Asthma - Adults

Question 1

What is a definition of asthma?

Answer 1

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

Question 2

What are some common asthma symptoms?

Answer 2

Wheezing
Coughing
Chest tightness
Shortness of breath
Together with difficulty in expiration

Question 3

Why is asthma important?

Answer 3

Common, dangerous and expensive

Question 4

Explain the scale of the problem in asthma

Answer 4

Children - 10-15% of UK children
Adults - 5-10%
Importance as large no. of people have this

Question 5

Explain the pathophysiology of asthma?

Answer 5

Airway inflammation mediated by the immune system causes widespread narrowing of airways. Also increases airway reactivity leading to airway narrowing spontaneously or in reaction to stimuli

Question 6

What happens to the airway of an asthmatic during an attack?

Answer 6

Tightening of smooth muscles and wall is inflamed and thickened
Air then trapped in alveoli

Question 7

What is atopy?

Answer 7

Is the body’s predisposition to develop an antibody called immunoglobulin E (IgE) in response to exposure to environmental allergens and is an inheritable trait
Associated with allergic rhinitis, asthma, hay fever and eczema

Question 8

Explain genetics and asthma

Answer 8

Risk of asthma is increased if first degree family member has asthma or another atopic disease
Maternal copy is the most influential
Complex and poorly understood

Question 9

What happens to respiration of child when there is maternal smoking during pregnancy?

Answer 9

Decrease in FEV1
Increase in wheezy illness
Increase chance of airway responsiveness
Increase in risk of asthma

Question 10

Explain how occupation affects risk of asthma

Answer 10

10-15% of onset of adult asthma
Interactions with smoking and atopy
Ex. bakers, painters and shell fish workers

Question 11

What can you look for in taking a history of someone who has respiratory symptoms?

Answer 11

Recurrent episodes of symptoms
Symptom variability
Absence of symptoms
Wheeze
Personal history of atopy
Historical record of variable PEFF or FEV1

Question 12

What is evidence of variable symptoms?

Answer 12

Daily - nocturnal or early morning
Weekly - occupational, weekends or holidays
Annual - environmental allergens like pollen

Question 13

What can be some triggers of asthma?

Answer 13

Exercise, cold air, cigarette smoke, perfumes, Upper respiratory infections, pets, pollens, food, drugs …

Question 14

What are some other important aspects in the history taking?

Answer 14

PMH - childhood asthma, bronchitis or wheeze as child, eczema and Hayfever
Drugs - inhalers, beta blockers, aspirin, NSAIDS
and their effects
Family history and social history

Question 15

What can a clinical examination of asthmatic patient show?

Answer 15

Breathless on exertion
Hyperinflated chest
Wheeze
Not very helpful in clinic and symptoms can be variable or not there

Question 16

What else could a patient have that is not asthma but shows symptoms of wheeze, cough and breathlessness?

Answer 16

Generalised airflow obstruction - COPD, Bronchiectasis and CF
Localised airway obstruction - tumour or foreign body
Cardiac

Question 17

In asthma, what are we looking for evidence of?

Answer 17

Airflow obstruction
Variability and/or reversibility of airflow obstruction

Question 18

What happens to the FEV1 in airway obstruction?

Answer 18

Decreases
Ratio is then smaller
But can be normal in some people with asthma

Question 19

What would you do next if spirometry showed there was obstruction?

Answer 19

Full pulmonary function testing which can exclude COPD/emphysema
Also can do Carbon Monoxide gas transfer - if reduced can show COPD
Then check reversibility to bronchodilator and oral corticosteroids

Question 20

Explain reversibility to bronchodilators

Answer 20

15 minutes post 400g of inhaled salbutamol
15 mins post neb 2.5-5mg of salbutamol
If significant reversibility then FEV1 > 200ml and baseline > 12%

Question 21

Explain reversibility to oral corticosteroids

Answer 21

Same measurements as bronchodilators. Monitor over 2 weeks by giving 0.6mg/kg. If significant and steady improvement then asthma
Peak flow and spirometry checked

Question 22

What would you look for if normal spirometry?

Answer 22

Variability of airflow obstruction
Peak flow meter and chart twice daily for 2 weeks
Looking for nocturnal or morning dips
Variability > 20% on more than 3 days a week
Can do bronchial provocation and FeNO test

Question 23

What is bronchial provocation?

