asthma lms

Question 1

airway hyperresponsiveness

Answer 1

exxaggerated response to noxious stimuli
present in all asthmatics
leads to airway inflammation which leads to airflow obstruction

Question 2

airway obstruction leads. to

Answer 2

smooth muscle hypertrophy
inflammatory cell infiltration
oedema
goblet cell / mucous gland hyperplasia
mucus hypersecretion
protein deposition eg. collagen

Question 3

risk factors for asthma

Answer 3

atopy/allergy - high igG
genetics
pollution
smoking
obesity

Question 4

triggers for asthma

Answer 4

viral upper and lower respiratory tract infections
exposure to pollutants
exposure to cold air
smoking
exercise
exposure to chemicals/irritants
cats and allergens

Question 5

symptoms

Answer 5

breathlessness
wheeze
tight chest
cough
sputum
variable in severity and time
always worst at night

Question 6

signs

Answer 6

when the patient is well there are no signs
when active there may be wheeze
resp rate increased and tachycardia
difficulty speaking if severe asthma attack

Question 7

diagnosis

Answer 7

no single diagnostic test
good histroy
peak flow twice a day for a period of two weeks can reveal variable airflow obstruction
FEV1: better tesst but harder to perform
spiromtry and peak flow in a well asthmatic will be normal
good reponse to inhaled bronchodilators corticosteoids

Question 8

bronchial provocation testing

Answer 8

if the diagnosis is really in doubt
to decide whether there is airway hyperresponsiveness - absense will rule out asthma
methacholine or histamine challenge

Question 9

what is bronchial provocation testing

Answer 9

methacholine or histamine challenge
- increasing concentrations via nebuliser
FEV1 measured. at 1,3,5, and 10 minutes
continue until FEV1 drops by 20% or more
if FEV1 drops by 20% before a predetermined point, airway hyperresponsiveness is considered to be present

Question 10

step 1 therapy

Answer 10

• aas required SABA
  or
• as required ICS + formoterol

Question 11

step 2 therapy should be initiated when

Answer 11

symptoms or need for reliever therapy twice a month or more

Question 12

step 2 therapy

Answer 12

regular daily low dose ICS plus as needed SABA
OR
as required low dose ICS + formoterol

Question 13

when to step up to step 3 therapy

Answer 13

troublesome asthma most days or waking due to asthma, or poor control despite step 2 therapy

Question 14

step 3 therapy

Answer 14

regular daily low dose ICS plus LABA and as required SABA
OR
regular daily low dose ICS plus formoterol plus as required low dose ICS plus formoterol

Question 15

step 4 therapy

Answer 15

regular daily low dose ICS plus LABA and as required SABA
OR
regular daily medium dose ICS plus formoterol plus as required low dose ICS plus formoterol

consider referral to specialist and adding a LAMA while awaiting referral

Question 16

step 5 therapy

Answer 16

refer to specialist for other therapies
consider
regular daily high dose ICS plus formoterol plus as required low dose ICS plus formoterol
consider adding a LAMA

Question 17

SABA relievers

Answer 17

salbutamol
terbutaline

Question 18

preventers

Answer 18

seretide
symbicort
flutiform

all contain ICS and LABA

Question 19

non pharmacological issues

Answer 19

inhaler technique
compliance
triggers - pets, smoking
allergy testing
occupation

Question 20

difficult asthma

Answer 20

harder to treat in obese patients
LTRA - montelukast, oral steroids
always involve a specialisst

Question 21

management of acute asthma attack

Answer 21

oxygen
bronchodilators
(8-12 puffs salbutamol or via oxygen driven nebuliser 2.5-5mg)
oral steroids: prednisolone 30-40mg IV steroids have no real advantage

Question 22

other agents that can be used. for acute asthma attack

Answer 22

Atrovent (MDI or nubulised) - can add if response is poor
Aminophylline - can give IV if severe, but potential for toxicity
magnesium sulphate

Question 23

severity assessment of asthma attack

Answer 23

resp rate
pulse rate
PEFR or FEV1
speech
wheeze
pulse oximetry on air at presentation - not reliable if on oxygen

Question 24

pCO2 and severity

Answer 24

mild/moderate asthma - CO2 will be low
severe asthma - CO2 will rise and be either normal or high

beware the asthmatic with a normal pCO2

Question 25

wheeze as an indicator for severity

Answer 25

absense of wheeze is. not necessarily a good sign as wheeze may be absent in severe asthma as the patient is unable to breathe

Question 26

o2 sats in assthma severity

Answer 26

> 95% is mild
90-95 moderate
<90 severe

Question 27

indicators of life threatening asthma

Answer 27

relative bradycardia
O2 sats < 90
fatigue
does not talk
altered mental status
reduced resp rate

Question 28

in life. threatening asthma management

Answer 28

adrenaline IV or IM
may need intubation/ICU

Question 29

should you get a CXR for an athsmatic in ED

Answer 29

no unless you suspect something else or diagnosis is in doubt

Question 30

should you give antibiotics for the asthmatic in ED

Answer 30

no

Question 31

asthma in pregnancy

Answer 31

treated the same as non pregnant except for oral leukotrienes

Question 32

sending the asthmatic home from hospital

Answer 32

oral pred - week to 10 day course
salbutamol inhaler and spacer
ICS or combined ICS and LABA
check inhaler techique
see GP within 2 weeks

Question 33

occupational asthma

Answer 33

flour in bakers
glutaraldehyde in hospitals
isocyanates in paint sprayers

symptoms will worsen over the course of the working day
fill in peak flow charts every 2 hours for diagnosis

Question 34

allergic bronchopulmonary aspergollisos

Answer 34

sensitivity to aspergillus fumigatus
asthma presentation
changing CXR shadows/areas of collapse
coughing up. sputum. plugs
eosinophillia
positive skin test for sensitivity to aspergillus
treatment is the same as for asthma with more aggressive use of inhaled ICS to prevent mucous plugging
refer to specialist clinic

Question 35

what should most people with asthma get

Answer 35

symbicort: budesonide + formoterol