Chronic Asthma

Question 1

Define Asthma

Answer 1

Inflammation of airyways
Secondary to Type 1 Hypersensitivity 
3 factors: 
1. Bronchial muscle contraction 
2. Mucosal swelling
3. Increased mucus production
Asthma can develop at any stage throughout life, but typically develops during childhood.

Question 2

Asthma Risk Factors:

Answer 2

Male
Family History
Atopy
Maternal Smoking

Question 3

Precipitating Factors for Asthma:

Answer 3

Cold Air
Exercise
Emotion
Allergens (house dust mite, pollen, fur)
Infection
Smoking
Pollution
NSAIDS
Beta Blockers
Aspirin - makes asthmatic symptoms worse

Question 4

Differential Diagnosis - other than Chronic asthma:

Answer 4

Bacterial Bronchitis
Pertussis 
Cystic Fibrosis 
Immune Deficiency 
Cillary Dyskinesia 
Tracheo-Bronchomalacia 
GORD

Question 5

Chronic Asthma: Symptoms:

Answer 5

Cough - dry, exertional, night, exercising/laughing
Dyspnea
Wheeze - recurrent episodes
Occasional Sputum 
Chest Tightness

Question 6

Chronic Asthma Signs:

Answer 6

Loss of cardiac dullness on percussion 
Palpable Liver
Scattered Wheeze on auscultation
Tachypnoea
Hyper-inflated Chest

Question 7

Chronic Asthma Investigations: List

Answer 7

Peak Expiratory Flow Rate - PEFR 
Spirometry 
Chest X-Ray
FBC
Methacholine Challenge Test
Exhaled Nitric Oxide
Eosinophillic Airway Inflammation Assessment 
Skin Prick Test - atopy

Question 8

Chronic Asthma Investigations: Peak Expiratory Flow Rate - PEFR

Answer 8

Peak Expiratory Flow Rate - PEFR - note the diurnal variation - take one reading in morning and one in evening > 20% for at least 3 days in a week for 2 weeks

Question 9

Chronic Asthma Investigations: Spirometry

Answer 9

Spirometry
Decreased FEV1/FVC, and increased RV
With SABA, or Corticosteroids, there is usually > 15% improvement in FEV1; this is a test to the reversibility of bronchodilator/corticosteroid.

Question 10

Chronic Asthma Diagnosis:

Answer 10

1. Exhaled FeNO of 40 parts per billion or greater.
2. Post-Bronchodilator improvement in FEV1 of 12% or more.
3. Post-Bronchodilator improvement in lung volume of 200ml.
4. Peak-Expiratory flow rate variability of 20% or more.
5. FEV1/FVC ratio <70% (if obstructive)

Question 11

Chronic Asthma Treatment: General Advice:

Answer 11

General Advice:
Stop Smoking
Avoid Precipitants
Teach proper inhaler technique
Teach PEFR use and monitoring - 2 x a day 
Educate on altering meds with severity
Give/create emergency advice/plan

Question 12

Chronic Asthma Treatment: General Step Approach:

Answer 12

1. Inhaled SABA
2. LD ICS (200-400mg/day (if less than 5 yrs give Leukotriene-Montelukast instead)
3. Add LTRA, then Add LABA, Increase ICS dose
4. Increase ICS dose
5. Prednisilone - daily steroid tablet
6. Refer.

Question 13

Chronic - Children Under 5

Answer 13

1. Inhaled SABA
2. LD ICS 200-400mg OR LTRA
3. ADD LTRA
4. Refer

Question 14

Chronic - Children Aged 5-12

Answer 14

1. Inhaled SABA
2. LD ICS 200-400mg
3. ADD LABA, then - Access response
4. Increase ICS to 800mg/day (if poor response)
5. Prednisilone (daily steroid tablet) & refer to Resp Pediatrician.

Question 15

Chronic - Adults

Answer 15

1. Inhaled SABA
2. LD ICS 200-400mg
3. ADD LABA, Access Response
4. Increase ICS dose 800mg/day (if poor response) & ADD LTRA
5. Increase ICS to 2000mg/day ADD LABA
6. Refer