asthma

Question 1

What is asthma characterised by?

Answer 1

bronchial hyperresponsiveness

Question 2

What are the symptoms of asthma

Answer 2

cough
SOB
episodic wheezing
chest tightness
secretions
diurnal variation

Question 3

What are the two main types of asthma?

Answer 3

eosinophilic

non-eosinophilic

Question 4

What is atopy?

Answer 4

tendency to develop IgE

mediated reactions to common aeroallergens

Question 5

What are the two subtypes of eosinophilic asthma?

Answer 5

atopic

non-atopic

Question 6

What types of allergens/exposures can cause atopic eosinophilic asthma?

Answer 6

fungal allergy
common aeroallergens
occupation
pets

Question 7

What subtypes of non-eosinophilic asthma are there?

Answer 7

non-smoking
smoking
obesity related

Question 8

What are the provoking factors of asthma?

Answer 8

allergens
infections 
menstrual cycle
exercise
cold air
emotion

Question 9

How can asthma severity be assessed?

Answer 9

RCP3 questions (indicates how well controlled the asthma is)

Question 10

What are the RCP 3 questions?

Answer 10

recent nocturnal waking
usual asthma symptoms in a day - wheeze, chest tightness, SOB
interference with ADL

Question 11

What are the other indicators of asthma severity?

Answer 11

no. of inhalers needed
A+E attendances, admissions, HDU, ventilation
attendance at GP for antibiotics and steroids

Question 12

What should you consider about the asthma in the history?

Answer 12

is it asthma
the type of asthma
severity
treatment

Question 13

What questions should be asked when assessing the history of the complaint?

Answer 13

age on onset
features at the onset eg weight loss
childhood ventilation or respiratory disease
obvious causes
PMH - previous pneumonias - bronchiectasis
neurological/renal problems (vasculitis)

Question 14

What conditions are associated with asthma?

Answer 14

eczema
hayfever
food allergies
drug allergies
reflux disease
nasal disease

Question 15

What questions should be asked about drugs with asthma?

Answer 15

• What are they supposed to be taking?
• What do they actually take?
• Are they taking beta blockers orally or
topically?
• Are they sensitive to NSAIDs or aspirin?
• Drugs with potential interactions:
theophyllines

Question 16

What questions need to be asked about FH and SH?

Answer 16

do they smoke
atopy in the family
pets at home
psychological and psychiatric history

Question 17

What questions should be asked about their occupation?

Answer 17

VDGF exposure

is asthma worse at work/ better on holidays?

Question 18

What are the features of COPD that are different to asthma?

Answer 18

later disease of smokers
relentless progressive SOB
less diurnal and day-day variation
winter symptoms with sputum production

Question 19

What can be found on examination in asthma

Answer 19

may be normal
wheeze, polyphonic, expiratory and widespread
absence of crackles, sputum, other signs

Question 20

What tests can be done for asthma?

Answer 20

blood count: eosinophils
tests for atopy and allergy: SPTs and 
Radioallergosorbent test (RAST)
CXR useful
oxygen sats

Question 21

What is the FEV1/FVC for obstructive conditions?

Answer 21

<70%

Question 22

What are the results of lung functions tests for people with asthma?

Answer 22

airways obstruction (reduced FEV1 and FEV1/FVC ratio <70%)
PEFR reductions and variability of 20%
increased responsiveness to challenge by mannitol and methacholine
reversibility testing with bronchodilators or anti-inflammatory

Question 23

What are the tests for airway inflammation?

Answer 23

FeNO - exhaled NO

direct measurement of cells - blood eosinophils

Question 24

What are the major definitions for severe asthma?

Answer 24

treatment with continuous steroids

or high dose inhaled steroids

Question 25

What are the minor characteristics of severe asthma?

