Treatment of Asthma

Question 1

Definition of Asthma

Answer 1

Chronic inflammatory disorder in susceptible individuals

- reversible either spontaneously / w/ treatment

Question 2

Symptoms of Asthma

Answer 2

Wheezing/coughing
Chest tightening
Breathlessness
Childhood

Question 3

Immediate phase of bronchoconstriction

Answer 3

Bronchospasm with wheezing

Question 4

Late phase of bronchoconstriction

Answer 4

Further inflammation + airway obstruction Cough + Sputum production

Question 5

How to diagnose asthma

Answer 5

Medical History
Signs + symptoms
Lung function tests
- spirometry
- PEF (peak expiratory flow)

Question 6

Chronic Asthma Treatment

Answer 6

Intermittent Reliever therapy

1) Regular preventer therapy (mild persistent asthma)
2) Initial-add on therapy (moderate persistent)
3) Additional add-on therapy
4) High dose therapy
5) Continuous/frequent use of oral steroids

Question 7

Intermittent reliever therapy

Answer 7

All patients with symptomatic asthma use
Reliever - short-acting Beta2 agonist e.g. salbutamol) when needed
- consider stepping up if using 3 doses a week or more

Question 8

2 types of medicines to treat chronic asthma

Answer 8

Controllers - taken daily to keep asthma under control

Relievers - used on a as-needed basis to reverse bronchoconstriction quickly

Question 9

Regular preventer therapy

Answer 9

Confirmed diagnosis of asthma
Need to be on a
- Inhaled corticosteroid (controller) = low dose
- Short-acting beta2 agonist (reliever)

Question 10

Initial add-on therapy

Answer 10

Low dose inhaled corticosteroids + long-acting beta2 agonist (controller)
- Adults/children>5years = LABA/leukotriene receptor antagonist
- children<5years = LABAs not licensed, just add LTRA
Short-acting beta2 agonist

Question 11

Additional add-on therapy

Answer 11

Increased inhaled corticosteroid dose + LABA (controller)

SABA (reliever)

Question 12

If control on additional add-on therapy is still inadequate, what should be trialled instead?

Answer 12

LTRA
Prolonged release theophylline
LAMA (long-acting muscarinic antagonist) in adults

Question 13

High dose therapies

Answer 13

Increased inhaled corticosteroids up to high doses
If ineffective, return to original dose + add on
- LTRA
- modified release theophylline
- oral beta2 agonist
- LAMA

Refer children to respiratory consultant

Question 14

Continuous/frequent use of oral steroids

Answer 14

Daily steroids (prednisolone) + inhaled corticosteroids + LABA (controller)
SABA (reliever)

Question 15

Aims of asthma treatment/well controlled asthma

Answer 15

No daytime symptoms 
No night-time waking due to asthma
No need for rescue meds
No exacerbations
No limitations on activity - including exercise
Normal lung function
Minimal side effects from medicines

Question 16

What to do when a patient is suspected with asthma

Answer 16

Trial them on inhaled steroids for 6 weeks
Asthma symptom questionnaire
Assess response by spirometry/home peak expiratory flow
- if response is good = confirm asthma diagnosis + personalised asthma action plan
- if response is poor = check adherence + inhaler technique; + arrange further tests

Question 17

What to do before stepping up or initiating new drug therapy

Answer 17

Check adherence
Check inhaler technique
Eliminate trigger factors

Question 18

Non-pharmacological management of asthma

Answer 18

Offer appropriate support to stop smoking
Weight loss interventions
Breathing exercise problems

Question 19

Newer treatments for chronic asthma

Answer 19

Omalizumab - NICE approved

• for adults, teens + children>6years
• add-on to optimise standard therapy
• prophylaxis of severe, persistent allergic asthma
• dose/per body weight/ IgE level

Question 20

What factors should be monitored + recorded in adults suffering from asthma in primary care

Answer 20

Symptomatic asthma control
Lung function assessed by spirometry/PEF
Inhaler technique
Adherence
Bronchodilator reliance
Asthma attacks, oral corticosteroid use + time off work since last assessment

Question 21

Acute asthma treatment

Answer 21

Oxygen
SABA
Ipratropium bromide (bronchodilator)
Corticosteroids
Magnesium
Aminophyline

Question 22

How to treat a acute moderate asthma

Answer 22

Start treatment at home or in surgery (GP) + assess response
Inhaled SABA using spacer/nebuliser
Prednisolone 40-50mg for at least 5 days
- if response is poor, send to hospital

Question 23

How to diagnose acute moderate asthma

Answer 23

Increasing symptoms
Peak flow>50% predicted/best
No features of acute severe asthma

Question 24

How to diagnose acute severe asthma

Answer 24

Cannot complete sentences in 1 breath
Respiration>25 breaths/min
Pulse>110 beats/min

Question 25

How to treat acute severe asthma

Answer 25

Start treatment + send to hospital 
High flow oxygen
Inhaled SABA + spacer/nebuliser
Oral prednisolone/IV hydrocortisone 
- consider IV beta2 agonist, aminophylline, magnesium sulphate

Question 26

How to diagnose acute life-threatening asthma

Answer 26

Peak flow < 33% best or predicted
Arterial oxygen saturation (SpO2) < 92%
Partial arterial pressure of oxygen (PaO2) < 8kPa
Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0kPa)
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion
Altered conscious level
Hypotension

Question 27

How to treat acute life-threatening asthma

Answer 27

Start treatment + send to hospital
IV beta2 agonist
Aminophylline
Magnesium Sulphate

Question 28

Personalised care in Asthma

Answer 28

Instruction on how to recognise signs of worsening asthma
Advice on the prompt use of SABA + oral corticosteroids
Monitoring response to medicines
Contact information
Follow-up to assess asthma control