Respiratory: Asthma - Management Flashcards
What do you need to tell patients (in an OSCE) about reviewing medication? [1]
Specialist nurses help to make changes to medication
Review post discharge (< 30 days)
What five steps should you educate / make on self management plans for patietns? [5]
How to use treatment
Self monitoring/assessment skills
Action plan with regard to goals
Recognition and management of exacerbations
Allergen/trigger avoidance
When a patient has an asthma attack - how many puffs of salbutamol inhaler is recomended? (as it’s equivalent to nebulised salbutamol) [1]
10 puffs of salbutamol inhaler
Take one puff of reliever inhaler every 30 to 60 seconds up to 10 puffs
Try 10 puffs and wait couple hours - if not controlled after another 10, then come to hospital
What are leukotrines? [1]
What do they cause in the pathophysiology of asthma? [3]
Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in the airways.
Name two drugs used for reliever medication for asthma? [1]
State the class of drug [1] and MoA [2]
Name:
* Salbutamol
* terbutaline
Class:
* beta 2 agonist
MoA:
- relax smooth muscle to cause bronchodilation and mucociliary clearane
- relieve bronchospasm
Name two LABAs [1]
What is the difference between a LABA and SABA? [1]
Salmeterol & Formoterol
MoA:
- relax smooth muscle
- relieve bronchospasm
Difference:
Take longer for action to occur, but last longer
What are the side effects of B2 agonists? [4]
o tremor
o tachycardia
o sweats
o agitation
Name three inhaled corticosteroids used to as long term asthma tx [3]
o budesonide
o beclometasone
o fluticasone
What are the side effects of ICS treatment for asthma? [3]
Sore throat
Oral candidiasis
Cough
What are low [1], moderate [1] and high doses [1] used ICS in asthma tx? [3]
Low dose:
* <= 400 micrograms budesonide or equivalent
Medium dose:
* 400 micrograms - 800 micrograms budesonide or equivalent
High dose:
* > 800 micrograms budesonide or equivalent
Name and describe the MoA of a leukotriene receptor antagonist (LTRA) [2]
Montelukast:
* blocking leukotriene receptors in smooth muscle
* reduce bronchoconstriction
Name two AEs of montelukast [2]
o nausea
o headache
Describe what is meant by MART therapy and how it is used [2]
Maintenance and reliever therapy (MART):
- involves a combination inhaler containing an inhaled corticosteroid and a fast and long-acting beta-agonist (e.g., formoterol).
- This replaces all other inhalers, and the patient uses this single inhaler both regularly as a preventer and also as a reliever when they have symptoms.
MART is only available for ICS and LABA combinations under which conditions? [1]
MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)
Name a LAMA
tiotropium
Name an anti-IgE medication [1]
Omalizumab
Describe the MoA of Omalizumab [1]
When is it indicated? [2]
Mechanism of action:
* monoclonal antibody to IgE
* decreases IgE
Considered when:
* confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy after all others used
* suffer from asthma with continuous or frequent treatment with oral corticosteroids (defined as 4 or more courses in the previous year)
Name 4 AEs of omalizumab [4]
- itching
- joint pain
- headache
- nausea
- anaphylaxis
State the treatment algorithm for asthma
- Newly-diagnosed asthma:
SABA; (salbutamol) - Inhaled corticosteroid (low dose) taken regularly
- BTS: Long-acting beta-2 agonists (e.g., salmeterol) or maintenance and reliever therapy (MART)
OR
NICE: Leukotriene receptor antagonist (e.g., montelukast) taken regularly - BTS: Increase the inhaled corticosteroid or add a leukotriene receptor antagonist (e.g., montelukast)
OR
NICE: Long-acting beta-2 agonists (e.g., salmeterol) taken regularly - BTS: Specialist management(e.g., oral corticosteroids)
OR
NICE: Consider changing to a maintenance and reliever therapy (MART) regime - NICE: Increase the inhaled corticosteroid to a moderate dose
- NICE: Consider high-dose inhaled corticosteroid or additional drugs (e.g., LAMA or theophylline)
Give three definitions of uncontrolled asthma (when you increase up the ladder) [3]
- 3 or more days a week with symptoms or
- 3 or more days a week with required use of a SABA for symptomatic relief or
- 1 or more nights a week with awakening due to asthma.
A 21-year-old woman attends for her annual asthma review. She reports having her usual symptoms of shortness of breath, wheeze and chest tightness around 3 times per week. These symptoms typically occur at night and she wakes up feeling wheezy around once per week. She currently only uses a salbutamol inhaler as required and gets good relief from this.
The patient otherwise has no medical history, takes no other medications and has no allergies.
How should this patient be managed?
Add a budesonide inhaler
Add a salmeterol inhaler
Add oral montelukast and a beclomethasone inhaler
Continue current salbutamol only
Switch to regular salbutamol
Add a budesonide inhaler
Adult with asthma not controlled by a SABA - add a low-dose ICS
Why do B2 agonists cause hypokalaemia? [1]
Activate Na/K ATPase; causing intracellular movement of K
Similar to Insulin
Describe the effect B2-agonists have on glucose levels [2]
Cause hyperglycaemia: promote glycogenolysis
What effect do B2-agonists have on lactate levels? [1]
Increase lactate levels
LABAs should only be prescribed alongside which drug class? [1]
Why? [1]
LABA & ICS
LABA on its own causes increase in asthma deaths
Care should be taken when prescribing B2-agonists to patients with which co-morbidities? [1]
Explain [2]
Cardiovascular disease
B2-agonists cause tachycardia; may provoke angina or arrhythmias
What is a common choice for SABA dose? [1]
Salbutamol 100-200 micrograms inhaled as required
What advice should you give about reliever medication and exercise? [1]
Take 10 mins before excercise
What is the maximum number of inhalations should take of SABA per 24hrs? [1]
8
What is a common side effect of tiotropium? [1]
Dry mouth
Also cough or horse voice
TIotropium: LAMA
Anti-muscarinics are contraindicated in which diseases? [2]
Arrhythmias
Urinary retention
What is important to note about taking ICS? [1]
How do you combat this? [1]
In some patients can cause paradoxical bronchospasm
Take SABA before to counteract.
State what you information you would say when prescribing ICS to a patient [3]
ICS ‘dampens down’ the immune system and inflammation of the lung
Wont feel immediate benefits after inhalation, treatment should gradually improve symptoms and flare ups, if taken regularly
Common side effects include a sore throat or horse throat, which can be minimised by rinsing or gargling with water after treatment
1/100 who take montelukast suffer from what type of symptoms? [1]
Give examples [2]
Neuropsychiatric reactions: sleep disturbance, depression, agitation
Describe the technique you should give patients with regards to inhaler technique.
If haven’t used it in 5 days or more / new - need to test: take cap off and shake well, undergo test spray
check that the inhaler dose counter is not at 0
check that there is nothing inhaler mouth piece
shake inhaler
sit / stand up straight and tilt head up
gently and slowly breath out away from inhaler
put lips around inhaler and form tight seal
slow and steady breath in and press inhaler once
continue breathing until lungs feel full
take inhaler off mouth and hold breath for 10 secs / as long as poss
breath out gently
if prescribed a second puff, wait 30 secs and repeat
if used steroids: wash mouth out
What is the rule about caring for pregnant asthma patients? [1]
Pregnant women who have a severe asthma attack should be admitted to hospital, EVEN if they initially improve with treatment