Answer 25

``` daily reliever medication persistent airway obstruction (FEV1<80%) diurnal variation PEFR >20% ≥1 emergency visits p.a. • ≥3 steroid courses p.a. • Prompt deterioration with ≤25% reduction in oral or inhaled steroid dose • Near-fatal event in past ```

Question 26

Who is most at risk of asthma death?

Answer 26

>= 3 classes of treatment recent admission/ frequent attender previous near fatal disease psychosocial factors

Question 27

What are the differential diagnoses of asthma?

Answer 27

``` Bronchiolitis • Bronchiectasis* • CF • PE • CEA • idiopathic pulmonary fibrosis • Hyperventilation* • Bronchial obstruction - foreign body, tumour, etc • Vocal cord dysfunction* • Aspiration • CCF - congestive cardiac failure • COPD ```

Question 28

What are the treatments of asthma?

Answer 28

avoidance of triggers bronchodilators anti-inflammatories Abs - new biologics

Question 29

What do steroids do?

Answer 29

reduce airway inflammation

Question 30

What are the side effects of oral steroids?

Answer 30

``` diabetes, cataracts, osteoporosis, hypertension, skin thinning, easy bruising, growth retardation, osteonecrosis of the femoral head hoarse voice Adrenal suppression ```

Question 31

What drugs are used for severe eosinophilic asthma?

Answer 31

Anti-IgE - Omalizumab anti-IL-5 oral steroids, additional immunosuppressants

Question 32

What drugs are used for non-eosinophilic asthma?

Answer 32

steroid therapy focus more on bronchodilator treatment bronchial thermoplasty (no biological therapies for non-eosinophilic asthma)

Question 33

What should be given to sb immediately when they come with an asthma attack?

Answer 33

high flow oxygen | emergency nebulised beta agonist

Question 34

What investigations do you need to recognise a severe attack?

Answer 34

PEFR, full clinical assessment oximetry CXR if suspect pneumothorax, consolidation and life threatening asthma

Question 35

What measures are used to classify an attack as moderate?

Answer 35

PEFR>50% of maximum RR <25 pulse <110 normal speech

Question 36

What measures would you use to classify an attack as severe?

Answer 36

``` ANY ONE OF: PEFR 33-50% of maximum RR >= 25 HR >=110 inability to complete sentences ```

Question 37

What measures would you use to classify an attack as life-threatening?

Answer 37

PEFR <33% SaO2 <92% or PaO2 <8 kPa Normal PaCO2 4.6-6 kPa altered consciousness level, exhaustion, hypotension, silent chest, poor effort, cyanosis

Question 38

What is used to classify an attack as near fatal?

Answer 38

raised PaCO2 and/or requiring ventilation with raised airway pressures

Question 39

What is done to immediately manage an acute asthma attack?

Answer 39

oxygen 40-60% salbutamol nebulised 5mg(+ ipratropium nebulised 0.5mg if life threatening) - repeated IV prednisolone +/- hydrocortisone consider magnesium ABGs CXR if suspect pneumothorax, consolidation or fails to respond to treatment

Question 40

How can we monitor the response to treatment during an asthma attack?

Answer 40

PEFR check within 15-30 mins /regularly oximetry to maintain SaO2 >92% repeat ABGs within 2 hours if severe attack or pt is deteriorating If deteriorating despite maximal treatment with worsening hypoxia, hypercapnia or coma / exhaustion - ITU transfer Watch K+, glucose, Consider rehydration

Question 41

What should be done on discharge?

Answer 41

Opportunity to educate and prevent readmissions • Achieve PEFR > 75% and <25% variability • Prednisolone for minimum 7-14 days (never decrease until improving) • Step up treatment • Asthma action plan • Nurse-led follow-up • Early clinical review (48 hours at GP surgery) need to be off nebulisers and on stable treatment 24 hours

Question 42

What is the difference between eosinophilic and non-eosinophilic asthma?

Answer 42

eosinophilic asthma - Th2 response, IL-5 produced which stimulates the production of eosinophils B cells produce antigen specific IgE mast cells degranulate IL4, 13, 5 involved non-eosinophilic asthma - Th1 and Th17 response activates monocytes, macrophages , mast cells and neutrophils the mast ells have complement receptors on them