Asthma

Question 1

Features?

when is cough worse?

when is peak flow worst?

Answer 1

Characterized by recurrent episodes of dyspnoea, cough, and wheeze caused by reversible airways obstruction.

Intermittent dyspnoea 
Wheeze 
Cough (worse at night) 
Chest tightness 
Diurnal variation – peak flow worse in morning.

Question 2

Risk Factors

FHx of Atopy - what is it?
- what Ig are these mediated by?

Answer 2

triad of asthma, eczema (atopic dermatitis) and hay fever (allergic rhinitis).

Patients with asthma usually suffer from these other IgE mediated atopic conditions.

Question 3

: if peak flow is normal on weekends – may be ?

Answer 3

occupational asthma (occurs in 10-15% of adult asthma).

Question 4

Precipitants

what drugs are contraindicated in asthma ?

Answer 4

Cold air, Exercise
Emotion
Allergens (house dust mite, pollen, fur)

NSAIDs, B-blockers (especially B blocker)

Question 5

what measurements determine a patients estimated PEFR and estimated FEV1?

how do you measure PEFR?
how do you measure FEV1?

Answer 5

age + sex + height

PEFR = peak flow 
FEV1 = spirometry

Question 6

ASTHMA DIAGNOSIS

• all patients aged >17?
• patients aged <5?

Answer 6

All patients aged >17 yrs of age:

should have spirometry* with a bronchodilator reversibility test (BDR) and a FeNO test.

*Do peak expiratory flow if spirometry is unavailable

Patients <5yrs:

Spirometry + BDR test. A FeNO test should be requested if there is normal spirometry

Question 7

FeNO test

Nitric oxide levels typically correspond to inflammation levels

therefore what is a positive result in children and adults?

Answer 7

• In adults: >40ppb is considered +ve.

- In children: >35 ppb is considered +ve.

Question 8

BDR Testing: (uses spirometry and bronchodilator)

+ve test is indicated by an improvement in FEV1 of?

and an increase in volume of?

Answer 8

+ve test is indicated by an improvement in FEV1 of 15% or more and increase in volume of 200ml or more.

Question 9

Typical spirometry results include the following - what is the result in asthmatics?

FEV1
FVC
FEV1% (FEV1/FVC)

Answer 9

• FEV1 significantly reduced
• FVC normal
• FEV1% (FEV1/FVC) <70% = obstructive.

Question 10

what type of resp failure seen in acute severe asthma

Answer 10

Type 1 resp failure (hypoxaemic - low O2, PO2 <60mmHg )

Question 11

A patient is admitted with breathlessness - do you do ABG or VBG?

Answer 11

ABG

tells you if Type 1 or Type 2 resp failure

otherwise VBG is fine for anyone that isn’t a resp or cardiac patient

Question 12

Mx of Acute Attack

O 
S
H
I
T
M
E

Answer 12

• Oxygen
• Salbutamol 5mg nebulized with O2
• Hydrocortisone 100mg IV (steroid – reduces inflam).
• Ipratropium – if PEF still <75%, repeat salbutamol every 15 mins with ipratropium.
• T (not used)
• Magnesium sulfate 1.2-2g IV single dose.
• Escalate (ICU) – if not improving

Question 13

Patients with PEF of what within one hour of initial treatment may be discharged?

otherwise rest must be stable on discharge medication for how long ?

Answer 13

PEF >75%

24 hours

Question 14

Should know severity of asthma:

• moderate: PEFR ?
• acute severe: RR? and inability to?
• life-threatening: chest action?

Answer 14

Should know severity

moderate:
- >50-75% PEFR

acute severe:

• inability to complete full sentences,
• RR >25
• PEFR 33-50%

life-threatening:

• silent chest or
• cyanosis or
• exhaustion
• PEFR <33%

Question 15

what drug is contraindicated in asthmatics?

Answer 15

b -blockers

Question 16

Mx of Asthma

Step 1 : what do you use? if using more than once daily - what do you move to?

Step 2: add what? increase dose from what to what as required?

Step 3: add what to help with nocturnal symptoms and morning dips?

Step 4: Add regular oral prednisolone and refer to specialist

Answer 16

Step 1: SABA (salbutamol) for symptom relief - if used more than once daily move to Step 2

Step 2: add inhaled steroid - reduce mucosal inflammation (beclometasone or fluticasone)
increase dose from 200-800mcg /day

Step 3: LABA - salmeterol whilst increasing steroid dose to 1000mcg/day

Step 4: o Add regular oral prednisolone and refer to specialist

Question 17

may be used in selected patients with persistent allergic asthma. ?

