Asthma Flashcards
with regards to epidemiology what is the prevalence of asthma in the adult welsh population
1:12 welsh adults
according to epidemiological studies list 2 environmental factors that may increase your risk of developing asthma
Increased risk • Caesarian delivery? • Childhood antibiotic use • Childhood use of paracetamol? • Exposure allergen • Sedentary life style • Obesity • Maternal smoking • Pollution
list three pathological features of asthma that may be found at post mortem
Any of the following • Inflammation of bronchial wall: eosinophilic • Mucus plugging • Airway remodelling: – Airway wall thickening: 50-300% (Bronchial smooth muscle hypertrophy \+ airway oedema) – Mucus gland hyperplasia – Loss of surface epithelium – Sub-epithelial fibrosis - thickening of basement membrane
list 2 mediators released by mast cells which cause bronchoconstriction clinically
Histamine, Prostaglandin D2, Leukotrienes (D4, E4)
T-helper 2 lymphocytes release the cytokine IL-5 which promtoes the differentiation of which inflammatory cell type
Eosinophils
in some individuals NSAIDs may worsen asthma. Which enzyme does this class of medication inhibit
COX (II)
Mr X is 34y/o asthmatic on inhaled budesonide and PRN salbutamol. which step of the asthma ladder is he currently on?
Step 2: low dose inhaled steroid + PRN B2 agonist
Mr X is 34y/o asthmatic on inhaled budesonide and PRN salbutamol. He attends your surgery as he is not sleeping at night due to cough and wheeze. If you were to increase his treatment name a class of drugs that you would add to his therapy
Try LABA first and if ineffective consider increasing ICS
then theophylline or leukotriene receptor antagonist
You are the A&E SHO on call. Miss B is a known
asthmatic who presents with cough and SOB. On arrival
the paramedics show you her ambulance card.
Observations are as follows. Pulse 120, RR 26, Sats
94% on air. When you review her she has marked
expiratory wheeze and is not able to talk full sentences.
Grade her asthma severity
severe
You are the A&E SHO on call. Miss B is a known
asthmatic who presents with cough and SOB. On arrival
the paramedics show you her ambulance card.
Observations are as follows. Pulse 120, RR 26, Sats
94% on air. When you review her she has marked
expiratory wheeze and is not able to talk full sentences.
name 3 medications that you would consider starting her on
Salbutamol 5mg nebulised, Ipratropium bromide 500mcg
nebulised, Prednisolone 40mg od po
Parameter Value Normal range pH 7.35 (7.35-7.45) pCO2 6.0 4.5-6kPA pO2 10 11.5.- 13 BE 1 -1 /+1 Bicarb 25 24/27
what concerns you about this blood gas
normal pCO2 worsening hypoxia
Parameter Value Normal range pH 7.35 (7.35-7.45) pCO2 6.0 4.5-6kPA pO2 10 11.5.- 13 BE 1 -1 /+1 Bicarb 25 24/27
ITU are contacted, list 2 other therapy that you might consider
IV magnesium sulphate
IV aminophylline/IV salbutamol
Mrs A is a 44 year old atopic asthmatic. She currently
taking symbicort tubohaler 400/12 (eformoterol +
budesonide 400). She is also taking uniphyllin
(theophylline).
which step of the asthma ladder is this patient currently on
Step 4: on high dose inhaled steroids, LABA and
theophylline
which enzyme do theophylline tablets inhibit
Phosphodiesterase: inhibiting the breakdown of cAMP
state the side effects you are most likely to see in a patient taking a beclometasone inhaler
Sore throat
Candidiasis
Hoarse voice
can be avoided with the use of spacers/improving technique or rinsing mouth out after
In patients taking 1mg/day beclometasone (or equivalent) we should
also monitor carefully for systemic side effects
for approximately how long would you espect to see the bronchodilation effects of salmeterol
12 hours
which of the inflammatory mediators does montelukast block from reaching its receptor
leukotriene
name a drug or condition which can increase the half life of theophylline? and what symptoms could this cause?
