Asthma Flashcards

Question

Investigations of asthma

Answer 1

Lung function test Histamine or methacholine bronchial provocation/challenge test Trial of corticosteroids Exhaled nitric oxide Blood and sputum tests CXR Skin tests Allergen provocation tests

Answer 2

PEFR Spirometry

Answer 3

PEFR measurements on waking, prior to taking a bronchodilator, before bed, and after taking a bronchodilator. This shows the variable airflow limitation. Diurnal variation in PEFR is a **good measure** of asthma activity.

Answer 4

Especially good for **assessing variability**. An improvement in FEV1 or PEFR following inhalation of a bronchodilator can diagnose asthma.

Answer 5

Improvement in FEV1 of 12% or more and increase in volume of 200 ml or more

Answer 6

Prednisolone 30 mg orally should be given daily for 2 weeks. Lung functions are measured before and after the course. An improvement of **15%** in **FEV1** confirms the presence of reversible element. It indicates that the administration of inhaled steroids will prove beneficial for the patient.

Answer 7

A measure of airway inflammation. Can also be used to assess corticosteroid response.

Answer 8

No diagnostic features. Overinflation is characteristic during an acute episode or in chronic severe disease. CXR is more helpful in **excluding pneumothorax,** and **allergic bronchopulmonary aspergillosis**.

Answer 9

Should be performed to help identify allergic trigger factors. ## Footnote **It is not diagnostic on its own.**

Answer 10

To investigate patients with suspected **occupational** asthma. Not ordinary.

Answer 11

It is a mix of **clinical features**, **past medical history** and **family history**. Also triggers should be evaluated and classical diurnal variation. A lung function test (spirometry) and PEFR. PEFR can be done in a calender for the patient to record it during the day. Trial of corticosteroids or beta-agonists is usually done to see improvement. eNO can support diagnosis. If all else fails bronchial challenge test is **definitive**.

Answer 12

Based on signs such as using your **reliever inhaler** more than **three times a week.** Need for tablet steroid therapy three days or longer, two or more times per year. Needing steroid tablets every day. Symptoms when an attack occurs. How many A&E visits If it severely affects your life. Then usual tests are carried out as well.

Answer 13

Abolish symptoms Restore normal or best possible lung function Reduce risk of severe attacks Enable normal growth to occur in children Minimise absence from school or employment

Answer 14

Education for both family and patient Participation of both patient and family in treatment Avoidance of triggers Use of the lowest effective doses possibly needed.

Answer 15

In children sublingual allergen immunotherapy can be done to reduce sensitivity to house dustmites Active and passive smoking should be avoided. Avoid beta-blockers in tablets or eye-drops. Avoid NSAIDs, COX-2i might be better tolerated.

Answer 16

Treat symptoms based on clinical judgement and observations. If they still have symptoms when they reach 5 yo, they should be able to carry out objective tests. If they still are not able to do so continue as before and review in 6 to 12 months and try the tests again.

Answer 17

When there is normal spirometry or non-reversible spirometry with bronchodilators.

Answer 18

Children = 35 ppb or more Adults = 40 ppb or more

Answer 19

Normal spirometry and... FeNO level of 40 ppb or more and no variability in peak flow readings or FeNO level of 39 ppb or less with variability in peak flow readings.

Answer 20

Improvement in FEV1 of 12% or more and increase in volume of 200 ml or more

Answer 21

Improvement in FEV1 of 12% or more.

Answer 22

20% or more

Answer 23

Provocative concentration of methacholine causing a 20% fall in FEV1 (PC20) of 8 mg/ml or less

Answer 24

It is not performed in children.

