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Asthma Flashcards

1
Q

What is asthma characterised by?

A

Increased responsiveness of the trachea and bronchi to various stimuli and manifested by a widespread narrowing of the airways that changes in severity either spontaneously or as a result of therapy

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2
Q

Is bronchitis common?

A

Yes

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3
Q

Presentation of bronchitis

A

Loose rattly cough
Noisy breathing
Post tussive vomit (glut)

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4
Q

What is pertussis also known as?

A

Whooping cough

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5
Q

Pathology of bacterial bronchitis

A

Disturbed mucociliary clearance

Secondary infection following URTI

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6
Q

Causes of bronchitis

A

RSV
Adenovirus
Rhinovirus
Haemophilus

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7
Q

Pathology of asthma

A 
Blocked airways because of mucus (luminal secretions)
Increased irritability 
Bronchoconstriction 
Airway wall thickening
Spontaneous or stimuli
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8
Q

Risk factors for asthma

A

Genetic
Occupation (painters, welding, labs, grains, bakers, antibiotics, salbutamol, crustaceans)
Smoking
Maternal smoking during pregnancy

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9
Q

Possible risk factors for asthma

A

Obesity
Diet
Reduced exposure to microbes/microbial products
Indoor pollution; chemical household products (volatile organic compounds, formaldehyde, fragrances, cleaning products)

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10
Q

Environmental allergens linked to asthma

A

House dust mite
Cats
Grass pollen

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11
Q

What is genetic atopy?

A

Inherited tendency to IgE response to allegens

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12
Q

Examples of atopy

A

Asthma
Eczema
Hay fever
Food allergy

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13
Q

What % of adult onset asthma is caused by occupation?

A

10-15%

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14
Q

What is higher BMI associated with in asthma?

A

Asthma
Wheezing
Airway hyperactivity

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15
Q

What is the allergen of house dust mite?

A

Protease in droppings

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16
Q

Types of onset of asthma

A 
Infant onset
Childhood onset
Adult onset
Exertional asthma
Occupational asthma
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17
Q

Triggers of asthmatic symptoms

A 
URTI (Rhinovirus in 75%)
Exercise
Allergen 
Cold air
Emotion
Menstruation 
Aspirin
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18
Q

What must be present for asthma to be diagnosed?

A

Wheeze

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19
Q

What children have asthma?

A

10 - 15%

M > F

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20
Q

What adults have asthma?

A

5 - 10%

F > M

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21
Q

What conditions can cause generalised airflow obstruction?

A 
Asthma (reversible)
COPD (irreversible)
Bronchiectasis 
Bronchiolitis 
CF
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22
Q

Presentation of asthma

A

Wheeze
SOB at rest
Cough
Chest tightness/pain

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23
Q

Features of cough in asthma

A

Dry
Nocturnal
Exertional
Occasional sputum

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24
Q

What kind of symptoms must be present to diagnose asthma?

