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Flashcards in Asthma Deck (30)
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1

Which of these spirometry results confirm diagnosis of asthma

A) FEV1 increase ≥160 mL and ≥10% from baseline

B) FEV1 increase ≥180 mL and ≥12% from baseline

C) FEV1 increase ≥200 mL and ≥12% from baseline

D) FEV1 increase ≥220 mL and ≥10% from baseline

C) FEV1 increase ≥200 mL and ≥12% from baseline

Spirometetry results:

FEV1 before and 10-15 minutes after bronchodilator

Reversible airflow limitation?
FEV1 increase ≥200 mL and ≥12% from baseline

Expiratory airflow limitation?
(FEV1/FVC < lower limit of normal for age)

2

Which of these are more likely to be diagnostic of asthma

A) Wheeze, Dizziness, Cough, Change in voice

B) Heavy smoker, Breathlessness, History of allergies, Cough

C) Wheeze, Light-headedness, Chronic sputum production, Cough

D) Breathlessness, Chest tightness, Cough, Wheeze

D) Breathlessness, Chest tightness, Cough, Wheeze

Asthma is more likely to explain the symptoms if any of these apply:

More than one of these symptoms:
- wheeze
- breathlessness
- chest tightness
- cough
- Symptoms recurrent or seasonal
- Symptoms worse at night or in the early morning
- History of allergies (e.g. allergic rhinitis, atopic dermatitis)
- Symptoms obviously triggered by exercise, cold air, irritants, medicines (e.g. aspirin or beta blockers), allergies, viral infections, laughter
- Family history of asthma or allergies
- Symptoms began in childhood
- Widespread wheeze audible on chest auscultation
- FEV1 or PEF lower than predicted, without other explanation
- Eosinophilia or raised blood IgE level, without other explanation
- Symptoms rapidly relieved by a SABA bronchodilator

Asthma is less likely to explain the symptoms if any of these apply:
- Dizziness, light-headedness, peripheral tingling
Isolated cough with no other respiratory symptoms
- Chronic sputum production
- No abnormalities on physical examination of chest when symptomatic (over several visits)
- Change in voice
- Symptoms only present during upper respiratory tract infections
- Heavy smoker (now or in past)
- Cardiovascular disease
- Normal spirometry or PEF when symptomatic (despite repeated tests)

3

At what age can a formal diagnosis of asthma be made

A) > 1 years old

B) > 2 years old

C) > 4 years old

D) > 6 years old

D) > 6 years old

There is no single reliable test (‘gold standard’) and there are no standardised diagnostic criteria for asthma.

The diagnosis of asthma is based on:

history
physical examination
considering other diagnoses
clinical response to a treatment trial with an inhaled short-acting beta2 agonist reliever or preventer

Infants (age 0–12 months)

Asthma should not be diagnosed in infants aged less than 12 months old. Wheezing in this age group is most commonly due to acute viral bronchiolitis or to small and/or floppy airways. Infants with clinically significant wheezing should be referred to a paediatric respiratory physician or paediatrician.

Preschool wheeze (age 1–5 years)

Although many individuals later diagnosed with asthma first show respiratory symptoms by the age of 5 years, it is difficult to make the diagnosis of asthma with a high degree of certainty in children aged 1–5 years, because:

- episodic respiratory symptoms such as wheezing and cough are very common in children, particularly in children under 3 years
- objective lung function testing by spirometry is usually not feasible in this age group
- a high proportion of children who respond to bronchodilator treatment do not go on to have asthma in later childhood (e.g. by primary school age).

Children aged 6–11 years

In school-aged children able to perform spirometry, the diagnosis is supported by documentation of variable expiratory airflow limitation.

Adolescents

In older adolescents, the guidance on the diagnosis of asthma in adults generally applies.

4

What peak expiratory flow rate (PEFr) would suggest a diagnosis of asthma

A) >6% diurnal variation in PEFr with twice-daily readings (averaged for one week)

B) >8% diurnal variation in PEFr with twice-daily readings (averaged for one week)

C) >10% diurnal variation in PEFr with twice-daily readings (averaged for one week)

D) >12% diurnal variation in PEFr with twice-daily readings (averaged for one week)

C) >10% diurnal variation in PEFr with twice-daily readings (averaged for one week)


Peak expiratory flow meters in asthma diagnosis

Occasional measurement of peak expiratory flow rate using a peak flow meter is not as reliable as spirometry in the diagnosis of asthma and should not be used as a substitute.

