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CR3 > Asthma > Flashcards

Asthma Flashcards

1
Q

Define asthma

A
  • chronic airway inflammation
  • cough, wheeze, breathlessness
  • variable outflow obstruction
  • airways hyper-responsiveness
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2
Q

Symptoms

A

Wheeze
breathlessness
Chest tightness
Cough

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3
Q

Different phenotypes of asthma

A
  • allergic
  • non allergic
  • adult onset (late)
  • asthma with persistent airflow limitation
  • with obesity
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4
Q

Sympathetic action of respiratory system

A

Beta 2 receptors
Bronchodilation
Mucociliary clearance

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5
Q

Parasympathetic action of respiratory system

A

Muscarinic receptors

Bronchoconstriction

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6
Q

What surrounds bronchioles

A

Terminal and respiratory bronchioles surrounded by SM

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7
Q

What holds large airways open

A

Cartilage

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8
Q

What does flow =

A

pressure change/resistance

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9
Q

What is flow increased by?

A
  • increased pressure change

- decreased resistance

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10
Q

Pouseille’s Law

A

Flow = 1/resistance^4

Decreased resistance = increased flow

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11
Q

What do mast cells cause in the acute phase?

A

Bronchospasm
Oedema
Mucous

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12
Q

What happens in the late phase?

A

Th2 helper cells activate B cells to produce IgE and eosinophils
- these cause bronchoconstriction and muco-secretion

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13
Q

Extrinsic causes

A
  • air pollution
  • allergen exposure
  • maternal smoking
  • hygiene hypothesis
  • genetics
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14
Q

Intrinsic causes

A
  • non-allergic
  • less responsive
  • colds/infections
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15
Q

Occupational causes

A
  • allergens at work
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16
Q

Diagnosis

A
  • clinical
  • Evidence of airflow obstruction or airway inflammation
  • respiratory symptoms, signs and test results
  • absence of alternative explanation for presentation
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17
Q

Symptoms and presentation

A 
Wheeze
Breathlessness
Chest tightness
Cough
Worse at night and morning
Triggers
Atopic features
FH
Low PEFR or FEV
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18
Q

What triggers it?

A 
Allergens
Exercise
Cold air
Aspirin
Beta blocker
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19
Q

Less likely symptoms/presentation

A
  • dizziness/light – headedness/peripheral tingling
  • productive cough in absence of wheeze of breathlessness
  • normal exam when breathless
  • voice disturbance
  • symptoms with colds
  • smoking history >20 pack years
  • cardiac disease
  • normal PEF or FEV1 when symptomatic
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20
Q

Wheeze differentials

A 
Asthma
COPD
Obstruction = foreign body
Anaphylaxis
Pulmonary oedema
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21
Q

Bronchodilator reversibility

A

> 12% or 200ml improvement in FEV1

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22
Q

Spirometry results

A

FEV1/FVC<70%

- may be normal when not symptomatic

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23
Q

Fraction exhaled nitric oxide

A

> 40 ppb

breath test marker of eosinophilic inflammation

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24
Q

Direct Challenge Testing

A
  • drop in FEV! when exposed to provoking substance

- concentration required for 20% fall in FEV1 of 8mg/ml or less

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25
Q

Peak Flow

A
  • twice daily readings over 2 weeks
  • diurnal variation
  • 20% variability
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26
Q

Diagnostic test

A 
Peak Flow
Spirometry
Bronchodilator reversibility
Fraction exhaled nitric oxide
Direct challenge testing
IgE
Allergy/skin prick testing
FBC/eosinophil count
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27
Q

Treatment

A
  • patient education and self management plan
  • avoidance of triggers and allergens = smoking
  • weight reduction
  • breath exercises
  • stepwise approach
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28
Q

What is not recommended

A
  • house dust mite avoidance

- air ionisers

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29
Q

When should patients be reviewed post discharge

A

<30 days if admitted

usually by specialist nurse

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30
Q

Drug treatment

A
  • short and long acting B2 agonists
  • corticosteroids
  • leukotriene antagonists
  • Anti-IgE monoclonal antibodies
31
Q

MOA of B2 agonists

A

Sympathetic action of B2 receptors = bronchodilation and mucociliary clearance

  • relax SM
  • relieve bronchospasm
32
Q

Example of short acting B2 agonist

A

Salbutamol

Terbutaline

33
Q

Example of long acting B2 agonist

A

Salmeterol

Formoterol

34
Q

Side effects of beta 2 agonists

A

Tremor
Tachycardia
Sweats
Agitation

35
Q

Mechanism of action of corticosteroid

A

decrease inflammation

36
Q

Examples of corticosteroids

A

Budesonide
Beclometasone
Fluticasone

37
Q

Side effects of corticosteroids

A

Oral candidiasis

Systemic rare with inhaled corticosteroids

38
Q

MOA of leukotriene antagonists

A
  • block leukotriene receptors in SM

- reduce bronchoconstriction

39
Q

Examples of leukotriene antagonists

A

Montelukast

40
Q

Side effects of leukotriene antagonists

A

Nausea

headache

41
Q

Example of Anti-IgE

A

omalizumab

subcutaneous

42
Q

Side effects of Anti-IgE

A
  • itching
  • joint pain
  • headache
  • nausea
  • anaphylaxis
43
Q

Indications for anti-IgE

A
  • confirmed allergic IgE mediated asthma
  • add on to optimised standard therapy
  • continuous/frequent treatment with oral corticosteroids (4 or more)
44
Q

Stepwise treatment

A
  • short acting B2 agonist
  • inhaled corticosteroid low dose
  • regular preventer
  • add LABA to low dose ICS and offer LTRA
  • increase ICS dose or add LTRA, consider stopping LABA if no response
  • MART, increase ICS OR fixed dose ICS/LABA + SABA then LAMA or theophylline
45
Q

How much to reduce ICS?

