What is step 0 of the BTS asthma guidelines?
SABA (PRN) - salbutamol
What is step 1 of the BTS asthma guidelines?
+ Low dose ICS (daily) - beclometasone, fluticasone
In what case does a person move from step 0 to 1?
Using inhaler >3x a week
What is step 2 of the BTS asthma guidelines?
+ LABA (daily) - salmeterol
What is step 3 of the BTS asthma guidelines?
A few options
- stop LABA, increase ICS
- continue LABA, increase ICS
- continue LABA, add montelukast, theophylline or a LAMA (tiotropium bromide)
How does montelukast work? Adv/Disadv?
Inhibit cysteinyl 4 receptor
Adv: very few side effects
Disadv: less effective
How does theophylline work? Adv/Disadv?
Phosphodiesterase inhibitor - raises cAMP and activates PKA, thus inhibiting leukotriene synthesis
Adv: very effective
Disadv: narrow therapeutic index
In which cases would you use a LAMA?
Patients who can’t tolerate adrenergic agonists, due to cardiac problems
What is step 4 of the BTS asthma guidelines?
- Increase ICS dose to high
- Addition of a 4th drug
- LTRA
- SR theophylline
- LAMA
- B agonist
What is step 5 of the BTS asthma guidelines?
- Daily steroid tablet
- Consider other treatments eg. omalizumab
In what circumstances does a patient qualify for omalizumab?
Over 4 courses of oral steroids a year
What drugs are contraindicated in asthmatics, and what can you use instead?
NSAIDS - use clopidogrel
B blockers - use prostaglandin
Describe the pathway of synthesis of the inflammatory markers in asthma
- Phospholipids are converted to arachidonic acid by phospholipase A1
- Arachidonic acid is broken down to prostaglandins and leukotrienes by COX and 5-lipoxygenas respectively.
- Inflammatory changes seen in asthma
What do prostaglandins do?
Bronchoconstriction
What do leukotrienes do?
Bronchoconstriction
Mucus secretion
Recruitment of immune cells
What features are indicative of a severe asthma attack? Should you admit?
PEFR < 50%
RR > 25
HR > 110
Cant complete sentences
Admit to hospital if features persist after initial therapy
What features are indicative of a life-threatening asthma attack? Should you admit?
PEFR < 33%
02 <92%
Normally pac02 (means patient is tiring)
Silent chest
ADMIT
How is an asthma attack managed in the community?
- Give 02
- Give beta agonist
- Give prednisolone
If secondary to bacterial infection, give amoxicillin
How is an asthma attack managed in hospital?
- Give 02
- Give salbutamol + ipatroprium NEB
- Give prednisolone PO or hydrocortisone IV
- Do ABG
- Repeat nebs
- Consider IV mag sulphate (seizures)
- Abx if indicated
PEFR should be monitored 30 mins post treatment, also do oximetry and repeat ABGs if needed.
Which abx should be avoided in a patient on theophylline?
Clarithromycin/ciprofloxacin as they will increase theophylline levels
What should PEFR be before discharging someone after an attack?
> 75% of best and diurnal variability of <25%
What should they leave hospital with after an acute asthma attack? Follow up appointments?
- Correct inhaler technique
- Own PEFR meter
- Oral/INH steroids and bronchodilators
- Written asthma action plan
See GP in 2 days and hospital in 4 weeks.
Describe the stepwise approach to COPD management in a patient with FEV1> 50%
- Smoking cessation and provide pneumonia/flu vaccine
- SABA or SAMA
- LABA or LAMA
- Pulmonary rehab
Describe the stepwise approach to COPD management in a patient with FEV1/FVC < 50%
- Smoking cessation and provide pneumonia flu/vaccine
- SABA or SAMA
- (LABA+ICS) or LAMA
- all of them
- Pulmonary rehab
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Drugs95
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Parkinson's/Epilepsy64
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Diabetes/Lipid Disorders39
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Liver Disease/Dyspepsia/Altered Bowel Habit43
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Asthma/COPD28
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Hypertension/HF64
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Pain/Palliative Care42
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Atrial Fib/Anticoagulants36
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Antibiotics55
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Poisoning70
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Week 3 - PD & E70
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Week 4 - Diabetes & Lipid Disorders69
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Week 5 - Dyspepsia & Altered Bowel Habit86
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Week 6 - Asthma & COPD81
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Week 7 - HTN & HF47
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Week 9 - Pain & Palliative Care87
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Week 10 - AF & Anticoagulation0
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Week 11 - Infection & Antibiotics0
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Week 12 - Poisoning & MH0
