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CR3 > Asthma > Flashcards

Asthma Flashcards

1
Q

What are the 3 main characterisations of asthma?

A

Reversible airflow limitation

Airway hyperresponsiveness

Inflammation of the bronchi

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2
Q

What is the meaning of the term Atopy? What are atopic individuals prone to?

A

A genetic predisposition to IgE-mediated allergen sensitivity -

People are prone

  • Allergic asthma
  • Atopic dermatitis
  • Allergic rhinitis
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3
Q

What is the Hygiene hypothesis?

A

Reduced exposure to infectious pathogens at a young age predisposes individuals to autoimmune and allergic disease in western countries.

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4
Q

What is aspirin induced asthma? What triad condition do individuals present with?

A

When asthma attacks can be triggered by aspirin due to a sensitivity - People have SAMTERS TRIAD

  • Asthma
  • Aspirin sensitivity
  • Nasal polyps
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5
Q

What is occupational asthma?

A

When asthma is triggered by occupational exposures

High molecular weight

  • Compounds trigger on a IgE response
  • Effects are immediate as soon as person is exposed
  • Flour
  • Latex

Low molecular weight

  • a complex immune response develops after repeated and long-term exposure
  • wood dust
  • isocyanates
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6
Q

To aid in diagnosing occupational asthma, the patient should keep a diary of what?

A

Peak expiratory flow diaries during periods of work and holiday

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7
Q

What is exercise induced asthma?

A

triggered by strenuous physical activity

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8
Q

What are key concepts in the early phase of asthma?

A

Inhalation of allergens causes type 1 hypersensitivity reaction in the airways

Sensitisation begins to develop causing the release of IgE antibodies

The IgE binds to mast cells

Subsequent exposure to antigen cases mast cells to degranulate and histamines to be released.

This causes smooth muscle contraction and bronchoconstriction (bronchospasm’s) whilst inflammation contributes to airway obstruction, oedema and mucous

late phase -
 Th2 helper cells -> B cells -> IgE
& eosinophils ->
• Constriction
• Muco-secretion
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9
Q

What are key concepts in the late phase of asthma?

A

Early phase may be followed by late phase hours later

Inflammatory mediators are recruited (e.g. polymorphonuclear cells, T-cells)

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10
Q

Do beta beta agonists cause complete reversal of the late phase?

A

No - it is more complex

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11
Q

In asthma chronic inflammation occurs. How does the airway change/ respond to this?

A
  • Fibrous tissue develops

- Airway remodelling causes airway obstruction which manifests as airway narrowing which is irreversible

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12
Q

What are the signs and symptoms of asthma?

A

Symptoms

  • Cough (may be worse at night)
  • Dyspnoea (SOB)
  • Chest tightness
  • Poor sleep

Signs

  • Expiratory polyphonic wheeze
  • Prolonged expiratory phase
  • Tachypnoea
  • Harrisons sulcus ( a groove at the inferior border of the rib cage that may be seen in children with chronic severe asthma. Also seen in rickets.)
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13
Q

What are the characterisation and symptoms of an asthma attack?

A
  • Worsening of normal symptoms
  • Reduction in PEF

In more severe attacks patients have signs of respiratory failure -

  • Tachypnoea
  • Tachycardia
  • Inability to complete sentences
  • Exhaustion
  • Reduced respiratory effort
  • Silent chest
  • Altered conscious level
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14
Q

There are 2 main types of receptors in the airways. What are the names and what does activation of them do?

A

Sympathetic -> β2 receptors -> bronchodilation & mucociliary clearance

Parasympathetic -> muscarinic receptors
-> bronchoconstriction

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15
Q

What is the formula for flow?

A

Pressure change/Resistance

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16
Q 
What is (Pouseille’s
law?
A

resistance = 1/r4

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17
Q

List 5 extrinsic causes of asthma

A 
Air pollution
•
 Allergen exposure
•
 Maternal smoking
•
 Hygiene hypothesis
•
 Genetics
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18
Q

List 2 key features of intrinsic asthma

A

Intrinsic -

  • non allergic
  • less responsive
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19
Q

Which drugs are known to trigger asthma?

