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Asthma Flashcards

1
Q

What are the 3 main characterisations of asthma?

A

Reversible airflow limitation

Airway hyperresponsiveness

Inflammation of the bronchi

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2
Q

What is the meaning of the term Atopy? What are atopic individuals prone to?

A

A genetic predisposition to IgE-mediated allergen sensitivity -

People are prone

  • Allergic asthma
  • Atopic dermatitis
  • Allergic rhinitis
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3
Q

What is the Hygiene hypothesis?

A

Reduced exposure to infectious pathogens at a young age predisposes individuals to autoimmune and allergic disease in western countries.

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4
Q

What is aspirin induced asthma? What triad condition do individuals present with?

A

When asthma attacks can be triggered by aspirin due to a sensitivity - People have SAMTERS TRIAD

  • Asthma
  • Aspirin sensitivity
  • Nasal polyps
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5
Q

What is occupational asthma?

A

When asthma is triggered by occupational exposures

High molecular weight

  • Compounds trigger on a IgE response
  • Effects are immediate as soon as person is exposed
  • Flour
  • Latex

Low molecular weight

  • a complex immune response develops after repeated and long-term exposure
  • wood dust
  • isocyanates
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6
Q

To aid in diagnosing occupational asthma, the patient should keep a diary of what?

A

Peak expiratory flow diaries during periods of work and holiday

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7
Q

What is exercise induced asthma?

A

triggered by strenuous physical activity

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8
Q

What are key concepts in the early phase of asthma?

A

Inhalation of allergens causes type 1 hypersensitivity reaction in the airways

Sensitisation begins to develop causing the release of IgE antibodies

The IgE binds to mast cells

Subsequent exposure to antigen cases mast cells to degranulate and histamines to be released.

This causes smooth muscle contraction and bronchoconstriction (bronchospasm’s) whilst inflammation contributes to airway obstruction, oedema and mucous

late phase -
 Th2 helper cells -> B cells -> IgE
& eosinophils ->
• Constriction
• Muco-secretion
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9
Q

What are key concepts in the late phase of asthma?

A

Early phase may be followed by late phase hours later

Inflammatory mediators are recruited (e.g. polymorphonuclear cells, T-cells)

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10
Q

Do beta beta agonists cause complete reversal of the late phase?

A

No - it is more complex

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11
Q

In asthma chronic inflammation occurs. How does the airway change/ respond to this?

A
  • Fibrous tissue develops

- Airway remodelling causes airway obstruction which manifests as airway narrowing which is irreversible

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12
Q

What are the signs and symptoms of asthma?

A

Symptoms

  • Cough (may be worse at night)
  • Dyspnoea (SOB)
  • Chest tightness
  • Poor sleep

Signs

  • Expiratory polyphonic wheeze
  • Prolonged expiratory phase
  • Tachypnoea
  • Harrisons sulcus ( a groove at the inferior border of the rib cage that may be seen in children with chronic severe asthma. Also seen in rickets.)
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13
Q

What are the characterisation and symptoms of an asthma attack?

A
  • Worsening of normal symptoms
  • Reduction in PEF

In more severe attacks patients have signs of respiratory failure -

  • Tachypnoea
  • Tachycardia
  • Inability to complete sentences
  • Exhaustion
  • Reduced respiratory effort
  • Silent chest
  • Altered conscious level
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14
Q

There are 2 main types of receptors in the airways. What are the names and what does activation of them do?

A

Sympathetic -> β2 receptors -> bronchodilation & mucociliary clearance

Parasympathetic -> muscarinic receptors
-> bronchoconstriction

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15
Q

What is the formula for flow?

A

Pressure change/Resistance

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16
Q 
What is (Pouseille’s
law?
A

resistance = 1/r4

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17
Q

List 5 extrinsic causes of asthma

A 
Air pollution
•
 Allergen exposure
•
 Maternal smoking
•
 Hygiene hypothesis
•
 Genetics
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18
Q

List 2 key features of intrinsic asthma

A

Intrinsic -

  • non allergic
  • less responsive
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19
Q

Which drugs are known to trigger asthma?

