Asthma

Question 1

What is a moderate acute asthma attack?
- Peak Flow
- Speech

Answer 1

Peak flow: >50%
Speech: Normal

Question 2

What is a Severe acute asthma attack?
- Peak Flow
- Speech
- SpO2

Answer 2

Peak Flow: 33-50%
Speech: Unable to complete full sentences
SpO2: >92%

Question 3

What is a Life Threatening acute asthma attack?
- Peak Flow
- SpO2
- Other symptoms

Answer 3

Peak flow: <33%
SpO2: <92%
Other Symptoms:
- altered consciousness
- arrhythmias
- Hypotension
- Cyanosis

Question 4

What is the management of a MODERATE acute asthma attack
- Adult
- Children

Answer 4

SABA- through large volume SPACER
- Up to 10 puffs

Adult: 4 puffs initially, then 2 puffs every 2 minutes
- oral prednisolone: 40-50mg for 5 days

Children: 1 puff every 30-60 seconds

Question 5

What is the dose of prednisolone given in an acute asthma attack compared to an exacerbation of COPD?

Answer 5

Asthma: 40-50mg for 5 days (in 12 years plus)

COPD: 30mg for 5 days

Question 6

When should someone having a moderate acute asthma attack be admitted to hospital?

Answer 6

• under 18
• pregnant
• previous severe asthma attack
• inadequate treatment response

Question 7

What is the management for SEVERE or LIFE-THREATENING acute asthma attack
- Adults
- Children

Answer 7

High dose SALBUTAMOL via a NEBULISER
- 5mg in >5 years
- 2.5mg in 2-5 years
+ nebulised ipratropium (SAMA)
+ IV magnesium or aminophylline
Oral PREDNISOLONE
- adult: 40-50mg for 5 days
- children >5 years: 30-40mg for 3 days
- children 2-5 years: 20mg for 3 days
- children <2 years: 10mg for 3 days

Question 8

What can be used instead of prednisolone in the management of severe acute asthma attack?
- e.g. if they have altered consciousness and cant have oral pred

Answer 8

Methylpednisolone
IV hydrocortisone

Question 9

Lifestyle changes for chronic asthma

Answer 9

• weight loss (if over weight)
• smoking cessation
• breathing exercises
• identifying triggers
• keeping warm and dry in cold weather

Question 10

Management of asthma in 12 years+
- 4 steps

Answer 10

Step 1: AIR therpay
- Low dose ICS + formerterol (LABA) PRN

Step 2: low dose MART
- AIR therapy as maintenance and reliever therapy

Step 3: moderate dose MART

Step 4: Test FeNO (fractional exhaled nitric oxide) and eosinophil count
- if raised = specialist
- if neither raised = LTRA OR LAMA trial (+ MART)
- refer to specialist if still uncontrolled

Question 11

Which two drugs are used in AIR therapy?
- licensed as of 2024

Answer 11

Fomoterol (LABA) and budesonide (ICS)

Question 12

When should someone step up from AIR therapy?
- what should they be switched to?

Answer 12

If they need the reliever more than 3+ days per week
OR
Having 1+ nights per week of night-time waking

• Switch to low dose MART therapy
• moderate dose MART therapy if still not controlled

Question 13

What to do if FeNO levels OR eosinophil count is raised? (Step 4 management)

Answer 13

Refer to specialist

Question 14

What to do if FeNO levels OR eosinophil count is normal? (Step 4 management)
- two options

Answer 14

Add either
- Leukotriene receptor antagonist (LTRA like montelukast)
- LAMA

Question 15

How long are LTRA or LAMAs trialed for?
- controlled?
- improved but inadequate?
- not improved?

Answer 15

Trailed for 8-12 weeks
- Controlled: continue
- improved but not adequate: add other (LAMA or LTRA)
- NOT improved: Stop either LTRA or LAMA and trial other
- No Improvement -> specialist

Question 16

When to switch someone from old to new asthma management guidelines

Answer 16

Only swap patients over if they are not controlled

Question 17

Switching someone from old to new guidelines if on:
- SABA alone
- Low dose ICS with SABA/LABA/LTRA
- Moderate ICS with SABA/LABA/LTRA
- High dose ICS

Answer 17

SABA alone -> AIR as needed
Low dose ICS with SABA/LABA/LTRA -> low-dose MART
Moderate ICS with SABA/LABA/LTRA -> Moderate dose MART
High dose ICS -> Specialist

Question 18

Management of Asthma in children under 5

Answer 18

8-12 week trial of BD paedriatic low-dose ICS

If symptoms are not resolving
- check inhaler technique, adherence or alternative diagnosis
- then refer to specialist

If symptoms resolve during trial
- stop ICS and SABA for 8-12 weeks and review
- if symptoms recur, restart ICS (low -> mod dose) + SABA and review
- if still uncontrolled, + LTRA (trial for 8-12 weeks)

Question 19

Management and treatment of Asthma in children aged 6-11

Answer 19

Step 1: offer paeds low-dose ICS + SABA

If asthma is still uncontrolled, either:
- MART (ICS + LABA)
- increase to moderate dose MART
- refer to specialist

Or, if MART is unmanageable :
- + LTRA to ICS + SABA for 8-12 weeks
- then, offer low dose ICS/LABA (+/- LTRA)
- then, offer moderate dose ICS/LABA (+/- LTRA)
- if asthma still not controlled, refer to specialist

Question 20

What to do if symptoms DO NOT resolve in 8-12 trial period of SABA + ICS for those under 5 in management of chronic asthma

Answer 20

• check inhaler technique, adherence, environmental factors (e.g. smoke, damp or allergy) and alternative diagnosis
• if non explain -> refer to specialist

Question 21

What to do if symptoms DO resolve in 8-12 trial period of SABA + ICS for those under 5 in management of chronic asthma?

Answer 21

Consider stopping and review in 3 months

If child has had acute episode after stopping
- Restart ICS + SABA (start on low dose and titrate up)
- Add LTRA (with 8-12 week trail)

Question 22

when should someone being treated for chronic asthma be dropped down a step in management?

Answer 22

Asthma that has been controlled for at least 3 months

Question 23

what should the dose of ICS be reduced by ?

Answer 23

Reduced every 3 months by 25-50% each time

Question 24

What is complete asthma control?

Answer 24

• no daytime symptoms
• no night time waking due to asthma
• no asthma attacks
• no need for rescue meds
• no exercise limitation due to asthma
• normal lung function
• minimal side effects

Question 25

What are the risks associated with SABA overuse?

Answer 25

1. Increase severity of severe asthma attacks 2. Masks underlying disease control 3. Side effects- tremors. Fast heart beat and headaches