Respiratory Treatment

Question 1

What are the pathophysiological changes in asthma?

Answer 1

Mucosal oedema
Bronchoconstriction
Mucous plugging
Airway remodeling
Bronchial hyperresponsiveness

Question 2

What counteracts smooth muscle dysfunction?

Answer 2

Beta-2 agonists
(Short acting: salbutamol)
(Long acting: formoterol)

Question 3

What reduces inflammation?

Answer 3

(cortico)steroids: inhaled (budesonide) and oral (prednisolone)

Question 4

What occurs in airway remodelling?

Answer 4

Mucous gland hyperplasia
Subepithelial fibrosis
Epithelial desquamation
Airway wall thickening
Increased smooth muscle mass

Question 5

What are the goals of asthma control?

Answer 5

Minimal symptoms during day and night
Minimal symptoms for reliever medication
No exacerbations or limitation of physical activity
Normal lung function (FEV1/PEF>80% predicted)

Question 6

What is the treatment for mild intermittent asthma?

Answer 6

Short acting B2 agonists
(Salbutamol, terbutaline)
Symptom relief, reversal/prevention of bronchoconstriction, use as required (NOT regularly)

Question 7

What occurs if short acting B2 agonists are used frequently?

Answer 7

Increased incidence of mast cell degranulation in response to allergen

Question 8

What are the side effects of B2 agonists?

Answer 8

Adrenergic, therefore tachycardia, palpations, tremor

Question 9

When should inhaled corticosteroids be given regularly as a preventer?

Answer 9

Using a B2 agonist >3 times/week
Symptoms >3 times/week
Waking >1 time/week

Question 10

What is the main goal of regular corticosteroid use?

Answer 10

Reducing bronchial hyperresponsiveness
(Improves symptoms and lung function)
(Reduce exacerbations, prevent death)

Question 11

What does the addition of a lipophilic side chain to corticosteroids confer?

Answer 11

High affinity for GCS receptor
Increase uptake and dwell time in tissue
Rapid inactivation following systematic absorption (GI, liver eliminates on first pass)

Question 12

Can systemic side effects occur with inhaled corticosteroids?

Answer 12

Yes, in high doses - may result in adrenal crisis

Question 13

What is the first choice for add-on therapy?

Answer 13

Long acting B2 agonists (formoterol, salmeterol)

Give when not controlled on 400mcg/day ICS

Question 14

What are the main uses of LABAs?

Answer 14

Reduce asthma exacerbations
Improve symptoms
Improve lung function
Not anti-inflammatory by themselves - give with ICS

Question 15

Should combination inhalers be given?

Answer 15

Yes - means that patients will take all of their medications

Question 16

What are alternative possible add-on therapies?

Answer 16

High dose ICS
Leukotriene receptor antagonists
Theophylline
Tiotropium

Question 17

What is the main action of leukotriene receptor antagonists?

Answer 17

Prevents action of LTC4 released by mast cells

Bronchoconstriction, mucous secretion, mucosal oedema, inflammatory cell recruitment

Question 18

What are the side effects of leukotriene receptor antagonists?

Answer 18

Angioedema
Dry mouth
Anaphylaxis
Fever
Gastric disturbance
Nightmares
(No important drug interactions)

Question 19

What is the main action of methylxanthines?

Answer 19

Antagonise adenosine receptors

Question 20

What are the side effect of methylxanthines?

Answer 20

Nausea, headache, reflux

Toxic complications - arrhythmia, fits

Question 21

When are long acting anticholinergics (LAMAs) given?

Answer 21

COPD and severe asthma
(Reduces severe exacerbations, some improvement in symptoms and lung function)
(Relative M3 muscarinic receptor selectivity)

Question 22

What are the side effects of LAMAs such as tiotropium bromide?

Answer 22

Dry mouth
Urinary retention
Glaucoma

Question 23

What is given at step 5?

Answer 23

Oral steroids (~10mg/daily, more for maintenance therapy)
Biological therapies
Anti-IGE (omalizumab) prevents IGE binding to high affinity IGE receptor, preventing mast cell activation
Anti IL-5 (eg mepolizumab) reduces peripheral blood and airway eosinophil count (reduces rate of severe asthma exacerbations)

Question 24

When should patients step down?

Answer 24

Once asthma is controlled, to prevent higher doses than necessary (maintain at lowest possible dose of inhaled steroid)

Question 25

What qualifies as severe asthma in adults?

Answer 25

Unable to complete sentences
Pulse > 110bpm
Respiration > 25/Mon
Peak flow 33-50% best/predicted
(Plus any of silent chest, cyanosis, hypotension, bradycardia, arrhythmia, exhaustion, confusion, coma)

Question 26

What qualifies as near-fatal?

Answer 26

PaCO2 >6kPa

Mechanical ventilation

Question 27

How is severe acute asthma treated?

Answer 27

High flow oxygen - aim for 94-98% says
Nebulised salbutamol, continuous if necessary, O2 driven
Oral prednisolone (~40mg/day, 10-14 days)
If not responding, add nebulised ipratropium bromide
If no improvement and life threatening features, consider IV aminophylline

Question 28

What is ipratropium bromide?

Answer 28

A quaternary anticholinergic agent

Slow and less intense bronchodilator (lasts up to 6 hours)