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Y4 Respiratory > Asthma > Flashcards

Asthma Flashcards

1
Q

Define what asthma is

A
  • It is a chronic inflammatory disorder of the small & large airways secondary to type 1 hypersensitivity.
  • The symptoms are variable & recurring and manifest as reversible bronchospasm resulting in airway obstruction.
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2
Q

What are the 3 factors which contribute to airway narrowing in asthma ?

A
  1. Bronchial muscle contraction (airway hypersensitivity) - triggered by a variety of stimuli
  2. Airway inflammation - caused by mast cell, basophils & eosinophils degranulation resulting in the release in inflammatory mediators
  3. Increased mucus production

Pic shows bronchoconstriction, inflammation (pus seen in pic)

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3
Q

What type of inflammation is asthma characterised by ?

A

Eosinophilic inflammation

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4
Q

List the risk factors for asthma development

A
  • Personal or family history of atopy
  • Antenatal factors: maternal smoking, viral infection during pregnancy (especially RSV)
  • Low birth weight
  • Not being breastfed
  • Maternal smoking around child
  • Exposure to high concentrations of allergens (e.g. house dust mite)
  • Air pollution
  • ‘Hygiene hypothesis’: increased risk of asthma and other allergic conditions in developed countries due to reduced exposure to infectious agents in childhood preventing normal development of the immune system
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5
Q

Focusing on atopy, patients with asthma also suffer from other IgE-mediated atopic conditions such as?

A
  • Atopic dermatitis (eczema) and allergic rhinitis (hay fever)
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6
Q

List the triggers for asthma that you should ask about in someone presenting with potential asthma/diagnosed asthma

A
  • Allergens; animal dander, dust mites, pollens, fungi
  • Exercise
  • Viral infection
  • Smoking (including passive)
  • Cold
  • Chemicals/ pollution
  • Drugs (NSAIDs, ß-blockers)
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7
Q

What arethe 2 most important drug triggers of asthma to check for ?

A

NSAIDs (such as acetylsalicylic acid) and ß-blockers

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8
Q

What drug are a number of asthma patients sensitive to ?

A

Aspirin

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9
Q

What do some patients with asthma also suffer from (excluding atopy here)?

A

Nasal polyps

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10
Q

What are the symptoms of asthma ?

A
  • Cough (non-productive): often worse at night
  • Intermittent dyspnoea
  • ‘Wheeze’, ‘chest tightness’
  • Diruinal variation in symptoms or peak flow - marked morning dipping of peak flow
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11
Q

What are the signs of asthma ?

A
  • Expiratory wheeze on auscultation (may be audible) - ‘widespread polyphonic wheeze’
  • Tachyponea
  • Hyperinflated chest - hyperresonant percussion note
  • Reduced peak expiratory flow rate (PEFR)
  • Atopy
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12
Q

How is asthma diagnosed in someone aged < 5?

A

Diagnosis should be made on clinical judgement

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13
Q

Once a child with suspected asthma reaches the age of 5 y/o what should be done ?

A

Objective tests should be performed to confirm the diagnosis (normal asthma diagnosis for ages 5-16)

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14
Q

What objective tests should be done in someone aged 5-16 with suspected asthma?

A
  • 1st line = All patients should have spirometry with a bronchodilator reversibility (BDR) test
  • 2nd line = a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
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15
Q

What objective tests should be done in someone aged ≥ 17 with suspected asthma?

A

1st line = spirometry + BDR test + a FeNO test

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16
Q

When diagnosing asthma in patients ≥ 17, they should be asked if their symptoms are better on days away from work/during holidays. If so what should be done ?

A

Referal to a specialist as possible occupational asthma

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17
Q

What are the main occupational causes of asthma ?

A
  • Isocyanates - the most common cause. Example occupations include spray painting and foam moulding using adhesives
  • Platinum salts
  • Soldering flux resin
  • Glutaraldehyde
  • Flour
  • Epoxy resins
  • Proteolytic enzymes
18
Q

Following referral to specialist for suspected occupational asthma what tests will be done ?

A

Serial measurements of peak expiratory flow at work and away from work. (will be better on weekends when not working)

19
Q

What 3rd line objective test can be done for diagnosing asthma in patients where there is diagnostic uncertainity after spirometry + BDR test + FeNO test ?

A

Monitor peak flow variability for 2-4 weeks

20
Q

What is considered a positive FeNO test for asthma ?

A
  • In adults level of ≥ 40 ppb is considered positive
  • in children a level of ≥ 35 ppb is considered positive
21
Q

What is considered a positive spirometry result for obstructive airway disease (asthma being one potential cause) ?

A

FEV1/FVC ratio < 70%

22
Q

What is considered a positive BDR test result for asthma ?

A
  • In adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
  • In children, a positive test is indicated by an improvement in FEV1 of 12% or more
23
Q

What is an asthma diagnosis made on in patients aged 5-16?

A
  • Obstructive spirometry and positive BDR test OR
  • FeNO level of 35 ppb or more and positive peak flow variability
24
Q

What is an asthma diagnosis made on in someone aged ≥ 17?

