Asthma Flashcards

Question

What are the Type 2 inflammation criteria? (only 1 is required to fulfil Type 2 inflam criteria)

Answer 1

i. Eosinophils ≥150/microL ii. FeNO ≥20ppb iii. Sputum eosinophils ≥2% iv. Asthma is clinically allergen driven (Repeat eosinophils & FeNO up to 3x, at least 1-2w after OCS or on lowest OCS dose)

Answer 2

_In Type 2 inflammation_: i. FeNO to check adherence ii. Increase ICS for 3-6m iii. Consider add-on non-biologic: LTRA, aspirin desensitisation, treat comorbidities iv. Add on non-biologic Rx e.g. ABPA, rhinosinusitis, nasal polyposis, atopic dermatitis Rx v. If biologic agents not an option: a) High dose ICS b) Add-on LAMA, LTRA, low dose azithro c) Low dose OCS with Rx to prevent SE d) Stop ineffective therapies vi. Biologic agents – consider checking & treating parasite infection first - Funding for biologic in Msia: self-funding, application from JPA _In non-type 2 airway inflammation_: i. Review DDx, inhaler technique, adherence, comorbidities, med side-effects ii. Avoid exposure: smoking, allergen, irritants (at home & work) iii. Other Ix that has not been done e.g. bronch (TRO tracheobronchomalacia, subglottic stenosis), HRCT iv. Trial of add-on Rx: LAMA, low dose azithromycin (check sputum for NT, do ECG and recheck after 1m) & consider Abx resistance v. Anti-IL4R (Dupilumab) if taking OCS vi. Anti-TSLP (Tezepelumab) vii. Low dose OCS + Rx to prevent SE viii. Bronchial thermoplasty ix. Stop ineffective therapies

Answer 3

**Anti-IgE**: a) eos ≥260/microL b) FeNO ≥20ppn c) Allergen-driven d) Childhood-onset **Anti-IL5/ Anti-IL5R**: a) Eos ++ (≥150 /microL or ≥300/microL) b) more exac in previous year c) Adult-onset d) Nasal polyposis **Anti-IL4R**: a) Eos ++ (≥150 and ≤1500/microL) b) High FeNO ≥25ppb c) taking OCS **Anti-TSLP**: a) Eos ++ b) High FeNO

Answer 4

i. Choose the most appropriate biologic ii. Trial of at least 4m and reassess response iii. If **good response**, re-evaluate every 3-6m - Consider reducing OCS (check for adrenal insuff. If unwell, need to get OCS for 6m post cessation of OCS), then stop other add ons. Continue mod dose ICS-LABA - Consider stopping biologic after 12m if Sx well controlled on mod dose ICS-LABA & no further exposure to allergic trigger. Some pts may relapse. iv. If **unclear response**, extend trial to 6 to 12m v. If **no good response**, consider switching to different biologic. vi. If still no good response, stop biologic. Do Mx as per non-Type2 – continue to optimise inhaler technique, adherence, non-pharmacological strategies, social/emo needs, communication with GP _Response review by looking at_: i. Asthma Sx, exac & lung function ii. Other Type 2 comorbids – nasal polyposis, atopic dermatitis iii. Meds: treatment side effects, affordability iv. Pt satisfaction

Answer 5

Pts who have persistent airflow limitation together with clinical features that are consistent with both asthma and COPD

Answer 6

i. All pts should receive written, electronic or pictorial asthma action plan ii. Details of the best PEF, current regimen iii. Details of signs of worsening Sxs & next step. iv. When to increase the dose/ present to hosp

Answer 7

_Asthma Action Plan_ i. All pts should receive written, electronic or pictorial asthma action plan ii. Details of the best PEF, current regimen iii. Details of signs of worsening Sxs & next step. iv. When to increase the dose/ present to hosp

Answer 8

Mx of exac of asthma in primary care: A) Determine severity _Mild-mod features_: - Talk in phrases - Prefers sitting (to lying) - Not agitated - RR increased - No accessory muscle use - HR 100-120 - SpO2 90-95% - PEF >50% predicted _Severe features_: - Talks in words - Sits hunched forward - Agitated - RR >30 - Accessory muscle use - HR >120 - SpO2 <90% - PEF ≤50% predicted _Life-threatening features_: - Drowsy - Confused - Silent chest B) Treatment: 1) ABC 2) SABA 4-10p, every 20mins for 1h, then every 1-4h PRN 3) Pred 40-50mg (1mg/kg) 4) O2 – aim SpO2 93-95% 5) Ax for d/c in mild-mod, or transfer to hosp in life-threatening - D/c if: i) Sx improved not needing SABA, ii) PEF >60-80%, iii) SpO2 >94%, iv) resources at home adequate 6) If d/c: Cont reliever, start or step up controller, pred for 5-7d, f/up 2-7d. Abx only if with infection evidence 7) F/up: - check whether exac resolving, - reduce reliever, - cont controller higher dose for 1-2w or 3m (depend on exact), - check risk factors inc technique & adherence. - Refer if >1-2 exac/year. - Ax whether action plan needs to be modified

