1 - Asthma Flashcards
1
Q
SABA
A
short acting bronchodilator (beta 2 agonist)
ex. Ventolin (salbutamol)
2
Q
ICS
A
inhaled corticosteroid
3
Q
LABA
A
long acting bronchodilator (beta 2 agonist)
4
Q
LAMA/LAAC
*equivalent
A
long acting muscarinic antagonist
long acting anticholinergic
5
Q
SAMA/SAAC
*equivalent
A
short acting muscarinic antagonist
short acting anticholinergic
6
Q
What are the 2 parts to the pathophysiology of asthma and how do we treat them?
A
1) Inflammatory processes and agents to reduce inflammation (“controllers”)
2) Bronchoconstriction and the use of bronchodilators (“relievers”)
7
Q
How often should you be using a SABA (reliever) if your asthma is controlled ?
A
<4 times per week
8
Q
What is the main therapy that every asthmatic should be on?
A
ICS - inhaled corticosteroid
9
Q
Ventolin/SABA is a ______ for asthma
A
bandaid (i.e. it doesn’t fix the problem)
10
Q
Is it safe to be on inhaled corticosteroids for a long time?
A
Yes
-inhaled corticosteroids do not give you the systemic symptoms that oral corticosteroids (e.g. prednisone)
11
Q
Are asthma attacks sudden?
A
No. It is a buildup of triggers and then the last trigger causes the attack. (water cup analogy)
12
Q
Asthma more common in adults or children?
A
children
13
Q
Can children grow out of asthma?
A
Yes but not everyone does
14
Q
Can you develop asthma later on in life?
A
Yes - usually occupational or stress-induced
15
Q
How many of deaths caused by asthma can be prevented?
A
80%-90%
16
Q
What is the most common cause of death in asthmatics?
A
inadequate assessment of the severity of airway obstruction by the patient or physician & inadequate therapy
17
Q
Describe the clinical presentation of asthma
A
- Episodic wheezing, breathlessness, chest tightness, and coughing
- *most people have these symptoms, but not all (about 6/10)
- Intervals between symptoms can be days, weeks, months or years
- Spirometry demonstrates obstruction (decreased FEV1/FVC) with reversibility following inhaled B2 agonist (at least a 12% improvement in FEV1 AND a difference of 200 mL)
- prob an important exam Q to know that is has to be BOTH and not one or the other
18
Q
What age can you do spirometry as part of asthma diagnosis?
A
over 6
For those under 6, have to rely on history and symptoms
19
Q
If a mom/person is looking for cough syrup for a cough that has been going on for a few months, do you give it to them?
A
LMAO NO
a cough shouldn’t last that long so you need to refer for spirometry to determine if it’s asthma or not
20
Q
If someone has asthma that is controlled with a SABA (ex. salbutamol), do they need additional therapy?
A
Yes - they need an ICS to help with the chronic inflammation of the airways
21
Q
For asthma to be controlled:
How often should they be having daytime symptoms?
A
<4 days/week
22
Q
For asthma to be controlled:
How often should they be having night-time symptoms?
A
<1 night/week
23
Q
For asthma to be controlled:
Should exercise be affected?
A
No - should be normal
24
Q
For asthma to be controlled:
How often should they be having exacerbations?
A
mild infrequent
25
For asthma to be controlled:
How often should they be having absence from work or school?
never
26
For asthma to be controlled:
How often should they be needing a SABA (ex. ventolin)?
<4 doses/week
NOTE: this used to exclude exercise/pre-exercise.
now this includes exercise/pre-exercise !!
27
For asthma to be controlled:
What FEV1 or PEF value should they have?
>90% personal best
28
For asthma to be controlled:
What PEF diurnal variation should they have?
<10-15%
29
For asthma to be controlled:
What % of sputum eosinophils should they have?
<2-3%
30
What else would indicate poor asthma control?
walk-in clinic, ER, hospitalization
31
What is the actual % of patients with controlled asthma?
43%
32
If someone has very mild asthma, do they need an ICS ?
What exactly should be their treatment?
Not necessarily - they do need an SABA or ICS/LABA
33
What is 2nd line if they can't use ICS?
NOTE: this is more of an add-on than a replacement for ICS
LTRA - Leukotriene receptor antagonist
34
What is the Flovent equivalent dose for ICS that patients need to be on?
