Main 4 symptoms of asthma?
1) Breathlessness
2) Expiratory wheeze
3) Chest tightness
4) Cough (esp at night)
Main differences between COPD and asthma:
- age of onset? 1
- symptoms? 2
- reversibility + disease course? 2
- associated conditions / SHx? 2
ASTHMA
- norm before 35 years
- symptoms worse in the evening/night (also big day to day variation)
- often identifiable triggers
- little sputum production
- symptoms fully reversible with bronchodilators
- stable disease course (with exacerbations)
- PMHx/FHx atopy/allergies
- no relation to smoking
COPD
- norm after 35 years (norm 50s+)
- little day to day variation in symptoms
- increased sputum production
- symptoms not fully reversible with bronchodilators
- progressive disease course (with exacerbations)
- often no PMHx/FHx atopy/allergies
- norm >10 pack year smoking
ASTHMA:
- what to look for in clinical exam?
- 1st, 2nd and 3rd line investigations?
Auscultate for widespread wheeze (though don’t exclude if not heard)
1) peak flow (before + after bronchodilator)
2) spirometry (before + after bronchodilator)
3) Fractional exhaled nitric oxide (FeNO)
- If asthma being considered in people >17
- If spirometry is uncertain for children (5-16)
- Positive result = >35 ppb for <16 (>40ppb for >16)
SPIROMETRY:
- what ratio is used to diagnose asthma?
- what should this be above/below to diagnose asthma?
FEV1/FVC ratio
if this is <70% then = asthma (or COPD if not reversible with bronchodilators)
main contraindications to spirometry? 4
- MI/PE etc in last 3mth
- recent chest infection
- AAA
- pregnancy
also any recent major surgery etc
basically has a big strain on the body so don’t do if it’s going to worsen any other condition
Common triggers for asthma:
- two groups of medications? 2
- other chemicals? 2
- others? 6
- NSAIDs
- beta blockers
- Pollution & chemical irritants
- Tobacco smoke
- outdoor allergens (pollen + mould)
- pets
- house dust mites
- exercise
- cold
- emotional arousal
How to explain using a peak flow to a patient? (7 steps)
Describe how you test for asthma using a peak flow test and inhaler?
- How to interpret peak flow?
- What to do if diagnostic uncertainty?
1) Sitting or standing (good posture)
2) Put mouthpiece on (and hold horizontally)
3) Ensure pointer at zero AND fingers not obstructing
4) Full breath in
5) Tight seal around mouth piece
6) Rapid forced expiratory puff
7) Best of 3 PEFR recordings recorded (remember to reset to zero after each)
Bronchodilator reversibility (BDR) test (do in all age >17):
- Do peak flow, then take SABA then repeat after 20min
- Positive if improvement of 12% or more (or 12ml of more)
Interpretation of peak flow
- COMPARE WITH CHART for age, sex & height
- Can do peak flow diaries to see if diurnal variation (especially done if diagnostic uncertainty (>20% variation over day is positive test))
What two questions should you ask to check for occupational asthma?
- are symptoms better on days away from work?
- are symptoms better when on holiday?
if so, refer to occupational asthm,a specialist
Potential reasons for uncontrolled asthma?
which should be checked every time stepping up treatment is considered
- POOR INHALER TECHNIQUE (can add a spacer)
- LACK OF ADHERENCE (eg dt confusion - always ask which inhalers use, when and how often)
- 1st or 2nd hand TOBACCO smoke
- OCCUPATIONAL exposures
- Seasonal or ENVIRONMENTAL factors
lifestyle advice for asthma? 6
prophylactic treatment for all?
- reduce WEIGHT
- improve EXERCISE tolerance
- BREATHING exercises (singing, brass instruments)
- STOP SMOKING (incl family)
- reducing DUSTMITES (mattress covers, dustmites)
- other TRIGGERS (pets, occupation)
ANNUAL flu vaccine for all!
ADULT BTS guidelines for ASTHMA:
- step 1?
- step 2?
- step 3?
- step 4? (2 options)
- step 5?
when do you move up ladder? (specific time)
STEP 1:
- SABA as required
STEP 2:
- add regular preventer (ICS)
STEP 3:
- add LABA
STEP 4: - increasing ICS to medium dose OR - add LTRA (if no response to LABA, stop it)
STEP 5:
- refer pt to specialist care
move up ladder if need THREE OR MORE doses of salbutamol PER WEEK
CHILDREN BTS guidelines for ASTHMA:
- step 1?
