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Flashcards in Asthma Deck (64):
1

with regards to epidemiology what is the prevalence of asthma in the adult welsh population

1:12 welsh adults

2

according to epidemiological studies list 2 environmental factors that may increase your risk of developing asthma

Increased risk
• Caesarian delivery?
• Childhood antibiotic use
• Childhood use of
paracetamol?
• Exposure allergen
• Sedentary life style
• Obesity
• Maternal smoking
• Pollution

3

list three pathological features of asthma that may be found at post mortem

Any of the following
• Inflammation of bronchial wall: eosinophilic
• Mucus plugging
• Airway remodelling:
– Airway wall thickening: 50-300% (Bronchial smooth muscle hypertrophy
+ airway oedema)
– Mucus gland hyperplasia
– Loss of surface epithelium
– Sub-epithelial fibrosis
- thickening of basement membrane

4

list 2 mediators released by mast cells which cause bronchoconstriction clinically

Histamine, Prostaglandin D2, Leukotrienes (D4, E4)

5

T-helper 2 lymphocytes release the cytokine IL-5 which promtoes the differentiation of which inflammatory cell type

Eosinophils

6

in some individuals NSAIDs may worsen asthma. Which enzyme does this class of medication inhibit

COX (II)

7

Mr X is 34y/o asthmatic on inhaled budesonide and PRN salbutamol. which step of the asthma ladder is he currently on?

Step 2: low dose inhaled steroid + PRN B2 agonist

8

Mr X is 34y/o asthmatic on inhaled budesonide and PRN salbutamol. He attends your surgery as he is not sleeping at night due to cough and wheeze. If you were to increase his treatment name a class of drugs that you would add to his therapy

Try LABA first and if ineffective consider increasing ICS
then theophylline or leukotriene receptor antagonist

9

You are the A&E SHO on call. Miss B is a known
asthmatic who presents with cough and SOB. On arrival
the paramedics show you her ambulance card.
Observations are as follows. Pulse 120, RR 26, Sats
94% on air. When you review her she has marked
expiratory wheeze and is not able to talk full sentences.
Grade her asthma severity

severe

10

You are the A&E SHO on call. Miss B is a known
asthmatic who presents with cough and SOB. On arrival
the paramedics show you her ambulance card.
Observations are as follows. Pulse 120, RR 26, Sats
94% on air. When you review her she has marked
expiratory wheeze and is not able to talk full sentences.
name 3 medications that you would consider starting her on

Salbutamol 5mg nebulised, Ipratropium bromide 500mcg
nebulised, Prednisolone 40mg od po

11

Parameter Value Normal
range
pH 7.35 (7.35-7.45)
pCO2 6.0 4.5-6kPA
pO2 10 11.5.- 13
BE 1 -1 /+1
Bicarb 25 24/27

what concerns you about this blood gas

normal pCO2 worsening hypoxia

12

Parameter Value Normal
range
pH 7.35 (7.35-7.45)
pCO2 6.0 4.5-6kPA
pO2 10 11.5.- 13
BE 1 -1 /+1
Bicarb 25 24/27

ITU are contacted, list 2 other therapy that you might consider

IV magnesium sulphate
(IV aminophylline/IV salbutamol)

13

Mrs A is a 44 year old atopic asthmatic. She currently
taking symbicort tubohaler 400/12 (eformoterol +
budesonide 400). She is also taking uniphyllin
(theophylline).
which step of the asthma ladder is this patient currently on

Step 4: on high dose inhaled steroids, LABA and
theophylline

14

which enzyme do theophylline tablets inhibit

Phosphodiesterase: inhibiting the breakdown of cAMP

15

state the side effects you are most likely to see in a patient taking a beclometasone inhaler

Sore throat
Candidiasis
Hoarse voice
can be avoided with the use of spacers/improving technique or rinsing mouth out after

In patients taking 1mg/day beclometasone (or equivalent) we should
also monitor carefully for systemic side effects

16

for approximately how long would you espect to see the bronchodilation effects of salmeterol

12 hours

17

which of the inflammatory mediators does montelukast block from reaching its receptor

leukotriene

18

name a drug or condition which can increase the half life of theophylline? and what symptoms could this cause?

