respi: asthma Flashcards
1
Q
low, med, high ICS doses: beclometasone diproprionate, standard particles
A
Beclo-asma
low: 200-500
med: 500-1000
high: >1000
2
Q
low, med, high ICS doses: beclomethasone dipropionate, extrafine
A
Beclomet easyhaler
low: 100-200
med: 200-400
high: >400
3
Q
low, med, high ICS doses: budesonide
A
Symbicort, Pulmicort
low: 200-400
med: 400-800
high: >800
4
Q
low, med, high ICS doses: fluticasone fuorate
A
Relvar Ellipta
low, med: 100
high: 200
5
Q
low, med, high ICS doses: fluticasone proprionate
A
Flixotide, Flutiform
low: 100-250
med: 250-500
high: >5001
6
Q
asthma is characterised by
A
chronic airway inflammation
defined by a history of respiratory symptoms:
- wheeze
- sob
- chest tightness
- cough
7
Q
pathophysiology of asthma
A
reduction in airway diameter due to contraction of smooth muscle, vascular congestion, thick secretions
> increased airway resistance, hyperinflation of lungs and increased work of breathing
8
Q
histologic changes in asthma
A
- hypertrophy or airway smooth muscle
- increased airway wall thickness and edema
- mucous gland hypertophy and hypersecretion
9
Q
classic triad of chronic asthma
A
dyspnea, wheezing, cough
10
Q
exercise-induced bronchoconstriction
A
acute airway narrowing that occurs as a result of exercise
- occurs in pt w or without asthma
- defined as a >= 10% decrease in FEV1 from pre-exercise value
11
Q
frequent sob, cough, wheezing symptoms but normal FEV1
A
cardiac disease? lack of fitness?
12
Q
few sob, cough, wheezing symptoms but low FEV1
A
poor perception? restriction of lifestyle?
13
Q
low ___ is an independent predictor of exacerbation risk
A
FEV1
14
Q
FEV1
A
volume of air exhaled forcefully in the first second of maximal expiration
normal: >= 80%
15
Q
FVC
A
maximum volume of air that can be exhaled after full inspiration
reported in liters and % predicted
- normal adults can empty 80% of air in < 6 seconds
16
Q
FEV1/FVC
A
differentiates between obstructive and restrictive disease
normal: within 5% of predicted range, which varies with age, usually 75-80% in adults
17
Q
in asthma, reversibility is shown by
A
an increase in FEV1 of >= 12% after SABA
18
Q
FEV1/FVC is ______ in obstructive disease (asthma, copd)
A
decreased, < 75%
19
Q
risk factors for poor asthma control
A
- uncontrolled asthma sx
- high SABA use (>= 3 canisters/year)
- having >= 1 exacerbation in the last 12 months
- low FEV1, higher bronchodilator reversibility
- incorrect inhaler technique and/or poor adherence
- smoking
- obesity, chronic rhinosinusitis, pregnancy, blood eosinophilia
- ever intubated for asthma
20
Q
risk factors for fixed airflow limitation include
A
- no ICS treatment
- smoking
- occupational exposure
- mucus hypersecretion
21
Q
categories of asthma severity: mild
A
well-controlled with steps 1 or 2
22
Q
categories of asthma severity: moderate
A
well-controlled with step 3
23
Q
categories of asthma severity: severe
A
requires step 4/5 or remains uncontrolled despite this treatmetn
24
Q
medications that may worsen asthma
A
NSAID, BB
25
non-pharmacological interventions
- avoidance of tobacco smoke exposure
- physical activity
- occupational asthma
- avoid medications that may worsen asthma
- remediation of dampness or mould in homes
- sublingual immunotherapy
26
higher use of SABA is associated with
adverse clinical outcomes
- patients with apparently mild asthma are at risk of serious adverse events (do not see the need for additional treatment due to the rapid relief of sx)
27
formoterol
selective beta2-adrenergic agonist that produces relaxation of bronchial smooth
muscle in patients with reversible airways obstruction.
- bronchodilating effect sets in rapidly,
within 1-3 minutes after inhalation, and has a duration of 12 hours after a single dose.
28
Acute overdose with budesonide, even in excessive doses, is not expected to be
a clinical problem. When used chronically in
excessive doses, systemic
glucocorticosteroid effects, such as hypercorticism and adrenal suppression,
may appear.
