Asthma Flashcards
What are 3 important questions to ask during an asthma annual review?
- In the last month/week have you had difficulty sleeping because of your asthma (including cough, SOB)?
- Have you had your usual asthma symptoms (cough, SOB, chest tightness, wheeze) during the day?
- Has your asthma interfered with your usual daily activities?
What are the characteristics of vesicular breathing?
- Normal sound on most of the lung
- Soft
- Low pitch
- Inspiration longer than expiration
- No gap between both phases
What are the characteristics of bronchial breathing?
- Abnormal in majority of lung that is far from main airways
- Loud and tubular quality
- High pitched
- Inspiratory and expiratory phases equal
- Definite gap between both phases
In what conditions is bronchial breathing heard?
- Consolidation
- Lobar Collapse with patent bronchus
- Lung Cavity
(Think “3Cs”)
What are the characteristics of a wheeze?
- Continuous and musical quality
- Expiratory usually
- Indicates narrowing of airways either due to bronchospasm or secretions in small airways
- Low pitch or high pitch
- High pitch polyphonic or monophonic
When is a high pitch wheeze heard?
Due to smaller airways narrowing in bronchospasm (i.e. asthma)
When is a low pitch wheeze heard?
When smaller airways narrow due to secretions (i.e. chronic bronchitis)
When is a polyphonic wheeze heard?
When there is variable degree of bronchospasm (i.e. asthma) and is more commonly heard
When is a monophonic wheeze heard?
When there’s a localized obstruction
What are the characteristics of crackles?
- Interrupted and non-musical quality
- Inspiratory usually
- Peripheral airway collapse on expiration due to interstitial fibrosis or secretions/fluid
- During inspiration, rapid air entry abruptly opens these collapsed smaller airways + alveoli producing a crackling noise
What conditions have the following crackles:
- Early inspiration
- Mid-inspiration
- End-inspiration
- Biphasic
- Small airway disease (i.e. bronchiolitis)
- Pulmonary oedema
- Pulmonary fibrosis, pulmonary oedema, COPD, resolving pneumonia, lung abscess, tuberculous lung cavities
- Bronchiectasis
What are the conditions that produce fine crackles?
- Bronchiolitis
- Pulmonary oedema
- Pulmonary fibrosis
What are the conditions that produce coarse crackles?
- COPD
- Bronchiectasis
- Resolving pneumonia
- Lung abscess
- Tuberculous lung cavities
What are the characteristics of pleural rub?
- Caused by inflammation of the visceral and/or parietal pleura
- Low pitched/grating sound
- Heard in inspiration when visceral and parietal pleura slide over one another
What conditions do you get pleural rub in?
- Consolidation
- Pulmonary infarction (i.e. PE)
- Uremia
List 5 conditions, other than asthma, where you can hear a wheeze on auscultation
- COPD
- Pulmonary disease
- Cardiac failure
- Eosinophilic lung disease
- Foreign body aspiration
What should you recommend for patients with exercise-induced asthma?
Take their bronchodilator (short-acting B2 agonist - salbutamol) inhaler with them and use it just before exercise to prevent an attack
Why it is particularly important to have the flu vaccination when you have asthma? What other vaccinations would you recommend for patients with chronic asthma?
Flu can be more serious for people with asthma, even if their asthma is mild or their symptoms are well-controlled by medication. This is because people with asthma have swollen and sensitive airways, and influenza can cause further inflammation of the airways and lungs. Influenza infection in the lungs can trigger asthma attacks and a worsening of asthma symptoms. It also can lead to pneumonia and other acute respiratory diseases.
A one-off vaccination against Pneumococcal disease is also recommended
Define the term peak expiratory flow rate
The maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration
How do you predict someone’s peak flow?
Calculated using the patient’s sex and height
How do you record serial readings of peak flow and for how long?
For diagnosis 2-4 weeks, twice daily (NICE 2017)
For Occupational Asthma it may require 2-4 hourly reading over several weeks
What on the peak flow chart would indicate asthma that is well-managed?
