Asthma in Adults

Question 1

What is asthma?

Answer 1

Chronic inflammatory condition of the airways that causes episodic exacerbations of bronchoconstriction

Question 2

What is bronchoconstriction?

Answer 2

When the smooth muscles of the airways (the bronchi) contract causing a reduction in the diameter of the airways.

Narrowing of the airways causes an obstruction to airflow going in and out of the lungs.

Caused by parasympathetic nerves

Question 3

What are typical asthma triggers?

Answer 3

Infection
Night time or early morning
Exercise
Animals
Cold/damp
Dust
Strong emotions

Question 4

What are presentations suggesting a diagnosis of asthma?

Answer 4

Episodic symptoms

Diurnal variability. Typically worse at night.

Dry cough with wheezing and shortness of breath

A history of other atopic conditions such as eczema, hayfever and food allergies

Family history

Bilateral widespread “polyphonic” wheeze heard by a healthcare professional

Question 5

Is asthma reversible?

Answer 5

Reversible airway obstruction that typically responds to bronchodilators such as salbutamol

Question 6

Diagnosis based off of BTS/Sign Guidelines

Answer 6

High probability of asthma clinically: Try treatment

Intermediate probability of asthma: Perform spirometry with reversibility testing

Low probability of asthma: Consider referral and investigating for other causes

Question 7

BTS guidelines for treatment

Answer 7

Step 1: short-acting inhaled B2-agonist (eg. Salbutamol)

Step 2: add low-dose inhaled corticosteroid
steroid (ICS)

Step 3: add long-acting B2-agonist (eg. Salmeterol). If no benefit, stop this and increase ICS dose; if benefit but inadequate control, continue and increase ICS dose.

Step 4: Trial oral leukotriene receptor antagonist, high-dose steroid, oral B2-agonist

Question 8

Investigations in chronic asthma

Answer 8

Peak flow: variability >20%

Fractional exhaled nitric oxide (FeNO): >40 ppb in adults or >35 ppb in children

Spirometry: FEV1/FVC <0.7 (obstructive spirometry)

Question 9

Symptoms

Answer 9

Wheeze
Dyspnoea
Cough (may be nocturnal)
Chest tightness
Diurnal variation (symptoms often worse in the morning)

Question 10

Signs of normal asthma

Answer 10

Tachypnoea
Hyperinflated chest
Hyper-resonance on chest percussion
Decreased air entry (sign of severe illness: silent chest)
Wheeze on auscultation

Question 11

Signs of severe asthma

Answer 11

Inability to speak in complete sentences

Respiratory rate >25

Peak flow 33-50% predicted

Question 12

Signs of life-threatening asthma

Answer 12

Silent chest
Confusion
Bradycardia
Cyanosis
Exhaustion

Question 13

Diagnosis based off NICE guidelines

Answer 13

First line investigations:

Fractional exhaled nitric oxide

Spirometry with bronchodilator reversibility

If there is diagnostic uncertainty after first line investigations these can be followed up with further testing:

Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks

Direct bronchial challenge test with histamine or methacholine

Question 14

BTS Stepwise Ladder:

Step One

Answer 14

Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.

Question 15

BTS Stepwise Ladder:

Step Two

Answer 15

Add a regular low dose corticosteroid inhaler.

Question 16

BTS Stepwise Ladder:

Step Three

Answer 16

Add LABA inhaler (e.g. salmeterol).

Continue the LABA only if the patient has a good response.

Question 17

BTS Stepwise Ladder:

Step Four

Answer 17

Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA (i.e. tiotropium).

Question 18

BTS Stepwise Ladder:

Step Five

Answer 18

Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist.

Question 19

BTS Stepwise Ladder:

Step Six

Answer 19

Add oral steroids at the lowest dose possible to achieve good control.

Question 20

NICE guideline ladder:

Step One

Answer 20

Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.

Question 21

NICE guideline ladder:

Step Two

Answer 21

Add a regular low dose inhaled corticosteroid.

Question 22

NICE guideline ladder:

Step Three

Answer 22

Add an oral leukotriene receptor antagonist (i.e. montelukast).

Question 23

NICE guideline ladder:

Step Four

Answer 23

Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.

Question 24

NICE guideline ladder:

Step Five

Answer 24

Consider changing to a maintenance and reliever therapy (MART) regime.

Question 25

NICE guideline ladder:

Step Six

Answer 25

Increase the inhaled corticosteroid to a “moderate dose”.

Question 26

NICE guideline ladder:

Step Seven

Answer 26

Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).

Question 27

NICE guideline ladder:

Step Eight

Answer 27

Refer to specialist

Question 28

What additional steps can be taken in the management of asthma?

Answer 28

Each patient should have an individual asthma self-management programme

Yearly flu jab

Yearly asthma review

Advise exercise and avoid smoking