Asthma Flashcards by Eilidh Middleton

What are the 3 key characteristic features of asthma

Reversible airflow limitation

Airway hyperresponsiveness

Inflammation of the bronchi

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Define asthma

Defined as chronic inflammatory disorder of the airways secondary to type 1 hypersensitivity

Asthma is characterised by intermittent airway obstruction and hyper-reactivity

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Asthma is an example of:

a) Obstructive lung disease
b) Restrictive lung disease

a) Obstructive lung disease

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What type of hypersensitivity reaction is associated with asthma

Type 1 hypersensitivity reaction

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Describe the pathogenesis of asthma

On insult by the trigger, results in type 1 hypersensitivity reaction causing mast cell degranulation and histamine release
Mast cell degranulation and histamine causes smooth muscle contraction causing the bronchoconstriction
Inflammation causes increased bronchial hyper-responsiveness contributing to the bronchoconstriction
Bronchoconstriction is where the smooth muscles of the airways (the bronchi) contract causing a reduction in the diameter of the airways leading to airflow obstruction
Bronchoconstriction is often reversible, either spontaneously or with treatment such as salbutamol a bronchodilator.

NOTE: Remember the immune system has to be primed with the trigger i.e. the first exposure primes the immune system so little response however the immune system is now ready to respond when next exposed

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Name the two types of asthma

Atopic: extrinsic – triggered by environmental factors

Non-atopic: intrinsic – not caused by exposure to an allergen

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Give examples of the triggers for asthma

History of atopy

Aspirin induced

Occupational asthma

Exercise induced

Allergies e.g. house dust mites, animal fur, pollen

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What is atopy

Genetic predisposition to IgE mediated allergen sensitivity.

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Name the 3 IgE medicated atopic conditions

Asthma

Atopic dermatitis i.e. eczema

Allergic rhinitis i.e. hay fever

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Name the symptoms of asthma

SoB

Chest tightness

Expiratory wheeze

Cough (often worse at night)

Diurnal variation (symptoms often worse in the morning)

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The cough associated with asthma is worse at what time of the day

At night

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Asthma symptoms are often worse at what time of the day

In the morning

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Name some of the signs of asthma

Tachypnoea (high RR)

Hyperinflated chest

Hyper-resonance on chest percussion

Use of accessory muscles

Reduced peak expiratory flow rate (PEFR)

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How is asthma diagnosed

Clinical diagnosis - history alone is enough

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What two investigations can be used to confirm a diagnosis of asthma

Fractional exhaled nitric oxide

Spirometry with bronchodilator reversibility

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How does fractional exhaled nitric oxide (FeNO) work in the investigation of asthma

A type of nitric oxide synthases rises in inflammatory cells, particularly eosinophils

The level directly correlates to the level of eosinophilic airway inflammation

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What level of fractional exhaled nitric oxide (FeNO) supports a diagnosis of asthma

> 40

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What pattern would be present in spirometry for asthma

Asthma is an obstructive lung disease and therefore an obstructive pattern will be seen

“Church steeple form on the flow volume chart

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What pattern is shown below (Spirometry results):

Reduced FEV1

Normal FVC

Reduced FEV1/FVC ratio

Obstructive lung pattern

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What pattern is shown below (Spirometry results):

Reduced FEV1

Reduced FVC

Normal FEV1/FVC ratio

Restrictive lung pattern

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How do we determine if the FEV1 is reduced

<80% of the predicted FEV1 value

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How do we determine if the FVC is reduced

<80% of the predicted FVC value

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How do we determine if the FEV1/FVC ratio is reduced

< 0.7

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What are the two axis of the flow volume chart

Volume (L) - x axis

Flow (L/sec) - y axis

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The spirometry results for asthma are reversible with bronchodilators. What bronchodilator is used

Salbumtaol

The spirometry results for asthma are reversible with bronchodilators. What value is improved with a bronchodilator

FEV1 improve which in turn improves the FEV1/FVC ratio

Asthma is chronically managed with inhaler. What is a non-pharmacological aspect of managing asthma

Help to quit smoking. Avoid precipitants/triggers

Patients are given two types of inhaler in the chronic management of asthma. Name these two types

Reliever inhalers Preventer inhaler

Give an example of a reliver inhaler for managing chronic asthma

Short acting beta agonist (SABA) e.g. salbutamol

When should reliever inhalers (As part of the management of asthma) be used

Used when needed to quickly relieve asthma symptoms for a short time. Should only be used occasionally as too much salbutamol can cause sudden death.

