Obstructive lung disease: asthma (R1)

Question 1

Symptoms?

Answer 1

• Chest tightness
• SOB
• Cough and wheeze

Question 2

Is asthma often worse at night and in the morning? Why

Answer 2

Yes - it often follows this diurnal pattern
Potentially due to dip in temperature (cold is a trigger for asthma)

Question 3

Risk factors?

Answer 3

Medical history
- Personal/family history of atopy (eczema, hay fever)
- Nasal polyps

Triggers
- Allergens
- Smoking
- URTI
- Medication: aspirin, beta blockers

Question 4

Taking an asthma specific history:

Answer 4

WWQQAA:
Aggravating factors
- Do you have any known triggers? Have you come into contact with them recently?
- How often do you take your reliever on a good day versus today?

PAST HISTORY
Previous asthma attacks
- Frequency: how often do you get them?
- Severity: medications used + quantities? Were you admitted to hospital or ICU? (Steroids + ICU are bad signs)

Asthma management plan
- Do you have one?
- Do you follow your plan?
- Any changes to your medications or delivery device?

Question 5

Exam
- General inspection

Answer 5

• Dyspnoea, potentially using accessory muscles of breathing
• Skin: pallor, flushed, cyanosed
• Posture - tripod (unable to lie supine)
• May be unable to speak in full sentences
• Mental state: distressed, exhausted

Question 6

Exam
- Vital signs

Answer 6

↑RR, ↑HR , ↓SpO2
Pulsus paradoxus

Question 7

Exam
- Chest?

Answer 7

• Deformities - barrel chest, pigeon chest
• Harrison’s sulcus - a linear depression of the lower ribs just above the costal margins at the site of attachment of the diaphragm

Question 8

Exam
- Lung sounds?

Answer 8

Expiratory wheeze
If severe, decreased breath sounds

Question 9

Investigations
- Diagnosis for asthma should be made based on history and exam findings, plus _________

Answer 9

Lung function testing/spirometry

Question 10

Investigations
- What will the findings be for asthma?

Answer 10

Obstructive: FEV1/FVC <70
Reversible: following bronchodilator administration, FEV1 increases by >=12%

Question 11

Investigations: supportive tests
- 1 bedside test?

Answer 11

Skin prick test - to demonstrate atopy

Question 12

Investigations: supportive tests
- 2x lab tests?

Answer 12

FBC: may show eosinophilia
ABG: if decreased PO2

Question 13

Investigations: supportive tests
- 1x imaging? What will this show?

Answer 13

CXR - normal or hyperinflated lungs

Question 14

Investigations: supportive test
- 1x special test?

Answer 14

Bronchial provocation test

Question 15

Investigations: bronchial provocation test
- When would it be used?
- How is the test run?
- How to determine if asthma is present?

Answer 15

• Used when spirometry is not positive for asthma
• Airway SMC is stimulated either directly (histamine, methacholine) or indirectly (mannitol, hypertonic saline, exercise), effect on FEV1 is recorded
• May be asthma if FEV1 reduces in response to these triggers. The exact cutoff varies by test

Question 16

Acute management
- How to differentiate mild-moderate, severe, life threatening asthma

Answer 16

Question 17

Acute management
- Immediate treatments for mild-moderate, severe, and life-threatening asthma?

Answer 17

Question 18

Acute asthma
- What to do within minutes and first hour?

Answer 18

Question 19

Acute management: what to do if
- Dyspnoea is resolved
- Dyspnoea is not resolved
- Asthma is persistent or life threatening

Answer 19

Question 20

Chronic management
- Level one medications?

Answer 20

Question 21

Chronic management

Answer 21

Question 22

Chronic management
- Level 2 medications?

Answer 22

Question 23

Chronic management

Answer 23

Question 24

Chronic management
- Level 3 medications?

Answer 24

Question 25

Chronic management

Answer 25

Question 26

Chronic management
- Level 4 medications?

Answer 26

Question 27

Chronic management
- Level 5 medications?

Answer 27

Question 28

Chronic management

Answer 28

Question 29

Chronic management
- Other aspects?

Answer 29

• Avoid triggers
• Patient education
• Asthma action plan
• Regular review

Question 30

Chronic management
- What is in an asthma management plan?

Answer 30

• When well, not well, if symptoms worsen
• Tells patients their preventers and relievers, dose and frequency, whether to use a spacer

Question 31

Patient explanation
- How to explain chronic management to a patient?

Answer 31

Question 32

Patient explanation
- How to explain using an MDI (metered dose inhaler)

Answer 32

• Take out canister, check it’s the right medication and within its use-by date
  
  • Put canister back in
  • Remove inhaler cap
  • Shake the inhaler
  • Exhale
  • Make seal around mouthpiece with your lips
  • Slowly and deeply inhale, whilst simultaneously pressing the MDI
  • Hold breath for as long as possible
    Just before you exhale, remove inhaler from mouth

Question 33

Patient explanation
- How to explain using an MDI with a spacer?

Answer 33

• The advantage - disperses the medication, so that it can get to your lungs
  
  • Take out canister, check it’s the right medication and within its use-by date
  • Put canister back in
  • Remove inhaler cap
  • Shake the inhaler
  • Attach the inhaler to the spacer
  • Breathe out gently into the spacer
  • Press down on the canister and either
    ○ Breathe normally for 4 breaths
    ○ Breathe in slowly and deeply, hold for around 5 seconds or for as long is as comfortable
  • Take spacer out of mouth (while holding breath)