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Question 1

What pattern of spirometry would you expect a patient with asthma to have?

Answer 1

You would expect an obstructive pattern (Low FEV1/FVC ratio) which is reversible after salbutamol use.

Question 2

What is step 1 of the BTS chronic asthma management guidelines?

Answer 2

Step 1: Patients with symptomatic asthma should be prescribed a reliever – salbutamol inhaler (short acting B2 agonist) and lose does inhaled corticosteroids (ICS).

Question 3

Question: Investigations in acute asthma

The following investigations should be ordered more urgently in the context of an acute asthma attack.

Answer 3

ABG: type 2 respiratory failure (low PaO2 and high PaCO2) is a sign of a life-threatening attack.
Routine blood tests (including FBC, CRP): to look for precipitating causes of an asthma attack, such as an infection.
Chest x-ray: to exclude differentials and possibly identify a precipitating infection.

Question 4

Investigations in chronic asthma

The following investigations and their associated results point to a diagnosis of asthma.

Answer 4

Peak flow: variability >20%
Fractional exhaled nitric oxide (FeNO): >40 ppb in adults or >35 ppb in children
Spirometry: FEV1/FVC <0.7 (obstructive spirometry)

Question 5

What is step 4 of the BTS chronic asthma management guidelines?

Answer 5

Step 4 Refer to a specialist.

Possible specialist options include:

Increasing ICS to high dose (2000ug/day)
Addition of one of the following drugs: Leukotriene receptor antagonist; Theophylline; Long acting muscarinic antagonist or beta agonist tablet.

Question 6

Asthma

Question: Pathophysiology

Answer 6

Asthma occurs due to a reversible airway obstruction. The pathophysiology of asthma includes airway narrowing due to bronchial muscle contraction, inflammation caused by mast cell degranulation and increased mucus production.

Question 7

Which symptoms can mimic asthma?

Answer 7

Acid reflux
Poly Arteritis Nodosa (PAN)
Churg Strauss Syndrome
Allergic Broncho-Pulmonary Aspergillosis (ABPA)

Question 8

What is the criteria for long term oxygen in COPD?

NICE guidelines state that LTOT can be prescribed for patients who:

Answer 8

Have a PaO2 <7.3kPa on two readings more than 3 weeks apart, and are non-smokers (but not absolutely contraindicated in smokers).
Or have a PaO2 of 7.3-8kPa alongside one of the following: nocturnal hypoxia, polycythemia, peripheral oedema and pulmonary hypertension.

Question 9

What are the differentials of a lung nodule on Chest XR?

Answer 9

Malignancy which could be primary or secondary
Foreign Body
Abscess
Cyst
Granuloma
Pulmonary Hamartoma
Arterio-venous Malformation
Encysted Effusion containing pus, fluid or blood
Carcinoid Tumor
Skin tumor

Question 10

What are the specific symptoms of asthma?

Answer 10

Intermittent dyspnea
Cough (can be worse at different times of the day)
Wheeze

Question 11

: Symptoms

Symptoms:

Answer 11

Wheeze
Dyspnoea
Cough (may be nocturnal)
Chest tightness
Diurnal variation (symptoms often worse in the morning)
Note: a personal/family history of atopy may be present, and symptoms may worsen following exercise or NSAIDs/beta-blockers

Question 12

How does surfactant prevent alveolar collapse?

Answer 12

Without surfactant, small alveoli would collapse as their radius is small. Surfactant helps to disrupt the molecules surrounding the alveoli reducing the surface tension. This prevents smaller alveoli from collapsing.

Question 13

sthma

Question: Management of an acute asthma attack

Answer 13

Ensure a patent airway
Ensure oxygen saturations of 94-98%
Nebulisers: Salbutamol, Ipratropium
Steroids: oral Prednisolone or IV Hydrocortisone (if severe)
IV Magnesium Sulphate: if severe
IV aminophylline: if severe and inadequate bronchodilatory response from nebulisers
If the patient does not improve following these measures, intensive care input will be required for consideration of an intensive care admission which may involve invasive ventilation.
How well did you know it?

Question 14

Asthma

Question: Pharmacological management of chronic asthma in children (stepwise approach)

Answer 14

Step 1: short-acting inhaled B2-agonist (eg. Salbutamol) + very low dose inhaled corticosteroid steroid (ICS)
Step 2: If >5yo add long acting B2 agonist (LABA), if <5yo add leukotriene receptor antagonist (LTRA)
Step 3: Increase ICS to low dose or add LABA/LTRA. If no response to LABA consider stopping it.
Step 4: Specialist referral

Question 15

What is step 3 of the BTS chronic asthma management guidelines?

Answer 15

Step 3 Increase inhaled corticosteroid to medium dose or add leukotriene inhibitor Consider stopping LABA if no response

Question 16

What are the signs of asthma on examination?

Answer 16

Tachypnea
Hyperinflated chest
Hyperresonant on percussion
Decreased air-entry
Polyphonic wheeze on auscultation

Question 17

What is step 2 of the BTS chronic asthma management guidelines?

Answer 17

Step 2: If a patient has any of the following:

Asthma attack last two years
Using inhaled B2-agonists three times a week or more
Symptomatic three times a week or more
Waking one night a week
Add a regular inhaled long acting beta-agonist to the SABA and regular low-dose ICS

Question 18

Non-pharmacological management of chronic asthma

Answer 18

Non-pharmacological management:

Smoking cessation
Avoidance of precipitating factors (eg. known allergens)
Review inhaler technique

Question 19

Signs

Answer 19

Tachypnoea
Hyperinflated chest
Hyper-resonance on chest percussion
Decreased air entry (sign of severe illness: silent chest)
Wheeze on auscultation
Signs of a severe attack: inability to speak in complete sentences, respiratory rate >25, peak flow 33-50% predicted
Signs of a life-threatening attack: silent chest, confusion, bradycardia, cyanosis, exhaustion