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Asthma Flashcards

1
Q

Define asthma

A

Chronic respiratory condition associated with airway inflammation and hyper-responsiveness leading to REVERSIBLE airflow limitation

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2
Q

Define acute asthma exacerbation

A

Onset of severe asthma symptoms, which can be life-threatening

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3
Q

Asthma symptoms

A

Cough, wheeze, chest tightness, and shortness of breath, and variable expiratory airflow limitation, that can vary over time and in intensity.

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4
Q

Asthma triggers

A

Exercise, allergen or irritant exposure, changes in weather, and viral respiratory infections.

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5
Q

Risk factors

A

Personal or family history of atopic disease (asthma, eczema, allergic rhinitis, or allergic conjunctivitis)
Respiratory infections in infancy e.g. RSV, rhinovirus
Premature birth and LBW
Obesity
Social deprivation e.g. due to damp housing, fungus, air pollution
Exposure to inhaled particulates
Workplace exposures e.g. flour dus, paint
Exposures to tobacco smoke

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6
Q

Complications of asthma

A

Death
Respiratory complications — irreversible airway changes, pneumonia, pulmonary collapse (atelectasis caused by mucus plugging of the airways), respiratory failure, pneumothorax, and status asthmaticus
Impaired quality of life e.g. time off work/school, fatigue

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7
Q

Briefly describe the anatomy of the airways from trachea to alveoli

A 
Trachea
Primary/main bronchus
Secondary bronchi
Bronchiole
Terminal bronchiole
Respiratory bronchiole
Alveoli duct
Alveolar sac
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8
Q

There are 2 major elements in the pathophysiology: inflammation and airway hyper-responsiveness.

A

Inflammation and airway hyperresponsiveness

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9
Q

The inflammatory reaction is Th1 or Th2 response?

What is this characterised by?

A

Th2 lymphocytic response. Th2

CD4+ lymphocytes that secrete IL-4, IL-5, and IL-13, TNF-alpha, and the leukotriene LTB4

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10
Q

Mechanism of mucus hypersecretion, oedema and bronchoconstriction

A

Allergen binds to IgE on mast cells, causing them to degranulate and release inflammatory mediators and chemotactic factors.
This damages the epithelium and causes decreased ciliary function, which stimulates afferent nerves which increase mucus secretion (glands are also hypertrophied) and bronchoconstriction.

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11
Q

History taking for asthma

A

Presence of more than one variable symptom of wheeze, cough, breathlessness, and chest tightness.
Episodic
Diurnal (worse at night or in the early morning)
Triggers - exercise, viral infection, exposure to cold air or allergens, emotion/laughter (in children), NSAIDs, beta blockers
Is it better on days off from work/on holidays?
PMH - atopy
DH
FH - atopy
SH - high risk job?

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12
Q

Examination findings

A

Expiratory polyphonic wheeze
Hyperexpansion of the thorax
Atopic dermatitis, eczema, or other allergic skin conditions

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13
Q

Investigations for asthma

A

No single diagnostic test

Fractional exhaled nitric oxide (FeNO) testing (40 ppb or higher = positive)
Spirometry if symptomatic (FEV1/FVC ratio <70%)
Bronchodilator reversibility (improvement in FEV1 of 12% or more, increase in 200ml)
Variable peak expiratory flow readings (if diagnostic uncertainty) - 20% variability monitoring twice daily for 2-4 weeks
Direct bronchial challenge test with histamine or methacholine (specialist test)
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14
Q

Differential diganoses

A 
Bronchiectasis 
COPD
Ciliary dyskinesia
Cystic fibrosis 
Dysfunctional breathing
Foreign body aspiration
Gastro-oesophageal reflux
Heart failure
Interstitial lung disease 
Lung cancer 
Pertussis 
Pulmonary embolism (PE)
Tuberculosis
Upper airway cough syndrome 
Vocal cord dysfunction
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15
Q

What is complete control of asthma?