However, peak expiratory flow monitoring can be used to support the diagnosis of asthma in some patients (e.g. as one of several investigations in the assessment of suspected work-related asthma).

When using peak expiratory flow rate to measure lung function in diagnostic investigation, greater than 10% diurnal variation in peak expiratory flow rate with twice-daily readings (averaged for one week) suggests a diagnosis of asthma

*Do not use peak flow meters in place of spirometry for diagnosing asthma*

5

Which of the following are a variable expiratory airflow limitation according to the guidance

A) A clinically important increase in FEV1 15–30minutes after administration of bronchodilator

B) A clinically important increase in lung function after a trial of 2 or more weeks of treatment with an inhaled corticosteroid

C) A clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on separate visits)

D) A clinically important variation in peak expiratory flow (diurnal variability of more than 20%)

C) A clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on separate visits)

Definition of Variable expiratory airflow limitation:

Most of the tests for variable airflow limitation are based on showing variability in FEV1 measured by spirometry. While reduced FEV1 may be seen with many other lung diseases (or due to poor spirometric technique), airflow limitation is identified by a reduction in the ratio of FEV1 to FVC, compared with population-derived normal values for the person’s age.

Variable airflow limitation (beyond the range seen in healthy populations) can be documented if any of the following are recorded:

A clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children)
- 10–15 minutes after administration of bronchodilator
- after a trial of 4 or more weeks of treatment with an inhaled corticosteroid

A clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on separate visits)

A clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing uses different criteria for exercise-induced bronchoconstriction)

A clinically important variation in peak expiratory flow (diurnal variability of more than 10%)

A clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness (exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

6

An asthmatic currently taking regular daily low-dose ICS and as required SABA experiences night time wheezing and is using their salbutamol 3 times per week, what changes would you make

A) Review inhaler technique and adherence and make no changes

B) Review inhaler technique and adherence and consider adding regular LABA

C) Review inhaler technique and adherence and increase ICS dose

D) Review inhaler technique and adherence, add LABA and refer to specialist for consideration of tiotropium

B) Review inhaler technique and adherence and consider adding regular LABA

7

An asthmatic currently taking regular daily medium-high dose ICS-LABA combo and as required SABA for the past 12 weeks has experienced some chest tightness twice weekly and is requiring salbutamol on each occasion, but has had no serious flare ups for the past year what changes would you make

A) Review inhaler technique and adherence and make no changes

B) Review inhaler technique and adherence and add tiotropium

C) Review inhaler technique and adherence and reduce ICS-LABA to low dose

A) Review inhaler technique and adherence and refer to specialist for review

C) Review inhaler technique and adherence and reduce ICS-LABA to low dose

8

An asthmatic currently taking regular daily low-dose ICS-LABA combo and as required SABA for the past 2 years and has recently developed some breathlessness since the temperature has dropped, these symptoms are particularly worse during his morning runs, what would you advice

A) Consider increasing treatment for 4-6 weeks, then dropping back down when symptoms resolve

B) Consider investigating for a possible alternative diagnosis

C) Consider reducing treatment as he has relatively good control of his asthma symptoms

D) Advice no need for any changes currently

D) Advice no need for any changes currently

9

An asthmatic currently taking SABA as required has needed to increase ventolin use up to 3 times almost daily for the past 6 weeks due to continued breathlessness and wheezing, sometime waking him at night. What's the best option in managing this

A) Investigate for alternative diagnosis

B) Add low dose ICS-LABA and continue with SABA reliever PRN

C) Add medium-high dose ICS-LABA and continue with SABA reliever PRN

D) Trial Symbicort Turbuhaler (Budesonide/formoterol) as required for the next 6 weeks instead of SABA

D) Trial Symbicort Turbuhaler (Budesonide/formoterol) as required for the next 6 weeks instead of SABA

