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Respiratory System > Asthma in Adults > Flashcards

Asthma in Adults Flashcards

1
Q

FEV1/FVC ratio?

A

Obstructive - so decrease

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2
Q

Pathology

A

Inflammatory condition characterised by bronchoconstriction by smooth muscle contraction and airway oedema (mucus)

Reversible

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3
Q

Aetiology

A

Passive smoking
Maternal smoking - lungs don’t develop
Air pollution
Occupation - jobs exposing to dust, vapours, fumes
Airway hyper responsiveness - Type 1 hypersensitivity

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4
Q

Symptoms

A 
SOB
Wheeze
Cough 
Chest tightness
Diurnal variability - timing 
Episodic 
Atopy
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5
Q

Signs

A 
Tachypnoea 
Wheeze 
Eczema
Response to bronchodilators 
Peak flow returns to normal (reversible)
Obstructed spirometry
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6
Q

Useful Investigations

A

CXR (hyperinflation, hyperlucent)
Skin prick test to measure serum IgE (assess atopy)
FBC (eosinophilia - atopy)
U+Es (renal function)

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7
Q

Aims of treatment

A 
No day/night symptoms 
No need for rescue meds
No asthma attack (Exacerbation) 
Normal lung function (no limitations)
FEV1 or PEF > 80% 
Minimal side effects
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8
Q

Non pharmacological management

A

Exercise
Smoking cessation
Weight management
Flu/pneumococcal vaccines

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9
Q

Pharmacological management

A 
Inhaled short acting B agonist - reliever 
Inhaled corticosteroid (ICS)
Inhaled LABA

Add on:
Leukotriene receptor antagonists
Theophyllines
Oral steroids

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10
Q

Benefits of inhalers

A 
Small dose 
Delivered straight to airways and lungs
Onset of effect faster 
Low systemic exposure
Side effects less severe and less frequent
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11
Q

When to escalate treatment

A

If there is no response to inhaled LABA - stop LABA and increase dose of ICF

If benefit from LABA but control by patient is inadequate - continue LABA and increase ICS to medium dose. If still inadequate then consider trial of other therapy

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12
Q

Acute asthma sign

A

Can they complete sentence before breathlessness?

Hunch forward and shoulders raised to increase vol. into lungs

Wheezy, cough

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13
Q

How to prevent acute asthma attack

A 
Patient specific 
Know trigger (patients know their action plan and their signs)
Avoid delays 
Follow guidelines
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14
Q

Asthma attack features

A

PEF 33-50% of normal
RR > 25
HH > 110
Cant finish sentence in one breath

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15
Q

What cause the narrowing of the airways?

A

Airway inflammation mediated by immune system cause bronchoconstriction, and releases ACh, histamine and leukotrienes from mast cells, eosinophils and macrophages and asthmatics usually have increased airway reactivity causing further narrowing

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16
Q

Risk factors

A

Genetic - atopy
Occupation
Smoking - decrease FEV1 and increase airway responsiveness

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17
Q

Describe the genetic factors in the risk of developing asthma

A

Genetic tendency for IgE to respond to allergens

Immune response genes: IL-4 / 5, IgE
Airway gene: ADAM33

3x more likely to develop if mother has atopy

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18
Q

What to look for in clinical history

A

PMH:
Childhood asthma, bronchitis
Hayfever

Drugs:
Current inhalers, check technique and compliance
B-blockers, aspirin, NSAIDs

FMH:
Atopic disease

PSH:
Smoking
Pets
Occupation

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19
Q

Interpretation of spirometry

A

FEV/FVC ratio <70%

FEV1 < 80% predicted

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20
Q

Use of PEF

A

Lung function in clinic may be normal, PEF used to look for variability in airflow obstruction

Peak flow meter and chart, twice daily for 2 weeks

Look for:
Morning/nocturnal dips
Decline over weeks/days
Variability > 20%

Can diagnose occupation asthma (lowest PEF during weekdays)

21
Q

What are the main investigations?

