Outline the pattern for Mixed Obstructive and Reduced Spirometry
- Reduced FVC
- Reduced FEV1/FVC ratio
List some conditions that Spirometry can cause problems in
- Heart issues, Uncontrolled/ Low BP, Aneurysms
- Pulmonary HyperT, PE, PT
- Late term pregnancy
- Recent Concussion or Surgery on Brain/ Middle ear/ Sinuses/ Eyes/ Chest/ Abdomen
How often should pts monitor their PEF during Asthma Diagnosis
At least x2/day for 2-4wks
What things can affect levels of NO exhaled in breath?
What do we advise pts to do before a FENO test?
(1/5 False Negatives and Positives)
- Caffeine, Alcohol, Smoking
- Corticosteroids (Reduced)
- Nitrate-rich foods
- Avoid food/ drink for 1hr before test
One special test used to diagnose asthma is the Direct Bronchial Challenge test.
Describe it
Inspiration of gradually increased doses of medication that irritate airways
Name the 3 types of inhaler
pMDIs: pressurised Metered Dose (generates aerosol)
SMIs: Soft Mist
DPIs: Dry Powder
Name 2 types of Combination Inhalers
When can they be used
LABA/ ICS: Asthma and COPD
LABA/ LAMA: Mainly used in COPD (Can add ICS)
Describe the pMDI technique
After testing before 1st use: Shake, release puff in air
(Check dose counter) Sit/ stand straight and tilt chin. Breathe out gently, slowly until lungs empty.
Tight seal around mouthpiece. Breathe in slowly and gently until lungs full, while pressing canister once.
Close mouth and hold for 10s. Breathe out gently. Wait 30-60s before 2nd puff if prescribed. Repeat steps.
Rinse and spit if inhaler contains Steroids
Describe the Turbohaler technique
One-time Prep for use;
- Hold upright with coloured base at bottom. Turn base as far as possible in any direction, then all the way back again.
- Should hear a click on one of the turns. Repeat once.
USING;
- Check dose counter. Hold upright, turn base as far right as possible, then to left until it clicks.
- Sit/ stand straight and tilt chin. Breathe out gently, slowly until lungs empty. Hold horizontally, but not upside down.
- Tight seal around mouthpiece. Breathe in quickly and deeply until lungs full. Close mouth and hold for 10s. Breathe out gently. Take 2nd puff if prescribed.
- Rinse and spit if inhaler contains Steroids
Spirometry is offered to all people >5
What is classed as a +ve result for Bronchodilator Reversibility
Increase of 12%
What is the PFV?
- Difference between Highest and Lowest readings, as % of Average PEFR
(+ve result if PFV >20%)
What is classed as “Complete control’ of Asthma
- No daytime symptoms, No activity limitations, Minimal ADRs
- No Asthma attacks, No need for rescue medication, Normal lung function
Briefly outline Pharmaceutical Asthma management
- SABA to all symptomatic pts
- ICS x2/day (Not Ciclesonide) as prophylaxis
- ICS add-on therapy if needed
Who can be offered ICS x2/day as prevention therapy?
- If using SABA/ have symptoms x3 a week
- If woken at night once weekly
- If >5 + had asthma attack in last 2yrs needing Oral Corticosteroids
Outline Add-on therapy from ICS in those 17/+
1st, 2nd, 3rd, 4th line
- 1: LTRA/ LABA (Can add LABA to LTRA and ICS)
- 2: Consider Low maintenance dose ICS (with or w/o MART)
- 3: Moderate maintenance dose ICS (with or w/o MART)
- 4: Add drug (LAMA/SAMA or Theophylline) or consider High maintenance dose ICS
Outline Add-on therapy from ICS in those 5-16
1st, 2nd, 3rd, 4th line
- 1: Consider adding LTRA (replace with LABA if needed)
- 2: Paediatric Low maintenance dose ICS (with or w/o MART)
- 3: Paediatric Moderate Maintenance Dose ICS (with or w/o MART)
- 4: Add drug/ Paediatric High Maintenance Dose ICS, usually supervised by specialist
How is Suspected Asthma managed in <5s?
8wk trial of Paediatric Moderate Dose ICS if symptoms indicate need
(x3/week, night-waking, uncontrolled with SABA alone).
After trial, monitor symptoms.
What do you do after the 8wk trial in <5s with suspected Asthma if;
- 1: Symptoms don’t resolve during trial
- 2: Symptoms come back <4wks after trial stops
- 3: Symptoms come back >4wks after trial stops
- 1: Consider alternate diagnosis
- 2: Paediatric Low Maintenance Dose ICS, consider adding LTRA
- 3: Repeat 8wk trial
What are alternatives to ICS if there are contra-I or not tolerated?
- Theophyllines
- LTRA If <5
- Na Cromoglicate or Nedocromil Na if >5
What should you consider in asthma deterioration?
7 days of increased ICS dose, if 5-16
Outline follow-up in asthma pts
- 4-8wks after adjusting treatment
- Annually in all pts
Before treating an Asthma Exacerbation, you need to determine the severity.
What features do you look at?
- Degree of agitation and consciousness
- Inability to complete sentences, Cyanosis, Accessory muscle use at rest
- Chest exam, RR, HR, BP
- PEFR (use best of 3 readings) compared to Best within last 2 yrs or Predicted
Describe a Moderate Asthma Exacerbation
PEFR: 50-75% of best/ predicteda
Describe an Acute Severe Asthma Exacerbation
- PEFR: >33%, Sats 92+ or more
- RR: >24 if >12, >29 if >5, >39 if >2
- HR: >109 if >12, >124 if >5, >139 if >2
- Inability to complete sentences, Accessory muscle use
