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Med 1 Block > Asthma > Flashcards

Asthma Flashcards

1
Q

What is the basic cellular underpinning of asthma?

A

Hyper-responsive airways disease
(type 1 hypersensitivity - IgE mediated)
Exposure - Th2 response, mast cells become sensitised to antigen, IgE binds to Fc epsilon receptors on mast surface
Second + exposure - mast cell degranulation, release mediators such as histamine (broncho constrict, vasodilate), PGD2 (vascperm inc), LTA4 (inc mucus), and pro-inflammatory cytokines TNF-A, IL4, IL12 etc
Later inflammatory response: eosinophils, basophils, Th2 cells. Proteases damage lung tissue. Leads to destruction of epithelium chronic inflammatory changes and risk of airway remodelling.

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2
Q

What are the key gross changes in the pathophysiology of asthma?

A

Reduced airway diameter due to airway inflammation and production of excess mucous.
Bronchoconstriction
Airway oedema.
Difficult to exhale

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3
Q

Define asthma

A

Chronic inflammatory airway disease characterised by: chronic bronchial inflammation, airway hyperresponsiveness and obstructive air-flow limitation

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4
Q

What are the key distinctive features of asthma?

A

Diurnal variability - PEFR variation >20% - worse at night or early morning.
Usually presents in childhood, however can develop in adults.

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5
Q

What are the different forms of asthma?

A

Eosinophilic
Non-eosinophilic
Occupational
Irritant induced
Exercise-induced bronchospasm.

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6
Q

What are the typical symptoms of asthma?

A

Cough (nocturnal /dry)
Wheeze (widespread polyphonic wheeze)
Chest tightness
SOB - intermittent, worse at night/monring/trigger
Variable expiratory airflow limitation - vary in time and intensity
Triggerd by exercise, allergen, irritant, changes in weather, viral respiratory infection
May resolve spontaneously or in response to medication - may be absent for weeks or months at a time

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7
Q

What is meant by acute asthma exacerbation?

A

Onset of severe asthma symptoms, can be life-threatening.

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8
Q

What can cause a wheeze sound in the lungs?

A

Airway obstruction - narrowed airway - results in a wheeze
Asthma - reversible
COPD - fixed
Upper airway obstruction (stridor)
Foreign body
Pulmonary edema (cardiac wheeze)
Eosinophilic vasculitis /EGPA / MPO-ANCA
Respiratory bronchiolotitis

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9
Q

What is important to do when taking a history from a potential asthmatic patient?

A

Characterise resp pathology - pattern of symptoms (variation, timing)
Explore trigger (pets, carpets, temp, occupational exposure, smoking)
Personal or family history of atopy
Assess severity of asthma - best expected and recent PEFR, treatment adherence, attendance to hospital with exacerbation/previous ICU
Normal SABA requirements

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10
Q

What may be found during respiratory examination of an asthmatic patient?

A

Around bedside - oxygen, inhaler, space, PEFR meter
Inspection - inc work of breathing, cyanosis, cough, audible wheeze
Peripheries - fine tremor (salbutamol), tachycardia, oral candidiasis (steroid inhaler use)
Chest - polyphonic expiratory wheeze.

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11
Q

What are some risk factors and triggers for asthma?

A

Irritant induced - chemical and perfumes - cause tissue damage and generate an immune response
Allergic/sensitized - classic, repeated trigger recongised as foreign (pets, pollen), should establish relationship between trigger and when asthma worse.
Family history - first degree relatives with atopic history
Prematurity and LWB
Medications - beta blockers and NSAIDs - exacerbate asthma.

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12
Q

What is meant by occupation asthma?
Types?

A

Symptoms improve when patient away from work
Onset >1yrs after starting work - time for sensitivity to develop
Sensitised induced (allergen response) or irritant induced (chemical cause local inflammation, immune response to inflamed tissue)

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13
Q

What is the diagnostic process behind asthma?

A

More than one variable wheeze, cough, breathlessness and chest tightness
pMH or FH of atopic conditions
FeNO - eosinophilic inflammation is 17yrs+, 40ppb+
Spirometry - obstructive (FEV1/FEV <70%)
Bronchodilator reversibility - 12% improvement
Variable PEFR - 20% variability after BD for 2-4w.

May also give a BHR test, IgE blood test, RAST test.

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14
Q

Describe the difference between obstructive and restrictive lung disease on spirometry.

A

Obstructive - FVC remains normal or slightly reduced, FEV1 reduced, FEV1/FVC <70

Restritive - FVC reduced, FEV1 reduces proportionately . FEV1/FVC ration remains around normal.

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15
Q

How do we assess the functional impact of asthma on a patient?

A

Number of SABA used per week/day
Number of days missed from school/work
Nocturnal symptoms
Any recent exacerbation?
Ever required hospital attendance?
Ever been to intensive care?

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16
Q

What safety netting should be provided to patients receiving community chronic asthma treatment?

A

Use of SABA >3x weekly - go to GP
<4hr gas between requirements for salbutamol - go to A&E
10 puffs of salbutamol without relief of symptoms - call 999

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17
Q

What conservative management is often recommended for asthmatics?

A

Smoking cessation/avoidance of triggers
PEFR diary
Regular annual asthma reviews (typically in GP annually) - presonalised asthma plan and inhlaer technique education
Vaccination - flu, covid-19,

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18
Q

What are some side effects of inhaled salbutamol ? (asthmatics)

A

Tachycardia
Tremor (fine)

19
Q

When is the use of inhlaed corticosteroids indicated in asthmatics?

