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TCD > Case 2: asthma > Flashcards

Case 2: asthma Flashcards

1
Q

Features of asthma

A 
wheeze
cough
breathlessness
chest tightness
recurrent episodes
symptom variability
recorded observations of wheeze
personal history of atopy
historical record of variable PEF and FEV1
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2
Q

Normal FEV1/FVC

A

~80%

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3
Q

What happens to FEV1/FEV in asthma?

A

Decreases because FEV1 decreases in asthma

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4
Q

Define asthma

A

A heterogeneous disease
Chronic airway inflammation
History of respiratory symptoms e.g. wheeze, breathlessness, chest tightness and cough that vary over time and severity, together with variable expiratory airflow limitation

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5
Q

Pathophysiology of allergic asthma

A

B cells make IgE
Mast cells develop receptors for IgE on their surface
After priming, another allergen binds to IgE causing cross linking of IgE receptors on mast cells
Mast cell degranulation (release of bronchoconstrictors, chemoattractants, vasoactive compounds)

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6
Q

Describe the early and late phase of an asthma attack

A

Early phase: inhale allergen - immediate bronchoconstriction - FEV1 recovers in a couple of hours - cleared with bronchodilators
Late phase: inflammation - takes longer to clear - cleared with anti-inflammatories

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7
Q

Where do B2 agonists act

A

B2 adrenoceptors in bronchiole SM

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8
Q

Actions of B2 agonists

A

SM relaxation and inhibit mast cell degranulation

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9
Q

Features of salbutamol

A

SABA
Short acting
Max effects in 30 minutes
Effects for 4-6 hours

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10
Q

Features of salmeterol

A

LABA
Long acting
Effects for 12 hours
More for prophylaxis

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11
Q

Side effects of B2 agonists

A

tremor

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12
Q

Features of theophylline

A

PDE inhibitor
2nd line
Can be used via IV in acute asthma attack
SEs: CNS stimulant, CV, GIT

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13
Q

Ipratropium features

A 
Muscarinic receptor antagonist 
Adjunct to B2 agonists
Max effect: 30 minutes
Lasts 3-5 hours
Aerosol inhalation
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14
Q

Montelukast features

A

Is a Leukotriene receptor antagonist
Taken orally
adjunct therapy
Because leukotrienes usually cause bronchoconstriction on bronchiole SM cells

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15
Q

Glucocorticoids for asthma

A

e.g. beclomethasone, diproprionate
Anti-inflammatory
Inhalation usually
Take several days to have an effect
Reduce production of cytokines, spasmogens, leukocute chemotaxins
Reduce bronchospasms and recruitment of inflammatory cells
SE: suppress adrenal glands

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16
Q

3 Questions to ask in an annual asthma review

A

In the last month/week, have you had any DIFFICULTY SLEEPING DUE TO SYMPTOMS?
Have you had your USUAL ASTHMA SYMPTOMS DURING THE DAY?
Has your asthma INTERFERED WITH YOUR USUAL DAILY ACTIVITIES?

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17
Q

Describe normal breath sounds

A 
Vesicular
Low pitch
Soft
Inspiration longer and louder than expiration
No gap between inspn and expn
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18
Q

Describe bronchial breathing

A 
Loud and tubular quality
High pitched
Inspiration and Expiration equal length and loudness
Gap between inspn and expn
(Mimicked by listening over trachea)
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19
Q

What conditions cause bronchial breathing

A

Consolidation
Lobar collapse with patient bronchus
Lung cavity

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20
Q

Describe the crackles heard with different conditions

A

Bronchiolitis: early inspiratory
Pulmonary oedema: mid inspiratory
Pulmonary fibrosis/oedema/COPD/resolving pneumonia/lung abscess/tuberculous lung cavities: late inspiratory
Bronchiectasis: biphasic

21
Q

Causes of fine and coarse crackles:

A

Fine: broncholitis, pulmonary oedema, pulmonary fibrosis
Coarse: COPD, resolving pneumonia, lung abscess, TB, bronchiectasis

22
Q

Describe pleural rub

A

Commonly caused by inflammation of the visceral / parietal pleura
Low pitched, grating sound similar to walking on snow
Caused by consolidation, pulmonary infarction, uremia etc
Heard on inspiration when the pleura rub on eachother

23
Q

Differentials if you hear a wheeze

A 
Asthma
COPD
Foreign body aspiration
Cardiac failure
Eosinophilic lung disease
Pulmonary disease
24
Q

What is the link between asthma and flu

A

People with asthma are NOT more likely to get flu, but if they do it can be MORE SERIOUS because it can cause further inflammation of airways/lungs on top of already inflamed airways.
Flu can trigger asthma attacks or worsening of Sx. This can also lead to pneumonia.
Therefore a one off vaccination against Pneumococcal disease is recomended

25
Q

what vaccine is recommended in asthma?