A

No daytime symptoms.
No night-time waking due to asthma.
No need for rescue medication.
No asthma attacks.
No limitations on activity including exercise.
Normal lung function (FEV1 and/or PEF > 80% predicted or best).
Minimal side-effects from medication.

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16
Q

Non-pharm management of asthma

A 
Assess baseline 
Provide self-management education and a personalised asthma action plan
Ensure up to date with vaccinations
Provide sources of info/support
Advise on avoiding triggers
Provide advice on weight loss and smoking cessation
Assess for anxiety or depression
Ensure has own peak flow meter
Explain when and how to use inhalers
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17
Q

How often should people with asthma be followed up?

A

At least annually

If undergoing treatment adjustment, review after 4-8 weeks

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18
Q

Differential diagnosis for wheeze

A 
Anaphylaxis
Vocal cord dysfunction
Foreign body aspiration
Bronchiolitis
Bronchiectasis
COPD
Tumour causing obstruction 
Cardiac asthma
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19
Q

Diagnosis of atopy

A

Skin-prick tests
Blood eosinophilia of 4% or more
Raised allergen-specific IgE

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20
Q

Salbutamol mechanism of action

A

Short-acting beta-2 agonist

Stimulate B2 adrenergic receptors causing relaxation of bronchial smooth muscle (increase CAMP) and dilation and opening of the airways, acting within minutes.

21
Q

Salbutamol major side effects

A

hypokalaemia, fine tremor, anxiety, palpitations, headache, arrythmias and paradoxical bronchospasm (rare), seizure, acute angle-closure glaucoma

22
Q

Name two short acting beta 2 agonists

A

Salbutamol

Terbutaline

23
Q

LABAs - two examples + duration of action

A

Salmeterol, formoterol

12 hours

24
Q

Examples of inhaled corticosteroids + mechanism

A

Beclomethasone, budesonide, fluticasone

They act over days to decrease bronchial mucosal inflammation

25
Q

Side effects of inhaled corticosteroids

A

Oral candidiasis, taste altered, headache, voice alteration
Uncommon - anxiety, paradoxical bronchospasm, cataract, vision blurred
Rare - adrenal suppression, glaucoma, growth retardation, sleep disorder

26
Q

Oral steroids common side effects

A

Anxiety; behaviour abnormal; cataract subcapsular; cognitive impairment; Cushing’s syndrome; electrolyte imbalance; fatigue; fluid retention; gastrointestinal discomfort; headache; healing impaired; hirsutism; hypertension; increased risk of infection; menstrual cycle irregularities; mood altered; nausea; osteoporosis; peptic ulcer; psychotic disorder; skin reactions; sleep disorders; weight increased

27
Q

Montelukast mechanism and side effects

A

Leukotriene receptor antagonist - blocks the effects of cysteinyl leukotrienes (inflammatory mediators) in the airways by antagonising the CystLT1 receptor

SE: abdominal pain, headache, hyperkinesia (in young children), thirst

28
Q

Theophylline mechanism and side effects

A

Phosphodiesterase inhibitor -
reduces bronchoconstriction by increasing CAMP levels

SE: arrhythmias, GI upset, fits

29
Q

Omalizumab mechanism, route, side effects

A

Anti-IgE (monoclonal antibody)
Given every 2-4 weeks as sub-cut injections
SE: abdominal pain, arthralgia, headache, injection-site reactions, pyrexia, sinusitis, upper respiratory tract infection

30
Q

BTS/SIGN guidelines steps in adults (5 steps)

- consider moving up if using 3 doses of SABA or more a week

A
  1. SABA as required (continue along with all steps)
  2. Add low dose ICS
  3. Add LABA
  4. Increase to medium dose ICS OR add LRTA
  5. Refer to specialist
31
Q