A

Spirometry
Pulmonary function test (to look for COPD)
Reversibility
PEF - if spirometry is normal

22
Q

Sign of life threatening acute severe asthma

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

Sao2 < 92% (no ventilation)
PaO2 < 60mmHg
PaCO2 normal

23
Q

Sign of asthma attack (fatal)

A

Raised PaCO2

24
Q

Step 1 in treatment

A

Start on inhaled short acting B2 agonist - relievers

Salbutamol (MDI, DPI)
Terbutaline (DPI)

25
Q

Step 2 in treatment of adults

A

Add low-dose ICS (200-800mg) - preventer

26
Q

Step 3 (add on therapies) in treatment of adults

A

Add inhaled long acting B2 agonist to ICS

27
Q

In step 3, what happens if there is no response to LABA?

A

Stop LABA and increase dose of ICS to 800mg

28
Q

Step 4 of treatment in adults

A

Consider trials of:
Increasing ICS to 2000mg
Addition of fourth drug - LTRA, theophylline, beta agonist tablet, LAMA

29
Q

Step 5 of treatment in adults

A

Use daily steroid TABLET
Maintain high dose of ICS
May refer patient to specialist

30
Q

Three oral therapies

A

Leukotriene receptor antagonist
Theophylline
Prednisolone

31
Q

Use of ICS criteria

A

If using inhaled B2 agonist > x3 a week
Waking 1 night a week
Sub-normal exercise tolerance

32
Q

Specialist options for treatment

A

Omalizumab (anti-IgE)
Mepolizumab (anti-interleukin-5)
Bronchial thermoplasty

33
Q

Response to mild/moderate acute asthma attack

A 
Increase inhaler use 
Oral steroid 
Treat trigger
Early follow up plan
Back up plan
34
Q

Response to sever acute asthma attack

A 
HOSPITAL 
Nebulisers - salbutamol, ipratroprium 
Oral/IV steroid
Magnesium (helps bronchoconstriction)
Aminophylline 
Know triggers - infection/allergen 
Complication - do CXR
35
Q

Benefit of inhalers over oral therapy

A

Direct delivery to target organ (airway and lungs)
Onset of effect faster
Minimal systemic exposure (adverse effect less)

36
Q

What is a pMDI?

A

Metered dose inhalers:

Delivers specific dose of drug by aerosol

37
Q

Advantages and disadvantages of pMDIs

A

Doesn’t require deep breath (low inspiratory flow)

But requires coordination for simultaneous push and inspiration - no effective for young and elderly

38
Q

What is a DPI?

A

Dry powder inhaler:
Requires high inspiratory flow
Less coordination required

39
Q

What can occupation expose a person to which would increase risk of developing asthma?

A

Isocyanates (paint)
Grains
Enzymes
Crustaceans

40
Q

Describe the effect of maternal smoking during pregnancy in asthma

A

Nicotine causes modification in oocyte in female foetus’

Decrease FEV1
Increase wheeze
Increase airway response
Increase asthma and severity

41
Q

What is the ‘grandmother’ effect of asthma risk?

A

Mother smoked: 50% chance of developing
Maternal grandmother smoked: 150%
Mother and maternal smoked: increased further

42
Q

What are conditions that cause general airflow obstruction?

A 
Asthma (reversible AFO)
COPD (irreversible AFO)
Bronchiectasis 
Bronchiolitis 
CF
43
Q

What is investigated in pulmonary lung function tests?

A

Lung volumes:
Increase residual volume
Increase total lung capacity
RV/TLC > 3-%

CO Gas Transfer

44
Q

How do you intemperate reversibility to bronchodilator investigation?

A

Baseline and then 15mins post salbutamol

Significant reversibility: FEV1 >200ml and FEV1 > 15% of baseline

45
Q

What are the steps in investigations if spirometry is obstructed?

A
  1. Spirometry = obstructed
  2. Pulmonary function test
  3. Reversibility to bronchodilators
  4. Reversibility to corticosteroids
46
Q

How is reversibility to corticosteroids investigation carried out?

A

0.6mg/kg Predinisolone for 2 weeks
Peak flow chart and meter
Baseline and 2 week spirometry

47
Q

What are the steps in investigation if the spirometry is normal?

A
  1. Spirometry = normal
  2. Peak flow meter and chart, twice a day for 2 weeks
  3. ‘Optional’ investigation for SPECIALIST - airway responsiveness to histamine/exercise and exhaled nitric oxide (FeNO)
48
Q

What can a CXR show in asthma?

A

Hyperinflated
Hyperlucent

(No effusion, collapse, opacities, interstitial changes)

Respiratory System (29 decks)

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