Asthma

Question 1

What is the lifethreatening peak flow for asthma?

Answer 1

PEFR <33% baseline

Question 2

Criteria for asthma patinet -> hospital

Answer 2

-Can’t finish sentence
Blue inhaler more than hourly
RR over 20

Question 3

When is asthma worse

Answer 3

First thing morning and at night - diurnal variation in PEFR

Question 4

What is asthma?

Answer 4

Chronic inflammatory condition of the AWs characterised by hyperresponsiveness and constriction in response to variety of stimuli
Intermittent symptoms but inflammation can lead to irreversible AW obstruction

Question 5

Pathophysiology of asthma

Answer 5

Excessive Th2 mediated IgE immune response to exposure of environmental pathogen.
IgE bonds to bronchial mast cells -> degranulation + release of pro inflammatory mediators

Question 6

Phases of inflamamtion

Answer 6

Acute phase - bronchosconstirction and AW oedema
Delayed phase - bronchial hyperresponsiveness

Question 7

How does the delayed phase of asthma cause bronchial hyperresponsiveness?

Answer 7

Delayed phase = Pro inflammatory mediators eg IL5 recruit eosinophils, basophils and Th2 lymphocutes -> inflammation, sensitisation of sensory nerve endings, -> bronchial hyperresponsiveness

Question 8

What is the acute phase of asthma?

Answer 8

bronchosconstriction + AW oedema - within minutes exposure, resolves within hours

Question 9

Risk factors for asthma

Answer 9

Personal history of atopy - eczema, hayfever
FH asthma or atopy
Inner city environment, socioeconomic deprivation
Obesity
Prematurity and low birth weight
Viral infections in early childhood
Smoking
Maternal smoking
Early exposure to broad spectrum antibiotics

Question 10

Asthma triggers

Answer 10

Resp inections
Cold air
Exercise
Pollution
Allergens eg pollen, dust mites, animals
Time of day
Work related
Drugs eg beta blockers, NSAIDs
Emotional factors eg stress, laughter
GORD

Question 11

Symptoms of asthma

Answer 11

Intermittent SOB
Wheeze - polyphponic
Cough often nocturnal, with or without sputum

Question 12

Asthma signs

Answer 12

Decreased chest expansion
Bilateral polyphonic wheeze
Tachypnoea
Tachycardia
Reduced air entry
Hyperinflated chest

Question 13

Complications of asthma

Answer 13

Pneumonia
Pneumothorax
Pneumomediastinum
Respiratory failure and arrest
Pulmonary collapse

Question 14

Investigations for acute asthma

Answer 14

Bloods
ABG - if sPO2 <92%
CXR - rule out pneumonia/pneumothorax, normal or hyperinflation and flattened diaphram
Peak flow - % of patients previous best value
ECG - often sinus tachycardia

Question 15

Investigations for chronic asthma

Answer 15

Spirometry
Peak flow
FeNO

Question 16

Bloods in acute asthma and what for

Answer 16

FBC - raised WCC + typically eosinophilia
U+Es - salbutamol -> hypokalemia
CRP - rule out infection

Question 17

What spirometry value is considered obstructive?

Answer 17

FEV1/FVC ratio under 70%

Question 18

What is the other option except spirometry for obstruction measuring?

Answer 18

Bronchodilator reversibility reversibility tes t indicated by improbement 12% FEV1 or more and increased involume 200ml

Question 19

What is PEFR useful for in asthma?

Answer 19

Monitoring patients with established astham
Basic
Diurnal variation

Question 20

What is FeNO?

Answer 20

Gold standard for diagnosing asthma, fractional exhaled nitric oxide
Measures level of NO in exhaled breath _ provides indication of eosinophilic inflammation in lungs - adults >40 = positive

Question 21

Grading of asthma

Answer 21

Moderate
Severe
Life threatening
Near fatal

Question 22

Moderate asthma parameters?

Answer 22

PEFR 50-75% predicted or best
Speech normal
RR <25/min
Pulse <110BPM

Question 23

What is the SpO2, PaO2 and PaCO2 in life threatening asthma?

