Asthma

Question 1

What is asthma?

Answer 1

A disease characterised by an increased responsiveness of the trachea and bronchi to various stimuli and manifested by a widespread narrowing of the airways that changes in severity either spontaneously or as a result of therapy.

Question 2

What word is asthma derived from?

Answer 2

Aazein - To pant heavily or gasp for breath

Question 3

Why is asthma important?

Answer 3

Common

Dangerous

Expensive

Question 4

What is the prevalence of asthma?

Answer 4

5.4 million on treatment incidence is higher in children but increasing in adults.

75% of hospital admissions for asthma are avoidable.

~1200 people die a year (women > men) 90% of deaths are preventable.

Question 5

What is the cost to Nhs?

Answer 5

£1 billion a year

60,000 admissions/year

Question 6

Asthma: the scale of the problem

Answer 6

5.4 million people living with asthma in the uk

Every 10 seconds someone is having a potentially life-threatening asthma attack in the uk

Every day, the lives of three families are devastated by the death of a loved one to an asthma attack - 2/3 of these deaths are preventable.

Question 7

Pathophysiology of asthma

Answer 7

Airway inflammation mediated by the immune system - Increased airway reactivity - Airway narrowing - Spontaneously stimuli

Airway inflammation mediated by the immune system - Widespread narrowing of airways.

Question 8

What is atopy?

Answer 8

-Atopy is the body’s predisposition to develop an antibody called immunoglobulin E (lgE) in response to exposure to environmental allergens and is an inheritable trait.

-Associated with allergic rhinitis, asthma, hay fever and eczema.

Question 9

What does a structured clinical assessment for asthma look like?

Answer 9

Recurrent episodes of symptoms

Symptom variability

Absence of symptoms of alternative diagnosis.

Recorded observation of wheeze

Personal history of atopy

Historical record of variable PEF or FEV.

Question 10

What are the symptoms of asthma?

Answer 10

Wheeze

Shortness of breath (dyspnoea), severity.

Chest tightness

Cough, paroxysmal, usually dry

Sputum (occasional)

Question 11

What is normal peak expiratory flow rate?

Answer 11

80-100% of predicted

Question 12

What type of hypersensitivity is asthma?

Answer 12

Type 1

Question 13

What is the main cause of chronic bronchitis and emphysema?

Answer 13

Smoking

Question 14

How is chronic bronchitis defined?

Answer 14

A chronic productive cough for 3 months out of a year, for at least 2 consecutive years.

Question 15

What are the morphological changes in large airways in chronic bronchitis?

Answer 15

Mucus gland hyperplasia

Goblet cell hyperplasia

Inflammation and fibrosis

Question 16

What are the morphological changes in small airways in chronic bronchitis?

Answer 16

Goblet cells appear

Inflammation and fibrosis.

Question 17

How is emphysema pathologically defined?

Answer 17

Increase in the size of airspace distal to the terminal bronchiole arising from either dilation or from destruction of their walls and without obvious fibrosis.

Question 18

What is the acinus?

Answer 18

Everything that is distal to the terminal bronchiole.

Question 19

What are the 2 main types of emphysema?

Answer 19

Centri-acinar emphysema

Pan-acinar emphysema

Question 20

Where does centriacinar emphysema usually effect?

Answer 20

Upper regions of lung lobes

Question 21

Where does panacinar emphysema usually effect?

Answer 21

Lower regions of lung lobes

Question 22

What would be seen on a chest x-ray of someone with emphysema?

Answer 22

Hyperinflated lungs, indicated by more ribs highlighted than usual.

Question 23

What can alpha-1 antitrypsin deficiency cause?

Answer 23

Emphysema

Question 24

What is the role of alpha 1 antitrypsin?

Answer 24

Inhibits elastase which prevents breakdown of lung tissue.

Question 25

How does smoking cause emphysema?

Answer 25

Smoking decreases alpha-1-antitrypsin activity It increases neutrophil and macrophage activity therefore increasing elastase production even further.

Question 26

How does emphysema impact smaller airways?

Answer 26

Loss of alveolar attachments

Question 27

What is cor pulmonale?

Answer 27

Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.

Question 28

What causes cor pulmonale?

Answer 28

Pulmonary hypertension caused by chronic pulmonary vasoconstriction

Question 29

What is the main symptom of asthma?

Answer 29

Wheeze

Question 30

What % of causation of asthma is gene related?

Answer 30

30-80%

Question 31

What 2 tests can be useful for determining a diagnosis of asthma in children?

Answer 31

Spirometry and nitrous oxide test

Question 32

What are the features of a cough in a child with asthma?

Answer 32

Dry, nocturnal, exertional

Question 33

In a child, what should you prescribe as a trial for suspected asthma?

Answer 33

Inhaled corticosteroid for a 2 month trial, then stop to see if symptoms return.

Question 34

What are the ideal factors to diagnose asthma?

Answer 34

Wheeze SOB Parental asthma Responsive to treatment

Question 35

What are the goals of asthma treatment?

Answer 35

Minimal symptoms during day and night Minimal need for reliever medication No exacerbations No limitation of physical activity

Question 36

What mnemonic is used to measure control of asthma in children?

Answer 36

SANE Short acting beta agonist/week Absence school/nursery Nocturnal symptoms/week Exertional symptoms/week

Question 37

What is the contrast of asthma treatment in children under 12 compared to adults?

