Asthma

Question 1

What are the RFs for developing asthma?

Answer 1

• family history (of asthma or atopy)
• antenatal: maternal smoking, viral infection during pregnancy (especially RSV) , low birth weight
• maternal: no breast feeding, smoking around child
• exposure to high conc. of allergens: house dust mites or pollution
• hygiene hypothesis: reduced exposure to infective agents in childhood leading Th2 predominance

Question 2

What medical conditions is asthma related to?

Answer 2

atopic triad:
eczema + hay fever

samter’s triad: nasal polyps + aspirin sensitivity

Question 3

Asthma Diagnosis

1. At what age should objective tests be carried out in order to give an asthma diagnosis
2. How is diagnosed in
   a) people >17
   b) children 5-16

Answer 3

1. > 5 years old
2. a)
   - bronchodilator reversibility test (spirometry before and after medication)
   result: improvement of FEV1 by >12% AND >200ml
   - FeNO test (fractional exhaled nitric oxide test - nitric oxide released by inflammatory cells)
   result: >40 parts per billion positive

b)
- bronchodilator reversibility test (BRT)
result: improvement of >12%
- FeNO requested IF normal spirometry or negative (BRT)
result: >35 parts per billion positive

Question 4

What clinical features are classically seen in asthma?

Answer 4

• cough: worse at night
• dyspnoea
• “wheeze” “chest tightness”

signs:
- expiratory wheeze
- reduced peak expiratory flow rate

Question 5

Describe how asthma is managed in adults

Answer 5

Step 1: SABA

Step 2: SABA + ICS
(go straight to step 2 if symptoms 3 times a week or waking at night)

Step 3: add LTRA

Step 4: add LABA (only continue LTRA if patient has responded)

Step 5: change ICS and LABA for low dose ICS maintenance and reliever therapy (MART)
(MART is combi inhaler with ICS and fast acting LABA to be used PRN supplying daily maintenance and relief of symptoms)

Step 6: change to moderate dose ICS MART or simply moderate dose ICS and LABA

Step 7: add LAMA or theophylline or seek professional advice

Question 6

State an example for each of the following medications

1. SABA
2. ICS
3. LABA
4. Leukotriene receptor antagonist

Answer 6

1. salbutamol
2. • beclometasone
   • fluticasone
3. salmeterol
4. montelukast

Question 7

What side effects can be seen in

1. SABA
2. ICS

Answer 7

1. tremor
2. • oral candida
   • stunted growth in children

Question 8

What is seen as a

1. low
2. moderate
3. high

dose of ICS

Answer 8

1. <400mcg budesonide or equivalent
2. 400-800 mcg budesonide or equivalent
3. > 800 mcg budesonide or equivalent

Question 9

Stepping down treatment

1. How often should you consider stepping down treatment?
2. When you reduce ICS dose, by how much should you do so at a time?

NOTE: this is reducing ICS only - not the other medications

Answer 9

1. every 3 months

2. 25-50%

Question 10

Occupational Asthma

1. What clinical feature is seen?
2. What are the most common chemicals to cause it?
3. What investigation is done?
4. How is it managed?

Answer 10

1. patients that present with symptoms are better away from work / at weekends
   OR
   patient may suspect occupational hazard from work themselves
2. isocyanates
   e. g. spray painting or foam moulding using adhesives
3. serial peak flow both at and away from work
4. referral to resp. specialist

Question 11

When is acute asthma described as the following:

1. moderate
2. severe
3. life-threatening

Answer 11

1. • PEFR>50%
   • can talk in complete sentences
   • RR<25
   • HR <110 bpm
2. • PEFR 33-50%
   • cannot talk in complete sentences
   • RR>25
   • HR>110bpm
3. • PEFR <33%
   • silent chest / feeble resp effort
   • cyanosis / O2 sats <92%
   • bradycardia / dysrhythmia / hypotension
   • exhaustion / confusion / coma
     ALSO normal pCO2 is life-threatening as indicates exhaustion

Question 12

When and what investigations would be carried out in acute asthma?

Answer 12

ABG if sats <92%

CXR:

• life threatening
• failure to respond to treatment
• suspected pneumothorax

Question 13

When should someone with an asthma attack be admitted to hospital?

Answer 13

• life-threatening
• severe which fails to respond to treatment
• previous near fatal attack
• pregnancy
• take ICS
• presentation at night

Question 14

How is acute asthma managed?

Answer 14

O2
SABA
prednisolone: 40-50mg PO daily
ipratropium: in severe or life-threatening or no response to SABA
IV magnesium sulphate
IV aminophylline to be considered by senior team

Question 15

When can a patient who has had an asthma attack be discharged from hospital

Answer 15

• 12-24 hrs stable on discharge medication
• PEFR>75% of expected
• inhaler technique checked