2 - Asthma

Question 1

Main sx of asthma

Answer 1

• 4 main sx = coughing, wheezing, tightness in chest, shortness of breath (sometimes children will only present w/ a dry cough)
• Can send for spirometry test when 6 & older
• Worsening doesn’t necessarily mean exacerbation (exacerbation = hospitalization)
• *Asthma + smoking = COPD (airways are inflamed, so continuously irritating them will lead to irreversible damage)

Question 2

Jana is 7 y/o female w/ 4-year hx of asthma. Since her diagnosis she has been using salbutamol 100 ug, 2 puffs prn to manage her symptoms. Over the last while her sx have mainly been intermittent including SOB once or twice weekly & no nighttime awakenings. She effectively uses 1-2 doses of her salbutamol inhaler per week. She is able to participate in normal physical activity. What signs/sx does Jana have that are consistent w/ chronic asthma?

Answer 2

Intermittent SOB, reversible w/ salbutamol inhaler
- Can’t get spirometry until age 6, so only had asthma-like sx for 4 years (spirometry is only diagnostic tool so can’t truly have asthma until diagnosis)

Question 3

Jana is 7 y/o female w/ 4-year hx of asthma. Since her diagnosis she has been using salbutamol 100 ug, 2 puffs prn to manage her symptoms. Over the last while her sx have mainly been intermittent including SOB once or twice weekly & no nighttime awakenings. She effectively uses 1-2 doses of her salbutamol inhaler per week. She is able to participate in normal physical activity. How would you describe Jana’s current asthma control?

Answer 3

Still technically under “control”

Question 4

Jana is 7 y/o female w/ 4-year hx of asthma. Since her diagnosis she has been using salbutamol 100 ug, 2 puffs prn to manage her symptoms. Over the last while her sx have mainly been intermittent including SOB once or twice weekly & no nighttime awakenings. She effectively uses 1-2 doses of her salbutamol inhaler per week. She is able to participate in normal physical activity. Is she receiving the appropriate treatment?

Answer 4

Add a steroid; also think about non-pharms

Question 5

Over the next 4-6 weeks Jana begins experiencing increased episodes of SOB, up to 3 days each week. She also finds that she needs to take her salbutamol inhaler 2 puffs, 15 minutes before gym class (3x/week). She currently doesn’t have any shortness of breath at night. What is Jana’s current level of asthma control?

Answer 5

Not in control b/c needs salbutamol w/ exercise & now using 6x/week

Question 6

Describe the clinical presentation of asthma

Answer 6

• Episodic wheezing, breathlessness, chest tightness, & coughing
• • Wheezing = high-pitched, whistling sound created by turbulent airflow through an obstructed airway, usually when breathing out
• Intervals between sx can be days, weeks, months, or years
• Spirometry demonstrates obstruction (decreased FEV1/FVC) w/ reversibility following inhaled beta 2-agonist (at least 12% improvement in FEV1 & a difference of 200 mL)
• Just b/c someone goes months w/o sx doesn’t mean it isn’t a big deal – it is still chronic!!

Question 7

Describe the asthma control criteria

Answer 7

• Daytime sx = < 4 days/week
• Night-time sx = < 1 night/week
• Physical activity = normal
• Exacerbations (any acute care visit indicates poor control) = mild, infrequent
• Absence from work/school due to asthma = none
• Need for fast-acting beta 2-agonist = < 4 doses/week (includes exercise!!)

Question 8

Describe the general rules for asthma management

Answer 8

• Regularly reassess inhaler technique, adherence, & triggers!!
• For those 6-11 y/o we increase ICS
• For those 12 years & older, we add a LABA (don’t get more benefit from increasing steroid, only get more adverse effects)
• LRTAs help w/ allergic component in upper airways, so prevent further inflammation (better at prevention than tx)
• *Focus of asthma therapy is prevention & suppression of the underlying inflammation

Question 9

What are some other questions we should ask about asthma?

Answer 9

• Feel like you’re getting a cold/flu?
• Exposure to triggers?
• Limitation in activities?
• Referred to action plan?
• Rule out exacerbation

Question 10

Asthma red flags

Answer 10

• Unable to speak
• SOB at rest
• Reliever not working
• Peak flow < 60% predicted best
• Pt knows from past experience they are having a serious attack

Question 11

What are some triggers for asthma?

Answer 11

• Respiratory tract infections
• Allergens (pollens, house dust mites, animal dander, fungal spores)
• • For pet dander, best recommendation is avoidance, but if they can’t get rid of the pet at least get it out of the bedroom; pet dander can remain in a house for years
• Environment
• Food additives
• Exercise
• Drugs/ preservatives
• Occupational
• Emotions

Question 12

How do asthma sx occur?

