Asthma

Question 1

Definition

Answer 1

Increased responsiveness of trachea and bronchi giving inflammation, widespread narrowing of smooth muscle in airways. Changes in severity either spontaneously or by a result of therapy.

Question 2

What are the epithelial cells of the airways normally like?

Answer 2

Pseudostratified ciliated columnar

Question 3

Proven risk factors

Answer 3

Genetics - inherited tendency to IgE response to allergens
Occupation - baker
Smoking - including children born to mums who smoke

Question 4

Symptoms (VARIABILITY)

Answer 4

wheeze
breathlessness
chest tightness (pain)
dry cough
sputum

Question 5

Differential diagnosis

Answer 5

Inspiratory stridor, tumour or foreign body, COPD, bronchiectasis, bronchiolitis, cystic fibrosis, viral induced wheeze

Question 6

Triggers for asthma exacerbation

Answer 6

exercise, cold air, smoke, perfume, URTIs, pets, tree, grass pollen, food, aspirin

Question 7

Describe variation in asthma

Answer 7

Daily variation - worse in morning and at night
Weekly - occupational asthma
Annual variation - environmental allergens such as hayfever

Question 8

Examination

Answer 8

Asthma affects both lungs

No clubbing, stridor, assymetrical expansion, dull percussion note or crepitations.

Question 9

Investigations

Answer 9

Spirometry (with and without inhaler)
Peak expiratory flow rate
Lung volume tested with helium
Carbon monoxide gas transfer
Steroid trial
(airway responsiveness to histamine)
(nitric acid)
(chest x-ray, skin prick test, full blood count)

Question 10

What are the levels of acute asthma? (asthma attack)

Answer 10

Moderate, severe, life threatening, near fatal

Question 11

What do you have to test when someone comes in with an acute asthma exacerbation?

Answer 11

Ability to speak
Heart rate
Respiratory rate
Peak expiratory flow
Oxygen saturation
Blood gas - PaO2, PaCO2

Question 12

What is the difference in asthma treatment between children and adults?

Answer 12

In children there is a lower ceiling of treatment - max dose of ICS is 800mg. No oral beta 2 agonist tablet. LTRA is first line preventor in under 5s.

Question 13

Asthma treatment in children

Answer 13

Short acting beta 2 agonists as required.

1. Regular preventer (low dose ICS or LTRA < 5s)
2. Initial add-on preventer (low dose ICS + inhaled LABA)
3. Additional add-on therapies (stop LABA and increase ICS OR continue LABA and increase ICS OR consider LTRA)
4. High dose therapies (Increase ICS, addition of 4th drug such as theophylline)
5. Continuous or frequent use of oral steroids

Question 14

Other management of asthma

Answer 14

remove environmental triggers
smoking cessation
weight loss
vaccines
patient education
inhaler technique
bronchial themoplasty

Question 15

Side effects of reliever inhaler (SABA)

Answer 15

tremor, cramp, headache, flushing, palpitations and angina

Question 16

Name drugs for SABA, low dose ICS, LTRA and oral steroids

Answer 16

Salbutamol
Beclomethasone, budesonide, fluticasone
Montelukast or Zafirlukast
Prednisolone

Question 17

How do you treat mild/moderate asthma exacerbation?

Answer 17

Oral prednisolone for 7 days
SABA relievers
ICS and LABA

Question 18

How do you treat severe asthma exacerbation?

Answer 18

Hospital
Oral/IV steroids
Nebulised bronchodilators
Oxygen
Antibiotics if infection
Chest x-ray
May need anaesthesia, intubation and ventilation 
In extreme cases ECCO2 (to remove carbon dioxide) may be life saving