Clinical Features of Asthma in Adults

Question 1

What is a definition of asthma?

Answer 1

(No universally accpted definition)
- A 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 as a result of therapy

Question 2

What are the main symptoms of asthma?

Answer 2

wheezing, coughing, shortness of breath, chest tightness, together with difficulty in expiration, sputum (occasionally).

Question 3

Why is asthma important?

Answer 3

It is common, dangerous and expensive.

Question 4

What gender is thought to have the most cases of asthma in childhood?

Answer 4

Males

Question 5

What gender is thought to have the most cases of asthma in adulthood?

Answer 5

Females.

Question 6

What two disease processes result in asthma?

Answer 6

Widespread narrowing of airways and increased airway recativity

Question 7

What can airway reactivity cause?

Answer 7

It can cause airway narrowing either sponatneously or to a stimuli.

Question 8

What is atopy?

Answer 8

The body’s predisposition to to develop an antibody called immunoglobin E in response to exposure to environmental allergens and is an inheritable trait.

Such as asthma, eczema and hay fever.

Question 9

What are proven risk factors for asthma?

Answer 9

Hereditary, Smoking, Ocupation, Obesity, Diet

Question 10

Which parent is more important in passing on an atopical disease?

Answer 10

Mother by 3x

Question 11

What is the hygiene hypothesis?

Answer 11

There is reduced exposure to microbes and so children born on farms are less likely to develop asthma

Question 12

What are the types of variations of symtoms?

Answer 12

• Daily variation (Nocturnal/early morning)
• Weekly variation (occupation, better at weekends or holidays)
• Annual variation (environmental allergens)

Question 13

What are other triggers to asthma?

Answer 13

Exercise, cold air, cigarette smoke, perfumes, Pets, Tree, Pollen, Food and drugs.

Question 14

What are important questions to ask in the past medical history of an asthmatic patient?

Answer 14

Childhood asthma
Wheeze
Eczema
Hay Fever.

Question 15

What are important questions to ask about during the history?

Answer 15

Current inhalers (also confirm the technique)
Beta-blockers, aspirin, and NSAIDs (Non-steroidal anti-inflammatory drugs)
Effect of previous drugs/inhalers.

Question 16

What are important questions to ask in the family history?

Answer 16

Asthma and other atopic disease.

Question 17

What are important questions to ask in the social history?

Answer 17

Tobacco, recreational drugs, vaping
Pets
Occupation
Psychological aspects

Question 18

What might be helpful to do in an clinical examination for asthma?

Answer 18

Breathless on exertion
Hyperinflated chest
Wheeze

Question 19

What signs might be present if it isn’t asthma?

Answer 19

Finger clubbing, Stridor, Asymmetrical expansion, dull percussion note, cervical lymphadenopathy (lymph nodes in the neck)

Question 20

If it isnt asthma, what could it be?

Answer 20

• Generalised airflow obstruction (COPD (Irreversible AFO), Bronchiectasis, Cystic Fibrosis
• Localised airway obstruction: Tumour and foreign body
• Cardiac

Question 21

What is a good test to differentiate between asthma and COPD?

Answer 21

Full pulmonary function testing

Question 22

What is reversibility testing?

Answer 22

This is when the FEV1 is measured before and 15 minutes after a dose of salbutamol (inhaled or nebulized).

Response to oral corticosteroids is checked after 2 weeks.

Question 23

What 3 chemicals are used to measure airway responsiveness?

Answer 23

Methacholine, Histamine, exhaled nitric oxide and Mannitol

Question 24

What are other useful investigations for asthma?

Answer 24

Chest X-Ray (hyperlucent or hyperinflated)
Skin prick testing
Total and specific IgE
Full blood count

Question 25

How do we assess how severe acute asthma is?

Answer 25

- Ability to speak - Heart rate - Respiratory rate - PEF - Oxygen saturation / Arterial blood gases

Question 26

What symptoms are present in moderate asthma?

Answer 26

Able to speak and complete sentences, HR < 110, RR < 25, PEF (Peak expiratory flow) 50 - 75%

Question 27

What symptoms are present in severe asthma?

Answer 27

Inability to complete sentences in one breath, HR > 110, RR > 25, PEF 33 - 50%

Question 28

What symptoms are present in life-threatening asthma?

Answer 28

Grunting, impaired consciousness, confusion, exhaustion, bradycardia, arrhythmia, hypotension, PEF < 33%, silent chest

Question 29

What are the main symptoms of near fatal asthma?

Answer 29

Raised PaCO2 and need for mechanical ventilation.

Question 30

What causes the airways to be inflamed?

Answer 30

Immune system

Question 31

What is the prevalence of asthma?

Answer 31

Children 10-15% M > F, Adults 5 - 10% F > M

Question 32

What are the genetic risk factors for asthma?