- step 2? (for all)
- step 3? (if under 5, if over 5 - 2 options)
- step 4? (if under 5, if over 5 - 2 options)
- step 5? (for all)
when do you move up ladder? (specific time)
STEP 1:
- SABA as required
STEP 2:
- add regular preventer (paeds dose ICS)
STEP 3:
- under 5: add LTRA
- over 5: add LABA OR LTRA
STEP 4: - increasing ICS to low dose (only one for under 5s) OR - add LTRA OR LABA (if no response to LABA, stop it)
STEP 5:
- refer pt to specialist care
move up ladder if need THREE OR MORE doses of salbutamol PER WEEK
main differences between paeds and adult BTS asthma guidelines? 2
1) STEROIDS DOSE:
- low to medium in adults
- paeds (very low) to low in children
2) WHEN INTRODUCE LTRA/LABA:
- introduce LTRA after ICS for kids (esp under 5s) - but last resort for adults before see specialist
- introduce LABA after ICS for adults - but norm only after LTRA for kids (and not at all for under 5s)
REVIEWING ASTHMA SYMPTOMS:
- how often to review after changing/adding medication?
- main method used to review effectiveness?
- Three questions to assess smptoms? (nb these aren’t validated in children)
Review response to each step at 4-8 week intervals
Use symptom score to see how well controlled!
Short symptom score (nb not validated in kids):
- Have you had difficulty sleeping because of asthma symptoms (incl cough)?
- Have you had your usual asthma symptoms during the day (eg cough, wheeze, chest tightness, SOB)?
- Has you asthma interfered with your usual activities (eg housework, work, school)?
Definition of ‘complete control’ of asthma? (ie what aiming for)7
- No daytime symptoms
- No night-time wakening due to asthma
- No need for rescue medications
- No asthma attacks
- No limitations on activity, including exercise
- Normal lung function (FEV1 and/or PEF >80% predicted)
- Minimal side effects from medication
What to tell patients about side effects of SABA/salbutamol? 3
- when to tell patients to come back? (ie when to step up treatment)
May give you a slight TREMOR and may feel your HEART RACING, that’s normal, if feel DIZZY, sit down, if severe, see dr
if needing to use >3 times a week (or waking at night) come back!
What to tell patients about using ICS inhaler?
rinse mouth with water after using (to prevent thrush)
GENERIC drug names for asthma medications:
- SABA? 1
- ICS? 3
- LABA? 2
- LTRA? 1
which one is a tablet??
SABA
- salbutamol
ICS
- beclomethasone
- fluticasone
- budenoside
LABA
- salmeterol
- formoterol
LTRA
- montelukast (TABLET! - take at night)
Which class(es) of asthma medications are in:
1) Airomir + Ventolin?
2) Clenil, Flixotide, Kelhale, Pulmicort + Qvar?
3) Atimos + Serevent?
4) Seretide, Symbicort?
SABA
- Airomir
- Ventolin
ICS
- Clenil
- Flixotide
- Kelhale
- Pulmicort
- Qvar
LABA
- Atimos
- Serevent
ICS AND LABA
- Seretide
- Symbicort
Brand name for montlukast tablet?
what class of drug is it?
singulair
LTRA
Which class of medications are in each of these branded inhalers (nb 2 have 2 in):
- Airomir?
- Atimos?
- Clenil?
- Flixotide?
- Kelhale?
- Pulmicort?
- Qvar?
- Seeretide?
- Serevent?
- Symbicort?
- Ventolin?
Airomir = SABA (salbutamol)
Atimos = LABA (formoterol)
Clenil = ICS (beclomethasone)
Flixotide = ICS (fluticasone)
Kelhale = ICS (beclamethasone)
Pulmicort = ICS (budenoside)
Qvar = ICS (beclamethasone)
Seretide = ICS AND LABA (fluticasone + salmeterol)
Serevent = LABA (salmeterol)
Symbicort = ICS AND LABA (beclomethasone + formoterol)
Ventolin = SABA (salbutamol)
Definitions of acute asthma:
- moderate?
- severe?
- life-threatening?
x
Something about 33 92 chest
x
then on to diabetes
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