A

Aspirin and beta blockers

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20
Q

Which of the many features of asthma if present make it more likely? (6)

A

More than one of:

  • wheeze
  • breathlessness
  • chest tightness
  • cough

variability - worse at night and in the morning

Triggered by allergies, exercise, drugs cold air

Atopic features

Family history

Low PEFR AND FEV

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21
Q

Features/ symptoms make asthma less likely? (8)

A
  • Dizziness
  • Peripheral tingling
  • Productive cough in the absence of wheeze of breathlessness
  • Consistent normal examination with breathless
  • Voice disturbances
  • Symptoms only with colds
    Significant smoking history (>20 pack years )
  • Cardiac disease
  • Normal PEF or FEV1 when symptomatic
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22
Q

List 5 possible differential diagnosis for a wheeze

A

Asthma

COPD

Obstruction e.g. foreign body

Anaphylaxis

Pulmonary oedema

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23
Q

List the main differences between asthma and COPD

A

Asthma -

  • Daily FEV1 variation
  • Reversibility

COPD

  • Older >35
  • Smoking history
  • Sputum production (chronic productive cough)
  • Persistent/progressive breathlessness
  • Variability uncommon
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24
Q

Which diagnostic investigations are conducted to diagnose asthma and what would the results show? (5)

A

Spirometry - FEV1/FVC <70% ratio

Bronchodilator reversibility -

  • FEV1 pre and post beta agonist inhibition
  • > 12% or 200ml improvement in FEV1

Fraction exhaled nitric oxide
normal is >25
Asthma is >40ppd

Direct challenge testing (eg
methacholine)

drop in FEV1 when
exposed to provoking
substance e.g. histamineor methacholine
concentration required to
cause 20% fall in FEV1
(PC20) OF 8mg/ml or less

Low false negative rate

Peak flow variability

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25
Q

Would all asthmatics have a abnormal spirometry?

A

Many asthmatics may have
normal spirometry especially
when not symptomatic

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26
Q

State 2 negative aspects of the Fraction exhaled

nitric oxide test?

A

Multiple confounders

1 in 5 false positive/negative rate

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27
Q

There are 3 extra tests which can be done for people with asthma, what are they?

A

◦IgE,
◦allergy/skin prick testing,
◦FBC/eosinophil count

28
Q

Which life style advice is given to those with asthma?

A

Avoidance of triggers and allergens

 Avoid smoking exposure
Weight reduction
•
 Breathing control exercises may help
•
 Not recommended:
  • House dust mite avoidance
  • Air ionisers
29
Q

What is the role of specialist nurses in asthma treatment?

A

Asthma nurse review at/shortly
after admission improves:

• Symptom control
• Self management
• Re-attendance rates
Review post discharge (< 30 days)

30
Q

What should the written action plans for the self management of asthma include?

A
  • How to use treatment
  • Self monitoring/assessment skills
  • Action plan with regard to goals
  • Recognition and management of
    exacerbations
  • Allergen/trigger avoidance
31
Q

What is the mechanism of action for beta 2 agonists?

A
  • Relax smooth muscle

- relieve bronchospasm

32
Q

Give 2 example drugs for short acting beta agonists and long acting beta agonists?

A

Short acting - salbutamol, terbutaline

Long acting - salmeterol, formoterol

33
Q

What are the side effects of beta 2 agonists?

A

o tremor
o tachycardia
o sweats
o agitation

34
Q

What is the mechanism of action/ purpose of corticosteroids in the treatment of asthma?

A

decrease inflammation

35
Q

Give 3 examples of corticosteroids used in the treatment of asthma

A

o budesonide
o beclometasone
o fluticasone

36
Q

What the main side effects of inhaled corticosteroids?

A

o oral candidiasis
o systemic side effects rare with inhaled
corticosteroids

37
Q

What is the mechanism of action of Leukotriene antagonists?

A

blocking leukotriene receptors in smooth muscle

reduce bronchoconstriction

38
Q

The name the Leukotriene antagonists drug used in the treatment of asthma

A

Montelukast

39
Q

What are the side effects if Leukotriene antagonists drugs?

A

nausea

headache

40
Q

What is the mechanism of action for anti IgE drugs used in the treatment of asthma?

A

monoclonal antibody to IgE

decrease IgE

41
Q

Which anti IgE drug is used in asthma treatment?

A

Omalizumab

42
Q

What are the side effects of anti IgE drugs used in asthma treatment?

A
  • itching
  • joint pain
  • headache
  • nausea
43
Q

Describe the progression of asthma treatment

A

Step 1- Low does inhaled corticosteroids

Step 2- Inhaled LABA plus inhaled corticosteroid

Step 3- Responds to LABA? - Continue but increase inhaled corticosteroid to medium dose
Does not respond to LABA? Stop LABA increase inhaled corticosteroid dose

Or ADD Leukotriene receptor agonist or SR theophylline or long acting muscarinic receptor agonist

Step 4 - Increase inhaled steroid to high dose
Add fourth drug (leukotrien, theophyline, beta agonist, long acting muscarinic)

Refer patient to specialist

Step 5 - Daily steroid tablets - lowest dose
Continue high dose inhaled corticosteroids

  • consider other treatments to minimize steroid use

Refer patient to specialist

44
Q

List 12 precipitating factors for an asthma attack

A
  • Pollen
  • Bugs in the house
  • Chemical fumes
  • Cold air
  • Fungus spores
  • Dust
  • Smoke
  • Strong odors
  • Pollution
  • Anger
  • Stress
  • Pets
  • Exercise
45
Q

What are the 5 names used to categories asthma attack severity

A
  • Near fatal
  • Life threatening
  • Acute sever
  • Moderate
  • Brittle
46
Q

What is brittle asthma? - there are 2 types

A

Type 1 - Wide PEF variability (>40% diurnal variation for >50% of the time over a period >150 days) despite intense therapy

Type 2 - sudden severe attacks on a background of apparently well-controlled asthma

47
Q

What is moderate asthma exacerbation?