Answer 17

Anti-IgE monoclonal antibody: Omalizumab

Question 18

A 7-year-old boy is brought in to the GP surgery with an exacerbation of asthma. On examination he has a bilateral expiratory wheeze but there are no signs of respiratory distress. His respiratory rate is 24 / min and PEF around 60% of normal. What is the most appropriate action with regards to steroid therapy?

oral prednisolone for 3 days
admit for IV steroids
don’t give steroids
double his beclometasone dose

Answer 18

oral prednisolone for 3 days

Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery.

Tapering of beclometasone dose is unnecessary unless the course of steroids exceeds 14 days.

Question 19

A 22-year-old man diagnosed with asthma one year ago has since been using a salbutamol inhaler when required. He is otherwise well with no significant past medical history. He lives alone in a student accommodation. He does not smoke and drinks 2-3 cans of beer every week. His symptoms were well controlled but he has recently been using his inhaler more frequently, about five times per week. He also reported having night cough which disrupts his sleep. The GP decides to modify his treatment regimen to better manage the patient’s symptoms and improve his quality of life. Which of the following is the most appropriate next step in the management of this patient?

add LABA
add daily steroid tablet
add low dose ICS
add leukotriene receptor antagonist

Answer 19

add low dose ICS

Question 20

A 24-year-old male is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone. Despite initial treatment there is no improvement. What is the next step in management?

IV aminophylline
IV magnesium sulphate
IV salbutamol
IV adrenaline

Answer 20

IV magnesium sulphate

Question 21

A 28-year-old woman presents with a persistent cough and feeling of wheeziness after exercising. Which one of the following would make a diagnosis of asthma more likely?

only gets symptoms after viral URTI

peripheral pins and needles during an episode

symptoms worsen after taking aspirin

cough productive of clear sputum

Answer 21

symptoms worsen after taking aspirin

Question 22

A 23-year-old woman comes for review. Despite using beclometasone 200mcg bd she is regularly having to use her salbutamol inhaler. Her inhaler technique is good.

C. Increase inhaled steroid to 2000 mcg/day
D. Course of prednisolone for 5 days
E. Double inhaled steroids until symptoms resolve
F. Add inhaled long-acting B2 agonist
G. Trial of leukotriene receptor antagonist

Answer 22

Trial of leukotriene receptor antagonist

The 2017 NICE guidelines now advocate using a leukotriene receptor antagonist before trying a long-acting beta agonist.

SABA + ICS + LRTA

then

SABA + ICS + LABA

(carry on LRTA if patient is responding to it, if not - then take it out )

Question 23

You review a 4-year-old boy in clinic. He has been diagnosed with asthma after having multiple wheezy episodes over the past 3 years. Around 4 months ago he was admitted with shortness-of-breath and wheeze and was diagnosed as having a viral exacerbation of asthma by the paediatric team. Prior to his discharge he was given a Clenil (beclometasone dipropionate) inhaler 50mcg bd in addition to salbutamol 100mcg prn via a spacer.

His mother reports that he has a persistent night-time cough and is regularly having to use his salbutamol inhaler. Clinical examination of his chest today is normal.

What is the most appropriate next step in management?

Add LABA
Add SAMA
Add LAMA
Add leukotriene receptor antagonist

Answer 23

Add leukotriene receptor antagonist

NEW 2017 GUIDELINES:

1

Short-acting beta agonist (SABA)

2

Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking SABA + paediatric low-dose inhaled corticosteroid (ICS)

3

SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)

4

SABA + paediatric low-dose ICS + long-acting beta agonist (LABA)

In contrast to the adult guidance, NICE recommend stopping the LTRA at this point if it hasn’t helped

Question 24

A 22-year-old woman attends the Emergency Department following an exacerbation of asthma. She currently only uses a salbutamol inhaler 2 puffs prn. Her symptoms settle quickly with a salbutamol nebuliser. You give the patient standard advice on inhaler technique and what to do if her symptoms return. What is the most appropriate further action to ensure that this current exacerbation settles?

Prescribe 7 day course of amoxicillin

Prescribe salmeterol inhaler

Prescribe beclometasone inhaler

prescribe prednisolone 40mg OD for 5 days + beclometasone inhaler 200mcg

Answer 24

prescribe prednisolone 40mg OD for 5 days + beclometasone inhaler 200mcg

The most appropriate initial treatment is a short course of oral prednisolone (the BNF/BTS recommend 40-50mg od) to settle her exacerbation.

it would also be appropriate to start an inhaled corticosteroid, particularly as she has presented with an exacerbation.