A
  • A FeNO ≥ 40 ppb + either a pos BDR test or pos peak flow variability or bronchial hyperreactivity OR
  • A FeNO between 25 and 39 ppb + a pos BDR test OR
  • A pos BDR test + pos peak flow variability irrespective of FeNO level.
25
Q

When may the use of direct bronchial challenge test (Airway hyperreactivity measures) with histamine or methacholine be used in the diagnosis of asthma in someone aged ≥ 17?

A

If there is diagnostic uncertainty after a normal spirometry and either a:

  • FeNO ≥ 40 ppb and no variability in peak flow readings OR
  • FeNO ≤ 39 ppb with variability in peak flow readings.
26
Q

What is the step-wise maintanence treatment of asthma ?

A
  • 1st line = SABA (PRN) + low dose ICS
  • 3rd line = add LABA (as combo inhaler - MART) or add a LTRA if a child
  • 4th line = increase ICS dose to medium OR add a LTRA
  • 5th line = Increase ICS dose to high OR add LTRA OR add tiotropium OR add theophylline
27
Q

Explain what is meant by MART therapy in asthma treatment

A

Maintenance and reliever therapy (MART)

  • A form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
  • MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, budesonide/formoterol)
28
Q

For adults what are considered low, medium and high dose corticosteroids in the treatment of asthma ?

A
  • ≤ 400 micrograms budesonide or equivalent = low dose
  • 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose
  • > 800 micrograms budesonide or equivalent= high dose.
29
Q

Define what complete control of asthma is ?

A

Complete control of asthma is defined as:

  • No daytime symptoms
  • No night-time awakening due to asthma
  • No need for rescue medication
  • No asthma attacks
  • No limitations on activity including exercise
  • Normal lung function (in practical terms FEV1 and/or PEF>80% predicted or best)
  • Minimal side effects from medication.
30
Q

What may suggest an asthma attack is occuring in someone ?

A

Obv features of asthma as discussed already

31
Q

How is the severity of an acute asthma attack graded ?

A

Moderate, severe & life-threatening

32
Q

Define the criteria for a moderate asthma attack ?

A
  • Typical asthma symptoms +
  • PEFR > 50-75% best or predicted
  • & no features of severe acute asthma
33
Q

Define the criteria for a severe asthma attack ?

A
  • PEFR 33 - 50% best or predicted
  • Can’t complete sentences in one breath
  • RR > 25/min
  • Pulse > 110 bpm
34
Q

Define the criteria for a life-threatening asthma attack ?

A
  • PEFR < 33% best or predicted
  • Oxygen sats < 92%
  • PaO2 <8kPa
  • PaCO2 normal (should be low due to blowing off, normal indicates tiring and is very bad)
  • Silent chest, cyanosis or feeble respiratory effort
  • Bradycardia, dysrhythmia or hypotension
  • Exhaustion, confusion or coma
35
Q

Define what a near fatal asthma attack is

A
  • Raised PaCO2
  • &/or requiring mechanical ventilation with raised inflation pressures
36
Q

What is the treatment of acute asthma ?

A
  • 1st line for all acute asthma attacks = high dose nebulised beta2-agnoists (salbutamol or terbutaline) with O2 + steroids either IV hydrocortisone or PO prednisolone or both
  • If severe or life-threatening attack or there is a poor inital response to beta2-agonist therapy then add nebulised ipratropium bromide
  • 2nd line = single dose IV magnesium sulphate for patients with severe or life-threatening which is not responding to treatment

note if severe or life-threatening asthma attack you jump straight to using NEB salbutamol but if it is mild-moderate then use high dose inhaled salbutamol or terbutaline and then if poor response move to the nebulised treatments, regardless of severity everyone gets steroids

37
Q

If someone is experiencing a life-threatening asthma attack where should they be referred to?

A

Refer to ICU urgently

38
Q

What patients presenting with an asthma attack should be admitted ?

A

Those with life-threatening features or severe features persistent after initial treatment

39
Q

Appreciate this

A
  • The two divisions of the autonomic nervous system are the sympathetic division and the parasympathetic division.
  • The sympathetic system is associated with the fight-or-flight response, and parasympathetic activity is referred to by the epithet of rest and digest.
  • Homeostasis is the balance between the two systems.
40
Q

Give a very general overview of the effect of the parasympathetic and sympathetic divisions of the ANS in the regulation of airway function

A

Stimulation of parasympathetics (cholinergic fibres) which act via M3 muscarinic ACh receptors, causes:

  1. Bronchial smooth muscle contraction
  2. Increased mucus secretion

Sympathetic stimulation which acts via via b2-adrenoceptors, causes:

  1. Bronchial smooth muscle relaxation
  2. Decreased mucus secretion
  3. Increased mucociliary clearance
41
Q

There is no direct innervation by sympathetics to the bronchial smooth muscle (there is for the submucosal glands and blood vessels) ==> how does sympathetic stimulation cause bronchial smooth muscle relaxation ?

A

They act on chromaffin cells in the adrenal medulla which when activated release adrenaline which act on b2-adrenoceptors (β2-ADR) on ASM cells to cause relaxtion

Y4 Respiratory (27 decks)

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