Asthma Flashcards
What are the 3 most important questions to ask the patient at an asthma review?
- In the last month/week have you had difficulty sleeping due to your asthma (e.g. cough symptoms, SoB)?
- Have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, SoB) during the day?
- Has your asthma interfered with your usual daily activities?
What vaccinations are recommended in asthma?
Influenza
&
Pneumococcal
[& COVID-19?]
- Asthma pts aren’t more likely to get flu, but are more likely to get serious complication as it exacerbates their symptoms due to increased inflammation
- Flu can also lead to pneumonia
- Flu/coryzal symptoms: fever, cough, sore throat, rhinorrhoea, body aches, headache, chills, fatigue
How is flu treated in asthma patients?
- Start treatment ASAP, as it works best when started within 48hrs of symtpoms starting
- Drugs (anti-virals):
- Oseltamivir
- Peramivir
What non-modifiable factors influence a patients PEFR (Peak Expiratory Flow rate)?
- Age
- Height
- Ethnicity
- Gender
How would you explain to a patient how to use a Peak Flow meter?
- Ensure mouthpiece is inserted into peak flow meter
- Ensure dial is set to zero
- Technique:
- Sit/stand up straight
- Take as deep a breath as possible
- Form a tight seal with your lips around the mouthpiece
- Breath out as hard and as fast as you can
- Hold peak flow meter level horizontally
- Hold peak flow meter on the sides (make sure fingers don’t interfere with the dial)
- Ask patient to repeat back what you’ve told them
- Get patient to demonstrate technique
- Take 3 measurements and record the best of those measurements
How long does a patient record their PEFR and how often when diagnosing asthma?
How is this different in occupational asthma?
Diagnosis:
- Record PEFR twice daily (morning + bedtime) - for 2-4 weeks
Occupational asthma diagnosis:
- Record PEFR every 2-4 hrs over several weeks
What changes might be seen on peak flow diary pre- and post- preventer inhaler?
- PEFR values increase
- Diurnal variation is minimised (less difference between peaks and troughs)
What is an MDI inhaler? How does it compare to other inhaler types?
Are different inhaler formats as effective as one another?
- MDI = metered does inhaler (sometimes called pMDI = pressurised metered dose inhaler)
- Other types include:
- Turbohaler = breath activated dry powder inhaler
- Accuhaler = breath activated dry powder inhaler (circle shaped)
- In general, a pMDI + spacer = as affective as any other device for adults + children >5yrs
Explain to a patient how to use an inhaler with a spacer.
Method 1:
- Insert inhaler
- Form seal around spacer with lips at other end
- Squirt a dose into the spacer
- Take a breath + hold for 10 seconds
Method 2: (more popular with young children / elderly / coordination issues)
- Insert inhaler
- Form seal around space with lips at other end
- Squirt a dose into the space
- Breath in and out several times as normal
N.B. plastic spacers last ~6-12 months, clean once a month and leave to airdry (don’t towel dry, as it produces static which affects particle deposition)
What is a wheeze and what conditions can cause it?
Wheeze = sound caused by narrowing of airways resulting in high velocity airflow, mainly heard in upper airways and during expiration (can be inspiratory)
Some conditions causing wheeze:
- Asthma
- COPD
- Foreign body aspiration
- Heart failure
- Large goitre
- Mucus plugs produced by; pneumonia, CF, allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis
- Tumours
Consult a patient on how to use a metered dose inhaler.
- Check inhaler expiration date
- Shake the inhaler
- Check mouthpiece for dust/foreign objects
- If pt hasn’t used it before or in a while –> squirt 2 puffs into the air (check it’s working)
- Procedure
- Sit or stand upright
- Hold inhaler upright, thumb on bottom and 2 fingers on top
- Breath out normally
- Put mouthpiece in mouth, between teeth, forming a tight seal with lips
- Press down on the inhaler whilst taking a slow deep breath in
- Hold breath for up to 10 seconds
- Exhale
- Wait for 30 seconds
- Take second dose (many pts require 2 puff doses)
Define Asthma.
Define: Asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity
How would a patinet with new diagnosis of Asthma present?
