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Respiratory > Asthma > Flashcards

Asthma Flashcards

1
Q

What is Asthma (broad definition of symptoms)

A

Chronic Inflammatory disorder of the airways, causing recurrent episodes of wheezing, breathlessness, chest tightness and coughing. With hyper-responsiveness of the airways.
Symptoms are worse at night or the early hours of the morning with widespread but variable airflow obstruction - reversible either spontaneously or with treatment.

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2
Q

What is Asthma (histopathologically)

A
  • infiltration of the mucosa (inner lining of the airways) with inflammatory cells (esp. eosinophils)
  • oedema of the mucosa, thickening of the basement membrane.
  • damaged mucosal epithelium
  • hypertrophy of the mucus glands with increased mucus secretion
  • smooth m.m constriction
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3
Q

Asthma stats

  • age of onset
  • prognosis
  • common presentations
  • incidence in - childhood and adulthood.
A
  • normally between 2-7yrs (but any age)
  • most children ‘grow out of it’ by puberty
  • often presents with cough ( post exercise, early morning, disturbed sleep)
    1 in 4-5 children (mild), 1 in 8 adults has or had asthma
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4
Q

what is the focus in asthma management

A

PREVENTION - asthma attack = failed treatment

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5
Q

What are some key triggers for asthma attack

NB - how common is dust mite allergy in atopic asthmatics

A

ABCDEFGHIJ

A - Allergens (pollens, moulds, dander, mites)
B - Bronchial infections
C- cold air, exercise
D - Drugs - aspirin, NSAIDS (20%), b-Blockers
E - Emotion (laughter, stresss), Exercise
F - Food (seafood, nuts, MSG, sodium metabisulphate)
G - GORD
H - Hormones (pregnancy, Menses)
I - irritants (smoke, perfume, smells)
J - Job (wood dust, flour dust, isocyanates, animals)

NB 90% of kids with atopy (with asthma) are skin prick + to dust mite extract.

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6
Q

Clinical Symptoms of Asthma

NB - what presentations should you be suspicious of.

A
  • Wheeze
  • coughing (esp at night)
  • chest tightness
  • breathlessness

NB suspect in any child with recurrent nocturnal cough and in those with intermittent dyspnoea or chest tightness (esp after exercise)

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7
Q

Clinical findings in Asthma

A
  • diffuse, high pitched wheeze throughout inspiration and part of expiration.
  • prolonged expiration.

If wheeze absent on normal beathing may appear with forced expiration
BUT absent wheeze in breathless person is serious sign.

WHEEZE DOES NOT = ASTHMA

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8
Q

How to investigate asthma (and results that indicate it)

A
  • Peak flow measurement - variations in values at different times
  • spirometry = 6yr olds
  • Measurement of above before & after bronchodilators = >15% FEV1 and PEFR improvement
  • airway reactivity test - rarely done
  • mannitol inhalation test
  • Allergy testing
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9
Q

Reasons for suboptimal asthma control

A
  • poor compliance
  • inefficient use of device
  • lack of preventer medication
  • using bronchodilators alone
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10
Q

What is good control in asthma

A 
no cough, wheeze, breathlessness most of the time
- no nocturnal waking due to asthma
no limitation of normal activity
good exercise ability
minimal need for ventolin
no severe attacks
no side effects from medication
near normal lung fn - >80% predicted
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11
Q

What are the 6 steps in an asthma mx plan

A

1) Assess the severity - when stable - (intermittent/episodic, mild persistent, moderate persistent. severe persistent)
2) achieve best lung fn - monitor with regular spirometry
3) avoid triggers
4) maintain best lung fn
5) develop an individual plan - needs to recognise deterioration, knows when to initiate medication, knows when to seek help
6) educate and review regularly

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12
Q

Drugs to treat asthma

A

1) reliever - Bronchodilator ( B2 agonist - salbutamol, terbutaline (bricanyl) adrenaline - erol, anticholinergics -ipatropium bromide (atrovent), methylxanthines - theohpyline (brondecon))
2) preventer - antiinflammatory (steroids (inh/oral) mast cell stabilisers - cromolyns (cormoglycate & nedocromil), leucotriene antagonists (monteleukast)
3) symptom controller - long acting B2 agonist

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13
Q

When to use a preventer

A

if asthma episodes are >3/week or using SABA > 3/week
>1 canister/3months
evidence of reversible airflow when asymptomatic
interfering with exercise despite pre-treatment
asthma attacks every 6-8 weeks
or infrequent but severe - life threatening

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14
Q

when using corticosteroid inhalers what do you need to watch out for?

A

oral thrush
hoarse voice (dysphonea)
bronchial irritation - cough
adrenal suppression - possible at doses >800mcg daily, likely at doses of 2000mcg

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15
Q

what 2 options are there for fixed dose combination asthma medications?

A

inhaled corticosteroids with LABA

1) Seretide - fluticasone + salmeterol (LABA) - MDI or Accuhaler
2) symbicort - budesonide + formeterol - turbuhaler or MDI

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16
Q

prophylactic treatment options

A

LABA 5 minutes before lasts 1-2hrs
mast cell stabilisers (MCS) - sodium cromoglycate (SCG)/ nedocromil - 2 puffs
SCG + B2 agonist 5-20mins prior
montelukast 10mg daily or 1-2hrs prior

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17
Q

what is low dose Inhaled corticoid steroid

A

<160ngs ciclesonide

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18
Q

what is high doe ICS

A

> 400mcg beclomethasone
800mcg budesonide
500mcg fkuticasone
320mcg ciclesonnide

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19
Q

What dose of prednisolone would you consider for an exacerbation?

