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Respiratory > Asthma > Flashcards

Asthma Flashcards

1
Q

What is asthma ?

How does it present?

A

chronic inflammatory disorder of the airway,
secondary to type 1 hypersensitivity.

presents as reversible bronchospasms which lead to airway obstruction

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2
Q

What are risk factors for developing asthma?

A
  1. personal or family history of atopy
  2. antenatal factors e.g: maternal smoking, viral infection during pregnancy esp RSV
  3. low birth weight
  4. Not being breastfed
  5. Maternal smoking around child
  6. exposure to high concentration of allergens e.g house dust mites
  7. air pollution
  8. hygiene hypothesis
  9. OCCUPATIONAL - allergens in workplace
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3
Q

What other atopic conditions are associated with asthma?

what do people with asthma have a higher chance of being sensitive to?

What do patients who are most sensitive to asthma tend to suffer from?

A
  1. Atopic dermatitis (eczema)
  2. Allergic rhinitis (hayfever)
  • Aspirin
  • nasal polyps
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4
Q

What is samter’s triad?

A

association of

  1. Asthma
  2. Aspirin sensitivity
  3. Nasal polyposis
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5
Q

What are common workplace allergens?

How do you investigate and manage occupational asthma?

A 
Isocyanates (paints, lacquers, foams, fibre)
flour
platinum salts
soldering flux resin
glutaraldehyde
epoxy resins
proteolytic enzymes
  • serial measurements of peak expiratory flow at work and away
  • referral should be made to respiratory specialists for suspected cases
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6
Q

What are the typical triggers for asthma?

A
  • Infection
  • Night time or early morning
  • Exercise
  • Animals
  • Cold/damp
  • Dust
  • Strong emotions
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7
Q

What are the symptoms of asthma ?

A
  1. episodic symptoms with diurnal variation
  2. dry cough - often worse at night
  3. wheeze, chest tightness
  4. SOB
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8
Q

What are the signs of asthma?

A
  1. polyphonic, bilateral wheeze on auscultation

2. reduced peak expiratory flow rate

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9
Q

What would you look for in PMH/SH?

A
  • history of atopy - eczema, hayfever, food allergies

- family hx of atopy

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10
Q

What presentation indicates something other than atopy?

A
  • Wheeze related to coughs and colds more suggestive of viral induced wheeze
  • Isolated or productive cough
  • Normal investigations
  • No response to treatment
  • Unilateral wheeze. This suggests a focal lesion or infection.
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11
Q

What investigations would you do for asthma?

What further investigations can you do if diagnostic uncertainty?

A
  1. spirometry, with bronchodilator reversibility
  2. Fractional exhaled nitric oxide (FeNO)

consider: Chest X-Ray esp in older patients or those with history of smoking

if still diagnostic uncertainty:

  1. peak flow variability (diary, several times per day 2-4 weeks)
  2. direct bronchial challenge test with histamine or methacholine
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12
Q

What is a spirometry test ?

A

measure the amount (volume) and speed (flow) of air during inhalation and expiration

helps to distinguish between obstructive and restrictive lung diseases

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13
Q

What is FEV1 and FVC?

A

FEV1 - Forced expiratory volume: volume of air that has been exhaled after 1st second of forced expiration

FVC - Forced vital capacity: volume of air that has been exhaled after maximal expiration following full inspiration

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14
Q

What are the typical spirometry results in asthma?

A

FEV1: Significantly reduced
FVC: normal

FEV1/FVC = <70%

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15
Q

What is FeNO?

A

Fractional exhaled nitrates

  • nitric oxide is produced by 3 types of nitric oxide synthases (NOS)
  • one of them is inducible (iNOS) and levels tend to rise in inflammatory cells esp basophils
  • so levels of NO correlate with levels of inflammation

> 40 Parts per billion (ppb) = positive in adults

> 35 parts per billion = positive in children

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16
Q

How do you diagnose asthma in the following age ranges:

  • > =17
  • 5-16
  • <5
A
  1. > = 17:
    - ask if symptoms better away from work/during holidays - if yes refer to specialiaist as possible occupational asthma
    - spirometry with BDR + FeNO for all
  2. 5-16
    - Spirometry with BDR for all
    - FeNO should be requested if normal spirometry or obstructive spirometry with negative BDR
  3. <5 - diagnosis should be made on clinical judgment. once they reach 5, test
17
Q

What is a positive bronchodilator reversibility result?