250 ug/day
| usually dosed as 125 ug BID
35
Is there any benefit to increasing the Flovent equivalent dose past 250 ug/day long term?
No - only increase SE and not any increase in benefit
*think about switching therapy
36
Is there any benefit to increasing the Flovent equivalent dose past 250 ug/day short term?
Yes - can increase it to get it back into control but then should either go back to the minimum dose
37
What if adults are not controlled with ICS at a low dose ?
add LABA
38
What if children are not controlled with ICS at a low dose ?
try medium dose before adding LABA
39
What are some other questions we should be asking ?
- Feel like you're getting a cold/flu?
- Exposure to triggers?
- Limitation of activities?
- Referred to action plan?
- Rule out exacerbation!!!
40
What symptoms what indicate she is experiencing an asthma exacerbation?
- Unable to speak
- Shortness of breath at rest
- Reliever (SABA) is not working
- Peak Flow < 60% predicted best
- Patients knows from past experience that they are having a serious attack
41
What are some triggers?
- Respiratory tract infections
- Allergens
- Environment (cold air, fog, smoke)
- Food additives (sulphites, MSG)
- Exercise
- Drugs/preservatives (ASA, NSAIDS, B-Blockers, benzalkonium chloride)
- Occupational (bakers, farmers, paint)
- Emotions
42
Once an individual is sensitized to a pet, ______ is recommended because continued exposure is associated with worsening airway inflammation and deterioration in asthma control.
avoidance
43
If a person doesn't want to get rid of their pet, what is they key thing they must do?
keep it out of the bedroom and don't spoon with the animal
44
People with asthma have a high probability of having ?
allergic rhinitis
45
Inflammation is _____
chronic
46
Symptoms are _____
episodic
47
Airway narrowing is ____
variable
48
What causes airway narrowing?
Contraction of airway smooth muscle
- increase responsiveness to certain triggers (aka: bronchospasm)
- airway edema
- mucus hypersecretion
- airway thickening ("remodelling")
49
What causes remodelling?
When you do not treat with ICS preventatively
50
Describe airway remodelling
- Repair in response to chronic inflammation
- Increased airway wall thickness
- Fibrosis
- Increased smooth muscle size and number
- Increased number and size of mucous glands
- Increased number of blood vessels
51
What is the trigger for acute asthma?
release of inflammatory mediators
52
Describe the early phase of acute asthma?
bronchoconstriction (within 10-20 min), mucous hypersecretion, edema
53
What is the duration of the early phase of acute asthma?
about 1 hr
54
About ____ hours later, the late phase of acute asthma occurs
6-9
55
Describe the late phase of an acute asthma attack
- Continued inflammation, epithelial damage, intensified hyper responsiveness (triggers are even worse than normal)
- More severe, more prolonged & more difficult to reverse (may last for weeks)
56
What is the focus of asthma therapy?
the prevention and suppression of the underlying inflammation
57
What are the major risk factors for severe exacerbations ?
Underutilization of anti-inflammatory drugs and excessive reliance on short-acting inhaled B2-agonists are the major risk factors for severe exacerbations
58
How many inhalers per year of the SABA should a person be filling ?
1-2
59
Black bos warning for using LABA as ________
monotherapy
60
Why are LABA not okay as monotherapy?
they are not treating the inflammation and increase the risk for serious adverse events
61
List some reassessments that should be done regularly
- control
- spirometry or PEF
- inhaler technique
- adherence
- triggers
- comorbidities
62
What are some benefits of inhaled corticosteroids
- decrease airway hyperresponsiveness
- decrease airway inflammation
- improving pulmonary function
- decrease asthma symptoms
- decrease exacerbations
- decrease hospitalizations
- improving QOL
- decrease asthma-related deaths
63
How do you choose between different ICS to use?
doesn't matter which one they use as long as they use one
64
What does do you use for an ICS?
start low and adjust as needed
65
How much do ICS usually cost?
About $30-50 for a 30 day supply
66
Less than __ years old, cannot use dry powdered inhalers or MDIs without spacers
5
67
______ does not improve efficacy, use spacers instead
nebulization
68
What is the preferred device for a person aged 0-3 years ?
Pressurized metered-dose inhaler plus dedicated spacer with FACE MASK
69
What is the preferred device for a person aged 4-5 years ?
