Bronchial Asthma Flashcards
What is Bronchial Asthma?
Chronic inflammation
Ccc by bronchial hyper reactivity
And reversibility
With or without ttt
What are the types of bronchial asthma?
Atopic or allergic
Non allergic
Bronchospasm
How to confirm atopic asthma ?
Skin pin prick test
Immediate wheal and increase in serum IgE
What is an indicative sign of atopic asthma ?
Positive family history
What type is atopic asthma ?
Localized type 1
What is the onset of asthma ?
Childhood
What is the most common chronic disease in childhood ?
Bronchial asthma
What sex is more predisposed to asthma ?
Boys
What are the other signs or commodities that indicate atopic asthma ?
IgE
Allergic rhinitis
Eczema
What trigger atopic asthma ?
Environmental allergens
Dust
Pollen grains
Fungi
Pets
What triggers non allergic asthma ?
Respiratory viral infection with vagal overtime
What triggers bronchospasm ?
Drugs as aspirin, beta blockers and ACE
Occupational fumes metal dust animals
Exercise gerd stress smoking sinusitis and obesity
What is the sign of severity of asthma ?
Silent chest
Asthma without wheezes
What are the symptoms of asthma ?
Night or early morning episodes
•Dyspnea
•wheezes
•coughing thick pellets
•Chest tightness
•anxiety
•Sweating
Most important trigger in atopic asthma ?
Fungi
When do signs of asthma appear ?
During attacks
What are the signs of asthma ?
c- Signs:
1- G
a- Pulse = Pulsus Paradoxus or Arrhythmias
b- Head & Neck
1- Congested pulsating neck veins with Kussmaul’s sign
2- Tachypnea + Working accessory ms
- LL edema
2- L
I: Symmetrical, equal movement & increased A-P diameter, Hyper-inflation
P: Trachea (Centralized), TVF (Equal)
P: Bilateral hyper-resonance + Encroaching on heart & liver
A:
a- Breath S.: Type: Harsh vesicular (Prolonged expiration) + decreased Air entry Bilaterally
b- Additional S: Coarse crepitations + Rhonchi
What are the complications of bronchial Asthma ?
Lung collapse, pneumothorax, pneumonia and respiratory failure type 2
Corpulmonale
Decreased work capacity
Asthmatic bronchitis
Allergic broncho pulmonary aspergillosis
What is asthmatic bronchitis ?
Increase in amount of sputum and poor response to treatment
What is ABPA?
Type 1 HS to Aspergillus Fumigatus antigens leading to increase in IgE
What is the Clinical picture of ABPA?
Fever
Chest pain
Worsening of asthma
What are the investigations of ABPA?
Hyperesinophilia (more than 1500 mm3)
Increase total and specific IgE
Positive skin prick test for aspergillus
What is the ttt of ABPA?
Oral prednisone and itraconazole are 200mg 2x/day for 2 mins
What is reversibility test (when is it positive) and in this case what does this indicate?
Post bronchodilator increase of FEV1 by 12% or 200ml
If positive = bronchial asthma
What are the investigations of Asthma ?
Immunological
Increase in esinophils
Increase in serum IgE total and specific
Skin test
ABG
ABG: Hypoxia and Hypercapnia
Radiology
Radiology: Same as blue bloater
Spirometery
DLco: not impaired
TLC inc
Dec FEV1
Dec FVC
PEFR sec
Nebulized Oz dosage for acute severe asthma
60%
As needed
Salbutamol dosage for acute severe asthma
5 mg repeated every 20 mins if needed, max is 3 x
IV Methyl prednisolone dosage for acute severe asthma
60 mg
Repeated every 6 hrs in the 1st day then oral for 10 - 14 days after
Salbutamol dosage if failed initially in acute severe asthma
10 mg could be repeated every 1 hr
Investigations for hospitalized Status Asmathicus or imminent asthma
PEFR + Pulse oximetry + CXR
Ipratropium bromide route of administration in acute severe asthma
And what is it
SAMA TO
Nebulized 02
If ipratropium bromide fails ?
Add IV MgSO4
If MgSO4 fails ?
Add IV Salbutamol
If salbutamol fails ?
Add IV Theophylline
acute severe asthma may need ?
May need ICU & Correction of Acidosis or Hypokalemia if occurred
Cortisone inhaler of budenoside dosages
Low dose < 400 ug
Medium 400 - 800 ug
High dose > 800 ug
There are 10 steps to follow in cases of
Status Asmathicus/severe asthma
Imminent asthma
List the 10 steps to follow
TTT plan of Acute severe asthma (Status asthmaticus) & Imminent asthma
1- Nebulized Oz (60 %) as needed
2- Salbutamol 5 mg repeated every 20 mins if needed max is 3 x
3- If failed IV Methyl prednisolone 60 mg (repeated every 6 hrs in the 1st day then oral for 10 - 14 days after)
4 If failed give Salbutamol again 10 mg could be repeated every 1 hr
5- If failed → Hospitalization
→ PEFR + Pulse oximetry + CXR
6- Ipratropium bromide on nebulized 02
7- If failed add IV MgSO4
8- → If Failed add IV Salbutamol
9- → if Failed add IV Theophylline
10- May need ICU & Correction of Acidosis or Hypokalemia if occurred
What are the criteria’s to assess in asthma exacerbation?
Talking
Posture Dyspnea
Respiratory Rate
Pulse
Rate volume
SO2
Wheezes
I hate should not be used to assess severity of exacerbations?
RR as they are usually very low
What is Pulsus Pardoxus?
Inspiring obliterates pulse
Why does silent chest occur?
