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MBBS 4: Family Medicine > Asthma > Flashcards

Asthma Flashcards

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1
Q

What is asthma?

A

a disease characterized by recurrent attacks of breathlessness and wheezing which vary in severity and frequency from person to person
- asthma affects all age groups but usually starts in childhood

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2
Q

What causes asthma?

A

due to inflammation of the air passages in the lungs and affects the sensitivity of the nerve endings in the airways so they become easily irritated
- in an attack the lining of the passages swell causing the airways to narrow and reducing the flow of air in and out of the lungs

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3
Q

Epidemiology?

A
  • Affects around 300 million people worldwide
  • Half of patients with childhood asthma will not continue to have symptoms in adulthood (”grow out of it”)
  • Prevalence in Africa: 13% (and rising), Malawi: unknown
  • But according to WHO: 3 people die each day in Malawi from asthma
    > Underdiagnosed and underrecognized.
    > Most recorded deaths are in adults >45 years
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4
Q

Pathogenesis?

A
  1. Airflow limitation/obstruction
  2. Airway hyperresponsiveness
  3. Inflammation of the bronchi
    - Airway wall remodelling; &
    epithelial damage
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5
Q

Pathogenesis of airflow obstruction in acute asthma?

A
  1. Bronchoconstriction
  2. Airway edema
  3. Mucous plugs (take weeks to resolve)
  4. Hyperinflation
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6
Q

Airflow obstrction in chronic asthma?

A
  1. Chronic mucous plugging, & long standing inflammation → airway remodeling with excess narrowing
  2. Epithelial damage → more susceptible to infection and allergens.
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7
Q

Airway hyperresponsiveness?

A

Airway response to exogenous and endogenous stimuli
1. Exogenous are direct stimulation (allergens etc)
2. Endogenous include activator substances secreted from mast cells and sensory neurons

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8
Q

Asthmatic attack triggers?

A
  1. exercise
  2. pollen
  3. bugs in the home
  4. chemical fumes
  5. cold air
  6. fungus spores
  7. dust
  8. smoke
  9. strong odors
  10. pollution
  11. anger/stress
  12. pets
  13. medication e.g. NSAIDS, beta blockers
  14. viral infections
  15. GERD
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9
Q

Etiology of asthma?

A
  1. Extrinsic (atopy) vs intrinsic (no identified causative agent).
  2. Atopy
    - asthma, eczema, allergy
    Ig E-antibody production is influenced by genetic and environmental factors.
  3. Hygiene theory
    - exposure to bacteria/viruses/fungi in childhood directs the immune and inflammatory response away from the allergic pathways (uncertain)
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10
Q

Symptoms of asthma?

A

classic triad
1. breathlessness
2. cough
3. wheeze (sometimes only nightly cough)

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11
Q

Important history questions?

A
  1. Symptoms & Severity
  2. Previous hospitalizations (frequency, last)
  3. Medication history
  4. What do they take? How is adherence?
  5. Exposures > allergens (“triggers”), smoking, method of cooking
  6. Clues to other possible etiologies
    - Infectious symptoms, TB contacts, weight loss, etc.
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12
Q

Physical exam in asthma?

A
  1. VITALS (count the RR)
  2. Wheezing
    - Differential diagnosis, target your physical exam to exclude other pathologies
    - Inspiratory or expiratory?
  3. Signs of atopy
    Note: Approach depends on the severity (ABCD in severe exacerbation)
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13
Q

Ddx for wheezing?

A
  1. heart failure
  2. vocal cord dysfunction
  3. viral infections in children
  4. tracheal lesions
  5. foreign body aspiration
    Note:
    - In mild asthma may only be expiratory
    - in more moderate severe inspiratory and expiratory
    - In very severe, lungs may be too clamped down to have any wheezing
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14
Q

Signs of atopy?

A
  1. Allergic shiners
  2. transverse crease on nose from allergic rhinitis
  3. atopic dermatitis (eczema; 25% has Dennie Morgan lines)
  4. Nasal crease: caused by re[eated nose rubbing (allergic rhinitis)
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15
Q

Clinical diagnosis of asthma?

A
  1. history taking
  2. physical examination
  3. trial of bronchodilators
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16
Q

Diagnosing asthma with a trial of bronchodilators?

A
  1. Peakflow meter
    - Measure FEV1 (forced expiratory volume in the first second)
    - FEV1 reduces in case of obstructed airway, but in case of Asthma is mostly reversible after bronchodilators
  2. Spirometry;
    - FEV1/FVC before and after bronchodilators
    - improvement of FEV1 >12% and >200ml after bronchodilator
17
Q

Ddx of acute dyspnea and their exam findings?

