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Respiratory System > Asthma - Clinical Features (Adults) > Flashcards

Asthma - Clinical Features (Adults) Flashcards

1
Q

What is the definition of asthma?

A

A disease characterised by an increased responsiveness of the trachea and bronchi to various stimuli and manifested by a widespread narrowing of airways that changes in severity either spontaneously or as a result of therapy.

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2
Q

Summarise the pathophysiology of asthma.

A

Airway inflammation mediated by the immune system (IgE)
—>
increased airway reactivity/widespread narrowing of the airways
—>
spontaneously/stimuli

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3
Q

Is asthma more prevalent in children or adults?

A

children

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4
Q

Who is most affected by asthma: males or females?

A

Male children

Female adults

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5
Q

How many people are receiving treatment for asthma?

A

5.4m

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6
Q

Who is most likely to die from asthma?

A

> 60 years

Smoker

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7
Q

How many children in the UK are receiving treatment for asthma?

A

1.1m

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8
Q

How many adults in the UK are receiving treatment for asthma?

A

4.3m

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9
Q

What kinds of everyday things are totally or very limited by asthma?

A 
Running
Sport
Stairs
Pets
DIY
Gardening
Pub
Walking
Sleeping
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10
Q

What is airway reactivity in asthma?

A

Tendency for airways to narrow/shut either to stimuli or spontaneously.

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11
Q

How much does asthma cost the NHS annually?

A

£889m

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12
Q

How much does asthma cost the UK annually?

A

£2,349m

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13
Q

How many working days a year are lost due to asthma?

A

12.7m

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14
Q

How has asthma prevalence changes over the last 60 years?

A

Increased massively until about 2010 when it began to drop

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15
Q

What are the main causes of airway obstruction?

A
  • Debris in the alveoli and airways such as mucous and cells.
  • Constriction of smooth muscles around airways.
  • Inflammation/thickening of the airway walls.
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16
Q

Outline the proven aetiological factors of asthma.

3 points

A
  • Genetics
  • Occupation
  • Smoking
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17
Q

Define atopy.

A

Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema).

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18
Q

Describe atopic asthma in terms of its triggers and origin.

A

Atopic asthma is triggered by a variety of environmental agents such as dust, pollens, foods, and pets.

There is often a family history of asthma, hay fever or atopic eczema.

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19
Q

What are the strongest risk factors in terms of atopic asthma (genetic)?

A

Familial atopic tendency

Maternal atopy is 3x more influential than paternal.

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20
Q

Bronchoconstriction is mediated by a type ____ hypersensitivity reaction.

A

I

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21
Q

Outline the pathogenesis of allergic asthma.

A

Inhalation of allergen (antigen) causes degranulation of mast cells bearing specific IgE (antibody) molecules. Release of vasoactive substances from the mast cells causes bronchial constriction, oedema and mucus hypersecretion.

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22
Q

Bronchoconstriction leads to the clinical effects of _________, __________ and ___________.

A

weezing, dyspnoea, tachypnoea

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23
Q

Which vasoactive substances are released from mast cells exposed to antigens.

A

Histamine
SRS-A
ECF-A
PAF

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24
Q

Which immune response genes are involved in atopic asthma?

A

IL-4
IL-5
IgE

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25
Q

Which airway genes are involved in atopic asthma?

A

ADAM33

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26
Q

How much of adult onset asthma is due to occupation?

A

Underestimated at 10-15%

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27
Q

What kinds of things are people exposed to at work that leads to asthma?

A 
Isocyanates (twin pack paints)
Colophony (welding)
Laboratory animals
Grains (flour)
Enzymes (e.g. amylase, subtilisin)
Drugs (salbutamol, antibiotics)
Crustaceans (shell fish)
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28
Q

Give some examples of occupations that will increase your risk of developing asthma.

A

Baker
Welder
Builder
Cleaners

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29
Q

Explain what is meant by the ‘grandmother effect’.

A

Children are more at risk of asthma if:

Mother smoker - 1.5 (50%)
Maternal grandmother smoker - 2.1 (100%)
Both of the above - 2.6 (150%)

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30
Q

What effect does maternal smoking during pregnancy have on the babies breathing?

A
  • Decreases FEV1
  • Increases wheezy illness
  • Increases airway responsiveness
  • Increases asthma
  • Increases severity
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31
Q

Outline the possible (putative) risk factors for asthma?

A
  • Obesity
  • Diet
  • Reduced exposure to microbes
  • Indoors pollution (e.g. chemical household products)
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32
Q

How is obesity considered a possible risk factor for asthma?