Pressurized metered-dose inhaler plus dedicated spacer with MOUTHPIECE
70
ICS inhaler options:
What age group can use Alvesco (ciclesonide) ?
> 6 years
71
ICS inhaler options:
What age group can use Asmanex Twisthaler (mometasone) ?
> 4 years
72
ICS inhaler options:
What age group can use Flovent HFA MDI (fluticasone) ?
> 1 years
73
ICS inhaler options:
What age group can use Flovent Diskus (fluticasone) ?
> 4 years
74
ICS inhaler options:
What age group can use Pulmicort Tubuhaler (budesonide) ?
> 6 years
75
ICS inhaler options:
What age group can use QVAR MDI (beclomethasone) ?
> 5 years
76
How long will it take for an ICS response ?
Most patients see a decrease in symptoms in days to 1-2 weeks and often achieve minimum improvement in 2-4 weeks and maximum symptomatic improvement within 4-8 weeks.
77
When should we follow up with a patient after starting an ICS ?
Should be seen within 1-3 months after starting treatment.
78
When should we follow up with a patient after being stable on an ICS ?
Every 3-12 months thereafter (have them call or return if concerned about increased symptoms)
79
Can you consider stepping down to an even lower ICS dose if they are controlled?
Can decrease by a 25-50% at 3-month intervals is feasible and safe for most patients or to a once daily ICS.
KNOW THAT IT'S AT THE 3 MONTH MARK
80
Can you ever stop controller treatment ?
only if there have been NO symptoms for 6-12 months and patient has no risk factors - request repeat spirometry and if no longer in the "mild" asthma category (i.e. VERY mild) then could consider
**complete cessation of ICS in adults is not advised as the risk of exacerbations is increased
81
Describe "doing it right" for stopping/decreasing ICS
- choose an appropriate time (no respiratory infection, not during allergy season, patient not travelling, not pregnant)
- provide a written asthma action plan
- monitor closely and have them report increased reliever use
82
What are the components of an action plan ?
1) Outline recommended daily preventive management strategies to maintain control
2) When & how to adjust reliever and controller therapy for loss of control
3) Provide clear instructions regarding when to seek urgent medical attention
83
What are some potential reasons for lack of ICS response?
1) Erroneous diagnosis of asthma
2) Comorbidities (sinusitis, GERD, vocal cord dysfunction)
3) Poor inhaler device technique
4) Poor adherence to maintenance ICS treatment
5) Ongoing exposure to environmental triggers
84
For a 10 year old:
If after reviewing these factors, asthma remains uncontrolled on low-dose ICS, there are three initial options for escalation pharmacological therapy:
1) Increasing to medium or high doses of ICS
2) Adding a LABA
3) Adding an LTRA
What do you pick for the 10 year old?
1) Increasing to medium or high doses of ICS
85
The 10 year old's mom is concerned that using higher-dose steroids will stunt Jack's growth. How do you respond?
Effects of ICS on growth:
- Seems to be maximal during the first year of therapy and less pronounced during subsequent years
- For budesonide ug/d for a mean of 4.3 years during prepubertal age there was a mean decrease of 1.2 cm in adult height vs placebo
-in children who had long term treatment with budesonide attained normal adult height
Keep in mind: uncontrolled or severe asthma also adversely affects growth and final adult height
86
How does the DOSE of ICS affect growth?
higher ICS dose stunts growth more than lower ICS dose
87
What do the findings support for the use of ICS regarding growth ?
findings support the use of the minimal effective ICS dose in children with asthma
*but measure height at least yearly in kids on ICS
88
What are some other ICS cons?
- Thrush (candidiasis)
- Dysphonia (change in voice)
If dysphonia occurs you can switch to an MDI with a spacer
89
Thrush and dysphonia are ____-dependent
dose
90
How do you minimize thrush and dysphonia ?
- Spacer (for MDI) with mouthpiece vs mask
| - Rinse with water "swish, swish, spit"
91
For a 13 year old:
If after reviewing these factors, asthma remains uncontrolled on low-dose ICS, there are three initial options for escalation pharmacological therapy:
1) Increasing to medium or high doses of ICS
2) Adding a LABA
3) Adding an LTRA
What do you pick for the 13 year old?