A

1mg/kg/day for 1-2 weeks

20
Q

What is a basic Mx plan for asthma (adults)

A

PRN B2 -Agonist
then:
ICS + PRN B2 -Agonist (with Prophylactic cromolyn or B2 agonist)
then:
Med-high dose ICS + LABA or theophyline or leukotriene (oral pred for exacerbations)

21
Q

signs of a severe asthma attach

A 
exhaustion
drowsiness/confusion
silent chest
quite wheeze
cyanosis
chest retraction

RR >25 adults, >5o children
PR >120bpm
peak flow <90%

22
Q

What is the 4x4x4 rule

A

4 puffs, with 4 breaths after each puff, every 4 minutes - ambulance called after 2nd round if no improvement

23
Q

What is the guidelines for treating a severe asthma attack with spacer in 35kg

A

Every 20min for the first hour give:
35kg 12 puffs, 4 puffs
ipatropium not needed in moderate attack.

24
Q

how to treat the acute severe attack (adult)

A

Continuous neb salbut + ipatrop
IV salbut (500mcg)
steroids - pred 50mg or hydrocort 250mg IV/IM Q6hrly
o2 8l/min face mask - maintain sat >95%

if ?cardioresp arrest
adrenaline 0.5mg 1:1000SC/IM or 1:10,000 IV
MgPO4 25-100mg/kg (max 2gm) IV over 20min

25
Q

Are bronchodilators effective in 2yr olds?

what about 1yr olds?

A

Yes in 2yrs, often not under 12 months.

26
Q

at what dose do you need to be careful of side effects (incl growth suppression) in kids on corticosteroids?

A

400mcg or greater. Aim for 100-400mcg.

27
Q

what is the stepwise mx of asthma in children for mild - mod - severe

A

mild = prn SABA

mod = PRN SABA + montelukast (2-5yrs 4mg nocte, 6-14yrs 5mg nocte) OR cromolyn OR ICS @ min effective dose (beclomethasone 100-200mcg/day, budesonide 200-400mcg/day)

severe = prn SABA +ICS ( as above), ?LABA with ICS, ADD as needed - theophyline CR (sprinkles) , ipatropium bromide (neb), oral pred

28
Q

what is considered - mild, mod, severe asthma in children

A

mild = infrequent & episodic - attacks not severe, more than 6-8 weeks apart
mod = frequent episodic - attacks 1/week, multiple ED visits
XXXXXXXXX

29
Q

In a child on high does ICS what diet supplements may be useful

A

calcium supplements

30
Q

What vitamin and mineral supplements have been shown to have some benefit?

A

Vitamin C,E and magnesium

31
Q

What are some Acute causes of wheezing in children

A 
asthma
bronchiolitis
bronchitis
laryngotracheobronchitis
bacterial tracheitis
foreign body aspiration
oesophageal foreign body
32
Q

What are some Chronic causes of wheezing in children

A 
Structural abnormalities:
- vascular compression/rings
-tracheo-bronchomalacea
- cystic lesions/masses
tumours/lymphadenopathy
cardiomegaly
Functional Abnormalities
- Asthma
- GORD
- CF
- immunodeficiency
-Primary Ciliary Dyskinesia
- Bronchopulmonary Dysplasia
- retained foreign body
bronchiolitis obliterans
pulmonary oedema
vocal cord dysfunction
interstitial lung dx
33
Q

If a child has a first episode of wheeze in the first year of life what are the chances of them developing asthma

A

50%

34
Q

True or false - The older a child is when they have their first episode of wheeze the more likely it is due to asthma?

A

True

35
Q

If a child has recurrent or persistent wheeze what are the chances that they have asthma?

A

80%

36
Q

What other symptoms or illnesses increase the likelihood of asthma in a child

A

any features of atopy (eczema or hay fever)
positive allergen test
elevated IgE antibodies
any of the above makes the diagnosis a=of asthma to be about 95% likely

37
Q

what is more effective, regular or PRN SABA dosing

A

PRN is as good as regular

38
Q

what percentage of kids with asthma will only require a SABA?

A

75%

39
Q

when would you consider adding in an ICS to a mx plan

A

when >15% reversal seen while well
>3/week SABA use
ASthma interfering with physical activities
severe/life threatening attacks

40
Q

What long term side effects have been associated with ICS use

A

cataracts
dcr BMD
glaucoma
1cm growth retardation in children.

41
Q

What is symbicort? and what do you use it for?

A

RED
a LABA and ICS - efometerol/Budesonide
Reliever and Maintenance

42
Q

what is atrovent?

A

ipatropium bromide - Antimuscarinic

43
Q

what is sere tide and what do you use it for?

A

(purple)
LABA and ICS - salmeterol/fluticasone
Just maintenance

44
Q

What is Bricanyl and what is it used for?

A

Terbutaline - SABA

45
Q

What is SIngulair

A

Montelukast - a leukotriene receptor antagonist

Respiratory (9 decks)

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