Hepatic cirrhosis
CHF
Acute pulmonary oedema
Erythromycin
Fluconazole
Other drugs also inhibit metabolism of theophylline – check Appendix 1
of BNF for details
Symptoms of toxicity include N&V, arrhythmias, restlessness,
convulsions, coma

19

mary has come to her GP and described worsening asthma symptoms, what would you discuss with her before making changes to her drug treatment

Possible triggers for worsening symptoms
Inhaler technique and compliance

20

Jack, aged 31years is using a Seretide 125 evohaler
(fluticasone and salmeterol) regularly and a salbutamol
inhaler when required. His asthma has been well
controlled for many years, with him rarely using his
salbutamol inhaler and he has come for a review of his
treatment.

You decide that stepping down his treatment would be appropriate. Which of his drugs should be discontinued?

Salmeterol
But patient should remain on fluticasone and when required
salbutamol so no reduction in dose count

21

T/F In children with wheeze:
A) Bronchiolitis only affects children over 2 years of age
B) Haemoptysis is a common symptom of childhood
asthma
C) Congenital lung abnormalities can present as old as 5
years age
D) Toddlers are the commonest age group for inhaled
foreign bodies
E) Nocturnal cough is a sign of asthma
F) A child who is not wheezing by 3 years of age will not
develop asthma

In children with wheeze
C) Congenital lung abnormalities can present as old as 5
years age
D) Toddlers are the commonest age group for inhaled
foreign bodies
E) Nocturnal cough is a sign of asthma

22

T/F Exercise and children:
A) Cross country running is usually more of a problem
than football for children with asthma
B) A high organic content or insufficient chlorine in a
swimming pool can trigger asthma
C) Swimming is well tolerated in most children with
asthma
D) Warming up before exercise can have a ‘protective
effect’ for children with asthma
E) Professional athletes do not have asthma

A) Cross country running is usually more of a problem
than football for children with asthma
B) A high organic content or insufficient chlorine in a
swimming pool can trigger asthma
C) Swimming is well tolerated in most children with
asthma
D) Warming up before exercise can have a ‘protective
effect’ for children with asthma

23

T/F In acute asthma in children:
A) 10-12 puffs of salbutamol via a spacer is usually as
effective as the appropriate dose via a nebulizer in
acute asthma in children
B) Oral steroids are not given in acute asthma preteenage
years due to their effect on growth
C) Teachers have a legal requirement to give children
their medication in school
D) Stress/emotion is not a trigger in primary school
children
E) Toddlers with a tight chest may complain of ‘tummy
ache’

In acute asthma in children:
A) 10-12 puffs of salbutamol via a spacer is usually as
effective as the appropriate dose via a nebulizer in
acute asthma in children
E) Toddlers with a tight chest may complain of ‘tummy
ache’

24

T/F Inhalers/PEFRs in children:
A) Washing and air drying a spacer in ‘fairy’ washing up
liquid significantly reduces its static
B) An MDI and spacer is the first choice for inhaled
treatment in children under 5 years.
C) A dry powder inhaler is first choice for inhaled steroid
treatment in children aged 6 – 12 years
D) Children 3 years and over are able to give reliable
PEFRs
E) An MDI directly into the mouth should be used for
bronchodilators in Teenagers
F) PEFRs in children are charted against their height

Inhalers/PEFRs in children:
A) Washing and air drying a spacer in ‘fairy’ washing up
liquid significantly reduces its static
B) An MDI and spacer is the first choice for inhaled
treatment in children under 5 years
F) PEFRs in children are charted against their height

25

which factors reduce risk of asthma development

Reduced Risk
• Vaginal delivery
• Breast feeding
• Infection: “The Hygiene
Hypothesis”
• Exposure to rural environment
• Increase antioxidants

26

what are the parameters for mild asthma attack

Mild Asthma
PEFR >75%
Pulse 96%

27

what are the parameters for moderate asthma attack

Mod Asthma
PEFR 50-75%
Pulse 100-110
RR 20-25
Sats >92%

28

what are the parameters for severe asthma attack

Severe Asthma
PEFR 33-55%
Unable to talk full sentences
Pulse >110
RR>25
Sats <92% on air

29

what are the parameters for life threatening asthma attack

Life threatening
PEFR <33%
Confused
Acidotic
Normal to high pCO2
Hypoxic
Bradycardia/hypotension
Poor respiratory effort

30

what is the definition of asthma

airways hyperresponsiveness with air flow obstruction which is reversible spontaneously or with treatment

31

there are two main types of asthma: extrinsic and intrinsic. What types of extrinsic asthma are there