29
after starting treatment, patients should preferably be seen
1-3 months
then 3-12 months after that
in pregnancy, must be reviewed every 4-6 weeks
after an exacerbation, review visit within 1 week
30
step 1
sx less than twice a month
- track 1: PRN low-dose ICS-formoterol
- track 2: take ICS whenever SABA taken, PRN ICS-SABA or SABA
31
step 2
sx more than twice a month but less than 4-5 days a week
- track 1: PRN low-dose ICS-formoterol
- track 2: low-dose maintenance ICS, PRN ICS-SABA or SABA
32
step 3
sx most days, or waking with asthma once a week or more
- track 1: low-dose maintenance ICS-formoterol, PRN low-dose ICS-formoterol
- track 2: low-dose maintenance ICS-LABA, PRN ICS-SABA or SABA
33
step 4
daily sx or waking with asthma once a week or more and low lung function
- track 1: medium-dose maintenance ICS-formoterol, PRN low-dose ICS-formoterol
- track 2: medium/high dose ICS-LABA, PRN ICS-SABA or SABA
34
step 5
refer to phenotypic assessment +/- biologic therapy
- add on LAMA
- consider high-dose ICS/formoterol or ICS-LABA
PRN ICS-formoterol or other ICS-SABA or SABA
35
exercise-induced bronchoconstriction
acute airway narrowing that occurs as a result of exercise
- occurs in pt with or wo asthma
- defined as a >= 10% decr in FEV1 from pre-exercise value
36
treatment of exercise-induced bronchoconstriction
- SABA, 15mins before exercise
- for pt w sx despite SABA before exercise, long-term use of ICS may improve underlying disease which may decrease the frequency of EIB
- alt: LTRA (approx 2hr before exercise or once every 24hrs) or mast-cell stabilisers
- stop the activity, usually resolves in 20-30mins
37
________ dose ICS provides most of the clinical benefit of ICS for most patients with asthma
low
38
stepping up asthma treatment: sustained step-up
for at least 2-3 months
- important: first check for common causes (sx not due to asthma, incorrect inhaler technique, poor adherance)
39
stepping up asthma treatment: short-term step up
for 1-2 weeks eg. with viral infection or allergen
- may be initiated by patient with written asthma action plan
40
stepping up asthma treatment: day-to-day adjustment
for patients prescribed low-dose ICS-formoterol MART
- approved only for PRN low-dose beclo/bude-formoterol
41
stepping down asthma treatment
consider after good control maintained for 3 months
- find each patient's minimum effective dose that controls symptoms and minimises risk of exacerbations
- reduce the ICS dose by 25-50% at intervals of 2-3 months
42
is it recommended to stop ICS completely?
no! risk of exacerbations
43
acute asthma exacerbation
flare-up, acute or sub-acute worsening of symptoms and lung function compared with the patient's usual status
44
patients at risk of asthma-related death
- any history of near-fatal asthma requiring intubation and ventilation
- hospitalisation or emergency care for asthma in the last 12 months
- not currently using ICS, or poor adherance with ICS
- currently using or recently stopped using OCS
- overuse of SABAs, especially if more than 1 canister per month
- lack or written asthma action plan
- history of psychiatric disease or psychosocial problems
- confirmed food allergy in a patient w asthma
45
magnesium sulfate: place in therapy
not for routine use, may have a role in patients with moderate-severe asthma who fail to respond to B-agonists +/- systemic steroids
- adult: 1.2-2g IV infusion over 20-30mins
- children: 25-100mg/kg
46
written asthma action plans should include
- pt's usual asthma meds
- when/how to incr reliever/controller or start OCS
- how to access medical care if sx fail to respond
47
add OCS if needed, dose?
prednisolone 1mg/kg/day, up to 50mg, usually 5-7 days
48
tapering of OCS dose is needed if taken
for less than 2 weeks
49
common OCS side effects
sleep disturbance, incr appetite, reflux, mood changes
50
SABA moa
rapidly relax bronchial smooth muscle from the trachea to the bronchioles through action on the b2-receptors
51
SABA adr
palpitations, tachycardia, tremor, headache
52
SABA
salbutamol, terbutaline
53
LABA
salmeterol, formoterol, bambuterol
54
LABA: place in therapy
recommended only in combi with inhaled steroid
- data showing incr risk of asthma-related deaths and life-threatening events when used as monotherapy
- use of LABA alone without long-term asthma control meds such as ICS is c/i
55
inhaled corticosteroids moa
- reduce the initial inflammatory response by decreasing the formation and release of many inflammatory mediators such as histamine, leukotrienes and cytokines
- reduce vasoconstriction and subsequent serum production, swelling and discomfort
- produce an immunosuppressive state that limits the body's hypersensitivity reaction, which in turn may limit bronchospasm and other associated sx
BUT do not cure asthma!