2) Add a LABA
92
What is the benefit of doing ICS/LABA instead of increasing dose of ICS?
**we do this in kids >12
- decreases rate of exacerbations
- increase morning and evening PEF
- decrease time taken to achieve well-controlled asthma
- improve exercise response
93
Why do we increase dose of ICS instead of use ICS/LABA combo for those under 12?
little evidence is available to guide use of LABA for children
94
LABA+ICS options:
What age can you use Advair MDI (Salmeterol/Fluticasone) ?
>12
95
LABA+ICS options:
What age can you use Advair Diskus (Salmeterol/Fluticasone) ?
>4
96
LABA+ICS options:
What age can you use Breo Ellipta (Fluticasone/Vilanterol) ?
>18
97
LABA+ICS options:
What age can you use Symbicort Turbuhaler (Budesonide/Formoterol) ?
>12
98
LABA+ICS options:
What age can you use Zenhale MDI (Mometasone/Formoterol) ?
>12
99
Zehale is technically for ______ only
asthma (off-label for COPD)
100
OOA of formoterol
5 mins, making it a FABA (like salbutamol) with max effect in 2 hours
101
Describe "SMART" dosing
The combination of rapid-onset LABA (formoterol) and low dose ICS (budesonide) in a single inhaler as both the controller and the reliever medication is effective in improving asthma control, and in at-risk patients, reduces exacerbations requiring OCS and hospitalizations
102
What is SiT
Single-inhaler therapy
103
Describe the "SMART" dosing concept
- Asthma exacerbations evolve slowly over a few days with a fall in PEF and increase symptoms and reliever medication use
- Recent evidence that ICS begins reducing airway inflammation in as early as 6 hours
- So by using "as needed" ICS and formoterol (instead of a SABA) you have an immediate intervention with one inhaler to control symptoms and prevent exacerbation
- Most likely benefit from TIMING (early administration) of higher ICS dose relative to worsening in symptoms as opposed to higher total dose
- Long-acting effects of formoterol also contribute to improved benefit over SABA
104
Other advantages of SMART dosing
- Even with max doses, you get a lower corticosteroid exposure overall compared to traditional protocols
- Use of one inhaler may be an advantage for adherence
105
Max dosing of "SMART" dosing practical points ?
Maximum daily dose: 8 inhalations - if more needed, contact physician
*Recall that 4 doses of reliever/week = poor control (this counts towards that)
106
Who can we consider Single inhaler therapy in? (budesonide/formoterol)
In those > 12 with asthma uncontrolled on fixed dose ICS/LABA combination therapy in lieu of increasing the ICS dose of the combination therapy.
107
What are the most common adverse effects of Beta 2 agonists ?
- tremor
- excitement, nervousness
- palpitations, tachycardia
108
75% of asthmatics have ______ ________
allergic rhinitis
109
List 3 of the 2nd gen antihistamines
- reactine
- claritin
- aerius
110
What are some less common adverse effects of Beta 2 agonists ?
- headache
- prolonged QT
- decreased K+
- increased insulin secretion
- increased glucose esp. diabetic
111
Is it better to add LABA or LTRA to ICS ?
addition of LABA to ICS is modestly superior to the addition of LTRA
112
Don't forget about the ________ and _____.
antihistamines and INCS's
113
What is the "September Spike" and how does it contribute to asthma attacks?
- farmers are burning stubble
- kids go back to school and may get viruses from other kids
*both of these are triggers for asthma attacks
114
What is PEF (peak expiratory flow) ?
- maximal flow produced during forced expiration (expressed as L/min)
- sometimes used to quickly assess effectiveness of bronchodilators (in ED/clinic) during acute attack
- it is compared to patient's own previous best measurements using the same peak flow meter
- measurements are effort dependent
- CTS recommends for "poor perceivers"
115
PEFM readings:
| What is green zone ?
85-100% of predicted best
116
PEFM readings:
| What is yellow zone ?
60-85% of predicted best
117
PEFM readings:
| What is red zone ?
<60% of predicted best
118
What is the Personal (predicted) best ?
- Greatest peak flow achieved over a 2 week period when asthma well controlled
- Take 3 times (record highest one) - twice daily for 2 weeks (using same meter)
119
When to use PEFM ?
