Asthma Guideline

Question 1

Diagnosis

Answer 1

• history, examination

- spirometry

Question 2

Wheeze in infants

Answer 2

• three phenotypes
  1. transient early wheezers (0-3)
  2. nonatopic wheezers (3-6)
  3. IgE associated wheeze/asthma (>6)

Question 3

Mild asthma

Answer 3

• occassional wheeze/tightness/cough/SOB
• no nocturnal symptoms
• nil symptoms upon waking
• bronchodilator use < 2 x a week
• FEV1 > 80% predicted

Question 4

Common symptoms in asthma

Answer 4

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

Question 5

Spirometry diagnosis of asthma

Answer 5

Reversible airflow limitation
Increase in FEV1 > 12% and by > 200ml on spirometry
FEV1/FVC < 80%

Question 6

Initial treatment: symptoms less than twice per month with nil other symptoms

Answer 6

Consider SABA as needed or low dose PRN budesonide/formoterol

Question 7

Initial treatment: symptoms > twice a month, waking asthma, flare requiring steroids, history of ICU admission

Answer 7

Regular daily (low dose) ICS + PRN SABA or PRN budesonide/formoterol

Alternative: montelukast + PRN SABA

Question 8

Initial treatment: frequent daytime symptoms

Answer 8

Regular medium to high dose ICS + SABA
> aim to downtitrate dose when symptoms improve

OR
Regular daily low dose ICS + LABA (private script) + PRN SABA

OR
Low dose ICS-formoterol maintenance and reliever therapy

Question 9

Initial treatment: severe uncontrolled asthma

Answer 9

High dose ICS + PRN SABA
OR
ICS-LABA + PRN SABA
OR
ICS formoterol reliever + maintenance 

Alternative
Short course of oral steroid + ICS

Question 10

What are the doses of budesonide/formoterol

Answer 10

200/6mcg – dry powder inhaler, 1 inhalation/dose

100/3mcg – PMDI, 2 puffs per dose

Question 11

Side effect of montelukast

Answer 11

Neurpsychiatric adverse effects, including suicidality

Question 12

Describe the “most, some and few” patients approach to medication for asthma in adults and adolescents

Answer 12

Most patients - low dose ICS + PRN SABA or budesonide/formoterol PRN

Some patients - regular ICS-LABA reliever and maintenance or ICS-LABA + PRN SABA

Few patients - ICS-LABA (medium-high dose) with low dose ICS-LABA as PRN or PRN SABA

Question 13

What is low dose ICS?

Answer 13

Beclometasone: 100-200
Budesonide: 200-400
Fluticasone: 50-200 depending on formula

Question 14

Definition of “good control”

Answer 14

Daytime symptoms <2 days per week
Need for SABA < 2 days per week
No limitation of activities
No symptoms during night or waking

Question 15

Definitional of “partial control”

Answer 15

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

Question 16

Definition of “poor control”

Answer 16

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

Question 17

Describe maintenance and reliever regimen

Answer 17

Budesonide/formoterol
MAINTENANCE
- 200/6mcg DPI: 1-2 puffs BD
- 100/3mcg MDI: 2-4 puffs BD
- 50/3mcg MDI: 2-4 puffs BD

PRN dosing

• 1 extra actuation of DPI or 2 actuations for MDI repeated after several min if symptoms persist
• max 72mcg formoterol per day

Question 18

Classification of asthma severity

Answer 18

Intermittent: < 2 symptomatic days/week, < 2 night time sx per month, normal FEV1 between exacerbations, normal FEV1/FVC

Persistent
> mild: > 2 days/week, FEV1>80% predicted, use of SABA > 2 a week but only once a day
> moderate: daily symptoms, > 1 night per week, daily SABA use, FEV1 60-80%, FEV1/FVC reduced by 5%
> severe: daily, 7 x a week night sx, use of ventolin daily, FEV1 <60%

Question 19

Management of acute asthma

Answer 19

• assess severity: mild/mod/severe
• O2 if SPO2 < 92% in adults and <95% in kids
• systemic corticosteroids within 1 hour (30=50mg PO for 5-10 days or IV 100mg hydrocortisone Q6H)

Mild - 4-12 puffs SABA via MDI Q20min
Severe - 12 puffs SABA or 5mg neb + ipratropium 8 puffs via MDI - Q20min
Life threatening - continuous neb with ipratropium - continuous

If poor response add IV MgSo4 10mmg (2.5g) over 20 min