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Asthma (ASTHMA REVIEW (Current symptoms
In the last month/week have to…
Asthma
ASTHMA REVIEW
Current symptoms
- In the last month/week have to had difficulty sleeping due to your asthma?
- Have you had your symptoms during the day?
- Has your asthma interfered with your usual daily activities?
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Smoking status, cessation advice
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Review peak flow diaries, record current PEFR
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Peak flow measurement
Indications:
- Diagnosis: diary (diurnal variability greater than 20% for at least 3 days in a week for 2 weeks, or improvement 10 mins after bronchodilator, after 6 week course of steroids or after 14 days of 30mg prednisolone)
- Assessment of response to treatment
- Monitoring
Method:
- Standing or sitting up
- Ensure pointer at zero and fingers not obstructing
- Full breath in, rapid forced expiratory puff through meter, tight seal around mouthpiece
- Best of 3 readings recorded
Interpretation:
- Charts of normal values are available
- Men tend to have a higher PEFR than women
- Expected PEFR increases with height and varies with age
- Peak flow diaries may be useful
- Reversibility = >60l/min
- Objective warning of clinical deterioration
Diagnosis
Clinical features increasing probability of asthma:
- Presence of more than one relevant symptoms (wheeze, breathlessness, chest tightness, cough), particularly where these are worse at night and in early morning, triggered by exercise or cold air, provoked by aspirin or beta blockers
- A personal or family history of atopy
- Widespread wheeze on chest examination
- Otherwise unexplained low FEV1 or PEFR
- Otherwise unexplained peripheral blood eosinophils
When diagnosis uncertain but FEV1/FVC <0.7
- Reversibility testing
- Trial of treatment
Causes
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Potential triggers include:
- House dust mites
- Pollution
- Pet dander
- Outdoor allergens (pollens and moulds)
- Tobacco smoke
- Chemical irritants
- Air pollution
- Emotional arousal
- Physical exercise
- Medications: aspirin, NSAIDs, beta blockers
BTS guidelines
STEP 1
- SABAas required
STEP 2
- ICS 200-800mcg per day
STEP 3
- LABA (combo inhaler w/ ICS)
STEP 4
- Consider inc. ICS (800mcg) or start trial of LRTA or theophylline SR
STEP 5
- Consider inc. ICS (2000mcg), addition of 4th drug (LRTA, theophylline SR, B2 agonist tablet)
STEP 6
- Oral steroids, 2000mcg ICS, refer to specialist
Self management
- V important for asthma control
- Inhaler technique
- Written asthma action plan
- Importance of regular asthma review
- When to seek emergency treatment