Asthma Flashcards by Hannah Nolan

What is the lifethreatening peak flow for asthma?

PEFR <33% baseline

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Criteria for asthma patinet -> hospital

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

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When is asthma worse

First thing morning and at night - diurnal variation in PEFR

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What is asthma?

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

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Pathophysiology of asthma

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

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Phases of inflamamtion

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

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How does the delayed phase of asthma cause bronchial hyperresponsiveness?

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

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What is the acute phase of asthma?

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

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Risk factors for asthma

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

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Asthma triggers

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

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Symptoms of asthma

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

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Asthma signs

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

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Complications of asthma

Pneumonia
Pneumothorax
Pneumomediastinum
Respiratory failure and arrest
Pulmonary collapse

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Investigations for acute asthma

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

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Investigations for chronic asthma

Spirometry
Peak flow
FeNO

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Bloods in acute asthma and what for

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

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What spirometry value is considered obstructive?

FEV1/FVC ratio under 70%

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What is the other option except spirometry for obstruction measuring?

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

What is PEFR useful for in asthma?

Monitoring patients with established astham
Basic
Diurnal variation

What is FeNO?

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

Grading of asthma

Moderate
Severe
Life threatening
Near fatal

Moderate asthma parameters?

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

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

SpO2 <92%
PaO2 <8kPa
‘Normal’ PaCO2

Parameters for severe asthma

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

Life threatening asthma symptoms

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

Life threatening asthma symptoms

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

When is life threatening asthma nearly fatal?

Raised PaCO2 and or requiring mechanical ventilation with raised inflation pressures

Management of acute asthma

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

What is slabutamol?

Beta 2 agonist

What is an antimuscarinic used in treatment of acute asthma?

ipatropium bromide - 0.5mg

When refer acute asthma to ITU?

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

Management for acute asthma pneumonic

O SHIT ME Oxygen Salbutamol Hydrocortisone Ipatropium Theophylline Magnesium sulphate Escalation

How does ipatropium work?

Antimuscarinic - prevent smooth muscle contraction in larger airways

Management chronic asthma phase 1

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

Second stage chronic asthma management

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

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

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

What are the options for unresponding chronic asthma?

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

What class of drug is theophylline, tiotropium

Long acting antimuscarinic receptor antagonist

Signs that asthma is unmanaged

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

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

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

When is someone having an asthma attack?

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

What to do in an asthma attack

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

What to monitor in asthma review?

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

What to ask specifically in an asthma history?

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