2- secondary care management of asthma Flashcards
what are redflags for diagnosis other than asthma?
i.e. signs that definetely aren’t asthma
- myalgia, weight loss
- crackles, clubbing, cyanosis, cardiac disease, monophonic wheeze or stridor (what is difference?)
- persistent non variable breathlessness
- chronic sputum production (make mucus but not thick green sputum)
- unexplained restrictive spirometry
- chest x-ray shadowing
- marked blood eosinophilia
what is the general approach when patient referred to secondary care for asthma?
- do they have asthma?
- is it just asthma or something else too?
if asthma and nothing else:
3. why is this asthma being difficult to control?
what are a few reasons that could contribute to asthma being difficult to control?
- smoking history - makes solving asthma tricky
- anxiety or depression
- reflux
- relation to menstrual cycle
- non-compliance
- occupation
*high BMI also associated with difficult to control asthma
what are the most common misdiagnoses of asthma?
(things that it was if wasn’t asthma)
- dysfunctional breathing
- bronchiectasis
- severe COPD
- vocal cord dysfunction
- other
= shows how tricky asthma diagnosis can be sometimes
what is vocal cord dysfunction?
inducible laryngeal obstruction
if vocal cords close= sounds like stridor
if vocal cords open during both = sounds like wheeze in expiration
it’s difficulty breathing in rather than out
what sign suggests induced laryngeal obstruction?
stridor = think about laryngeal obstruction (often see feel like something in throat) - triggered by exercise, perfume, strong smells, flowers, change in temperature
*not allergic
what are exacerbating factors of asthma?
- exposure to allergens
- smoking
- poor compliance = wrong inhaler, wrong technique, not using
- psychopathology
- aspergillus (fungus) & SAFS
what are the effects of smoking that can be problematic for asthma?
- reduces ciliary beat frequency (sometimes to 0)
= sputum retention = increased infections - steroids are less effective and macrolide antibiotics are not effective
*macrolide antibiotics are effective
do people make mistakes taking inhalers?
yes, all the time - some on purpose, some by mistake
= important to know how to correctly use
what is allergic broncho-pulmonary aspergillosis (ABPA)?
= get allergic reaction & mucus plugging leading to proximal bronchiestasis
- response to aspergillosis (fungus) = test for it a lot
has IgE more than 100
what is treatment for Allergic Broncho-Pulmonary Aspergillosis (ABPA)?
steroids, consider Itraconazole, discuss MDT
what are severe asthma with fungal sensitization (SAFTS)?
says in name really = people with severe asthma sensitized to funghi
= in study itraconazole given which helped but it’s a toxic drug with lots of side effects
what is the atopic triad?
- Asthma
- Eczema
- Rhinitis
*usually childhood onset
when is more common onset for eosinophilic asthma?
usually adult onset with lots of females (don’t know why)
what are the struggles with the adult onset eosinophilic asthma?
- more steroid resistance usually
- often stuck on prednisolone (steroid) as when go off feel rubbish but steroids long term is not good = loads and loads of side effects
- anti-allergy therapy not effective
what drugs are more effective for adult onset eosinophilic asthma?
anti-IL5 therapy does work (biologic) = mepolizumab or benralizumab (very good life-changing drugs now made) not cheap and only prescribable in secondary care
what conditions can benefit from biologics (mepolizumab & benralizumab)?
adult onset eosinophil asthma, High FeNO, High Eos, Atopy, CRSWNP
what can help predict who will die from asthma?
people who:
- had previous athma admission
- are on multiple drugs (3 or more classes)
- are relying on beta 2 agonist and not taking as much inhaled corticosteroids
- just go to ED when asthma bad instead of clinic or GP
what are markers for moderate acute asthma?
- increasing symptoms
- PEF >50-75% best or predicted
- no features of acute severe asthma
what are markers of acute severe asthma?
any one of:
- PEF 33-50% best or predicted
- resp rate ≥ 25/min
- heart rate ≥ 110/min
- inability to complete sentences in 1 breath
what are clinical signs of life threatening asthma?
- altered conscious level
- exhaustion
- arrhythmia
- hypotension
- cyanosis
- silent chest
- poor respiratory effort
what are measurements of life threatening asthma?
- PEF <33% best predicted
- SpO2 <92%
- PaO2 <8 kPa
- normal PaCO2 (4.6-6 kPa)
what is a sign of near fatal asthma?
raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
what are the reasons pCO2 can rise?
- the patient is getting better, their breathing is slowing down, so pCO2 starts to rise.
- the patient is getting tired, unable to maintain the Vmin, so the pCO2 starts to rise.
= The first is a good sign, the second is very dangerous. The key to telling the difference is to look at the patient, and talk to them.
what are the 4 key components of treatment of acute asthma?
- controlled oxygen
- nebulisers for beta 2 agonists
- steroids
- bronchodilators (SABA)
what additional nebulised drug can be given for patients with acute severe asthma?
nebulised magnesium sulphate if PEF <50% best or predicted and have not had good initial response to inhaled bronchodilator therapy
*not sure how works but probably mimics calcium
what is very important to frequently watch?
pCO2
when is it good to make a severity assessment?
early