A

Aspirin and beta blockers

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20
Q

Which of the many features of asthma if present make it more likely? (6)

A

More than one of:

  • wheeze
  • breathlessness
  • chest tightness
  • cough

variability - worse at night and in the morning

Triggered by allergies, exercise, drugs cold air

Atopic features

Family history

Low PEFR AND FEV

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21
Q

Features/ symptoms make asthma less likely? (8)

A
  • Dizziness
  • Peripheral tingling
  • Productive cough in the absence of wheeze of breathlessness
  • Consistent normal examination with breathless
  • Voice disturbances
  • Symptoms only with colds
    Significant smoking history (>20 pack years )
  • Cardiac disease
  • Normal PEF or FEV1 when symptomatic
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22
Q

List 5 possible differential diagnosis for a wheeze

A

Asthma

COPD

Obstruction e.g. foreign body

Anaphylaxis

Pulmonary oedema

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23
Q

List the main differences between asthma and COPD

A

Asthma -

  • Daily FEV1 variation
  • Reversibility

COPD

  • Older >35
  • Smoking history
  • Sputum production (chronic productive cough)
  • Persistent/progressive breathlessness
  • Variability uncommon
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24
Q

Which diagnostic investigations are conducted to diagnose asthma and what would the results show? (5)

A

Spirometry - FEV1/FVC <70% ratio

Bronchodilator reversibility -

  • FEV1 pre and post beta agonist inhibition
  • > 12% or 200ml improvement in FEV1

Fraction exhaled nitric oxide
normal is >25
Asthma is >40ppd

Direct challenge testing (eg
methacholine)

drop in FEV1 when
exposed to provoking
substance e.g. histamineor methacholine
concentration required to
cause 20% fall in FEV1
(PC20) OF 8mg/ml or less

