CLINICAL- ASTHMA Flashcards
(47 cards)
What is the first line investigation used for asthma in adults and children over 5?
Spirometry
Work out the FEV1 to FVC ratio
(Forced expiratory volume in 1 second vs Forced vital capacity)
A ratio of less than 70% is a positive result for obstructive airway disease
Bronchodilator reversibility test showing improvement in FEV1 would show positive for asthma
What is asthma?
A chronic INFLAMMATORY disease characterised by recurrent attacks of breathlessness and wheezing
It’s caused by airways inflammation (controlled by ICS) and airway smooth muscle dysfunction (controlled by LABA: dilates the airway)
Asthma is more inflammatory than COPD therefore more responsive to what type of medication?
ICS (inhaled corticosteroids)
Asthmas inflammatory characteristic is driven by which inflammatory cell infiltrates?
Eosinophils
Lymphocytes
Neutrophils
(COPD is predominately neutrophil driven. Less response to ICS)
Which disease, COPD or asthma, results in airway remodelling, bronchial hyperactivity and mucosal oedema?
Asthma
But remember mucus is not present in asthma: patients don’t have a chronic productive cough (but may have a cough) or sputum production!
What two types of inhalers used synergistically (together) tackle both smooth muscle dysfunction and airway inflammation that leads to symptoms and exacerbations in asthma?
LABAs (for smooth muscle dysfunction)
And ICS (for airway inflammation)
If symptoms are worse at night, what’s it more likely to indicate- COPD or asthma??
Asthma
If someone’s spirometry results are Normal and they’re free of symptoms, does this exclude asthma?
No
If a patient is experiencing Voice disturbance, what would this indicate?
Probably not asthma
How do we confirm asthma diagnosis after it is deemed that a patient has a high probability that they have asthma??
We trai them on treatment
If we see a response: asthmas diagnosis is confirmed
If we don’t see a response: assess inhaler technique, reconsider the diagnosis
What can we use to assess how well a patient is controlling their asthma with their medication?
The Asthma Control Test
Asks patients how they have found certain things over the past 4 weeks
Once a patient has persistently good asthma control (e.g for 3 months), what should we consider?
Consider stepping down to the lowest dose of ICS that maintains symptom control.
Note: there is limited evidence of increasing ICS dose to over 800mcg of BDP per day or equivalent actually improves asthma control.
ALL METERED DOSE INHALERS SHOULD BE ADMINISTERED USING A _______
SPACER
(New guidance)
Spacers avoid deposition in the lungs
They’re quite big! So some bag sized spacers are now coming out
What does new guidance recommend is now used at stage 3 asthma treatment?
Combination devices consisting of ICS combined with LABA.
Eg. Symbicort: Budesonide plus Formeterol
Seretide: fluticasone propionate plus salmeterol
There are now 6 of these combination inhalers available!
How much Fluticasone propionate is equivalent to 1000 mcg Beclometadone Dipropionate per day?
The ratio is 2:1 beclo: fluticasone
So it’s equivalent to 500mcg per day or 250mcg BD of FP
A magic number in the asthma treatment plan in 800 mcg per day of Beclometasone Dipropionate when talking about ICS.
What is this equivalent to for fluticasone propionate?
400 mcg per day FP or 200 mcg BD
The ratio is 2:1 beclo: fluticasone
Relvar Elliptar is an inhaler containing fluticasone furoate and vilanterol. There are 2 strengths available: 92:22 and 184:22 micrograms.
One strength can be used in both asthma and COPD, the other can only be used in asthma.
Which one is which?
92: 22 can be used in both asthma and COPD
184: 22 can be used in asthma only
Relvar is a preventer, but it was blue in colour, now changed to yellow as people thought it was a reliever.
What is Symbicort SMART?
Symbicort inhaler contains a combination of ICS and a LABA
It can be used alone as BOTH maintenance (preventer) and reliever medication- so patients don’t have to use two inhalers blue and brown.
Patient takes a fixed maintenance dose each day, with additional puffs as reliever of symptoms as needed. Very convenient for patients as they only need one inhaler!
We now use these combination inhalers at step 3 of the asthma treatment plan as it will IMPROVE PATIENT COMPLIANCE
One of the aims of asthma therapy is to achieve normal lung function. This is classed as over what percentage (FEV1)?
Over 80%
Difficult to treat asthma (I.e. Asthma where symptoms are present despite maximal treatment) causes a high rate of __________ co-morbidities
Psychological co morbidity
Eg. Depression
Anxiety
Stress
We quite often have to question: is it actually difficult to treat asthma? As it could just be more psychological and the patient just panicky and stresses which worsens the asthma
As it’s hard for patient to cope and have a good QoL
What medical conditions could aggregate difficult to treat asthma?
Rhinosinusitis, allergic rhinitis Allergy Nasal polyps Depression or anxiety Gastro-oesophageal reflux disease (GORD) Relation to the menstrual cycle
What DRUGS CAN AGGREVATE/ SHOULD NOT BE USED IN ASTHMA?
Beta blockers: these constrict airways (but dilate blood vessels so good in HTN, AF)
Aspirin
NSAIDS!!! E.g. Ibuprofen in an asthmatic: had this in 3rd year dispensing
ACEinhibitors
Patients with difficult to treat asthma have persistent and frequent exacerbations despite treatment at step 4/5. They usually have oral corticosteroids either intermittently or long term. What can this cause??
Steroid related adverse effects
Osteoporosis
Cushings
Diabetes! (A symptom of cushings)
What co-existing LUNG related conditions could worsen asthma??
Dysfunctional breathing Bronchiectasis: airways become too wide and excess mucus builds up: prone to infection Severe COPD (some patients are unfortunate enough to have both) Vocal cord dysfunction
