2. Asthma Flashcards
What is asthma
chronic inflammatory condition caused by hypersensitivity of the airways leading to bronchoconstriction
Name the typical triggers of asthma
infection night time or early morning exercise animals cold/damp dust strong emotions
Name some key presentations that would suggest a diagnosis of asthma
episodic symptoms
diurnal variability, typically worse at night
dry cough with wheeze and SOB
history of atopic conditions such as eczema, haha fever and food allergies
family history
Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
When auscultation for asthma what would you hear which would be suggestive of asthma
Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
What presentation would indicates a diagnosis other than asthma
wheeze related to coughs and colds more suggestive of a viral induced wheeze
isolated or productive cough
normal investigations
no response to treatment
unilateral wheeze, this would suggest a focal lesion or infection
what are the first line investigations fo diagnosis of asthma
fractional exhaled nitric oxide (not routine in the UK)
Spirometry with bronchodilator reversibility
what are other investigations that can be carried out for diagnosis of asthma
peak flow variability (keep a diary of peak flow measurements several times a day for 2-4 weeks)
FEV1/FVC ratio
direct bronchial challenge test with histamine or methacholine
As well as medication to treat asthma, what other additional management should patients with asthma have
an individual self-management plan
yearly flu jab
yearly asthma review
advice on exercise and avoiding smoking
What is the first line treatment for ongoing asthma
Short acting beta 2 agonist inhaler ie salbutamol as required for infrequent wheezy episode’s
add a low dose inhaled corticosteroid (such as beclametasone ), ICS if having symptoms 3 times a week or more
what other treatment options are there if the asthma isn’t controlled with a SABA and low dose corticosteroid
can use an oral leukotriene receptor antagonist such as montelukast (LTRA) and ICS
then LABA and ICS
then maintenance and deliver therapy (MART) or fixed dose of ICS and LABA and SABA as reliever therapy
how do you describe an acute exacerbation of asthma
a rapid deterioration in symptoms that could be triggered by any of the typical asthma triggers such as an infection, exercise or cold weather
how does someone with acute exacerbation of asthma present
progressively worsening SOB
use of accessory muscles
fast respiratory rate (tachypnoea)
symmetrical expiratory wheeze on auscultation
the chest can sound tight with reduced air entry
How do you grade acute asthma into moderate, severe and life threatening in terms of their PEFR
moderate- PEFR 50-75% of predicted
severe- 33-50% of predicted
life threatening- less than 33%
in addition to reduced PEFR what other things would make you grade the acute asthma as severe
resp rate above 25
heart rate above 110
unable to complete sentences
in addition to reduced PEFR what other things would make you grade the acute asthma as life threatening
becoming tired
no wheeze ie ‘silent chest’
haemodynamic instability (ie shock)
If the patient has moderate acute asthma what is the treatment
Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)
Nebulised ipratropium bromide- anti-muscarinic
Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days
Antibiotics if there is convincing evidence of bacterial infection
If the patient has severe acute asthma what is the treatment
- Oxygen if required to maintain sats 94-98%
- Aminophylline infusion
- Consider IV salbutamol
if the patient has life threatening acute asthma what is the treatment
- IV magnesium sulphate infusion
- Admission to HDU / ICU
- Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction
What would the ABG look like in patients with acute asthma
respiratory alkalosis as tachypnoea causes a drop in CO2
normal pCO2 or hypoxia is concerning as shows they are tiring and indicates life threatening asthma
respiratory acidosis due to high CO2 is very bad sign in asthma
why do you need to monitor serum potassium when on salbutamol
causes potassium to be absorbed from the blood into the cells
also causes tachycardia
when dischaging patient home after an acute asthma attach what should you give them
asthma action plan that shows a clear plan of what they need to know
consider prescribing a ‘rescue pack’ or steroid for someone if they have another episode
when should you refer to a respiratory specialist
after 2 attacks in 12 months
at an annual asthma review what 3 questions is it important to ask
In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms, SOB
Have you had your usual asthma symptoms (eg cough, wheeze, chest tightness, SOB) during the day
Has your asthma interfered with your usual daily activities (eg school, work, housework)
What is the marketing name of salbutamol
ventolinl/blue inhaler