A

25-50% reduction in dose every 3 months consider if not getting worse

46
Q

Define uncontrolled asthma

A
  • 3 ore more days a week with symptoms
    OR
  • 3 or more days a week with required use of SABA for symptomatic relief
    OR
  • 1 ore more nights a week with awakening due to asthma
47
Q

Risk of future attacks in children

A
  • comorbid atopic conditions
  • younger age
  • obesity
  • exposure to environmental tobacco smoke
48
Q

Risk of future attacks in adults

A
  • older age
  • female
  • reduced lung function
  • obesity
  • smoking
  • depression
49
Q

Asthma control assessment

A
  • scored 5-25
  • 25 = complete control
  • ACT score >19 indicates well controlled asthma
50
Q

Precipitating factors to acute asthma

A
  • pets
  • exercise
  • pollen
  • bugs in home
  • chemical fumes
  • cold air
  • fungus spores
  • dust
  • smoke
  • strong odors
  • pollution
  • anger
  • stress
51
Q

Brittle asthma

A
  • 2 types
  • difficult to control
  • unstable/unpredictable
52
Q

Type 1 brittle asthma

A
  • wide PEF variability
  • > 40% diurnal variation for >50% of time period >150 days
  • despite intense therapy
53
Q

Type 2 brittle asthma

A
  • sudden severe attacks on background of apparently well controlled asthma
54
Q

Moderate acute asthma

A
  • increasing symptoms
  • no features of acute severe
  • PEF >50-75% best or predicted
55
Q

Acute severe asthma

A

Any 1 of

  • PEF 33-50%
  • RR 25>/min
  • HR 110/min>
  • inability to complete sentences in 1 breath
56
Q

Life threatening asthma

A

Any 1 of

  • PEF <33%
  • Sats <92%
  • PaO2 <8
  • Silent chest
  • Cyanosis
  • hypotension
  • exhaustion
  • feeble respiratory effort
  • tachy or bradycardia
  • dysrhythmia
  • confusion
  • coma
57
Q

What to do if life threatening asthma

A

Call anaesthetist

58
Q

When to admit in acute asthma

A
  • if acute severe persisting after treatment or > life threatening
59
Q

Near fatal asthma

A
  • raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
60
Q

When to discharge in acute asthma

A
  • PEF>75% after 1 hour
  • unless = symptoms significant, compliance concerns, live alone, psychological problems, previous near fatal/brittle asthma, pre-existing steroids, night time, pregnant
61
Q

Management of acute asthma

A
  • high flow oxygen
  • aim sats >92%
  • O2 driven nebs
  • IV fluids
  • reassess every 15 mins with PEFR
62
Q

Drugs on management of acute asthma

A

OSHIT

  • oxygen
  • salbutamol
  • hydrocortisone/prednisolone
  • ipratropium bromide
  • theophylline
  • magnesium sulphate
63
Q

Dose for salbutamol in acute

A
  • 2.5-5mg every 10 mins

- nebulised with oxygen

64
Q

Side effects of salbutamol

A
  • tremor
  • arrhythmias
  • hypokalemia (monitor ECG)
65
Q

Hydrocortisone dose in acute

A
  • IV 100-200mg QDS

- or prednisolone PO 40mg OD

66
Q

Ipratropium bromide dose in acute

A

500mg every 4-6 hours

67
Q

Side effects of ipratropium bromide

A
  • arrhythmias
  • cough
  • dizziness
  • dry mouth
  • headache
  • nausea
68
Q

Magnesium sulphate dose in acute

A

1.2-2g over 20 mins IV

For acute severe

69
Q

Side effects of theophylline

A
  • palpitations
  • arrhythmias
  • nausea
  • seizures
  • alkali burns if extravasation occurs
  • drug interactions
70
Q

When to involve ITU?

A
  • If require ventilatory support
  • near fatal asthma
  • life threatning/acute severe not improving
  • early
71
Q

Monitor In acute asthma

A
  • peak flow reg.
  • ox sats
  • chest auscultation
  • ABG repeat 1hr?
  • potassium and glucose bloods
  • ECG = potassium, Mg, beta 2 agonists
72
Q

When to repeat ABG every hour?

A
  • hypoxic
  • normo-hypercapnoeic
  • patient deteriorates
73
Q

Acute asthma follow up

A
  • within 48 hours
  • <30 days post discharge by GP/nurse specialist
  • under specialist supervision for near fatal asthma
  • at least 1 year for severe asthma attack

CR3 (30 decks)

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