Asthma in Adults Flashcards

1
Q

What is asthma?

A

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

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2
Q

What is bronchoconstriction?

A

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

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3
Q

What are typical asthma triggers?

A

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

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4
Q

What are presentations suggesting a diagnosis of asthma?

A

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

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5
Q

Is asthma reversible?

A

Reversible airway obstruction that typically responds to bronchodilators such as salbutamol

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6
Q

Diagnosis based off of BTS/Sign Guidelines

A

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

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7
Q

BTS guidelines for treatment

A

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

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8
Q

Investigations in chronic asthma

A

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)

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9
Q

Symptoms

A

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

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10
Q

Signs of normal asthma

A

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

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11
Q

Signs of severe asthma

A

Inability to speak in complete sentences

Respiratory rate >25

Peak flow 33-50% predicted

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12
Q

Signs of life-threatening asthma

A

Silent chest
Confusion
Bradycardia
Cyanosis
Exhaustion

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13
Q

Diagnosis based off NICE guidelines

A

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

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14
Q

BTS Stepwise Ladder:

Step One

A

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

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15
Q

BTS Stepwise Ladder:

Step Two

A

Add a regular low dose corticosteroid inhaler.

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16
Q

BTS Stepwise Ladder:

Step Three

A

Add LABA inhaler (e.g. salmeterol).

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

17
Q

BTS Stepwise Ladder:

Step Four

A

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).

18
Q

BTS Stepwise Ladder:

Step Five

A

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

19
Q

BTS Stepwise Ladder:

Step Six

A

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

20
Q

NICE guideline ladder:

Step One

A

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

21
Q

NICE guideline ladder:

Step Two

A

Add a regular low dose inhaled corticosteroid.

22
Q

NICE guideline ladder:

Step Three

A

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

23
Q

NICE guideline ladder:

Step Four

A

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

24
Q

NICE guideline ladder:

Step Five

A

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

25
Q

NICE guideline ladder:

Step Six

A

Increase the inhaled corticosteroid to a “moderate dose”.

26
Q

NICE guideline ladder:

Step Seven

A

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

27
Q

NICE guideline ladder:

Step Eight

A

Refer to specialist

28
Q

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

A

Each patient should have an individual asthma self-management programme

Yearly flu jab

Yearly asthma review

Advise exercise and avoid smoking