The case of the breathless teenager

Question 1

Tachypnoea

Answer 1

tachypnoea

Increased respiratory rate, usually > 20 per minute

Question 2

dyspnoea

Answer 2

unpleasant awareness of increased respiratory effort

Question 3

hyperpnoea

Answer 3

increased level of ventilation/increased VE

Question 4

Minute Ventilation (VE)

Answer 4

volume of air inspired or expired per minute (l/min)

Question 5

Hyperventilation

Answer 5

increased pulmonary ventilation in excess of metabolic demand causing decreased pCO2

Question 6

orthopnoea

Answer 6

Shortness of breath when lying flat

Question 7

paroxysmal nocturnal dyspnea

Answer 7

sudden awakening from sleeping with shortness of breath

Question 8

bradypnoea

Answer 8

abnormally slow breathing

Question 9

Cheyne-Stokes respiration

Answer 9

abnormal cycle of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea

Question 10

what controls normal breathing?

Answer 10

medulla oblongata

Question 11

What nerve conveys sensation of breathing/dyspnoea?

Answer 11

vagus nerve

Question 12

respiratory system receptors

Answer 12

carotid body receptors
pulmonary artery baroreceptors
central medullary chemoreceptors
lung stretch receptors

Question 13

pulmonary causes of dyspnea

Answer 13

COPD
fibrosis
airway obstruction
PE
asthma
pneumonia
neoplasm
anaphylaxis

Question 14

cardiovascular causes of dyspnoea

Answer 14

pulmonary oedema
ACS
arrhythmia
tamponade
valvular disease

Question 15

2 infections that could cause dyspnoea

Answer 15

2 infections that could cause dyspnoea
epiglottitis
pneumonia

Question 16

3 traumatic causes of dyspnoea

Answer 16

flail chest
pneumothorax
haemothorax

Question 17

psychiatric causes of dyspnoea

Answer 17

anxiety

hyperventilation

Question 18

metabolic causes of dyspnoea

Answer 18

metabolic acidosis
toxins
renal failure

Question 19

ascites
obesity
pregnancy

Answer 19

ascites
obesity
pregnancy

Question 20

prevalence of asthma

Answer 20

most common respiratory disease worldwide

Question 21

asthma symptoms

Answer 21

shortness of breath, wheezing, cough, chest tightness

Question 22

is there a gold standard test for asthma?

Answer 22

no

Question 23

what investigations could be done in suspected asthma?

Answer 23

PEFR variability
spirometry
FeNO
inducible airway hyperresponsiveness
eosinophil count
atopy tests

Question 24

what FeNO is expected in someone with airway inflammation?

Answer 24

above 40ppb

Question 25

do negative investigations fully rule out asthma?

Answer 25

no as can be normal when well controlled

Question 26

When is asthma most likely?

Answer 26

when clinical features match asthma and a positive objective test

Question 27

asthma mimics

Answer 27

``` airway obstruction inducible laryngeal obstruction cough hypersensitivity sinus disease exercise induced laryngeal obstruction ```

Question 28

Asthma triggers

Answer 28

``` cold air smoke URTI exercise stress inhaled allergens poor treatment adherence ```

Question 29

criteria for moderate acute asthma

Answer 29

increasing symptoms | PEF>50-75% best

Question 30

criteria for severe acute asthma

Answer 30

``` RR>25 can't complete sentences HR >110 PEF 33-50% best (any 1) ```

Question 31

criteria for life threatening asthma

Answer 31

``` altered consciousness exhaustion cyanosis hypotension PEF<33% best ```

Question 32

when does asthma become near fatal?

Answer 32

when so severe mechanical ventilation is required or PaCO2 becomes raised

Question 33

treating acute asthma (6)

Answer 33

``` nebulised salbutamol oxygen if hypoxemic oral prednisolone nebulised ipratropium bromide consider IV magnesium sulphate consider aminophylline ```

Question 34

Aminophylline

Answer 34

Bronchodilator poor data on whether actually useful in acute asthma but try with severely ill patients not responding to other therapies

Question 35

1st offered treatment for a newly diagnosed asthmatic

Answer 35

SABA e.g. salbutamol

Question 36

next step if SABA not controlling asthma

Answer 36

SABA + low dose ICS

Question 37

next step if SABA + low dose ICS not controlling asthma

Answer 37

SABA + low dose ICS + LTRA /LABA - contradicted

Question 38

treatment options if very unresponsive asthma

Answer 38

adding a LAMA or theophylline but will need specialist input