A

BMI is positively associated with: - asthma

  • wheezing
  • airway hyper-reactivity
  • breathlessness (not technically asthma)
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33
Q

What changes in a persons diet is a possible risk factor for asthma?

A
  • Less antioxidants
  • Less n-3 polyunsaturated fatty acids
  • More n-6 polyunsaturated fatty acids
  • More/less vitamin D
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34
Q

What associations have been made between asthma and diet, that could indicate a correlation?

A
  • decreases in FEV1 & decreases in vitamins E/C/D, carotene.
  • increased wheeze & decreases in vitamins E/C, fruit, eating margarine.
  • decreases in asthma with increased oily fish consumption, and butter
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35
Q

Why do we know reduced exposure to microbes might increase the risk of asthma?

A

Children born on farms are less likely to develop asthma.

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36
Q

How do we know indoor pollution might increase the risk of asthma?

A

Cleaners are more at risk of developing asthma.

37
Q

What are some environmental allergens linked to asthma?

A

House dust mite
Cats
Grass pollen

38
Q

What are some things that might cause localised airway obstruction?

A

Inspiratory stridor
Tumour
Foreign body

39
Q

What are some things that might cause generalised airway obstruction?

A 
Asthma
COPD
Bronchiectasis
Bronchiolitis
Cystic fibrosis
40
Q

Does allergen exposure cause asthma?

A

No, it is more to do with the way we live nowadays.

41
Q

What is most important for making the asthma diagnosis?

A

History, examination is rarely useful.

42
Q

What are the symptoms of asthma that you must look out for in the history?

A
  • Wheeze
  • Dyspnoea, severity
  • Chest tightness (pain)
  • Cough, paroxysmal, usually dry
  • Sputum (occasional)
43
Q

Describe the colour and viscosity of sputum produced in asthmatics?

A

Thick, white to yellowish

44
Q

What is dyspnoea?

A

Breathlessness, difficult or laboured breathing.

45
Q

What is a wheeze?

A

A high pitched whistling noise from the chest (not throat).

46
Q

What is paroxysmal?

A

Sudden intensification of symptoms, exacerbation.

47
Q

What variations in symptoms must you look out for when taking a history?

A
  • Triggers
  • Daily variation (nocturnal or early morning)
  • Weekly variation (occupational risk)
  • Annual variation (seasonal)
48
Q

What are some triggers for asthma?

A

exercise, cold air, smoke, perfume, URTI’s, pets, grass pollen, food, aspirin

49
Q

What does an asthmatic bringing up green sputum mean?

A

Not always an infection, neutrophils and polymorphs from inflammation also cause this.

50
Q

What is important to look out for in patients PMH?

A

childhood asthma
bronchitis
eczema
hayfever

51
Q

What is important to look out for in patients DH?

A 
Current inhalers (microg NOT puffs) - check technique/compliance
B-blockers
Aspirin
NSAIDS
Effects of previous drugs, inhalers
52
Q

What is important to look out for in patients FH?

A

Atopic disease (atopic asthma, eczema, hay fever)

53
Q

What is important to look out for in patients SH?

A

Are they a smoker? (or around smokers)
Any pets?
Occupation - past/present
Psychosocial aspects

54
Q

What are some observations in an examination of an asthmatic?

A
  • Breathless on exertion
  • Hyperexpanded chest
  • Polyphonic wheezes
55
Q

What if seen on examination suggests it is not asthma?

A
  • clubbing
  • cervical lymphadenopathy
  • stridor
  • assymetrical expansion
  • dull percussion note, (lobar collapse, effusion)
  • crepitations (bronchiectasis, CF, alveolitis, LVF)
56
Q

What is crepitation?

A

a crackling sound

57
Q

What is bronchiectasis?

A
  • long-term condition
  • airways of the lungs become abnormally widened
  • leading to a build-up of excess mucus
  • lungs more vulnerable to infection
58
Q

What are the two main things looked for in investigations?

A
  • Airway obstruction (spirometry)

- variability and/or reversibility of airflow obstruction (drugs/monitoring)

59
Q

What spirometry results are indicative of an obstructive airway disease?

A

FEV1 less than 80%
FEV1/FVC ratio less then 70%

May be completely normal though as in asthma airway obstruction is variable.

60
Q

What investigations should be carried out if there is evidence of an OBSTRUCTED airway from the spirometry?

A
  • Full pulmonary function testing
  • Reversibility to bronchodilator (B2-agonist)
  • Reversibility to oral corticosteroids (e.g. brown inhaler)
61
Q

What is the first investigation we do for asthma?

