S8) Asthma Flashcards
What is asthma?
Asthma is a chronic inflammatory disorder of the airways, wherein widespread but variable airflow obstruction and increased airway responsiveness to a variety of stimuli occurs
Identify 5 defining characteristics of asthma
- Chronic inflammatory process
- Susceptibility
- Variable airflow obstruction
- Airway hyper-responsiveness
- Reversibility
Airways obstruction is a feature of both Asthma and Chronic Obstructive Pulmonary Disease (COPD).
How can one distinguish between the two conditions?
- Asthma: airway obstruction is often reversible (> 15% improve spontaneously, with bronchodilators/steroids)
- COPD: airway obstruction is not fully reversible (< 15% improve with treatment)
Identify the most influential cells in asthma
Asthma is a chronic inflammatory process driven by TH2 cells
What do TH2 cells do?
- Release cytokines, which attract and activate inflammatory cells (incl. mast cells and eosinophils)
- Activate B cells, which produce IgE
In a sensitised atopic asthmatic, exposure to antigen results in a 2 phase response.
Briefly, identify and describe these 2 phases
- Immediate response (< 20 mins)
- Late phase response (3 – 12 hours later)
What type of immune response is the immediate response to asthma?
The immediate response is an example of type 1 hypersensitivity
In 5 steps, describe the immediate response to asthma
⇒ Allergen interacts with specific IgE antibodies
⇒ Mast cell degranulation occurs
⇒ Mediators are released (histamine, prostaglandin D2, leukotriene)
⇒ Bronchial smooth muscle contracts
⇒ Bronchoconstriction occurs
What type of immune response is the late phase response to asthma?
The late phase response is an example of type IV hypersensitivity
The late phase response to asthma involves inflammatory cells.
What do they do?
Inflammatory cells release mediators and cytokines which cause airway inflammation
Identify 4 inflammatory cells involved in the late phase response to asthma
- Eosinophils
- Mast cells
- Lymphocytes
- Neutrophils
causes chronic inflammation
What do eosinophils do in the late phase response to asthma?
Eosinophils release Leukotriene C4 and other mediators, some of which are toxic to epithelial cells, and causes shedding of epithelial cells
Identify 5 events which causes the airway narrowing observed in asthma as a result of inflammation
- Mucosal oedema due to vascular leak
- Bronchial wall thickening due to inflammatory cell infiltration
- Mucous over-production
- Smooth muscle contraction
- Epithelium shedding
Identify 6 major precipitating factors for asthma
- Allergens e.g. pollen, animals hair/dander
- Cold air (airway hyper-responsiveness)
- Exercise
- Irritants e.g. car exhaust fumes, smoke, strong smells
- Emotional distress
- Viral infections
Identify 6 signs and symptoms of asthma
- Expiratory wheeze
- dry Cough
- Diurnal variability (worse at night & morning)
- Breathlessness
- Chest tightness
- Exercise induced wheeze
- use of accessory muscles to try and breathe
What 3 questions can one ask a patient to ascertain asthma?
- Have you had difficulty sleeping because of your asthma symptoms?
- Have you had your usual asthma symptoms during the day?
- Has your asthma interfered with usual activities?
What is the most common test used to confirm a diagnosis of asthma?
Spirometry
What do the spirometry tracings in an asthmatic patient usually show?
Obstructive condition – FEV1/FVC is reduced
Which further test can be used to confirm an asthma diagnosis if the spirometry tracing is normal?
Methacholine / histamine challenge to determine airway hyper-responsiveness
Identify 3 investigations used to measure the airway inflammation in asthma
- Peripheral blood eosinophil count (FBC)
- Induced sputum (eosinophils, neutrophils)
- FeNO (exhaled nitric oxide)
Identify 5 aims of asthma management
- No daytime symptoms
- No night-time awakening due to asthma
- No asthma attacks
- No limitations on activity
- Normal lung function
Identify and describe 3 factors which affect asthma treatment
- Pharmacological management: incorrect or suboptimal prescribing
- Clinical factors: environmental (triggers), medication, co-existing condition
- Behavioural factors: sub-optimal adherence, poor inhaler technique, smoking
Outline the principles of asthma treatment
- Smoking cessation
- Inhaler technique
- Monitoring
- Pharmacotherapy
- Lifestyle
- Education
Identify the 5 stages in asthma treatment
- Regular preventer
- Initial add-on therapy
- Additional add-on therapies
- High dose therapies
- Continuous/frequent use of oral steroids
What is the regular preventer in asthma treatment? (first line)
Low dose inhaled corticosteroid (ICS)
What is the initial add on therapy in asthma treatment? (second line)
- Low dose inhaled corticosteroid (ICS)
- Inhaled long acting β2 agonists (LABA)
What are the additional add on therapies in asthma treatment? (third line)
If no response / inadequate control from LABA:
- Increase ICS dose + continue LABA
- Continue LABA + ICS and trial LTRA, LAMA or theophylline
What are the high dose therapies in asthma treatment? (fourth line)
- Increase to high-dose ICS
- Addition of 4th drug (LTRA, theophylline, LAMA, β2-agonist tablet)
Describe the continuous/frequent use of oral steroids in asthma treatment (last line)
- Low dose steroid tablet
- Maintain high dose ICS
- Refer to specialist care
Describe the treatment of acute severe asthma
- Oxygen (high flow, 94-98%)
- Nebulised salbutamol
- Oral prednisolone
Describe the treatment of life threatening asthma
- Nebulised ipratropium bromide (add to acute treatments) anticholinergic
- IV magnesium and/or IV aminophylline (add to acute treatments)
- Discuss with senior doctor and ICU
what is peak flow
how quickly you can blow out air out lung
people with COPS or asthma will have a longer peak Flow as the mucus is obstructing the airflow
what is FEV1 and FVC
- FEV1 - amount of air you can breathe out in one second
- FVC - forced vital capacity: total vol of air you can exhale for max inspiration
FeNO - Fractional exhaled nitric oxide
- breathing test looking at the level of nitric oxide in a single exhaled breath
- marker for eosinophilic inflammation of the lungs
classification of asthma attacks
mild: HR < 110/min, RR <25/min, can speak full sentences
severe: HR > 110/min RR>25/min, can’t speak full sentences
life threatening: Po2 < 92%, altered conscious levels
what gas can appear normal but the person still be having a severe asthma attack
c02 levels can be normal
- normally in an asthma attack you would be hyperventilating to get 02 in and to remove as much c02
- in this case, the muscles are all tired from forcefully contracting to remove co2
- the fact co2 is normal shows the body is not compensating for the asthma and it is not hyperventilating
- the body is exhausted and they can have a silent chest at this point
- their 02 is low <8
what are some management options
- oxygen
- salbutamol (can give it as IV if chest becomes silent)
- steroids → reduce inflammation
- magnesium infusion
