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Asthma Flashcards

1
Q

Pt presents with cough, but no other symptoms. Has raised FeNO but no airway hyper-responsiveness. What is most likely diagnosis?

A

Eosinophilic bronchitis
- chronic cough but no lower airway symptoms (wheeze/SOB)
- raised FeNO and sputum Eos
- no airway hyper-responsiveness

–> treat with steroids and will always respond

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2
Q

Pt presents with cough, but no other symptoms. Has raised FeNO but no airway hyper-responsiveness. What is best treatment

A

Steroids

Eosinophilic bronchitis
- chronic cough but no lower airway symptoms (wheeze/SOB)
- raised FeNO and sputum Eos
- no airway hyper-responsiveness

–> treat with steroids and will always respond

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3
Q

Pt presents with throat tightness while exercising. What is most likely diagnosis?

A

Intermittent laryngeal obstruction
- Exercise-induced and symptoms at peak of exercise
- With exercise asthma, get 20mins after
- Can also be triggered by irritant, emotional stress

Clues: sudden onset, throat tightness, inspiratory noise

Treat: avoidance, SLT

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4
Q

Pt present with sudden onset throat tightness when stressed. What is best treatment?

A

Trigger avoidance and SLT.

Intermittent laryngeal obstruction
- Exercise-induced and symptoms at peak of exercise
- With exercise asthma, get 20mins after
- Can also be triggered by irritant, emotional stress

Clues: sudden onset, throat tightness, inspiratory noise

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5
Q

Pt presents with SOB, cough and wheeze. Found to have 52% of tracheal lumen collapse on review . What is diagnosis?

A

Excessive dynamic airways collapse (EDAC)
- posterior tracheal membrane collapse >50% lumen
- often co-exist with asthma/COPD
- symptoms: SOB, cough, wheeze

Treat: CPAP +/- stent (but response poor)

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6
Q

Pt presents with SOB. Gets score of 23 on Nijmengen score. What is diagnosis?

A

Breathing-pattern disorder
- Nijmengen score 23+/64

Treat: PT

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7
Q

Can asthma cause fixed airflow obstruction?

A

Yes if chronically untreated eosinophilic asthma as get airway remodelling

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8
Q

Pt has wheeze and SOB. What PEFR would be considered suggestive for asthma?

A

Variable of >10% when measured over 2 readings a day for at least 2 weeks. Each reading is best of 3.

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9
Q

What factors on spirometry suggestive of asthma?

A

FEV1/FVC <0.7 + increased by 12% and 200ml with bronchodilator (after 15mins)

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10
Q

What tests are there for bronchial hyper-responsiveness and what is positive?

A

Histamine or Metacholine challenge.

PC20 ≤8mg/ml considered positive
PC20 16mg/ml considered normal

(PC20 = mg/ml of metacholine required to give drop of FEV1 of 20%) nb. for mannitol, use 15%

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11
Q

What is considered a positive FeNO test?

A

> 40

25-39 intermediate and may warrant testing of bronchial hyperresponsiveness

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12
Q

What factors can artifically lower FeNO?

A

Smoking, steroids, leukotriene receptor antagonists, caffeine

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13
Q

What cause high FeNO?

A

Asthma
Allergic rhinitis
Eosinophilic bronchitis
(COPD, OSA, ILD)

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14
Q

What is FeNO measuring?

A

Indirect marker of Th2 inflammation i.e. IL4/13. Therefore won’t be reduced by IL5 inhibition

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15
Q

What are risk factors for dying from asthma?

A

Overuse of SABA for >1month
Underuse of ICS
Use of oral steroids
ED/hospital admissions
Previous near fatal asthma (ITU)
Psychosocial

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16
Q

What are risk factors for future asthma attacks?

A

Older age
Female
Reduced lung function
Obesity
Smoking
Depression

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17
Q

Pt with asthma takes PRN salbutamol. Still getting symptoms >3/week. What is next best appropriate therapy? When should this be reviewed?

A

Add low dose ICS. Review 4-8 weeks after

Also consider alternative diagnoses, poor adherence, inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal & environmental factors

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18
Q

Asthma pt taking salbutamol and beclametasone. Waking at night wheezing. What is next best treatment?

