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Asthma Flashcards

1
Q

What is asthma

A

Chronic hyper responsiveness of airway - type I
Reversible bronchospasm = obstruction
Smooth muscle contraction
Inflammation + mucous = narrowing

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2
Q

What are the types of onset of asthma

A 
Early infant / VIW
Childhood
Adult
Exertional
Occupational - normal peak flow when not at work (refer to specialist)
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3
Q

What causes asthma / RF

A

Genetic factors - to be hyper allergic / responsiveness

Environment - childhood exposure to allergens / maternal smoking

Familial atopic tendency / atopy - tendency to be hyper allergic and produce IgE

Occupation - smoke decreased FEV1 and increases wheeze

Other

  • LBW
  • Not breast
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4
Q

What is atopy and what happens in atopy

A

1st exposure sensitises T cells, B cells produce IgE which binds to mast cells
2nd exposure mast cells release contents

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5
Q

What do mast cells release and what does this cause

A

Histamine, leukotrienes and inflammatory cells

Oedema, mucous and smooth muscle contraction

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6
Q

What triggers asthma

What drugs should be avoided

A 
Exercise
Cold air
Aspirin 
BB
NSAID
Sedatives 
Allergies - Pets, Pollen, Food
Smoke / parenteral smoking 
URTI / infections 
Poor inhaler technique
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7
Q

What are the symptoms of asthma

A

VARIABLE + REVERSIBLE
Often worse at night - diurnal variation
Expiratory wheeze - narrow airways = turbulent
SOB - more effort to inflate hyper inflated lungs
Cough - dry, exertion, nocturnal
Chest tight - voluntary contract muscles
Haemoptysis

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8
Q

What are the signs of asthma

A 
Tachycardia
Tachypoea 
Hypercpania + hypoxaemia 
Cyanosis 
Reduced PEFR
Hyperinflated CXR as air is trapped 
Acccessory muscles
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9
Q

What are complications of asthma

A

Pneumothorax - parenchyma ruptures due to increased alveolar pressure

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10
Q

What is a delayed eosinophil response

A 
Atopic triad 
- Conjunctivitis 'Hayfever'
- Allergic Rhinitis
- Dermatitis 
Bronchiole constriction
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11
Q

How does asthma present in children

A 
NO WHEEZE = NO ASTHMA
Dry nocturnal cough
Respiratory difficulty / obstruction
Sooking in of ribs -  recession 
<18 months = more infection
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12
Q

What suggests its not asthma

A 
Dizzy
Productive cough
Smoking Hx
Cardiac disease
Normal PEFR when symptomatic
Clubbing
Stridor - harsh vibrating 
Asymmetrical expansion
Dull percussion 
Crepitations
No response to RX 
Unilateral Sx
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13
Q

What is suggestive of asthma

A 
Wheeze / SOB / tight chest
Diurnal variation
Exercise / allergic / cold air worsens
Aspirin / BB worsens
Evidence of atopy 
FH atopy 
Low FEV1 / PEF
Blood eosinophilia
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14
Q

How do you investigate asthma

A

Spirometry with bronchodilator reversibility = 1st line
FeNO - released by eosinophil and show atopy
Peak flow variability over 2 weeks

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15
Q

What does spirometry look at

A

Amount of air and speed during exhalation
FEV1 <70% = suggestive
FVC = normal
Ratio reduced

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16
Q

What does bronchodilator reversibility show

A

Large increase in FEV1 >12%

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17
Q

What are other investigations

A 
CXR - old / smoking HX
PEFR for 2 weeks - >15% variability = suggestive + diurnal variation >2%
PFT to exclude COPD
- Helium dilution
- CO gas transfer = normal
Bronchial hyper responsiveness 
Skin prick for allergen
Total IgE
FBC
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18
Q

What do you do if >17

A

Spirometry
BDR
FeNO

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19
Q

What do you do 5-17

A

Spirometry + BDR

FeNO if normal but still suspect

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20
Q

What do you do in <5

A

Clinical
Trial of Rx
If unsuccessful = refer

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21
Q

What do you do for occupational asthma

A

Serial peak flow
Exposed and unexposed periods
If Sx better on holiday
Refer to occupational health

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22
Q

What should you ask about in the Hx

A 
Variation
- Diurnal / Weekly variation / better in holiday / annual - pollen ?
Triggers
- inc drugs that worsen 
Childhood asthma / bronchitis / hay fever / excema
FH
Days of work
Sleep disturbance
Acid reflux - Rx improves spirometry
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23
Q

What drugs are CI in asthma

A 
BB
NSAID
Aspirin
Sedatives 
Esp if nasal polyps
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24
Q