Answer 9

_SABA overuse_: Regular use of SABA in 1-2w --> beta-receptor downregulation --> increased airway hyperresponsiveness and increased eosinophilic inflammation --> reduce bronchodilator response SE: hypoK, hyperlactatemia, hyperglycemia, tachycardia, tremors _OCS_: Short term SE: - sleep disturbance, - increased appetite, - reflux, - mood change, - sepsis, - VTE #Use of ICS 4-5 lifetime courses assoc with osteoporosis, fractures, DM, CCF, cataract

Answer 10

Treatment of asthma exac in ED: 1) ABC – if drowsy/ confused/ silent chest → refer ICU, SABA & prepare intubation 2) Ax severity features Mild-mod features: - Talk in phrases - Prefers sitting (to lying) - Not agitated - RR increased - No accessory muscle use - HR 100-120 - SpO2 90-95% - PEF >50% predicted Severe features: - Talks in words - Sits hunched forward - Agitated - RR >30 - Accessory muscle use - HR >120 - SpO2 <90% - PEF ≤50% predicted 3) Mild-mod Mx: SABA, consider ipratropium, O2 supp (aim 93-95%), OCS 4) Severe Mx: SABA, ipratropium, O2 supp, OCS or iv steroid, consider IV Mg, consider high dose ICS 5) Ax frequently with lung function to be Ax in 1h after Rx 6) Monitor K level with high dose of SABA 7) D/c if FEV1 or PEF 60-80% predicted or personal best 8) If required ICU, below are other Mx in refractory bronchospasm; - NIV/ IMV - Bronch for mucous plugging - Sedative/ muscle relaxant (e.g. Ketamine, propofol) - Inhaled anaesthetics (e.g. isoflurane) - ECMO, ECCO2-R

Answer 11

Dosing of meds: a) Salbutamol neb: - Salbutamol 0.5% inhalation solution - Dose: 2.5-5mg, repeat every 20mins for 1 hour b) Salbutamol infusion: - Salbutamol 5mg/5ml - Dose: **Loading** dose 0.25mg over 10mins Dilute 0.5mls (0.5mg) of salbutamol in 20mls N/saline Use syringe pump. Rate: 60mls/hr (20mls over 20mins) **Infusion** dose: 5-20mcg/min Dilute 3mls (3mg) of salbutamol in 50mls N/saline or D5% 1ml /hr = 1mcg/min Run 5-20mls/hr c) Ipratropium bromide - Ipratropium bromide 0.025% inhalation solution (250mcg/ml) - Dose: 0.5mg, repeat every 4-6h d) MgSo4 - Dose: 2g over 20mins e) Hydrocortisone - Dose: 200mg stat, and 100mg TDS f) Pred - Dose: 1mg/kg (max 50mg) OD 5-7d g) Adrenaline - Use in angioedema/ allergy - Adrenaline 1:1000 (1mg/ml) - Dose: IM: 0.5mg every 20mins (max 3 doses) S/cut: (same as IM) IV: 0.1mcg/kg/min h) Aminophylline - Not recommended due to adverse & cardiac effects - Dose: iv 6mg/kg over 30mins, then IVI 0.5mg/kg/h. Check serum level with aim 8-12 mcg/ml i) Ketamine - Dose: 0.1-0.5mg/h j) Propofol - Dose: 5-50mcg/kg/min

Answer 12

Criteria for hospitalisation vs D/c from ED 1) Pre-Rx FEV1 or PEF <25%, or post-Rx FEV1 or PEF <40% → admit 2) Post-Rx 40-60%, d/c possible after Ax pt’s risk & availability of f/up 3) Post-Rx >60% → d/c Other risk factors for admission: 1) Female, older, non-white 2) ≥8x SABA in past 24h 3) Severe exac 4) PHx of severe exac (intubation, admission) 5) Previous OCS use 6) Social circumstance

Answer 13

D/c planning post exac: 1) F/up 2-7d 2) Use MART or AIR (to reduce severe exac & OCS use) compared to SABA reliever 3) Review pt’s understanding of triggers, modifiable risk factors (i.e. smoking), technique, actions needed if deteriorated 4) Optimise pt’s Rx

Answer 14

a) Spiro with reversibility test: Increase in FEV1 >12% and >200ml b) Excessive variability in twice-daily PEF over 2 weeks: **>10%** c) Increase lung function after 4 weeks of Rx: Increase FEV1 >12% and >200ml d) Positive **exercise challenge test**: **Decrease FEV1 >10% and >200ml** e) Positive **bronchial challenge test**: **Decrease FEV1 ≥20%** (with methacholine) or **≥15%** (with hyperventilation, hypertonic saline or mannitol) f) Excessive variation in lung function between visits: Decrease FEV1 >12% and >200ml

Answer 15

_Phase 3 trials for specific biologics_: Mepolizumab: MENSA, SIRIUS Benralizumab: CALIMA, SIROCCO, ZONDA Dupilumab: QUEST, VENTURE Omalizumab: EXTRA _Special points_: - Anti-IL5/5R does not look at FENO - so FENO is not applicable in deciding for it - Dupilumab has specific advantages: a) better FEV1 improvement (QUEST study) b) biggest reduction in OCS use (SINUS 24 study) c) biggest reduction in nasal polyposis (SINUS 24 study) - Dupilumab can unmask EGPA

Answer 16

1) OCS regular use 2) EOS 3) FENO 4) Allergy driven 5) CRSwNP