How many times a week of reliever inhaler use would you consider 'stepping up' therapy.

Three times a week

Which type of inhaler should be used daily even in the absence of asthma symptoms? a) Reliever inhalers b) Preventer inhalers

b) Preventer inhalers

When should SABA be consider as a monotherapy in the management of asthma

For those with infrequent exacerbations and normal lung function.

What is the first line preventer inhaler in the management of asthma

Inhaled corticosteroids (ICS)

What is the second line inhaler management of asthma

ICS + Leukotriene receptor antagonist (LTRA)

What is the **third** line inhaler management of asthma

ICS + Long acting beta agonist (LABA) +/- LTRA *Keeping LTRA depends on the responsiveness they have been to this medication. If not, remove*

What is the **fourth** line inhaler management of asthma

Maintenance and reliver therapy (MART) +/- LTRA ## Footnote *Keeping LTRA depends on the responsiveness they have been to this medication. If not, remove*

Give an example of a short acting beta 2 agonist (SABA)

Salbutamol

When is SABA used in the management of asthma

The first-line drug to be used in the reliever management of asthma Can be used as a monotherapy management option in cases of very mild asthma however commonly it is used alongside preventer inhaler(s)

What is a potential side effect of SABA

Tremor

What is the target of SABA

beta 2 adrenergic receptor, which are located in the bronchioles of the lungs

Why is it important that the beta agonist used in the manage of asthma is specific to beta 2 adrenergic receptors

To limit off target effects of the medication There are two types of beta adrenergic receptors: Beta 1 and beta 2 Beta 1 are found in the heart and stimulation of these increases the heart rate and contractibility Beta 2 receptors are located in the bronchioles of the lungs

There are two types of beta adrenergic receptors: Beta 1 and beta 2. Where are beta 1 receptors located and what are their function?

Beta 1 are found in the heart and stimulation of these increases the heart rate and contractibility

There are two types of beta adrenergic receptors: Beta 1 and beta 2. Where are beta 2 receptors located and what are their function?

Beta 2 receptors are located in the bronchioles of the lungs

What inhaler are patients referring to when they say "blue inhaler" - used in asthma

Salbutamol (SABA)

Give an example of the inahled corticosteroids (ICS) [management of asthma]

Beclometasone Fluticasone propionate

At what stage in the management of asthma are inhaled corticosteroids (ICS) inhaler used

It is the 1st line preventer inhaler Used alongside SABA (SABA is for symptom relief but no long term effects)

What a potential side effect of inhaled corticosteroids (ICS) inhaler [management of asthma]

Oral candidiasis Shunted growth in children

Give an example of a long acting beta 2 agonist (LABA)

Salmeterol

When should LABA be used in the management of asthma

When asthma is not controlled with just ICS and LTRA ## Footnote * SABA is used as well but that is for symptom relief instead* * When adding LABA check whether there is adequate response to LTRA as that can removed if it is not working*

Give an example of a Leukotriene receptor antagonist

Monteleukast

Describe the step wise approach to preventer inhaler asthma therapy regimen

* Used every day to prevent asthma symptoms from occurring. * 1^st line: Inhaled corticosteroids (ICS) * 2^nd line: ICS + Leukotriene receptor antagonist (LTRA) * 3^rd line: ICS + Long acting beta agonist (LABA) +/- LTRA * 4^th line: Maintenance and reliver therapy (MART) +/- LTRA

How is Leukotriene receptor antagonists given

Oral tablet

When during the asthma preventer inhaler step wise regimen is leukotriene receptor antagonists added

Added if there asthma is not controlled with ICS alone

What is the first step of preventer inhaler regimen in managing asthma

Inhaled corticosteroids (ICS) Alongside SABA (For symptom relief)

What is the **second** step of preventer inhaler regimen in managing asthma

Inhaled corticosteroids (ICS) + Leukotriene receptor antagonist (LTRA) Alongside SABA (For symptom relief)

What is the **third** step of preventer inhaler regimen in managing asthma

Inhaled corticosteroids (ICS) + Long acting beta agonist (LABA) +/- Leukotriene receptor antagonist (LTRA) Alongside SABA (For symptom relief) *Only continue LTRA if they are responsive to it. Otherwise remove.*