56
fluticasone 2butx vs
budesonide and beclomethasone
57
relief of sx with use of ICS
1-2 weeks
max effects seen in 4-8 weeks
58
relief of sx with use of IV/oral corticosteroids
4-6 hours in acute exacerbations
59
oral pred dose
acute: 0.5-2mg/kg/d (adults = 30-40mg/d)
chronic: 5-10mg/d (step 5)
60
methylprednisolone/hydrocortisone dose
40-125mg q6h
61
systemic corticosteroids adr
osteoporosis, htn, diabetes, hpa axis suppression, obesity, cataracts, glaucoma, skin thinning, cutaneous striae, easy bruising, muscle weakness
62
ICS adr
local - cough, dysphonia, oral thrush
63
LABA as an add-on therapy to ICS
- relaxing bronchial smooth muscle
- inhibit the release of hypersensitivity mediators from mast cells for up to 12hrs through action on the b2 receptors
64
Seretide
salmeterol + fluticasone
65
Symbicort
formoterol + budesonide
66
Dulera, Zenhale
formoterol + mometasone
67
Flutiform
formoterol + fluticasone
68
Foster
formoterol + beclometasone
69
Relvar
vilanterol + fluticasone
70
tiotropium: place in therapy
LAMA - induces bronchodilation via inhibition of the muscarinic receptor on airway smooth muscle
- adjunctive therapy in pt on ICS+LABA
- step 4 or 5 and still uncontrolled
71
tiotropium dose
2.5mcg OD (respimat)
72
tiotropium adr
bronchitis, cough, pharyngitis, sinusitis
73
mast-cell stabilisers (chromones)
cromolyn sodium < nedocromil
- stabilise membranes of mast cells and inhibit release of mediators of inflammation
- max clinical effect after 2-6 weeks
no longer recommended for routine use as monotherapy, not as effective as inhaled steroids
alt for exercise-induced asthma
nausea, headache, diarrhea
nedocromil has an unpleasant taste
74
leukotriene modifiers moa
- interfere with the pathway that allows mast cells, eosinophils and basophils to release leukotriene mediators that participate in the slow phase reaction of anaphylaxis
- reduce sx associated with the inflammatory allergic component of asthma, including swelling of the airway and smooth muscle constriction
75
LTRA
montelukast
- adults: 10mg on
- children > 6yo: 5mg on
- children 2-5yo: 4mg on
76
LTRA ddi
warfarin, phenytoin, carbamazepine
- metabolised by cyp450 enzymes
77
LTRA adr
headache, nausea, neuropsychiatric events (based on post-marketing reports: agitation, depression, suicidal behaviour, insomnia, restlessness)
78
theophylline serum conc monitoring
therapeutic range: 5-20mg/L
79
theophylline adr
gi: n/v
cardiac: tachycardia, arrhythmias
cns: insomnia, headache, seizures
80
theophylline moa
multifactorial:
- induces sm relaxation
- resulting in bronchodilation
- inhibiting the body's reaction to external allergic stimuli
81
omalizumab
recombinant monoclonal antibody against lgE
- binds free lgE and prevents binding of lgE to receptors on mast cells and basophils
approved for treatment of adults and children >12yo with severe allergic asthma who are not controlled by high-dose ICS-LABA (step 5)
82
IL-5 receptor antagonists
monoclonal antibodies that bind to the IL-5 receptor on the surface of eosinophils and basophils
> lessen the inflammatory response to allergic triggers
- severe persistent asthma as adjunctive maintenance therapy for >12yo who have an eosinophilic phenotype
- benralizumab, mepolizumab, reslizumab
83
IL-4 receptor antagonists
binds to IL-4 receptor alpha, blocking both IL-4 and IL-13 signalling
- dupilumab
84
