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Flashcards in Asthma Deck (69):
1

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

• excessive variation in lung function
• respiratory symptoms (

2

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)

3

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.

4

BA

It has an unacceptable mortality rate of
approximately________of the population.

5 per 100 000

5

BA

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

2 and 7 years,

6

Key test for BA

Spirometry is the key investigation

7

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

hydrofluoroalkanes,

8

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)

9

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

positive skin-prick

10

Classic Sx of BA

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

11

Auscultation findings of BA

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

12

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

forced expiration

13

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%

14

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.

15

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

Inhalation challenge tests:

16

Other tests for BA

Mannitol inhalation test.
An exercise challenge may also be helpful.

17

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).

18

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.

19

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

PEFR,

20

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

21

______ are not a substitute for spirometry

Peak flow meters

22

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

‘spacer’

23

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.

24

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)

25

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)

26

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

‘Preventer’ drugs or anti-inflammatory
agents

27

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

>3/week
>3 times a week

28

ICS types

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

29

Dose range of ICS

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

30

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

31

Intermittent BA

Status before treatment

Lung function FEV1 or PEFR (% predicted)


Episodic Symptoms

32

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

33

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%

34

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

35

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 %

36

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

37

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%

38

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

39

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

flat dose–response

40

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

Prednisolone

41

Dose of Prednisolone

• up to 1 mg/kg/day for 1–2 weeks

42

These are sodium cromoglycate (SCG) and nedocromil
sodium

Cromolyns

43

AE for Cromolyns

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

44

_______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

45

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

46

Montelukast is taken as a _________

5 or 10 mg chewable tablet once daily

47

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

48

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

49

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

50

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

51

Onset of B2 agonist

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

52

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.

53

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

Theophylline derivatives

54

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

55

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

Prophylactic agents

56

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

57

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

58

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

59

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

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

60

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

61

The usual dose of standard MDI is _____

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

62

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

Autohaler

63

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

Turbuhaler

64

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

65

Dangerous sign (pulse) associated with BA

Pulsus paradoxus

66

T or F

This is a good sign in BA

Chest becoming ‘silent’ with a quiet wheeze, yet
breathing still laboured

f

67

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

68

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

69

ICS in children

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

400 mcg