Chronic Asthma - Adults

Question 1

What is asthma?

Answer 1

An increased responsiveness of trachea & bronchi to stimuli, changes in severity spontaneously or as a response to therapy

Causes inflammation and smooth muscle contraction causing narrowing of airways that makes expiration difficult

Question 2

What else does inflammation do to the airways?

Answer 2

Increases their irritability causing them to narrow easier and more spontaneously

Question 3

What does it mean that asthma is diurnal?

Answer 3

Worse during the day than in evening/night

Question 4

Aetiology of asthma? What can cause worsening?

Answer 4

Genetic
Environmental
Obestiy and diet
Cold air and exercise
Occupational

Question 5

What is the genetic aspects, What genes are suspected to be involved?

Answer 5

Immune gene - IL-4, IL-5 and IgE

Airways - ADAM33

Atopy related - a group of family disorders that are caused by increased responsiveness of IgE

Question 6

What are some enviromental aspects?

Answer 6

Maternal smoking

Allergen exposure - induced IgE response (house mites, dust, pets)

Question 7

Why does obesity and diet affect asthma?

Answer 7

High BMI is associated with asthma, obesity is also pro-inflammatory

Diet - increased intake of fresh fruit/veg gives protective antioxidants. No evidence that supplements help asthma though once you have it

Question 8

What is exercise driven asthma caused by?

When does the wheeze occur when exercising/inhaling cold air?

Answer 8

Likey by a relase of prostoglandins, leukotrines and histamine from mast cells

Wheeze usually happens after exercise or inhalation of cold air

Question 9

What are the 2 types of occupational exposure and whats it the difference?

Answer 9

Low molecular weight - non IgE

High molecular weight - IgE

Question 10

Symptoms of asthma?

Answer 10

Wheeze
Dyspnoea
Chest pain
Cough - dry, nocturnal and paroxysmal

Question 11

What is the problem with going off these symptoms alone?

Answer 11

Not very specific and cover a wide range of respiratory diseases

Question 12

What should be focused on in a history?

Answer 12

Onset

Varitaion - daily, weekly, annually (chronic, occupational, seasonal allergies)

Exercise tolerance

Disturbed sleep

History of atopic disease - personal and family

Pets, new pillow, carpets

If already on inhalers

If used other drugs such as NSAIDS or beta blockers

Question 13

What can be found in an examination and are they helpful?

Answer 13

Hyperexpanded chest
Polyphoic wheeze

Not really that helpful

Question 14

What are some signs that show it might NOT be asthma?

Answer 14

Clubbing
Inspiratory stridor rather than a expiratory wheeze
Crepitations

Question 15

What investigation should be done first? What levels show abnormality?

Answer 15

Spirometry
FEV1:FVC - <70%
FEV1 - <80%

Question 16

If spirometry if abnormal what follow up test should be done?

Answer 16

A full pulmonary function test to look for COPD or other caused of obstuction

Question 17

What is involved in a full pulmonary function test

Answer 17

Helium dilation - tests lung volume and capacity

Co gas transfer - shows gas exchange in Hb

Question 18

What test should be done after a full pulmonary test?

Answer 18

If asthma symptoms are reversible with B2 agonists and ICS - seperates it from COPD

Question 19

What should be done if spirometry came back normal, but asthma is still suspected?

Answer 19

Peak flow test programme, 2x daily

AFO has variation, might catch it with this

OR

Provoke the bronchus to react via exercise

OR

NO exhalation - measure of inflammation and index of steroid response

Question 20

What should be done if occupation asthma is suspected?

Answer 20

Peak flow test - 2x hourly for 5 days with 2 pairs of exposed and 2 pairs of not exposed reading to compare to

Question 21

What other useful investigations can be done?

Answer 21

CxR - look for hyperinflated lungs

Skin prick or total/specific IgE count - look for atopy

FBC for eosinphills (sputum eosinphill count may be better)

Question 22

What is some non-pharmalogical aspects to managing asthma?

Answer 22

Action plans
Weight loss
Stop smoking
Change jobs
Avoid allergens

Bronchial thermoplasty

Question 23

What is step 1 in the medical approach to asthma treatment (NICE guildelines)

Answer 23

Monitored initiation of ICS - to confirm an asthma diagnosis

Question 24

What is step 2?

Answer 24

[Throughout ALL steps a SABA (salbutamol) should be given as a reliver]

If asthma confirmed keep on low dose ICS

Question 25

Step 3?

Answer 25

Consider adding a LABA in with ICS inhaler

Question 26

Step 4?

Answer 26

In no response to the added LABA - remove and up the ICS dose

If some response to LABA but control still low - keep LABA and up ICS dose

Question 27

Step 5?

Answer 27

If LABA and ICS benefitial but still not enough control - refer to specialist care

Consider either:

Upping ICS dose
Adding a 4th drug - LTRA, LAMA, B2 agonist tablets or SR theophylline

Question 28

Step 6?

Answer 28

Use a daily oral steroid tablet in lowest dose possible which still maintaining good control

Prednisolone drug of choice

Question 29

Is it good to be on oral steroids for extended periods of time?

Answer 29

No, want off ASAP