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Year 3 > Asthma (RESP) > Flashcards

Asthma (RESP) Flashcards

1
Q

Define asthma.

A

Chronic inflammatory airway disease characterised by reversible, intermittent airway obstruction and hyper-reactivity

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2
Q

What is asthma characterised by? (3)

A
  • bronchial hyper-responsiveness
  • episodic acute asthma exacerbations
  • reversible airflow obstruction
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3
Q

When do the symptoms of allergic asthma begin?

A

Childhood

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4
Q

What is allergic asthma associated with?

A

Atopy e.g.

  • allergic rhinitis
  • eczema
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5
Q

What gender is asthma more common in?

A

Males

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6
Q

Describe the pathophysiology of asthma.

A
  • IgE-mediated type 1 hypersensitivity leading to mast cell degranulation and release of histamine
  • 3 main pathological processes include:
    • bronchial hyper-responsiveness
    • bronchial inflammation
    • endobronchial obstruction
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7
Q

What are the main pathological processes in asthma? (3)

A
  • bronchial hyper-responsiveness
  • bronchial inflammation
  • endobronchial obstruction
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8
Q

What factors contribute to airway narrowing in asthma? (3)

A
  • bronchial muscle contraction due to stimuli
  • mucosal swelling/inflammation caused by mast cell and basophil degranulation leading to release of inflammatory mediators
  • increased mucus production
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9
Q

What are some of the key features of asthma?

A
  • recurrent episodes of SOB, chest tightness, wheezing or coughing
  • characterised by an expiratory wheeze (but in severe asthma, poor air entry = chest is silent)
  • may develop progressive, irreversible, obstructive lung disease
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10
Q

What are the clinical features of asthma? (9)

A
  • episodic symptoms
  • expiratory wheezes
  • dyspnoea
  • dry cough
  • chest tightness
  • diurnal variability of symptoms (worse at night/early morning)
  • historical record of variable peak expiratory flow (PEF) or FEV1
  • nasal polyposis
  • recent upper respiratory tract infection
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11
Q

When is the dry cough in asthma worse? (3)

A
  • at night
  • with exercise
  • with exposure to irritants
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12
Q

What are some precipitating factors/triggers for asthma?

A
  • cold air
  • viral infection
  • drugs
  • exercise
  • emotions
  • allergens - ask about dust mites, pollen, fur, pets
  • smoking
  • pollution
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13
Q

What is key in the Hx of asthma?

A

Symptoms come and go in response to triggers

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14
Q

What are some things to ask asthma patients?

A
  • ask about previous hospitalisation due to acute asthma attacks - gives indication of severity of asthma
  • ask about Hx of atopic disease:
    • Semter’s Triad: asthma, nasal polyps, aspirin sensitivity
    • nasal polyposis
  • ask if symptoms remit at weekend - may be triggered at work (occupational asthma - main trigger isocyanate)
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15
Q

What are some findings on examination for asthma?

A
  • prolonged expiratory wheeze
  • tachypnoea
  • use of accessory muscles
  • polyphonic wheeze
  • hyperinflated chest
  • hyper-resonant percussion
  • reduced air entry
  • prolonged expiratory phase on auscultation
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16
Q

What are the risk factors for asthma?

A
  • Fx
  • allergens/irritants e.g. dust mites, pets
  • atopic disease history (eczema, allergic rhinitis)
  • cigarette smoking / vaping
  • respiratory viral infection early in life
  • nasal polyposis
  • low socioeconomic status
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17
Q

When do we suspect a high probability of asthma? (5)

A
  • recurrent episodes of symptoms (attacks)
  • wheeze confirmed by a healthcare professional
  • positive history of atopy
  • historical record of variable airflow obstruction (spirometry)
  • no features to suggest an alternative diagnosis
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18
Q

What do we do in patients with a high probability of asthma?

A

6 week trial of ICS - if there is a good response, then it can be diagnosed as asthma

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19
Q

What are the 1st line investigations for asthma?

A
  • spirometry (FEV1/FVC and bronchodilator reversibility)
  • peak expiratory flow (PEF)
  • (FeNO test)
20
Q

What results would you see on spirometry for asthma?

A
  • FEV1/FVC ratio <70%
  • bronchodilator reversibility test (BDR test): >12% in response to beta agonists (200-400mg salbutamol)/corticosteroid trial, together with an increase in volume of 200mL or more
21
Q

What other investigations are considered for asthma?

A
  • CXR (exclude other pathologies; hyperinflation)
  • FBC with differential (elevated blood eosinophil count associated with severe exacerbations and poorer asthma control; neutrophilia)
  • fractional exhaled nitric oxide (FeNO): >40ppb in a corticosteroid-naive adult
  • bronchial challenge test (+ve)
  • allergen testing (+ve for allergen)
22
Q

What do other pulmonary function tests show in asthma?

A
  • normal/raised total gas transfer (TLCO)
  • raised transfer coefficient (KCO)
23
Q

What is FeNO used for?

A
  • exhaled FeNO of 40 parts per billion or more (>40ppb)
  • can show degree of eosinophilic inflammation
  • can be used to follow patients over time
  • monitor adherence
24
Q

How is occupational asthma investigated?

A

Serial peak flow measurements at home and work

25
Q

What are the NICE recommendations for investigating asthma?

A
  • all patients should have spirometry with bronchodilator reversibility (BDR)
  • all patients should have a FeNO test
26
Q

How can acute asthma attacks be classified? (4)

A
  • moderate
  • severe
  • life-threatening
  • near fatal
27
Q

What are the features of a moderate asthma attack? (4)

A
  • PEFR: >50-70% predicted
  • normal speech
  • RR <25
  • pulse <110
  • (treated with SABA + CS)
28
Q

What are the features of a severe asthma attack? (4)

A
  • PEFR: 33-50% predicted
  • cannot complete sentences
  • RR > 25
  • pulse >110
  • (treated with SABA + CS + monitoring)
  • (normal CO2 –> life threatening attack)
29
Q

What feature elevates a severe asthma attack to a life threatening attack?

