Asthma

Question 1

Definition of asthma

Answer 1

Disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person

Question 2

Bronchoconstriction

Answer 2

Contraction of the smooth muscle in the bronchial wall

Question 3

Bronchial secretions and plugs of mucus

Answer 3

Due to inflammation of the bronchial wall

Question 4

Atopy

Answer 4

Tendency to form IgE antibodies to allergens (such as pollen, house dust mites or animals).

Often associated hay fever or eczema in the personal or family history

Question 5

Risk factors

Answer 5

Genetics
Smoking
Obesity
Pollution
Occupational asthma

Question 6

Symptoms

Answer 6

Cough
Wheeze
Breathlessness

The symptoms are episodic. They are often worse at night eg 3-4 am, or after exposure to triggers such as exercise or infection. There is often a feeling of tightness in the chest

Question 7

Diagnosis

Answer 7

The history is crucial

Past medical history (previous wheezing illness, hay fever, eczema), family history (of any atopic disease), and social history (occupation, pets) can provide clues

Physical examination may be normal except during an attack

Question 8

Investigations

Answer 8

The chest X-ray is often normal, but may show hyperinflation

There may be an increased eosinophil count in the blood

Skin prick or blood tests may confirm allergies

Lung function tests may show airflow obstruction, but may be normal between attacks

Question 9

Test of lung function

Answer 9

Does obstruction vary over time?
- peak flow monitoring
Is it reversible?
- with bronchodilators or a course of steroids
15% improvement from baseline
Would a bronchial challenge test help?
- if the story suggests asthma, but lung function is normal

Question 10

FeNO

Answer 10

Measure of airway eosinophilic inflammation

Question 11

Management of asthma

Answer 11

relievers

• beta 2 agonists (eg
  salbutamol,terbutaline).
  - theophylline, anticholinergics

Question 12

Patients with difficult asthma treatments

Answer 12

Desensitisation to proven inhalant allergens

Monoclonal anti-IGE antibody injections (omalizumab)

Immunosuppressant therapy (apart from corticosteroids) eg methotrexate

Bronchial thermoplasty

Question 13

Treatment compliance/adherence - unintentional

Answer 13

Misunderstanding
Poor inhaler technique
Language
Forgetfulness, stress

Question 14

Treatment compliance/adherence - intentional

Answer 14

Concern about side-effects

Denial

Question 15

Personal asthma action plan

Answer 15

List daily medication to take and explain why

List which asthma triggers to avoid

List indicators, such as increasing cough, or deterioration of asthma

List names and doses of medication to be taken to treat worsening asthma

List indicators of how and when to seek medical attention

Question 16

Management of asthma - features of severe asthma

Answer 16

PEF 33-50% best or predicted
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Respiratory rate >25 breaths/min
Pulse >110 beats/min

Question 17

Management of asthma - life threatening features

Answer 17

Hypoxia (O2 sats <92%)
Silent chest, poor resp effort
Bradycardia or hypotension
Exhaustion, confusion, coma

Question 18

Management of asthma

Answer 18

Oxygen
Corticosteroids - prednisolone 40-60 mgs orally (IV hydrocortisone if unable to take orally)
Nebulised bronchodilators – salbutamol + ipratropium
If poor response, IV MgSO4, salbutamol or aminophylline
Exceptionally, ventilation (IPPV) is required

Question 19

Hospital discharge

Answer 19

Diurnal variation of PEF < 25%
Support/safety at home
Education
Personalised written asthma action plan
Follow up