Obstructive lung disease: asthma (R1) Flashcards
Symptoms?
- Chest tightness
- SOB
- Cough and wheeze
Is asthma often worse at night and in the morning? Why
Yes - it often follows this diurnal pattern
Potentially due to dip in temperature (cold is a trigger for asthma)
Risk factors?
Medical history
- Personal/family history of atopy (eczema, hay fever)
- Nasal polyps
Triggers
- Allergens
- Smoking
- URTI
- Medication: aspirin, beta blockers
Taking an asthma specific history:
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?
Exam
- General inspection
- 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
Exam
- Vital signs
↑RR, ↑HR , ↓SpO2
Pulsus paradoxus
Exam
- Chest?
- 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
Exam
- Lung sounds?
Expiratory wheeze
If severe, decreased breath sounds
Investigations
- Diagnosis for asthma should be made based on history and exam findings, plus _________
Lung function testing/spirometry
Investigations
- What will the findings be for asthma?
Obstructive: FEV1/FVC <70
Reversible: following bronchodilator administration, FEV1 increases by >=12%
Investigations: supportive tests
- 1 bedside test?
Skin prick test - to demonstrate atopy
Investigations: supportive tests
- 2x lab tests?
FBC: may show eosinophilia
ABG: if decreased PO2
Investigations: supportive tests
- 1x imaging? What will this show?
CXR - normal or hyperinflated lungs
Investigations: supportive test
- 1x special test?
Bronchial provocation test
Investigations: bronchial provocation test
- When would it be used?
- How is the test run?
- How to determine if asthma is present?
- 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
Acute management
- How to differentiate mild-moderate, severe, life threatening asthma
Acute management
- Immediate treatments for mild-moderate, severe, and life-threatening asthma?
Acute asthma
- What to do within minutes and first hour?
Acute management: what to do if
- Dyspnoea is resolved
- Dyspnoea is not resolved
- Asthma is persistent or life threatening
Chronic management
- Level one medications?
Chronic management
Chronic management
- Level 2 medications?
Chronic management
Chronic management
- Level 3 medications?
Chronic management
Chronic management
- Level 4 medications?
Chronic management
- Level 5 medications?
Chronic management
Chronic management
- Other aspects?
- Avoid triggers
- Patient education
- Asthma action plan
- Regular review
Chronic management
- What is in an asthma management plan?
- When well, not well, if symptoms worsen
- Tells patients their preventers and relievers, dose and frequency, whether to use a spacer
Patient explanation
- How to explain chronic management to a patient?
Patient explanation
- How to explain using an MDI (metered dose inhaler)
- 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
Patient explanation
- How to explain using an MDI with a spacer?
- 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)
