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Y3 GP: Asthma and COPD > Asthma > Flashcards

Asthma Flashcards

1
Q

What is asthma?

A

Asthma is a chronic respiratory condition associated with airway inflammation and hyper-responsiveness.

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2
Q

What are the triggers for asthma?

A
  • Infection
  • Night time or early morning
  • Exercise
  • Animals
  • Cold/damp
  • Dust
  • Strong emotions
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3
Q

Briefly describe the pathophysiology of asthma

A

Asthma is a chronic inflammatory condition of the airways that causes episodic exacerbations of bronchoconstriction. Bronchoconstriction is where the smooth muscles of the airways (the bronchi) contract causing a reduction in the diameter of the airways. Narrowing of the airways causes an obstruction to airflow going in and out of the lungs.

This bronchoconstriction is caused by hypersensitivity of the airways and can be triggered by environmental factors.

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4
Q

What are the signs of asthma?

A
  • Expiratory wheeze
  • Nasal polyps
  • Tachypnoea
  • Hyperinflated chest
  • Hyperesonant percussion note
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5
Q

What are the symptoms of asthma?

A
  • Wheeze
  • Dry cough
  • Breathlessness
  • Chest tightness
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6
Q

Briefly describe atopy

A

Personal/family history of other atopic conditions, particularly atopic eczema/dermatitis and/or allergic rhinitis.

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7
Q

What presentation would suggest a diagnosis of asthma?

A
  • Episodic symptoms
  • Diurnal variability
    • Typically worse at night
  • Dry cough with wheeze and shortness of breath
  • A history of other atopic conditions such as eczema, hayfever and food allergies
  • Family history
  • Bilateral widespread “polyphonic” wheeze heard by a healthcare professional
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8
Q

What presentation would indicate a diagnosis other than asthma?

A
  • Wheeze related to coughs and colds more suggestive of viral induced wheeze
  • Isolated or productive cough
  • Normal investigations
  • No response to treatment
  • Unilateral wheeze
    • This suggests a focal lesion or infection
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9
Q

What investigations should be ordered for asthma?

A
  • FEV1/FVC ratio
  • Peak expiratory flow rate
  • CXR
  • FBC
  • Fractional exhaled nitric oxide (FeNO)
  • Bronchial challenge test
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10
Q

Why investigate FEV1/FVC ratio?

A

Forced expiratory volume at 1 second (FEV₁)/forced vital capacity (FVC) ratio is the primary diagnostic test.

A bronchodilator reversibility test may be used, which can demonstrate reversibility of airflow obstruction to short-acting bronchodilator.

FEV₁/FVC <80% of predicted.

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11
Q

Why investigate peak expiratory flow rate (PEFR)?

A

Long-term daily PEFR monitoring should be considered for: patients who have moderate or severe persistent asthma; patients who have a history of severe exacerbations; patients who poorly perceive airflow obstruction and worsening asthma; or patients who prefer this monitoring method.

Long-term daily PEFR monitoring can be helpful to: detect early changes in disease states that require treatment; evaluate responses to changes in therapy; and afford a quantitative measure of impairment.

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12
Q

Why investigate using CXR?

A

Indicated in first presentation to exclude other pathologies, and in acute exacerbations when complicating factors are suspected from history and examination.

May also show signs of infection in acute exacerbation or pneumothorax.

May show hyperinflation.

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13
Q

Why investigate FBC?

A

Indicated in first presentation and in acute exacerbations when complicating factors are suspected from history and examination.

May shown normal, raised eosinophils and/or neutrophilia.

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14
Q

Why investigate using fractional exhaled nitric oxide (FeNO)?

A

Reflective of the degree of eosinophilic inflammation.

NICE guidelines use FeNO as first-line investigation for suspected asthma where as others use it in addition to standard tests to aid diagnosis of asthma and/or determine asthma control.

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15
Q

Why investigate using bronchial challenge test?

A

Direct bronchial challenge test with histamine or methacholine may be considered if spirometry and peak expiratory flow rate do not show reversibility and variability.

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16
Q

What guidelines can be used to diagnose asthma?

A

There is a difference in the guidelines on diagnosis.

The British Thoracic Society (BTS) and SIGN guidelines from 2016 advise making a clinical diagnosis when there is a high clinical suspicion of asthma and testing when there is an intermediate or low clinical suspicion.

The newer NICE guidelines from 2017 advise against making a diagnosis without definitive testing.

17
Q

Briefly describe the BTS/ SIGN guidelines on asthma diagnosis

A

Probability of asthma:

  • Low probability of asthma: consider referral and investigating for other causes
  • Intermediate probability of asthma: perform spirometry with reversibility testing
  • High probability of asthma clinically: try treatment
18
Q

Briefly describe the NICE guidelines on asthma diagnosis

A

NICE recommend assessment and testing at a “diagnostic hub” to establish a diagnosis. They specifically advise not to make a diagnosis clinically and require testing:

First line investigations:

  • Fractional exhaled nitric oxide
  • Spirometry with bronchodilator reversibility

If there is diagnostic uncertainty after first line investigations these can be followed up with further testing:

  • Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks
  • Direct bronchial challenge test with histamine or methacholine
19
Q

What are the principles in stepwise management of asthma?