A

VARIABLE symptoms

  • triggers
  • daily variation (early morning/nocturnal)
  • Weekly variation (occupation, better at weekends and holidays)
  • annual (environmental holidays)
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25
When is asthma generally worse?
Morning | Night
26
PMH associations of asthma
Childhood asthma Eczema Hayfever
27
Drugs associated with asthma
Aspirin Complicance B blockers NSAIDs
28
What would you ask about FH of asthma?
Atopic disease | Asthma
29
What social history would be associated with asthma?
Smoking Pets Occupation Psychosocial
30
Possible signs of asthma
Breathlessness on exertion Hyperexpanded chest Polyphonic wheezes
31
What would a dull percussion note on examination indicate?
Lobar collapse | Effusion
32
What would crepitations on examination indicate?
Bronchiectasis CF Alveolitis LVF
33
What is used in clinic to asses lung function in asthma?
Spirometry
34
How does spirometry work?
Deep breath in and blow out hard and fast Best of 3 readings Compare off chart
35
What is FEV1?
Forced expiratory volume in 1 second
36
What does FEV1 essentially measure?
Airway diameter
37
What does FVC essentially measure?
Lung capacity
38
If there is an obstructed picture, what should be done and what is involved?
``` Full pulmonary function testing - Helium dilution - CO gas transfer Reversibility to bronchodilator Reversibility to oral corticosteriods ```
39
Interpretation of reversibility to bronchodilator
15 mins post 400ug inhaled salbutamol 15 mins post neb 2.5-5mg salbutamol Significant reversibility; difference in FEV 1 > 200ml and change in FEV1 > 15% baseline
40
What could cause no reversibility?
No bronchoconstriction | Severe bronchoconstriction
41
What does response to oral steroids separate asthma from?
COPD
42
What variability is present in asthma?
Morning/nocturnal dips Decline over weeks/days Variability >20% / highest
43
Diagnosis of occupational asthma
Suspicion from work related symptoms Working with recognised occupational sensitizer Serial peak flow readings (2 hourly best; 5 per day minimum) Antibodies +ve response to colophony
44
Useful investigations in asthma
``` CXR - hyperinflated - hyperlucent Skin prick testing (atopic status) Total and specific IgE (atopic status) FBC - eosinophilia (atopy) ```
45
Differential diagnosis for asthma
``` Viral induced wheeze Foreign body CF Immune deficiency Ciliary dyskinesia Tracheo-bronchomalacia Aspiration, GORD ```
46
What is anatomical space?
The air found in the conducting airways
47
What is alveolar dead space?
Air in the alveoli who has been ventilated but not perfused
48
What is physiological dead space?
Anatomical dead space plus alveolar dead space
49
Obs of moderate asthma
``` Increasing symptoms - no features of severe Able to speak complete sentences HR < 110 RR < 25 PEF 50 - 75% predicted or best Sa02 > 95% (No need for ABG) Pa02 > 8kPa ```
50
Features of severe asthma; any one of.....
``` Unable to speak, unable to complete sentences HR > 110 RR > 25 PEF 33-50% predicted or best Sa02 >92% Pa02 > 8kPa ```
51
Features of life threatening asthma; any one of....
``` Grunting Impaired consciousness, confusion, exhaustion HR >130 or bradycardic Hypoventilating PEF < 33% predicted or best Cyanosis Sa02 < 92% Pa02 <8kPa PaCO2 normal (4.6 - 6.0kPa) ```
52
What indicates near fatal asthma?
Raised PaCO2
53
If in doubt of asthma, what can be done?
Blood gas
54
When is it unlikely to be asthma?
``` Under 18 months (most likely infection) Isolated coughs - Bronchitis - Pertussis - Habitual cough - Tracheomalacia - CF ```
55
Features of cough in bronchitis
Wet cough
56
Features of cough in tracheomalacia
Life long loud cough
57
Goals of treatment for asthma
``` Minimal symptoms during day and night Minimal need for reliever medication No exacerbations (asthma attack) No limitation of physical activity Normal lung function (FEV1) ```
58
How to measure control in asthma
SANE - short acting beta agonist / week - absence school / nursery - nocturnal symptoms / week - exertional symptoms / week
59
Classes of medications used in asthma
``` Short acting beta agonists (SABA) Inhaled corticosteriods (ICS) Long acting beta agonists (LABA) Leukotriene receptor antagonists (LTRA) Theophyllines Oral steriods ```
60
S/Es of ICS
``` Height suppression (1cm) Oral candidiasis Adrenocortical suppression (very high doses) ```
61
Advantages of ICS
Decreased HTN | Decreased cataracts
62
What is a LABA always used with?
ICS
63
What is the LTRA drug?
Montelukast
64
Two types of delivery systems
MDI/Spacer | Dry powder device
65
Lung deposition with and without spacer
Without - < 5% | With - < 20%
66
What must be done to a spacer?
Washed monthly | Shaken between puffs to reduce static
67
What ages are suitable for dry powder devices?
Licenced in > 5s, < 8s cannot use them
68
Alternative management of asthma
Stop smoke exposure Remove environmental triggers - pets, house dust mites
69
