Asthma Series Presentation

  • Asthma Series Part 1: Introduction

    • Focus: Management of asthma based on the asthma handbook.
    • Asthma: A chronic inflammatory airway disorder.
    • Key feature: Chronic inflammation leading to hyper-responsiveness and episodes of:
      • Wheezing
      • Breathlessness
      • Chest tightness
      • Coughing (especially at night or early morning in children)
    • Associated with widespread but variable airflow obstruction that is reversible.
    • Variability: Symptoms fluctuate; no two days are the same.
    • Definition of Asthma:
    • Clinical: Combination of variable respiratory symptoms.
    • Excessive variation in lung function.
    • Patient Journey:
    • Untreated Asthma:
      • Poor lung function.
      • Variability between days.
    • Diagnosed and treated Asthma:
      • Ideally leads to well-controlled asthma.
      • Improved lung function.
      • Less variability.
    • Poorly Controlled Asthma:
      • Slow deterioration in respiratory function.
      • Return to greater variability.
    • Acute Exacerbation (Flare-up):
      • Significant worsening over a short time (days).
      • Often triggered by an acute event.
    • Acute Attacks of Asthma:
      • Severe episodes with a risk of death.
      • More likely during a flare-up.
    • Goal: Achieve well-controlled asthma to reduce variability, symptoms, and risk of severe attacks.
    • Asthma: Inflammatory condition with bronchoconstriction.
    • Mediators of inflammation are present in the airways.
    • Diagnosis Patterns:
    • Childhood diagnosis: May persist for life, or may be outgrown at an older age.
    • Later-in-life diagnosis: Can occur in the context of other respiratory diseases like COPD.
    • Diagnosis:
    • Based on symptoms:
      • Wheeze, chest tightness, shortness of breath, coughing (especially variable symptoms).
      • Symptoms can worsen with triggers or seasons.
      • Nighttime coughing (especially in children).
      • Exercise-induced symptoms.
    • Supported by diagnostic testing:
      • Spirometry.
      • Peak flow.
    • Initiating treatment and observing a response can confirm diagnosis.
    • Lung Function Assessment:
    • Spirometry:
      • Measures lung function.
      • FEV1 (forced expiratory volume in one second) is key.
    • Peak Flow Meter:
      • Simple device for home monitoring for asthma patients.
      • Technique-dependent.
      • Variability suggests poorly controlled asthma.
    • Spirometry:
    • Measures FEV1, the volume exhaled in one second.
    • Adults and children over 7 can typically perform.
    • FEV1 is compared to predicted values based on demographics (sex, age, height).
    • Lower FEV1 than expected suggests asthma.
    • Aim of therapy: Improve FEV1.
    • Reversibility:
    • Defined by spirometry.
    • Spirometry is performed before and after bronchodilator administration.
    • Significant increase in FEV1 after bronchodilator indicates reversibility.
    • Significant increase:
      • 12% increase if baseline FEV1 is above 1.7 liters.
      • 200ml increase if baseline FEV1 is less than this.
    • Diagnosis:
    • Symptoms, variability, history, considering alternative diagnoses (like COPD).
    • Spirometry (if possible).
    • Children:
    • If spirometry is not possible, symptoms guide diagnosis.
    • Treatment can be initiated to observe response.
    • Children's Symptoms Increasing Asthma Probability:
    • Wheeze, cough, chest tightness, worsening at night.
    • Asthma Patterns:
    • Infrequent Intermittent: Few symptoms, occasional relief needed.
    • Frequent Intermittent: More common symptoms.
    • Persistent: Assessed by FEV1 and nighttime symptoms.
      • Ranges from mild to moderate depending on FEV1 reduction.
    • Adults: Assessed on level of control.
    • Good Control: Symptoms less than two days per week, no limitations, no nighttime symptoms.
    • Partial or Poor Control: More frequent symptoms, limitations, nighttime symptoms.

