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MBBS 3: Internal Medicine > Asthma > Flashcards

Asthma Flashcards

1
Q

What is asthma?

A

Paroxysmal, recurrent attacks of cough, wheeze and dyspnea due to reversible airways narrowing with inflammation and hyper-responsiveness

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2
Q

Asthma risk factors and triggers?

A
  1. Genetic predisposition
  2. Often precipitated by environmental triggers
  3. Hormonal factors
  4. Gastrointestinal Reflux
  5. Stress
  6. Drugs: beta-blockers, NSAIDs
  7. Occupational Asthma
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3
Q

State environmental triggers of asthma?

A
  1. Allergens
    e.g. dust, pets, pollens, occupational
  2. Infections
    e.g. viral
  3. Environmental pollutants
    e.g. smoke, dust
  4. Physical factors
    e.g. cold air, exercise, hyperventilation
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4
Q

What is occupational asthma?

A

it is characteristically associated with symptoms at work with relief on weekends and holidays
- If removed from exposure within the first 6 months of symptoms, there is usually complete recovery

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5
Q

Describe the hormonal asthma trigger?

A
  • Some women show premenstrual worsening of asthma, which can occasionally be very severe
  • are related to a fall in progesterone and in severe cases may be improved by treatment with high doses of progesterone
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6
Q

What is the pathophysiology of asthma?

A
  1. genes predisposing to allergies + lack of early Th1 stimulation = increase Th2 expression
  2. Th2 releases IL-4 and IL-3
  3. B cells are activated and release IgE antibodies
  4. mast cells are activated by the IgE antibodies and allergens
  5. mast cells release histamine, leukotrines and cytokines
  6. there is a hyperactive response - bronchospasm, edema, airway obstruction
  7. there is chronic inflammation and tissue remodeling
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7
Q

Roles of Th1 and Th2?

A

Th1 - protective immunity
Th2 - allergic disease e.g. asthma

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8
Q

Factors favoring Th1 phenotype?

A
  1. presence of older sibling
  2. early exposure to day care
  3. TB, measles, hepatitis A infection
  4. rural environment
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9
Q

Factors favoring Th2 phenotype?

A
  1. widespread use of antibiotics
  2. western lifestyle
  3. urban environment
  4. diet
  5. sensitization to house dust mites and cockroaches
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10
Q

Clinical features?

A
  1. Episodic breathlessness
  2. cough
  3. expiratory wheezing
  4. Specific triggers (clinical history!)
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11
Q

What 2 clinical tests will show you characteristic features of asthma?

A
  1. peak flow diary
  2. spirometry
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12
Q

Peak flow diary in asthma?

A
  • normal PEFR is 300-700 litres/min
  • shows >20% diurnal variation on > / = 3 days in a week for two weeks
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13
Q

Explain the diurnal variation in the peak flow diary?

A

in the morning our bronchioles are more constricted so that’s when asthma patients usually have their exacerbations

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14
Q

Spirometry features in asthma?

A

decrease in FEV1 > 15% in response to stimulus challenge
e.g exercise, histamine, metacholine
Note: FEV1 improves by ≥ 12% and ≥ 200mls with bronchodilators

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15
Q

What is the skin pricktest for asthma?

A

a medical provider pricks your skin using a needle with a small amount of allergen
- if you are allergic the spot will get red, swollen and itchy

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16
Q

How does spirometry work?

A

a spirometer measures the amount of air you can breathe out in one second and the total volume of air you can exhale in one forced breath
- these measurements will be compared with the expected normal result for someone of your age, height and sex

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17
Q

Classification of drugs for asthma?

A
  1. bronchodilators
  2. leukotriene antagonists
  3. mast cell stabilizers
  4. corticosteroids
  5. anti Ig-E antibody
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18
Q

Bronchodilator classses and drugs?

A
  1. Beta-sympathomimetics
    - salbutamol, terbutaline, bambuterol, salmeterol
  2. methyl xanthines
    - theophylline, aminophylline
  3. anticholinergics
    - ipatropium bromide, tiotropium bromide
19
Q

Leukotriene antagonist drugs?

A
  1. montelukast
  2. zafirlukast
20
Q

Mast cell stabilizer drugs?

A
  1. sodium chromoglycate
  2. ketotifen
21
Q

Corticosteroids drugs?

A
  1. systemic
    - hydrocortisone, prednisolone
  2. inhalational
    - bevlomethasone, budesonide, fluticasone, flunisolide
22
Q

Anti Ig-E antibody?

A

omalizumab

23
Q

Features of mild asthma?

A
  1. undistressed
  2. RR < 25
  3. HR > 110bpm
  4. O2 stats > 97%
  5. PEFR > 75% predicted
24
Q

Treatment of mild asthma?

A
  1. 5mg salbutamol nebulizer
    OR
  2. salbutamol 4-10 puffs pMDI
    - repeat every 20 mins and reassess in 1 hr
    - discharge if stable
25
Q

Features of moderate asthma?

A
  1. distressed but no signs of severe asthma - can complete a sentence
  2. PEFR 50-75%
26
Q

Treatment of moderate asthma?

A
  1. salbutamol 4-10 puffs pMDI or spacer
    - repeat every 20 mins for 1 hr
    OR
  2. 5mg salbutamol nebulizer
    - repeat after 15-20 mins
  3. prednisolone 40mg PO od
    - observe overnight
27
Q

What do you discharge mild and moderate asthma on?