- Hx: recurrent episdoes/attacks - confirmed by variablity in peak flow when asymptomatic vs symptomatic
-
Symptoms: wheeze, cough, SoB, chest tightness - which all vary over time and can be ‘triggered’ by; allergens (dust mites, pets, tobacco smoke, pollen), exposure (to cold air, particulates) occupation (bakers, farmers, carpenters, plastics, foams or glues) emotions (anxiety, stress, laughter)
- Symptoms exacerbated by common cold or sinisitus
- Evidence of diurnal variability in symptoms (worse at night or early morning?)
- Personal / FHx: of other atopic conditions; atopic eczema, atopic dermatitis, allergic rhinitis
- Wheeze confirmed via auscultation by healthcare proffesional
What factors should be discussed/monitored for an asthmatic patient in primary care?
- How well their symptoms are controlled?
- Lung function via spirometry or peak expiratory flow (PEF)
- Any asthma attacks?
- Inhaler technique
- Adherance to inhaled corticosteroid
- Bronchodilator reliance (reliever/blue inhaler use)
- Possession/use of a self-management personal action plan
- Green section = this is what I do to stay on top of my asthma
- Yellow section = my asthma is getting worse if I notice the following
- Red section = I am having an asthma attack if any of the following occur
What lifestyle changes can be suggested to Asthma pts?
- Smoking cessation
- Weight-loss (dietary + exercise programmes)
- Breathing exercise programmes (taught by physiotherapist)
All improve QoL and reduce symptoms
What are the characteristics of the following severities of Acute Asthma;
- Moderate Asthma
- Acute severe Asthma
- Life-threatening Asthma
Moderate Asthma:
- ↑ symptoms
- PEF >50 - 75% of predicted
- No features of acute-severe asthma
Acute-severe Asthma:
- PEF 33-50% of predicted
- RR >= 25
- HR >= 110
- Inability to complete scentences in one breath
Life-threatening Asthma:
- PEF <33% of predicted
- SpO2 < 92%
- PaCO2 > 6.0 but < 8.0 kPa (normal range = 4.6-6.0 kPa)
- Silent chest
- Cyanosis
- Poor respiratory effort
- Alterned conciousness
- Hypotension
Describe how a graph of Volume vs Time would look when a patient is asked to fully exhale after a maximal inhalation
How are FVC, FEV1 and PEFR measured from this graph?
Describe how FEV1 , FVC and FEV1 / FVC change in Obstructive and Restrictive Lung disease?
Obstructive:
- FEV1 : ↓↓ (to <80% of predicted)
- FVC : ↓ (can be normal but if decreased is to lesser extent that FEV1)
- FEV1 / FVC : < 70%
N.B. Severity of obstruction is determined by degree of ↓ in FEV1 (as % of predicted)
Restrictive:
- FEV1 : ↓ (to <80% of predicted)
- FVC : ↓ (to <80% of predicted)
- FEV1 / FVC : ≥ 70% (normal or increased)
What staging system is used to classify the severity of COPD?
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
- Classifies COPD severity based on post-bronchodilator FEV1
- N.B. correlation between FEV1 and QoL is LOW
GOLD Stage I = FEV1 ≥ 80%
GOLD Stage II = 50% ≤ FEV1 ≤ 80%
GOLD Stage III = 30% ≤ FEV1 ≤ 50%
GOLD Stage IV = FEV1 ≤ 30%
Examine the diagnostic algorithm for Asthma.
- For pts with high probability of asthma, what treatment is likely to be initiated in order to then assess pts response?
- If a pt does indeed have Asthma what could cause their response to treatment to be poor?
- Typically pts with high probability of Asthma are given a 6-week course of Inhaled Corticosteroids and then have lung function tested again for response
- Check that the patients inhaler technique and adherence if you suspect them of having asthma but their response to treatment is poor
What are the steps of escalation in treatment for Asthma?
- SABA
- +ICS
- +LTRA
- +LABA (MART preferred, -LTRA if it doesn’t work)
- Check diagnosis is right, ↑ ICS dose gradually
- Specialist help, +LAMA, +theophylline
