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Yr 3 - Respiratory > Asthma > Flashcards

Asthma Flashcards

1
Q

What is Asthma?

A

Chronic inflammation of the airways.

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2
Q

What are the 3 mechanisms that lead to airway inflammation?

A
  1. Inflammatory cell infiltration of the airways
  2. Smooth muscle hypertrophy
  3. Thickening and disruption of the airway membrane.
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3
Q

What are acute exacerbations of chronic asthma most frequently caused by?

A
  1. Respiratory viruses

Other causes include bacterial infections, allergens, pollutants and occupational exposure.

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4
Q

What are 3 non-modifiable risk factors of asthma?

A

Personal or family history of atopy
Male sex (asthma development) or female sex (persistence to adulthood)
Prematurity and low birth weight

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5
Q

What are 4 modifiable risk factors of Asthma?

A

Exposure to tobacco smoke, inhaled particulates and occupational dust
Obesity
Social deprivation
Infections in infancy

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6
Q

What are the 3 main symptoms of asthma?

A
  1. Wheeze
  2. Cough
  3. Breathlessness
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7
Q

‘Symptoms are characteristically episodic and diurnal’ What does this mean?

A

worse at night and early morning

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8
Q

What are things that should be covered during a history of asthma?

A

Triggers (pets, carpets, temperature)
Occupation (exposure to dusts, chemicals)
Frequency of exacerbations and previous hospital/intensive care admissions
Personal or family history of atopy
Best expected and recent peak expiratory flow rate (PEFR)
Adherence with treatment
Smoking (including passive smoking) history

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9
Q

What can be found around the bedside that could indicate a patient has asthma?

A
  1. Oxygen
  2. Inhaler
  3. PEFR meter
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9
Q

What symptoms may be found upon clinical examination?

A
  1. Increased work of breathing
  2. Cyanosis
  3. Cough
  4. Audible wheeze

Peripheries: fine tremor (salbutamol use), tachycardia, oral candidiasis (steroid inhaler use)

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9
Q

What are some GI differential diagnoses of Asthma?

A

Gastrointestinal: gastro-oesophageal reflux

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9
Q

What are some respiratory differential diagnoses of asthma?

A

Respiratory: bronchiectasis, COPD, fibrosis, pulmonary embolism, infection (pertussis and tuberculosis), lung cancer

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10
Q

What are some cardiac differential diagnoses of asthma?

A

Cardiac: heart failure

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11
Q

What are some other non specific differential diagnoses of asthma?

A

Other: chronic sinusitis, allergic rhinitis, foreign body inhalation, vocal cord dysfunction

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12
Q

What are some bedside investigations that can be carried out for asthma?

A

PEFR is important for monitoring response to treatment and can demonstrate diurnal variation when there is >20% variability in twice-daily readings.1 Predicted PEFR can be calculated from age, sex and height.

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13
Q

What laboratory investigations can be carried out?

A
  • Basic blood tests include WCC and CRP to look for infection.
  • More specialist tests include eosinophil count and total IgE, IgE to aspergillus, and other allergens or fungus.
  • If the patient has a productive cough, a sputum sample should be sent for microscopy, sensitivity and culture (MCS).
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14
Q

What type of imaging can be used?

A

Chest X-ray - can rule out infection, collapse or pneumothorax

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15
Q

What test is important in the diagnosis of Asthma?

A

spirometry with bronchodilator reversibility testing

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16
Q

What spirometry finding would be suggestive of asthma?

A

Spirometry findings suggestive of asthma include:

FEV1/FVC ratio <70% indicates airflow obstruction
Improvement of FEV1 by 12% AND 200ml with bronchodilators
Improvement of FEV1 by 400ml with bronchodilators

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17
Q

What should be done of the patient has a high probability of asthma?

A

treatment should be initiated and monitored with spirometry and symptom scores

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18
Q

What should be done of there is an intermediate probability of asthma?

A

spirometry with bronchodilator reversibility should be carried out. Other subsequent tests might include peak flow charts and skin prick testing

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19
Q

What should be done of there is a low probability of asthma in a patient?

A

Other causes should be investigated

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20
Q

What general measurement should be carried out for a patient who has asthma?

A
  1. Personalised asthma action plan - patients should be encouraged to keep PEFR diaries
  2. Asthma reviews should be carried out annually
  3. Vaccinations should be kept up to date
  4. Lifestyle should be considered - smoking cessation and weight loss should be encouraged.
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21
Q

What are the aims of treatment for asthma?

A
  1. No daytime symptoms or night time waking due to asthma
  2. No asthma attacks or need for rescue medications
  3. No limitations on activity
  4. Normal lung function
  5. Minimal side effects
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22
Q

what is the mainstay medical management in asthma?

A

Inhalers

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23
Q

besides inhalers, what other medical management can be used for asthma?

A

Oral leukotriene receptor antagonist (LTRA)
Theophylline or biologic agents

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24
Q

How should treatment be escalated?

A

Treatment should be escalated in a step-wise approach, using the lowest possible dose of inhaled steroid needed for optimum control. Treatment should be escalated when symptoms are not adequately controlled

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25
Q

What is the standard step-wise approach for managing asthma?

A

1.All those with symptomatic asthma should be given a short-acting beta-2 agonist (SABA) for reliever therapy as required
2. Add low-dose inhaled corticosteroid (ICS)
3. Add long-acting beta-2 agonist (LABA) or trial of leukotriene receptor antagonist (LTRA)
4. ICS dose increased to medium or trial of LTRA (if not already taking)
5. ICS dose increased to high +/- refer for specialist input

26
Q

What are 4 respiratory complications of asthma?