Due to severe bronchospasm
What is the criteria of mild exacerbation?
Can say sentences
Can lie flat
RR 18-25
Pulse Normal
Rate Volume Normal
SO2 above 95%
Wheezes end expiratory
What is the criteria of moderate exacerbation?
Talking increase Dyspnea
Can only sit with working accessory muscles
RR 25-30
Pulse 100-120
Rate Volume PP 10-20
SO2 above 91-95%
Wheezes expiratory
What is the criteria of severe asthmatic exacerbation?
Can say words only
Tripod position with working accessory muscles
RR more than 30
Pulse more than120
Rate Volume PP 20-40
SO2 above less than 91
Wheezes expiratory and inspiratory
What is the criteria of imminent respiratory failure ?
Drowsy
Dec in RR
Dec in HR
Heavy sweating
What are the 2 types of TTT of BA and what are the names of guidelines ?
Pt education
Medical according to Gina 2021
What should be taught to patients regarding asthma ?
Diet
Exercise
Avoid triggers
Weight control
Domicilkiary follow up of PEFR
According to GINA 2021, steps are, when to step up, when to step down
Stepwise
2-6w before step up
If controlled for 3m step down
What is the difference between track 1 and 2?
Track 1= high risk of exacerbation (hospitalized once per year)
Track 2= low risk of exacerbation
Track 1 meds
Reliever: LICS + formetrol as needed
Step 1 and 2: LICS + Formetrol as needed
Step 3: LICS + Formetrol regularly
Step 4: MICS + Formetrol regularly
Step 5: LICS + Formetrol regularly with or without oral agents
Track 2 Meds
Reliever: SABA as needed
Step 1: LICS as needed
Step 2: LICS regular
Step 3: LICS + LABA regularly
Step 4: MICS + LABA regularly
Step 5: HICS + LABA regularly with or without oral agents
What is formetrol?
Mix of SABA and LABA that starts in 2m and lasts 12h
What are the relievers of asthma ?
LICS and formetrol
SABA
Theophyline
SAMA
What are the controllers of asthma ?
Inhaled Corticosteroids
Oral corticosteroids
LABA
LAMA
Montelukast
Zileuton
Theophyline
Disodium cromoglycate
Omalizumab
Cromones
What is omalizumab?
Anti IgE
How does Theophyline work ?
Inhibits PDE 3 and 4
Inhibits adenodsine receptors
Leads to smooth muscle relaxation
Decreased chemotaxis of neutrophils and esinophils
AES of Theophyline
Very severe Git upset and arrhythmia
What are the mechanism of action of montelukast and uses
lts receptor blocker used in aspirin, exercise and smoking triggered asthma
What is the mechanism of action of zileuton? And use
lts enzyme inhibitors used in aspirin, exercise and smoking triggered asthma
Ae of lama
Day mouth
Ae of laba and mc
Tremor mc
Palpitation
Hypokalemia
Ae or inhaled and oral corticosteroids
Hoarseness of voice
Oral Candiasis
What is the DOC of asthma
ICS
Step 1 symptoms
Intermittent
1 daytime attack per week
Step 2 symptoms
Mild persistent
2-6 daytime attacks per week
Step 3 symptoms
Moderate persistent
Daytime attacks all week
Step 4 symptoms
Severe persistent
All week long in addition to physical limitations
Refractory asthma
Failed to respond to HICS and LABA despite optimum TTT
List the mediators involved in airway remodeling and their origin
VEGF (TH2)
IL3 (Esinophils and TH2)
THF b (mast cell)
Which phase of ventilation is most limited in asthma ?
Expiratory
List the pathological features of airway remodeling
Neutrophil and esinophils in linen
Mucus excess
Mucus gland metaplasia
Mucus membrane swelling
Suepithial fibrosis and swelling
Smooth muscle contraction
What are indicators of asthma ?
Presence more than one of 5 of those
- wheeze, Dyspnea, tightness, pellets
Late night or early morning
Varying severity
Triggers present
What varies proportionally with severity of attack ?
The PEFR
Which points decrease the likelihood of it being asthma ?
Isolated cough
Chronically productive
Dizziness
Chest pain
Exercise induced dyspnea with stridor
What are the 2 cornerstones of asthma diagnosis ?
- Evidence of variable expiratory airflow limitation
• 2w daily PEFR variability through
(daily amplitude * 100/ daily mean)
• PEFR significant increase after 4w of controller - History of variable respiratory symptoms consistent with clinical picture
• as before
Normal FEV1 to FVC ratio
Normal more than 0.75 to 0.8
Child more than 0.9
If case is highly consistent with asthma but nothing shows up. What to do ?
Repeat during attack or after withholding BD
What are the 2 points used to assess severity of asthma regarding steps ?
Frequency of attacks and FEV1
Can asthma and COPD coexist ?
Yes especially if above 65y
What are asthma phenotypes ?
genetic and environmental factors
Leading to altered
Age of onset
Presence of atopy
Lung function
Despite having similar manifestations
Can phenotypes be further divided
Into endotypes based on pathophsyiological molecular mechanisms
DD of asthma other than dyspnea (htrz3hom hena 3ady)
Drug induced as ace
Infiltration with esinophils
VC dysfunction
Ciclesonide doses
80-160
161-320
Above 320
Ics doses units
Mcg
Budensonide
Less than 400
400 to 800
More than 800
How to assess asthmatic control
For past 4w
- daytime symptoms above 2/w
- night time waking above 2/w
- Reliever needed above 2/w
- activity limitation
Well controlled 0 maintain and find lowest suitable
Partly controlled 1-2 consider upgrading
Uncontrolled 3-4 keep upgrading till controlled
