Asthma Flashcards by Soorya Thavaraj

Define asthma?

Chronic inflammatory airway disease characterised by variable reversible airway obstruction, airway hyper-responsiveness and bronchial inflammation

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What are the genetic risk factors for asthma?

Family History

Atopy (tendency for T lymphocytes to drive production of IgE on exposure to allergens)

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What are the environmental factors?

House dust mites 
Pollen
Pets
Cigarette Smoke
Viral Respiratory Tract Infections
Aspergillus Fumigatus Spores
Occupational Allergens

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What is the epidemiology of asthma?

Affects 10% of children
Affects 5% of adults
Prevalance appears to be increasing

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What are the presenting symptoms of asthma?

Episodic History
Wheeze
Breathlessness
Cough (worse in the morning and at night)

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What’s important to ask when talking about asthma?

Ask about previous hospitalisation due to acute attacks - this gives an indication of the severity of the asthma

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What are the precipitating factors of Asthma?

Cold
Viral Infection
Drugs (e.g. beta-blockers, NSAIDs)
Exercise
Emotions
Check for history of atopic disease (e.g. allergic rhinitis, uritcaria, eczema)

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What are the signs of asthma on physical examination?

Tachypnoea 
Use of accessory muscles 
Prolonged expiratory phase 
Polyphonic Wheeze 
Hyperinflated chest

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What are the signs of a Severe Attack of Asthma?

PEFR < 50% predicted
Pulse > 110/min
RR > 25/min
Inability to complete sentences

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What are the signs of a Life-Threatening Attack of asthma?

PEFR < 33% predicted 
Silent Chest 
Cyanosis 
Bradycardia 
Hypotension 
Confusion 
Coma

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What are the acute appropriate investigations for asthma?

Peak Flow 
Pulse oximetry 
ABG 
CXR 
FBC 
CRP 
U&amp;Es 
Blood and sputum cultures

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Why do we do a Chest X-Ray (CXR)?

To exclude other diagnoses e.g. pneumonia, pneumothorax

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What might we see on a FBC?

Raised WCC if infective exacerbation

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What are some of the investigations we might do in chronic asthma?

Peak flow monitoring
Pulmonary Function Test
Bloods to check Eosinophilia, IgE level, Aspergillus antibody titres
Skin Prick Tests

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What would we expect to see if we monitored peak flow?

Often shows diurnal variation with a dip in the morning

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Why do we do skin prick tests for asthma?

Helps identify allergens

What is a management plan for acute asthma?

ABCDE 
Resuscitate 
Monitor O2 sats, ABG and PEFR 
High-flow oxygen 
Salbutamol nebulizer 
Ipratropium Bromide 
Steroid Therapy

What do we do if there’s no improvement after the acute management plan?

IV magnesium sulphate

How much salbutamol nebulizer do we give in acute asthma?

5 mg, initially continously, then 2-4 hourly

How much Ipratropium Bromide do we give?

0.5 mg 4 times a day

What is the steroid therapy we give to patients to treat acute asthma?

100-200mg IV hydrocortisone

Followed by, 40mg oral prednisolone for 5-7 days

What can you consider when thinking of the acute management plan for asthma?

Consider IV aminophylline infusion

Consider IV salbutamol

What may be needed if the patient is getting exhausted?

Anaesthetic Help

What is a bad sign in a patient having an asthma attack?

A normal PCO2

Why is a normal PCO2 a bad sign in a patient having an asthma attack?

This is because during an asthma attack they should be hyperventilting and blowing off their CO2, so PCO2 should be low A normal PCO2 suggests that the patient is fatiguing

When would you give Antibiotics in an asthma attack?

You want to treat the underlying cause and if it is an infective exacerbation then you give antibiotics

Why do we monitor electrolytes closely in an asthma attack?

Bronchodilators and aminophylline causes a drop in K+

What may be needed in severe attacks of asthma?

Invasive Ventilation

When do you discharge a patient after an acute asthma attack?

PEF > 75% predicted Diurnal variation < 25% Inhaler technique checked Stable on discharge medication for 24 hours Patient owns a PEF meter Patient has steroid and bronchodilator therapy Arrange follow-up

How does chronic therapy of asthma work?

There are 5 steps and you start on the step that matches the severity of the patient's asthma

What is Step 1 in the chronic therapy of asthma?

Inhaled short-acting beta-2 agonist used as needed | If needed > 1/day then move onto step 2

What is Step 2 in the chronic therapy of asthma?

Step 1 + regular inhaled low-dose steroids (400 mcg/day)

What is Step 3 in the chronic therapy of asthma?

Step 2 + inhaled long-acting beta-2 agonist (LABA) If inadequate control with LABA, increase steroid dose (800 mcg/day) If no response to LABA, stop LABA and increase steroid dose (800 mcg/day)

What is Step 4 in the chronic therapy of asthma?

Increase inhaled steroid dose (2000 mcg/day) | Add 4th drug (e.g. leukotriene antagonist, slow-release theophylline or beta-2 agonist tablet

What is Step 5 in the chronic therapy of asthma?

Add regular oral steroids Maintain high-dose oral steroids Refer to specialist care

What advice do you need to give to patients with chronic asthma?

Teach proper inhaler technique Explain importance of PEFR monitoring Avoid provoking factors

What are some of the possible complications of asthma?

``` Growth retardation Chest wall deformity (e.g. pigeon chest) Recurrent infections Pneumothorax Respiratory Failure Death ```

What is the prognosis for patients with asthma?

Many Children improve as they grow older | Adult-onset asthma is usually chronic