BTS/SIGN guidelines steps in children under 5

- consider moving up if using 3 doses of SABA or more a week

A
  1. SABA as required (continue along with all steps)
  2. Very low dose ICS
  3. Add LTRA
  4. Increase ICS to low dose
  5. Refer to specialist, increase ICS to medium, or add theophylline
  6. Refer to specialist, consider oral steroid
32
Q

BTS/SIGN guidelines steps in children over 5

- consider moving up if using 3 doses of SABA or more a week

A
  1. SABA as required (continue along with all steps)
  2. Very low dose ICS
  3. Add LABA
  4. Increase ICS to low dose (stop LABA if not helping, consider LTRA trial)
  5. Refer to specialist, increase ICS to medium, or add theophylline
  6. Refer to specialist, consider oral steroid
33
Q

What does FEV1 mean?

A

Forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration

34
Q

What does FVC mean?

A

Forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration

35
Q

Precipitating factors for asthma attack

A
  • Viral infection
  • Dust/house dust mite
  • Animal dander
  • Pollen
  • Smoke/pollution
  • Exercise
  • Atmospheric conditions e.g. lightening
  • Medications – aspirin, NSAIDs
36
Q

Define moderate acute asthma (3)

A

Increasing symptoms
PEF >50–75% best or predicted
No features of acute severe asthma

37
Q

Define acute severe asthma

A

Any one of:

  • PEF 33–50% best or predicted
  • respiratory rate ≥25/min
  • heart rate ≥110/min
  • inability to complete sentences in one breath
38
Q

Define life-threatening asthma

A

Any one of:

  • PEF <33% best or predicted
  • SpO2 <92%
  • PaO2 <8 kPa
  • normal PaCO2 (4.6–6.0 kPa)
  • silent chest
  • cyanosis
  • poor respiratory effort
  • arrhythmia
  • exhaustion
  • altered conscious level
  • hypotension
39
Q

Define near-fatal asthma

A

Raised PaCO2 and/or requiring mechanical

ventilation with raised inflation pressures

40
Q

Indications for admission (acute asthma)

A

1) If life-threatening or near-fatal asthma attack

2) If severe asthma attack and persisting after initial treatment

41
Q

When can patients with asthma attacks be discharged?

A

When peak flow is >75% best or predicted one hour after initial treatment

42
Q

Treatment of asthma attack

A

Oxygen (aim 94–98% sats)
Salbutamol nebs (oxygen driven) 5 mg, repeat every 20–30 minutes
Ipratropium bromide nebs 0.5mg 4-6 hourly
Prednisolone 40-50 mg daily for at least 5 days
IV magnesium sulphate - ONLY DONE WITH SENIOR

43
Q

When to refer acute asthma to ICU

A

Refer any patient:
- requiring ventilatory support
- with acute severe or life-threatening asthma, who
is failing to respond to therapy (deteriorating PEF, persisting or worsening hypoxia, hypercapnia, ABG analysis showing decreased pH or raised H+, exhaustion, feeble respiration, drowsiness, confusion, altered conscious state, resp arrest)

44
Q

Monitoring when in hospital with acute asthma

A
  • Regular peak flow
  • Oxygen saturations
  • ABG
  • Serum potassium and glucose
  • ECG – watch for arrhythmias
45
Q

Follow up after asthma attack

A

Inform GP within 24 hours from discharge - need GP apt within 48 hours
Keep under specialist supervision if near-fatal attack
If severe attack, specialist follow up for at least one year after admission - first apt within 4 weeks

46
Q

What measures should be taken prior to discharge to prevent acute asthma recurrence?

A 
Check inhaler technique
Need steroid (inhaled and oral) and bronchodilator therapy, their own PEF meter and personalised asthma action plan
47
Q

Pharmacological interventions to prevent asthma exacerbations

A

Inhaled corticosteroids

Leukotriene receptor antagonists

48
Q

Non-pharmacological interventions to prevent asthma exacerbations

A

Buteyko breathing technique
Smoking cessation
Weight reduction

CR (19 decks)

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