Asthma and Allergic Rhinitis

Question 1

Asthma pattern of symptoms

Answer 1

1. variability - day and night, day to day, seasonal - days are better than nights
2. precipitated by range factors - aeroallergens, environmental factors (smoke, weather), emotions, exercise, irritants, and fumes and respiratory viruses
3. response to bronchodilators and corticosteroids

Question 2

Diagnosis of Asthma

Answer 2

1. Reversibility - post bronchodilator - SABA - improvement of FEV1 12% or 200ml or PEFR 15%
2. Inflammatory condition
   improvement of symptoms or FEV1 > 12% and 200ml after two weeks of daily corticosteroids
3. Hyperresponsiveness
   metacholine/histamine/exercise challenge (spirometry-exercise-spirometry) fall of FEV1 (15%) or PEF (20%)

Question 3

Symptoms of Asthma

Answer 3

chronic airway inflammation 
reversible airway disease 
cough 
wheeze 
dyspnoea
tight chest 
hyper-responsiveness - in response to stimuli 
symptoms vary over time and in intensity

Question 4

Genes associated

Answer 4

Gene mutation at 17q21 locus esp ORMDL3 and GSDMB gene

Question 5

Treatment of Asthma

Answer 5

Controllers 
- inhaled corticosteroids 
- LTRA - montelukast 
- oral corticosteroids
- LABA - salmeterol/ formoterol 
- LAMA - tiotropium 
- slow release theophyllones 
Relievers 
- SABA - salbutamol 
- SAMA - ipratropium bromide

Question 6

FeNO

Answer 6

fractional exhaled NO 
marker of eosinophilic airway inflammation 
sputum eosinophilia = higher FeNO levels 
cheaper than metacholine challenge 
differential 
- atopic asthma 
- eosinophilic bronchitis 
- COPD with mixed inflammatory phenotype

Question 7

Allegic Rhinitis

Answer 7

Induced after allergen exposure
Itching - nose, eyes, ears, palate
sneezing, rhinorrhoea, postnasal drip, nasal congestion, anosmia
Headache
Earache
Tearing, red eyes, eye swelling
Fatigue, drowsiness, malaise
Family hx of atopic disease
AR + ASTHMA = united airway - look for asthma and other allergies
Ask about environment - house dust, pets etc
Ask about foods and preservatives - sulphites

of asthma sufferers 40% have AR

Question 8

Allergic Rhinitis Physical Exam

Answer 8

nasal crease
allergic salute
hypertrophied turbinates
deviation/perforation of the nasal septum
injection and swelling of palpebral conjunctiva
lacrimation
dennie-morgan lines - prominent creases below inferior eyelid
allergic shiners - dark shiners around eyes
cobblestoning - lymphoid tissue on post pharynx
tonsillar hypertrophy
malocclusion
high arched palate
pale facies
elongated facies with mouth breathing

Question 9

Investigations for AR

Answer 9

skin prick test
immunocap - specific IgE testing - more expensive
total IgE/ total Eosinophils
radiological tests - structural abnormalities or comorbid conditions like sinusitis or adenoid hypertrophy

Question 10

Treatment of AR

Answer 10

Intra-nasal corticosteroids - symptomatic relief - + impact ocular sx NB controller therapy

Anthistamines - nasal and ocular sx most effective rhinorrhoea, sneezing and nasal itching less for nasal congestion , daytime sx

Leukotriene receptor antagonists - decongestant effect - less effective than INCS similar to antihist, nighttime sx

Cromones - intranasal sodium cromoglycate less effective than INCS and Antihist

Decongestants - nasal congestion - short course < 5/7 due to rhinitis medicamentosa

Anticholinergics - intranasal ipratropium bromide - rhinorrhoea

Systemic CS - short course not responding other treatment

Immunotherapy