A

one off Pneumococcal

26
Q

What is PEFR

A

Peak Expiratory Flow Rate
The maximum rate of expiration during a maximal expiratory effort after a maximal inspiration
Take 3 readings, best of 3

27
Q

What is used to predict a PEFR?

A

Sex

Height

28
Q

How to teach a pt to use a new inhaler

A

Shake
Check mouthpiece for dust, foreign objects
If new, check it works by squirting 2 puffs into the air
If ready to use, squirt 1 dose into mouth, hold breath for 10 seconds. then wait 30 seconds. then do second dose.
Check expiratory date and re-order before date.
Different inhalers have different tastes

29
Q

What blood results may indicate asthma?

A

High eosinophils (indicate an atopic problem)

30
Q

Diagnosis of asthma

A

Is based on a clinical judgement.
If there is a high suspicion of asthma, initiate Tx and closely monitor. If the pt is responding well to the Tx, can diagnose it as asthma and then titrate the Tx dose to the lowest dose that keeps the pt free from Sx.
Offer pt self management advice.

31
Q

Asthma triggers

A 
Cold
Dust
Pollen
Allergies
Stress
Exercise
Cigarette smoke
Fur
Chest infections
32
Q

what system is used to classify COPD severity?

A

GOLD

based on post-bronchodilator therapy

33
Q

What is GOLD stage I?

A

Normal

FEV1 >/= 80%

34
Q

What is GOLD stage II?

A

Mild COPD

FEV1 50-79%

35
Q

What is GOLD stage III?

A

Moderate COPD

30-49% fEV1

36
Q

What is GOLD stage IV?

A

Severe COPD

FEV1 <30%

37
Q

If you see bruising on a pt, differentials

A

steroids
depression with self harming behaviour
domestic violence
sports related trauma

38
Q

Tx for an acute asthma episode

A

6 puffs of inhaler (SABA - salbutamol, terbutaline, levalbuterol, pirbuterol)
+ ipratropium bromide

39
Q

Tx for a pt who presents with GP with acute asthma episode

A
  • 999
  • sit pt upright (easier to breathe)
  • insert IV catheter (Access for hydrocortisone / bronchodilators)
  • give nebulised salbutamol and ipratropium or MDI
  • give O2 cylinder and mask - high flow
  • document all Tx including times, routes, dose
40
Q

How do you assess consciousness?

A 
AVPU
alert
responding to vocal stimuli
responding to painful stimuli
unresponsive to all stimuli
41
Q

What is the A-a gradient?

A

The difference between the O2 the pt breathes in and the arterial partial pressure of oxygen
>10 indicates a lung problem

42
Q

what do you give in acute asthma attack

A

SABA
ipratropium
O2 if needed (high flow - 15L)
MgSO4 sometimes given if severe

43
Q

Any changes to be made in pregnant asthmatic patients?

A

None, just monitoring

44
Q

Define atopy

A

genetic tendency to develop allergic diseases e.g. asthma, hayfever, eczema

45
Q

Acute moderate asthma

A

increasing symptoms
peak flow 50-75% best or predicted
No features of acute severe asthma

46
Q

acute severe asthma

A

Any one of the following:

  • Peak flow 33-50% best or predicted
  • Respiratory rate ≥ 25/min
  • Heart rate ≥ 110/min
  • Inability to complete sentences in one breath
47
Q

acute life threatening asthma

A 
Any one of the following, in a patient with severe asthma:
Peak flow < 33% best or predicted
Arterial oxygen saturation (SpO2) < 92%
Partial arterial pressure of oxygen (PaO2) < 8 kPa
Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0 kPa)
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion
Altered conscious level
Hypotension
48
Q

What should you do before discharging a pt with asthma?

A

check inhaler technique
inform GP of admission - follow up should be within 2 working days
issue a peak flow meter and written asthma management plan

TCD (7 decks)

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