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1

the asthma treatment pyramid

(Bottom of pyramid)

1. reliever - short-acting B2-agonist PRN
2. preventer 1st line - inhaled steroid
3. add 2nd line controller - cromoglycate or LABA/LAMA
4. oral steroid/biologies

2

corticosteroids

- anti inflammatory
- used in asthma and COPD
- may cause pneumonia in COPD due to local immune suppression altered micro biome and MC clearance
- very-fat soluble
- low therapeutic ratio = not suitable long term

3

inhaled steroids in COPD

never use an inhaled steroid beginning with letter F, use one beginning with B

4

what can pass through the trachea?

anything less than 5 microns

5

what can get pass the smaller airways eg bronchioles (generation 8)?

anything less than 2 microns

6

what does a spacer do?

1. avoids coordination problems with pMDI
2. reduces oropharyngeal and laryngeal side effects
3. reduces systematic absorption from swallowed fraction
4. acts a holding chamber for aerosol
5. reduces particles size and velocity
6. improves lung deposition

7

cromones

- anti inflammatory
- only used in asthma eg cromoglycate
- mast cell stabiliser - weak anti inflammatory of steroids
- cromoglycate effective in atopic children
- inhaled route only
- not used much due to poor efficacy

8

is blocking LTD4 good for treating asthma?

yes

9

leukotriene receptor antagonists

- anti inflammatory
- only used in asthma
- montelukast
- less potent anti inflammatory than inhaled steroid
- effective in allergic rhinitis with anti histamine

10

montelukast

never use on it's own
oral route
- once daily
- high therapeutic ratio

11

anti-IgE

- anti-IgE monoclonal antibody: omalizumab

12

omalizumab

- inhibits the binding to the high affinity IgE receptor - inhibits TH2 response and assoc mediator release from basophils/mast cells
0 injection every 2-4 weeks for asthma only
- for patients with severe persistant . allergic asthma
- very expensive
- little effect on pulmonary function but reduces exacerbations and oral steroid sparing effect

13

anti- IL5

- mepolizumab

14

what is mepolizumab?

- blocks effect of TH2 cytokine IL-5 whichis responsible for eosinophilic iflammtion in asthma
- injection every 4 weeks for asthma only
- for patients with sever refractort eosinophili asthma
- v expensive
- Little effect on pulmonary function or symptoms but reduces exacerbations and oral steroid sparing effect

15

B2- angonists

- stimulate bronchial smooth muscle B2 receptors
- short-acting = sabutamol
- long acting = salmeterol
- combination inhalers = beclometasone
- used in asthma and COPD
- higher therapeutic ration when given by inhaled route
- b2 down regulation and thacyphylacis with chronic LABA
- systematic B2 effects when given systematically or at high inhaled doses
- high nebulised doses (SABA) given in acute attack

16

are LABA every used on their own?

never, only in combination with an inhaled steroid for asthma

17

what is used for high nebulised doses?

SABAs eg salbutamol

18

what does acytylecholine do?

blocks the airway

19

muscarinic antagonists

- aka anticholinergics
- block post junctional end plate M3 receptors
- in COPD used with a LABA or as a triple inhaler
- in asthma used as a triple therapy at step 4 with LABA
- high nebulised doses of ipratropium used in acute COPD and in acute asthma

20

methylxanthines

- bromchodilator/anti inflammatory
- oral for maintanence therapy
- SR formulation usedful for nocturnal dips
- used as add to inhaled steroid as complimentary non steroidal anti infalmmatory
- IV for acute attacks
- non selective phosphodiesterase inhibitor
- aclso acs as adenosine antagonist
- low therapeutic ratio
- used in asthma and COPD

21

treatment of chronic asthma

- aims are to abolish symptoms, minimum use of B2, noamliise REV1, reduce PEf varibalitiy, reduce exac, prevent long term airway remodelling
- Suppress inflammatory cascade with inh steroid
- Stabilise smooth muscle with LABA/LAMA
- Supress eosinophils with anti-IL5
- Treat allergy with anti-IGE

22

treatment of acute astham

- oral prenisolone,
- nebulised high dose of salbutamol

23

COPD management

non pharmacological
- stop smoking or cessation
- immunisation
- pharamcotherapy
- pulmonary rehan
- oxygen

pharmacological
- LABA/LAMA
- ICS/LABA/LAMA combo (triple inhalers)

24

treatment of acute COPD

- neublised high dose of salbutamol plus ipratropium
- oral predinisolone
- antibiotic if infection
- physio to get sputum up
- non invasivel ventilation to allow FiO2