Asthma Flashcards
Clinical Presentation
- Episodes of SOB, chest tightness, coughing (mostly at night), wheezing
-exercise, spontaneous, allergen
Agents & Events Triggering Exacerbations
-Resp. infections
-Allergens
-Environment
-Emotions
-Exercise
-Job stimuli (dust, spice, mold, chemicals)
-Host factors (AA, hispanic, obesity)
Drugs
-Acet, Aspirin, NSAIDs
-NS BB = carvedilol/propranolol/labadolol
-Sulfites
-Benza chloride
BANANS
In asthma, reversibility is shown by an increase in _____ after SABA
FEV1 >12%
Asthma Sx Control
In the last 4 weeks:
-Daytime sx more than twice a week?
-Waking up at night?
-SABA used more than twice a week?
-Activity limitation?
- Well controlled: none
- Partly controlled: 1-2
- Uncontrolled: 3-4
Treatment GOALS
Goals
-few asthma sx, no sleep disturbance, no exercise limitation
-maintain normal lung function
-prevent flare ups / asthma deaths
-minimize side effects
Assess
-take every opportunity to assess, routine visit once a year but also when pts get refill or are having sx
12+ Adults - Track 1: Preferred Controller and Reliever
1-2. As needed only Symbicort (12 puffs max)
3. Maintenance Symbicort 2 puffs twice a day of 80/4.5 AND as needed Symbicort
4. Maintenance 160/4.5 Symbicort AND as needed Symbicort
5. Symbicort 160/4.5 PLUS Spiriva PLUS as needed Symbicort reliever
-OR Trelegy, SABA or SABA ISC reliever
*Refer - type 2 phenotype: add biologic therapy
START AT IF
1-2. less than 4-5 days a wk
3. sx most days, waking with asthma
4. daily sx, waking with asthma, low lung function
12+ Adults - Track 2: Alternative Controller and Reliever
2 inhlaers needed
-Controller
-Reliever: ProAir (albuterol) or AirSuptra
- Take ICS whenever SABA taken
- Low dose maintenance ICS (Flovent diskus, Flovent HFA, or QVAR)
- Low dose ICS LABA (Dulera or Symbicort)
- Medium/high dose ICS LABA (Dulera or Symbicort)
- Add Spiriva or switch to Trelegy
*refer - biologics therapy
Other Controller Options
-LTRA: Singular/Montelukast (ex)
-Can add azithromycin in step 5 for adults
Track 1 Advice
-Emphasize that they should use ICS formoterol instead of previous SABA and additional inhaler with more sx
-1 at home, 1 to go
-Rinse and spit out after maintenance doses (not needed for reliever)
Difficult to Tx/Severe
-Refer to specialist
-Blood Eosinophils/FeNO
-Biologics if tx already optimized
-Maintenance OCS as last resort
6-11 yo Children Track
- low dose ICS taken whenever SABA taken (FQ + ALB)
- daily low dose ICS (FQ)
- low dose ICS LABA or medium dose ICS, or low dose ICS formoterol (FQ OR SYM/DU)
- medium dose ICS LABA or low dose ICS formoterol (DU OR SYM)
- Refer, phenotype assess, high dose ICS LABA, biologic therapy
Reliever
-As needed SABA (or ICS formoterol for MART only in step 3-4)
Follow Ups
- Patients should be seen 1-3 months after starting treatment & every 3-12 months thereafter
- Every 4-6 weeks in pregnancy
- After an exacerbation, within 1 week
New med: 1-2 weeks, 1 month max
Stepping Up
Short term step up
-for 1-2 weeks during viral infection or allergen exposure
Sustained step up
-for 2-3 months if sx persist
-assess technique, adherence, risk factors, conditions
Consider stepping down when:
- Good asthma control has been achieved and maintained for 2–3 months
- If asthma is well controlled on low-dose ICS or LTRA, as- needed low-dose ICS-formoterol is a step-down option
- Do not completely withdraw ICS, except if needed temporarily while confirming the diagnosis of asthma
Management of Exacerbation in Primary Care
Mild or Mod
-SABA 4-10 puffs every 20 min for 1 hr
-Prednisolone: 40-50 mg for adults (5-7 days), 1-2 mg/kg for children (40 max, 3-5 days)
-Oxygen
Severe or Life Threat
-Transfer to acute care
-SABA, ipratropium bromide (Atrovent), oxygen, systemic CS
Management of Exacerbation in Acute Care (Emergency Department)
Mild or Mod
-SABA
-Ipro bromide (Atrovent)
-Oxygen
-Oral CS
Severe
-SABA
-Ipra bromide (Atrovent)
-Oxygen
-Oral or IV CS
*oral is as effective/preferred (quicker, less invasive, cheaper)
*BUT give IV if pt is too SOB to swallow or unconscious
Dose: prednisolone 50 mg as single dose or hydrocortisone 200 mg/day in divided doses
Short Acting Beta-2 Agonists (SABA)
-Albuterol (ProAir, Ventolin)
-Levalbuterol (Xopenex®)
Adverse Effects:
-Nervousness
-Tremor
-Tachycardia
-HA
-N/V
-Hypokalemia
NN TT HH