10

An asthmatic currently using SABA as required has partial control of their asthma with more than twice weekly daytime symptoms and symptoms waking through the night. This has been ongoing for a few months. He is aware he requires more medication but reluctant to start taking steroids despite knowing this is the next step. What would you advise

A) Start taking the SABA more regularly each day

B) Consider a 6 week trial of montelukast daily

C) Consider a 6 week trial of LABA daily with SABA as required

D) Advise them unfortunately they will have to add daily ICS to their regime but this can be stopped in 3 months if their symptoms improve

B) Consider a 6 week trial of montelukast daily

Info from ETG: https://tgldcdp.tg.org.au/viewTopic?topicfile=asthma-maintenance-management#toc_d1e431

An alternative option for Step 2 therapy is to take a low dose of an ICS (using the doses above) whenever a dose of SABA is required, following a similar principle to using as-required low-dose budesonide+formoterol.

Montelukast can be considered instead of an ICS-based treatment, although it is less effective than regular daily low-dose ICS for controlling asthma symptoms and reducing exacerbation risk. It can be trialled in patients who have experienced adverse effects with ICS, or who remain unwilling to use steroid-based therapy after an informed discussion with their clinician. It may also be useful in patients with coexisting allergic rhinitis, or in whom inhaled therapy is not practical.

Use: Montelukast 10 mg orally, once daily

11

An asthmatic recently increased dose of their regular ICS-LABA combo due to poor control. They have been on the higher dose for more than 8 weeks with little effect. You have considered alternative diagnoses but are confident this is poorly controlled asthma. What's the next step in management

A) Consider adding tiotropium and refer to specialist

B) Consider adding tiotropium and review in 4-8 weeks

C) Increase ICS-LABA use from BD to TDS with continued SABA reliever as required

D) Add montelukast to their regime and review in 4-8 weeks

A) Consider adding tiotropium and refer to specialist

Assessing control (https://www.asthmahandbook.org.au/management/adults/initial-assessments/control-risk)

Maintenance/Management of asthma:

ETG - https://tgldcdp.tg.org.au/viewTopic?topicfile=asthma-maintenance-management#toc_d1e543

Asthma handbook - https://www.asthmahandbook.org.au/management/adults

Good Control

All of:
- Daytime symptoms ≤2 days per week
- Need for SABA reliever ≤2 days per week†
- No limitation of activities
- No symptoms during night or on waking

Partial Control

One or two of:
- Daytime symptoms >2 days per week
- Need for SABA reliever >2 days per week†
- Any limitation of activities
- Any symptoms during night or on waking

Poor Control

Three or more of:
- Daytime symptoms >2 days per week
- Need for SABA reliever >2 days per week†
- Any limitation of activities
- Any symptoms during night or on waking

12

When making a rapid primary assessment you note a patient is in respiratory distress and unable to complete sentences in one breath due to dyspnoea. Their O2 sats are 90% an they are using their accessory muscles and you note there is tracheal tug presents.

Which level of severity would you class them?

A) Mild

B) Mild/Moderate

C) Severe

D) Life Threatening

C) Severe

Mild/Moderate:
- Can walk, speak whole sentences in one breath (For young children: can move around, speak in phrases)
- Oxygen saturation >94%

Severe:
- Use of accessory muscles of neck or intercostal muscles or ‘tracheal tug’ during inspiration or subcostal recession (‘abdominal breathing’)
- Unable to complete sentences in one breath due to dyspnoea
- Obvious respiratory distress
- Oxygen saturation 90–94%

Life Threatening:
- Reduced consciousness or collapse
- Exhaustion
- Cyanosis
- Oxygen saturation <90%
- Poor respiratory effort, soft/absent breath sounds

13

A patient presents to ED unable to complete full sentences, using intercostal muscles to breath and is cyanosed.

Which level of severity would you class them?

A) Mild

B) Mild/moderate

C) Severe

D) Life Threatening

D) Life Threatening

If features of more than one severity category are present, record the higher (worse) category as overall severity level

The severity category may change when more information is available (e.g. pulse oximetry, spirometry) or over time.

The presence of pulsus paradoxus (systolic paradox) is not a reliable indicator of the severity of acute asthma.

Oxygen saturation measured by pulse oximetry. If oxygen therapy has already been started, it is not necessary to cease oxygen to do pulse oximetry.

