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Respiratory > Asthma > Flashcards

Asthma Flashcards

1
Q

Asthma is a common condition, what percentage of the population are affected?

A

10% population

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2
Q

What 3 factors contribute to airway narrowing in asthma?

A
  1. Bronchial hyper-responsiveness due to triggers
  2. Mucosal swelling and inflammation due to mast cell and basophil degranulation which releases inflammatory cytokines
  3. Increased mucus production which further narrows the airway and can block it
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3
Q

What is the atopic march?

A

combination of asthma, hay fever and eczema

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4
Q

Asthma can be divided into eosinophilic and non-eosinophilic. Which cells are involved in each?

A

Eosinophilic: eosinophils are recruited which damage the epithelium. Th2 cells make pro-inflammatory cytokines

Non-eosinophilic: Th1 cells

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5
Q

non-eosinophilic asthma can be divided into what?

A

non-smoking non-eosinophilic
smoking associated
obesity related

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6
Q

eosinophilic asthma can be divided into what?

A

atopic: occupation, pets, common autoallergens, fungal allergens.
non-atopic

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7
Q

What is atopy?

A

Genetic pre-disposition or tendency to have IgE mediated allergen sensitivity.
Atopic march: allergic asthma, atopic dermatitis, allergic rhinitis.

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8
Q

what type of hypersensitivity reaction is atopy?

A

type 1

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9
Q

occupational asthma is what type of hypersensitivity reaction?

A

type 3 - bakeries, hospitals, pet shops, farms, zoos

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10
Q

What is the key to diagnosing occupational asthma?

A

PEF diaries during work and on holidays

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11
Q

What happens in the initial sensitisation in asthma?

A
  • Inhalation of allergens results in type 1 hypersensitivity in the airways (Th2)
  • Th2 cells produce cytokines (IL4 and IL5) leading to production of IgE antibodies which coat mast cells and cause them to release histamine, leukotrienes and prostaglandins and histamine causes the smooth muscle to contract
  • IL5 activates eosinophils which promote an immune response releasing more cytokines and leukotrienes
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12
Q

What happens in the early phase in asthma?

A
  • Minutes after the exposure to the allergen, smooth muscle around the bronchioles start to spasm and there is increased mucus secretion.
  • This narrows the airways making it difficult to breathe
  • Increased vascular permeability and recruitment of additional immune cells from the blood
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13
Q

What happens in the late phase of asthma?

A

Additional immune cells are recruited from the blood hours after the early phase causing damage to the endothelium of the lungs and over years, oedema, scarring and fibrosis build up in the lungs which permanently reduces the airway diameter

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14
Q

What are the clinical features of asthma?

A 
Cough
Dyspnoea
Diurnal variation
Episodic wheeze
Brittle disease
Chest tightness
Poor sleep
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15
Q

Clinical signs of asthma?

A

Bi-lateral, polyphonic, expiratory wheeze
Absence of crackles
Tachypnoea

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16
Q

Signs of a severe asthma attack

A
  • Tachypnoea
  • Cyanosis
  • Tachycardia
  • Inability to complete sentences
  • Exhaustion
  • Reduced respiratory effect
  • Silent chest
  • Altered conscious level
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17
Q

What are some associated problems with asthma?

A 
Acid reflux - 40/60% of those with asthma
Eczema 
Hayfever
Nasal disease
Food allergies or drug allergies
18
Q

What family and social history is important in asthma diagnosis?

A 
do they smoke
atopy is inherited
fam hx of asthma, eczema or hayfever
pets in the home
psychological illness
19
Q

What occupational history is important in asthma diagnosis? What question can we ask?

A

exposure to dust, fumes or allergens in the work place
lab workers, vet staff, animal breeders, bakers, paint sprayers

Is your asthma worse at work or better when you go on holidays?

20
Q

What blood tests can we do for asthma?

A
  • eosinophils
  • tests for atopy
  • CXR often useful
  • Skin prick tests for allergies
21
Q

Name some triggers for asthma

A
  1. Infections
  2. Night and early morning time
  3. Menstrual cycle - just before period in some women
  4. Exercise
  5. Animals
  6. Pollution
  7. Cigarette smoke
  8. Damp and Cold air
  9. Dust and mold
  10. Strong Emotions
  11. NSAIDs
  12. B-blockers
22
Q

What are some ways we can categorise the severity of asthma?

A
  • Level of treatment required (number of inhalers)
  • A&E attendances, admission, HDU/ITU care, ventilation (ventilation on ICU dictates severe asthma and high risk for attacks)
  • Attendance at GP for courses of antibiotics and steroids

Day to day control - recent nocturnal waking, interference with ADLs

Exacerbations - A&E attendances, GP visits, admissions, ITU admissions

23
Q

What lung function tests are available for diagnosing asthma?