  • Asthma Series Part 2: Triggers

    • Non-drug management is important for asthma.
    • Avoiding triggers can be beneficial.
    • Common triggers:
    • Inhaled allergens:
      • Pollen.
      • Pet allergens (can persist long after animal removal).
      • House dust mites.
    • Tobacco smoke.
    • Respiratory tract infections:
      • Hygiene practices (hand sanitizer, avoid touching face) can help reduce risk.
      • Influenza and pneumococcal vaccines.
    • Exercise, especially in cold, dry environments.
      • Techniques to reduce exercise-induced asthma:
      • Salbutamol before exercise.
      • Inhaled corticosteroids.
      • Appropriate warm-up.
      • High-level athletes must be aware of medicine restrictions and anti-doping regulations; some medicines, also salbutamol, have usage quantity limits.
    • Medicine Triggers:
    • Balance benefit and risk; assess asthma history.
    • Beta Blockers:
      • Can worsen asthma.
      • Consider asthma severity and patient history.
      • Beta-1 selective drugs are preferred, with cautious dosing and monitoring.
      • Alternative: rate-limiting calcium channel blockers.
    • NSAIDs:
      • Can worsen asthma in some patients.
      • Paracetamol is a safer alternative.
    • Complementary medicines:
      • Royal jelly can cause severe asthma attacks.
    • Beta Blockers and Airway Function:
    • Beta blockers can reduce FEV1 (Atenolol, Metoprolol, Bisoprolol).
    • Propranolol (non-selective) has a more significant effect.
    • Responsiveness to Beta-2 Agonists:
    • Beta-2 agonists (like salbutamol) are still effective, but potentially to a lesser extent.
    • Nuance needed in using beta blockers in asthma patients:
    • Assess patient history.
    • Choose appropriate beta blocker and dose.
    • Monitor response.

  • Asthma Series Part 3: Medicines Management

    • Two primary uses of medicines:
    • Managing Symptoms:
      • Mild symptoms: PRN reliever.
      • Severe acute asthma attack: potentially fatal needing appropriate and immediate relief.
      • Rapid-acting beta agonists (relievers).
    • Obtaining Good Control:
      • Minimal symptoms.
      • No nighttime symptoms.
      • Limited reliever use.
      • Few exacerbations.
      • No limitation to physical activity.
      • Best possible lung function.
    • Approach Guided by Asthma Action Plan.
    • Types of Medicines:
    • Relievers: Provide rapid relief of symptoms.
    • Preventers: Used to prevent symptoms by treating underlying inflammation.
    • Symptom Controllers: Long-acting, control symptoms but don't address cause.
    • Critical Factors: Compliance and Technique.
    • Irrelevant to choose the best medicine if patient doesn't use it correctly.
    • Inhaler Devices:
    • Variety of devices (MDIs, spacers, dry powder inhalers, etc.).
    • Spacers are effective for MDIs, particularly in children or for severe episodes.
    • Dry powder devices (Turbuhalers) need good inspiratory flow rates.
    • Device Technique:
    • Each device has specific steps for proper use.
    • Common Errors:
      • Not breathing out before inhaling.
      • Stopping inhalation immediately after firing.
      • Inhaling too forcefully.
      • Failing to hold breath after inhalation.
    • Care for Spacers: Clean regularly; avoid polishing with cloth.

  • Asthma Series Part 4: Managing Symptoms and Severe Attacks

    • Focus: Managing symptoms, especially severe asthma attacks.
    • Medication: Beta-2 agonists (relievers).
    • Types of Beta Agonists:
    • Short-Acting Beta Agonists (SABAs): Salbutamol (Ventolin), Terbutaline.
      • Rapid-acting, not just short duration.
    • Comparison of Beta Agonists:
      • Salbutamol (rapid onset of effect).
      • Formoterol (rapid-acting, can be used as a reliever).
      • Salmeterol (slower onset, not for relief).
    • Salmeterol:
      • Slower onset (10 minutes to peak effect), making it inappropriate for rapid relief.
    • Management of Symptoms:
    • Times when patients may use relievers:
      • Periods of higher variability in airflow function
      • Mild symptoms one or two puffs may provide sufficient relief.
    • Managing Severe Acute Attacks:
    • First Aid: "Four by four by four".
      • Salbutamol.
      • The Turbuhaler is not so effective during an asthma attack because of the difficulty of generating the required airflow.
    • Steps:
      • Sit down, relax, remain calm.
      • Administer four puffs of salbutamol via a spacer, if possible.
      • One puff to the spacer, four breaths from the spacer. Repeat.
      • Wait a few minutes to assess response.
      • If no improvement, repeat the process.
      • If still not breathing normally, call an ambulance.
      • Continue administering four puffs every four minutes until help arrives.
    • Side Effects of Salbutamol:
      • Tremor (expected).
      • Palpitations (possible).
      • Increased heart rate (possible).
      • Hypokalemia (theoretical, hard to induce with inhaled salbutamol).
    • First Aid for Asthma:
      • A nebulized salbutamol (5 mg dose) is equivalent to twelve puffs of salbutamol via a spacer.
    • Avoid nebulizers due to COVID-19, and administer salbutamol via a spacer!
    • One or two puffs PRN are for relief of mild symptoms whereas one can safely administer twelve puffs for the relief of severe, acute asthma attack.
    • Assessing Severity:
    • Ability to speak:
      • Whole sentences: mild to moderate.
      • Few words: severe.
    • Life-threatening: obvious signs of distress.
    • Hospital Management:
    • Oxygen, nebulized salbutamol, ipratropium (if not responding to salbutamol).
    • Systemic corticosteroids:(IV hydrocortisone or oral prednisolone) to reduce inflammation.

