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Respiratory Flashcards

1
Q

What year did NICE, the British Thoracic Society, and SIGN produce joint guidelines on asthma management?

A

2024

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2
Q

What do the new guidelines on asthma management represent?

A

A major step change in the management of asthma

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3
Q

What are the first-line investigations for suspected asthma in adults according to NICE?

A

Measure the eosinophil count OR fractional nitric oxide (FeNO)

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4
Q

What eosinophil count indicates a diagnosis of asthma without further investigations?

A

Eosinophil is above the reference range

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5
Q

What FeNO level indicates a diagnosis of asthma without further investigations?

A

FeNO is 50 ppb

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6
Q

What should be measured if asthma is not confirmed by eosinophil count or FeNO?

A

Bronchodilator reversibility (BDR) with spirometry

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7
Q

What FEV1 increase indicates a diagnosis of asthma?

A

12% and 200 ml or more from the pre-bronchodilator measurement

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8
Q

What is another criterion for diagnosing asthma based on FEV1?

A

10% of the predicted normal FEV1

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9
Q

What should be done if spirometry is not available or delayed?

A

Measure peak expiratory flow (PEF) twice daily for 2 weeks

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10
Q

What PEF variability percentage indicates a diagnosis of asthma?

A

20%

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11
Q

What should be considered if asthma is still suspected but not confirmed by eosinophil count, FeNO, BDR, or PEF variability?

A

Refer for consideration of a bronchial challenge test

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12
Q

What is the purpose of a bronchial challenge test?

A

To diagnose asthma if bronchial hyper-responsiveness is present

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13
Q

What is the first-line investigation for suspected asthma in children aged 5 to 16?

A

Measure the fractional nitric oxide (FeNO)

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14
Q

What FeNO level indicates a diagnosis of asthma?

A

FeNO is 35 ppb or higher

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15
Q

What should be done if the FeNO level is not raised or if FeNO testing is not available?

A

Measure bronchodilator reversibility (BDR) with spirometry

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16
Q

What FEV1 increase indicates a diagnosis of asthma when measuring bronchodilator reversibility?

A

FEV1 increase is 12% from the pre-bronchodilator measurement or 10% of the predicted normal FEV1

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17
Q

What should be measured if spirometry is not available or delayed?

A

Peak expiratory flow (PEF) twice daily for 2 weeks

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18
Q

What PEF variability percentage indicates a diagnosis of asthma?

A

PEF variability is 20% or more

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19
Q

What should be done if asthma is not confirmed by FeNO, BDR, or PEF variability but is still suspected?

A

Perform skin prick testing to house dust mite or measure total IgE level and blood eosinophil count

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20
Q

What excludes asthma when performing skin prick testing?

A

No evidence of sensitisation to house dust mite on skin prick testing or if the total serum IgE is not raised

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21
Q
A
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22
Q

What is the first-line investigation for suspected asthma in children aged 5 to 16?

A

Measure the fractional nitric oxide (FeNO)

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23
Q

What FeNO level indicates a potential diagnosis of asthma?

A

FeNO is 35 ppb

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24
Q

What should be measured if the FeNO level is not raised or testing is unavailable?

A

Bronchodilator reversibility (BDR) with spirometry

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25
Q

What FEV1 increase indicates a diagnosis of asthma?

A

12% from the pre-bronchodilator measurement or 10% of the predicted normal FEV1

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26
Q

What should be done if spirometry is not available or delayed?

A

Measure peak expiratory flow (PEF) twice daily for 2 weeks

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27
Q

What PEF variability percentage indicates potential asthma?

A

20%

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28
Q

What should be performed if asthma is suspected but not confirmed by FeNO, BDR, or PEF variability?

A

Skin prick testing to house dust mite or measure total IgE level and blood eosinophil count

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29
Q

What indicates that asthma can be excluded based on skin prick testing?

A

No evidence of sensitisation to house dust mite or total serum IgE not raised

31
Q

What is required to diagnose asthma?

A

Evidence of sensitisation OR a raised total IgE level and eosinophil count of 0.5 x 10°/L

If there is still doubt about the diagnosis, refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test.

32
Q

What do the guidelines suggest for children under 5 suspected of having asthma?

A

Treat with inhaled corticosteroids as per management guidelines with regular review

If symptoms persist at age 5, attempt objective tests.

33
Q

When should a specialist respiratory paediatrician be consulted?

A

For any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period.

34
Q

What role do eosinophils play in asthma?

A

Eosinophils are involved in type 2 inflammation and are a targeted marker for disease activity

They directly contribute to airway inflammation by releasing cytotoxic proteins.

35
Q

What cytokine is important for eosinophil activation in asthma?

A

Interleukin-5 (IL-5)

This distinguishes eosinophils from neutrophils or lymphocytes, which are associated with other immune responses.

36
Q

Fill in the blank: Eosinophils release granules containing _______ and major basic protein.

A

[eosinophil peroxidase]

37
Q

True or False: Eosinophils are more associated with type 1 immune responses.

A

False

Eosinophils are specifically involved in type 2 inflammation.

38
Q

What is a key characteristic of eosinophils compared to other white blood cells?

A

They play a direct role in airway inflammation

Unlike neutrophils or lymphocytes, which are more associated with other immune responses.

40
Q

What does Fractional exhaled nitric oxide (FeNO) reflect?

A

The level of nitric oxide produced by airway epithelial cells in response to eosinophilic inflammation

A hallmark of asthma

41
Q

How is FeNO measured?