Hepatic cirrhosis CHF Acute pulmonary oedema Erythromycin Fluconazole Other drugs also inhibit metabolism of theophylline – check Appendix 1 of BNF for details Symptoms of toxicity include N&V, arrhythmias, restlessness, convulsions, coma
mary has come to her GP and described worsening asthma symptoms, what would you discuss with her before making changes to her drug treatment
Possible triggers for worsening symptoms
Inhaler technique and compliance
Jack, aged 31years is using a Seretide 125 evohaler
(fluticasone and salmeterol) regularly and a salbutamol
inhaler when required. His asthma has been well
controlled for many years, with him rarely using his
salbutamol inhaler and he has come for a review of his
treatment.
You decide that stepping down his treatment would be appropriate. Which of his drugs should be discontinued?
Salmeterol
But patient should remain on fluticasone and when required
salbutamol so no reduction in dose count
T/F In children with wheeze:
A) Bronchiolitis only affects children over 2 years of age
B) Haemoptysis is a common symptom of childhood
asthma
C) Congenital lung abnormalities can present as old as 5
years age
D) Toddlers are the commonest age group for inhaled
foreign bodies
E) Nocturnal cough is a sign of asthma
F) A child who is not wheezing by 3 years of age will not
develop asthma
In children with wheeze
C) Congenital lung abnormalities can present as old as 5
years age
D) Toddlers are the commonest age group for inhaled
foreign bodies
E) Nocturnal cough is a sign of asthma
T/F Exercise and children:
A) Cross country running is usually more of a problem
than football for children with asthma
B) A high organic content or insufficient chlorine in a
swimming pool can trigger asthma
C) Swimming is well tolerated in most children with
asthma
D) Warming up before exercise can have a ‘protective
effect’ for children with asthma
E) Professional athletes do not have asthma
A) Cross country running is usually more of a problem
than football for children with asthma
B) A high organic content or insufficient chlorine in a
swimming pool can trigger asthma
C) Swimming is well tolerated in most children with
asthma
D) Warming up before exercise can have a ‘protective
effect’ for children with asthma
T/F In acute asthma in children:
A) 10-12 puffs of salbutamol via a spacer is usually as
effective as the appropriate dose via a nebulizer in
acute asthma in children
B) Oral steroids are not given in acute asthma preteenage
years due to their effect on growth
C) Teachers have a legal requirement to give children
their medication in school
D) Stress/emotion is not a trigger in primary school
children
E) Toddlers with a tight chest may complain of ‘tummy
ache’
In acute asthma in children:
A) 10-12 puffs of salbutamol via a spacer is usually as
effective as the appropriate dose via a nebulizer in
acute asthma in children
E) Toddlers with a tight chest may complain of ‘tummy
ache’
T/F Inhalers/PEFRs in children:
A) Washing and air drying a spacer in ‘fairy’ washing up
liquid significantly reduces its static
B) An MDI and spacer is the first choice for inhaled
treatment in children under 5 years.
C) A dry powder inhaler is first choice for inhaled steroid
treatment in children aged 6 – 12 years
D) Children 3 years and over are able to give reliable
PEFRs
E) An MDI directly into the mouth should be used for
bronchodilators in Teenagers
F) PEFRs in children are charted against their height
Inhalers/PEFRs in children:
A) Washing and air drying a spacer in ‘fairy’ washing up
liquid significantly reduces its static
B) An MDI and spacer is the first choice for inhaled
treatment in children under 5 years
F) PEFRs in children are charted against their height
which factors reduce risk of asthma development
Reduced Risk • Vaginal delivery • Breast feeding • Infection: “The Hygiene Hypothesis” • Exposure to rural environment • Increase antioxidants
what are the parameters for mild asthma attack
Mild Asthma
PEFR >75%
Pulse 96%
what are the parameters for moderate asthma attack
Mod Asthma PEFR 50-75% Pulse 100-110 RR 20-25 Sats >92%
what are the parameters for severe asthma attack
Severe Asthma PEFR 33-55% Unable to talk full sentences Pulse >110 RR>25 Sats <92% on air
what are the parameters for life threatening asthma attack
Life threatening PEFR <33% Confused Acidotic Normal to high pCO2 Hypoxic Bradycardia/hypotension Poor respiratory effort
what is the definition of asthma
airways hyperresponsiveness with air flow obstruction which is reversible spontaneously or with treatment
there are two main types of asthma: extrinsic and intrinsic. What types of extrinsic asthma are there
IgE mediated
atopic
occupational
there are two main types of asthma: extrinsic and intrinsic. what types of intrinsic (non-immune) are there?
