Asthma and Dyspnea, Pleural Effusion, Pneumothorax, Hydrocephalus Flashcards
Asthma is a global disease currently affecting over 300 million individuals worldwide
•Annually there are an estimated 250,000 deaths from asthma, many of which may be preventable
•Asthma is a burden on patients’ lives and the healthcare system
•It is important to assess asthma control to prevent exacerbations
•With the right treatment approach, asthma care can be improved
True or false
True
What is asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.
Diagnosis of asthma is based on?
•The diagnosis of asthma should be based on:
●A history of characteristic symptom patterns
●Evidence of variable airflow limitation, from bronchodilator reversibility testing or other tests
•
Document evidence for the diagnosis in the patient’s notes, preferably before starting controller treatment
●It is often more difficult to confirm the diagnosis after treatment has been started cuz after treatment had started the person will be looking fine as if nothing happened
Asthma is usually characterized by?
Airway inflammation is chronic
•Asthma exacerbations are episodic true or false
Difference between COPd and asthma
Name six features of asthma
Asthma is usually characterized by airway inflammation and airway hyperresponsiveness, but these may not be necessary or sufficient to make the diagnosis of asthma.
•Usually show variability
•
True
Asthma - reversible airway obstruction (unlike COPD which is not reversible
Asthma is a variable disease – –severity varies from day to day, –differences between morning and evening –Seasonal variation in some –Can change in an individual over time –Recurrent –Reversible - symptoms resolve spontaneously or with medication
What is the pathophysiology of asthma
Asthma is a chronic inflammatory disease of medium and small airways. This manifests as:
•Mucosal oedema, epithelial shedding, bronchial inflammation, - Bronchial hyperresponsiveness, bronchoconstriction.
•Mucous gland hypertrophy, mucous hypersecretion.
•Airway Remodelling - Smooth muscle hypertrophy, basement membrane thickening, and fibrosis
Smooth muscle dysfunction causes bronchial hyper reactivity,bronchoconstriction(caused by mucosal edema),hyperplasia (causing cell proliferation and epithelial damage),inflammatory mediators release
Airway inflammation remodeling causes inflammatory cell activation,mucosal edema,cell proliferation and epithelial damage,basement membrane thickening
Name ten factors influence asthma development and expression
And name six factors that worsen asthma
Host Factors
●Genetic
- Atopy
●Gender
●Obesity
Environmental Factors ● Indoor allergens • Outdoor allergens • Occupational sensitizers • Tobacco smoke • Air Pollution • Respiratory Infections • Diet • Excercise
Allergens – HDM, cockroach, pets, pollen, •Respiratory infections •Exercise •Hyperventilation •Emotions •Weather changes •Air pollutants eg. Sulfur dioxide •Food, additives, drugs
What history will an asthmatic patient present w
Name three associated disorders
Can be diagnosed on the basis of symptoms
•Symptoms - Recurrent
•Wakes the patient up at night, worse at night – due to diurnal variation of cortisol production
•Reversible - Relieved by bronchodilator use
•Associated disorders – nasal polyps, rhinosinusitis, Aspirin allergy
What is seen in the family history of atopy
What trigger factors can be talked about by the patient
What can be seen in the past medical history,social history, drug history
Family history of Asthma •FH Allergic rhinitis and associated sinus disease - Rhinosinusitis •Allergic / vernal conjunctivitis •Eczema •Aspirin/NSAID allergy
Trigger factors –
house dust mite(dust)
exercise, strong scents, smoke, pollen(seasonal)
Respiratory infections(URTI - viral)
change in weather, strong emotion
animal fur - pets
foods, drugs –aspirin, NSAIDS, beta blockers
Other PMH – Hypertension, diabetes, sickle cell disease, TB
•Social HX – Occupation, Smoking, Pets
•Drug HX – beta-blockers(incl. eye drops for glaucoma), Aspirin/NSAIDS
State five signs and five symptoms of asthma
SIGNS •Often none – in between attacks •Barrel chest - Hyperinflated lungs •Tachpnoea, accessory muscles(neck, abdomen), sit upright •Tachycardia, BP – may go up •Hyperresonance •Reduced BS – silent chest if severe •Rhonchi (diffuse, variable, exp +/- insp
How is asthma diagnosed using variable airflow limitation
Confirm presence of airflow limitation
●Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
●FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children
•Confirm variation in lung function is greater than in healthy individuals
●The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma
●Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted)
●Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)
●Significant increase in FEV1 or PEF after 4 weeks of controller treatment
●If initial testing is negative:
•Repeat when patient is symptomatic, or after withholding bronchodilators
•Refer for additional tests (especially children ≤5 years, or the elderly)