Answer 12

• Inflammation is chronic; symptoms are episodic
• Airway narrowing is variable & caused by:
• • Contraction of airway smooth muscle (increased responsiveness to certain triggers)
• • Airway edema
• • Mucous hypersecretion
• • Airway thickening

Question 13

Describe what happens in the body during an acute asthma attack

Answer 13

• Trigger => release of inflammatory mediators (histamine, leukotrienes, prostaglandins)
• Early phase = bronchoconstriction (w/in 10-20 min), mucous hypersecretion, edema (duration ~ 1 h)
• Late phase (6-9 h later) = continued inflammation, epithelial damage, intensified hyperresponsiveness; more severe, prolonged, & difficult to reverse; may last for weeks

Question 14

Risk factors for a severe asthma exacerbation?

Answer 14

• Under-utilization of anti-inflammatory drugs

- Excessive reliance on short-acting inhaled beta 2-agonists

Question 15

Describe the use of ICS for asthma

Answer 15

• Always start at lowest possible dose (250 mcg/day is baseline low dose fluticasone or beclomethasone equivalents)
• Ciclesonide breaks down & activates into true anti-inflammatory in the lungs so less thrush issues – very good in children
• Most px see decreased sx in days to 1-2 weeks & often achieve minimum improvement use 2-4 weeks & maximum symptomatic improvement w/in 4-8 weeks
• Follow-up 1-3 months after starting tx, then every 3-12 months if stable
• *Always assess technique, adherence, & triggers
• Adverse effects (dose dependent; more common w/ dry powder inhaler DPIs) = thrush (uncommon in children), dysphonia
• • Can minimize w/ aerochamber & rinse w/ water after use

Question 16

When is ICS tapering required for asthma?

Answer 16

• Stepping down to an even lower ICS dose (decrease by 25-50% at 3-month intervals) is feasible & safe for most px or to once daily
• Monitor closely & have pt report increased reliever use

Question 17

Describe the asthma action plan

Answer 17

• Components:
• • Outline recommended daily preventive management strategies to maintain control
• • When & how to adjust reliever & controller therapy for loss of control
• • Provide clear instructions regarding when to seek urgent medical attention
• For children 11 years and younger – recommended controller step-up therapy for “yellow zone” = prednisone/prednisolone 1 mg/kg * 3-5 days
• For children 12 years & older – recommended controller step-up therapy for “yellow zone” = quadruple ICS for 7-14 days

Question 18

Jack is 10 y/o. He has been on budesonide 200 mcg 1 puff BID for 2 months after being on only salbutamol for many years. He continues to have sx most days (usually ~ 2 puffs most days, sometimes 4 puffs) & he sometimes coughs at night. What else do you want to know?

Answer 18

• Has he had a spirometry?
• How many years has he been using salbutamol?
• How has he been using it (adherence)?
• Technique & triggers

Question 19

Jack is 10 y/o. He has been on budesonide 200 mcg 1 puff BID for 2 months after being on only salbutamol for many years. He continues to have sx most days (usually ~ 2 puffs most days, sometimes 4 puffs) & he sometimes coughs at night. Jack’s mom is concerned that using higher-dose steroids will stunt Jack’s growth. How do you respond?

Answer 19

Stunts growth temporarily but does not have effect on final adult height

Question 20

Jack is 10 y/o. He has been on budesonide 200 mcg 1 puff BID for 2 months after being on only salbutamol for many years. He continues to have sx most days (usually ~ 2 puffs most days, sometimes 4 puffs) & he sometimes coughs at night. What if Jack was 13? Would our original decision change?

Answer 20

Add a LABA

Question 21

What are some potential reasons for lack of ICS response?

Answer 21

• Erroneous diagnosis of asthma
• Comorbidities
• Poor inhaler device technique
• Poor adherence to maintenance ICS tx
• Ongoing exposure to environmental triggers
• *Ask & educate
• Must wait 1-3 months when starting or increasing ICS b/c takes 4-8 weeks for drug to kick in & provide benefit

Question 22

Describe “SMART” dosing for asthma

Answer 22

• Combination of rapid-onset LABA (formoterol) & low dose ICS (budesonide) in a single inhaler as both controller & reliever
• Most benefit likely from timing (early admin) of higher ICS dose relative to worsening in sx as opposed to higher total dose
• Even w/ maximum doses, have lower steroid exposure overall
• Use of one inhaler may be an advantage for adherence
• Maximum daily dose = 8 inhalations (2 inhalations/dose) – if need more, contact physician; max 6 puffs in 1 use, but this indicates a problem
• Limited data in children under 12 y/o

Question 23

Describe the use of LTRAs for asthma

Answer 23

• Leukotriene receptor antagonists
• Good as add-ons or if pt or parent is refusing ICS
• Not intended to replace steroid, ICS is still first line
• Will help w/ px that have allergy component
• Can be added on to antihistamines