Less variation between peaks and trough levels
What are asthma triggers?
- Cold weather
- Allergies
- Smoke, pollen, pollution, mould/damp
- Atopic (combo of eczema, hayfever + asthma)
- Cold/flu (chest infections)
- Medicines (i.e. NSAIDs, aspirin)
- Emotions (laughter, stress)
- Exercise
- Occupational asthma
What is the pathophysiology of asthma?
- Submucosal gland hypertrophy + hyperplasia
- Goblet cells metaplasia -> more mucus production
- Infiltration by eosinophils + neutrophils
- Oedema
- Smooth muscle hypertrophy + hyperplasia
- Thickening of basement membrane
- Epithelial desquamation
What is asthma?
Chronic condition that causes the airways to narrow and swell resulting in wheezing and difficulty breathing
In asthma the airways are sensitive to triggers that causes the airways to inflame
What occurs in metabolic acidosis?
Reduced HCO3- concentration in the blood due to increased H+ production, decreased excretion, or loss of bicarbonate
What are the 4 main causes of metabolic acidosis?
- Diabetic ketoacidosis
- Lactic acidosis
- Renal failure
- Chronic diarrhea
What occurs in metabolic alkalosis?
Increased HCO3- in the blood due to excess alkali intake, loss of gastric acid or K+ depletion
What occurs in respiratory acidosis?
CO2 retention (increased) that may be due to primary lung pathology (i.e. pneumonia) or other respiratory diseases
What occurs in respiratory alkalosis?
Fall in pCO2 as a result of hyperventilation
What is the FEV1/FVC ratio in obstructive lung disease?
< 70%
What is the FEV1/FVC ratio in restrictive lung disease?
> 70% with individual values each <80% of predicted values
How do you diagnose asthma?
- Spirometry -> ratio < 70% (obstructive disorder)
- Peak flow -> look for variability
- FBC -> look at eosinophil count (for eosinophilic asthma)
- Chest xray -> usually normal/hyperinflated
What is a FeNO test?
It’s a simple test to see how much nitric oxide – a substance that can be found in high amounts in people who have sensitive airways – is in your breath.
A result > 40ppb of nitric oxide on patient’s breath indicates asthma
What is the treatment for asthma?
- Give short-acting b2 agonist (salbutamol) + steroid inhaler (beclomethasone)
- Atrovent (ipratropium bromide) nebulizer + salbutamol nebuliser
- Prednisolone/hydrocortisone IV
- O2 therapy
- Magnesium + aminophylline (bronchodilators)
- In community give beclomethasone as an inhaler
What is a side effect of b2 agonists?
Tachycardia
If FEV1 and FVC are both < 80% but the ratio is < 70% what is this disorder?
A mixed disorder
If a nebulizer isn’t available, what other treatment is just as effective for a patient having an acute asthma attack?
6 puffs of salbutamol via a spacer
In addition to the medicinal treatment for asthma what else should be done during an attack?
- Insert an IV cannula (if there’s poor response to oral bronchodilators)
- Ensure patient is sitting upright
- Document all treatments including route, dose, time
What does the RIP mnemonic stand for when analyzing chest x-rays?
Rotation: The spinous process should be at the midpoint between the heads of both clavicles
Inspiration: 5-7 ribs should be visible anteriorly
Penetration: Is the spine visible behind the heart?
Does asthma treatment change in pregnancy?
No the patient can continue all their normal asthma medications
List 6 contraindications for spinal anaesthesia
- Patient refusal
- Infection at injection site
- Uncorrected hypovolemia
- True allergy to any of the drugs
- Increased intracranial pressure
What is a feature of acute severe asthma?
Peak flow 33-50% of best/predicted
A 45 year old man comes in wheezing and short of breath. On examination you can hear breath sounds in his left lung but you cannot hear any breath sounds in his right lung. What is the most likely diagnosis?
