Asthma: Symptoms and Treatment

• Symptoms of asthma include wheezing, coughing, and chest tightness.
• Asthma symptoms are often worse at night and can be triggered by exercise or certain factors.
• Beta-blockers or aspirin intake can also be associated with asthma symptoms.
• FEV1/FVC ratio below 0.7 suggests airway obstruction in conditions such as asthma and COPD.

Asthma Treatment Steps

• Step 1: Use SABA (short-acting beta-agonist) as needed for both adults and children.
• Step 2: For adults, add an ICS (inhaled corticosteroid) at a dosage of 200-800mcg; for children, add either an ICS or LRA (leukotriene receptor antagonist).
• Step 3: Adults should add a LABA (long-acting beta-agonist).
• If there's no response to LABA, consider LRA or Theophylline.
• Step 4: Increase ICS up to 2000mcg and consider adding a fourth agent.

Inhaled Corticosteroids

• Starting dose for adults is 400mcg of beclometasone dipropionate equivalence per day.
• Smoking, both current and previous, reduces the effectiveness of ICS.
• Symptom alleviation typically occurs within 3 to 7 days after starting treatment.
• In COPD, ICS can reduce exacerbations when given with a LABA.
• Doses above 800mcg of beclometasone dipropionate per day are associated with a higher occurrence of side effects.
• Side effects from higher ICS doses can include lower respiratory tract infections (especially in COPD), reduced bone mineral density (BMD), reduced growth velocity, and a small risk of glaucoma.
• Doses below 800mcg of beclometasone dipropionate per day do not cause detrimental effects, except for local side effects.
• Local side effects: dysphonia, hoarseness, and oral candidiasis.
• Use a spacer device with pressurized metered dose inhalers and rinsing the mouth after each use can minimize local side effects.
• High doses of ICSs can lead to adrenal suppression, so patients may need a "steroid card."

Inhalers and Equivalence Ratios

• Beclometasone dipropionate (Clenil): 1:1 equivalence ratio
• Beclometasone dipropionate (QVAR): 2:1 equivalence ratio
• Budesonide (Pulmicort): 1:1 equivalence ratio
• Ciclesonide (Alvesco): 2.5:1 equivalence ratio
• Fluticasone Propionate (Flutiform): 2:1 equivalence ratio
• Fluticasone Furoate (Relvar Ellipta): 5:1 equivalence ratio

Antimuscarinics

• Ipratropium (Atrovent): Provides short-term relief in COPD for those not using a long-acting antimuscarinic drug, with a duration of action of 3-6 hours. Use three times daily.
• Aclidinium (Eklia Genuair) Glycopyrronium (Seebri), Tiotropium (Spiriva) and Umeclidinium (Incruse Ellipta) are licensed for the maintenance of COPD, but are not suitable for acute bronchospasm.
• Cautions: Use with caution in patients with prostatic hyperplasia, bladder obstruction, and glaucoma. Protect patients' eyes from nebulized drugs.
• Side effects: dry mouth, GI disturbance (diarrhoea and constipation), cough, and urinary retention.

Long Acting Beta Agonists (LABAs)

• For asthma, LABAs must be used with an ICS. Introduce slowly and review, stepping down once asthma control is achieved.
• Combination inhalers reduce flexibility in adjusting the dose of each component.
• Formoterol: Used for short-term relief and prevention of exercise-induced asthma due to its quick onset, similar to salbutamol.
• Symbicort (Budesonide and formoterol) can be used as a reliever in addition to prophylaxis.
• Indacaterol (Onbrez) and Olodaterol: LABAs for COPD and are not for acute bronchospasm.
• Vilanterol: Combined with fluticasone (Relvar Ellipta) or umeclidinium (Anoro Ellipta).

Short Acting Beta Agonists (SABAs)

• Salbutamol and terbutaline: If needed more than twice weekly, or if nighttime asthma occurs more than once per week, consider prophylaxis.
• Reduction of exercise-induced asthma with SABA use is a possible reflection of poorly controlled asthma.
• Nebuliser solutions are for severe acute attacks.

Additional Medications and Devices

• Bambuterol (pro-drug of terbutaline): An oral tablet used for nocturnal asthma.
• Spacer device is recommended for children under five years old.
• Cautions for some medications: Hyperthyroidism, arrhythmias, hypertension, and diabetes. Risk of hypokalaemia.
• Side effects of some medications: Tremor, nervous tension, headache, palpitations, sleep disturbances, and bronchospasm.
• Seek medical advice if beta-2 agonists fail to provide the usual symptomatic relief.

COPD Characteristics and Treatment

• COPD is characterized by airflow obstruction that is not fully reversible. The FEV1/FVC ratio is less than 0.7.
• Breathlessness is alleviated by SABA or SAMA (ipratropium).
• FEV1 Predicted >50%: Use LAMA (tiotropium) or LABA (formoterol or salmeterol).
• Stop SAMA (ipratropium) if using LAMA.
• FEV1 Predicted <50%: Use LABA with ICS or LAMA with ICS.
• Indacaterol is a LABA used for the maintenance of COPD.