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Respiratory > Asthma > Flashcards

Asthma Flashcards

1
Q

Pathophysiology [4]

A

Environmental/genetic triggers cause CD4+ T cell inflammation
Eosinophil, mast cell, macrophage infiltration
Airway obstruction caused by:
- Chronic hyper responsiveness of airway - type I
- Smooth muscle contraction
- Inflammatory infiltrate + mucous = narrowing

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2
Q

What are the types of onset of asthma [5]

A 
Early infant / VIW
Childhood
Adult
Exertional
Occupational - normal peak flow when not at work (refer to specialist)
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3
Q

Aetiology [2]

A
  • Susceptibility loci in the genes ADAM33, GPRA and ORMDL3, and polymorphisms of tumour necrosis factor.
  • Infection (rhinovirus, influenza, mycoplasma), allergens (pollen), occupational exposures and stress.
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4
Q

What is atopy and what happens in atopy [2]

A
  • 1st exposure sensitises T cells, B cells produce IgE which binds to mast cells
  • 2nd exposure mast cells release contents
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5
Q

What triggers asthma [5]

What drugs should be avoided [3]

A
  • Exercise
  • Cold air
  • Pollen
  • Smoke
  • URTI

BB
NSAID
Aspirin

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6
Q

What are the symptoms of asthma [4]

A
  1. VARIABLE + REVERSIBLE
    - Often worse at night - diurnal variation
  2. Expiratory wheeze - narrow airways = turbulent
    SOB - more effort to inflate hyper inflated lungs
  3. Cough - dry, exertion, nocturnal
  4. Chest tightness - voluntary contract muscles
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7
Q
  • What are the signs of asthma in a severe presentation [6]
A

Severe presentations:
* Tachycardia
* Tachypoea
* Hypercapnia + hypoxaemia
* Cyanosis
* Reduced PEFR
* Using acccessory muscles

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8
Q

What are complications of asthma

A

Pneumothorax - parenchyma ruptures due to increased alveolar pressure

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9
Q

What is a delayed eosinophil response [4]

A

Conjunctivitis
Rhinitis
Dermatitis
Bronchiole constriction

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10
Q

What are RF for asthma [4]

A

Atopy, family history of asthma
Nasal polyposis, obesity
Reflux esophagitis
Maternal factors: vit D deficiency, LBW, pre-term labour

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11
Q

Investigations in asthma

A
  • Blood tests: FBC, eosinophilia (e.g. ABPA or Churg Strauss), IgE and aspergillus precipitins.
  • Imaging: CXR may show hyperinflation.
  • Spirometry, PEFR: show obstructive picture & diurnal variability.
  • Allergy testing: on clinical suspicion specific IgE test (formerly known as a Radioallergosorbant test) or skin prick test can be performed.
  • Bronchial challenge test: used in diagnostic uncertainty, this test uses inhaled histamine or metacholine to measure bronchial hyperresponsiveness (BHR).
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12
Q

What would spirometry results look like in a patient with asthma?

A

Amount of air and speed during exhalation
FEV1 <70% = obstructive
FVC = normal
Ratio reduced
◆ May be normal between episodes due to variability. A confident diagnosis of asthma can be made if there is:
◆ 15% diurnal PEFR variation on >3 days a week.
◆ FEV1 >15% decrease after 6 minutes of exercise.
◆ Reversibility with bronchodilator – FEV increase >2% or 200 mL increase.

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13
Q

Chronic asthma management [11]

BTS guidelines 2019 Steps 1-3

NICE guidelines 2017 Steps 4-7

A

SABA as adjunct

  1. SABA + ICS
  2. Add LTRA
  3. Add LABA
  4. SABA +/- LTRA + MART
  5. SABA +/- LTRA + MART (medium dose)
  6. SABA +/- LTRA: (choose one)
    6a) MART (high dose)
    6b) Add theophylline
    6c) Refer to specialist
  7. Oral steroids daily + high dose ICS
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14
Q

What are lifestyle measures [7]

A 
Smoking cessation
Weight loss
Inhaler technique
PEF 2x daily
Asthma action plan
Flu vaccine
Yearly review
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15
Q

What should be covered in an annual review of a chronic asthma patient? [5]

A 
Assess symptoms
Measure lung function
Check inhaler technique
Adjust dose
Consider step down
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16
Q

Salbutamol SE [4]

A

Tremor
Cramp, Headache
Flushing, Palpitations, Tachycardia
Hypokalaemia so monitor U+E

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17
Q

When do you start ICS (preventer) [3]

A

SABA 3x
Waking one night
Oral steroids for exacerbation in past 2 years

18
Q

Beclometasone SE [4]

A

Adrenal crisis
Dysphona
Oral candidiasis
Stunted growth in children

19
Q

What are SE of LAMA [4]

A

GI
Dry mouth
Headache
Glaucoma

20
Q

How do you measure control [4]

A

S- SABA used 1+ a week
A- Absence from school or work
N- Nocturnal Sx
E- Exertional Sx

21
Q

What should chronic asthma have [5]

A 
Asthma action plan
Vaccines for flu and pneumonia
Smoking cessation
Bronchial thermoplasty
Annual review
22
Q

What is Ddx of asthma [8]

A 
Pulmonary oedema
COPD
Obstruction - foreign body / tumour
SVC obstruction - wheeze and SOB (not episodic)
Pneumothorax
PE
Bronchiectasis
Bronchiolitis
23
Q

DDX for wheeze [3]

A

Tumour
FB
Localized obstruction

24
Q

What are the low medium and high doses for ICS?