Answer 25

Alternative diagnoses Lack of adherence Suboptimal inhaler technique Smoking Occupational exposures Environmental exposures Psychosocial factors

Answer 26

If there is an infrequent short-lived wheeze and normal lung function offer a **SABA** alone. **Bold means symptom relief**. If asthma is uncontrolled for 4 to 8 weeks **or** if initial symptoms indicate maintenance therapy right away... Offer low dose of ICS with a **SABA**. If asthma is uncontrolled for 4 to 8 weeks... Low dose ICS, LTRA and a **SABA**. If asthma is uncontrolled for 4 to 8 weeks... Low dose ICS, LABA, **SABA** +/- LTRA. If asthma is uncontrolled for 4 to 8 weeks... Low dose ICS, LABA within MART regimen +/- LTRA and **Low dose ICS, LABA within MART regimen.** If asthma is uncontrolled for 4 to 8 weeks... Moderate ICS dose, LABA either within MART regimen or as a fixed dose +/- LTRA and **Low dose ICS, LABA within MART regimen or consider changing to SABA**. If asthma is uncontrolled for 4 to 8 weeks... High dose ICS, LABA as fixed dose, +/- LTRA + **SABA** or Continuing moderate ICS dose with another treatment such as LAMA or theophylline + **SABA or low dose ICS with LABA within MART regimen.** or Refer to specialist

Answer 27

Infrequent and short lived wheeze and normal lung function used **SABA** alone. If asthma is uncontrolled for 4 to 8 weeks or if the initial symptoms suggest maintenance treatment... Paediatric low dose of ICS and **SABA** If asthma is uncontrolled for 4 to 8 weeks... Paediatric low dose of ICS, LTRA and **SABA** If asthma is uncontrolled for 4 to 8 weeks... Paediatric low dose of ICS, LABA and stop LTRA. Also give **SABA.** If asthma is uncontrolled for 4 to 8 weeks... Paediatric low dose of ICS, LABA within a MART regimen, **paediatric low dose of ICS, LABA within a MART regimen.** If asthma is uncontrolled for 4 to 8 weeks... Paediatric moderate dose of ICS, LABA within a MART regimen or as a fixed dose, **paediatric low dose of ICS, LABA within a MART regimen or change to SABA**. If asthma is uncontrolled for 4 to 8 weeks... Refer to specialist or Paediatric high dose of ICS and LABA as a fixed dose + **SABA** or Paediatric moderate dose of ICS and trial of treatment of e.g. theophylline + **SABA or low dose ICS with a LABA within a MART regimen.**

Answer 28

Symptoms that do not indicate immediate maintenance therapy **use SABA alone**. If asthma is uncontrolled for 4 to 8 weeks or if symptoms indicate need for immediate maintenance therapy... 8 week trial dose of paediatric low dose of ICS + **SABA** If symptoms did not resolve consider alternative diagnoses. If symptoms did resolve, but reverted after more than 4 weeks after the trial ended then repeat the 8 week trial. If symptoms did resolve but reverted before 4 weeks after the trial ended... Paediatric low dose of ICS and **SABA** If asthma is uncontrolled for 4 to 8 weeks... Paediatric low dose of ICS and LTRA + **SABA** If asthma is uncontrolled for 4 to 8 weeks... Stop LTRA but continue with paediatric low dose of ICS + **SABA** and refer to specialist.

Answer 29

Salbutamol Terbutaline Should only be used as a reliever

Answer 30

Two puffs as required

Answer 31

Salmeterol Formoterol Given once or twice daily

Answer 32

Beclometasone (most common) Budesonide Fluticasone propionate Fluticasone furoate Mometasone furoate Triamcinolone

Answer 33

Oral thrush (**rinse mouth after use**) Hoarseness of voice Subcapsular cataract formation Osteoporosis.

Answer 34

Methotrexate Ciclosporin Nowadays biologic monoclonal antibodies are now preferred.

Answer 35

Ipratropium used in acute severe exacerbations of asthma.

Answer 36

Tiotropium Aclidinium

Answer 37

Sodium cromoglicate Nedocromil sodium.

