Asthma in adults

Question 1

What is the definition of asthma?

Answer 1

Increase in responsiveness of trachea and bronchi to various stimuli, resulting in widespread narrowing of airways that changes in severity; spontaneously or due to therapy.

Question 2

What is the pathology of asthma?

Answer 2

Airway inflammation is mediated by the immune system.
- widespread narrowing of airways
- increased airway resistance
- airway narrowing (spontaneously and with stimuli)

Question 3

What is the aetiology of asthma?

Answer 3

Hereditary
Smoking
Occupation
Risk factors

Question 4

Explain hereditary risk of asthma

Answer 4

Atopy - predisposition to developing antibody IgE in response to exposure to allergens
Genes

Question 5

Explain smoking risk of asthma

Answer 5

Maternal smoking during pregnancy
Grandmother effect - increased risk more than just mother smoking

Question 6

Explain occupational risk of asthma

Answer 6

Responsible for 10-15% of adult asthma
Bakers, painters and shellfish workers at highest risk

Question 7

Explain other possible risk factors relating to asthma

Answer 7

Obesity = inc in BMI increases chance of asthma
Diet
Hygiene = kids not exposed to sufficient microbes/germs during childhood

Question 8

What are the symptoms of asthma?

Answer 8

Wheeze
SOB
Chest tightness
Cough, paroxysmal, usually dry
Sputum (occasional)
Variation (daily, weekly and annually)

Question 9

What are some of the triggers of asthma?

Answer 9

Exercise
Cold air
Smoking
Perfumes/strong scents
URTI’s
Pets
Food
Tree/grass pollen
Drugs (aspirin/NSAIDS)

Question 10

What can be found out during clinical examination?

Answer 10

Useful to rule things out
Finger clubbing (cervical lymphadenopathy)
Stridor (harsh wheeze on inspiration)
Asymmetrical expansion (collapsed lung)
Dull percussion (collapsed lung)
Crepitations (bronchiectasis, CF, ILD, LVF)

Question 11

Important aspects of a history to take?

Answer 11

Past med history
- Childhood asthma, bronchitis or wheeze in infancy
- Eczema
- Hay fever
Drugs
- Current inhalers (check technique!), other asthma therapies, compliance
- B-blockers, aspirin, NSAIDS
- Effects of previous drugs/inhalers
Family history
- Asthma and other atopic diseases
Social history
- Smoking, drugs, vaping
- Pets
- Occupation (past and present)
- Physiological aspects

Question 12

What else could it be if not asthma but similar?

Answer 12

Generalised airflow obstruction
- COPD
- Bronchiectasis
- Cystic fibrosis
Localised airway obstruction (stridor)
- Tumour
- Foreign body
Cardiac

Question 13

What are the key things your looking for evidence of?

Answer 13

• Airflow obstruction
• Variability and or/reversibility of airflow obstruction

Question 14

What investigations are commonly done to determine if its asthma?

Answer 14

Spirometry
- Obstructive or normal

If obstructive (FEV1/FVC<70%, FEV1<80% predicted) then:
- Full pulmonary function test (excludes emphysema and COPD)
- The check reversibility to asthma treatment

If normal then try:
- Peak Flow Monitoring (PFM - 2x daily for 2 weeks, variability = asthma)
- Bronchial provocation
- Nitric oxide

Question 15

What special investigations could you do?

Answer 15

Airway responsiveness
Exhaled nitric oxide
Chest X-ray (hyperinflated, effusion, collapse, opacities, interstitial changes)
Skin prick test (atopic status)
Total and specific IgE (atopic status)
Full blood count (eosinophilia = atopy)

Question 16

What are the grades of an acute asthma attack?

Answer 16

Moderate
Severe
Life threatening
Near fatal

Question 17

What are the physiological signs of an acute asthma attack? (6)

Answer 17

Ability to speak
HR
Resp rate
PEF
O2 sat
ABG

Question 18

What are the signs of a moderate attack?

Answer 18

Able to speak in complete sentences
HR<110
RR<25
PEF 50 -70% predicted best
So2 > 92%
PaO2 > 8kPa

Question 19

What are the signs of a severe attack?

Answer 19

Inability to complete whole sentences in one breath
HR>110
RR>25
PEF 33-50% predicted/best
SaO2 > 92%
PaO2 > 8kPa

Question 20

What are the signs of a life threatening attack? (10)

Answer 20

Grunting
Impaired consciousness
Confusion, exhaustion
HR<60bpm
Cyanosis
Silent chest
Poor resp effort
SaO2 < 92% (need ABG)
PaO2 < 8kPa
PaCO2 NORMAL (4.6 - 6 kPa)

Question 21

What are the signs of a near fatal attack? (2)

Answer 21

Raised PaCO2
Need for mechanical ventilation

Question 22

What does complete control of asthma look like?

Answer 22

No daytime symptoms
No night time waking
No need for rescue medication
No asthma attacks
No limitations on activity including exercise and normal lung function
Minimal side effects from medication

Question 23

What are some non-pharmacological management options?

Answer 23

Patient education 7 self management plans
Exercise
Smoking cessation
Weight management
Flu/pneumococcal vaccinations

Question 24

What are some pharmacological managements?

Answer 24

Inhaled therapy
Oral therapy
Specialised treatments (severe asthma)

Question 25

What are types of inhalers?

Answer 25

pMDI (metered dose inhaler - have to coordinate puff with inspiration)
pMDI and spacer (patient performs normal tidal breathing and gets max dose of drug)
Dry powder inhalers (suck out does so need certain respiratory ability, good for patients with dexterity issues)
SABA (relievers - salbutamol (MDI/DPI) and terbutaline, side effects: tremor, inc HR, loss height)

Question 26

How do you treat a moderate/mild attack?

Answer 26

Increased use of inhaler
Oral steroid
Treat trigger
Early follow up
Back up plan

Question 27

How do you treat moderate/severe (hospital) attacks?

Answer 27

Nebulisers
Oral/IV steroids
Magnesium
Aminophylline
Triggers - infection/allergy
Complications - chest X-ray
Review
Level 2 & 3 care

Question 28

What is the difference between asthma and COPD?

Answer 28

• Age of onset - older for COPD
• Smoking history - those with COPD
• Response to treatment (treatment minimises COPD symptoms and reverses asthma symptoms)
• Treatment goals

Question 29

What are the similarities between asthma and COPD?

Answer 29

Similar therapies
Non-pharmacological interventions are the same