W2 - Asthma Features and Management Flashcards
Define asthma. Is it obstructive or constrictive?
Asthma: Inappropriate constriction of bronchiole smooth muscle, or inflammation of bronchioles. It’s an obstructive disorder from Greek (aazein) meaning “to gasp for breath”
In asthma, how are inspiration, expiration and ventilation affected?
Increased resistance means expiration phase is most affected. During inspiration the airway is pulled open by physical forces, so it’s easy to get air in
Reduced diameter of bronchioles impedes ventilation.
In terms of pathophysiology, what 2 things make up asthma? They’re initiated by airway inflammation mediated by the immune system
Widespread narrowing of airways
Increased responsiveness of trachea and bronchi to stimuli
How many people in the UK have asthma?
How many in the UK die per day from asthma? How many are preventable?
5.4 m have asthma
3 die per day - 2 are preventable
What % of kids and adults have asthma in the UK and in what gender is it more common
10-15% of kids
5-10% of adults
Kids: Male more common
Adults: Female more common
What are the 6 risk factors of asthma?
Hereditary
Smoking
Occupation
Obesity
Diet
“Hygiene hypothesis”
Disease clustering of asthma in families suggests a genetic basis.
What inheritable trait is it caused by?
Asthma is more likely if this trait is inherited from whom?
Asthma is more likely if parents have any of which 4 diseases?
Inheritable trait: Atopy
Maternal atopy most influencial (3x father)
More likely if parents have: allergic rhinitis, asthma, hay fever or eczema
Maternal smoking during pregnancy does what to the lung and makes what 3 things more likely? What is the “grandmother effect”?
Reduces FEV1 in lung
Increases wheezy illness airway responsiveness and asthma in kids
Grandmother effect - likely epigenetic phenomena where smoke switches on genes which increase asthma in subsequent generations
What % of adult onset asthma is linked with occupation? Give 3 examples of jobs
10-15% linked with occupation
Bakers, painters, shellfish workers are some examples
In the diet, what 3 vitamins, 1 mineral and 3 fats might be contributing to an increase in asthma prevalence?
Less vitamin C, D and E
Selenium
Poly unsaturated fats, oily fish, margarine
Name the 9 symptoms of asthma
- Wheezing
- Coughing
- SOB (dyspnoea)
- Difficulty in expiration
- Chest tightness
- Green or yellow sputum (occasional)
- Symptoms worse at start/end of day
- Weekly variation (occupation, better at weekends/holidays)
- Annual variation (environmental allergens)
Name the 9 asthma triggers
(Remember, triggers are different for each individual)
- Exercise
- Cold air
- Cigarette smoke
- Perfume/strong scent
- URTIs
- Pets
- Tree or grass pollen
- