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respiratory system year 1 > adult asthma features > Flashcards

adult asthma features Flashcards

1
Q

defining features

A

increased responsiveness of trachea and bronchi to various stimuli
manifested by widespread narrowing of airways that changes in severity either spontaneously or as a result of therapy
airway inflammation is mediated by the immune system

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2
Q

symptoms of asthma

A 
SOB
Wheeze (check severity)
cough (paroxysmal, usually dry), sputum is occasional 
chest tightness (pain)
diurnal variability 
episodic
atopy
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3
Q

signs of asthma

A 
wheeze on auscultation
eczema 
obstructed spirometry 
PEF changes
response to treatment
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4
Q

epidemiology of asthma in children

A

10-15%m>f

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5
Q

epidemiology of asthma in adults

A

5-10%

f>m

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6
Q

how many deaths are caused by asthma each year

A

1000

2/3 are preventable

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7
Q

proven risk factors of asthma

A

genetic
occupation
smoking

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8
Q

genetic risk factor

A

atopy
strongest risk factor: personal, familial atopic tendency
maternal atopy is the main influencer (3x father)
2 groups of genetic associations: immune response genes (IL-4, IL-5, IgE); airway genes (ADAM33)
disease clustering in families may be linked to environmental exposure

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9
Q

define atopy

A

inherited tendency to IgE response to allergens

asthma, eczema, hayfever and food allergy

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10
Q

occupation risk factor

A

10-15% of adult onset asthma
interactions w/ smoking and atopy
high risk jobs: bakers, welders, lab workers w/ animals, working w/ shellfish etc.

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11
Q

smoking risk factor

A

maternal smoking during pregnancy: reduced FEV1, increased wheezy illness, increased airway responsiveness, increased asthma and severity
grandmother effect - epigenetic modification of oocytes

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12
Q

what is the grandmother effect

A

link between smoking and OR asthma age 5
mother smoked - 1.5
maternal grandmother smoked - 2.1
mother and maternal grandmother smoked - 2.6

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13
Q

possible risk factors of asthma

A 
obesity 
diet
reduced exposure to microbes
indoor pollution
environmental allergens
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14
Q

obesity risk factor

A

BMI +vely associated w/ asthma, wheezing, airway hyperreactivity

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15
Q

diet risk factor

A

reduced antioxidant, n-3 polyunsaturated FA, increased n-6 polyunsaturated FA, increased/decreased vit D has associations w/:
- reduced FEV1
- increased wheeze
- increased asthma
- reduced wheeze and asthma; increased oily fish consumption and butter
supplementation in established disease is ineffective

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16
Q

reduced exposure to microbes risk factor

A

includes microbial products (endotoxin, glucans, extra capsular polysaccharide)
children born on farms are less likely to develop asthma
microbial diversity appears to be important in reducing risk of asthma and allergy

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17
Q

indoor pollution (chemical household products) risk factor

A

volatile organic compounds
formaldehyde
fragrances
cleaners at increased risk (OR 1.97)
people who use sprays weekly: 1.49x more likely to be asthmatic
people who use sprays 4x/wk: 2.11x more likely to be asthmatic
mothers who use sprays during pregnancy: children increased asthma

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18
Q

environmental allergens risk factor

A 
house dust mite
cats
grass pollen 
exposure doesn't initiate atopy/asthma 
factors associated w/ affluence increase the likelihood of sensitisation to local allergens
19
Q

house dust mites

A 
warm, humid houses
europe and coastal australia
200x own weight in droppings
allergen is a protease in droppings
exposure - pillows and bed
20
Q

cats

A

universal exposure to allergen
evidence to show exposure may be protective
once sensitised, exposure is a major problem

21
Q

clinical aspects

A

try to differentiate from other causes of wheeze

  1. localised airway obstruction, inspiratory stridor, tumour, foreign body
  2. generalised airflow obstruction: asthma (reversible AFO), COPD (irreversible AFO), bronchiectasis, bronchiolitis, CF
22
Q

clinical Hx

A 
symptoms
evidence of variable symptoms: triggers and diurnal variation/weekly variation (occupational)/annual variation (environmental)
PMH
drugs
FMH - atopic disease
SH
23
Q

symptom triggers

A 
exercise
cold air
smoke
perfume 
URTIs
pets
tree and grass pollen 
food 
aspirin
24
Q

past medical Hx

A

childhood asthma
bronchitis
eczema
hay fever

25
Q

drugs Hx

A 
current inhalers (check technique and compliance)
beta blockers
aspirin
NSAIDs
effects of previous drugs/inhalers
26
Q

social Hx

A

smoking
pets
occupations
psychosocial aspects (stress)

