4) Asthma

Question 1

Definition of Asthma?

Answer 1

Paroxysmal and reversible obstruction of the airways. An inflammatory disease characterised by bronchospasm and excessive production of secretions

Question 2

3 Factors causing symptoms in asthma?

Answer 2

• Bronchial muscle contraction
• Mucosal swelling/inflammation (mast cell/basophil degranulation)
• Increased mucus production

Question 3

Symptoms of asthma?

Answer 3

Intermittent dyspnoea
wheeze
cough (often nocturnal)
Sputum

Question 4

Key things to get from the Hx?

Answer 4

Precipitants? 
Diurnal variation?
Exercise tolerance?
Sleep disturbance? (nights/week?)
acid reflux?
atopy?
job?

Question 5

Signs of Asthma?

Answer 5

Tacypnoea, audible wheeze, hyperinflation, hyperresonant, air entry decr. widespread polyphonic wheeze

Question 6

Signs of a severe asthma attack?

Answer 6

Cant complete sentence, high pulse, RR>25, PEF 33-50%

Question 7

Signs of life threatening attack?

Answer 7

Silent chest, confusion, exhaustion, cyanosis, bradycardia, PEF<33%
IF CO2 STARTS TO RISE THEY GON DIE

Question 8

Risk factors for developing asthma?

Answer 8

FHx of atopy
Low BW
not breastfeeding
Maternal smoking
Air pollution

Question 9

What is samters triad?

Answer 9

Asthma, polyps, aspirin sensitivity

Question 10

Testing for chronic asthma?

Answer 10

PEF monitoring
20% variation on 3 days/week for 2 weeks

Spirometry shows obstructive defect
Usually an increase of 15% with b agonists

Question 11

DD of asthma?

Answer 11

Pulmonary oedema ('cardiac asthma')
COPD
Airway obstruction
SVC obstruction
Pneumothorax
PE
Bronchiectasis
Obliterative bronchiolitis (suspect in elderly)

Question 12

Diagnosis of asthma?

Answer 12

Is on clinical judgement of symptoms and objective tests, but a normal spirometry does not rule out asthma. Bronchodilator revesibility is highly sugestive, PEF, FHx

Question 13

Management of Chronic Asthma?

Answer 13

Conservative: Stop smoking, avoid precipitants, check inhaler technique, written asthma plan

Question 14

What is the first stage of asthma medication?

Answer 14

SABA and low dose ICS

Question 15

When should you move up the asthma ladder?

Answer 15

If using SABA more than 3x a week

Question 16

Step 2 on asthma ladder?

Answer 16

Add LABA, usually as combi with ICS

Question 17

Step 3 on asthma ladder?

Answer 17

Depends on response to LABA

If some response, keep going and incr. ICS
OR add LTRA, LAMA, theophylline

If no response stop LABA and increase ICS

Question 18

Step 4 on asthma ladder?

Answer 18

Trial:
High dose ICS
4th drug: (LTRA, theophylline, B agonist PO, LAMA)
REFER

Question 19

Step 5?

Answer 19

Oral Pred

REFER

Question 20

Why should you prescribe beclemetasone by name?

Answer 20

QVAR is twice as potent

Question 21

How do B agonists work? S/E?

Answer 21

Relax bronchial smooth muscle by incr. cAMP

s/e: tremor, anxiety, decr. k+

Question 22

how do LABA work?

Answer 22

Help nocturnal symptoms and reduce morning dips. Can cause paroxysmal bronchospasm

Question 23

Corticosteroids? S/E?

Answer 23

Act over days to reduce mucosal inflammation. Rinse mouth after to prevent candidiasis, s/e as all steroids

Question 24

Aminophylline?

Answer 24

Becomes theophyliine in the body, inhibits phosphodiesterase and therefore incr. cAMP and decr. Bronchospasm. Narrow therapeutic window

Question 25

LTRA?

Answer 25

eg monteleukast-- block leukotreines by antagonising cystLT1 receptor

Question 26

Omalizumab?

Answer 26

Anti IgE MAb Highly selective pts with persistant allergic asthma. Specialist only

Question 27

Acute asthma spirometry changes?

Answer 27

FEV1, FEV1/FVC down FVC down RV up Increased FRC and TLC

Question 28

What to get in the HX in acute attack?

Answer 28

previous admissions ITU admissions? Best PEFR?

Question 29

How do you grade severity?

Answer 29

Moderate: PEFR 50-75% best Severe: 33-50% RR 25+ Hr 120+ Cant finish sentences ``` Life threatening:<33% altered consciousness exhaustion arrhythmia hypotension cyanosis silent chest poor effort hypoxaemia ``` IF CO2 rises then peri arrest intubate with raised inflation pressure

Question 30

Treatment for exacerbation of asthma?

Answer 30

Oxygen Bronchodilatiors: -Drive with o2 at 6l/min Salbutamol 2.5-5mg and repeat at 15-30 Ipratropium bromide 500 ug QDS Steroids: Pred 40-50mg at least 5 days or til recovery Magnesium: bronchodilatior, 2g IV over 20 min if life threatening

Question 31

When should you refer asthma to ITU?

Answer 31

``` Deteriorating PEF Hypoxia worsening hypercapnia exhaustion arrest altered mental state ```

Question 32

How should management change in pregnancy?

Answer 32

It doesnt, give the drugs

Question 33

Asthma review questions

Answer 33

Have you had any difficulty sleeping because of your asthma? Have you had you had your usual asthma symptoms during the day? Has your asthma interfered with your usual activities? Check inhaler technique and compliance and use of inhalers