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2. Respiratory Medicine (Lectures) > Asthma > Flashcards

Asthma Flashcards

1
Q

What is asthma characterised by?

A

Increased responsiveness of the trachea and bronchi to various stimuli and manifested by a widespread narrowing of the airways that changes in severity either spontaneously or as a result of therapy

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2
Q

Is bronchitis common?

A

Yes

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3
Q

Presentation of bronchitis

A

Loose rattly cough
Noisy breathing
Post tussive vomit (glut)

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4
Q

What is pertussis also known as?

A

Whooping cough

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5
Q

Pathology of bacterial bronchitis

A

Disturbed mucociliary clearance
Secondary infection following URTI

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6
Q

Causes of bronchitis

A

RSV
Adenovirus
Rhinovirus
Haemophilus

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7
Q

Pathology of asthma

A

Blocked airways because of mucus (luminal secretions)
Increased irritability
Bronchoconstriction
Airway wall thickening
Spontaneous or stimuli

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8
Q

Risk factors for asthma

A

Genetic
Occupation (painters, welding, labs, grains, bakers, antibiotics, salbutamol, crustaceans)
Smoking
Maternal smoking during pregnancy

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9
Q

Possible risk factors for asthma

A

Obesity
Diet
Reduced exposure to microbes/microbial products
Indoor pollution; chemical household products (volatile organic compounds, formaldehyde, fragrances, cleaning products)

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10
Q

Environmental allergens linked to asthma

A

House dust mite
Cats
Grass pollen

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11
Q

What is genetic atopy?

A

Inherited tendency to IgE response to allegens

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12
Q

Examples of atopy

A

Asthma
Eczema
Hay fever
Food allergy

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13
Q

What % of adult onset asthma is caused by occupation?

A

10-15%

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14
Q

What is higher BMI associated with in asthma?

A

Asthma
Wheezing
Airway hyperactivity

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15
Q

What is the allergen of house dust mite?

A

Protease in droppings

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16
Q

Types of onset of asthma

A

Infant onset
Childhood onset
Adult onset
Exertional asthma
Occupational asthma

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17
Q

Triggers of asthmatic symptoms

A

URTI (Rhinovirus in 75%)
Exercise
Allergen
Cold air
Emotion
Menstruation
Aspirin

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18
Q

What must be present for asthma to be diagnosed?

A

Wheeze

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19
Q

What children have asthma?

A

10 - 15%
M > F

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20
Q

What adults have asthma?

A

5 - 10%
F > M

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21
Q

What conditions can cause generalised airflow obstruction?

A

Asthma (reversible)
COPD (irreversible)
Bronchiectasis
Bronchiolitis
CF

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22
Q

Presentation of asthma

A

Wheeze
SOB at rest
Cough
Chest tightness/pain

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23
Q

Features of cough in asthma

A

Dry
Nocturnal
Exertional
Occasional sputum

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24
Q

What kind of symptoms must be present to diagnose asthma?

A

VARIABLE symptoms
- triggers
- daily variation (early morning/nocturnal)
- Weekly variation (occupation, better at weekends and holidays)
- annual (environmental holidays)

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25
Q

When is asthma generally worse?

A

Morning
Night

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26
Q

PMH associations of asthma

A

Childhood asthma
Eczema
Hayfever

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27
Q

Drugs associated with asthma

A

Aspirin
Complicance B blockers
NSAIDs

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28
Q

What would you ask about FH of asthma?

A

Atopic disease
Asthma

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29
Q

What social history would be associated with asthma?

A

Smoking
Pets
Occupation
Psychosocial

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30
Q

Possible signs of asthma

A

Breathlessness on exertion
Hyperexpanded chest
Polyphonic wheezes

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31
Q

What would a dull percussion note on examination indicate?

A

Lobar collapse
Effusion

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32
Q

What would crepitations on examination indicate?

A

Bronchiectasis
CF
Alveolitis
LVF

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33
Q

What is used in clinic to asses lung function in asthma?

A

Spirometry

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34
Q

How does spirometry work?

A

Deep breath in and blow out hard and fast
Best of 3 readings
Compare off chart

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35
Q

What is FEV1?

A

Forced expiratory volume in 1 second

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36
Q

What does FEV1 essentially measure?

A

Airway diameter

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37
Q

What does FVC essentially measure?

A

Lung capacity

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38
Q

If there is an obstructed picture, what should be done and what is involved?

A

Full pulmonary function testing
- Helium dilution
- CO gas transfer
Reversibility to bronchodilator
Reversibility to oral corticosteriods

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39
Q

Interpretation of reversibility to bronchodilator

A

15 mins post 400ug inhaled salbutamol
15 mins post neb 2.5-5mg salbutamol
Significant reversibility; difference in FEV 1 > 200ml and change in FEV1 > 15% baseline

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40
Q

What could cause no reversibility?

A

No bronchoconstriction
Severe bronchoconstriction

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41
Q

What does response to oral steroids separate asthma from?

