Case 2: Sub Acute Breathlessness Flashcards
what are the common histological features of asthma?
mucus plugs
no ciliated epithelium
thickened basal membrane
hypertrophy/hyperplasia of the smooth muscle
what common questions do we ask about a cough?
how long have you had the cough? is it there all the time?
does anything make the cough better or worse? is it worse at any particular time of the day e.g. when you lie down at night or does it wake you up at night?
is it a dry cough or are you producing sputum?
what is the colour/volume/tenacity of the sputum?
are there any red flag symptoms, e.g. haemoptysis?
how is the cough impacting your day-to-day life?
what tests can be conducted for asthma?
exhaled NO
peak flow diary
spirometry
peak flow
a higher than normal level of NO means that there is inflammation in the lining of the airways or it could mean that you have allergic asthma. inflammation responds well to corticosteroid therapy.
what is the normal range for peak flow?
400-700 litres per min
what does use of an ICS inhaler increase the chance of?
oral candiases - unless you clean your mouth out after inhalation
what is salbutamol?
beta 2 agonist
it is a short acting bronchodilator and is classed as a reliever medication. it works quickly to relax the airway muscles and has an immediate effect
what is QVAR?
beclomethasone dipropionate
this is an inhaled corticosteroid which acts to reduce inflammation in the airways. it is classed as a preventer medication as it doesn’t have an immediate effect and may take weeks to work and is used to prevent ongoing asthma symptoms, by reducing airway inflammation and thereby bronchial hyper-reactivity to stimuli like cold air.
what are some common SABA medications?
albuterol
levalbuterol
pirbuterol
salbutamol
tetrabutaline
what are some common LABA medications?
salmeterol
formoterol
what are some common ICS (inhaled corticosteroid) medications?
beclomethasone (QVAR)
Budesonide (Pulmicort Flexhaler, Pulmicort Respules)Ciclesonide (Alvesco)Fluticasone (Flovent HFA)Mometasone (Asmanex Twisthaler, Asmanex HFA)
Ciclesodine
Budesonide
which health conditions are commonly associated with a wheeze?
COPD
obstructive pulmonary disease
cardiac failure
eosinophilic lung disease
asthma
what are the reccommendations for someone with asthma participating in sport?
exercise is not always a trigger for asthma. even those with exercise-induced asthma can safely partake in sport. such patients should be advised to carry their bronchodilator inhaler (SABA - blue) with them and then take an additional dose in advance if physical activity is known to precipitate an attack
why is it important to have the flu vaccination if you have asthma?
flu can be more serious for people with asthma, even if their asthma is mild or their symptoms are well-controlled by medication. This is because people with asthma have swollen and sensitive airways and lungs and flu can cause further inflammation of this. flu infection in the lungs can trigger asthma attacks and a worsening of asthma symptoms. it also can lead to pneumonia and other acute respiratory diseases.
asthma that requires continuous or repeated use of inhaled/systemic steroids or with previous exacerbations requiring hospital admission should therefore be offered the flu vaccination and be up to date with the government covid vaccination policies
what is PEFR?
the PEFR is the rate of maximal volume of air that a person can exhale during a short maximal expiratory effort after a full inspiration.
predicted peak flow rates are calculated using the patient’s sex and height. normal values can be found on charts, online and on handy calculation wheels sometimes handed out by pharmaceutical companies.
how do you record serial readings of PEFR and for how long?
for diagnosis 2-4 weeks, twice daily
for occupational asthma it may require 2-4 hourly reading over several weeks
what is the link between bruising and steroid use?
you can get bruising as a result of steroid use - although this is very unlikely at inhaled doses
what are some possible differential diagnoses for bruising?
bruising due to steroid use
bruising due to self-harming behaviour
domestic violence
sports-related trauma
if a patient is having an asthma crisis and waiting for an ambulance, what treatment should you initiate whilst waiting?
using a salbutamol metred dose inhaler with a spacer has been shown to be as effective as jet nebuliser therapy. different treatment regimens can be used, from one puff every five minutes to six puffs in the spacer at once.
inhaled SABA (short acting beta 2 agonists) such as salbutamol, terbutaline, levalbuterol or perbuterol are the treatment of choice for treating acute symptoms of asthma and exacerbations.
Inhaled ipratropium bromide combined with an inhaled beta 2 agonist provide significantly greater bronchodilation than treatment with a beta 2 agonist alone, leading to a faster recovery and shorter duration of admission in severe or life threatening asthma
what is respiratory acidosis?
this is a drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of CO2
what is respiratory alkalosis
a rise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2
what is metabolic acidosis?
this is a decrease in pH in blood and body tissues as a result in upset metabolism
what is metabolic alkalosis?
high pH, high HCO3
what is mixed metabolic and respiratory acidosis?