Question 24

Brock is a 9 y/o boy w/ a hx of moderate persistent asthma that has varied between controlled & uncontrolled over the last several months. He has a hx of emergency room visits for acute episodes of asthma & has missed 3 days of school in the last year b/c of acute exacerbations. On his way home from school today, he started coughing quite a lot. His mother notes that he is wheezing & seems to be having difficulty finishing sentences b/c of SOB. Over the last month, there has been smoke in the air from farmers burning stubble. His mother checks his PEF and finds it is 50% of normal. His current medications include salbutamol 1-2 puffs PRN & beclomethasone HFA (QVAR) 100 ug 2 puffs BID (already doubled from 1 puff BID over last couple of weeks). What should Brock’s mother do? What are the red flags?

Answer 24

• Not in control – think about triggers (burning stubble), adherence, & technique.
• Doubling his QVAR likely won’t do anything for this exacerbation, should give prednisone.
• Follow-up regarding prednisone in 1-2 weeks; monitor 1-3 months

Question 25

Brock is a 9 y/o boy w/ a hx of moderate persistent asthma that has varied between controlled & uncontrolled over the last several months. He has a hx of emergency room visits for acute episodes of asthma & has missed 3 days of school in the last year b/c of acute exacerbations. On his way home from school today, he started coughing quite a lot. His mother notes that he is wheezing & seems to be having difficulty finishing sentences b/c of SOB. Over the last month, there has been smoke in the air from farmers burning stubble. His mother checks his PEF and finds it is 50% of normal. His current medications include salbutamol 1-2 puffs PRN & beclomethasone HFA (QVAR) 100 ug 2 puffs BID (already doubled from 1 puff BID over last couple of weeks). What is an appropriate longer-term care plan for Brock?

Answer 25

Increase ICS to get under control (can possibly decrease at later point)

Question 26

Describe peak expiratory flow meter (PEFM)

Answer 26

- Maximal flow produced during forced expiration in 1 s (expressed as L/min) - Sometimes used to quickly assess effectiveness of bronchodilators during acute attack - Used for self-monitoring by comparing to px own previous best measurements using same peak flow meter - To record a personal best, take 3 times (record highest one) BID for 2 weeks using same meter when asthma well controlled - For young children, symptom-based action plans are better than those based on peak flows

Question 27

What are the 3 primary early therapies for asthma exacerbations?

Answer 27

1. Repetitive administration of rapid-acting inhaled beta 2 agonist – 4-10 puffs q20minutes x 1 h, then if stable 2-4 puffs prn (ex: q1-4h) 2. Early introduction of systemic glucocorticosteroids 3. Oxygen supplementation

Question 28

Describe the use of systemic corticosteroids for acute asthma exacerbations

Answer 28

- “Burst” of systemic glucocorticosteroids orally (or IV) - Kids = prednisone 1-2 mg/kg/day x 3-5 days - Adults = prednisone 50 mg daily x 5-7 days - Tapering not required for short term steroids - Continue ICS - Benefits = prevent progression of exacerbation, reduce need for ER visit, prevent early relapse after emergency tx - Acute effects are 4-6 h - Harms = dose & duration dependent adverse effects, no serious toxicity w/ short-term “bursts” - Short-term adverse effects = hyperglycemia, increased appetite, fluid retention, weight gain, mood alteration, peptic ulcer - Oral prednisone not used long term b/c preventative ICS much better & safer - - Long term prednisone can cause osteoporosis, diabetes, & glaucoma

Question 29

Describe the tx for asthma post-exacerbation

Answer 29

- May continue SABA 2-4 puffs q1-4h until sx resolve - Step up tx (add LABA) & monitor over 1-3 months, then may consider reducing ICS to lowest effective dose * Check inhaler technique, adherence to ICS, & trigger avoidance

Question 30

Describe exercise-induced bronchoconstriction. How is it different from asthma?

Answer 30

- Develops 5-10 mins after completing exercise (rarely during) - More common in cold, dry climates - Typical asthma sx or troublesome cough - Resolves spontaneously w/in 30-45 mins - Diagnosis – rapid improvement after inhaled beta 2-agonist or prevention w/ pre-tx w/ inhaled beta 2-agonist before exercise - If underlying asthma, may indicate asthma is poorly controlled - > step-up controller therapy - If no underlying asthma, yet require SABA prior to exercise – recommend they have a spirometry test - - If pt needs to use SABA more than 3 times/week including for exercise then they need an ICS (not considered well controlled) * *Salbutamol 2 puffs 5-15 min pre-exercise no longer the standard recommendation

Question 31

Should asthma px be recommended the pneumococcal vaccine?

Answer 31

No evidence that pneumococcal vaccination decreases risk of pneumococcal disease (people w/ asthma, especially children & elderly, are at higher risk of pneumococcal disease)