Asthma

Question 1

Definition of asthma

Answer 1

Chronic inflammatory airway disease leading to variable airway obstruction

Type 1 hypersensitivity reaction

Question 2

Risk factors for asthma

Answer 2

Personal or family history ofatopy

Antenatal factors: maternal smoking, viral infection during pregnancy (especially RSV)

Low birth weight

Not being breastfed

Maternal smoking around child

Exposure to high concentrations of allergens (e.g. house dust mite)

Air pollution

Question 3

Common asthma triggers

Answer 3

Dust (house dust mites)

Animals

Cold air

Exercise

Smoke

Fool allergens (e.g. peanuts, shellfish, eggs)

Question 4

Symptoms of asthma

Answer 4

Cough (often worse at night)

Dyspnoea

Wheeze

Tight chest

Question 5

Asthma signs

Answer 5

Expiratory wheeze on auscultation

Reduced PEFR

Question 6

Pathophysiology of asthma

Answer 6

Smooth muscle in airways is hypersensitive, and responds to stimuli by constricting and causing airflow obstruction

Question 7

Asthma investigations

Spirometry

Answer 7

Forced expiratory volume (FEV1) - significantly reduced

Forced vital capacity (FVC) - normal

Question 8

Asthma investigations

Answer 8

Spirometry

Fractional exhaled nitric oxide (FeNO)

Question 9

Asthma investigations

FeNO

Answer 9

Nitric oxide produced by 3 types of nitric oxide synthases (NOS)

One of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils

Levels of NO therefore typically correlate with levels of inflammation

Question 10

Asthma management in under 5s

Answer 10

1) SABA inhaler e.g. salbutamol as required
2) Add low dose corticosteroid inhaler or leukotriene antagonist e.g. oral montelukast
3) Add other option from step 2
4) Refer to specialist

Question 11

Asthma management in 5-12s

Answer 11

1) SABA
2) SABA + paeds low-dose ICS
3) SABA + paeds low-dose IC + LTRA
4) SABA + paeds low-dose ICS + LABA
5) SABA + switch ICS/LABA for MART (including paeds low-dose ICS)
6) SABA + paeds low-dose ICS MART or change back to fixed dose of moderate-dose ICS and separate LABA

7) SABA + one of the following:
- Increase ICS to paeds high-dose
- Trial of additional drug e.g. theophylline
- Seek advice from asthma expert HCP

Question 12

Maintenance and reliever therapy (MART)

Answer 12

Form of combined ICS and LABA treatment in which a single inhaler (containing ICS and fast-acting LABA) is used for both daily maintenance therapy and relief of symptoms as required

Question 13

Inhaler technique (without spacer)

Answer 13

Remove the cap

Shake the inhaler (depending on the type)

Sit or stand up straight

Lift the chin slightly

Fully exhale

Make a tight seal around the inhaler between the lips

Take a steady breath in whilst pressing the canister

Continue breathing for 3 – 4 seconds after pressing the canister

Hold the breath for 10 seconds or as long as comfortably possible

Wait 30 seconds before giving a further dose

Question 14

Inhaler technique (with spacer)

Answer 14

Assemble the spacer

Shake the inhaler (depending on the type)

Attach the inhaler to the correct end

Sit or stand up straight

Lift the chin slightly

Make a seal around the spacer mouthpiece or place the mask over the face

Spray the dose into the spacer

Take steady breaths in and out 5 times until the mist is fully inhaled

Question 15

Acute asthma definition

Answer 15

Rapid deterioration in the symptoms of asthma

Question 16

Clinical features of acute asthma

Answer 16

Progressively worsening shortness of breath

Signs of respiratory distress

Tachypnoea

Expiratory wheezeon auscultation heardthroughout the chest

Chest can sound “tight” on auscultation, with reduced air entry

Silent chest (life-threatening, easily mistaken for no wheeze/distress)

Question 17

Features of moderate asthma

Answer 17

Peak flow >50% predicted

Normal speech

Question 18

Features of severe asthma

Answer 18

Peak flow <50% predicted

Saturations <92%

Unable to complete sentences in one breath

Signs of respiratory distress

RR >40 in 1-5s, >30 in >5s

HR >140 in 1-5s, >125 in >5s

Question 19

Features of life-threatening asthma

Answer 19

Peak flow <35% of predicted

Saturated <92%

Exhaustion and poor respiratory effort

Hypotension

Silent chest

Cyanosis

Altered consciousness/confusion

Question 20

Management of acute asthma

Answer 20

Supplementary O2 (if sats <90 or working hard)

Bronchodilators (salbutamol, ipratropium, magnesium sulphate)

Steroids (prednisolone orally, hydrocortisone IV)

Abx if bacterial cause suspected (amoxicillin or erythromycin)

Question 21

Outline bronchodilator step-up

Answer 21

Inhaled or nebulised salbutamol(beta-2 agonist)

Inhaled or nebulised ipratropium bromide(anti-muscarinic)

IVmagnesium sulphate

IVaminophylline

Question 22

Mild acute asthma management

Answer 22

Managed as outpatient with regular salbutamol inhalers via spacer

4-6 puffs every 4hrs

Question 23

Management of moderate to severe acute asthma

Answer 23

Stepwise approach until control achieved

Salbutamol inhalers via spacer starting with 10 puffs every 2hrs

Nebulisers with salbutamol/ipratropium bromide

Oral prednisolone

IV hydrocortisone

IV magnesium sulphate

IV salbutamol

IV aminiphylline

If still not controlled, call anaesthetist & ITU

Question 24

Prednisolone dose

Answer 24

2-5yrs: 20mg OD

> 5yrs: 30-40mg OD

Question 25

Acute asthma discharge criteria

Answer 25

Can be considered when child is well on 6 puffs 4 hourly salbutamol

Can be prescribed reducing regime of salbutamol to continue at home

Finish course of steroids if started

Safety-netting

Individualised written asthma action plan