Answer 37

Max dose ICS 800mg No oral beta 2 tablet No LAMAs LTRA first line preventer in ,5s Only 2 biologicals

Question 38

How often would you need to use a beta 2 agonist to be considered uncontrolled?

Answer 38

More than 2 days a week

Question 39

What is the adverse effects of inhaled corticosteroid steroids?

Answer 39

Height suppression (0.5-1cm)

Question 40

What is the main leukotriene receptor antagonist?

Answer 40

Montelukast

Question 41

What are the 2 types of delivery methods used in medication for asthma?

Answer 41

MDI/spacer Dry powder device

Question 42

Name 3 ways that lung composition can be increased when using metered dose inhaler (MDI)

Answer 42

Use spacer Shake inhaler between puffs Wash spacer monthly

Question 43

What are the non-pharmacological treatments for asthma?

Answer 43

Reduce tobacco smoke exposure Remove environmental triggers

Question 44

What are the methods of drug administration used for treating acute and chronic asthma in children?

Answer 44

Chronic asthma - Inhaled steroids Acute asthma - Oral steroids

Question 45

What are the factors that determine level of treatment required in acute asthma exacerbation?

Answer 45

Respiratory rate Heart rate Oxygen sats Work of breathing Ability to complete sentences

Question 46

When prescribing a LABA inhaler for a child, what 2 things are necessary?

Answer 46

Do not use without ics Use as fixed dose inhaler

Question 47

What is the prevalence of asthma in children?

Answer 47

10-15%

Question 48

Give 3 proven risk factors for developing asthma

Answer 48

Hereditary Maternal smoking Occupation

Question 49

Name triggers of asthma

Answer 49

Exercise Cold air Cigarette smoke URTIs Drugs (aspirin, NSAIDS) Pets Pollen

Question 50

Name some differential diagnosis of asthma

Answer 50

COPD Bronchiectasis Cystic fibrosis Lung tumour Cardiac related disease

Question 51

Name 4 tests that are used to try and diagnose asthma

Answer 51

Spirometry Full pulmonary function test Reversibility of bronchodilator Variability of airflow obstruction

Question 52

What are factors to consider when assessing acute asthma exacerbations?

Answer 52

Ability to speak Heart rate Respiratory rate Peak expiratory flow rate Oxygen saturation

Question 53

What are the clinical features of someone having a moderate asthma exacerbation?

Answer 53

Able to speak in sentences HR < 110 RR < 25 PEF - 50%-75% of predicted/best SpO2 > 92% PaO2 > 8pKa

Question 54

What are the clinical features of someone having a severe asthma exacerbation?

Answer 54

Unable to finish sentences in one breath Heart rate > 110 Respiratory rate > 25 PEF - 33-50% of predicted/best SpO2 > 92% PaO2 > 8pKa

Question 55

What are the clinical features of someone having a life threatening asthma exacerbation?

Answer 55

Grunting Exhaustion Impaired consciousness Bradycardia Arrhythmia Hypotension PEF < 33% of predicted/best cyanosis Silent chest SpO2 < 92% (needs blood gas) PaO2 < 8pKa PaCO2 normal (4.6-6.0pKa) Poor respiratory effect

Question 56

What are the clinical features of someone having a near fatal asthma exacerbation?

Answer 56

Raised PaCO2 Requiring mechanical ventilation with raised inflation pressures

Question 57

Name 4 non-pharmacological managements for asthma

Answer 57

Exercise Smoking cessation Weight management Flu/pneumococcal vaccine

Question 58

What are the 2 main SABA inhalers?

Answer 58

Salbutamol (MDI and DPI) Terbutaline (DPI)

Question 59

Name 3 oral therapies used to treat asthma

Answer 59

Leukotriene receptor antagonist Theophylline Prednisolone

Question 60

Name 3 specialist therapies used to treat asthma

Answer 60

Omalizumab (anti-lgE) Mepolizumab (anti-interleukin-5) Bronchial thermoplasty

Question 61

What treatment can be used for a patient having a mild/moderate asthma attack?

Answer 61

Increase inhaler use Oral steroid Treat trigger Early follow up Back up plan

Question 62

What treatment can be used for a patient having a moderate/severe asthma attack?

Answer 62

Nebuliser - Salbutamol/Ipratropium Oral/Iv steroid Magnesium Aminophylline Triggers - Infection/allergen Complications - CXR Review Level 2/3 care

Question 63

What are some of the contrast between COPD and asthma?

Answer 63

Age of onset Smoking history Response to treatment Treatment goals Trajectory

Question 64

What are some of the similarities between COPD and asthma?

Answer 64

Similar therapies Same non-pharmacological interventions

Question 65

What is the main difference between asthma and COPD?

Answer 65

Reversibility

Question 66

Inhalers

Answer 66

Small dose of drugs Delivery directly to the target organ (airways and lung) Onset of effect is faster Minimal systemic exposure Systemic adverse effects are less severe and less frequent

Question 67

What can complete control of asthma be defined as?

Answer 67

No daytime symptoms No night time wakening No need for rescue medication No asthma attacks No limitations on activity including exercise and normal lung function ( in practical terms FEV1 and/or PEF > 80%) Minimal side effects from medication.