A

FEV1 testing (spirometry)

62
Q

What do we do if spirometry testing for FEV1 is NORMAL?

A

Test variability of airflow obstruction using a peak flow meter and chart twice daily for two weeks.

Variability suggests asthma

63
Q

If the FEV1 testing is normal, how often and for how long is a peak flow meter used to test variability of airflow obstruction?

A

Twice daily for 2 weeks

64
Q

what is full pulmonary function testing?

A
  • Used to exclude COPD or emphysema.
  • The two tests carried out are:
    1. lung volumes by helium dilution and;
    2. carbon monoxide gas transfer (transfer of CO to Hb across alveoli, this tests for tissue destruction).
65
Q

What does full pulmonary testing exclude?

A

COPD/emphysema

Increase gas transfer suggests asthma, decreased suggests COPD.

66
Q

When does full pulmonary testing suggest asthma?

A

If increase gas transfer

67
Q

what is the reversibility to bronchodilator test used for?

A

It tests for bronchoconstriction. For significant reversibility the change in FEV1 must be greater than 200ml and greater than 15% of base line.

68
Q

When does testing the reversibility to bronchodilator suggest asthma?

A

Increase in FEV1 after salbutamol suggests asthma, no increase suggests COPD

69
Q

What is the process of testing reversibility to bronchodilator?

A

1) Take baseline measurement
2) Give salbutamol
3) Compare the difference

70
Q

What is the reversibility to oralcorticoseroids test used for?

A
  • It tests for inflammation in airways

- used to separate COPD from asthma when there is an obstructed picture from initial spirometry

71
Q

What is the prescription for a reversibility to oral corticosteroid test and what is measured?

A
  • 0.6mg/kg of Prednisolone for 14 days.
  • peak flow chart and meter
  • baseline and 2 week spirometry
72
Q

When testing reversibility to oral corticosteroids, what suggests asthma?

A

Improvement suggests reversibility so asthma, no improvement suggests COPD

73
Q

What is the FEV1/FVC ratio for an airway obstruction?

A

Less than 70%

74
Q

What might suggest occupational asthma?

A
  • Suspicion from work related symptoms

- Working with recognised occupational sensitiser

75
Q

How is occupational asthma confirmed?

A

Serial peak flow readings, 2 hourly best for 2 days minimum.

Difference in and out of work shows occupational asthma.

76
Q

What are examples of specialised investigations?

A
  • airway responsiveness to methacholine/histamine/mannitol/exercise
  • exhaled nitric oxide
77
Q

What are some additional useful investigations?

A

Chest x-ray
Skin prick testing
Total and specific IgE
Full blood count

78
Q

What could a chest x-ray of someone with asthma show?

A

looking for hyperinflation, hyperlucent (less dense than normal)

or checking for no effusion, collapse, opacities, interstitial changes

79
Q

What does skin prick testing; total and specific IgE; and full blood count test?

A

Atopic status

Blood count: looking for eosinophilia associated with atopy

80
Q

Why is being objective more important than subjective?

A

Life threatening asthma may not induce any visible distress

81
Q

What physiological indicators are checked when dealing with asthma?

A 
Ability to speak
Heart rate
Respiratory rate
PEF
Oxygen saturation/arterial blood gases
82
Q

What is acute asthma?

A

Flare up of asthma

83
Q

What are the different kinds of acute asthma?

A

Mild
Severe
Life threatening
Near fatal

84
Q

What are the features of an asthmatic in moderate condition?

A

Essentially increasing symptoms, no features of severe.

Able to speak, complete sentences
HR <110
RR <25
PEF 50 - 75% predicted or best
SaO2 > 92% (no need for ABG)
PaO2 > 8kPa
85
Q

What are the features of an asthmatic in a severe condition?

A 
Unable to speak, unable to complete sentences 
HR >110
RR >25
PEF  33 - 50% predicted or best
SaO2 > 92% 
PaO2 > 8kPa
86
Q

What are the features of an asthmatic in a life threatening condition?

A 
Grunting
Impaired consciousness, confusion, exhaustion
HR >130, or bradycardic
Hypoventilating
PEF < 33% predicted or best
Cyanosis

SaO2 < 92%
PaO2 < 8kPa
PaCO2 normal (4.6 - 6.0kPa)

87
Q

When is an asthmatic in a near fatal condition?

A

PaCO2 is raised

88
Q

What does near fatal asthma require?

A

Mechanical ventilation

Respiratory System (26 decks)

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