Asthma Flashcards
Criteria for Asthma Diagnosis (2)
- history of variable respiratory sx’s (Current or historical sx’s of wheezing, cough, hard to breathe, chest tightness)
-Sx’s that worsen with exercise, viral infection, environmental factors, weather changes
-Sx’s that occur or worsen at night or awaken the pt - Evidence of variable expiratory airflow limitations
-FEV1 increases after inhaling SABA
PFT findings with asthma ?
What’s a normal FEV1?
WHat’s a normal FEV1/FVC ratio?
Incr in FEV1 of >12% 10-15 mins after 200-400 mcg albuterol or equivalent
> 80% or about 4L in adults
Normal : within 5% of predicted range, usually 80% in adults
Assessment of Sx’s Control
In the past 4 weeks has the patient had? List the four criteria and state which criteria are met for well controlled, partly controlled, and uncontrolled
- Daytime sx’s more than twice/week
- Any night time waking due to asthma?
- SABA reliever needed more than twice a week?
- Any activity limitation due to asthma?
Well = none of these
Partly = 1-2 of these
Uncontrolled = 3-4 of these
Risk factors for exacerbations ?
Medications (SABA overuse)
Exposures : smoking allergens air pollution
Lung function : low fev1
Type2 inflamm markers like eosinophils
Comorbidities : obesity, GERD, food allergy , anxiety, depression
Asthma Severity Categories : GINA
-Asthma severity is assessed ___, after at least ___ of tx, from the level of tx required to control sx’s and reduce exacerbations
Describe each Asthma Severity Category
MILD, MODERATE, SEVERE
-retrospectively
-2-3 months
MILD : Asthma that’s well controlled with as needed ICS FORMOTEROL , or w/low dose ICS
*Mild asthma still needs ICS tx
-30-37% of adults
*still at high risk of serious adverse effects and exacerbations
Moderate : Asthma that’s well controlled with Step 3 or 4 maintenance tx i.e with low or medium dose ICS-LABA in either tx track
SEVERE : Asthma remains uncontrolled despite optimized tx with high dose ICS-LABA or that requires high dose ICS-LABA to prevent it from becoming uncontrolled
-3-10% of pt’s w asthma
GINA 2023 Starting tx in adults and adolescents with diagnosis of asthma
First you need to assess :
-Confirm ___
-Sx control and ____
-C
-Inhaler __ and __
-Patient __ and __
diagnosis
modifiable risk factors
comorbidities
technique, adherence
preference, goals
GINA GUIDELINES ADULT TRACK 1
Describe Steps 1-2,3,4,5 and what med you would use for each step
Describe what the reliever medication is
Note, steps 3-5 use MART which is symbicort!
STEPS :
1-2 –> Sx’s less than 4-5 days a week . As needed only low dose ICS-formoterol (AIR)
3 –> Sx’s most days, or waking w/asthma once a week or more. Low dose maintenance ICS-formot.
4–> Daily sx’s or waking with asthma once a week or more, AND low lung function .Medium dose maintenance ICS-formot
5–> Add-on LAMA. Refer for phenotypic assessment +/- biologic therapy. Consider high dose ICS formoterol .
RELIEVER : As needed Low dose ICS formoterol
GINA GUIDELINES ADULT TRACK 2
Describe Steps 1,2,3,4,5 and what med you would use for each step
Describe what the reliever medication is
STEPS
1–> Sx’s less than 2x a month. Take ICS whenever SABA taken (AIR option?)
2–> Sx’s twice a month or more, but less than 4-5 days a week. Low dose maintenance ICS
3–> Sx’s most days, or waking with asthma once a week or more. Low dose maintenance ICS -LABA
4–> Daily sx’s, or waking with asthma once a week or more, and low lung function . Medium/high dose maintenance ICS-LABA.
5–> Add on LAMA. refer for phenotypic assessment +/- biologic therapy. Consider high dose ICS-LABA .
RELIEVER : As needed ICS-SABA or as needed SABA
ICS Formoterol should not be used as the reliever by which group of pt’s ?
Pt’s who are taking a different maintenance ICS-LABA (Like advair or breo) –> U should use ICS-SABA or just plain SABA in these patients
Or if a pt is on Trelegy (LAMA, LABA + ICS) –> switch reliever to SABA or ICS SABA
When should pt’s be seen after starting tx?
And how often thereafter?
What about for pregnancy?
After an exacerbation ?
Individualized to the pt based on ?
1-3 months after starting tx. every 3-12 months thereafter
4-6 wks in preg
within 1 wk
risks
Stepping Up :
Describe the short term step up. Who initiates, why, mostly done for which set of pt’s?
Describe the sustained step up. Durations, why, and what you need to assess before considering step up
Short term step up for 1-2 weeks by clinician or pt with written asthma action plan during viral infection or allergen exposure! Mostly only needed for pt’s in track 2 whose reliever is SABA
Sustained step up for at least 2-3 months if sx’s and or exacerbations persist despite 2-3 months of ICS containing tx, assess the following common issues before considering step up : Incorrect inhaler technique, poor adherence, modifiable risk factors like smoking, are sx’s due to comorbid conditions like allergic rhinitis?
How to manage uncontrolled asthma in primary care clinic ?
- watch pt use their inhaler. Discuss __ and __
- COnfirm ___ of asthma
- Remove potential RF and assess and manage ___.
-switch to ___
Check RF such as ?
Check comorbidities such as? - COnsider tx ___
- Refer to ?
adherence, barriers
diagnosis
comorbidities
GINA TRACK1 if possible
smoking, non selective Beta blockers, NSAIDS, allergen exposures
rhinitis, obesity, gerd, depression or anxiety
step up
specialist
When should you consider stepping down ?
Good asthma control has been achieved and maintained for 2-3 months
-Dont completely withdraw ICS!
-If asthma is well controlled on low-dose ICS or LTRA , as needed low dose ICS formoterol is a step down option
Non pharm stratgies and interventions?
Smoking cessation
physical activity-regular exercise
avoid meds that make asthma worse
avoid allergens
weight reduction
dealing with emotional stress
GINA for 6-11 years
Before deciding where they are on a track, you need to ASSESS. What are you assessing?
confirmation of diagnosis, sx control and modifiable risk factors, comorbidities, inhaler technique and adherence, child and parent/caregiver preferences and goals.