What is the **fourth** step of preventer inhaler regimen in managing asthma

Maintenance and reliver therapy (MART) +/- Leukotriene receptor antagonist (LTRA) Alongside SABA (For symptom relief) *Only continue LTRA if they are responsive to it. Otherwise remove.*

Give an example of a Maintenance and reliever therapy (MART) [managing chronic asthma]

Turbohaler

What is Maintenance and reliever therapy (MART)

Combination of ICS and fasting-acting LABA

Define acute asthma

It is an acute episode of worsening asthma exacerbation Characterised by worsening dyspnoea, wheeze and cough that is not responding to salbutamol Medical emergency

Acute asthma is categoried into 4 categories. Name them

Moderate Severe Life-threatening Near-fatal

What is the peak expiratory flow rate (PEFR) that would categories someone in the moderate acute asthma class

PEFR 50-75% best or predicted

What is the peak expiratory flow rate (PEFR) that would categories someone in the **severe** acute asthma class

PEFR 33-50% best or predicted

What is the peak expiratory flow rate (PEFR) that would categories someone in the **life threatening** acute asthma class

PEFR \<33% best or predicted

What are the 4 medications used in the initial management of acute asthma

SABA nebules e.g. salbutamol, terbutaline LAMA (long acting muscarinic antagonist) nebules e.g. Ipratropium Oxygen (if hypoxaemic) Steroids (either oral prednisolone or IV hydrocortisone)

Give two example of SABA nedules that can be used in the initial treatment of acute asthma

Salbutamol and Terbutaline

How does SABA nedules help in the initial treatment of acute asthma

Relieves bronchospasm

SABA is used in the initial treatment of acute asthma. What two ways can it be given

Metered-dose inhaler or nebuliser

Give an example of LAMA nedules that can be used in the initial treatment of acute asthma

LAMA - Long acting muscarinic antagonist Ipratropium

How does LAMA nedules help in the initial management of acute asthma

Combining nebulised ipratropium bromide with a nebulised β2 agonist produces significantly greater bronchodilation than β2 agonist alone, leading to faster recovery and shorter duration of admission.

In what patients group should oxygen be used in the initial management of acute asthma

Used in patient is hypoxaemic (common in acute asthma)

What is the maintenance target for oxygen in patient suffering from acute asthma attack

SpO2 level of 94–98%

Give an example of an **oral** steroid that is used as part of the initial management of acute asthma attack.

oral prednisolone

Give an example of an **IV** steroid that is used as part of the initial management of acute asthma attack.

IV hydrocortisone

How long should steroids be used in the management of acute asthma attack

Continue until recovery (minimum 5 days) In cases where IV hydrocortisone has been used, switch to oral prednisolone when appropriate

Second line therapies are used in patient who do not improve after 15 minutes of initial treatment or if there are life threatening features present. Name two second line therapies

IV magnesium sulphate IV aminophylline (only following consultation with senior clinicians) Referral to senior clinicians are ICU team for intubation and ventilation

Describe how IV mangesium sulphate is used as a second line therapy for acute asthma attack

Single dose Evidence to suggest magnesium sulphate has bronchodilator effects.

Name the two types of Positive airway pressure (PAP)

BiPAP and CPAP

In what type of respiratory failure is BiPAP used and how does it help?

Bi-level positive airway pressure Delivers higher air pressure during inspiration Useful for remove CO2 retention and thus Type 2 respiratory failure

In what type of respiratory failure is CPAP used and how does it help?

Continuous positive airway pressure Delivers same air pressure in inspiration and expiration Useful for Type 1 respiratory failure

_COPD vs Asthma:_ What age is it seen in

COPD: over 35s Asthma: Any age

_COPD vs Asthma:_ Which one does dyspnoea varies

Asthma - usually acute episodes of exacerbation COPD it is do not vary much

_COPD vs Asthma:_ Which one is dyspnoea common at rest

Asthma

_COPD vs Asthma:_ Which one is associated with a smoking history

COPD definitively In asthma it could be a trigger but it has variable association

_COPD vs Asthma:_ Which one has commonly a morning cough

COPD

_COPD vs Asthma:_ Which one is commonly a noctural cough

Asthma

_COPD vs Asthma:_ Which one has a family history of the condition as a risk factor

Asthma

_COPD vs Asthma:_ Which one is commonly associated with atopy

Asthma