Oxygen saturation levels are a guide only and are not definitive; clinical judgment should be applied.

14

Initial bronchodilator treatment in acute Mild/Moderate asthma for adults and children over 6 years old

- Give salbutamol† 4-12 puffs (100 microg/actuation) via pMDI and spacer

- Give one puff at a time followed by 4 breaths

- Repeat every 20-30 minutes for the first hour if required (sooner, if needed to relieve breathlessness)

15

Initial bronchodilator treatment in acute Severe asthma for adults and children over 6 years old

Give salbutamol plus ipratropium

Salbutamol†: 12 puffs (100 microg/actuation) via pMDI and spacerIf patient unable to breathe through a spacer, give 5 mg nebule via nebuliser‡Ipratropium: 8 puffs (21 microg/actuation) via pressurised metered-dose inhaler and spacer every 20 minutes for first hour

Repeat 4–6 hourly for 24 hours

If salbutamol delivered via nebuliser add 500 micrg ipratropium to nebulised solution every 20 minutes for first hour

Repeat 4–6 hourly

Start oxygen therapy if oxygen saturation <92% in adults or <95% in children and titrate to target:
Adults: 93–95%
Children: 95% or higher

Repeat salbutamol as needed. Give at least every 20 minutes for first hour (3 doses)

16

Initial bronchodilator treatment in acute Life Threatening asthma for adults and children over 6 years old

Give salbutamol plus ipratropium

Salbutamol: 2 x 5 mg nebules via continuous nebulisation driven by oxygen Ipratropium: 500 microg ipratropium added to nebulised solution every 20 minutes for first hour.

Repeat 4–6 hourly

Maintain oxygen saturations
Adults: 93–95%
Children: 95% or higher

Arrange immediate transfer to higher-level care

When dyspnoea improves, consider changing to salbutamol via pMDI plus spacer or intermittent nebuliser‡ (doses as for severe acute asthma)

17

Four important points to be aware of in acute asthma treatment

⚠ Do not use IV short-acting beta2 agonists routinely for initial bronchodilator treatment

⚠ Do not give oral salbutamol

⚠ Monitor for salbutamol toxicity (e.g. tachycardia, tachypnoea, metabolic acidosis, hypokalaemia) – may occur with inhaled or IV salbutamol

⚠ Give adrenaline if anaphylaxis suspected. Consider adrenaline if the patient is unresponsive, cannot inhale bronchodilators, or is considered to be peri-arrest.

18

An 8 month boy is brought in by mum for respiratory distress and loud wheeze.
Which would be the best option for management:

A) Give inhaled adrenaline and monitor for improvement

B) Give SABA2 agonist and systemic corticosteroids and monitor for improvement

C) Discharge home with oral antibiotics and advise follow up with the GP

D) Call the paediatrician on-call for advice

D) Call the paediatrician on-call for advice

Wheezing infants younger than 12 months old should not be treated for acute asthma. Acute wheezing in this age group is most commonly due to acute viral bronchiolitis.

Advice should be obtained from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids or inhaled corticosteroids to an infant.

19

Salbutamol doses

Intermittent nebulisation with salbutamol

Use one nebule:

Adults and children over 6: 5 mg nebule

Children aged 1-5 years: 2.5 mg nebule


Continuous nebulisation with salbutamol using nebules:

Put two nebules into nebuliser chamber at a time and repeat to refill when used up

Adults and children over 6: use two 5 mg nebules (10 mg) at a time

Children aged 1-5 years: use two 2.5 mg nebules (5 mg) at a time

20

Ipratropium doses

Add one nebule to salbutamol nebuliser solution:

Adults and children over 6: 500 microg nebule

Children aged 1-5 years: 250 microg nebule

21

Two important points to remember in using nebulisers

⚠ If using oxygen to drive a nebuliser, do not exceed 8–10 L/minute and avoid over-oxygenation (increases risk of hypercapnoea).

⚠ The use of nebulisers increases the risk (to staff and patients) of nosocomial aerosol infection. If using a nebuliser, follow your organisation’s infection control protocols to minimise spread of respiratory tract infections.