A
  • Increasing symptoms
  • No features of acute sever asthma
  • PEF> 50-75% best or predicted
48
Q

What is acute sever asthma exacerbation?

A

Any one of -

  • PEF 33-50% best or predicted
  • Resp rate > 25/min
  • Heart rate > 110
  • Inability to complete sentences when breathing

Patient must be admitted

49
Q

What is life threatening asthma exacerbation? (13)

Think 33, 92, CHEST

A

One of the following

  • PEF <33% best or predicted
  • SpO2 <92%
  • PaO2 <8 kPa
  • normal paCO2 (4.6-6.0 kPa)
  • Silent chest
  • Cyanosis
  • Feeble respiratory effort
  • Bradycardia
  • dysrhythmia
  • hypotension
  • Exhaustion
  • Confusion
  • Coma

Call Call anaesthetist

50
Q

What is near fatal asthma exacerbation?

A

Raised PaCO2 and/or requiring mechanical ventilation with

raised inflation pressures

51
Q

When should a patient be discharged after being admitted with an asthma attack?

A

PEF >75% after 1 hour, unless:

Significant symptoms
Compliance concerns
Lives alone
Psychological/physical/learning
problems
Previous near fatal or brittle
asthma
Pre-existing steroids
Night time
Pregnant
52
Q

When a patient has been admitted with asthma which treatment would they be given?

A

ABCDE approach

Oxygen

  • High flow (aim >92% - 94-98%)
  • Give O2 driven nebulisers

IV fluids

  • Rehydration
  • Correct electrolyte imbalances
Drugs 
- Salbutamol 
- Hydrocortisone 
- Ipratropium bromide 
- Theophylline 
- Magnesium sulphate 
Reassess - every 15mins with PEFR
53
Q

How should salbutamol be administered in someone hospitalised with asthma?

A

Nebulised with oxygen -

2.5-5mg every 10 minutes

54
Q

How are the side effects of nebulised salbutamol?

A

Tremor
Arrhythmias
Hypokalaemia (monitor ECG)

55
Q

Why should the ECG of a patient being treated with nebulised salbutamol be monitored?

A

Hypokalaemia (monitor ECG)

56
Q

How should hydrocortisone be administered in someone who has been hospitalised with asthma?

A

IV 100-200mg QDS
Corticosteroid

Prednisolone PO 40mg OD

Can cause systemic side effects

57
Q

How should Ipratropium bromide be administered in someone who has been hospitalised with asthma?

A

Nebulised with oxygen

500 micrograms every 4-6 hours

58
Q

What type of drug is Ipratropium bromide?

A

Muscarinic receptor antagonist

59
Q

How should Magnesium sulphate be administered in someone who has been hospitalised with asthma?

A

1.2 – 2 grams over 20 minutes IV

Acute severe asthma

60
Q

What is the mechanism of action for Theophylline? When should the drug be used?

A

Inhibit phosphodiesterase and increase cAMP

Life-threatening asthma with
Senior guidance

61
Q

What are the side effects of Theophylline?

A

Palpitations

Arrhythmias

Nausea

Seizures

Alkali burns if extravasation occurs

Drug interactions

62
Q

When should ITU be involved in a patients treatment of asthma at hospital?

A

In ventilatory support required

Life threatening / acute severe not improving

63
Q

After treating a patient in hospital with sever asthma, what should you continue to monitor while they are in hospital?

A

Regular peak flow

Oxygen saturation

ABG- Repeat at 1 hour if:
Hypoxic
Normo-hypercapnoeic
Patient deteriorates

Bloods-
Potassium
Glucose

ECG -
K+ ; Mg 2+ ; b2

64
Q

After being discharged from hospital due to a sever asthma attack how often should a patient be followed up?

A

Follow up Within 48h (can be by hospital, GP, nurse

Follow up again in <30days after discharge by GP or specialist nurse or respiratory clinic appointment

65
Q

In someone having an acute asthma attack and has been admitted to hospital - what is the first line treatment

A
  1. Salbutamol, oxygen, steroids

ipratropium bromide

66
Q

In someone having an acute asthma attack and has been admitted to hospital - what is the second line treatment

A
  1. Magnesium sulphate
    beta 2 antagonist infusion (those not responding)

Aminophylline/ theophylline - levels should be checked daily

CR3 (10 decks)

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