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103 Theme 4 - Lungs > Asthma > Flashcards

Asthma Flashcards

1
Q

What did the British Thoracic Society/SIGN 2019 state about how is asthma diagnosed?

A

No consistent gold standard diagnostic criteria

Central to diagnosis is presence of symptoms

–More than one of wheeze, breathlessness, chest tightness, cough

–Variable airflow obstruction

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2
Q

What is the definition of asthma?

A

Heterogeneous disease characterised by chronic airways inflammation

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3
Q

What is the WHO definition of asthma?

A

Is a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day.

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4
Q

On average, _____ people die from an asthma attack in the UK every day

Does the UK or EU have higher asthma death rates?

A

3

UK

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5
Q

When does asthma most commonly first present?

A

Asthma most commonly presents in childhood or in middle age

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6
Q

At what age will the majority of children be asthma-free?

A

Age 21

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7
Q

Which patients with asthma are more likely to have persistant asthma?

A

Adult-onset asthma is more likely to be persistent

70% of children with more persistent asthma will continue to have symptoms in adult life

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8
Q

What causes the airflow obstruction?

A
  • Bronchoconstriction - contraction of the smooth muscle in the bronchial wall
  • Bronchial secretions and plugs of mucus - due to inflammation of the bronchial wall
  • Oedema of the bronchial wall - due to inflammation the lining mucosa of the bronchial wall
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9
Q

What is atopy?

A
  • Asthma in young people usually linked to atopy
  • Tendency to form IgE antibodies to allergens (such as pollen, house dust mites or animals).
  • Often associated hay fever or eczema in the personal or family history
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10
Q

Complete the diagram on asthma pathophysiology

A
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11
Q

What are the symptoms of asthma?

A
  • Cough
  • Wheeze
  • Breathlessness
  • Chest tightness
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12
Q

When do asthma symptoms occur?

A

Occurs in episodes with periods of no (or minimal symptoms)

Diurnal variability-so worse at night or early morning

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13
Q

Which medications are triggers for asthma?

A

–Aspirin

–Ibuprofen

–Beta blockers

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14
Q

List the triggering factors for asthma

A
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15
Q

How is a diagnosis of asthma made?

A
  • History is crucial-need more than one symptom
  • Symptom free periods
  • Past medical history (previous wheezing illness, hay fever, eczema), family history (of any atopic disease), and social history (occupation, pets) can provide clues
  • Physical examination may be normal except during an attack
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16
Q

What are the investigations for asthma?

A

•Tests done by GP-

Peak flow monitoring-twice day for 2 weeks

Spirometry may show airflow obstruction, but may be normal between attacks

•Tests done by GP/Hospital

Chest X-ray often normal, but may show hyperinflation

Increased eosinophil count in the blood

Fraction exhaled nitric oxide (FeNO)

•Tests done by hospital

Skin prick or blood tests may confirm allergies

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17
Q

What tests of lung function are done for asthma?

A

•Is there airflow obstruction?

–FEV1/FVC ratio <70

•Does it vary over time?

–peak expiratory flow rate (PEFR) monitoring-20% diurnal variation worse at night/early morning

•Is it reversible?

–with bronchodilators (so after treatment with salbutamol) 15% and 200mls improvement in FEV1 from baseline

18
Q

What does this peak flow show?

A

Nocturnal variation

19
Q

What is FeNO-Fraction of exhaled nitric oxide?

A
  • Measure of airways eosinophilic inflammation
  • Performed on patients not on any treatment, a positive test (> 40ppb) supports diagnosis of asthma
  • Can be done in GP and hospital clinics
  • Can be used to monitor treatment/look at compliance
20
Q

What are the non-pharamcological management of asthma?

A

–Smoking cessation

–Weight reduction

–Pollution-may provoke acute asthma or aggravate existing asthma but effects from allergens, smoking and infection more significant

21
Q

What preventers can be used in asthma?

A

–Inhaled corticosteroids (ICS)

  • Key part of first line treatment in patients with asthma
  • Beclometasone, fluticasone, budesonide, ciclesonide

–Inhaled Long acting beta 2 agonists (LABA)

  • Formoterol, salmeterol
  • In combination with ICS as add on treatment if still symptomatic
  • Never a single agent treatment alone: associated with increased deaths
22
Q

What are the long term oral treatments for asthma?

