wheezing coughing (especially at night) tightness in the chest breathlessness

Asthma Flashcards by MA CARMELA CONCEPCION SALES

Asthma is defined by the presence of both of the
following:
1
2

excessive variation in lung function

* respiratory symptoms (

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What is meant by excessive variation in lung function

(‘variable airflow limitation’ i.e. variation in expiratory
airflow that is greater than that seen in healthy
people)

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In young children in whom lung function testing
is not feasible, including most preschool children,
asthma is defined by the___________

presence of variable respiratory symptoms.

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It has an unacceptable mortality rate of
approximately________of the population.

5 per 100 000

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It tends to develop between the ages of _______ but can develop at any age

2 and 7 years,

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Key test for BA

Spirometry is the key investigation

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New aerosols, notably _________
have non-CFC propellants leading to increased
lung deposition and thus requiring overall lower
dosage.

hydrofluoroalkanes,

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Pathophysio of BA

infiltration of the mucosa with_______
_________
intermittent airway narrowing (due_______

inflammatory cells (especially eosinophils) and cellular
elements

airway hyper-responsiveness

to bronchoconstriction, congestion or oedema of
bronchial mucosa or a combination of these)

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About 90% of children with atopic symptoms
and asthma demonstrate ________
responses to dust mite extract

positive skin-prick

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Classic Sx of BA

wheezing
coughing (especially at night)
tightness in the chest
breathlessness

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Auscultation findings of BA

diffuse, high-pitched wheezes throughout inspiration and most of expiration, which is usually prolonged

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If wheeze
is not present during normal tidal breathing it may
become apparent during a ______

forced expiration

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Spirometry: a value of________ for FEV 1 /VC ratio
indicates obstruction. It is the more accurate test
and recommended for those who can perform it
(i.e. most adults and children >6 years).

<75%

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Measurement of peak expiratory flow rate
(PEFR) or spirometry before and after SA β A: has
a characteristic_________

improvement >15% in FEV 1 and

PEFR.

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__________ airway reactivity is
tested in a respiratory laboratory to inhaled
histamine, methacholine or hypertonic saline.
Sometimes useful to confirm diagnosis

Inhalation challenge tests:

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Other tests for BA

Mannitol inhalation test.

An exercise challenge may also be helpful.

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Significant advances in the management of asthma

The realisation that asthma is an inflammatory
disease. Therefore the appropriate first- or secondline
treatment in moderate to severe asthma
is ____ or _________

inhaled sodium cromoglycate (especially in

children) or inhaled corticosteroids (ICS).

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Significant advances in the management of asthma

2 The regular use of _________
3 The use of spacers attached to_______
4 Improved and more efficient inhalers.
5 Combined________

spirometry.

inhalers/puffers.

long-acting relievers and preventers including combinations of long-acting β -agonists
(LA β A) and ICS—the fixed-dose inhalers.

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Patients with moderate to severe chronic asthma
require regular measurement of ______ which is more
useful than subjective symptoms in assessing asthma
control

PEFR,

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Goal of measuring PEFR

This allows the establishment of a baseline
of the ‘patient’s best’, monitors changes, and allows
the assessment of asthma severity and response to
treatment

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______ are not a substitute for spirometry

Peak flow meters

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Some people who have trouble using metered dose
inhalers (MDIs) can have a special________fitted onto
the mouthpiece of the inhaler

‘spacer’

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Children under 5–6 years and/or 20 kg can use an

MDI and a ______

small volume valved spacer (AeroChamber,

Breath-A-Tech) with a face mask.

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Goals of BA Tx

• absent or minimal _________
• maintain best possible lung function at all
times—keep asthma under control

daytime symptoms and no nocturnal symptoms; restore normal airway function (>80% of predicted)

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Definition of good BA control

• Minimal symptoms day and night • No nocturnal waking due to asthma • No limitation of normal or physical activity • Minimal need for reliever medication • No exacerbation • Normal lung function (FEV 1 and/or PEFR >80% predicted or best) • No side effects of medication • Near or near-normal lung function (i.e. >80% predicted)

These medications are directed towards the underlying abnormalities—bronchial hyperreactivity and associated airway inflammation

‘Preventer’ drugs or anti-inflammatory | agents

Treatment with a ‘preventer’ is recommended if asthma | episodes are ______ or those who use SA β A____

>3/week | >3 times a week

ICS types

* beclomethasone * budesonide * ciclesonide (single daily dose) * fluticasone

Dose range of ICS

• 400–1600 mcg (adults); aim to keep below 500 | mcg children and 1000 mcg (adults)

SE of ICS ``` • oropharyngeal candidiasis, dysphonia (hoarse voice)—less risk with once daily_______ • bronchial irritation: cough • _________ (doses of 2000 mcg/daily; sometimes as low as 800 mcg) ```

ciclesonide adrenal suppression

Intermittent BA Status before treatment Lung function FEV1 or PEFR (% predicted)

Episodic Symptoms

Intermittent BA Recommended β-agonist Estimated starting daily dose range of ICS required to achieve good control

SAβA prn Regular ICS not required Add preventer if ≥3 SAβA/week

Mild persistent Status before treatment Lung function FEV1 or PEFR (% predicted

Symptoms >weekly, not every day Night symptoms >2 per month Symptoms regularly with exercise ≥ 80%

Mild persistent Recommended β-agonist Estimated starting daily dose range of ICS required to achieve good control

SAβA prn ``` <250 mcg beclomethasone <400 mcg budesonide <250 mcg fluticasone <160 mcg ciclesonide Increase dose if >2 SAβA 2–3 times daily ```

Moderate persistent Status before treatment Lung function FEV1 or PEFR (% predicted