Treatment of acute asthma attack in adults - the escalation of care
1. Oxygen 2. Salbutamol nebulisers 3. Ipratropium bromide nebulisers 4. Hydrocortisone IV or Oral prednisolone 5. Magnesium sulphate IV 6. Aminophylline / IV salbutamol
70
Drugs to avoid in asthma
Beta blockers NSAIDs Aspirin Sedatives/strong opiates (unless in critical care)
71
What does a pMDI (meter dose inhaler) require?
Coordination
72
Benefits of using a pMDI with a spacer
Low oro pharyngeal deposition of aerosol Reduced speed of aerosol Decreases bad taste associated with aerosol deposition Reduced risk of oral candidiasis and dysphonia with steriods Reduced cold Freon effect in some
73
What does SABA stand for?
Short acting beta agonist
74
Examples of SABAs
Salbutamol | Terbutaline
75
S/Es of beta 2 stimulants
``` Tremor Cramp Headache Flushing Palpitations Angina ```
76
Are side effects of B2agonists common or rare in inhaled steroids or oral steroids?
Inhaled - rare | Oral - common
77
Examples of ICS (Preventers)
Beclomethasone Budesonide Fluticasone Mometasone
78
Long term S/Es of oral steriods
``` Red cheeks Moon face Fat pads / buffalo hump Thin skin High BP Thin arms and legs Osteoporosis Poor wound healing Pendulous abdomen Red striation ```
79
S/Es of long term inhaled steriods
Dysphonia | Oropharyngeal candidiasis
80
What is dysphonia?
Hoarseness
81
Examples of ICS + LABA
Fostair (beclomethasone with formoterol) Symbicort (budenoside with formoterol) Flutiform (fluticasone propionate with formetrol)
82
Examples of LTRA
Monteleukast | Zafirlukast
83
Who are LTRAs most effective in?
Those who are highly allergic
84
How are LTRAs taken?
Oral
85
What is theophylline?
Non specific phosphodiesterase inhibitor and adenosine receptor antagonist - weak bronchodilator
86
S/Es of theophylline
``` Anorexia Headache Malaise Vomiting Nervousness Abdo discomfort Insomnia Tachycardia Tachyarrythmias Convulsions ```
87
Examples of LAMAs
Tiotropium bromide via spirivia respimat
88
What does LAMA stand for?
Long acting anti muscarinic
89
What is the main long term oral steroid used for asthma?
Prednisolone
90
What can abrupt cessation of long term oral steroids lead to and when would this occur?
Acute adrenal insufficiency | > 3 weeks
91
What happens in acute adrenal insufficiency?
Failure of adrenal glands to produced endogenous glucocorticoid
92
What is Omalizumab?
Monoclonal antibody (mab) against IgE
93
What is Omalizumab for?
IgE mediated severe allergic asthma
94
What is meplolizumab and what is it used for?
``` monoclonal antibody (mab) against interleukin 5 Poor asthma control (long term steroid or frequent steroid) with blood eosinophillia ```
95
What is sometimes tried as a last resort?
Immune suppressive drugs e.g. methotrexate, ciclosporin
96
Non pharmacological methods of controlling asthma
``` Patient education and self management plans Inhaler technique Smoking cessation Flu/pneumococcal vaccinations Treating comorbidities (Obesity, allergic rhinitis, GORD) Stepping down treatment when controlled Allergen avoidance Bronchial thermoplasty ```
97
What is the first line preventer in < 5s?
LTRA
98
What is the max dose of ICS used in children?
800 micrograms
99
Stepladder approach of treating asthma
1. SABA as required 2. Regular preventer - very low dose ICS (or LTRA in < 5s) 3. Add on preventer - add on LABA - add on LTRA - Increase ICS dose
100
When is a regular preventer needed?
Using inhaled B2 agonists 3x a week or more Symptomatic 3x a week or more, or waking one night a week Exacerbations of asthma in last 2 years
101
Management of acute asthma
1. Mild - SABA via spacer - SABA via spacer and pred 2. Moderate - SABA via nebuliser + pred - SABA + ipra via neb + pred 3. Severe - IV salbutamol - IV aminophylline - IV magnesium (neb) - IV hydrocortisone - nebulised bronchodilators - intubate and ventilate - antibiotics if pneumonia/bacterial infection
102
How much pred is given in acute asthma (mild/moderate) and for how long?
0.5 mg/kg/day for 7 days
103
What type of drug is ipratropium?
SAMA
104
How to assess patient with acute asthma?
``` Resp rate Work of breathing HR O2 sats Ability to complete sentences Confusion Air entry ```
105
Age and features of cough COPD vs asthma
COPD - > 35 years - persistent and productive | Asthma - any age - intermittent and non productive
106
SOB features asthma vs COPD
COPD - progressive and intermittent | Asthma - intermittent and variable
107
Nocturnal symptoms COPD vs asthma
COPD - uncommon unless in severe disease | Asthma - common
108
FH COPD vs asthma
COPD - uncommon unless family members also smoke | Asthma - common
109
What does a Ph < 7.35 represent in asthma? What does it require?
CO2 retention in a tiring patient and is an ominous sign in acute asthma Intubation and ventilation may be needed
110
What does a normal PaCO2 in an acute asthma attack indicate?
Exhaustion and should be classified as life threatning

Respiratory Pathology (16 decks)

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