Answer 23

Checks airway responsiveness
Breath in chemicals at increasing dose and check for responsiveness - FEV1 would fall
Ex. methacholine, histamine and mannitol

Question 24

What is Nitric oxide test?

Answer 24

Nitric oxide can indicate inflammation in the lungs
FeNO exhaled is measured

Question 25

What are other useful investigations to help exclude other disease?

Answer 25

Chest X-ray Skin prick testing Total and specific IgE - can show atopy Full blood count

Question 26

What 5 signs/tests help assess acute asthma severity?

Answer 26

Ability to speak Heart rate Respiratory rate Peak flow Oxygen saturation/ Arterial blood gases

Question 27

Explain moderate acute asthma?

Answer 27

Able to complete full sentences HR < 110 RR < 25 Sa > 92% PaO2 > 8kPa PEF 50-75%

Question 28

Explain serve acute asthma?

Answer 28

Inability to complete sentences in one breath HR > 110 RR > 25 Sa > 92% PaO2 > 8kPa PEF 33-50%

Question 29

Explain life threatening acute asthma?

Answer 29

Grunting Impaired consciousness, confusion Cardiovascular instability Cyanosis Silent chest Poor resp. effort SaO2 < 92, PaO2 < 8kPa and PaCO2 normal

Question 30

Explain near fatal acute asthma

Answer 30

Raised PaCO2 and should be blowing it off due to hyperventilation Need for mechanical ventilation

Question 31

What are the aims of asthma treatment and show complete control?

Answer 31

No daytime symptoms No night time wakening No need for rescue medication No asthma attacks No limitations on activity which include exercise and normal lung function Minimal side effects of medication

Question 32

What is non-pharmacological management of asthma?

Answer 32

Patient education and self management plans Exercise Smoking cessation Weight management Flu/ Pneumococcal vaccinations

Question 33

What does an asthma action plan show?

Answer 33

What the patient needs to do to be on top of their asthma Signs to look out for and what to do if it is getting worse What to do if their having an asthma attack

Question 34

Describe benefits of inhalers

Answer 34

Small dose of drugs Delivery directly to target organ Onset of effect is faster Minimal systemic exposure Systemic adverse effects are less severe and less frequent

Question 35

What is a pMDI?

Answer 35

Metered Dose Inhaler Canaster is pressurised Take breath as medication is released - so need good coordination

Question 36

What is the benefit of using a pMDI with a spacer?

Answer 36

Medication is accumulated in a chamber so requires less coordination than pMDI

Question 37

What are positives and negatives with Dry powder inhalers (DPI)?

Answer 37

Open device which primes the medication then it is sucked up by patient Need enough respiratory for this medication Do not need coordination with breathing and letting medication out

Question 38

Explain Short acting B2 agonists

Answer 38

SABAs work by relaxing smooth muscle of the airways These are relivers - for symptom control for flares or triggers Salbutamol - MDI and DPI Terbutaline - DPI

Question 39

What are the 3 pharmacological managements for asthma?

Answer 39

Inhaled therapy Oral therapy - used in higher steps Specialist treatments

Question 40

What are the types of oral therapy?

Answer 40

Leukotriene receptor antagonist Theophylline Prednisolone - acute exacerbation, used with inhaler

Question 41

What are specialist options for treating asthma?

Answer 41

Omalizumab - Anti-IgE Mepolizumab - Anti-lnterleukin-5 (help come off oral steroids) These modify asthma response Bronchial thermoplasty

Question 42

What are the signs of acute asthma severity?

Answer 42

If patient can not complete sentences in one breath PEF, RR, HR Life threatening - cyanosis, silent chest, consciousness, Hypotension Near fatal - raised PaCO2 and need for mechanical ventilation

Question 43

What would the treatment of a mild/moderate acute asthma attack?

Answer 43

Increase of inhaler use Oral steroid Treat trigger Early follow up Back up plan

Question 44

What would be the treatment of a moderate/severe asthma attack?

Answer 44

Nebulisers - salbutamol/ ipratropium Oral/IV steroid Magnesium Aminophylline Triggers Chest x-ray Review, Possible level 2/3 care

Question 45

What are the differences between Asthma and COPD?

Answer 45

Age of onset - asthma is younger Smoking history - COPD more likely Treatment goals and trajectory Similar therapies, non-pharmacological interventions are the same (exercise, smoking and weight loss)