialist care. Under specialist care high doses of ICS can be given (with a spacer) in the BTS guidelines or trial another asthma drug ![]()

If a MART inhaler is used, the (...) inhaler should be stopped

SABA inhaler Examples: Salbutamol, Terbutaline

According to BTS guidelines, ICS doses should initially be used TWICE DAILY except (...) which should be used ONCE daily unless in severe asthma

Ciclesonide

True or false: BTS _recommend_ that inhalers should be prescribed by brand

True ## Footnote *NB - BNF: Chronic asthma summary*

Exercise-induced asthma could mean the patient's asthma is not well controlled. Advise the patient to use a (...) inhaler **immediately** before exercise Otherwise, review their current inhalers.

SABA inhaler ## Footnote *Patient may need additional therapy for exercise-induced asthma: Montelukast, LABA, Theophylline or Sodium cromoglycate or Nedocromil sodium*

COPD is characterized by persistent (...) symptoms and airflow limitation that is usually **progressive** and not fully (...)

COPD is characterized by persistent (**respiratory**) symptoms and airflow limitation that is usually **progressive** and not fully (**reversible**) ## Footnote *Symptoms are the same as asthma except production of sputum is common with COPD and symptoms can get generally worse over time causing health complications.*

(...) is the number one lifestyle risk factor of developing COPD

(**tabaco smoking**) is the number one lifestyle risk factor of developing COPD

What is step one in treating COPD (hint: PRN drugs)?

SABA or SAMA prn Example: Salbutamol or Terbutaline or Ipratropium *\*\*\* SABA can be continued at all stages but SAMA must be discontinued if a LAMA is used (i.e. wouldn't be using ipratropium and tiotropium together) \*\*\**

After step 1 treatment in COPD and the patient's symptoms are failing to improve or they are having exacerbations, what test should be determined before deciding the step-up treatment?

determine asthmatic feature or patient's response to steroid If ↑ FEV1 by \> 50% after bronchodilator is diagnostic for **(asthma**::condition) hence the patient will be positive for asthmatic feature

A COPD patient already on Step 1 therapy needs a step-up treatment. A high-dose ICS inhaler or oral prednisolone test was carried out and they showed positive responses e.g. symptoms improved. Which drug combination should be offered?

LABA + ICS (MART) because asthmatic features are positive here Only step up to LABA + ICS + LAMA if the patient experiences symptoms that limit their daily activities, have had 2 moderate exacerbations in a year or 1 severe exacerbation. Note you must stop the SAMA (ipratropium when a LAMA is in use) ![]()

THREE non-pharmacological advice regarding COPD?

**Stop smoking** - "does anyone in your household smoke?" **Pulmonary rehab** (6-12W program for physical activity, nutrition advice) **prevent viral airborne infection** - Flu vaccine (annual) + pneumococcal vaccine (one off)

What is the management of COPD exacerbations? O SPIT5

**O SPIT5** **O**2 - controlled **S**albutamol *nebulised* **p**rednisolone PO stat - 30mg once daily for 7-14 days **I**V aminophylline **T**etracycline (doxy 2 caps first day→ 1 daily), clarithromycin (bd) or amoxicillin (tds) 5 days tx of infection

A COPD patient already on Step 1 therapy needs a step-up treatment. A high-dose ICS inhaler or oral prednisolone test was carried out and they showed NO responses e.g. symptoms persisted. Which drug combination should be offered?

LABA + LAMA because patient has NO asthmatic features (no response to steroid); patients who have asthma will usually respond to this tx. *Stop the SAMA (ipratropium) is orginially used; If this combination fails e.g. 2 moderate exacerbations in a year, 1 severe exacerbation in a year or reduced quality of life...use tripple therapy LABA + LAMA + ICS. If that fails then consider othert treatment options like abx etc.* ![]()

What is the main difference between the BNF NICE guidelines for COPD and the BTS/SIGN gold standard guidelines for COPD?

BTS/SIGN gold standard guidlines for COPD take into account the FEV1 test to determine which step up treatment from regular prn initial treatment is most suitable. If 50% or higher then treat as "no asthmatic features" and give LABA **or** LAMA. But if \<50% offer MART **or** LAMA. If they fail step up to tripple therapy. Also stop SAMA whenever LAMA used.

What is the target O2 level in COPD patients? Why?

88-92% saturation anything higher than that → increased CO2 retention → respiratory failure