27
Q

examination

A

THERE IS NO SINGLE DIAGNOSTIC TEST FOR ASTHMA

examination is usually unhelpful in clinic

28
Q

what are we looking for on clinical examination

A

breathlessness on exertion
hyper-expanded chest
polyphonic wheeze

29
Q

what would suggest asthma is unlikely on examination

A

clubbing, cervical lymphadenopathy (lung cancer)
stridor (tumour/foreign body aspiration)
asymmetrical expansion
dull percussion note (lobar collapse, effusion)
crepitations (bronchiectasis, CF, LVF, alveolitis)

30
Q

what are we looking for evidence for in the essential investigations

A

airflow obstruction
variability and/or reversibility of AFO
spirometry: FEV1 <80%, predicted w/ FEV1/FVC ratio <70%
- in asthma may be completely normal

31
Q

what would we do if spirometry shows airflow obstruction

A

exclude COPD/emphysema
reversibility to bronchodilator
reversibility to oral corticosteroids

32
Q

how would we exclude COPD/emphysema

A 
lung volumes (He dilution)
gas trapping (increased residual vol, increased TLC, RV/TLC >30%
CO gas transfer: transfer of CO to Hb across alveoli, looking for tissue destruction
33
Q

how to we check for reversibility to bronchodilator

A

baseline
15 mins post inhaled salbutamol

baseline
15 mins post neb salbutamol

look for significant reversibility (change in FEV1 >200ml and change in FEV1 >12% baseline

BUT: no bronchoconstriction/severe bronchoconstriction, no reversibility

34
Q

how to we check for reversibility to oral corticosteroids

A 
anti-inflammatory 
separates COPD from astham 
prednisoslone for 14 days
peak flow chart and meter 
baseline and 2wk spirometry
35
Q

what do we do if spirometry shows normal airflow

A

check variability of lung function - lung function in clinical is usually normal
peak flow meter and chart - 2x daily for 2wks
- look for morning/nocturnal dips, reduction over wks/days, variability >20%
bronchial provocation - Nitrous oxide

36
Q

diagnosis of occupational asthma

A 
work related symptoms 
working w/ recognised occupational sensitiser
confirmation: serial peak flow readings
- 2hrly best: 5 days minimum
- 2 pairs of exposed/unexposed periods

check antibodies
bronchial challenge
+ve response to colophony

37
Q

specialist investigations for asthma

A

airway responsiveness to metacholine/histamine/mannitol
- normal lungs won’t respond
exhaled NO

38
Q

what 3 other investigations can also be useful

A

CXR: hyperinflation, hyperlucent (no effusion, collapse, opacities, interstitial changes)
skin prick test: total and specific IgE (atopic status)
FBC: eosinophilia (atopy)

39
Q

assessment of acute severe asthma

A

subjective parameters, not reliable
looks at: ability to speak, HR, RR, PEF, O2 sat/ABG
moderate, severe, life threatening, near fatal

40
Q

moderate asthma

A 
increased symptoms, no features of severe
able to speak complete sentences
HR <110
RR <25
PEF 50-75% predicted/best 
SaO2 >92% (no need for ABG)
PaO2 >8kPa
41
Q

Severe asthma

A 
any one of: 
unable to speak, unable to complete sentences
HR >110
RR >25
PEF 33-50% predicted/best
SaO2 >92%
PaO2 >8kPa
42
Q

Life threatening asthma

A

any one of:
grunting
impaired consciousness, confusion, exhaustion
HR >130 or bradycardia (also arrhythmia and hypotension)
hypoventilation, silent chest, poor resp effort
PEF <33% predicted/best
cyanosis, SaO2 <92%, PaO2 <8kPa
PaCO2 normal (4.6-6.0kPa)

43
Q

near fatal asthma

A

increased PaCO2
not being offloaded well enough
need for mechanical ventilation

respiratory system year 1 (25 decks)

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