A

Normal CO2

30
Q

What are the features of a life threatening asthma attack?

A
  • PEFR: <33% predicted
  • oxygen <92%
  • normal CO2
  • confusion
  • bradycardia
  • cyanosis: PaO2<8kPa, normal/high PaCO2>4.6kPa, low pH<7.35
  • CHEST - cyanosis, hypotension, exhaustion, silent chest, tachy/bradycardia
31
Q

What is the distinguishing feature of near fatal asthma?

A

Raised PaCO2 +/- require mechanical ventilation

32
Q

How is an acute asthma attack investigated and what will it show?

A

ABG showing type 2 respiratory failure (hypoxia + hypercapnia)

33
Q

What are some differential diagnoses for asthma?

A
  • cystic fibrosis (sweat chloride testing)
  • chronic rhinosinusitis (nocturnal cough, anterior rhinoscopy)
  • tracheomalacia (expiratory stridor, barking cough, bronchoscopy)
  • vascular ring
  • foreign body aspiration (one-sided wheezing, CXR)
  • vocal cord dysfunction
  • alpha-1 antitrypsin deficiency
  • COPD
  • bronchiectasis (dyspnoea, cough, wheeze, bronchial wall thickening CT)
  • pulmonary embolism
  • congestive heart failure
  • common variable immunodeficiency
34
Q

What are the principles of asthma management? (5)

A
  • assess treatment adherence
  • assess inhaler technique
  • manage comorbidities
  • manage environmental factors
  • explain the importance of PEFR monitoring
35
Q

What are the 5 steps for asthma symptom control? IMPORTANT

A

1. infrequent symptoms
- SABA (salbutamol) as needed
2. initial therapy
- SABA + low-dose ICS (beclomethasone/budesonide)
- (ICS added if symptoms >3/wk or night-time waking etc)
3. initial add-on therapy
- fixed-dose LABA (formoterol/salmeterol) + low-dose ICS + SABA as needed
- fixed-dose ICS/LABA inhaler e.g. beclomethasone/formoterol or fluticasone propionate/salmeterol
- never prescribe LABA on its own
- OR: MART LABA (maintenance and reliever therapy) + low-dose ICS (no SABA needed)
4. additional controller therapies
- fixed-dose LABA + medium-dose ICS + SABA as needed
- OR MART LABA + medium-dose ICS
- OR fixed-dose LABA + low-dose ICS + LTRA (montelukast) + SABA as needed
- OR MART LABA + low-dose ICS + LTRA
5. specialist therapies (e.g. daily steroid tablet + high-dose ICS; biologics e.g. omalizumab anti-IgE, dupilumab anti-IL4/13R, mepolizumab anti-IL5)

36
Q

Describe the salbutamol inhaler.

A
  • blue inhaler (reliever, SABA)
  • tremor side effect
  • taken when needed
37
Q

Describe the beclomethasone inhaler.

A
  • brown inhaler (maintainer, LABA)
  • oral candidiasis side effect
  • taken morning and night regardless of symptoms
38
Q

What do we do if we need to step-down treatment in well-controlled asthma?

A

Reduce 25-50% of ICS

39
Q

When do we admit an acute asthma exacerbation/attack to the hospital?

A
  • features of severe acute asthma and failure to respond to initial treatment
  • previous near fatal attack, pregnancy, attack occurring despite already using oral CS + presentation at night
40
Q

How do we manage an acute asthma attack?

A
  1. supplementary oxygen if hypoxemic, target sats 94-98% (Venturi mask/nasal cannula)
  2. 5mg salbutamol nebulised every 15min, 100mg IV hydrocortisone OR PO prednisolone
  3. in children - administer nebulised ipratropium bromide + IM adrenaline
  4. if no improvement: 1.2-2mg IV MgSO4 over 20mins + monitor ECG (do not give for COPD exacerbation)
  5. if no improvement: IV aminophylline + monitor electrolytes
  6. no improvement: intubation + ventilation in ICU
  7. if improvement within 15-20mins –> nebulised salbutamol every 4h, prednisolone 40-50mg PO OD 5-7d, monitor PEFR + SpO2
  8. if infection, consider Abx (but often viral)
  9. supportive care - IV fluids if needed
41
Q

Summary of escalating care during acute asthma attack.

A
  1. oxygen
  2. salbutamol nebulisers
  3. ipratropium bromide nebulisers
  4. hydrocortisone IV / oral prednisolone
  5. magnesium sulfate IV
  6. aminophylline / IV salbutamol
42
Q

What do we do if a patient with acute asthma exacerbation has normal PaCO2?

A

Escalate to intensive care team as it is a sign of exhaustion + life threatening

Normal asthma attack = hyperventilating –> reducing CO2

43
Q

When can a patient be discharged post-asthma attack?

A
  • PEF > 75% predicted
  • diurnal variation <25%
  • inhaler technique checked
  • stable on discharge for 24 hours
  • patient owns PEF meter + steroids + bronchodilator therapy
44
Q

What are some complications of asthma? (4)

A
  • moderate / severe exacerbation
  • airway remodelling
  • oral candidiasis secondary to use of ICS
  • dysphonia secondary to use of ICS
45
Q

Describe the prognosis of asthma.

A
  • many children improve as they get older
  • adult onset asthma is usually chronic

Year 3 (22 decks)

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