A
  1. prednisolone 40mg PO od for 5-7 days
    - prednisolone 1mg/kg (max 50 mg od)
  2. salbutamol inhaler
  3. beclomethasone inhaler 2 buffs bd
  4. see clinic in 4-6 weeks
28
Q

Signs of severe asthma?

A
  1. distressed with signs of severe asthma
  2. cannot complete a sentence
  3. RR>25
  4. HR>110bpm
  5. O2<97%
  6. PEFR- 33-50%
29
Q

Treatment of severe asthma?

A
  1. 5 mg salbutamol nebulizer
    - repeat every 20 minutes for i hr and then reassess O2 supplement (aim 93-95%)
  2. prednisolone 40mg PO od
  3. magnesium sulphate 2g slow IV (over 20 mins) stat (dose 40mg/kg max 2g)
  4. +/- aminophylline IV (250 mg slow over 20 mins)
30
Q

Signs of life threatening asthma?

A
  1. exhausted
  2. drowsy
  3. confused
  4. silent chest
  5. cyanotic O2 stats <92%
  6. PEFR 33%
31
Q

Treatment of life threatening asthma?

A
  1. 5mh salbutamol nebulizer and repeat every 10-20 mins for reassess O2 supplement
  2. prednisolone 40mg PO od or IV hydrocortisone 2–mg 6-8 hrly
  3. magnesium sulphate 2g slow IV
  4. +/- aminophylline IV
  5. ICU review for elective intubation and mechanical ventilation
32
Q

Ongoing care for severe and life threatening asthma?

A
  1. regular medical review
  2. if no improvement, needs ITU review
    - consider pneumothorax
    - chest infection
    - other respiratory pathology
  3. ensure adequate hydration
    - including IV fluids
33
Q

Treatment of a mild/moderate asthma attack?

A
  1. Carefully teach and monitor correct inhaler technique
  2. Salbutamol inhaler 4-10 puffs via a spacer device or salbutamol nebulizer repeated as required initially, then every 8 hours
  3. Keep under observation at least 24 hours after the attack
34
Q

Clinical signs of life threatening asthma?

A
  1. Silent chest
  2. Central cyanosis
  3. Tachypnoea RR > 30
    - exhaustion
    - inability to speak through a sentence
  4. Persistent tachycardia > 110 bpm
    - bradycardia
    - hypotension
    - pulsus paradoxus
  5. Use of accessory muscles
  6. Confusion, agitation, coma
  7. Peak flow < 33 % of predicted
35
Q

What to do for life threatening asthma?

A

immediate hospitilization

36
Q

Severe/life threatening asthma differentials?

A
  1. Acute LVF
  2. Pneumothorax
  3. PE
  4. Upper airways obstruction
  5. Massive pleural effusion
  6. Severe pneumonia
37
Q

Severe asthma treatment?

A
  1. IV line, rehydrate with 0.9% NS
  2. High flow oxygen 5l/min
  3. Salbutamol nebuliser solution 5 mg by nebulizer
    - repeat as required (every 15-30 min), then q 6 hrs
    or Salbutamol MDI 4 puffs via spacer
  4. Hydrocortisone 200mg iv q 8 hours 3-5 days
  5. If you use steroids > 10 days, gradually taper the dose for steroids, 10 mg per week initially, and decrease by 5 mg until you stop.
  6. Antibiotic: Amoxycillin 500 mg q 8 hours or Doxycycline
38
Q

What to do if there is no improvement in treatment for severe asthma?

A
  1. add Aminophylline 250 mg slow over 10 min
  2. If no response:
    - Aminophylline 250 mg over 12 hours
    - Magnesium sulphate 1.2-2 g iv over 20 min
    - Adrenaline 0.5-1.0 ml of 1:1000 slowly nebulised or i.m.
39
Q

Management of acute asthma principles?

A
  1. Exclude other conditions:
    - stridor and upper airway obstruction (inspiratory difficulty rather than expiratory wheeze of asthma)
    - heart failure
  2. Give antibiotics
    - only with evidence of precipitating infection
40
Q

What to do before discharge of n acut asthma attack?

A

Check correct use of Metered Dose Inhaler (MDI) in your patients
- use a spacer device, especially during attacks.
- Can use plastic bottle (cut hole in bottom of bottle), shake MDI before use, prime bottle with 2 puffs

41
Q

Maintenance and preventive treatment of asthma?

A

STEP 1: Salbutamol MDI with Spacer
STEP 2: if required more than once every day add inhaled steroid (Beclamethasone 2 puffs) BID, increase to 4 puffs as required
STEP 3: Refer to specialist if not controlled

42
Q

Describe assessment of symptom control?

A

in the past 4 weeks has the patient had:
1. daytime symptoms more than twice a week
2. any night waking due to asthma
3. SABA reliever needed more than twice a week
4. any activity limitation due to asthma

43
Q

Classifying level od asthma control?

A
  1. well controlled - none
  2. partly controlled - 1-2 symptoms
  3. uncontrolled - 3-4 symptoms
44
Q

Stepwise management of asthma?

A
  1. mild intermittent
    - SABA
  2. mild persistent
    - SABA
    - ICS low dose
  3. moderate persistent
    - SABA
    - ICS low dose
    - LABA
  4. severe persistent
    - SABA
    - ICS high dose
    - LABA
  5. very severe persistent
    - SABA
    - ICS high dose
    - LABA
    - OCS

MBBS 3: Internal Medicine (72 decks)

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