18 Asthma
18.1 What this covers
- Definitions
- Diagnosis
- Reliever
18.2 Learning objectives
- Definitions
- Diagnosis
- Reliever
18.3 Bottom line / summary
- Atopy: predisposition to generate IgE vs environmental antigens.
- Mechanisms of asthma:
- severity: determines initial treatment controlled (assess with a std questionnaire)
- ##Management Have asthma action plan:
- If well controlled for 3 weeks (months?
18.4 Approach
- GINA
- EPR3
- ATS/ERS management of severe asthma
- NEJM 2017 Severe and Difficult to treat asthma
- type 2 allergic / eosinophilic. Generally assocaited with elevated FeNO and Blood Eosinophilia
18.5 Red flags / when to escalate
- Singulair black box warnings (neuropsychiatric)
18.6 Common pitfalls
- the idea is to avoid a lot of ICS use.
18.7 References
- https://ginasthma.org/gina-reports/
- https://erj.ersjournals.com/content/early/2019/09/19/13993003.00588-2019
- https://www.nejm.org/doi/10.1056/NEJMra1608969
- https://erj.ersjournals.com/content/53/4/1802223
- https://photos.collectednotes.com/photos/5187/b5e55f2e-202f-4e1a-805f-f75bb8532bc2
18.8 Source notes
18.8.1 Asthma
19 Asthma
19.1 Definitions
Atopy: predisposition to generate IgE vs environmental antigens.
Mechanisms of asthma:
- type 2 = allergic / eosinophilic. Generally assocaited with elevated FeNO and Blood Eosinophilia
- non type-2 = neutrophilic and other. Less responsive to inhaled corticosteroid. More often later onset, associated with obesity, and preferential effects women.
19.2 Diagnosis
Symptoms
- varying in intensity
- nocturnal (but never early at night)
- exposure provoked
- wheeze/cough/tightness
19.3 Assessment
severity: determines initial treatment controlled (assess with a std questionnaire) - impairment (symptoms are well/not well/very poorly controlled). peak flow not helpful - risk (number of exacerbations)
19.4 Management
Have asthma action plan:
If well controlled for 3 weeks (months? per NHLBI), step down therapy.
Mild asthma (either intermittent or persistent) - can use symbicort (budesonide / formoterol - because the formoterol is fast onset) - the idea is to avoid a lot of ICS use.
Singulair = black box warnings (neuropsychiatric)
When severe, look for other things (e.g. IgE, Eos elevated for IL-5 and IL-4 respectively).
19.4.0.1 Reliever
Both GINA 2020 and NHLBI update recommend budesonide-formoterol over albuterol in a variety of circumstances. Why?
-SABA use masks insufficient ICS. Increasing ICS can avert exacerbations, SABAs can’t. -poor adherence to ICS with intermittent symptoms when separate -safety concerns from SABA overuse
https://erj.ersjournals.com/content/53/4/1802223
