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Define 'asthma'

Long term inflammatory disease of the airways
Results in airflow obstruction that is reversible
Characterised by spasms of the bronchi


Describe asthma

Decrease in the lumen of the airways due to inflammation
There is hypertrophy of the airway muscle wall, increased mucous production and inflammatory cell infiltration

Produces wheezing - cough and get breathless

Is generally atopic


Give the pathogenesis of asthma

Allergens activate Th2 cells which release IL4

IL4 (and 13) activates B cells - the B cells produce IgE - the IgE activates mast cells

IL4 also activates mast cells

The mast cells (also activated by IL4, 6, 9, IgE) release mediators of inflammation - histamine, kinins, PGD3 and LTC4

These mediators activate nerve endings, produce mucous, produce airway wall oedema and cause bronchoconstriction


What different components can cause asthma?

Irritants e.g. dust
Infection - e.g. chest infection inflames the airways and they are then more likely to get irritated
Exercise - exercise induced asthma i.e. this is the only time they get their symptoms and their wheezing
Changing hormone levels - worse symptoms in a woman during her period


Why else may a patient be wheezing? (not asthma)

Bronchilitis - in children
Upper airway obstruction e.g. epiglotitis
Upper airway dysfunction


How would asthma present on a spirometer? (physiology of asthma)

During an asthma attack, all indices of expiratory flow are reduced - peak flow, FEV1, FEV1/VC (these then increase following treatment with a bronchodilator)

The vital capacity is also reduced due to closure of the airways


What is peak flow?

The person's maximum speed of expiration
This is the best way to analyse obstructive diseases - measured morning and evening and measurements vary between the two - the worse the asthma is, the greater the difference


How can you measure flow through the airways easily to be able to diagnose a patinet?

Can use flow volume loops - these show the maximum inspiratory and expiratory flow

You can then see if this matches a flow loop of someone with restrictive or obstructive respiratory disease


Define asthma, relating to peak flow

20% variation of peak flow for three days a week, for two weeks on their PEFR diary


Airflow through a tube - what components can impact the flow?

Radius of the tube (raised to the fourth power)
Viscosity of the gas
Pressure difference across the tube
Length of the tube


What is 'challenge testing' and how is it used in asthma diagnosis?

Monitor the peak flow (PEFR) over time and see what happens when the patient comes into contact with an allergen e.g. pets


What stimuli can be used in challenge testing?

Allergens (may be a bit risky)
Cold air - this is cheap and easy


What is 'bronchial hyper reactivity' and how does this differ to asthma?

This is a bronchial spasm due to an irritant only - there is no involvement of allergens

The person experiences coughing, wheezing and breathlessness in response to an irritant

Aka. Reactive Airways Dysfunction Syndrome (RADS)


What is the lung function of an asthma patient between asthma attacks?

In some instances this will be reduced but in many patients, lung function may be normal between attacks - normal PEFR, FEV1, FEV1/VC, VC


What are common allergens causing asthma?

Dust, dust mite, grasses, tree pollen, pet fur, urine


What are common irritants causing asthma?

Sulphur dioxide, nitrogen dioxide, ozone, cigarrete smoke, wood smoke, rapeseed pollen


What kinds of infection can lead to asthma?

Viral infections generally impacting the upper respiratory tract and any respiratory infection can worsen symptoms in asthmatics


Why can exercise induce asthma?

Exercise - causes increased ventilation
This increased ventilation causes cooling of the airways, which can result in spasm

BUT treatment with drug before exercise may be sufficient for the asthmatic to continue


When does asthma get worse?

During the night
There can be acid reflux - worsens asthma
There can be allergens in the bed
(Don't know why)


How would you asses a patient to see if they have asthma?

History - family, environment, occupation, previous allergic conditions
Examination for wheeze
Peak flow and peak flow monitoring


Give the stages of treatment for asthma

Stage 1 - Salbutamol as required
Stage 2 - regular inhaled steroids
Stage 3 - add long acting bronchodilators and increase the inhaled steroids - may consider leukotriene antagonsists
Stage 4 - Theophyllines and leukotriene antagonists
Stage 5 - Oral steroids


What further methods of treatment may be considered for a patient who is at stage 5 of treatment?

Anti IgE therapy
Steroid sparing agents


What is acute severe asthma?


Life threatening - 1200 deaths per year


How do you treat acute severe asthma?

Needs immediate treatment with inhaled high dose bronchodilators, oxygen, steroids
Patient must remain in hospital until PCO2 levels are back to normal and they are off nebulisers


Describe the idea of tolerance and allergens

Idea that people and allergens kept in clean environments get more allergies as they have not developed tolerace


How can smoking cause asthma?

Smoking results in oxidative stress - increases NFkB
Smoking also blocks steroid response by HDAC2