A

Nocturnal symptoms
Recent severe exacerbation
SABA use >3 times/week

20
Q

What are the side effects of inhaled corticosteroid use? (asthmatic inhlaers)

A

Oral candida

21
Q

What is the pharmacological treatment pathway for adult asthmatics?

A
  1. Newly diagnosed - SABA
  2. SABA only if infrequent, short lived wheeze, normal lung function
  3. ICS first line maintenance if symp 3>w, night waking, SABA use >3w
  4. Then offer LTRA
  5. Then offer combined LABA and ICS, review LTRA or consider inc ICS dose
  6. MART (budesonide and formoterol) regime and refer for specialist care.
22
Q

Name the typical drug used for each class of inhaler/medication given in asthmatics?

A

SABA = salbutamol
ICS = inhaled budesonide, oral prednisolone
LABA = salmeterol
LTRA = montelukast

23
Q

What are some common complications of asthma?

A

Exacerbations
Secondary Pneumothorax

24
Q

What is an asthma exacerbation?

A

Infective of non-infective
Bronchospasm, mucosal thickening and mucous production
Narrows terminal airway = acute deterioation in breathlessness
Leads to hyperventilation until exacerbation resolves

25
Q

At what severity is asthma considered moderate acute?

A

Increasing symptoms
PEF >50-75% best or predicted
No features of acute severe

26
Q

At what point is asthma considered acute severe?

A

PEF 35-50% best or predicted
RR >25/min
HR >110bpm
Inability to complete sentences in one breath

27
Q

At what point is asthma considered life-threatening?

A

Acute severe asthma with any one of the following:
PED <33% BEST or predicted
SpO2 <92%
PaO2 <8 kPa
Normal PaCo2
Altered conscious level /exhausation
Arrhythmia
Hypotension
Cyanosis
Silent chest
Poor respiratory effort

28
Q

At what stage is asthma considered near fatal?

A

Raised PaCO2 and/or mechanical ventilation with raised inflation pressures.

29
Q

What investigations should be done on an asthmatic?

A

Peak flow - severity
Observations - severity
Sputum culture - infective exacerbation
ECG - tachy/arryhtmia
FBC - eosinophils
CRP - inflammatory markers
ABG - respiratory alkalosis in moderate exacerbation, nor in life threating asthma, high in near fatal.
CXR - focal changes, pneumothorax
Spirometry - obstructive and reversibility pattern

30
Q

What acute management should be used for asthmatics?

A
  1. oxygen - 15L non-rebreath
  2. Help
  3. Salbutamol - 2.5-5mg nebs
  4. Hydrocortisone - 100mg IV or prednisolone 40mg PO
  5. Ipatropium 500mg neb
  6. Theophylline (PDE5 inhibitor)- aminophylline infusion
  7. Magneisum sulphate 2g IV over 20mins
    Escalate care
  8. +/- antibiotics if infective exacerbation.
31
Q

Before discharging an acute asthma admission what should be ensured?

A

Stable for 4hrs after exacerbation
Ensure PEFR returned to >75%

32
Q

If infective exacerbation of asthma how long should steroid/abx be continued?

A

Pred for 5 days +/- antibitoics

33
Q

In life threatening asthma/tiring asthmatic what additional support may be required in ICU?

A

BPAP
Intubation
ECMO
Due to loss of respiratory drive.

34
Q

When is it not safe to send ana cute asthmatic home from ED?

A

Exacerbation whilst on course of steroids
History of poor compliance with treatment
History of depression/anxiety
History of severe/refractory asthma (previous ICU)
Pregnancy
Poor social circumstances.

35
Q

What should be done at the annual review of an asthmatic?

A

Asthma control - spirometery or peak flow variability testing
Inhlaer technique
Risk factors
Discuss treatment options
Check/update asthma action plan
Assess asthma severity
May discuss smoking, exercise, healthy weight maintenance

36
Q

What are the four key disease processes that occur in asthma?

A

Chronic bronchial inflammation
Airway hyper-responsiveness
Obstructive airflow limitation
Reversible

37
Q

What type of hypersensitivity reaction is asthma?

A

Type 1

38
Q

What are the several forms of bronchial asthma?

A

Occupational
Exercise induced
NSAID induced
Allergic
Thunderstorm

39
Q

What is meant by brittle asthma?

A

Term to describe a severe type of asthma
Type 1 - uncontrolled - regularly use high doses of inhaled steroids but still have large changes in PEF and active symptoms
Type 2 - suddenly develop severe asthma attacks for no apparent reason despite having otherwise well-controlled asthma.

40
Q

How do we assess the severity of asthma?

A

Best expected and recent PEFR
Adherence with treatment
Attendance to hospital with exacerbation/previous ICU admission
Normal requirement for SABA/whether this has changed.

41
Q

What on examination can be a sign that an asthmatic is reliant on their medication?

A

Fine tremor due to salbutamol
Oral candidiasis due to oral steroids.

42
Q

When using clinical judgment to determine the probability of an asthma diagnosis, what features should it be based on?

A
  1. Variable symptoms of wheeze, cough, breathlessness and chest tightness
  2. Personal/FH of atopic conditions
  3. Results of FeNO testing
  4. Results of objective tests including - spirometry, BDR, PEFV
  5. Results of a direct bronchial challenge test with histamine or methacholine (requires specialist)
43
Q
A

Med 1 Block (32 decks)

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