A

–Oral leukotriene antagonist-montelukast

–Oral theophyllines

–In patients with chronically poorly controlled asthma: low dose longterm oral steroids (prednisolone). Hospital directed treatment

23
Q

What are the relievers for asthma?

A

Short/immediate relief of symptoms (relievers)

•Short acting beta agonists (SABA)

–Salbutamol

–Terbutaline

–As inhaler (salbutamol 100mcg) or nebuliser (high dose salbutamol 2.5mg, driven by oxygen)

24
Q

What is maintenance and reliever therapy (MART) for asthma?

A
  • LABA formoterol has short onset of action
  • Equivalent of salbutamol (SABA)
  • So certain specific ICS/LABA combinations can be used as relievers as well as preventers
  • So patients can take additional doses (4/day) for short period (2-3 days) to rapidly treat any worsening asthma symptoms
  • Aim to address and treat the inflammatory aspect of disease by having both ICS and LABA
25
Q

Complete the diagram on the guidelines for treating asthma

A
26
Q

What are the 2 different inhaler devices?

A

Dry power inhalers

Pressurised metered dose inhalers

27
Q

How do dry power inhalers work?

A

•Activated by inspiration by the patient

•Powdered drug is dispersed into particles
by the inspiration

28
Q

How do pressurised metered dose inhalers work?

A

Drug dissolved in a propellant hydrofluorocarbons (HFCs) under pressure Valve system releases a metered dose

29
Q

Which inhaler device is associated with better technique?

A

DPIs

30
Q

Which inhaler device is this?

A
31
Q

What should GP/practice nurse/ hospital doctor consider before prescribing an inhaler?

A
  • Where are they in treatment (so stepping up going from ICS to ICS/LABA
  • What device can they use
  • Dexterity
  • Inspiratory flow
  • Side effects-oral candidiasis/thrush (ICS), tremor + tachycardia (SABA/LABA)
  • What device do they want to use (HFCs) - carbon footprint
  • Counter so know how many doses left

Cost

32
Q

What are the 3 key questions to ask asthma patients?

A
  1. Have you had difficulty sleeping because of your asthma symptoms (including cough)?
  2. Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
  3. Has your asthma interfered with your usual activities (eg housework, work, school)?
33
Q

Name 2 very specialised treatments for small numbers of patients with difficult asthma?

A

•Monoclonal antibody

–anti-IgE injections (omalizumab)

–anti IL-5 treatment (mepolizumab)

•Bronchial thermoplasty

34
Q

What factors may effect patient adherence or compliance with treatment?

A

•Unintentional

Misunderstanding

Poor inhaler technique

Language

Forgetfulness

Stress

Intentional

Concern about side-effects

Denial

Cost

35
Q

What does a personal asthma action plan (PAAP) do?

A

–Improves asthma control

–Reduces emergency contacts with GP

–Reduces hospital admissions

36
Q

When is asthma a medical emergency?

A

Acute Severe asthma

37
Q

What are the features of acute severe asthma?

A

–Peak expiratory flow rate (PEFR) 33-50% of best (use % predicted if recent best unknown)

–Can’t complete sentences in one breath

–Respirations ≥25 breaths/min

–Pulse ≥110 beats/min

38
Q

When does acute severe asthma become life threatening?

A

–PEFR <33% of best or predicted

–SpO2 <92%ƒ (regardless of air or oxygen)

–Silent chest, cyanosis, or feeble respiratory effort

–Arrhythmia or hypotension

–Exhaustion, altered consciousness

39
Q

How is acute severe asthma managed?

A
  • Oxygen- how? What target saturations?
  • Corticosteroids - prednisolone 40-60 mgs orally (intravenous hydrocortisone if unable to take orally)
  • Nebulised bronchodilators – salbutamol + ipratropium bromide
  • If poor response, intravenous MgSO4, or intravenous aminophylline
  • Exceptionally, intubation and ventilation is required
40
Q

When are patients with acute severe asthma discharged from hospital?

A
  • Been on discharge medication for 24 hours
  • Inhaler technique checked and recorded
  • Increase in PEFR >75% of best or predicted and PEFR diurnal variability<25%
41
Q

What is an acute severe asthma patient discharged with?

A
  • Treatment with oral and inhaled steroids in addition to bronchodilators
  • Own PEFR meter and written PAAP
  • GP/Nurse follow up arranged within 2 working days
  • Follow up appointment in respiratory clinic within 4 weeks

103 Theme 4 - Lungs (21 decks)

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