A
  1. Acute heart failure > bilateral basal crepitations
  2. Pneumothorax > diminished breath sounds
  3. Pulmonary embolism > normal chest auscultation
  4. Upper airway obstruction > wheezing
  5. Massive pleural effusion > absent breath sounds
  6. Severe pneumonia > crepitation
18
Q

Asthma clinical clues?

A
  1. onset before 20 years
  2. associated hay fever, eczema, allergic conjuctivitis, allergies
  3. intermittent symptoms with normal breathing in between
  4. symptoms worse at night, early morning, with cold or stress
  5. patient or family have a history of asthma
19
Q

COPD clinical clues?

A
  1. onset after 40 years age
  2. symptoms are persistent and worsen over time
  3. cough with sputum starts long before difficult breathing
  4. patient is or was a heavy smoker
  5. previous doctor diagnosis of COPD
20
Q

Diagnosis of severe/life threatening asthma?

A
  1. Silent chest
  2. Central cyanosis
  3. Tachypnea (>30 RR), exhaustion, inability to complete sentences
  4. Persistent tachycardia (110 bpm), bradycardia, hypotension, pulsus paradoxes
  5. Use of accessory breathing muscles
  6. Confusion, agitation, coma
  7. Peak flow < 33%
21
Q

Mangement of severe asthma attack?

A
  1. O2 (until sat > 95%)
  2. Salbutamol 5mg (<4 yrs 2,5mg) + Ipratropium 0,5mg via nebulizer (if not available via spacer)
    - Start with 3 back-to-back.
    - Repeat every 20 min (1st hour)
    - Observer 24h after symptoms have relieved
    - Discharge on 2-4 puff every 3-4 h with tapering schedule
  3. Prednisolone 40 mg p.o. OD for 3 days (paeds 1-2mg/kg)
    OR Hydrocortisone 100mg i.v. OD (<5 yrs 50mg)
    OR dexamethasone 0,6 mg/kg OD (max 10mg).
  4. No improvement: magnesium sulphate 40 mg/kg i.v. (diluted to at least 10%) over 20 min
    OR Aminophylline 5mg/kg i.v. (diluted, max 25 mg/ml) (max 300mg) over 20 min
22
Q

Who not to give aminophylline to?

A

patients with recent hx of MI or tachy-arythmia
- because it cases QT prolongation

23
Q

Consequences of too quick of an infusion of aminophylline?

A
  1. seizures
  2. severe vomiting
  3. tachycardia/arrythmia.
24
Q

Clinical signs of mild asthma attack?

A

wheeze, no respiratory distress, feeding well, spO2 >92% (no moderate signs)

25
Q

Clinical signs of moderate asthma attack?

A

respiratory distress, accessory muscle use, feeding well, spO2 >92% (no severe signs)

26
Q

Clinical signs of severe asthma attack?

A

marked respiratory distress, cant talk/feed, RR >30 (>50 under 2-5 yrs), sat <92%

27
Q

4 Cs of chronic care consultations?

A

Complaints : concerns?
Control : is disease controlled?
Compliance : behaviour
Complications : detect

28
Q

Control?

A
  1. History
    Breathlessness, Cough, Wheeze, Nocturnal cough, Chest tightness
    Triggers
    Emergency visits
    Use of inhaler – what type, how often
  2. Diagnostics
    Peak Flow
29
Q

Compliance?

A

Inhaler technique & use
No smoking
Exposure to allergens (smoke, pollen, dust, dander)
Loosing weight (when overweight) reduces amount and severity of asthma attacks
Seek medical help early during attack
Avoid drugs that can trigger attacks (NSAIDS incl. aspirin, b-blockers)

30
Q

Complications?

A

If frequent ORAL TABLETS steroid
Deprivation of growth in children
Osteoporosis
Diabetes Mellitus
If frequent ORAL INHALER steroid
Oral candidiasis (explain to rinse mouth with water after use)

31
Q

Plan 5 A’s of behavior change?

A
  1. assess - risk factors, behaviors’, symptoms, attitudes and preferences
  2. advice - specific personalized options to reduce symptoms and increase quality of life and functioning
  3. agree - collaboratively select goals based on patient interest and motivation to change
  4. assist - provide information, teach skills, problem solve barriers to reach goals
  5. arrange - specific plan for follow up
32
Q

How to use an inhaler?

A
33
Q

How to clean the spacer?

A

MBBS 4: Family Medicine (27 decks)

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