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Flashcards in Chronic asthma Deck (25)
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1

Describe the pathophysiology of asthma

  • Chronic bronchial inflammation:
    • T lymphocytes, mast cells, eosinophils
    • Smooth muscle hypertrophy
    • Epithelial damage
    • Mucus plugging
  • Reversible variable airway obstruction
  • Airway hyper-responsiveness

2

Name three asthma phenotypes

  • Allergic: eg. dust mites, pollens, animal
  • Non-allergic: chemical and biological products
  • Respiratory infection: often starts in middle age
  • Exercise-induced
  • Brittle asthma: recurrent severe attacks
  • Steroid-resistant asthma

3

Define atopy

Genetic tendency to develop allergic IgE-mediated diseases

Includes asthma, allergic rhinitis, and dermatitis/eczema

4

Name four characteristic clinical features of asthma

Episodic or daily/seasonal variation of: worse at night and morning

  • Expiratory polyphonic wheeze; respiratory distress
  • Cough: often nocturnal
  • Chest tightness
  • Dyspnoea
  • Variable expiratory airflow limitation

Symptoms can be triggered by factors

May resolve spontaneously or with medication

5

Suggest two questions to check for possible occupational asthma

  • Are symptoms better on days off work?
  • Are symptoms better when on holiday?

6

Outline the diagnostic criteria of chronic asthma in adults

Asthma symptoms plus +ve objective tests

  • FeNO: (aged 17+) ≥40 parts per billion (ppb)
  • Spirometry: FEV1/FVC <70%
  • Bronchodilator reversibility (BDR): ≥12% improvement in FEV1

Consider

  • Peak expiratory flow variability over 2-4wks: >20% variability
  • Direct bronchial challenge test: PC20 <8 mg/ml

7

Outline the diagnostic criteria of chronic asthma in children

Asthma symptoms plus +ve objective tests

  • FeNO: (aged 5-16) ≥35 ppb
    • Children if diagnosis uncertain with normal spirometry/-ve BDR test
  • Spirometry: FEV1/FVC <70%

Consider

  • Bronchodilator reversibility (BDR): ≥12% improvement in FEV1
  • Peak expiratory flow variability over 2-4wks: >20% variability

8

Outline the diagnostic criteria for asthma in young children <5yr

  • Asthma symptoms on observation and clinical judgement
  • Not indicated for objective tests till aged 5

9

Name five possible reasons for uncontrolled asthma

  • Alternative diagnoses
  • Lack of adherence
  • Suboptimal inhaler technique
  • Smoking
  • Seasonal or environmental factors
  • Occupational exposures
  • Psychosocial factors

10

List 5 differentials of eosinophilia

  • Airway inflammation: asthma or COPD
  • Allergic rhinitis
  • Allergic bronchopulmonary aspergillosis
  • Drugs
  • Eosinophilic granulomatosis with polyangiitis
  • Eosinophilic pneumonia
  • Lymphoma
  • SLE
  • Hypereosinophilic syndrome

11

Provide instructions for how to use a metered-dose inhaler

  1. Shake canister
  2. Exhale fully
  3. Placed aerosol nozzle in mouth - tight seal
  4. Rapid inhalation whilst pressing the aerosol
  5. Inhalation complete
  6. Hold breath for 10s if possible

Good technique still only inhales 15%. Spacer is useful for children and elderly.

12

Outline the initial management for chronic asthma in adults

  • SABA reliever therapy
  • Low dose ICS maintenance therapy

13

Outline the initial add-on therapy for chronic asthma after SABA + ICS

Offer leukotriene receptor antagonist (LTRA)

Review response to treatment in 4-8 weeks

14

What is offered for asthma in adults uncontrolled by ICS + LABA?

  • Offer LABA in combination with ICS
  • Review continuation of LTRA

15

How should asthma therapy in adults be altered if uncontrolled with low dose ICS + LABA?

Change LABA + ICS to a MART (combined LABA + low dose ICS) regimen

16

How is adult asthma therapy changed if uncontrolled by MART regimen?

Either

  • Adjust MART to include moderate dose ICS
  • Fixed dose regimem moderate dose ICS + LABA, with SABA reliever

17

What changes are made to adult asthma management if uncontrolled by MART with moderate dose ICS or fixed-dose regiment?

Either:

  • Fixed dose regimen: high dose ICS, with SABA reliever
  • Trial of additional drug eg. LAMA or theophylline
  • Seek expertise from asthma specialist

18

Outline the initial management of asthma in children

  • SABA reliever therapy
  • Paediatric low dose ICS

19

What is the next step in childhood asthma management if uncontrolled by SABA + low dose ICS?

Add-on LTRA

Review treatment response in 4-8 weeks

20

How is childhood asthma therapy changed if uncontrolled by LTRA + ICS?

  • Consider stopping LTRA
  • LABA + paediatric low dose ICS

21

Outline the next step in childhood asthma medication if uncontrolled by LABA + paediatric low dose ICS

Change ICS + LABA to a MART regimen (combined low dose ICS + LABA)

22

How is childhood asthma treatment changed is uncontrolled by MART (combined low dose ICS + LABA)?

Either

  • Adjust MART to contain paediatric moderate dose ICS
  • Fixed-dose regimen of moderate dose ICS + LABA, with SABA reliever

23

What is the next step if childhood asthma is uncontrolled with MART (combined moderate dose ICS + LABA) or fixed-dose regimen?

Either:

  • Seek expert advise from asthma specialist
  • Fixed-dose regiment of paediatric high dose ICS with SABA reliever
  • Trial additional drug eg. theophylline

24

Give three self-management steps for asthma management

  • Asthma self-management programme
    • Personalised action plan
    • Education
    • Increased dose of ICS (adults) for 7d if asthma deteriorates
  • Weight loss
  • Smoking cessation
  • Breathing exercise programmes

25

Outline the management for asthma in young children <5yrs

SABA reliever ± maintanence therapy:

  1. 8/52 trial of paediatric moderate dose ICS
    • Not resolved: likely alternative diagnosis
    • Recurred within 4/52 after trial: paediatric low dose ICS
    • Recurred beyond 4/52 after trial: repeat trial of ICS
  2. Consider additional LTRA
  3. Stop LTRA and refer to asthma specialist