A

Spirometry - Measures the flow and volume of air during inhalation and exhalation
PEFR
FeNO

24
Q

What results do you expect to see in an obstructive lung disease? (FVC and FEV1/FVC ratio)

A

FVC normal but often low due to air trapping
FEV1 reduced
FEV1/FVC: <70%

25
Q

What indicates a positive bronchodilator reversibility test?

A

Increase in 12% in FEV1 together with increase of 200mL volume is positive

26
Q

What is characteristically seen on PEFR in someone with asthma?

A

Diurnal variability

27
Q

What is FeNO testing?

A
  • FeNO testing is typically offered to patients being investigated for asthma at the same time as spirometry.
  • FeNO is a newer way of testing for eosinophilic airway inflammation.
  • FeNO is measured in parts per billion and a level >25 ppb at 50 ml/sec is seen in 70-80% of patients with untreated asthma.
    FeNO > 40 ppb: supportsadiagnosis of asthma
    FeNO 25-39 ppb: suggestive of a diagnosis of asthma. Peak flow variability useful.
28
Q

What non-pharmacological management can we offer to patients with asthma?

A
  • Smoking cessation
  • Weight loss
  • Avoid triggers where possible
  • Check inhaler technique
  • Flu vaccine
29
Q

What reliever medications are available for asthma? What do reliever medications do?

A
  • beta agonists relax constricted muscles allowing the airways to widen
  • beta agonists, leukotriene receptor antagonists, theophylline, long acting beta agonists, anticholinergics
  • these treat symptoms but not the underlying cause
30
Q

What preventative medication is available for asthma? What do preventative medications do?

A

These treat asthma over the long term and contain corticosteroids

  • They reduce airway sensitivity and inflammation and prevent long term damage of the airways
  • ICS
31
Q

Describe step 1 in asthma management
How does this medication work?
When do you step up?
What is the most common side effect from treatment?

A

Step 1: salbutamol - Short Acting Beta Agonist (SABA)
Step up: if exceeds use 3x a week, waking at night due to wheeze etc.
MoA: dilates bronchioles and improves bronchoconstriction short term
Side effects: tremor is the most common, tachycardia, palpitations and cardiac arrhythmias can also occur.

32
Q

Describe step 2 in asthma management.
How do these medications work?
What is the main adverse side effect?

A

Inhaled corticosteroid - beclomethasone or budesonide
These reduce the inflammation and reactivity of the airways over a period of days
These are maintenance or preventer medications taken regularly even when feeling well
Adverse effects: oral candidiasis is the main unwanted effect. Regular high dose can cause adrenal suppression and in children, stunted growth.

33
Q

Describe step 3 in asthma management.

A

Add a long acting beta agonist / LABA + ICS
Salmeterol or formeterol + beclomethasone or budesonide.
Can consider MART (combined inhaler such as fostair)

34
Q

Describe step 4 in asthma management.

A

Increase ICS or add leukotriene antagonist (montelukast)

In NICE, they recommend this at step 3 rather than 4.

35
Q

How does theophylline work and what is the draw back?

A
  • Works by relaxing bronchial smooth muscle and reducing inflammation.
  • Unfortunately it has a narrow therapeutic window and can be toxic in excess so monitoring plasma theophylline levels in the blood is required.
36
Q

What is the initial management for acute asthma attack?

A 
oxygen
salbutamol neb
prednisolone
consider magnesium or aminophylline IV
ABGs
watch for complications: tension pneumothorax, arrhythmias, hypokalaemia
37
Q

What do we do when discharging a patient who has had an acute asthma attack?

A 
Educate your patient to prevent re-admission
Achieve PEFR >75%
Prednisolone 7-14days
Step up treatment plan
Asthma action plan needed
38
Q

An asthmatic patient presents with these signs and symptoms

  • PEFR >50%
  • RR <25
  • Pulse <110
  • No markers of severe disease, normal speech.

Is this a moderate, severe, life-threatening or near fatal asthma attack?

A

Moderate showing uncontrolled asthma

39
Q

An asthmatic patient presents with these signs and symptoms

  • PEFR 33-50% predicted
  • RR >25
  • HR >110
  • Inability to complete sentences.

Is this a moderate, severe, life-threatening or near fatal asthma attack?

A

Severe

40
Q

An asthmatic patient presents with these signs and symptoms

  • PEFR <33% predicted
  • SaO2 <92% or PaO2 <8kPa
  • Normal PaCO2 4.6-6kPa
  • Altered conscious level, exhaustion, arrhythmia, hypotension, silent chest, poor effort, cyanosis.

Is this a moderate, severe, life-threatening or near fatal asthma attack?

A

life threatening

41
Q

An asthmatic patient presents with these signs and symptoms
- Raised PaCO2 and or requiring ventilation with raised airway pressures.

Is this a moderate, severe, life-threatening or near fatal asthma attack?

A

Near fatal asthma attack

Respiratory (13 decks)

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