Symptoms every day Night symptoms >weekly Several known triggers apart from exercise 60–80 %

MOd persistent Recommended β-agonist Estimated starting daily dose range of ICS required to achieve good control

LAβA + SAβA prn ``` 250–400 mcg beclomethasone 400–800 mcg budesonide 250–500 mcg fluticasone 160–320 mcg ciclesonide ```

Severe persistent Status before treatment Lung function FEV1 or PEFR (% predicted

Symptoms every day Wakes frequently at night with cough/ wheeze, Chest tightness on waking, Limitation of physical activity <60%

Severe persistent Recommended β-agonist Estimated starting daily dose range of ICS required to achieve good control

LAβA + SAβA prn ``` >400 mcg beclomethasone >800 mcg budesonide >500 mcg fluticasone >320 mcg ciclesonide ```

ICSs have a________ curve so it may not be necessary to prescribe above ICS doses considered high

flat dose–response

________ is used mainly for exacerbations. It is given with the usual inhaled corticosteroids and bronchodilators

Prednisolone

Dose of Prednisolone

• up to 1 mg/kg/day for 1–2 weeks

These are sodium cromoglycate (SCG) and nedocromil | sodium

Cromolyns

AE for Cromolyns

local irritation may be caused by the dry powder. Systemic | effects do not occur.

_______is used for frequent episodic asthma in children over 2 years of age for the prevention of exercise-induced asthma and the treatment of mildto- moderate asthma in some adults

Nedocromil

These drugs, which include montelukast and zafirlukast, are very useful for seasonal asthma and aspirin-sensitive asthma and reduce the need for inhaled steroids or

Leucotriene antagonists

Montelukast is taken as a _________

5 or 10 mg chewable tablet once daily

Indications for preventive therapy Guidelines for introducing preventive asthma therapy in adults and children include any of the following: * requirement of β 2 -agonist _______ * symptoms (non-exercise______ * spirometry showing ______

>3–4 times each week or >1 canister every 3 months (excluding preexercise) >3–4 times per week between attacks reversible airflow obstruction during asymptomatic phases

Indications for preventive therapy Guidelines for introducing preventive asthma therapy in adults and children include any of the following: • asthma significantly interfering with physical activity despite appropriate pre-treatment • asthma attacks_______ • infrequent asthma attacks but ________

>every 6–8 weeks severe or lifethreatening

The three groups of bronchodilators are 1 2 3

• the β 2 -adrenoceptor agonists ( β 2 -agonists)— short acting (SA β A) and long acting (LA β A) • methylxanthines—theophylline derivatives • anticholinergics

These drugs ‘stimulate’ the β 2 adrenoreceptors and thus relax bronchial smooth muscle. The inhaled route of delivery is the preferred route

β 2 -agonists

Onset of B2 agonist

The inhaled drugs produce measurable bronchodilation in 1–2 minutes and peak effects by 10–20 minutes

The traditional agents such as _______are short-acting preparations. The new longer acting agents (LA β A) include____

salbutamol and terbutaline salmeterol, eformoterol and vilanterol.

These oral drugs may have complementary value to the inhaled agents but tend to be limited by side effects and efficacy

Theophylline derivatives

This anti-IgE agent is marketed for SC injection in patients >12 years with moderate to severe allergic asthma treated by ICS and who have raised serum IgE levels

Omalizumab

This term is reserved for those medications that are taken prior to known trigger factors, particularly for exercise-induced asthma

Prophylactic agents

Meds of exercise induced asthma

β 2 -agonist inhaler (puffer): two puffs 5 minutes immediately before exercise last 1–2 hours. LA β A such as salmeterol and eformoterol are more effective

Other drugs for exercise induced asthma

• SCG or nedocromil, two puffs. • Combination β 2 -agonist + SCG (5–10 minutes beforehand). • Montelukast 10 mg (less in children ≥ 2 years) (o) daily or 1–2 hours beforehand

What are the 3 steps in BA control

Step 1: Assess asthma symptom control and identify the patient’s risk factors Step 2: Treat and adjust to achieve good control. Step 3: Review response and monitor to maintain control

For breakthrough asthma or persistent poorly controlled asthma with poor compliance switch to _________

``` combined medication (e.g. Seretide MDI Accuhaler, or Symbicort). ```

Techniques on how to use MDI The open-mouth technique and the closed-mouth technique are the main methods, and both are effective but the _________ is preferred

closed-mouth technique

The usual dose of standard MDI is _____

one or two puffs (adult) every 3–4 hours for an attack (four puffs in children

The _______ is a breath-activated MDI which can improve lung deposition in patients with poor inhaler technique.

Autohaler

The _______ is a dry powder delivery system that is widely used as an alternative to the MDI. It is a breath-activated device

Turbuhaler

People who have experienced one or more of the | following are more likely to have severe attacks:

• previous severe asthma attack • previous hospital admission, especially admission to intensive care • hospital attendance in the past 12 months • long-term oral steroid treatment • carelessness with taking medication • night-time attacks, especially with severe chest tightness • recent emotional problems • frequent SA β A use

Dangerous sign (pulse) associated with BA

Pulsus paradoxus

T or F This is a good sign in BA Chest becoming ‘silent’ with a quiet wheeze, yet breathing still laboured

Patients who are sensitive to________ need to be reminded that salicylates are present in common cold cure preparations and agents such as Alka-Seltzer

aspirin/salicylates

The non-steroidal medications, ______, ________ or _________ by inhalation, are the prophylactic drugs of choice in childhood chronic asthma of mild-to-moderate severity.

montelukast (oral) | and SCG and/or nedocromil sodium

ICS in children Any dose equal to or greater than _______ in children can have side effects, including growth suppression and adrenal suppression

400 mcg