- PEF monitoring should also be considered in patients who are poor symptom perceivers or those with a history of severe exacerbations
- Long-term peak expiratory flow (PEF) monitoring is now generally only recommended for patients with severe asthma, or those with impaired perception or airway limitation
120
What are the 3 primary early therapies for exacerbations?
1) Repetitive administration of rapid-acting inhaled B2 agonist
- 4-10 puffs q20minutes x 1 hr, then if stable, 2-4 puffs prn (ex. q1-4hrs)
2) Early introduction of systemic glucocorticoids
3) Oxygen supplementation
121
Describe systemic glucocovrticosteroids for acute exacerbation
-May be in action plan if history of recent severe exacerbations and do not respond to inhaled SABAs within 6-8 hours
-Burst of systemic glucocorticosteroid orally
Kids: Prednisone 1-2 mg/kg/day for 3-5 days
Adults: Prednisone 50 mg daily x 5-7 days
* tapering is not required for short term steroids
- Continue ICS
122
Benefits of systemic glucocorticosteroids ?
Treatment of severe acute exacerbations:
- Prevent progression of exacerbation
- Reduce need for ER visit/hospitalization
- Prevent early relapse after emergency treatment
Acute effects after 4-6 hours:
-PO preferred over IV - convenience
123
Harms of systemic glucocorticosteroids ?
- Dose and duration-dependent adverse effects
| - No serious toxicity with short-term "bursts"
124
Short term adverse effects of systemic glucocorticosteroids ?
- Hyperglycemia
- Increased appetite
- Fluid retention
- Weight gain
- Rounding of the face ?
- Mood alteration
- Hypertension
- Peptic ulcer
- Aseptic necrosis of the femur
125
Why not use oral prednisone long term ?
- Osteoporosis
- Hypertension
- Diabetes
- Hypothalamic-pituitary-adrenal axis suppression
- Obesity
- Cataracts
- Glaucoma
- Skin thinning
- Easy bruising
- Muscle weakness
- Risk of adrenal failure with withdrawal
- Immunosuppressant
- Peptic ulcers
126
Describe the stability treatment post-exacerbation
- May continue SABA 2-4 puffs q1-4 hours until symptoms resolve
- Won't likely be discharged home until not needing SABA more than q2-3h and PEF/FEV1 is > 70-80% personal best/predicted
-Set up treatment (add LABA) and monitor over 1-3 months, then may consider reducing ICS to lowest effective dose
- AND, especially if associated with gradual loss of control
- Check inhaler technique
- Adherence to ICS
- Trigger avoidance
127
What is EIB ?
Exercise-induced bronchoconstriction:
- Physical activity may be the only common trigger in some asthma patients
- Develops 5-10 minutes after completing exercise (rarely during)
- More common in cold, dry climates
- Typical asthma symptoms or troublesome cough
- Resolves spontaneously within 30-45 minutes
128
How is EIB diagnosed?
- Rapid improvement after inhaled B2 agonist
- Prevention was by pretreatment with inhaled B2-agonist before exercise
- Fall in FEV of >15% following 6-8 minutes of near maximal exercise
129
What do you do for EIB if there is underlying asthma ?
May indicate asthma is poorly controlled so step-up controller therapy
130
What do you do for EIB if there is no underlying asthma yet?
they will require SABA prior to exercise and recommend they have a spirometry test
*if patient needs to use SABA more that 3 times a week INCLUDING for exercise then they NEED and ICS! They are not considered well controlled
131
Both LABAs and regular use of SABAs provide ___ effective protection against EIB than intermittent prophylactic use of B2 agonist ?
less
132
List some biologics that are used as second to last resort
```
Omalizumab - IgE
Mepolizumab - IL-5
Reslizumab - IL-5
Benralizumab - IL-5R
Tralokinumab - IL-13
Dupilamab - IL-4
```
133
What is the absolute last resort for asthma therapy ?
prednisone taken orally
134
When is Tiotropium recommended ?
as add-on therapy for individuals 12 years of age and over with severe asthma, who remain uncontrolled despite combination ICS/LABA therapy
135
Who is tiotropium bromide not currently approved for by HC ?
those aged 6-17 years old
136
What immunizations should asthmatics be getting?
- pneumococcal vaccine
| - influenza vaccine
137
Is education better done by a doctor, pharmacist or nurse?
doesn't matter who educates patient as long as they get the education