IgE mediated
atopic
occupational

32

there are two main types of asthma: extrinsic and intrinsic. what types of intrinsic (non-immune) are there?

infection
cold
exercise
stress
irritants

33

what is the dual pathophysiology of asthma

bronchial hyperreactivity --> bronchospasm
bronchial inflammation --> eosinophilic

34

which lifestyle factors predispose to asthma

smoking
pollution
occupation

35

what are the symptoms of asthma

recurrent wheeze, breathlessness, cough, and chest tightness
diurnal variation in peak flow (morning dippers)

36

which diagnostic investigations would be performed for asthma

peak flow diary
spirometry
CXR
ECG
FBC (eosinophils)
IgE levels
Saturations
Blood gases

37

what is the criteria for intermittent asthma

symptoms < once a week - asymptomatic and normal PEF between attacks
night time symptoms < twice a month
PEF/FEV1 > 80%

38

what is the criteria for mild persistent asthma

symptoms > once a week but < once a day
night time symptoms > twice a month
PEF/FEV1 ~80%

39

what is the criteria for moderate persistent asthma

symptoms daily with daily use of SABA
night time symptoms > once a week
PEF/FEV1 80-60%

40

what is the criteria for severe persistent asthma

symptoms: continuous limited physical activity

frequent night time symptoms

REF/FEV1 <60%

41

briefly outline the asthma step ladder for adults

STEP 1 SABA prn
STEP 2 SABA +ICS
STEP 3 SABA + ICS + LABA
STEP 4 SABA + inc ICS +LABA (+leukotriene)
STEP 5
daily oral steroids and referral to specialist care

42

which acronym can be used to remember p450 enzyme inhibitors

Allopurinol
Omeprazole
Disulfram
Erythromycin
Valproate
Isoniazid
Cimetidine
Ethanol
Sulphanomides

43

list some biologics which can be used against asthma

anti IgE (omaluzimab + xolair)
Anti IL-13 + -14
Anti IL-5 (mepoluzimab)
Anti-TNF

44

what are the management steps in acute asthma

oxygen
nebulised beta agonist
steroid therapy (early!!)
ipratropium bromide
magnesium sulphate

45

what are the predictors of mortality in acute asthma

previous near fatal asthma (ITU admission)
previous admission in the last year with asthma
>3 classes of medication
repeated attendances
brittle asthma

46

which drug used in an acute setting is not actually licensed for asthma

anti-muscarinics such as ipratropium

47

how does magnesium sulphate aid in the management of acute asthma

decreased calcium conc therefore leading to muscle relaxation

48

how does sodium cromoglicate work

stabilises mast cells

49

under which circumstances is omalizumab used

in severe persistent allergic asthma

50

what are the side effects of SABAs

tremor
tachycardia
hypokalaemia (can be used to treat!!)

51

how does SABA work in asthma

relaxes smooth muscles rapidly (30min peak lasts 4-6hrs)

decr release of inflamm mediators

incr mucus clearance (ca be desensitized)

52

how do corticosteroid work in asthma

decr immune cells, inflam mediators, vascular permeability

53

list some examples of inhaled corticosteroids

beclometasone
fluticasone
budesonide

54

which LABA has the faster onset

formeterol

55

which combined ICS and LABA preparations are available

Seretide
symbicot - can be used for prevention and relief
Fostair

56

which type of asthma is leukotriene receptor antagonists most effective in the treatment of

exercise
nocturnal
NSAID induced

57

xanthines such as theophylline and aminophylline have a narrow therapeutic range - what is it?
also what are the side effects of overdose

10-20mg/L
N+V
tachycardia
convulsion
coma

58

which T helper cells are involved in pro-atopic asthma

Th2

59

which ILs promote Ig subclass switching in B/Plasma cells

IL 4 and 13

60

which cytokine are involved in activating eosinophils

IL5 and GM-CSF

61

what do eosinophils secrete in asthma

Major basic protein
eosinophil cation protein
leukotrienes
cytokines

62

which ILs activate mast cells

IL 4 and 5

63

what happens on mast cells in the early phases of the allergic asthmatic response sequence

IgE crosslinking leading to degranulation and bronchoconstriction

64

what happens on mast cells in the late phases of the allergic asthmatic response sequence

IMMEDIATE:
degranulation releasing
1. histamine
2. TNF alpha
3. proteases
4. heparin

MINUTES:
lipid mediators such as prostaglandins and leukotrienes

HOURS: cytokine production (IL4 and IL13)