A

Pneumonia
Collapse and pneumothorax
Respiratory failure
Status asthmaticus

27
Q

What is the prevalence of asthma?

A

It affects over 10% of children and around 5-10% of adults, with the prevalence of asthma increasing. Not only does asthma account for a significant morbidity burden it should be remembered that around 1,000 people die in a year from asthma in the UK, 30-40 of whom are children.

28
Q

Is asthma obstructive or restrictive?

A

Obstructive
The symptoms are variable and recurring and manifest as reversible bronchospasm resulting in airway obstruction.

29
Q

What do patients with asthma also suffer from?

A

IgE-mediated atopic conditions such as:

atopic dermatitis (eczema)

allergic rhinitis (hay fever)

30
Q

Which commonly used drug can asthma patients be sensitive to?

A

Aspirin

31
Q

What is spirometry?

A

spirometry is a test which measures the amount (volume) and speed (flow) of air during exhalation and inhalation. It is helpful in categorising respiratory disorders as either obstructive (conditions where there is obstruction to airflow, for example due to bronchoconstriction in asthma) or restrictive (where there is restriction to the lungs, for example lung fibrosis).

32
Q

What is FEV1?

A

FEV1: forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration

33
Q

What is FVC?

A

FVC: forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration

34
Q

How is fractional exhaled nitric oxide used to investigate asthma?

A

nitric oxide is produced by 3 types of nitric oxide synthases (NOS).
one of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils
levels of NO therefore typically correlate with levels of inflammation.

35
Q

Give an example of a short-acting beta-agonist?

A

Salbutamol

36
Q

How does SABA help manage asthma?

A

They work by relaxing the smooth muscle of airways

37
Q

when is SABA used?

A

The first-line drug to be used in the management of asthma
Typically used if the patient develops symptoms
When discussing with patients often termed ‘the reliever’ or ‘the blue inhaler’

38
Q

what are the side effects of SABA?

A

tremor

39
Q

When are inhaled corticosteroids used?

A

Used in patients whose asthma is not controlled by SABA alone
Taken everyday, regardless of whether the patient has symptoms
When discussing with patients often termed ‘the preventer’

40
Q

Give 4 examples of inhaled corticosteroids used?

A

Beclometasone
dipropionate
Fluticasone
propionate

41
Q
A
41
Q

What does LABA stand for?

A

Long-acting beta-agonists

42
Q

Give an example of LABA?

A

Salmeterol

43
Q

Give an example of Leukotriene receptor antagonist

A

Monteleukast

44
Q

What is MART?

A

Maintenance and reliever therapy

a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)

45
Q

What are the current NICE guidelines for Asthmatic patients?

A

patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist, not a LABA
MART is now an option for patients with poorly controlled asthma

46
Q
A
47
Q

What are features of acute asthma?

A

worsening dyspnoea, wheeze and cough that is not responding to salbutamol

maybe triggered by a respiratory tract infection

48
Q

What are the 3 categories for an acute asthma attack?

A
  1. Moderate
  2. Severe
    3.life-threatening
49
Q

What is classified as a moderate acute asthma attack?

A

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

50
Q

What is classified as a severe acute asthma attack?

A

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

51
Q

What is considered as a life-threatening acute asthma attack?

A

PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

52
Q

What does a normal pCO2 in an acute asthma attack indicate?

A

indicates exhaustion and should, therefore, be classified as life-threatening.

53
Q

What categorises a fourth category of ‘near-fatal asthma’?

A

a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.

54
Q

When is an arterial blood gas recommended in an acute clinical setting?

A

the BTS guidelines recommend arterial blood gases for patients with oxygen sats < 92%

55
Q

When is a chest x-ray recommended in an acute clinical setting?

A

life-threatening asthma
suspected pneumothorax
failure to respond to treatment

56
Q

What is the admission criteria for acute asthma attacks?

A

all patients with life-threatening should be admitted in hospital
patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment.
other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night

57
Q

If patients are hypoxaemic, how much oxygen should be given?

A

15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they can maintain a SpOâ‚‚ 94-98%.

58
Q

What medication is given in management of acute asthma?

A
  1. bronchodilation with short-acting betaâ‚‚-agonists (SABA
  2. corticosteroid
  3. ipratropium bromide
  4. IV magnesium sulphate
  5. IV aminophylline
59
Q

How is SABA given to patients without features of life-threatening or near fatal asthma?

A

high-dose inhaled SABA e.g. salbutamol, terbutaline
in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer

60
Q

How is SABA given to patients with life-threatening exacerbation of asthma?

A

in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended

61
Q

What should all patients be given in terms of corticosteroids?

A

all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
during this time, patients should continue their normal medication routine including inhaled corticosteroids.

62
Q

When is ipratropium bromide used?

A

in patients with severe or life-threatening asthma, or in patients who have not responded to betaâ‚‚-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist

63
Q

When is IV magnesium sulphate used?

A

commonly given for severe/life-threatening asthma

64
Q

What happens to patients who fail to respond to these interventions?

A

patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include:
intubation and ventilation
extracorporeal membrane oxygenation (ECMO)

65
Q

What is the criteria for discharge in acute asthma attacks?

A

been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted

Yr 3 - Respiratory (11 decks)

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