Asthma

Question 1

Normal spirometry does not exclude asthma

Common reasons for lack of reversibility

Answer 1

Baseline FEV1 is normal
Recent use of a bronchodilator
Airway inflammation & oedema (poorly controlled asthma) – reversibility may return after treatment

Question 2

Asthma is a disease of the airways characterised by:

Answer 2

1. Variable airflow obstruction
2. Bronchial hyper-responsiveness
3. Airway inflammation

Question 3

use of peak flow monitoring in asthma diagnosis

Answer 3

A period of peak flow monitoring (2 weeks at least) can be very useful if the diagnosis is uncertain or if occupational asthma is suspected (PEF low in certain places/ scenarios)

Question 4

When is laboratory confirmation of bronchial hyper-responsiveness used?

Answer 4

Only occasionally needed where clinical features are atypical or where the diagnosis has important implications (defence force employment)

Unnecessary if clinical features and treatment response are typical of asthma
Unnecessary if variable airflow obstruction has already been documented
Can be hazardous in setting of poorly controlled asthma or severe airflow obstruction

Question 5

Use of Exhaled nitric oxide testing

Answer 5

marker of allergic inflammation, steroid responsiveness

Question 6

Use of blood eosinophil count

Answer 6

if >0.3 x 10 9per litre, airway eosinophilia is likely

Question 7

Samter’s triad

Answer 7

Asthma, aspirin intolerance, nasal polyps

“Aspirin-exacerbated respiratory disease”

Question 8

ABPA clinically (and Ix)

Answer 8

Chronic asthma, recurrent pulmonary infiltrates, bronchiectasis
Very high total IgE (>1000 IU/mL)
Evidence of Aspergillus sensitivity

Question 9

EGPA clinically

Answer 9

Necrotising Vasculitis, granulomas, tissue eosinophilia

Asthma + blood eosinophilia essential

Cardiac disease accounts for 50% of deaths

Question 10

STEP 1 in asthma management 2019 GINA guidelines

Answer 10

PRN Low dose ICS-formeterol

OR

SABA + ICS

Question 11

STEP 2 in asthma management 2019 GINA guidelines

Answer 11

Regular LOW dose ICS-formeterol (plus PRN)
OR
Regular low dose ICS

Consider montelukast

Question 12

STEP 3 in asthma management 2019 GINA guidelines

Answer 12

Daily LOW dose ICS-formeterol (plus PRN)

OR consider
Medium Dose ICS
Consider montelukast (w low dose ICS)

Question 13

STEP 4 in asthma management 2019 GINA guidelines

Answer 13

Daily MEDIUM dose ICS-formeterol (plus PRN)

consider
- add on tiotropium
- montelukast
- high dose ICS

Question 14

STEP 5 in asthma management 2019 GINA guidelines

Answer 14

Daily HIGH dose ICS-formeterol (plus PRN)
AND
Phenotypic assessment + immunological

consider
- OCSs

Question 15

place for long term oral steroids in asthma

Answer 15

Adrenal insufficiency

Asthma variants
* Allergic bronchopulmonary aspergillosis (induction therapy)
* Eosinophilic granulomatosis with polyangiitis (EGPA)

Question 16

Low dose oral steroids adverse effects in asthma patients

Answer 16

Question 17

Clues for add on therapies for severe asthma

Answer 17

Tiotropium - Airflow obstruction, exacerbations
Macrolides - Exacerbations, cough & sputum
Montelukast - Aspirin sensitive
Monoclonal Abs - Exacerbations, type 2 biomarker

Question 18

Use of specific biologics for asthma

Answer 18

These monoclonal Abs are used in addition to ICS + LABA.

In appropriately selected patients, mABs induce ~50% reduction in exacerbations

Oral steroid sparing

Modest improvements in lung function