A

COPD

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42
Q

What variability is present in asthma?

A

Morning/nocturnal dips
Decline over weeks/days
Variability >20% / highest

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43
Q

Diagnosis of occupational asthma

A

Suspicion from work related symptoms
Working with recognised occupational sensitizer
Serial peak flow readings (2 hourly best; 5 per day minimum)
Antibodies
+ve response to colophony

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44
Q

Useful investigations in asthma

A

CXR
- hyperinflated
- hyperlucent
Skin prick testing (atopic status)
Total and specific IgE (atopic status)
FBC - eosinophilia (atopy)

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45
Q

Differential diagnosis for asthma

A

Viral induced wheeze
Foreign body
CF
Immune deficiency
Ciliary dyskinesia
Tracheo-bronchomalacia
Aspiration, GORD

46
Q

What is anatomical space?

A

The air found in the conducting airways

47
Q

What is alveolar dead space?

A

Air in the alveoli who has been ventilated but not perfused

48
Q

What is physiological dead space?

A

Anatomical dead space plus alveolar dead space

49
Q

Obs of moderate asthma

A

Increasing symptoms - no features of severe
Able to speak complete sentences
HR < 110
RR < 25
PEF 50 - 75% predicted or best
Sa02 > 95% (No need for ABG)
Pa02 > 8kPa

50
Q

Features of severe asthma; any one of…..

A

Unable to speak, unable to complete sentences
HR > 110
RR > 25
PEF 33-50% predicted or best
Sa02 >92%
Pa02 > 8kPa

51
Q

Features of life threatening asthma; any one of….

A

Grunting
Impaired consciousness, confusion, exhaustion
HR >130 or bradycardic
Hypoventilating
PEF < 33% predicted or best
Cyanosis
Sa02 < 92%
Pa02 <8kPa
PaCO2 normal (4.6 - 6.0kPa)

52
Q

What indicates near fatal asthma?

A

Raised PaCO2

53
Q

If in doubt of asthma, what can be done?

A

Blood gas

54
Q

When is it unlikely to be asthma?

A

Under 18 months (most likely infection)
Isolated coughs
- Bronchitis
- Pertussis
- Habitual cough
- Tracheomalacia
- CF

55
Q

Features of cough in bronchitis

A

Wet cough

56
Q

Features of cough in tracheomalacia

A

Life long loud cough

57
Q

Goals of treatment for asthma

A

Minimal symptoms during day and night
Minimal need for reliever medication
No exacerbations (asthma attack)
No limitation of physical activity
Normal lung function (FEV1)

58
Q

How to measure control in asthma

A

SANE
- short acting beta agonist / week
- absence school / nursery
- nocturnal symptoms / week
- exertional symptoms / week

59
Q

Classes of medications used in asthma

A

Short acting beta agonists (SABA)
Inhaled corticosteriods (ICS)
Long acting beta agonists (LABA)
Leukotriene receptor antagonists (LTRA)
Theophyllines
Oral steriods

60
Q

S/Es of ICS

A

Height suppression (1cm)
Oral candidiasis
Adrenocortical suppression (very high doses)

61
Q

Advantages of ICS

A

Decreased HTN
Decreased cataracts

62
Q

What is a LABA always used with?

A

ICS

63
Q

What is the LTRA drug?

A

Montelukast

64
Q

Two types of delivery systems

A

MDI/Spacer
Dry powder device

65
Q

Lung deposition with and without spacer

A

Without - < 5%
With - < 20%

66
Q

What must be done to a spacer?

A

Washed monthly
Shaken between puffs to reduce static

67
Q

What ages are suitable for dry powder devices?

A

Licenced in > 5s, < 8s cannot use them

68
Q

Alternative management of asthma

A

Stop smoke exposure
Remove environmental triggers
- pets, house dust mites

69
Q

Treatment of acute asthma attack in adults - the escalation of care

A
  1. Oxygen
  2. Salbutamol nebulisers
  3. Ipratropium bromide nebulisers
  4. Hydrocortisone IV or Oral prednisolone
  5. Magnesium sulphate IV
  6. Aminophylline / IV salbutamol
70
Q

Drugs to avoid in asthma

A

Beta blockers
NSAIDs
Aspirin
Sedatives/strong opiates (unless in critical care)

71
Q

What does a pMDI (meter dose inhaler) require?

A

Coordination

72
Q

Benefits of using a pMDI with a spacer

A

Low oro pharyngeal deposition of aerosol
Reduced speed of aerosol
Decreases bad taste associated with aerosol deposition
Reduced risk of oral candidiasis and dysphonia with steriods
Reduced cold Freon effect in some

73
Q

What does SABA stand for?

A

Short acting beta agonist

74
Q

Examples of SABAs

A

Salbutamol
Terbutaline

75
Q

S/Es of beta 2 stimulants

A

Tremor
Cramp
Headache
Flushing
Palpitations
Angina

76
Q

Are side effects of B2agonists common or rare in inhaled steroids or oral steroids?