Answer 38

Prevents activation of mast cells, eosinophils and epithelial cells. However not lymphocytes. This is through blocking a specific chloride channel preventing calcium influx. **These drugs are not routinely used**

Answer 39

Omalizumab Mepolizumab Reslizumab Benralizumab

Answer 40

Chelates free IgE and downregulates the number and activity of mast cells and basophils. It is given subcut every 2-4 weeks depending on total serum IgE levels and body weight. Can be cost-effective in patients with frequent exacerbations requiring oral corticosteroids.

Answer 41

Acts against IL-5 or its receptor. Can be effective in eosinophilic asthma.

Answer 42

Bronchial thermoplasty.

Answer 43

Novel approach in moderate to severe persistent asthma. Uses radiofrequency radiation to heat the bronchial wall and reduce the mass of airway smooth muscle, decreasing bronchoconstriction.

Answer 44

Lack of adherence Respiratory virus infections Exposure to an allergen or triggering drug.

Answer 45

Increasing symptoms; Peak flow \> 50-75% best or predicted; No features of acute severe asthma.

Answer 46

Any one of the following: Peak flow 33-50% best or predicted; Respiratory rate ≥ 25/min; Heart rate ≥ 110/min; Inability to complete sentences in one breath.

Answer 47

Peak flow \< 33% best or predicted; Arterial oxygen saturation (SpO2) \< 92%; Partial arterial pressure of oxygen (PaO2) \< 8 kPa; Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0 kPa); Silent chest; Cyanosis; Poor respiratory effort; Arrhythmia; Exhaustion; Altered conscious level; Hypotension.

Answer 48

Raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures. PaO2 \<8kPa despite treatment with O2 Low and/or falling arterial pH

Answer 49

Supplementary O2 to stay between 94-98% SpO2. Salbutamol 5mg (or terbutaline 10mg) nebulised with O2 IV hydrocortisone 100mg or oral Prednisolone 40-50mg. Nebulised Ipratropium bromide can be given in acute severe or life-threatening along with SABA, or if SABA does not give enough of a bronchodilation. 0.5 mg/6h nebulised IV magnesium sulfate can be given . In worst case scenarios IV aminophylline can also be given. Ventilation is required for patients deteriorating past this regime. CXR can be helpful to rule of pneumothorax.

Answer 50

Usually viral.

Answer 51

S. pneumoniae H. influenzae

Answer 52

Irritating, non-productive cough, together with discomfort behind the sternum. Chest tightness Dyspnoea Wheezing. Cough can become productive later on.

Answer 53

Otherwise healthy adults the disease improves spontaneously usually in 4-8 days without serious illness. Antibiotics are however often given, although their purpose is not always clear.

Answer 54

ABCDE SpO2 of 94-98% ABG if sats are \<92% 5 mg nebulised Salbutamol 40mg oral Prednisolone STAT (IV hydrocortisone if PO not possible)

Answer 55

Nebulised ipratropium bromide 500 micrograms Consider back to back salbutamol

Answer 56

Urgent ITU or anaesthesist assessment Urgent portable CXR IV aminophylline Consider IV salbutamol if nebulised route is ineffective.

Answer 57

PEFR \>75% within an hour of treatment can be dischared if there are no other reasons to admit. Stop regular nebulisers for 24 hours prior to discharge Inpatient asthma nurse review to reassess inhaler technique and adherence Provide PEFR meter and written asthma action plan 5 days oral prednisolone GP follow up within 2 working days Resp clinic follow up within 4 weeks For severe or worse, also consider psychosocial factors.

Answer 58

Been stable on discharge medication for 24h Had inhaler technique checked PEFR \>75 predicted or best with diurnal variability \<25% Steroid inhaled and oral + bronchodilator therapy up to date Their own PEF meter and written management plan GP appointment within 2d Resp clinic appointment within 4wks.

Answer 59

A combination inhaler containing a low dose inhaled corticosteroid and a fast acting LABA. This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.