A

<400mcg
(different dosage for children)
400-800mcg medium dose
>800mcg is high dose

25
Q

Presentation: moderate attack [3]

A

Increasing symptoms
PEF>50-75% predicted
No features of acute severe asthma
Current guidelines suggest patient may be discharged from hospital if PEFR >75% 1 hour post-bronchodilator treatment.

26
Q

Presentation: severe attack [4]

A

Any one of:

  • PEF 33-50% predicted
  • RR>25
  • HR>110
  • Inability to complete sentences.
27
Q

What is life threatening? [8]

A

Any one of:

  • PEF <33% of predicted
  • SPO2 <92%, O2 <8kpa, normal PaCO2
  • Silent chest
  • Cyanosis
  • Exhaustion
  • Impaired consciousness
  • Arrhythmia
28
Q

What are signs of a (near) fatal attack? [2]

A

Raised PaCO2

Requiring mechanical ventilation with raised inflation pressures

29
Q

What do you do for mild attack [3]

A

Oral prednisone 7 days
SABA
Antibiotic therapy if infection

30
Q

Management of severe acute exacerbations [6]

A
  1. Oxygen (SpO2 target 94-98%)
  2. High dose nebulised SABA (if deterioration continuous with 4-6h SAMA)
  3. Nebulised IPATROPIUM BROMIDE
  4. Oral PREDNISOLONE 40-50mg daily for at least 5d (or IV HYDROCORTISONE)
  5. MAGNESIUM SULPHATE INFUSION after consultation with senior medical staff
  6. IV AMINOPHYLLINE or SALBUTAMOL
31
Q

Management of life-threatening asthma attack [8]

A

ITU - always if raised PaCO2

IV theophylline, IV salbutamol
IV magnesium sulphate
IV steroid = final step

NIV
Intubation
ECMO in extreme cases

32
Q

DDX asthma attack [5]

A 
Exacerbation COPD
PE
anaphylaxis
Pulmonary oedema
Obstruction
33
Q

When do you discharge [4]

Describe follow up

A 
PEF >75% within 1h of Rx
Stable 24 hours
Steroid and bronchodilator therapy
Written management plan
Organise follow up with GP in 2 days and asthma clinic in 4 weeks
34
Q

Occupational asthma

Causes - name 10

A
  • baking, pastry making
  • spray painting
  • lab work, dental work
  • animal work
  • food processing
  • welding, soldering, metalwork, woodwork, chemical processing
  • textile, plastics and rubber manufacture
  • farming
35
Q

Occupational asthma
Classification [2]
Presentation [3]

A
  • Hypersensitivity induced occupational asthma:
  • Irritant induced asthma (reactive airways dysfunction syndrome (RADS))

Consider in all workers with recurrence of childhood asthma or a diagnosis of new asthma in adulthood
Improve when away from work

36
Q

Occupational asthma

Ix [4]

A
  1. Serial PEFR measurements at home and at work every 2h from waking to sleeping for 4w, keeping mx constant and documenting times at work
    - >3 days in each consecutive work period, >3 series of consecutive days at work and 3d away from work >4 readings/d
  2. Skin prick testing
  3. Specific bronchial provocation testing
37
Q

Describe specific bronchial provocation testing [3]

A
  • gradual increase in specific inhalational agent with spirometry
  • positive result would be if FEV1 falls by ≥15% from baseline
  • generally safe and this is the gold standard but only done at tertiary centers
38
Q

Management of occupational asthma

A

Relocation away from exposure

Within 12m of first symptoms

39
Q

How does Mag sulf work in severe asthma?

A

Magnesium sulfate has bronchodilator activity, possibly due to inhibition of calcium influx into airway smooth muscle cells.

40
Q

Further treatment for chronic asthma

A
  • Daily oral steroid may be commenced at the lowest dose that gains control.
  • Steroid sparing agents if poor control persists. Methotrexate and ciclosporin are recommended, but
    there is limited evidence to support their use.
  • Continuous terbutaline (β2 agonist) infusions via a portable syringe driver.
  • Omalizumab (an IgE recombinant monoclonal antibody) has been approved by NICE as an add-on
    therapy to step 5 treatment in patients with severe atopic asthma. It has been shown to reduce
    exacerbation rates and asthma symptoms with a reduction in steroid usage (2).
  • Mepolizumab (an anti-IL-5 monoclonal antibody) may also be considered in severe eosinophilic asthma.

Respiratory (14 decks)

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