A

They principles of using the stepwise ladder are to:

  1. Start at the most appropriate step for the severity of the symptoms
  2. Review at regular intervals based on severity
  3. Step up and down the ladder based on symptoms
  4. Aim to achieve no symptoms or exacerbations on the lowest dose and number of treatments. This is often difficult in practice.
  5. Always check inhaler technique and adherence at review
20
Q

Briefly describe the BTS/SIGN Stepwise Ladder in asthma management

Note: adapted form 2016 guidelines

A

BTS/SIGN Stepwise Ladder

  1. Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
  2. Add a regular low dose corticosteroid inhaler
  3. Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
  4. Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA (i.e. tiotropium).
  5. Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist.
  6. Add oral steroids at the lowest dose possible to achieve good control.
21
Q

Briefly describe NICE Guidelines in asthma management

Note: adapted from 2017 guidelines

A

NICE Guidelines:

  1. Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes
  2. Add a regular low dose inhaled corticosteroid
  3. Add an oral leukotriene receptor antagonist (i.e. montelukast).
  4. Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
  5. Consider changing to a maintenance and reliever therapy (MART) regime.
  6. Increase the inhaled corticosteroid to a “moderate dose”.
  7. Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
  8. Refer to a specialist.
22
Q

How does the BTS/SIGN and NICE Guidelines differ in asthma management

A

The medications they recommend are the same but they differ slightly in the stepwise ladder of which medications to introduce at what point.

Most importantly they both start with a short acting beta 2 agonist followed by a low dose inhaled corticosteroid. The next step is then either a leukotriene receptor antagonist (NICE) or an inhaled LABA (BTS/SIGN).

23
Q

What is Maintenance and Reliever Therapy (MART)?

A

This is a combination inhaler containing a low dose inhaled corticosteroid and a fast acting LABA. This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.

24
Q

What conservative treatment is recommended to patients with asthma?

A
  1. Each patient should have an individual asthma self-management programme
  2. Yearly flu jab
  3. Yearly asthma review
  4. Advise exercise and avoid smoking
25
Q

What are the 4 different classifications of asthma severity exacerbation?

A
  1. Moderate acute
  2. Acute severe
  3. Life-threatening
  4. Near-fatal
26
Q

How does moderate acute asthma present?

A
  • Increasing symptoms
  • PEF >50–75% best or predicted
  • No features of acute severe asthma
27
Q

How does acute severe asthma present?

A

Any one of:

  • PEF 33–50% best or predicted
  • Respiratory rate ≥25/min
  • Heart rate ≥110/min
  • Inability to complete sentences in one breath
28
Q

How does life-threatening asthma present?

A

In a patient with severe asthma any one of:

  • PEF <33% best or predicted
  • SpO₂ <92%
  • PaO₂ <8 kPa
  • ‘Normal’ PaCO₂ (4.6–6.0 kPa)
  • Altered conscious level
  • Exhaustion
  • Arrhythmia
  • Hypotension
  • Cyanosis
  • Silent chest
  • Poor respiratory effort
29
Q

How does near-fatal asthma present?

A

Raised PaCO₂ and/or requiring mechanical
ventilation with raised inflation pressures.

30
Q

What are the complications of asthma?

A
  • Exacerbation
  • Airway remodelling
  • Oral candidiasis infection due to inhaled corticosteroid use
  • Dysphonia due to inhaled corticosteroid use
31
Q

What differentials should be considered for asthma?

A
  1. Cystic fibroisis
  2. Foreign body obstruction
  3. COPD
  4. Bronchiectasis
32
Q

How does asthma and cystic fibrosis differ?

A

Differentiating signs and symptoms:

  • Chronic, sometimes productive cough with a possible family history of cystic fibrosis
  • Nasal polyposis at or before 12 years of age and symptoms related to other organ involvement, such as diarrhoea, malabsorption or failure to thrive

Differentiating investigations:

  • Sweat chloride testing: level of sweat chloride ≥60 mEq/L
  • Consider repeat testing
33
Q

How does asthma and foreign body obstruction differ?

A

Differentiating investigations:

  • Wheezing, shortness of breath, occasional stridor are common
  • If the foreign body is in the peripheral airway, localised one-sided wheezing or collapse of the distal lung tissue is found

Differentiating investigations:

  • CXR, CT chest or bronchoscopy shows the foreign body
34
Q

How does asthma and COPD differ?

A

Differentiating signs and symptoms:

  • History of smoking or long-standing asthma
  • Dyspnoea occurs with or without wheezing and coughing
  • Examination may show barrel chest, hyper-resonance to percussion, and distant breath sounds

Differentiating investigations:

  • Pulmonary function tests (PFTs) with elevated residual volume (RV), total lung capacity (TLC), and a flow volume loop with bronchodilator showing an obstructive pattern with an increase in TLC and RV and a reduction in forced expiratory flow at one second (FEV₁), FEV₁/forced vital capacity (FVC) ratio <70%; total absence of reversibility is neither required nor the most typical result, but PFTs must not return to normal after administration of aerosolised bronchodilator
  • CXR showing hyper-inflation of the lungs
35
Q

How does asthma and bronchiectasis differ?

A

Differentiating signs and symptoms:

  • Dyspnoea, cough, and wheezing and, if severe, recurrent pulmonary infections

Differentiating investigations:

  • High-resolution CT chest: dilated airways, bronchial wall thickening
  • Can occasionally be seen on CXR

Y3 GP: Asthma and COPD (2 decks)

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