Asthma Osce

Front 1

hi

Back 1

hi

Front 2

What is the definition of asthma?

Back 2

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the historyof respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and inintensity, together with variable expiratory airflow limitation

Front 3

What are the sub-types of asthma?

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1) Allergic asthma: this is the most easily recognized asthma phenotype, which often commences in childhood and isassociated with a past and/or family history of allergic disease such as eczema, allergic rhinitis, or food or drugallergy. Examination of the induced sputum of these patients before treatment often reveals eosinophilic airwayinflammation. Patients with this asthma phenotype usually respond well to inhaled corticosteroid (ICS) treatment.

2) Non-allergic asthma: some adults have asthma that is not associated with allergy. The cellular profile of thesputum of these patients may be neutrophilic, eosinophilic or contain only a few inflammatory cells(paucigranulocytic). Patients with non-allergic asthma often respond less well to ICS.

3) Late-onset asthma: some adults, particularly women, present with asthma for the first time in adult life. Thesepatients tend to be non-allergic, and often require higher doses of ICS or are relatively refractory to corticosteroidtreatment.

4) Asthma with fixed airflow limitation: some patients with long-standing asthma develop fixed airflow limitation that isthought to be due to airway wall remodeling.

5) Asthma with obesity: some obese patients with asthma have prominent respiratory symptoms and littleeosinophilic airway inflammation.

Front 4

How to diagnose asthma?

Back 4

1. History (demonstrate variability in wheeze/cough/SOB/chest tightness)

- Generally more than one type of respiratory symptom(in adults, isolated cough is seldom due to asthma)

- Symptoms occur variably over time and vary in intensity

- Symptoms are often worse at night or on waking

- Symptoms are often triggered by exercise, laughter, allergens, cold air

- Symptoms often appear or worsen with viral infections

2. Confirmatory tests (just need one of these tests)

- positive bronchodilator reversibility test (>12% or >200 ml improvement in FEV1, 10-15 mins after 200-400 mcg albuterol)

- Excessive variability in daily diurnal PEF over2 weeks (for adults >10%, kids >13%)

- Significant increase in lung function after4 weeks of anti-inflammatory treatment (>12% or >200 ml improvement in FEV1, after treatment and without infectious exacerbations)

- Positive exercise challenge test (Adults: fall in FEV1 of >10% and >200 mL from baseline, Children: fall in FEV1 of >12% predicted, or PEF >15%)

- Positive bronchial challenge test (Fall in FEV1 from baseline of ≥20% with standard doses of methacholineor histamine)

Front 5

How to assess asthma control in kids?

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1. Assess asthma control

- assess symptom control over the last 4 weeks (via ACT scoring)

- Identify any other risk factors for exacerbations, fixed airflow limitation or side-effects of medications (beta-blocker/steroids associated)

- Measure lung function at diagnosis/start of treatment, 3–6 months after starting controller treatment, thenperiodically

2. Assess treatment issues

- Document the patient’s current treatment step

- Watch inhaler technique, assess adherence and side-effects

- Check that the patient has a written asthma action plan

- Ask about the patient’s attitudes and goals for their asthma and medications

3. Assess comorbidities

- Rhinitis, rhinosinusitis, gastroesophageal reflux, obesity, obstructive sleep apnea, depression and anxiety cancontribute to symptoms and poor quality of life, and sometimes to poor asthma control

Front 6

What are the side effects of ICS?

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high-dose ICS include easy bruising; anincrease beyond the usual age-related risk of osteoporosis, cataracts and glaucoma; and adrenal suppression. Localside effects of ICS include oral thrush and dysphonia.

Patients are at greater risk of ICS side-effects with higher dosesor more potent formulations, and, for local side-effects, with incorrect inhaler technique

Front 7

When is peak expiratory flow rates monitored?

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Once the diagnosis of asthma is made, short-term PEF monitoring may be used to assess response to treatment, toevaluate triggers (including at work) for worsening symptoms, or to establish a baseline for action plans. After startingICS, personal best PEF (from twice daily readings) is reached on average within 2 weeks.

Average PEF continues toincrease, and diurnal PEF variability to decrease, for about 3 months.

Excessive variation in PEF suggests suboptimalasthma control, and increases the risk of exacerbations.

Long-term peak expiratory flow (PEF) monitoring is now generally only recommended for patients with severe asthma,or those with impaired perception of airflow limitation. For clinical practice, displaying PEFresults on a standardized chart may improve accuracy of interpretation.

Front 8

When can asthma severity be assessed?

What are the different severity levels?

Back 8

1. Assessed after patient has been on regular treatment for several months

2.

Mild = symptoms controlled with step 1/2 treatment

Moderate = symptoms controlled with step 3 treatment

Severe = symptoms controlled under step 4/5 treatment, or refractory asthma

Front 9

What are the common causes of uncrontrolled asthma?

Back 9

Think of comorbidities, environment, occupation and psycho-social factors

• Poor inhaler technique
  
• Poor medication adherence
  
• Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as upper airway dysfunction,cardiac failure or lack of fitness
  
• Comorbidities and complicating conditions such as rhinosinusitis, gastroesophageal reflux, obesity and obstructivesleep apnea
  
• Ongoing exposure to sensitizing or irritant agents in the home or work environment.
  

Front 10

What is the stepwise approach to management of asthma?

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Step 1 & 2:

- As needed SABA

- Step 1 => consider low dose LCS

- Step 2 => start low dose LCS (consider low dose theophylline/LTRA)

Step 3, 4 & 5:

- As needed SABA and/or low dose ICS

- Step 3 => Start low dose ICS + LABA (Consider med dose ICS or low dose LCS + LTRA/theophylline)

- Step 4 => Start med/high dose ICS + LABA (consider adding tiotropium, high dose ICS + LTRA)

- Step 5 => Refer for add-on treatment, IgE etc (consider adding tiotropium, oral steroids)

Front 11

When should patients be followed up for asthma?

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For most controller medications,improvement begins within days of initiating treatment, but the full benefit may only be evident after 3–4 months. Insevere and chronically under-treated disease, it may take longer.

All health care providers should be encouraged to assess asthma control, adherence and inhaler technique at everyvisit. The frequency of visits depends upon the patient’sinitial level of control, their response to treatment, and their level of engagement in self-management. Ideally, patients should be seen 1–3 months after starting treatment and every 3–12 months thereafter. After an exacerbation, a reviewvisit within 1 week should be scheduled

Front 12

When should physicians step down asthma medications?

Back 12

Consider stepping down when asthma symptoms have been well controlled and lung function has been stablefor 3 or more months

Front 13

Name some non-pharmacological methods of asthma control

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1. Treat co-morbidities - obesity, psychiatric disorders

2. Avoid allergens/occupational exposures if any

3. Swimming

4. Breathing exercises

5. Healthy diet

6. Vaccination for influenza, pneumococcus

Front 14

What are the 3 factors in an effective asthma self management?

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1. self-monitoring of symptoms/lung funtion (based on history and PEF)

2. written asthma action plan

3. regular review by doctor

Front 15

How should the doses be adjusted by the patients during an acute exacerbation?

Back 15