what is the market name of beclomethasone
clenil/brown inhaler
what advice would you give patients about asthma and exercise
not always a trigger for asthma and even if it is they can still take part in sport quite safely
should cary with blue inhaler with them and take an additional dose in advance if the exercise is known to precipitate the attack
what advice would you give asthma patients about a flu jab
flu can be more serious in patients with asthma, even if it is mild or well controlled by meds
can lead to pneumonia and other rerspitaroy disease as well as trigger their asthma
a one-off vaccination against pneumococcal disease is also recommended in asthma
if patients struggle to press down they inhaler what can they ask their pharmacy for
a ‘meter aid’
how many doses does a MDI salbutamol contain
200
what is a good technique for using a MDI
squirt dose and hold breath for 10 seconds or use a spacer (need a gap of 30 seconds between doses)
acute exacerbation of asthma before getting to A&E
what should you tell the patient to do
sit up straight, take one puff of inhaler every 30-60 seconds up to a max of 10 doses
call 999 if don’t feel any better
take blue inhaler again after 15 mins while waiting
acute exacerbation of asthma before getting to A&E
what would you ideally given this situation
Salbutamol MDI with a spacer
can use a SABA such as salbutamol, terbutaline, levalbuterol or perbuterol
inhaled ipratropium bromide combined with SABA is shown to be the best at bronchodilation
acute exacerbation of asthma before getting to A&E
why would you not give IV salbutamol
only indicated in life-threatening exacerbation of asthma
acute exacerbation of asthma before getting to A&E
why would you not give 500 microgram of intramuusclar adrenalin
this is the treatment for anaphylaxis
when handing over a patient you can use the “SBAR” tool, what does it stand for
Situation
background
assessment
recommendation
what is the symptom triad of asthma
air flow obstruction
broncho hyper responsiveness (due to histamine)
inflammation
Name some conditions that would cause metabolic acidosis
(reduced bicarbonate dude to increased H+ production or decreased excretion/loss of bicarbonate)
diabetic ketoacidosis
lactic acidosis
renal failure
chronic diaarhoea
name some conditions that would cause metabolic alkalosis
(increased bicarb due to excess alkali intake, loss of gastric acid during vomitting or potassium depletion)
name come conditions that would lead to respiratory acidosis
(CO2 retention) pneumonia disease of the respiratory centre disease of the respiratory muscles upper airway obstruction
what causes respiratory alkalosis
hyperventilation
Spirometry
what is forced vital capacity (FVC)
the maximum amount of air a person can expel from the lungs after maximal inhalation
Spirometry
what is FEV1
the amount of air you can face out from your lungs in 1 second
what is an obstructive lung disease and give some examples
when the lungs are unable to expel air properly during evaluation asthma bronchiectasis COOPD emphysema
what is a restrictive lung disease
lungs are unable to fully expand, so limit the amount of oxygen taken in during inhalation
Spirometry: describe the changes that you would see in obstructive lung disease in terms of;
FEV1
FVC
FEV1/FVC ratio
FEV1: normal or decreased
FVC: normal or decreased
FEV1/FVC ratio: decreased (less than 70%)
Spirometry: describe the changes that you would see in lung disease in terms of;
FEV1
FVC
FEV1/FVC ratio
FEV 1: normal or decreased
FVC: decreased
FEV1/FVC ratio: normal or increased (above 70%)
when you give a bronchodilator, what percentage increased in the patients PEFR is significant in obstructive lung disease
12-15%
name support agencies that are available for domestic violence and that can provide information on refuge accommodation
o Social services
o The police adult safeguarding
o PCT adult safeguarding units
what advice can you give about smoking cessation
- Plan your quit, remember why you decided to quit, use the money you save to treat yourself, quit with a friend, identify what makes you crave a cigarette, keep busy to resist the urge, lean on your loved ones
- Can try nicotine replacement therapy (NRT)
what kind of things do you need to think about with pregnancy patients that have asthma
Although a spinal anaesthetic is commonly used in a planned C-section, sometimes a general anaesthetic is required in an emergency or if there are contraindications to spinal anaesthesia
As the patient has atopic asthma there is an increased risk of asthma, eczema and other atopic conditions
Always check the BNF as some medications are contraindicated for asthma during pregnancy
give some examples of why a persons asthma may have uncontrolled asthma before thinking about changing their medication
alternative diagnosis lack of adherence poor technique smoking occupational factors psychological factors seasonal or environmental factors
