Asthma

Question 1

Red flags for asthma in adults?

Answer 1

Prominent systemic features (such as myalgia, fever, and weight loss).
Unexpected clinical findings (such as crackles, finger clubbing, cyanosis, evidence of cardiac disease, monophonic wheeze, or stridor).
Persistent, non-variable breathlessness.
Chronic sputum production.
Unexplained restrictive spirometry.
Chest X-ray shadowing.
Marked blood eosinophilia

Question 2

Red flags for asthma in children?

Answer 2

Failure to thrive.
Unexplained clinical findings (such as focal signs, abnormal voice or cry, dysphagia, and/or inspiratory stridor).
Symptoms that are present from birth.
Excessive vomiting or posseting.
Evidence of severe upper respiratory tract infection.
Persistent wet or productive cough.
A family history of unusual chest disease.
Nasal polyps

Question 3

Investigations for asthma in > 17 years old patient?

Answer 3

FeNO (1st line)
Spirometry (2nd line)
- FEV1/FVC ratio< 70%
- FEV1 improvement by >12% after B2-agonist/steroid use
Peak Expiratory Flow (3rd line)
- >20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result:
Direct bronchial challenge test (4th line)

Question 4

Investigations for asthma in 5 - 16 years old patient?

Answer 4

Spirometry (1st line)
- FEV1/FVC ratio< 70%
- FEV1 improvement by >12% after B2-agonist/steroid use
Peak Expiratory Flow (2nd line)

Question 5

Treatment for asthma in adults (>16 years) [first line to last line]

Answer 5

SABA
SABA + ICS
SABA + ICS + montelukast
SABA + ICS + LABA
MART (ICS + fast-acting LABA) regimen + low maintenance dose ICS
Increase steroid to moderate maintenance dose
Add theophylline/anti-muscarinic/increase steroid dose to high maintenance dose
Use oral prednisolone

Question 6

Treatment for asthma in adults (5 - 16 yrs) [first line to last line]

Answer 6

SABA
SABA + ICS
SABA + ICS + LRTA4 antagonist
SABA + ICS + LABA
SABA + MART + low dose ICS
Increase ICS dose to moderate
Increase ICS dose to high/add theophylline

If ICS not tolerated/contraindicated, can try: sodium cromoglicate, nedocromil sodium

Always assess inhaler technique

Question 7

What delivery system used for paediatric asthma?

Answer 7

pMDI with spacer

Question 8

What are the features of the different severities for asthma exacerbation?

Answer 8

Moderate: PEFR more than 50–75% best or predicted and normal speech, with no features of acute severe or life-threatening asthma.

Severe:
PEFR 33–50% best or predicted
RR > 25/minute in people over 12 years of age
RR > 30/minute in children 5 - 12 years of age
Pulse rate of at least 110/min in people over the age of 12 years, 125/min in children between the ages of 5 and 12 years
Inability to complete sentences
O2 sats of at least 92%

Life-threatening:
PEFR <33% predicted
Cyanosis
Silent chest
Confusion
Poor respiratory effort
Exhaustion
Hypotension
O2 sats < 92%

Question 9

PEF variation to diagnose asthma?

Answer 9

20%

Question 10

FEV1 improve with reversibility from B2-agonist?

Answer 10

15%

Question 11

At what stage do you admit to hospital for the different asthma severities?

Answer 11

Admit all people with features of a life-threatening asthma exacerbation.
Admit people with any feature of a severe asthma attack persisting after initial bronchodilator treatment.
Admit people with a moderate asthma exacerbation with worsening symptoms despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack –> also consider lower threshold: i.e recent admission, < 18 years

Question 12

Treatment for acute asthma exacerbation?

Answer 12

O2 (target stats: 94 - 98%)
SABA
- nebuliser for life-threatening or severe
- MDI for moderate

Life-threatening or sever asthma:
Nebulised ipratropium
Oral steroids/IM methylprednisolone/IV hydrocortisone