Asthma

Question 1

What is Asthma?

Answer 1

Asthma is a chronic inflammatory condition of the airways that causes episodic exacerbations of bronchoconstriction.

Question 2

In asthma, there is reversible airway obstruction that typically responds to ________ such as _________

Answer 2

bronchodilators, salbutamol

Question 3

What causes bronchoconstriction in asthma?

Answer 3

Airway hypersensitivity

Question 4

What are some typical asthma triggers?

Answer 4

• Infection
• Nighttime or early mornings
• Exercise
• Animals
• Cold, damp, or dusty air
• Strong emotions

Question 5

What are some patient presentations that could suggest a diagnosis of asthma?

Answer 5

• Episodic symptoms
• Diurnal variability. Typically worse at night
• Dry cough with wheeze and shortness of breath
• History of other atopic conditions such as eczema, hayfever, and food allergies
• Family history
• Bilateral widespread “polyphonic” wheeze heard by a healthcare professional

Question 6

What are some patient presentations that could suggest a diagnosis other than asthma?

Answer 6

• Wheeze related to coughs and colds more suggestive of viral-induced wheeze
• Isolated or productive cough
• Normal investigations
• No response to treatment
• Unilateral wheeze suggesting a focal lesion or infection

Question 7

According to the BTS/SIGN guidelines from 2016, when should you make a clinical diagnosis for asthma?

Answer 7

When there is a high clinical suspicion of asthma

Question 8

According to the BTS/SIGN guidelines from 2016, when should you conduct testing for asthma?

Answer 8

When there is an intermediate or low clinical suspicion of asthma

Question 9

What do the NICE 2017 guidelines suggest regarding asthma diagnosis?

Answer 9

They advise against making a diagnosis without definitive testing

Question 10

What are the BTS/SIGN guidelines on asthma diagnosis when there is a high probability of asthma treatment?

Answer 10

Try treatment

Question 11

What are the BTS/SIGN guidelines on asthma diagnosis when there is an intermediate probability of asthma treatment?

Answer 11

Perform spirometry with reversibility testing

Question 12

What are the BTS/SIGN guidelines on asthma diagnosis when there is a low probability of asthma treatment?

Answer 12

Consider referral and investigating for other causes

Question 13

List the key treatments for long-term management of asthma.

Answer 13

• Short-acting beta 2 adrenergic receptor agonists
• Inhaled Corticosteroids (ICS)
• Long-acting beta 2 agonists (LABA)
• Long-acting muscarinic antagonists (LAMA)
• Leukotriene Receptor Antagonists (LTRA)
• Theophylline
• Maintenance And Reliever Therapy (MART)

Question 14

An example of SABA includes

Answer 14

Salbutamol

Question 15

How do Short-acting beta 2 adrenergic receptor agonists work?

Answer 15

• They work quickly but the effect only lasts for an hour or two
• Adrenalin acts on the smooth muscles of the airways to cause relaxation resulting in dilatation of bronchioles

Question 16

When are Short-acting beta 2 adrenergic receptor agonists used?

Answer 16

Used as “reliever” or “rescue” medication during acute exacerbations of asthma when the airways are constricting.

Question 17

An example of ICS includes

Answer 17

Beclometasone

Question 18

What do Inhaled Corticosteroids (ICS) do?

Answer 18

Reduce inflammation and reactivity of the airways

Question 19

When are Inhaled Corticosteroids (ICS) used?

Answer 19

Used as “maintenance” or “preventer” ‘medications and are taken regularly even when well

Question 20

An example of LABA includes

Answer 20

Salmeterol

Question 21

How do Long-acting beta 2 agonists (LABA) work?

Answer 21

They work in the same way as SABA’s but have a much longer action

Question 22

An example of LAMA includes

Answer 22

Tiotropium

Question 23

How do Long-acting muscarinic antagonists (LAMA) work?

Answer 23

They block the acetylcholine receptors that are stimulated by the parasympathetic nervous system causing the bronchial smooth muscles to contract. Blocking these receptors leads to bronchodilatation.

Question 24

An example of LTRA includes

Answer 24

Montelukast

Question 25

What are leukotrienes?

Answer 25

Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction, and mucus secretion in the airways.

Question 26

How do LTRA's work?

Answer 26

By blocking the effects of leukotrienes

Question 27

How do theophyllines work?

Answer 27

By relaxing bronchial smooth muscles and reducing inflammation

Question 28

What is the therapeutic window of theophyllines?

Answer 28

It has a narrow therapeutic window and can be toxic if used in excess, so monitoring plasma theophylline levels in the blood is required.

Question 29

How frequently should plasma theophylline levels be monitored when on theophylline treatment?

Answer 29

5 days after starting treatment and 3 days after each dose changes

Question 30

What is MART?

Answer 30

It is a combination inhaler containing a low-dose inhaled corticosteroid and a fast-acting LABA. This replaces all other inhalers and the patient uses this single inhaler regularly as a preventer and as a reliever when symptoms show.

Question 31

Both BTS/SIGN and NICE guidelines start with __________ followed by ___________

Answer 31

SABA; low dose inhaled corticosteroid

Question 32

After the first-line treatment, what medication is provided in the next step?

Answer 32

LTRA or an inhaled LABA

Question 33

List the principles of using the stepwise ladder.

Answer 33

- Start at the most appropriate step for the severity of the symptoms - Review at regular intervals based on severity - Step up and down the ladder based on the symptoms - Aim to achieve no symptoms or exacerbations on the lowest dose and number of treatments - Always check inhaler technique and adherence at review

Question 34

List out the steps in the BTS/SIGN 2016 guidelines stepwise ladder

Answer 34

- Add a SABA as required for infrequent wheezy episodes - Add a regular low dose ICS - Add LABA inhaler and continue ONLY if the patient has a good response - Consider a trial of an oral LTRA, oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA - Titrate the ICS up to high dose. Combine additional treatments from step 4. Refer to a specialist. - Add oral steroids at the lowest dose possible to achieve good control.

Question 35

List out the steps in the NICE 2017 guidelines stepwise ladder

Answer 35

- Add a SABA as required for infrequent wheezy episodes - Add a regular low dose ICS - Add an oral LTRA - Add LABA inhaler and continue ONLY if the patient has a good response - Consider changing to a MART regime - Increase the inhaled corticosteroid to a 'moderate dose' - Consider increasing the ICS dose to "high dose" or oral theophylline or an inhaled LAMA - Refer to a specialist

Question 36

Additional management for patients with asthma include

Answer 36

- Each patient should have an individual asthma self-management programme - Yearly flu jab - Yearly asthma review - Advise exercise and avoid smoking