Answer 23

SpO2 <92%
PaO2 <8kPa
‘Normal’ PaCO2

Question 24

Parameters for severe asthma

Answer 24

PEFR 33-50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse >110BPM

Question 25

Life threatening asthma symptoms

Answer 25

Altered consciousness level Exhaustion Arrhythmia Hypotension Cyanosis Silent chest Poor respiratory effort

Question 25

Life threatening asthma symptoms

Answer 25

Altered consciousness level Exhaustion Arrhythmia Hypotension Cyanosis Silent chest Poor respiratory effort

Question 26

When is life threatening asthma nearly fatal?

Answer 26

Raised PaCO2 and or requiring mechanical ventilation with raised inflation pressures

Question 27

Management of acute asthma

Answer 27

Sit patient up and high flow oxygen 15 L Nebulised beta 2 agonist - salbuatmol 5mg and nebulised antimuscarinic - ipatropium bromude 0.5mg Corticosteroid: prednisolone (40-50mg) or IV hydrocortisone Consider IV magnesium sulphate (1.2-2.0g IV over 20 min). If little response to above considerIV aminophylline ITU referral

Question 28

What is slabutamol?

Answer 28

Beta 2 agonist

Question 29

What is an antimuscarinic used in treatment of acute asthma?

Answer 29

ipatropium bromide - 0.5mg

Question 30

When refer acute asthma to ITU?

Answer 30

Fail to respond to theray eg Deteriorating PEF, persisting or worsening hypoxia, hypercapnia, resp acidosis, exhaustion, feeble respiration, drowsiness, confusion, altered consciousness state, respiratory arrest

Question 31

Management for acute asthma pneumonic

Answer 31

O SHIT ME Oxygen Salbutamol Hydrocortisone Ipatropium Theophylline Magnesium sulphate Escalation

Question 32

How does ipatropium work?

Answer 32

Antimuscarinic - prevent smooth muscle contraction in larger airways

Question 33

Management chronic asthma phase 1

Answer 33

Short acting beta agonist SABA eg Salbutamol If nto controlled on this SABA + low dose inhaled corticosteroid eg beclomethasone or budesonide

Question 34

Second stage chronic asthma management

Answer 34

Add Leukotriene receptor antagonist (LTRA) eg montelukast 10mg OD to existing SABA and low dose ICS

Question 35

What drug do you perscribe if a LTRA doesnt work in chronic asthma?

Answer 35

add a LABA (long acting beta agonist) eg formoterol, potnetially continuing LTRA if still responded a bit to it

Question 36

What are the options for unresponding chronic asthma?

Answer 36

MART - maintenance and reliever therapy incl low dose ICS eg symbicort (budenoside with formoterol) Long acting antimuscarinic receptor antagonist eg tiotropium , theophylline

Question 37

What class of drug is theophylline, tiotropium

Answer 37

Long acting antimuscarinic receptor antagonist

Question 38

Signs that asthma is unmanaged

Answer 38

Symtpoms are coming back - wheeze, tight chest, SOB, cough Nocturnal, waking up Symptoms interfering with ADL Using reliever inhaler 3x or more a week

Question 39

How many hours in between needing an inhaler counts as an asthma attack?

Answer 39

if more than every 4 hours - having an asthma attack, need to take emergency action

Question 40

When is someone having an asthma attack?

Answer 40

Need a reliever inhaler more than every 4 hours Difficult to walk or talk Difficult to breathe Wheezing a lot or have v tight chest or coughing a lot

Question 41

What to do in an asthma attack

Answer 41

Sit up straight and try and keep calm Take one puff of your reliever inhaler - blie every 30-60s, max of 10 puffs If feel worse or dont feel better after 10 puffs call 999 Repeat step 2 after 15 minutes while waiting for an ambulance See GP within 48 hours

Question 42

What to monitor in asthma review?

Answer 42

- Peak flow - Education - Symptom recognition - quality life indicators eg - symptoms during day - difficulty sleeping - usuial activities

Question 43

What to ask specifically in an asthma history?

Answer 43

- Best peak flow - Home nebulisers - Recent exacerbations and antibiotics - ICU admissions