A

Add LABA. Review 4-8 weeks after
NICE says LRTA

Also consider alternative diagnoses, poor adherence, inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal & environmental factors

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19
Q

Pt with asthma taking SABA, ICS and LABA. Having to use SABA every day. What is next best treatment option?

A

Medium dose ICS or leukotriene-receptor antagonist. Review 4-8 weeks after

Also consider alternative diagnoses, poor adherence, inhaler technique, smoking, occupational exposures, psychosocial factors, seasonal & environmental factors

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20
Q

What is MART therapy in asthma?

A

Single maintenance and reliever therapy - only licensed for SABA and low dose ICS (although higher doses often used in reality)

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21
Q

When should you consider referral to a specialist in asthma?

A

Not controlled on moderate dose ICS
Diagnosis unclear
Suspect occupational
Poor response to treatment
Severe/life-threatening attack

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22
Q

Pt with well-controlled asthma becomes pregnant. What should they be told? Should any changes be made to asthma therapy?

A
  • Peak exacerbation in 3rd trimester
  • Leukotriene RA shouldn’t be stopped without careful consideration
  • Theophylline safe for preg and BF (but more monitoring as lower levels from increased metabolism and protein binding)
  • Tiotropium (LAMA) best avoided
  • if >7.5mg pred in 2 weeks before labour then give 100mg hydrocortisone qds during labour
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23
Q

What is definition of severe asthma for biologics consideration?

A

Needing high dose ICS + LABA or leukotriene/theophylline
OR 4xoral steroids is past year
OR steroids for >50% year

24
Q

What is Omalizumab and what are indications?

A

Anti-IgE (helps stop allergic p/w)

Criteria:
- Confirmed allergic-medicated severe asthma (perennial aeroallergens i.e. not seasonal)
- ≥4 pred in 12/12
- FEV1 <80%
- Symptoms
- Already on high dose ICS and LABA

–> dose based on weight and total IgE

25
Q

What are GINA treatment steps for asthma?

A

1) PRN SABA
2) Add low dose ICS (400-800)
3) Add LABA then if needed, increase ICS to 800 and consider LABA/leukotriene/theophylline/oral LABA
4) Increase ICS up to max of 2000, consider the other things from step 3
5) Refer to specialist care. Add oral steroids and lowest dose possible to maintain control

26
Q

What are SEs of omalizumab?

A

SE: headache, fatigue, muscle aches, local rash (nb. systemic rash unlikely)

Risk of anaphylaxis: need to give epipen

Nb. no need to stop during infections and IgE very specific to allergy pathway

27
Q

How monitor omalizumab?

A

Review at 16 weeks and consider stopping if no effect

28
Q

How is omalizumab given?

A

S/c every 2-4 weeks

29
Q

What is Mepolizumab and what are indications?

A

Anti-IL5

Severe asthma
+ [≥4 pred/yr + EP >0.3) OR [EP >0.4 + ≥3 pred]

Nb. EP >0.4 + ≥3 pred is same criteria as for benralizumab and reslizumab

Nb2. EP needs to be within last year (as gets suppressed by steroids)

30
Q

How should Mepolizumab be monitored?

A

Need clinically meaningful response at 1 year. Assess every year
- clinically meaningful reduction in exacerbations
- or clinically meaningful reduction in oral steroids

31
Q

How is Mepolizumab given?

A

S/c 1/12. Fixed dose.

32
Q

What are SE of Mepolizumab?

A

SE: headache, fatigue, muscle aches, local rash (nb. systemic rash unlikely)

Specific: shingles

33
Q

What is Reslizumab and what are indications for use?

A

Anti-IL5

Severe asthma
+ EP >0.4 + ≥3 pred

Nb. EP needs to be within last year (as gets suppressed by steroids)

34
Q

What are SE of Reslizumab?

A

SE: headache, fatigue, muscle aches, local rash (nb. systemic rash unlikely)

35
Q

How is Reslizumab given?

A

IV (only one that can be given this way). Weight-based dose

36
Q

What is Benralizumab and what are indications?

A

Binds NK cells and EP (causes apoptosis)

Severe asthma
+ [≥4 pred/yr + EP >0.3) OR [EP >0.4 + ≥3 pred]

Nb. EP needs to be within last year (as gets suppressed by steroids)

37
Q

How is Benralizumab given?

