Asthma

Question 1

Why would you use nebuliser instead of inhaler in acute asthma attack?

Answer 1

not technique dependent, patient doesn’t tire

Question 2

How can you class the severity of asthma attack?

Answer 2

Moderate, acute severe, life threatening. Only one feature of criteria for this to each classification to be true

Question 3

Name three features of acute severe asthma

Answer 3

can’t complete sentences in one breath
RR >25
Pulse >110
SpO2 >92%

Question 4

Name three features of life threatening asthma

Answer 4

SpO2 <92%
Silent chest
Arrhythmia
hypotension
Altered mental status, exhaustion 
cyanosis
PaO2 <8

Question 5

What is a near fatal sign of acute asthma

Answer 5

A rise in PCO2

Question 6

What is the treatment for acute asthma?

Answer 6

oxygen, salbutamol, ipratropium, steroid (prednisolone)

Question 7

Define chronic asthma

Answer 7

Episodic, reversible airway obstruction due to

bronchial hyper-reactivity to a variety of stimuli.

Question 8

Briefly describe the pathophysiology of asthma

Answer 8

Mast cell-Ag interaction → histamine release
Bronchoconstriction, mucus plugs, mucosal swelling
T H 2 cells release IL-3,4,5 → mast cell, eosinophil and
B cell recruitment
Airway remodelling

Question 9

Two causes of asthma?

Answer 9

Atopy-T1 hypersensitivity to variety of antigens

Stress- cold air, emotion, exercise

Toxins- smoking, pollution, drugs

Question 10

Name two drugs that causes symptoms of asthma

Answer 10

beta blockers

NSAIDs

Question 11

Three symptoms indicative of asthma?

Answer 11

Wheeze
Dry cough
Dyspnoea
Diurnal variation

Question 12

Two associations of asthma in history which would make diagnosis more likely?

Answer 12

Other atopic conditions

Family history

Question 13

Two investigations for asthma?

Answer 13

1. Spirometry with bronchodilator reversibility
2. Fractional exhaled nitric oxide
3. Peak flow variability- diary
4. Direct bronchial challenge test with histamine or metacholine

Question 14

Describe the drug ladder approach to treatment of asthma. Provide class and a drug example from each

Answer 14

1. SABA PRN- salbutamol
2. Add Low dose inhaled steroid (ICS)- beclometasone
3. Replace SABA with LABA- salmeterol
4. If control still poor, trial LAMA- tiotropium, leukotriene receptor antagonist- montelukast, theophylline
5. Titrate ICS to high dose.
6. Refer to specialist. Consider oral steroids

Question 15

Name two non-pharmacological approaches to managing asthma

Answer 15

1. Yearly asthma review
2. Advise exercise
3. Smoking/cannibis cessation
4. Yearly flu jab
5. Individual self-management programme

Question 16

MOA of ipratropium?

Answer 16

SAMA
acetylcholine antagonist via blockade of muscarinic cholinergic receptors
decreased contraction of the smooth muscles.

Question 17

Two signs of severe asthma?

Answer 17

 PEFR <50%
 RR >25
 HR >110
 Can’t complete sentence in one breath

Question 18

Two signs of life threatening asthma?

Answer 18

 PEFR <33%
 SpO 2 <92%, PCO 2 >4.6kPa, PaO 2 <8kPa
 Cyanosis
 Hypotension
 Exhaustion, confusion
 Silent chest, poor respiratory effort
 Tachy-/brady-/arrhythmias

Question 19

Two differentials for acute asthma?

Answer 19

pneumothorax
acute exacerbation of COPD
pulmonary oedema

Question 20

Treatment for acute asthma if moderate?

Answer 20

Sit upright
100% O2 via non-rebreathe mask (aim for 94-98%)
Nebulised salbutamol (5mg) and ipratropium (0.5mg)
Hydrocortisone 100mg IV or pred 50mg PO (or both)

Question 21

Treatment for severe/life threatening?

Answer 21

Senior help (should really do this from the beginning)
Consider ICU transfer
Aminophylline
IV salbutamol infusion
IV magnesium sulphate (don’t ever do this as a junior…requires you to monitor and deliver continually, very time consuming)

Question 22

What is the pattern of ABG in acute asthma?

Answer 22

initially respiratory alkalosis
Type 1 resp failure
Then respiratory acidosis- type 2 respiratory failure

Question 23

How can acute asthma be monitored?

Answer 23

O2 sats
RR
Peak flow
Chest auscultation 
Respiratory effort

Question 24

Which electrolyte must be monitored whilst on salbutamol?

Answer 24

potassium- as this causes promotion of potassium absorption into cells

Question 25

Two side effects of corticosteroids?

Answer 25

diabetes, osteoporosis, hypertension, cushing’s syndrome, adrenal suppression, hyperlipidaemia, increased appetite…

Question 26

Two side effects of salbutamol?

Answer 26

mostly related to partial B1 activity, although much higher specificity for B1 receptors. Arrhythmia, flushing, tachycardia, hyperglycaemia, muscle cramps, headache, tremor

Question 27

Two side effects of antimuscarinics?

Answer 27

blurred vision, dry mouth, constipation, nausea

Question 28

MOA of theophylline?

Answer 28

non selective inhibition of PDEs, increases intracellular cAMP, bronchial smooth relaxation

Question 29

What happens to the FEV1, FVC, and FEV1/FVC in restrictive lung disease?

Answer 29

FEV1 and FVC reduced, FEV1/FVC ratio >70%

Question 30

What does a transfer factor test measure?

Answer 30

is a measurement of the ease of transfer for CO molecules from alveolar gas to the hemoglobin of the red blood cells in the pulmonary circulation.

Question 31

What is the most significant histological finding in asthma?

Answer 31

airway smooth muscle hypertrophy

Question 32

Patient with asthma, her condition is deteriorating after getting a dog. She is already on ICS and LABA. Which drug should she now be prescribed?

Answer 32

allergic deterioration- montelukast

Question 33

Name two indicators for exacerbation of asthma, meaning that a change in treatment management is necessary

Answer 33

worsening in asthma control requiring ICS, overall asthma control score- nocturnal wakening, increased frequency of salbutamol, increased wheeze.