Asthma

Question 1

What is asthma ?

Answer 1

chronic inflammatory condition of the airways that causes episodic exacerbations of bronchoconstriction.

Question 2

What triggers asthma?

Answer 2

Infection
Night time or early morning
Exercise
Animals
Cold/damp
Dust
Strong emotions

Question 3

Asthma presentation ?

Answer 3

-Episodic symptoms
-Diurnal variability. Typically worse at night.
-Dry cough with wheeze and shortness of breath
-A history of other atopic conditions such as eczema, -hayfever and food allergies
-Family history
-Bilateral widespread “polyphonic” wheeze heard by a healthcare professional

Question 4

Presentation Indicating a Diagnosis other than Asthma

Answer 4

Wheeze related to coughs and colds more suggestive of viral induced wheeze
Isolated or productive cough
Normal investigations
No response to treatment
Unilateral wheeze. This suggests a focal lesion or infection.

Question 5

Diagnosis

Answer 5

First line investigations:

Fractional exhaled nitric oxide
Spirometry with bronchodilator reversibility
If there is diagnostic uncertainty after first line investigations these can be followed up with further testing:

Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks
Direct bronchial challenge test with histamine or methacholine

Question 6

Long Term Management

Answer 6

-Short acting beta 2 adrenergic receptor agonists, for example salbutamol.
-Inhaled corticosteroids (ICS), for example beclometasone. These reduce the inflammation and reactivity of the airways.
-Long-acting beta 2 agonists (LABA), for example salmeterol.
-Long-acting muscarinic antagonists (LAMA), for example tiotropium. These block the acetylcholine receptors. Acetylecholine receptors are stimulated by the parasympathetic nervous system and cause contraction of the bronchial smooth muscles.
-Leukotriene receptor antagonists, for example montelukast. Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in the airways
-Theophylline. This works by relaxing bronchial smooth muscle and reducing inflammation.
-Maintenance and Reliever Therapy (MART). This is a combination inhaler containing a low dose inhaled corticosteroid and a fast acting LABA.

Question 7

What are the NICE guidelines step ladder for treatment?

Answer 7

1) Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
2) Add a regular low dose inhaled corticosteroid.
3) Add an oral leukotriene receptor antagonist (i.e. montelukast).
4) Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
5) Consider changing to a maintenance and reliever therapy (MART) regime.
6) Increase the inhaled corticosteroid to a “moderate dose”.
7) Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
Refer to a specialist.

Question 8

Additional Management

Answer 8

Each patient should have an individual asthma self-management programme
Yearly flu jab
Yearly asthma review
Advise exercise and avoid smoking