Asthma

Why is respiratory health important?

Large numbers of people affected. Many GP consultations. Large number of deaths. High costs for treatments (medicines/devices)

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Outline the lung anatomy and physiology (1)

Right lung (3 lobes) and left lung (2 lobes). Larynx - trachea, bronchi, bronchioles (not wall cartilage). Lung perfusion (alveoli, pulmonary vein/artery), gas exchange, type I/II alveoli cells, macrophages

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Outline the lung anatomy and physiology (2)

Tidal volume, respiratory rate, resistance of airways. Dead space. Pleural cavity – lubricant, reduce surface tension, allows lungs to expand and return to normal size. Capillary network . Sympathetic, parasympathetic stimulation

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Outline features of the oxy-haemoglobin dissociation curve

Sigmoid shape. 4 oxygen molecules per Hb. Bohr effect - CO2 + H2O to form carbonic acid which dissociates to form H+ and HCO3- (chloride shift takes place). Alkalosis/acidosis

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What is extrinsic asthma?

Allergen. Childhood onset

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What is intrinsic asthma?

No external cause. Adulthood onset. Immunoglobulin independent

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What are the main causes of asthma?

House dust mite, pollen, dander, spores

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Describe what happens during an exposure to an antigen

Bronchoconstriction as immediate response. Late phase - inflammation, mucosal oedema, mucus, epithelial damage, hyperresponsiveness, bronchoconstriction, airway remodelling. Release of histamine, cytokines eosinophil, T-lymphocytes, B cells etc

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Describe the effects of extrinsic asthma

Mucosal oedema, inflammatory cell infiltration, bronchoconstriction, hyperresponsivness, remodelling, mucus hypersecretion, epithelial damage

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What needs to be checked to confirm symptoms of asthma?

Clinical symptoms, medical history, social history, drug history

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Describe features of diagnosing asthma

Presence of symptoms (more than 1) - wheeze, breathlessness, cough, chest tightness and variable airflow obstruction-objective measure

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Which instruments are used to measure lung function?

Spirometry (FEV1, FVC, ratio) and peak flow meter (compare to normal values). If results change (better, by 400 mLs) – asthma. If no change - COPD (differential diagnosis)

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Describe features of treating asthma (1)

The least clinically effective and least cost effective asthma medications are those that the patient cannot and cannot take correctly

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Describe features of treating asthma (2)

Treatments include bronchodilators and anti-inflammatory drugs

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Outline the pharmacology of bronchodilators

Beta 2 adrenergic agonists (salbutamol or terbutaline). Binds to GCRP to cause cAMP elevation in cell which results in relaxation of airway smooth muscle cells

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Outline the pharmacology of corticosteroids

Decrease levels of inflammatory cells e.g. eosinophils, T-lymphocytes, mast cells, macrophages, dendritic cells, decrease number of cytokines/decrease apoptosis. Targets smooth muscle, epithelial, endothelial cells, and mucus gland (reduce mucus)

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Which guidelines are used for management of asthma?

British guidelines (also NICE guidelines - controversy)

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Outline the BTS guidelines (1)

Patients start with at least 2 inhalers (preventer and reliever where preventer is more important). Increase dose if required (e.g. symptoms 3x week, woken up at night)

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Outline the BTS guidelines (2)

Can move to long acting inhalers, LK agonists, muscarinic antagonists, theophylline, combination treatments etc. Can also move down treatment – reduce dose by 25-50%

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Outline the asthma prescribing guidelines for adults

Either use MDI or DPI. Doses titrated. Important to check patient's adherence, provide personalised action plan and refer patients to smoking cessation services as appropriate

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Majority of asthma treatments target what?

Symptoms caused by cytokine pathways e.g. IgE, ILS, histamine, serotonin, prostaglandins, leukotrienes etc. (omalizumab, mepolizumab, reslizumab, benralizumab, monetlukast - biologics)

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Describe features of steroid rescue packs

Patient education. Action plans based on symptoms/peak flows. Patients can record asthma triggers, monitor for any possible asthma attacks, inhaler techniques etc. Improve patient's adherence

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What are the rational steps for treatment of asthma?

Inhaler device type - inspiratory effort and dexterity. Patient's belief/behaviour/any other barriers e.g. BD dosing seretide 500 accuhaler vs OD dosing relvar 184 ellipta or MART. Medication strength

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Describe features of inhaler technique

>90% of patients cannot use an MDI effectively, 91% of healthcare professionals who teach use of respiratory inhalers cannot demonstrate them correctly, 34% collect <50% for inhaled combination therapy

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What are the types of MDI inhaler?

MDI, Easibreath, Autohaler

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What are the types of DPI inhaler?

Turbohaler, Accuhaler, Handihaler, Breezehaler, Ellipta, Nexthaler, Genuair, Duoresp Spiromax

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What are the other types of inhaler devices?

