Asthma

Question 1

what is asthma

Answer 1

Asthma is a chronic respiratory disorder characterised by variable airway inflammation, airway obstruction, and airway hyper-responsiveness.

Question 2

what is the pathophsyiology of asthma acutely/ allergic asthma

Answer 2

IgE-mediated type 1 hypersensitivity leading to mast cell degranulation and release of histamine

Question 3

what are some key aspects of pathophysiology of chronic asthma in the airways

Answer 3

• type 2 immunity - involves Th2 T helper cells
• Bronchial hyper-responsiveness
• Bronchial inflammation
• Endobronchial obstruction

Question 4

what is allergic asthma associated with

Answer 4

atopy eg. eczema or allergic rhinitis

Question 5

which gender is asthma more common in

Answer 5

male

Question 6

risk factors

Answer 6

• FH or PMH of asthma
• Exposure to allergens e.g. dust mites or pets
• history of atopic disease
  -maternal stuff: smoking around kid, or in pregnancy or viral inf in preg ect, not being breastfed

Question 7

what are the symptoms

Answer 7

• End-expiratory wheeze
• Dyspnoea
• Chest tightness

Question 8

signs

Answer 8

• Symptoms may worsen after NSAID use
• Prolonged expiratory phase on auscultation
• Hyper-resonance to lung percussion
  -Comes & goes in response to triggers

Question 9

what are the factors based on which they decide the severity of an asthma attack

Answer 9

peak flow
speech
RR
Pulse

Question 10

features of moderate asthma attack

Answer 10

normal speech
peak flow 50-75%
RR< 25
Pulse <110

Question 11

features of severe attack

Answer 11

peak flow 33-50%
Cant complete sentences
RR> 25
Pulse> 110

Question 12

extra features considered in life threatening + near fatal asthma attacks

Answer 12

CO2 levels, confusion, bradycardia, oxygen <92

Question 13

overall features of life threatening asthma attack

Answer 13

• Peak flow <33%
• Oxygen <92%
• Normal CO2
• Confusion
• Bradycardia

Question 14

What is the distinguishing feature of NEAR FATAL asthma?

Answer 14

RAISED CO2

Question 15

What are the most common investigations you do and some extra to consider

Answer 15

spirometry
Fractional Exhaled Nitric Oxide

to consider: CXR (MOTSLY IN OLDER and smokers)

Question 16

what values does spirometry provide

Answer 16

FEV1: forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration
FVC: forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration

Question 17

typical spirometry asthma findings

Answer 17

FEV1 - significantly reduced
FVC - normal
FEV1% (FEV1/FVC) < 70%

Question 18

why is NO present in asthmatic inflammation

Answer 18

increased production of it from inflamed activated epithelial cells

Question 19

diagnosis in >=17 yrs

Answer 19

1)patients should be asked if their symptoms are better on days away from work/during holidays.
- If so, referred to a specialist as possible occupational asthma

2) all patients should have spirometry with a bronchodilator REVERSIBILITY (BDR) test

3) all patients should have a FeNO test

Question 20

diagnosis in 5-16

Answer 20

1- all children should have spirometry with a bronchodilator reversibility (BDR) test

2-a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test

Question 21

diagnosis in under 5s

Answer 21

diagnosis should be made on clinical judgement

Question 22

what is a FeNO positive test

Answer 22

• in adults level of >= 40 parts per billion (ppb) is considered positive

-in children a level of >= 35 parts per billion (ppb) is considered positive

Question 23

What is meant by bronchodilator reversibility?

Answer 23

Improvement in FEV1 of 12% or more after inhalation of SABA (salbutamol)

Question 24

Reversibility testing results in children and adults

Answer 24

in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
in children, a positive test is indicated by an improvement in FEV1 of 12% or more

Question 25

How is an acute asthma attack investigated and what will it show?

Answer 25

ABG showing type 2 respiratory failure (hypoxia and hypercapnia)

Answer 26

1) SABA (Salbutamol)

2) SABA + low dose ICS (Beclomethasone or Budesonide)

• When do we add ICS? (3)
  
  • Symptoms 3 or more times a week
  • Night time waking
  • Can be either at diagnosis or review

3) SABA + ICS + LABA (Salmeterol)

4) SABA + ICS (increase dose to max) + LABA + LTRA (Montelukast) or SR theophylline or Beta 2 agonist tablet

5) Use daily steroid tablet + high dose ICS + refer for specialist care

Question 27

Describe the salbutamol inhaler (3)

Answer 27

• Blue inhaler (reliever)
• Tremor side effect
• Taken when needed

Question 28

Describe the beclomethasone inhaler (3)

Answer 28

• Brown inhaler (maintainer)
• Oral candidiasis side effect
• Taken morning and night regardless of symptoms

Question 29

What do we do if we need to step-down treatment in well-controlled asthma?

Answer 29

Reduce 25-50% of ICS

Question 30

How do you manage an acute asthma attack? (5)

Answer 30

• Oxygen (target sats 94-98%)
• Salbutamol nebulisers
• Ipratropium Bromide nebulisers
• Oral prednisolone- (if unable to swallow: IV hydrocortisone)
• IV magnesium sulfate
  ( BE CAREFUL - INAPPROPRIATE FOR COPD exacerbation)

Question 31

How might we treat patients not responding to full medical treatment an who have low O2, high CO2 and resp acidosis

Answer 31

Intubation and ventilation

Question 32

What do we do if normal PaCO2?

Answer 32

Escalate to intensive care team because it’s a sign of exhaustion and is life threatening

Question 33

Complications?

Answer 33

• Growth retardation
• Chest wall deformity
• Recurrent infections
• Pneumothorax
• Respiratory failure
• Exacerbations

Question 34

PROGNOSIS

Answer 34

Many children improve as they get older- Adult onset asthma is usually chronic