Foreign body aspiration
Practice prescribing a preventer inhaler. The patient uses a metered dose inhaler via a spacer. The patient has no known drug allergies.
Beclomethasone ‘clenil’ 200ug MDI
Route: Inhaler
Dose: 1 puff
What are the ethical principles?
- Autonomy
- Consent
- Beneficence
- Non-malificence
- Justice
What are the 5 principles of the Mental Capacity Act 2005?
- Presumption of consent
- Ensure all practical steps are taken
- Unwise decisions don’t mean they lack capacity
- Consider best interests
- Least restrictive intervention
What does the patient need to be able to do to show they have capacity?
- Understand info
- Retain info
- Use info
- Communicate the decision
Name conditions that can cause shortness of breath
- Heart failure
- Panic attack
- Pneumothorax
- Foreign body aspiration
- DKA
- Interstitial lung disease
- Asthma
- PE
- Acute exacerbation of asthma/COPD
- Anaphylaxis
Go through the ABCDE approach
Airway: Patent airway? Non-rebreathe mask (15L), nasopharyngeal/oropharyngeal airways
Breathing: Resp rate (most sensitive sensor of disease), polyphonic end-expiration wheeze (smaller bronchioles are narrowed), O2 sats
Circulation: Pulse, BP, cap refill, listen to chest
Disability: Blood glucose
What is the treatment used for asthma and the signs in a respiratory exam that indicate this disease?
B2 agonist nebuliser
- Increased respiratory rate + use of accessory muscles
- Wheeze
- White, viscous sputum
What is the treatment used for pulmonary oedema and the signs in a respiratory exam that indicate this disease?
Loop diuretics/continuous positive air pressure (CPAP)
- Fine basal crackles
- Sacral + pedal oedema
- Increased JVP
- Frothy, pink sputum
** Remember this is fluid IN the lung tissue (parenchyma)
What is the treatment used for tension pneumothorax and the signs in a respiratory exam that indicate this disease?
Chest drain
- Deviated trachea + mediastinum away from affected side
- Decreased breath sounds on affected side
- Hyper-resonant percussion on affected side
- Asymmetrical chest expansion
What is the treatment used for massive hemothorax and the signs in a respiratory exam that indicate this disease?
Chest drain
- Dull on percussion
- Decreased breath sounds
- Hypotensive (hypovolemic)
- Asymmetrical chest expansion
Compare a severe vs life-threatening acute asthma attack
Severe:
- Unable to complete sentences in 1 breath
- Resp rate ≥ 25/min
- Pulse rate ≥ 110/min
- Peak expiratory flow (PEF) 33-50% of predicted/best
Life-threatening:
- PEF ≤ 33% of predicted/best
- Silent chest, cyanosis, feeble respiratory effort
- Arrhythmia/hypotension
- Exhaustion, confusion, coma
- ABGs: Normal/high PaCO2 > 4.6kPa; PaO2 < 8kPa or SaO2 < 92%
What is the management of someone with an acute asthma attack?
- Salbutamol 5mg nebulised with O2 + prednisolone 30mg PO
- If PEF remains < 75% repeat salbutamol every 15-30min + ipratropium
- Monitor O2 sats, resp rate, heart rate
- Consider single dose of magnesium sulphate 1.2-2g IV over 20min without good initial response/life-threatening
What kind of drug is ipratropium and what are its side effects?
Anticholinergic
SE: urinary retention, dry mouth, acute closed angle glaucoma
What is the most effective treatment for asthma?
Corticosteroids (reduce inflammation)
What are the side effects of salbutamol?
Hypokalemia
What procedures require you to get written consent from the patient?
In general, higher risk procedures (i.e. fertility treatment, surgery)
- the investigation or treatment is complex or involves significant risks
- there may be significant consequences for the patient’s employment, or social or personal life
- providing clinical care is not the primary purpose of the investigation or treatment
- the treatment is part of a research programme or is an innovative treatment designed specifically for their benefit