A

Non-invasively by having the patient exhale steadily into a handheld device that analyses nitric oxide concentration in parts per billion (ppb)

This method provides a quick assessment of airway inflammation

42
Q

What does bronchodilator reversibility (BDR) testing evaluate?

A

The degree of airflow limitation that improves after administration of a bronchodilator

A key diagnostic feature of asthma

43
Q

What primarily causes airway obstruction in asthma?

A

Reversible bronchial smooth muscle constriction and airway inflammation

These factors respond to bronchodilators by relaxing the smooth muscle and reducing resistance

44
Q

What indicates significant improvement in BDR testing?

A

An increase of 12% and 2200 mL in FEV after bronchodilator administration

This result distinguishes asthma from fixed airway obstruction conditions like COPD

45
Q

What does peak expiratory flow (PEF) variability reflect?

A

Diurnal changes in airway calibre

A hallmark of asthma related to circadian rhythms in airway inflammation and bronchial smooth muscle tone

46
Q

When does airway narrowing tend to worsen in asthma?

A

At night and in the early morning

Due to increased parasympathetic activity, nocturnal histamine release, and lower circulating cortisol levels

47
Q

What percentage variation in PEF supports the diagnosis of asthma?

A

> 20% variation between morning and evening values

Highlights the dynamic and reversible nature of asthma

48
Q

What role does Immunoglobulin E (IgE) play in allergic asthma?

A

Mediates hypersensitivity reactions through binding to high-affinity IgE receptors on mast cells and basophils

This process leads to airway inflammation and bronchoconstriction

49
Q

What happens upon allergen exposure in allergic asthma?

A

CrosS linking of bound IgE triggers the release of inflammatory mediators like histamine and leukotrienes

This results in airway inflammation, bronchoconstriction, and asthma symptoms

50
Q

What is the significance of measuring serum IgE levels?

A

Helps identify atopic asthma phenotypes, predict responsiveness to anti-IgE therapy, and guide management strategies

Particularly in patients with allergic triggers

51
Q

Fill in the blank: Bronchodilator reversibility testing is a key diagnostic feature of _______.

52
Q

True or False: Airway obstruction in asthma is primarily due to fixed airway obstruction.

A

False

It is primarily due to reversible bronchial smooth muscle constriction and airway inflammation

54
Q

What are the classifications of asthma severity?

A

Moderate, Severe, Life-threatening

Each classification is based on specific clinical criteria.

55
Q

What is the PEFR for moderate asthma?

A

PEFR > 50% best or predicted

This indicates that patients can still maintain a reasonable airflow.

56
Q

List the clinical signs of moderate asthma.

A
  • Speech normal
  • RR < 25/min
  • Pulse < 110 bpm

Respiratory Rate (RR) and pulse rates are important indicators of asthma severity.

57
Q

What is the management for moderate asthma?

A
  • Consider admission
  • Prednisolone 40-50mg if PEFR between 50-75%

Management decisions depend on PEFR levels.

58
Q

What is the PEFR range for severe asthma?

A

PEFR 33 - 50% best or predicted

This indicates a significant reduction in airflow.

59
Q

List the clinical signs of severe asthma.

A
  • Can’t complete sentences
  • RR > 25/min
  • Pulse > 110 bpm

These signs indicate a more critical state requiring urgent intervention.

60
Q

What is the management for severe asthma?

A
  • Beta 2 agonists (salbutamol) nebulised or via spacer
  • 4-6 puffs, inhaled separately, repeated every 10-20 minutes

Beta 2 agonists are key in relieving bronchospasm.

61
Q

What characterizes life-threatening asthma?

A
  • PEFR < 33% best or predicted
  • Oxygen sats < 92%

Life-threatening asthma requires immediate attention.

62
Q

What are the management steps for life-threatening asthma?

A
  • Arrange immediate admission (999 call)
  • Administer oxygen to maintain SpO2 of 94-98%
  • Use nebulised beta 2 agonists + ipratropium
  • Prednisolone 40-50mg or IV hydrocortisone 100mg

These interventions are crucial to stabilize the patient.

63
Q

What are the signs of life-threatening asthma?

A
  • Silent chest
  • Cyanosis
  • Feeble respiratory effort
  • Bradycardia
  • Dysrhythmia
  • Hypotension
  • Exhaustion
  • Confusion
  • Coma
    PEFR <33
    Normal pco2

These signs indicate severe respiratory distress and potential respiratory failure.

64
Q

What is the step down treatment of a Asthma

A

Consider stepping down treatment every 3 months or so but look for the patient’s preference side effects and duration of treatment not it is strict to reduce the treatment

66
Q

How does steroids are reduced in asthma

A

Reduced it to 25 to 50% at a time

67
Q

What is the follow up for a Asthma

A

Stable asthma may have a formal review on annual basis If recently have asthma escalation review should be on more frequent basis

68
Q

Near fatal estima

A

Raised PCO2
requiring mechanical ventilation with raised inflation pressure

70
Q

What are the further assessments for asthma

A

Check ABG’s for patient with oxygen states below 92% xrays is not routinely recommended except life-threatening asthma suspected pneumothorax failure to respond treatment

71
Q

Admission criteria for asthma

A

All patient with life-threatening

patient feature of severe acute asthma if they are failed to respond to initial treatment

other admission criteria include previous near fetal asthma attack, pregnancy attack occurring despite already using corticosteroids oral and presentation at night

Respiratory Mrcgp (1 decks)

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