infection cold exercise stress irritants
what is the dual pathophysiology of asthma
bronchial hyperreactivity –> bronchospasm
bronchial inflammation –> eosinophilic
which lifestyle factors predispose to asthma
smoking
pollution
occupation
what are the symptoms of asthma
recurrent wheeze, breathlessness, cough, and chest tightness
diurnal variation in peak flow (morning dippers)
which diagnostic investigations would be performed for asthma
peak flow diary spirometry CXR ECG FBC (eosinophils) IgE levels Saturations Blood gases
what is the criteria for intermittent asthma
symptoms < once a week - asymptomatic and normal PEF between attacks
night time symptoms < twice a month
PEF/FEV1 > 80%
what is the criteria for mild persistent asthma
symptoms > once a week but < once a day
night time symptoms > twice a month
PEF/FEV1 ~80%
what is the criteria for moderate persistent asthma
symptoms daily with daily use of SABA
night time symptoms > once a week
PEF/FEV1 80-60%
what is the criteria for severe persistent asthma
symptoms: continuous limited physical activity
frequent night time symptoms
REF/FEV1 <60%
briefly outline the asthma step ladder for adults
STEP 1 SABA prn
STEP 2 SABA +ICS
STEP 3 SABA + ICS + LABA
STEP 4 SABA + inc ICS +LABA (+leukotriene)
STEP 5
daily oral steroids and referral to specialist care
which acronym can be used to remember p450 enzyme inhibitors
Allopurinol Omeprazole Disulfram Erythromycin Valproate Isoniazid Cimetidine Ethanol Sulphanomides
list some biologics which can be used against asthma
anti IgE (omaluzimab + xolair)
Anti IL-13 + -14
Anti IL-5 (mepoluzimab)
Anti-TNF
what are the management steps in acute asthma
oxygen nebulised beta agonist steroid therapy (early!!) ipratropium bromide magnesium sulphate
what are the predictors of mortality in acute asthma
previous near fatal asthma (ITU admission)
previous admission in the last year with asthma
>3 classes of medication
repeated attendances
brittle asthma
which drug used in an acute setting is not actually licensed for asthma
anti-muscarinics such as ipratropium
how does magnesium sulphate aid in the management of acute asthma
decreased calcium conc therefore leading to muscle relaxation
how does sodium cromoglicate work
stabilises mast cells
under which circumstances is omalizumab used
in severe persistent allergic asthma
what are the side effects of SABAs
tremor
tachycardia
hypokalaemia (can be used to treat!!)
how does SABA work in asthma
relaxes smooth muscles rapidly (30min peak lasts 4-6hrs)
decr release of inflamm mediators
incr mucus clearance (ca be desensitized)
how do corticosteroid work in asthma
decr immune cells, inflam mediators, vascular permeability
list some examples of inhaled corticosteroids
beclometasone
fluticasone
budesonide
which LABA has the faster onset
formeterol
which combined ICS and LABA preparations are available
Seretide
symbicot - can be used for prevention and relief
Fostair
which type of asthma is leukotriene receptor antagonists most effective in the treatment of
exercise
nocturnal
NSAID induced
xanthines such as theophylline and aminophylline have a narrow therapeutic range - what is it?
also what are the side effects of overdose
10-20mg/L N+V tachycardia convulsion coma
which T helper cells are involved in pro-atopic asthma
Th2
which ILs promote Ig subclass switching in B/Plasma cells
IL 4 and 13
which cytokine are involved in activating eosinophils
IL5 and GM-CSF
what do eosinophils secrete in asthma
Major basic protein
eosinophil cation protein
leukotrienes
cytokines
which ILs activate mast cells
IL 4 and 5
what happens on mast cells in the early phases of the allergic asthmatic response sequence
IgE crosslinking leading to degranulation and bronchoconstriction
what happens on mast cells in the late phases of the allergic asthmatic response sequence
IMMEDIATE: degranulation releasing 1. histamine 2. TNF alpha 3. proteases 4. heparin
MINUTES:
lipid mediators such as prostaglandins and leukotrienes
HOURS: cytokine production (IL4 and IL13)