A

Month 1, 2, 3 then every other month

38
Q

What are criteria for continuing Benralizumab?

A

Need clinically meaningful response at 1 year. Assess every year
- clinically meaningful reduction in exacerbations
- or clinically meaningful reduction in oral steroids

Nb. all 1 year except Omalizumab which is 16 weeks

39
Q

Can macrolides be used in asthma?

A

Limited evidence that decrease exacerbations and increase QOL
- 50-70 years
- symptoms despite high dose ICS
- ≥1 oral steroids/year

40
Q

Why do you have to monitor asthma biologics yearly?

A

Can generate Ab to them therefore stop working

41
Q

What is bronchial thermoplasty and what is its role?

A

Heat treatment to reduce smooth muscles in airways. Dont’ really know who it will help.

Can be used in severe asthma not controlled with drugs. FEV1 >50% and no bronchiectasis

42
Q

What are diagnostic criteria for EGPA?

A

Score of 6+:

EP >1 = +5
Obstructive airways disease = +3
Nasal polyps = +3
PR3 ANCA (cANCA) = -3 (as pANCA most common)
Extravascular eosoinophilic-predominant inflammation = +2
Mononeuritis multiplex/motor neuropathy not due to radiculopathy = +1
Haematuria = -1

43
Q

What is mononeuritis multiplex?

A

Damage to at least 2 different areas of peripheral nervous system

44
Q

What is biggest cause of death in patients with EGPA?

A

Cardiomyopathy - recommend echo

45
Q

What is EGPA? What are symptoms?

A

Small to medium vessel vasculitis. Necrotising granulomatous disease (central eosinophilic core)

Constitutional: fatigue, wt loss, fever, muscle aches
Asthma
Paranasal sinusitis
Allergic rhinitis
Cough/haemoptysis
Athralgia
Peripheral neuropathy
GI - diarrhoea, colitis
Rash

46
Q

What is the treatment for EGPA?

A

1mg/kg pred if organ/life-threatening
+/- cyclophosphamide or rituximab

Low dose steroid if mild/mod disease

Remission/maintenance: methotrexate, azathioprine

47
Q

What is definition of moderate acute asthma exacerbation?

A

Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe

Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence

Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort

Near-fatal:
- increased pCO2
- mechanical ventilation

48
Q

What is severe acute asthma exacerbation?

A

Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe

Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence

Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort

Near-fatal:
- increased pCO2
- mechanical ventilation

49
Q

What is life-threatening acute asthma exacerbation?

A

Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe

Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence

Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort

Near-fatal:
- increased pCO2
- mechanical ventilation

50
Q

When do you need ABG in acute asthma exacerbation?

A

If SATS<92% or features of life-threatening

Moderate:
- Increased symptoms
- PEFR >50-75%
- No features of Severe

Severe
- PEFR 33-50
- RR≥25
- HR≥110
- Can’t finish sentence

Life-threatening:
- PEFR <33
- SATS <92%
- paO2 <8
- pCO2 4.6-6 (ie normal)
- reduced conciousness
- exhaustion
- arrhythmia
- low BP
- cyanosis
- silent chest
- poor resp effort

Near-fatal:
- increased pCO2
- mechanical ventilation

51
Q

When need CXR in acute asthma exacerbation?

A
  • if suspect PNX or consolidation
  • life-threatening
  • failure to respond to treatment
  • need ventilation
52
Q

When can you discharge pt with acute asthma exacerbation?

A

if moderate/severe exacerbation and PEFR >75% after 1 hour treatment

Admit if life-threatening or near fatal

53
Q

How treat acute asthma?

A

O2 to get SATS 94-98
High dose B2 agonist (neb is severe + consider continuous delivery)
Pred 40-50mg for 5d
Ipatropium 4-6hrly if severe of haven’t responded to previous treatment
Consider Iv Mg if poor response to above (NOT nebulised)

Abx not routine

54
Q

When inform GP after asthma exacerbation?

A

Within 24 hours of d/c

55
Q

What is considered ‘difficult asthma’

A

Symptoms/frequent attacks despite:
- high dose ICS
- medium dose ICS + additional therapy
- continuous/frequent PO steroid

Need to assess:
- diagnosis
- adherence
- psychosocial factors
- consider sputum EP monitoring to guide steroid treatmnet

Revision (17 decks)

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