Asthma

Question 1

what is asthma

Answer 1

chronic inflammatory disorder of the airways, secondary to type 1 hypersensitivity, that causes episodic bronchospasm resulting in airway obstruction

Question 2

risk factors for developing asthma

Answer 2

atopy
family history of atopy / asthma
maternal smoking during pregnancy / smoking around child

Question 3

symptoms of asthma

Answer 3

SOB
dry cough - worse at night
wheeze

Question 4

signs of asthma on examination

Answer 4

expiratory wheeze on auscultation

reduced Peak flow

Question 5

what things can trigger symptoms of asthma

Answer 5

exercise
stress 
animal dander
dust
infections 
cold air

Question 6

what is spirometry

Answer 6

measures the amount (volume) and speed (flow) of air during inhalation and exhalation
differentiates disorders as
- obstructive: e.g. asthma where there is obstruction of airflow due to bronchoconstriction
- restrictive: e.g. fibrosis where there is restriction of the lung

Question 7

what is

• FEV1
• FVC

Answer 7

FEV1 = forced expiratory volume (amount of air person can exhale as fast as they can in 1 second)
- reduced if any obstruction to air flow out of lungs

FVC = forced vital capacity (total amount of air person can exhale after max inhalation)
- reduced if any restriction on the capacity of the lungs

Question 8

spirometry results in asthma

Answer 8

FEV1 - significantly reduced
FVC - normal

FEV1/FVC ratio < 70% = obstructive disease

Question 9

what does the airway obstruction in asthma respond to

Answer 9

bronchodilators - termed ‘bronchodilator reversibility’

- will improve obstructive picture

Question 10

apart from spirometry, what other tests are useful in asthma diagnosis

Answer 10

fractional inhaled nitrous oxide
- levels rise in correlation with eosinophilic inflammation in asthma
peak flow

Question 11

1st line drug given in asthma

Answer 11

short acting beta 2 agonist (SABA) e.g. salbutamol

- a ‘reliever’ drug when patient experiences symptoms

Question 12

common side effect of salbutamol

Answer 12

tremor

Question 13

2nd line drug if SABA insufficient alone

Answer 13

SABA + Inhaled corticosteroid (ICS) e.g beclametasone

• taken everyday regardless of if patient has symptoms
• termed ‘preventer’

Question 14

common side effect of ICS

Answer 14

oral candidiasis

stunted growth in children

Question 15

3rd line drug if SABA + ICS insufficient

Answer 15

add oral leukotriene receptor antagonist e.g. montelukast

Question 16

what further drug can be added if stage 3 therapy is not sufficient

Answer 16

LABA - long acting beta agonist e.g. salmeterol

Question 17

what treatment can be considered in severe asthma not controlled by stage 4 regime

Answer 17

SABA + MART (Maintenance and reliever regime)

- ICS + LABA combination

Question 18

what last resort therapies may be added before referral to specialist

Answer 18

oral theophylline or inhaled LAMA (long acting muscarinic antagonist e.g tiotropium)

Question 19

step up treatment summary for asthma

Answer 19

1. SABA
2. SABA + ICS
3. SABA + ICS + leukotriene receptor antagonist
4. SABA + ICS + LABA +/- leukotriene receptor antagonist
5. SABA + MART +/- leukotriene receptor antagonist
6. SABA + Theophylline / tiotropium +/- leukotriene receptor antagonist
7. specialist referral

Question 20

features of a moderate acute asthma attack

Answer 20

PEFR 50-75 % of predicted
speech normal
RR < 25

Question 21

features of a severe acute asthma attack

Answer 21

PEFR 33 - 50 % of predicted
can’t complete sentences
RR > 25
HR > 110

Question 22

features of a life threatening asthma attack

Answer 22

PEFR < 33 % of predicted 
02 sats < 92%
silent chest - chest so tight there is no wheeze at all 
bradycardia, hypotension 
confusion / tiredness / coma

Question 23

management of acute asthma attack

Answer 23

oxygen 15 L non-rebreather
nebuliser salbutamol 5mg repeated as required + nebulised ipratropium 0.5mg
oral prednisolone 40-50mg continued for 5 days

in severe cases under senior guidance

• IV magnesium sulphate
• IV aminophylline
• admission to HDU/ICU with possible need for intubation