No single definitive test to make a diagnosis of asthma
•Diagnosis is therefore made based on a combination of features
True or false
Name six investigations for asthma
True
FBC, eosinophils, ESR
•Stool RE – exclude helminthiasis
•Skin prick tests – shows atopy
•Specific Ig E – eg. to HDM, grass pollen, cockroach antigen - interpretation similar to skin prick test
•CXR(chest X ray) to exclude differential diagnosis, complications
Name five differentials for asthma
And three complications of asthma
Wheezing is also found in other conditions, for example:
●Respiratory infections
●COPD
●Upper airway dysfunction
●Endobronchial obstruction
●Inhaled foreign body
•Wheezing may be absent during severe asthma exacerbations (‘silent chest’)
Pneumothorax
•Sub-cutaneous emphysema
•Respiratory failure
How is asthma managed
Education
•Allergen avoidance
•Preventer/controller medication
•Reliever medication
•Regular follow-up – guided self management plan
•Rarely Immunotherapy – if single antigen trigger
How is clinical control of asthma defined
No (or minimal)* daytime symptoms ● No limitations of activity ● No nocturnal symptoms ● No (or minimal) need for rescue medication ● Normal lung function (FEV1, PEFR) ● No exacerbations \_\_\_\_\_\_\_\_\_ * Minimal = twice or less per week
What are the levels of asthma control and state the characteristics of each
a.Controlled (All of the following) b.Partly Controlled (Any measure present in any week) c.Uncontrolled
Characteristics:
- Daytime symptoms
a. None (twice or less/week)
b. More than twice/week
c. Three or more features of partly controlled asthma present in any week - Limitations of activities
c. None
b. Any
c.Three or more features of partly controlled asthma present in any week
Nocturnal symptoms/awakening
a. None
b. Any
c.Three or more features of partly controlled asthma present in any week
- Need for reliever/ rescue treatment
a. None (twice or less/week)
b. More than twice/week
c.Three or more features of partly controlled asthma present in any week
- Lung function (PEF or FEV1)
a. Normal >80%
b. < 80% predicted or personal best (if known)
c.Three or more features of partly controlled asthma present in any week
- Exacerbations
a. None
b. One or more/year*
c. One in any week†
What is the GINA assessment of symptom control
A.Symptom control
In the past 4 weeks, has the patient had: Well-controlled Partly controlled Uncontrolled •Daytime asthma symptoms more than twice a week? Yes No None of these(well controlled) 1-2 of these(Partly controlled) 3-4 of these(Uncontrolled) •Any night waking due to asthma? Yes No •Reliever needed for symptoms* more than twice a week? Yes No •Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
•Assess risk factors at diagnosis and periodically
•Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
•Exacerbations
•Fixed airflow limitation
•Medication side-effects
In the Assessment of risk factors for poor asthma outcomes risk factors for exacerbation includes, Risk factors for fixed airflow limitation include?, Risk factors for medication side-effects include?
Ever intubated for asthma
•Uncontrolled asthma symptoms
•Having ≥1 exacerbation in last 12 months
•Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter)
•Incorrect inhaler technique and/or poor adherence
•Smoking
•Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
•No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
•Frequent oral steroids, high dose/potent ICS, P450 inhibitors
PEFR/FEV1
•Mild – >80% of best, or predicted
•Moderate – 60-80%
•Severe – <60% true or false
True
What ar ethe types of asthma medications
Rescue medication/ relievers – are bronchodilators
•Beta 2 agonists eg salbutamol, terbutaline
•Anticholinergic drugs eg. ipratropium bromide
•Theophylline, aminophylline
•Inhaled preferred to oral
•Nebulized, IV for acute severe attack
Which medication are preventer or controller medicines
Which of the drugs are never used alone
Inhaled corticosteroids (ICS) eg. fluticasone, beclomethasone, budesonide
•Systemic corticosteroids eg. Oral prednisolone, IV hydrocortisone
•Long acting beta agonist (LABA)in combination with ICS - never used alone
- 12 hour bronchodilatory effect synergistic with steroid action
eg. salmeterol + fluticasone, formeterol + budesonide
•Leukotriene antagonists eg. Montelukast, zafirlukast
How to glucocorticoids and LABA work
LABA + ICS
•Complementary effects of Glucocorticoids and LABA
- glucocorticoids upregulate beta receptor recognition by beta agonist
- LABA improve uptake of glucocorticoid (steroid) into the cell nucleus
What’s r ethe side effects of the treatments
Side Effects •Salbutamol •Aminophylline •Prednisolone •Anticholinergics •LABA – salmeterol, formoterol •LTA – montelukast, zafirlukast
Which clinical outcomes ate measured in the follow up assessment
Follow-up Assessment •Clinical outcomes measured are: •change in FEV1 or PEFR (morning, evening) •daytime/nighttime symptoms •symptom-free days •frequency of use of rescue medication •limitation of normal activities •exacerbations - frequency of exacerbations