Respimat soft mist inhaler, small volume spacer, small volume spacer with mask, large volume spacer, in-check dial, peak flow meter

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Describe features of MDI inhalers

Remove mouthpiece, shake MDI inhaler, breath out gently, Put mouthpiece in mouth and close lips around it. Breath in slow/steady, press canister dow to release medicine and continue to inhale deeply, remove MDI and hold up to 10 s

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Describe features of Easibreath inhaler

Hold inhaler upright, shake inhaler, breath out gently, put mouthpiece in mouth and close lips around it, breath in slow/steady, do not stop breathing in when easibreath inhaler releases the dose. Remove inhaler and hold up to 10 s

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Describe features of the Autohaler

Hold inhaler upright, shake inhaler, push lever up, breath out gently, put mouthpiece in mouth and close lips around it, breath in slow/steady, do not stop breathing in when auto inhaler clicks, releasing dose. Remove inhaler and hold up to 10 s

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Describe features of the Turbohaler (1)

Unscrew and lift off the cover. Hold turbohaler upright and twist the grip in one direction then the other as far it will go, should hear a click. Breath out gently. Put mouthpiece in your mouth and close lips around it (may be no taste)

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Describe features of the Turbohaler (2)

Breath in, quickly/deeply as possible. Remove turbohaler from your mouth, then breath out slowly

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Describe features of the Accuhaler (1)

Hold the outer casing, slide thumb grip away until a click is heard. Hold the accuhaler with mouthpiece towards you, push level down until it clicks. Breath out gently. Put mouthpiece in mouth and close lips around it

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Describe features of the Accuhaler (2)

Breath in quickly/deeply as possible and hold your breath

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Describe features of the Handihaler (1)

Open dust cap of handihaler by pulling it upwards, then open the mouthpiece by pulling it upwards. Peel foil, place capsule in chamber in middle of handihaler. Close mouthpiece and press it down until you hear click

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Describe features of the Handihaler (2)

Press green button as far as it will go and release. Put mouthpiece in mouth and close lips around it. Breath in quickly/deeply as possible. Remove handihaler from mouth, hold breath up to 10 s then breath out slowly

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Describe features of the Breezehaler (1)

Pull off mouthpiece, hold base firmly and tilt mouthpiece. Peel back foil, expose capsule and place in middle of chamber. Close mouthpiece and press it down until you hear it click

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Describe features of the Breezehaler (2)

Pierce capsule by firming pressing together on both side buttons at the same time. Breath out gently. Put mouthpiece in mouth, close lips around it. Breath in quickly/deeply as possible. Remove inhaler from mouth and hold breath for 10 s

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Describe features of the Ellipta

Slide the cover down until you hear a click. Breath out gently. Put mouthpiece in mouth and close lips around it. Breath in long, steady/deeply as possible. Remove inhaler from mouth, hold breath for 10 s or as long which is comfortable

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Describe features of the Genuair

Pull off mouthpiece. Press and release green button, breath out gently. Put mouthpiece in mouth and close lips around it. Breath in, quickly/deeply as possible. Remove inhaler from mouth and hold breath for 10 s

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Describe features of the Duoresp Spiromax

Pull of mouthpiece, fold it down, hearing the click, do not cover air vent. Breath out gently. Put mouthpiece in mouth, close lips around it. Breath in quickly/deeply as possible. Remove inhaler from mouth, hold breath for 10 s

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Describe features of the Respimat Soft Mist Haler (1)

Insert cartridge. Hold inhaler upright, turn base in direction of red arrows on label until it clicks. Open mouthpiece cover. Breath gently. Put mouthpiece in mouth and close lips around it. As you breath in, slow/steady press dose-release button

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Describe features of the Respimat Soft Mist Haler (2)

Continue to inhale deeply. Remove respimat from mouth, hold breath for up to 10 s, then breath out slowly

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Describe features of the Aerochamber (small volume) (1)

Remove mouthpiece cover from MDI inhaler. Shake MDI and insert into hole at the end of the mouthpiece. Breath out gently. Put space mouthpiece in mouth and close lips around it. Press canister down to release on puff of medicine into spacer

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Describe features of the Aerochamber (small volume) (2)

Breath in slowly/steadily (if you hear a whistling sound, you are breathing in too quickly). Remove spacer from mouth and hold breath for up to 10 s. Tidal breathing is just as good (repeating it five times)

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Describe features of the Volumatic (large volume) (1)

Remove mouthpiece cover from MDI inhaler. Shake MDI and insert into hole at the end of the mouthpiece. Breath out gently. Put space mouthpiece in mouth and close lips around it. Press canister down to release on puff of medicine into spacer

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Describe features of the Volumatic (large volume) (2)

Breath in slowly/steadily. Remove spacer from mouth and hold breath for up to 10 s. Tidal breathing is just as good (repeating this five times)

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Describe features of the in-check dial

Reset in-check dial. Align scale with prescribed inhaler device. Check if patient inhales within the range (use inhaler resistance range as guide - patient may need to change inhaler device)

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Asthma

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Other cards in this set

Card 2

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Card 3

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Card 4

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Back

Card 5

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Back

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