Low false negative rate

Peak flow variability

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25
Would all asthmatics have a abnormal spirometry?
Many asthmatics may have normal spirometry especially when not symptomatic
26
State 2 negative aspects of the Fraction exhaled | nitric oxide test?
Multiple confounders 1 in 5 false positive/negative rate
27
There are 3 extra tests which can be done for people with asthma, what are they?
◦IgE, ◦allergy/skin prick testing, ◦FBC/eosinophil count
28
Which life style advice is given to those with asthma?
Avoidance of triggers and allergens ``` Avoid smoking exposure Weight reduction • Breathing control exercises may help • Not recommended: ``` - House dust mite avoidance - Air ionisers
29
What is the role of specialist nurses in asthma treatment?
Asthma nurse review at/shortly after admission improves: • Symptom control • Self management • Re-attendance rates Review post discharge (< 30 days)
30
What should the written action plans for the self management of asthma include?
- How to use treatment - Self monitoring/assessment skills - Action plan with regard to goals - Recognition and management of exacerbations - Allergen/trigger avoidance
31
What is the mechanism of action for beta 2 agonists?
- Relax smooth muscle | - relieve bronchospasm
32
Give 2 example drugs for short acting beta agonists and long acting beta agonists?
Short acting - salbutamol, terbutaline Long acting - salmeterol, formoterol
33
What are the side effects of beta 2 agonists?
o tremor o tachycardia o sweats o agitation
34
What is the mechanism of action/ purpose of corticosteroids in the treatment of asthma?
decrease inflammation
35
Give 3 examples of corticosteroids used in the treatment of asthma
o budesonide o beclometasone o fluticasone
36
What the main side effects of inhaled corticosteroids?
o oral candidiasis o systemic side effects rare with inhaled corticosteroids
37
What is the mechanism of action of Leukotriene antagonists?
blocking leukotriene receptors in smooth muscle reduce bronchoconstriction
38
The name the Leukotriene antagonists drug used in the treatment of asthma
Montelukast
39
What are the side effects if Leukotriene antagonists drugs?
nausea headache
40
What is the mechanism of action for anti IgE drugs used in the treatment of asthma?
monoclonal antibody to IgE decrease IgE
41
Which anti IgE drug is used in asthma treatment?
Omalizumab
42
What are the side effects of anti IgE drugs used in asthma treatment?
- itching - joint pain - headache - nausea
43
Describe the progression of asthma treatment
Step 1- Low does inhaled corticosteroids Step 2- Inhaled LABA plus inhaled corticosteroid Step 3- Responds to LABA? - Continue but increase inhaled corticosteroid to medium dose Does not respond to LABA? Stop LABA increase inhaled corticosteroid dose Or ADD Leukotriene receptor agonist or SR theophylline or long acting muscarinic receptor agonist Step 4 - Increase inhaled steroid to high dose Add fourth drug (leukotrien, theophyline, beta agonist, long acting muscarinic) Refer patient to specialist Step 5 - Daily steroid tablets - lowest dose Continue high dose inhaled corticosteroids - consider other treatments to minimize steroid use Refer patient to specialist
44
List 12 precipitating factors for an asthma attack
- Pollen - Bugs in the house - Chemical fumes - Cold air - Fungus spores - Dust - Smoke - Strong odors - Pollution - Anger - Stress - Pets - Exercise
45
What are the 5 names used to categories asthma attack severity
- Near fatal - Life threatening - Acute sever - Moderate - Brittle
46
What is brittle asthma? - there are 2 types
Type 1 - Wide PEF variability (>40% diurnal variation for >50% of the time over a period >150 days) despite intense therapy Type 2 - sudden severe attacks on a background of apparently well-controlled asthma
47
What is moderate asthma exacerbation?
- Increasing symptoms - No features of acute sever asthma - PEF> 50-75% best or predicted
48
What is acute sever asthma exacerbation?
Any one of - - PEF 33-50% best or predicted - Resp rate > 25/min - Heart rate > 110 - Inability to complete sentences when breathing Patient must be admitted
49
What is life threatening asthma exacerbation? (13) | Think 33, 92, CHEST
One of the following - PEF <33% best or predicted - SpO2 <92% - PaO2 <8 kPa - normal paCO2 (4.6-6.0 kPa) - Silent chest - Cyanosis - Feeble respiratory effort - Bradycardia - dysrhythmia - hypotension - Exhaustion - Confusion - Coma Call Call anaesthetist
50
What is near fatal asthma exacerbation?
Raised PaCO2 and/or requiring mechanical ventilation with | raised inflation pressures
51
When should a patient be discharged after being admitted with an asthma attack?
PEF >75% after 1 hour, unless: ``` Significant symptoms Compliance concerns Lives alone Psychological/physical/learning problems Previous near fatal or brittle asthma Pre-existing steroids Night time Pregnant ```
52
When a patient has been admitted with asthma which treatment would they be given?
ABCDE approach Oxygen - High flow (aim >92% - 94-98%) - Give O2 driven nebulisers IV fluids - Rehydration - Correct electrolyte imbalances ``` Drugs - Salbutamol - Hydrocortisone - Ipratropium bromide - Theophylline - Magnesium sulphate Reassess - every 15mins with PEFR ```
53
How should salbutamol be administered in someone hospitalised with asthma?
Nebulised with oxygen - | 2.5-5mg every 10 minutes
54
How are the side effects of nebulised salbutamol?
Tremor Arrhythmias Hypokalaemia (monitor ECG)
55
Why should the ECG of a patient being treated with nebulised salbutamol be monitored?
Hypokalaemia (monitor ECG)
56
How should hydrocortisone be administered in someone who has been hospitalised with asthma?
IV 100-200mg QDS Corticosteroid Prednisolone PO 40mg OD Can cause systemic side effects
57
How should Ipratropium bromide be administered in someone who has been hospitalised with asthma?
Nebulised with oxygen | 500 micrograms every 4-6 hours
58
What type of drug is Ipratropium bromide?
Muscarinic receptor antagonist
59
How should Magnesium sulphate be administered in someone who has been hospitalised with asthma?
1.2 – 2 grams over 20 minutes IV | Acute severe asthma
60
What is the mechanism of action for Theophylline? When should the drug be used?
Inhibit phosphodiesterase and increase cAMP Life-threatening asthma with Senior guidance
61
What are the side effects of Theophylline?
Palpitations Arrhythmias Nausea Seizures Alkali burns if extravasation occurs Drug interactions
62
When should ITU be involved in a patients treatment of asthma at hospital?
In ventilatory support required Life threatening / acute severe not improving
63
After treating a patient in hospital with sever asthma, what should you continue to monitor while they are in hospital?
Regular peak flow Oxygen saturation ABG- Repeat at 1 hour if: Hypoxic Normo-hypercapnoeic Patient deteriorates Bloods- Potassium Glucose ECG - K+ ; Mg 2+ ; b2
64
After being discharged from hospital due to a sever asthma attack how often should a patient be followed up?
Follow up Within 48h (can be by hospital, GP, nurse Follow up again in <30days after discharge by GP or specialist nurse or respiratory clinic appointment
65
In someone having an acute asthma attack and has been admitted to hospital - what is the first line treatment
1. Salbutamol, oxygen, steroids | ipratropium bromide
66
In someone having an acute asthma attack and has been admitted to hospital - what is the second line treatment
2. Magnesium sulphate beta 2 antagonist infusion (those not responding) Aminophylline/ theophylline - levels should be checked daily

CR3 (10 decks)

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