CO2 rises
HCO3 falls
low pH
what is mixed metabolic and respiratory alkalosis?
a pathological condition which there is an elevated pH, a low pCO2 and an elevated HCO3 level, which occurs when there i both a respiratory and metabolic cause present at the same time - very RARE
What is the effect of pregnancy on asthma?
asthma symptoms can improve, stay the same, or worsen in pregnancy. most women will have a normal outcome but severe asthma can cause complications
women with asthma should be closely monitored and it is particularly important that asthma is well controlled to reduce risk of complications
women should be counselled about the importance and safety of taking their asthma medication during pregnancy to maintain good control. women who smoke should be advised about the dangers to themselves and to their baby and be offered appropriate support to stop smoking.
SABA, LABA, oral/inhaled corticosteroids, sodium cromoglicate and nedocromil sodium and oral IV theophylline can be used as normal during pregnancy.
having twins can push on the diaphragm and thus reducing lung expansions as you enter the third trimester which causes increased breathlessness in healthy women
what is the link between anaesthesia and asthma?
although a spinal anaesthetic is commonly used in a planned C-section, sometimes a general anaesthetic is required in an emergency or if there are contraindications to spinal anaesthesia.
One of the main criteria for choosing the type of anaesthesia is the ease of postoperative recovery, including control of postoperative pain, nausea and vomiting, and urinary retention. These side effects may delay hospital discharge or result in unplanned readmission. Spinal anaesthesia is a simple and reliable technique with a success rate of over 90%. However, general anaesthesia is commonly preferred because of its faster onset of action. Spinal anaesthesia is also associated with a better control of postoperative nausea and vomiting and a higher possibility of early discharge.
A history of asthma has several implications in the perioperative setting. The patient may present for an anaesthetic poorly optimized, particularly in the setting of urgent or emergent surgery. Because of airway hyperreactivity, bronchospasm may readily be precipitated by instrumentation, a variety of drugs, and perioperative complications such as aspiration, infection, or trauma. Emergence from anaesthesia presents a constant risk of laryngospasm and bronchospasm. Pain, fluid shifts, and delayed mobilization can contribute to an increased risk of postoperative pulmonary complications in these patients. These risks are exacerbated by the co-existence of chronic obstructive pulmonary disease (COPD) or active smoking.
what is LTRA? how does it work?
leukotriene receptor antagonist
it blocks the effects of leukotrienes which contrict the bronchi in the airway and thus results in bronchodilation
they also reduce the eosinophils which travel to the airways thus reducing inflammation and hyper-reactivity of the airways
what are the dangers of smoking in pregnancy?
miscarriage- stillbirth (baby dying in womb or shortly after giving birth)- ectopic pregnancy (pregnancy growing outside of womb)- birth defects in babies- premature birth (before 37 weeks of pregnancy)- low birth weight- sudden infant death syndrome, or cot death- increased risk of infant mortality
what are some smoking alternatives during pregnancy?
Nicotine replacement therapy (NRT) delivers nicotine into the blood stream without the toxic component of cigarette smoking. NRT alleviates cravings for tobacco and is an effective and safe smoking cessation tool and can be used in pregnancy.E-cigarettes can also provide a form of nicotine replacement but they have not been licensed or controlled and their safety in pregnancy is unclear. There is not as much evidence for e-cigarettes being a useful and safe aid to quitting smoking as there is for licensed and well established stop smoking medications. However some women have stopped smoking completely using an e-cigaretteThe patient should be offered referral to the smoking cessation services and offered nicotine replacement therapy.
3/5ths of all asthma is hereditary
what is the atopic triad?
asthma
allergic rhinitis
atopic dermatitis
What is the link between COPD and asthma?
patients that have symptoms consistent with both COPD and asthma may have some improvement in symptoms with use of bronchodilators but not as much as asthmatics experience.
there are a cohort of patients who have symptoms of chronic breathlessness on exertion, daily cough productive of sputum and features of COPD on radiology imaging such as hyperinflation. their lung function may show a reduced FEV1 in line with COPD and also reversibility on spirometry in response to salbutamol or diurnal variation.
this is termed as asthma/COPD overlap.
what is the definition of asthma?
asthma is a reversible airflow limitation caused by inflammation in the airways characteristically described as a Th2 airway inflammation.
what is foreign body aspiration?
this is sudden onset of airway obstruction caused by aspiration of a foreign object.
it is the most likely explanation of both unilateral silent chest and wheeze as the foreign body is completely occluding some airways and partially occluding others
what are some of the features of severe acute asthma?
peak flow 33-50% of best or predicted PEFR
respiratory rate > 25 pm
heart rate > 110 bmp
inability to complete sentences in one breath
pneumocystis jiroveci
a fungus causing severe pneumonia
aspergillosis
a respiratory disease caused by the fungus aspergillus
Haemophilus influenzae
Haemophilus influenzae is a Gram-negative, coccobacillary, facultatively anaerobic capnophilic pathogenic bacterium of the family Pasteurellaceae. The bacterium was argued by some to be the cause of influenza
moxarella catarrhalis
Moraxella catarrhalis is a fastidious, nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus that can cause infections of the respiratory system, middle ear, eye, central nervous system, and joints of humans
cocci bacteria
any bacteria that is rounded, circular.
can be found almost anywhere and many good types are found in humans
it may cause skin irritations and sometimes serious diseases
diplococci
spherical bacteria that grow in pairs and cause diseases such as pneumonia