Asthma

Question 1

What might affect FeNo

Answer 1

Inhaled steroids (might make Feno normal)
But if you have a patient whose symptoms are severe at presentation don’t hold off.

Question 2

First line Ix for adults

What about if that is negative?

What about if you can’t get 2nd line test?

Answer 2

FeNo or eosinophils

If normal, do bronchodilator reversibility with Spiro.

If you can’t get Spiro or theres a delay then do peak flow diary for 2 weeks morning and night

If all these are negative then refer for consideration of a bronchial challenge test.

Question 3

What feno/ eosinophil count is diagnostic of asthma in adults

Answer 3

eosinophils above normal
FeNo above 50

Question 4

What bronchodilator reversibility is diagnostic of asthma in adults

Answer 4

Increase in FEV 1 of 12% or more and 200ml or more after bronchodilator
Or
FEV1 increase is 10% or more of the predicted normal FEV1.

Question 5

How to diagnose asthma from peak flow in adults ?

Answer 5

Do it twice daily for 2 weeks. Diagnose asthma if PEF variability is 20% or more.

Question 6

What FeNo is diagnostic in kids for asthma? WHat age would you use this value

Answer 6

35
Age 5-16** Careful becuase its not 12 as you might expect

Question 7

How to diagnose asthma in kids age 5-16

Answer 7

FeNo first

If -ve -> Spiro with Bronchodilator reversibility - diagnostic if change of 12% with bronchodilator or FEV1 increase is 10% or more of predicted.

If this is delayed or not available peak flow diary twice a day for 2 weeks. Diagnose if variability 20% or more.

If none of these are diagnostic do skin prick testing OR serum IgE and eosinophils. Diagnostic if evidence of sensitisation to house dust mites or eosinophils more than 0.5 x 10^9 per litre

If still not diagnostic ref to specialist for consideration of bronchial challenge

Question 8

What to do if you suspect a kid under 5 has asthma

Answer 8

Treat with low dose ICS and review them regularly. If still symptomatic age 5 do tests.

Refer anyone under 5 who’s been admitted with wheeze or 2 or more admissions to A&E in 12m.

Question 9

What to do if you suspect occupational asthma

Answer 9

refer to specialist.

Question 10

Asthma management in people age 12 and over.

Answer 10

1. Low dose AIR. If severe sx or frequent exacerbations go straight to 2 and skip AIR.
2. Low dose MART
3. Moderate dose MART

—If still symptomatic despite this check FeNo+/- eosin. If either raised then refer to specialist. If neither raised:

4.Consider a trial of either LTRA or LAMA + moderate-dose MART for 8 to 12 weeks. At the end of the trial:
- If asthma is controlled, continue the treatment
- if control has improved but is still inadequate, continue
the treatment and start a trial of the other medicine (LTRA or LAMA)
if control has not improved, stop one and start the other.

Question 11

when should you review a patient with asthma after a dose change

Answer 11

8-12 weeks

Question 12

What is uncontrolled asthma

Answer 12

It includes any asthma exacerbation needing treatment with steroids

Needing a reliever inhaler 3 or more days per week

Waking in the night due to asthma sx at least once a week.

Question 13

What is AIR
What is MART

Answer 13

AIR - Anti inflammatory reliever. Use this when symptomatic only. This has Steroid plus formetrol which is a fast acting long acting bronchodilator
Budesonide + formoterol = licensed
** This is used in age 12+

MART - Maintenance and reliever - use this regularly morning and night + PRN.

This is used in age 5+

Question 14

LTRA examples

Answer 14

Montelukast

Question 15

LAMA examples

Answer 15

–ium
Tiotropium (Spiriva), Umeclidinium (Incruse)

Question 16

Asthma management in age 5-11

Answer 16

1. Low dose ICS + PRN SABA
2. Can they manage MART?

If YES:
Low dose MART
Then if still symptomatic inc to moderate dose MART then ref paeds.

If NO:
Add LRTA so would be on low dose ICS, PRN SABA and LTRA.

If that doesn’t work
LOW DOSE ICS/LABA combination (with or without an LTRA)

If that doesn’t work
MODERATE dose ICS/ LABA +/- LTRA

If no good specialist.

Question 17

How would you go about stopping asthma tx

Answer 17

At annual review see how sx are. If none can consider stopping step by step. Review at 8-12 week intervals.

Question 18

What is different in diagnosing asthma in kids compared to adults

Answer 18

Eosinophil measurement and skin prick - these are one last line.
Eosinophils measured first in adults.

Question 19

How to work out % change in peak flow

E.g. if 450 is best but today 300 whats the answer

Answer 19

(original-new value) Divided by original x 100.
33% so to get that as percentage of predicted do 100-33 so 67

Question 20

Moderate, severe and life threatening parameters in adults

Answer 20

Mod
PEFR 50-75%
RR < 25
HR< 110

Severe:
PEFR 33-50%
HR >110
RR > 25

Life threatening
PEFR Less than 33
Sats less than 92

Question 21

What would make you manage acute asthma in primary care vs sending in

Answer 21

MODERATE initial exacerbation with:
- good response to initial treatment and symptoms have improved.
- PEF is improving to more than 60–80% of best or predicted.
- Sats > 94%
- Pt can manage at home and has support

Question 22

Features of Acute severe and life threatening asthma in kids

Answer 22

Acute severe:
Sats less than 92 (same as for life threatening)
PEFR 33-50%
HR > 125 if over 5 or > 140 if age 1-5
RR >30 if over 5 or 40 if age 1-5

Life threatening is if sats less than 92 or PEFR less than 33%

To remember it:
For kids HR Add 15 to adult value (for over 5) then double 15 (1-5)

For RR Add 5 then add 10