Diagnosis and Management of Asthma Flashcards
What is asthma?
Reversible inflammation of the airway of many different types and causes.
Describe the basic practice history and examination considerations for a patient with ?asthma.
- Consider age of onset, duration of symptoms, nature of symptoms.
- Chest tightness, breathlessness (on effort / conditional), cough (dry).
- Wheeze (should be difuse because this is a whole lung disease, it should not be localised) - scattered, widespread, polyphonic (whole lung small airway disease).
What are the relevant co-factors in asthma diagnosis?
- Upper airway disease - sinus, polyps, rhinitis, sinusitis.
- Gastro-oesophageal reflux disease.
- Obesity.
- Smoking.
- Exposures - cigarettes, dusts, work place (occupational asthma), infection.
- Allergies / aero-allergens: pets, pollen, aspergillus, HDM.
Aside from history and examination, and the relevant co-factors, what else must be considered in asthma diagnosis (basic practice 2 and 3)?
- Basic practice 2:
- Healthcare utilisation
- Emergency attendances
- Hospital admissions
- Exacerbations requiring steroids
- Qualiy of life
- Basic practice 3:
- Psychosocial factors.
- Education (on asthma).
- Liason with family, school, primary care (and secondary care).
- Learning about patient.
- Offer advice on when to ask for advice - ‘personalised action plan’.
What are the principles of asthma treatment?
- Define the disease. Describe the disease.
- Control drivers of inflammation
- U-Go-SEA.
- Control inflammation:
- Steroids - anti-inflammatory.
- Control upper airway disease.
- Antacids / anti-reflux, pro-kinetics (macrolides), surgery.
- Infection avoidance, vaccination, consider macrolide antibiotics.
What are the investigations used in the diagnosis of asthma?
- Peak flow diary - absolute values, variability, early morning dips.
- Spirometry - obstruction (FEV/FVC <0.7), FEV% predicted.
- Bronchial provocation tests - mannitol, methacholine (PD20).
- FeNO - 25ppb, >50ppb
- Possibly CXR, bloods (eosinophils, IgE, aspergillus), CT thorax, bronchoscopy).
Describe the diagnostic algorithm for asthma.
Describe a bronchial provocation test.
- Used to assist in the diagnosis of asthma.
- The patient is given mannitol and they breathe in nebulised methacholine.
- Provokes bronchoconstriction.
- The patient is then asked to exercise and those who have pre-existing airway hyperreactivity, such as asthmatics, will react to lower doses of the drug.
- The degree of airway narrowing can be quantified by spirometry.
Describe a FeNO.
- Fractional exhaled nitric oxide.
- It is a marker of eosinophilic / allergic inflammation.
- The majority of asthma patients have Th2 allergic/eosinophilic driven airway inflammation and higher levels of NO in their exhaled breath (IL4, 5, 13).
- High Feno means that treatment is not controlled well and something needs done about it. This does not necessarily mean more medication, possibly just greater adherence.
What are the non-pharmacological treatments for asthma?
- Loads of education!
- Psychosicial factors
- Allergen avoidance
What are the categories of pharmacological treatment for asthma?
- ICS, bronchodilators, stepwise ladder of treatment.
- Immune modulators - motelukast, macrolides.
- Biologics - ever-expanding area.
What is a clinical phenotype?
- Clinical features, observable characteristics, presentation.
- Clusters of shared demographic and clinical patterns.
What is a clinical endotype?
- Presumed biological pathways, pathophysiology and biomarkers.
What is stratified medicine?
- Treatment tailored to the phenotype and endotype of the patient, bespoke for that patient.
What are the different phenotypes of asthma?
- Allergic asthma
- Non-allergic asthma
- Late-onset
- Fixed airflow obstruction
- Asthma with obesity