Question 25

A 12-year-old boy presents for review. He was diagnosed with asthma three years ago by his general practitioner. He is currently on a salbutamol inhaler which he is using 2 puffs 3 times daily, a paediatric low-dose beclomethasone inhaler and oral montelukast. He still has a night time cough and has to use his blue inhaler most days. Unfortunately, there appears to have been little benefit following the addition of montelukast. His chest is clear on examination today with no wheeze and a near-normal peak flow. What is the next step in his management? stop montelukast and add salmeterol increase dose of beclemetasone add tiotropium add theophylline

Answer 25

stop montelukast and add salmeterol Children aged 5-6 whose asthma symptoms are not controlled on SABA + ICS + LTRA - stop LTRA and add LABA

Question 26

A 24-year-old female presents with episodic wheezing and shortness of breath for the past 4 months. She has smoked for the past 8 years and has a history of eczema. Examination of her chest is unremarkable. Spirometry is arranged and is reported as normal. What is the most appropriate next steps? trial of salbutamol inhaler FeNo + BDR test Arrange CXR trial of salbutamol inhaler and low dose ICS

Answer 26

FeNo + BDR test Adults with suspected asthma should have both a FeNO test and spirometry with reversibility

Question 27

A 29-year-old woman who is 14 weeks pregnant presents to the Emergency Department with an exacerbation of asthma. She quickly settles with nebulised salbutamol and you are asked to review her prior to discharge. She currently only uses a salbutamol inhaler (100mcg) as required and thinks that the most common trigger is grass pollen. Her peak flow is now 380 l/min (predicted 440 l/min) and inhaler technique is good. What is the most appropriate course of action? add SAMA arrange pollen desensitisation injections add inhaled salmeterol add inhaled beclomethasone

Answer 27

add inhaled beclomethasone

Question 28

A 9-year-old boy who is having an asthma attack is brought to surgery. Which one of the following findings would be categorise the asthma attack as life-threatening, rather than just severe, according to the British Thoracic Society guidelines? HR 140bpm Peak flow of 30% Sats 93% RR 36/min

Answer 28

Peak flow of 30%

Question 29

A 30-year-old woman is admitted to the Emergency Department with an exacerbation of asthma. On arrival her peak flow is 30% of predicted, respiratory rate is 36/min and oxygen saturations are 98% on 100% high-flow oxygen. She is given back-to-back nebulisers, intravenous hydrocortisone and started on a magnesium infusion. Which one of the following would be the strongest indicator of a need for intubation and ventilation? PEFR 20% of predicted pH 7.31 RR 50/min Sats 95%

Answer 29

pH 7.31 A pH less than 7.35 likely represents carbon dioxide retention in a tiring patient and is an ominous sign in acute asthma. Performing serial peak flows in a patient with life-threatening asthma is neither practical nor desirable.

Question 30

A four-year-old child with poorly controlled asthma attends GP surgery with his mother due to increasing frequency of his asthma exacerbations. He is already on salbutamol inhaler as required and beclometasone inhaler 200mcg/day. He uses these devices with a spacer and has good technique. What is the next best step in his management? add LABA Refer to resp paediatrician add leukotriene receptor antagonist increase dose of steroid

Answer 30

add leukotriene receptor antagonist Children < 5 years whose asthma symptoms are not controlled on a SABA + ICS - add a LTRA

Question 31

A 19-year-old lady presents to the GP clinic. She has a past medical history of asthma for which she is taking inhaled salbutamol PRN. She was recently started on a new drug which after a few weeks of intake, she has noticed several white patches in her mouth accompanied by a loss of taste. Which of the following medications is most likely to be causing her new symptoms? inhaled beclemetasone oral montelukast inhaled prednisolone inhaled tiotropium

Answer 31

inhaled beclemetasone Patients taking inhaled steroids to treat asthma are advised to rinse their mouth straight after intake to prevent development of oral candidiasis

Question 32

A patient with poorly controlled asthma is started on montelukast. What is the mechanism of action of this drug?

Answer 32

Leukotriene receptor antagonist

Question 33

A 7-year-old boy is brought in to see you by his mother. He has a diagnosis of asthma which has been treated with salbutamol as and when required. His mother feels that his symptoms have worsened and he now has a night time cough which is keeping him awake and affecting him during exercise at school. The examination is unremarkable. How should you manage this? refer to paeds add ICS arrange spirometry add in montelukast

Answer 33

add ICS