Answer 32

Atopy Inherited tendency to IgE response to allergens. Asthma, eczema, hayfever, food allergy Markers, skin prick tests, IgE. Strongest risk factor: personal, familial atopic tendency - Maternal atopy most influential

Question 33

What allergens can occupation expose you to?

Answer 33

Isocyanates (paints), Colophony (welding solder flux), Laboratry Animals, Grains, Enzymes, Drugs, Crustaceans

Question 34

What are essential investigation for asthma diagnosis?

Answer 34

Airflow obstruction Variability and reversibility of airflow obstruction

Question 35

What is the effect of maternal smoking on FEV1?

Answer 35

FEV1 is reduced.

Question 36

What is the effect of maternal smoking on Wheezy illness, airway responsiveness, asthma and severity?

Answer 36

All increase

Question 37

What is the grandmother effect?

Answer 37

Grandchildren are far more likely to suffer from asthma if their grandmothers smoked while pregnant.

Question 38

What is body mass index positively associated with?

Answer 38

Asthma, Wheezing, airway hyperactivity

Question 39

Which diet substances affect risk of asthma?

Answer 39

Decrease in anti oxidants and N-3 polyunsaturated fatty acids = risk factor. Increase in N-6 polyunsaturated fatty aids = risk factor. Too much or too little vitamin D

Question 40

Give an example of microbial products.

Answer 40

Endotoxin, glucans, extrascapular polysaccharide. Microbial diversity also important in redusing risk of asthma and allergy.

Question 41

Which indoor cleaning products have an increased risk of causing cancer?

Answer 41

Volatile organic compounds, Formaldehyde, Fragrances.

Question 42

What feature of the dust mite is allergenic?

Answer 42

Protease in droppings.

Question 43

What influence does affluence have on allergens?

Answer 43

Increases the likelihood of sensitisation to local allergens

Question 44

What is the most important consideration when making an asthma diagnosis?

Answer 44

HISTORY

Question 45

What common health conditions are important to consider when diagnosing asthma?

Answer 45

Childhood asthma, bronchitis, eczema, hayfever and eczema are other atopic conditions

Question 46

What are the two positive findings for asthma?

Answer 46

Airflow obstruction, variability and or reversibility of airflow obstruction.

Question 47

How can you determine if someone has obstructed airways?

Answer 47

FEV1 is less than 80% predicted and FEV1/FVC ratio<70%

Question 48

- What do FEV1 and FVC tell us respectively?

Answer 48

Airway diameter and lung capacity

Question 49

After confirmation of obstructed airways, what is your next step in the diagnosis of asthma?

Answer 49

Full pulmonary function tests, confirmation of reversibility with B2 agonists and steroids

Question 49

After confirmation of obstructed airways, what is your next step in the diagnosis of asthma?

Answer 49

Full pulmonary function tests, confirmation of reversibility with B2 agonists and steroids

Question 50

If airways are not obstructed what is your next step in diagnosis?

Answer 50

Peak flow monitoring, Bronchial provocation with nitric oxide

Question 51

What is a bronchial provocation test?

Answer 51

Evaluates how sensitive the airways in your lungs are. The spirometry results are compared before and after you inhale a spray to see what changes there are in your breathing. Spray is usually metyhacholine.

Question 52

What are the tests involved in the full pulmonary function testing?

Answer 52

Lung volumes, Carbon monoxide gas transfer.

Question 53

What is gas trapping?

Answer 53

Abnormal retention of air in the lungs where it is difficult to exhale completely. Observed in obstructive lung diseases such as asthma, bronchiolitis obliterans syndrome and chronic obstructive pulmonary diseases such as emphysema and chronic bronchitis.

Question 54

How is lung residual volume measured of the lungs?

Answer 54

Helium dilution technique: The patient inhales breaths of helium and oxygen in a closed system. Concentration of helium will decrease as it diffuses into all areas of the lung. The amount of concentration reduction it indicative of the residual capacity

Question 55

What is the residual volume and total lung capacity of a patient who is asthmatic?

Answer 55

Increased residual volume, increased total lung capacity.

Question 56

What is the carbon monoxide gas transfer used to determine?

Answer 56

Ability of gas transport across the alveoli, alveoli are unaffected in asthma it is only the airway that are affected.

Question 57

When spirometry is normal why is it important to measure peak flow?

Answer 57

Looking for variability in airflow obstruction. Lung function in clinic may(usually) be normal

Question 58

What test is likely to increase use of according to NICE?

Answer 58

Exhaled nitric oxide tests

Question 59

How would you read the methacholine responsiveness?

Answer 59

Reduction of FEV1 by over 20%

Question 60

What is the effect of methacholine?

Answer 60

Acts like acetylcholine to constrict airways. Nebulising the substance you think they are susceptible to can be useful too.

Question 61

What is the exhaled nitric oxide in an asthmatic patient compared to normal?

Answer 61

Increase in nitric oxide