How do you treat asthma

A 
Different depending on SIGN vs NICE 
SABA
Consider adding therapy every 4-8 weeks 
SABA + ICS - Budenoside 
Add LTRA - Montelukast 
Add LABA - Salmeterol 
Stop LABA / LTRA if no benefit
Consider starting MART (low dose ICS + LABA) - Seratide
Increase ICS
25
What do you do if still not controlled
``` High dose ICS >800 Theophylline LAMA - titropium bromide (not in children) Oral daily steroid Refer ```
26
What are lifestyle measures
``` Smoking cessation Weight loss Inhaler technique PEF 2x daily Asthma action plan Flu vaccine Yearly review ```
27
What are steroid sparing agents
Omalizumab | Mepolizumab
28
What should you consider every 3 months
Step down of maintenance Rx
29
What is a SABA
Salbutamol (Ventolin) - either accuhaler or easy breath Reliever Relax smooth muscle
30
What are the SE
``` Tremor Cramp Headache FLushing Palpitations Tachycardia Hypokalaemia so monitor U+E ```
31
When do you start ICS (preventer) or LTRA in <5
SABA 3x Waking one night Oral steroids for exacerbation in past 2 years
32
What does ICS do
Betaclometesone (Flixodide or QVAR) | Reduce inflammation
33
What are the SE
Adrenal crisis Dysphona Oral candidiasis Stunted growth in children
34
LTRA
Montelukast
35
LABA
Salmeterol or Severent
36
What are SE of LAMA
``` Anti-cholinergic SE Dry mouth / eyes Headache Glaucoma GI ```
37
How do you measure control
S- SABA used 1+ a week A- Absence from school or work N- Nocturnal Sx E- Exertional Sx
38
What is Ddx of asthma
``` Pulmonary oedema COPD Obstruction - foreign body / tumour SVC obstruction - wheeze and SOB (not episodic) Pneumothorax PE Bronchiectasis Bronchiolitis ```
39
DDX for wheeze
Tumour FB Localized obstruction
40
What is low dose ICS
<400 High dose = >800 Diff for children
41
What is a moderate asthma attack
``` Wheeze with stethoscope HR <110 RR <25 PEF 50-75% SaO2 >92% PaO2 >8 ```
42
What is a severe attack
``` Can't speak sentences Use of accessory muscle Audible wheeze >110 >25 PEF 33-50 SaO2 and Pao2 normal ```
43
What is life threatening
``` Silent chest / no wheeze as so constricted Cyanosis Poor response effort Exhaustion Impaired consciousness Coma HR >130 Brady / arrhythmia / hypotension EF <33% Sats <92% O2 <8 Normal PaO2 = life threatening as should be low as hyperventilating ```
44
What is fatal
Raised PaCO2
45
What are symptoms of asthma attack
``` SOB Wheeze Cough Accessory muscles Not responding to salbutamol ```
46
What should you ask in HX
Usual and recent Rx Previous attacks Best PEF Any ICU
47
What investigations should you do
``` PEF if can - before and after nebuliser ABG if sats <92% CXR if suspect pneumothorax / infection FBC, U+E, CRP Blood / sputum culture ```
48
How do you monitor
Sats RR and effort HR
49
When should you always admit
If previous life threatening
50
What do you do for mild attack
Check RR, HR, sats, PEFR, chest Oral prednisone 40mg 5 days for all attack Possibly cover with Ax SABA MDI with spacer 10 puffs Step up ICS dose Can use nebuliser if PEFR half of expected or look unwell
51
What do you do for severe
Admit to hospital Oxygen 15l NRB to maintain sats Burst therapy - back to back neb (prescribe all doses) Nebuliser - Salbutamol 5mg with O2 - 3 doses - Ipratropium bromide 500mg (SAMA) - 2 doses - Hydrocortisone 100mg IV 1 dose or prednisone 40mg PO Other Add theophylline - not much role
52
What do you do if not responding
``` ITU - always if raised PaCO2 IV magnesium sulphate 2g/20 minutes next step IV theophylline 5mg / kg IV salbutamol IV steroid / hydrocortisone = final step NIV Intubation ECMO in extreme ```
53
What do you need to monitor with theophylline
ECG - can cause arrytmhia
54
DDX asthma attack
``` Exacerbation COPD PE anaphylaxis Pulmonary oedema Obstruction ```
55
When do you discharge
``` PEF >75% within 1h of Rx Stable 24 hours Chek inhaler technique Steroid and bronchodilator therapy Written management plan ```
56
What do you organise for patient
GP in 2 days | Asthma clinic 4 weeks
57
If a patient with asthma has a chest infection what should you give
Antibiotic + increase steroid
58
What do you do if suspect theophylline toxicity
Activated charcoal Haemodialysis = definite Supportive
59
What is supportive
IV crystalloid for hypo Diazepam for seizure IV BB for SVT

Respiratory (23 decks)

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