A

Adults: improvement in FEV1 of 12% or more + increase in volume of 200ml or more

children: improvement in FEV1 of 12% or more

18
Q

What is the stepwise management of asthma in adults?

A
  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LRA
  4. SABA + ICS +/- LRA + LABA
  5. SABA +/- LRA + MART (maintenance and reliever therapy - combined low dose ICS + LABA)
  6. SABA +/- LRA + MART medium dose ICS
  7. SABA +/- LRA + MART high dose OR oral theophylline OR inhaled LAMA
19
Q

Give examples of SABA

A

salbumatol, terbutaline

20
Q

Give examples of SAMA

A

ipratropium

21
Q

LABA drug examples

A

salmeterol, formoterol

22
Q

LRA drug examples

A

Monteleukast

23
Q

What other management is required for patients with asthma?

A
  1. individual asthma self management programme
  2. yearly flu jab
  3. yearly asthma review
  4. advise exercise and avoid smoking
24
Q

How should treatment be stepped down in asthma?

A
  • review stepping down treatment every 3 months of so, taking into account duration of tx, side effects and patient preference
  • when reducing ICS btw advises reducing 25-50% at a time
  • normal review is annually but if recent escalation likely to review more freq.
25
Q

How does acute asthma present?

A
  1. progressive wheeze
  2. cough
  3. dyspnoea,
  4. tachypnoea
    - use of accessory muscles
    - chest may sound tight with reduced air entry

above not responding to salbutamol

26
Q

what can trigger acute asthma?

A

typical triggers e.g infection, cold, exercise

27
Q

what are the signs of moderate acute asthma?

A

PEFR 50-75% of predicted

28
Q

What are the signs of severe acute asthma?

A
  1. PEFR 33-50%
  2. cant complete sentences
  3. RR >25
  4. HR >110
29
Q

What are the signs of life threatening acute asthma?

A
  1. PEFR <33%
  2. sats <92%
  3. becoming tired/confusion
  4. no wheeze (bronchoconstriction severe enough to prevent air entry - silent chest)
  5. haemodynamic instability (bradychardia, dysarhythmia or hypotension)
30
Q

what does normal pCO2 indicate in acute asthma?

A

pC02 is usually low - respiratory alkalosis in acute asthma.

if normal indicates exhaustion = sign of life threatening asthma

raised pCO2 - respiratory acidosis = very bad sign

31
Q

When is ABG recommended?

A

recommended in patients with sats of <92%

32
Q

How do you manage moderate asthma exacerbation?

A
  1. high dose nebulised SABA
  2. Steroids: 40-50mg prednisolone or IV hydrocortisone, continued for at least 5 days (along with normal asthma tx)
  3. if not responding - nebulised ipratropium bromide
  4. Abx if convincing evidence of bacterial infection
33
Q

How to manage severe/ life threatening asthma exacerbation?

A
  1. oxygen if hypoxaemic, 15L supplemental oxygen through non rebreathable mask, titrated to maintain 94-98%
  2. high dose nebulised SABA
  3. Hydrocortisone IV or prednisolone 40-50mg oral, continue for at least 4 days
  4. nebulised ipratropium bromide
  5. IV magnesium sulphate

IV theophylline (consider following consultation with senior)

  1. admission to HDU/ICU
  2. Intubation and ventilation, extracorporeal membrane oxygenation
34
Q

Who should be admitted for acute asthma exacerbation?

A
  1. all life threatening asthma
  2. pts with severe acute asthma if they fail to respond
  3. those with previous near fatal asthma exacerbations
  4. pregnancy
  5. attack occurring despite oral corticosteroid use
  6. presentation at night
35
Q

When are patients safe to discharge?

What should you do if 2 attacks in 12 months?

A
  1. stable on discharge meds (no nebs)
  2. PEF >75% predicted
  3. inhaler technique checked
  4. provided with an action plan
  5. consider giving rescue pack of steroids

refer to specialist if 2 attacks in 12 months

36
Q

what should you monitor in patients on salbutamol? Why?

what can salbutamol also cause?

A

serum potassium
salbutamol causes potassium to be absorbed from blood into the cells

salbutamol can also cause tachycardia

Respiratory (16 decks)

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