  • Asthma Series Part 5: Obtaining Good Asthma Control in Adults and Adolescents

    • Focus: Achieving good asthma control in adults and adolescents.

    • Approach: Stepped management based on the Asthma Handbook.

    • Pyramid: Therapy progression based on patient control.

    • Aim: Good control via lung function optimization and variability reduction.

    • Considerations for Treatment:

    • Start with treatment to improve lung function.

    • Review patient status and consider down-titration after a period of good control.

    • Assess compliance and inhaler technique when evaluating control.

    • If optimization does not provide sufficient relief, then move up to the next treatment steps.

    • Medication and Recommendations for Newly Diagnosed Asthma:

    • Very few patients with asthma should be on SABA alone, as applies to patients with intermittent asthma.

    • Most patients should take low-dose of inhaled Corticosteroids+PRN.

    • Regular low-dose ICS are appropriate for most!

    • Initial Considerations for Severe Asthmatic Patients:

    • Commencing the patient on:

      • High dose ICS.
      • Short-term Oral Corticosteroids + Inhaled Corticosteroids.
      • Inhaled corticosteroids with LABA - (does not meet PBS Criteria but private prescription is adequate).
      • Maintenance and Relieved Therapy - review in later video.

    • Focus in getting patient under control quickly, then low level therapy must be maintained.

    • The PBS for ICSLABA products only apply when patients have been treated with oral or inhaled corticosteroids!

    • Low Inhaled Corticosteroids are defined, and those dose levels range and can be recognised.

    • Budesonide dose is important to learn.

    • Patient Guidance is critical because a tendency that patients that are taking preventor they tend to: stop taking the medication quickly since there is no immediate effect!

    • Benefits are to see effectiveness the patients need to take there inhaled steroid as needed, over a matter of weeks to reduce their episodes!

    • Patients may not feel like it is doing anything, but if they stick with it for a period of weeks, their asthma will become less frequent!

    • Patients will mostly just rely on a receiver, which is not a good outcome.

    • Counselling is crucial because it will allow to demonstrate what type of effect patients can anticipate.

  • Steroids DO NOT PRODUCE LONG TERM SIDE EFFECTS LIKE:
    - Osteoporosis.
    - Glaucoma and Cataracts from MDIs.
    - Adrenal Suppression or skin thinning.
    - Growth Suppression

    Steroids DO PRODUCE THE FOLLOWING SIDE EFFECTS: the can occur:
    - Oral Trush, hoarseness related to oral depression of inhaled corticosteroids, and dysphonia, so after the patient takes the product they need to rinse their mouth with water.

  • Patient are likely exposed to local affect on Corticosteroids from nebulisers which creates a vapor drug deposit near the eye!
    - As a protective mechanism, patients can wear swimming goggles!! (Not a Turbuhaler as drugs do not deposit near the eye) .

  • Poor compliance is a massive challenge in managing ashtma so it must be address with education

  • The aim is to have patient obtain good control meaning:
    - Daytime symptoms are less then two days per week
    - No physical activity Imitations.
    - NO symptoms at night.

What to do if the patient is not having this:

  • Are they compliant
  • Are they are it properly.
  • Should they still have therapy? Check for appropriate lung compliance and any technical difficulty.

How to move patients on corticosteroids:

  • the treatment requires to patients that take ORAL corticosteroids for exarcerbation and ICS. You can see a meta analysis suggested slightly better outcome with COMBINATION OF LAVA AND ICS for patients with FEV one.

-Asthma Series Part 6: Different Ways to Manage Good Asthmas in Adults
- Recognize their symptoms of becoming less well controlled and actively make decision to increase there LABA+ICS dose
Patients needed to recognize there asthma is becoming less well controlled
What happens when patients used there reliever too often?

The patient use mart(formeterol and Budenoside single inhaler for maintenance dose and relies also!
- Mart requires the product of the Lava to have a rapid onset of effect, therefore only Formoterol can be use NOT Salmeterol!!! because as symptoms increase because they re becoming less well controlled and needed to use ther releva, a=every time they use there relever there getting a dose of ICS.

Those with a high tendency to be in the Turbuhalers might face issues as for it to work:
- they have significant inhaler flow rates which they might not be able to generated during bad state of illness

Use formeterol, because with as asthma attacks they will rely on the SABA because of device limitations!!! with the proper reliever!

-New steps recommend low doses of Budenoside and PRN only so no regular ones and patient would use Formoterol Budenoside so the Foroterol would relieve the symptoms with relief of inflammation

-A significant change in therapy that might cause
B Receptor Downregulation, and will now have benefit From having a corticosteroid.

  • The results from these new changes are:
    - budesonide maintenance, but their are many patients who are not complaint!