A

Inhaled - rare
Oral - common

77
Q

Examples of ICS (Preventers)

A

Beclomethasone
Budesonide
Fluticasone
Mometasone

78
Q

Long term S/Es of oral steriods

A

Red cheeks
Moon face
Fat pads / buffalo hump
Thin skin
High BP
Thin arms and legs
Osteoporosis
Poor wound healing
Pendulous abdomen
Red striation

79
Q

S/Es of long term inhaled steriods

A

Dysphonia
Oropharyngeal candidiasis

80
Q

What is dysphonia?

A

Hoarseness

81
Q

Examples of ICS + LABA

A

Fostair (beclomethasone with formoterol)
Symbicort (budenoside with formoterol)
Flutiform (fluticasone propionate with formetrol)

82
Q

Examples of LTRA

A

Monteleukast
Zafirlukast

83
Q

Who are LTRAs most effective in?

A

Those who are highly allergic

84
Q

How are LTRAs taken?

A

Oral

85
Q

What is theophylline?

A

Non specific phosphodiesterase inhibitor and adenosine receptor antagonist - weak bronchodilator

86
Q

S/Es of theophylline

A

Anorexia
Headache
Malaise
Vomiting
Nervousness
Abdo discomfort
Insomnia
Tachycardia
Tachyarrythmias
Convulsions

87
Q

Examples of LAMAs

A

Tiotropium bromide via spirivia respimat

88
Q

What does LAMA stand for?

A

Long acting anti muscarinic

89
Q

What is the main long term oral steroid used for asthma?

A

Prednisolone

90
Q

What can abrupt cessation of long term oral steroids lead to and when would this occur?

A

Acute adrenal insufficiency
> 3 weeks

91
Q

What happens in acute adrenal insufficiency?

A

Failure of adrenal glands to produced endogenous glucocorticoid

92
Q

What is Omalizumab?

A

Monoclonal antibody (mab) against IgE

93
Q

What is Omalizumab for?

A

IgE mediated severe allergic asthma

94
Q

What is meplolizumab and what is it used for?

A

monoclonal antibody (mab) against interleukin 5
Poor asthma control (long term steroid or frequent steroid) with blood eosinophillia

95
Q

What is sometimes tried as a last resort?

A

Immune suppressive drugs e.g. methotrexate, ciclosporin

96
Q

Non pharmacological methods of controlling asthma

A

Patient education and self management plans
Inhaler technique
Smoking cessation
Flu/pneumococcal vaccinations
Treating comorbidities (Obesity, allergic rhinitis, GORD)
Stepping down treatment when controlled
Allergen avoidance
Bronchial thermoplasty

97
Q

What is the first line preventer in < 5s?

A

LTRA

98
Q

What is the max dose of ICS used in children?

A

800 micrograms

99
Q

Stepladder approach of treating asthma

A
  1. SABA as required
  2. Regular preventer
    - very low dose ICS (or LTRA in < 5s)
  3. Add on preventer
    - add on LABA
    - add on LTRA
    - Increase ICS dose
100
Q

When is a regular preventer needed?

A

Using inhaled B2 agonists 3x a week or more
Symptomatic 3x a week or more, or waking one night a week
Exacerbations of asthma in last 2 years

101
Q

Management of acute asthma

A
  1. Mild
    - SABA via spacer
    - SABA via spacer and pred
  2. Moderate
    - SABA via nebuliser + pred
    - SABA + ipra via neb + pred
  3. Severe
    - IV salbutamol
    - IV aminophylline
    - IV magnesium (neb)
    - IV hydrocortisone
    - nebulised bronchodilators
    - intubate and ventilate
    - antibiotics if pneumonia/bacterial infection
102
Q

How much pred is given in acute asthma (mild/moderate) and for how long?

A

0.5 mg/kg/day for 7 days

103
Q

What type of drug is ipratropium?

A

SAMA

104
Q

How to assess patient with acute asthma?

A

Resp rate
Work of breathing
HR
O2 sats
Ability to complete sentences
Confusion
Air entry

105
Q

Age and features of cough COPD vs asthma

A

COPD - > 35 years - persistent and productive
Asthma - any age - intermittent and non productive

106
Q

SOB features asthma vs COPD

A

COPD - progressive and intermittent
Asthma - intermittent and variable

107
Q

Nocturnal symptoms COPD vs asthma

A

COPD - uncommon unless in severe disease
Asthma - common

108
Q

FH COPD vs asthma

A

COPD - uncommon unless family members also smoke
Asthma - common

109
Q

What does a Ph < 7.35 represent in asthma? What does it require?

A

CO2 retention in a tiring patient and is an ominous sign in acute asthma
Intubation and ventilation may be needed

110
Q

What does a normal PaCO2 in an acute asthma attack indicate?

A

Exhaustion and should be classified as life threatning

2. Respiratory Medicine (Lectures) (50 decks)

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