22

Corticosteroids in acute asthma (Adults)

For adults with acute asthma, start systemic corticosteroids within 1 hour of presentation (unless contraindicated), regardless of severity at initial assessment.

Give starting dose of prednisolone 37.5–50 mg, then repeat each morning on second and subsequent days (total 5–10 days).

It is usually not necessary to taper the dose unless the duration of treatment exceeds 2 weeks.

23

Corticosteroids in acute asthma (Children)

For children aged 6-11 years with acute asthma (and children aged 1–5 if acute wheezing is severe), start systemic corticosteroids within 1 hour of presentation (unless contraindicated).

Give prednisolone 1 mg/kg (maximum 50 mg) orally each morning for 3 days.

It is usually not necessary to taper the dose unless the duration of treatment exceeds 2 weeks.

For children aged 1-5 years, systemic corticosteroids should generally be limited to those with severe acute wheezing to avoid over-use (particularly for those with intermittent viral-induced wheezing).

24

Can dexamethasone be given as an alternative to prednisolone?

Yes

Oral dexamethasone (if available) can be used as an alternative to prednisolone.

Children: 0.6 mg/kg as a single dose (can be repeated on the following day if needed)

Adults: 16 mg for 2 days then cease.

Do not exceed 2 days of treatment

25

What are the alternatives if oral corticosteroids can be taken?

For adults, if corticosteroids cannot be given orally, give IV hydrocortisone 4 mg/kg (maximum 100 mg) every 6 hours for 24 hours then reduce over next 24 hours or switch to oral prednisolone


For children, if corticosteroids cannot be given orally, give intravenously

Give either of the following:

- Hydrocortisone IV 4 mg/kg (maximum 100 mg) every 6 hours on day 1 then reduce (every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5) or switch to oral prednisolone

- Methylprednisolone IV 1 mg/kg (maximum 60 mg) every 6 hours on day 1 then reduce (every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5) or switch to oral prednisolone


For children aged 1-5 years, systemic corticosteroids should generally be limited to those with severe acute wheezing

Do not use inhaled corticosteroids as a substitute for systemic corticosteroids in adults or children

26

What are the second line bronchodilators that are recommended to use in acute ashtma

Inhaled ipratropium bromide
- Second-line bronchodilator if inadequate response to salbutamol

IV magnesium sulfate
- Second-line bronchodilator in severe or life-threatening acute asthma, or when poor response to repeated maximal doses of other bronchodilators

27

What are third line bronchodilators recommended for us in severe/life threatening asthma

IV salbutamol (only in ICU)
- Third-line bronchodilator in life-threatening acute asthma that has not responded to continuous nebulised salbutamol after considering other add-on treatment options

Aminophylline
- Third-line bronchodilator in life-threatening acute asthma that has not responded to continuous nebulised salbutamol after considering other add-on treatment options

Adrenaline
- Limit to patients unresponsive with poor respiratory effort where inhaled bronchodilators cannot be given, or where respiratory arrest imminent

28

When should you consider blood gas analysis in acute asthma assessment

- unable to speak due to dyspnoea

- reduced consciousness or collapse

- exhaustion

- cyanosis

- SpO2 <92%

- poor respiratory effort

- cardiac arrhythmia

29

When should you consider admitting the patient with acute asthma in Adults

- hypoxia at presentation

- FEV1 <60% predicted (or 50% of usual, if known) at 1-hour check

- respiratory distress/increased work of breathing unresolved or unable to lie flat without dyspnoea 1–hours after presentation

- a history of ICU admission for asthma presentation for acute asthma within the past 4 weeks

- frequent presentations for acute asthma (e.g. several over previous year)

- high recent use of beta2 agonists

- patient cannot be monitored adequately at home or cannot easily return to hospital if needed

- other risk factors for adverse outcomes

30

When should you consider admitting the patient with acute asthma in Children

- hypoxia at presentation

- respiratory distress/increased work of breathing unresolved 1–2 hours after presentation

- a history of ICU admission for asthma
presentation for acute asthma within the past 4 weeks
frequent presentations for acute asthma (e.g. several over previous year)

- high recent use of beta2 agonists

- patient cannot be monitored adequately at home or cannot easily return to hospital if needed

- confirmed food allergy

- other risk factors for adverse outcomes.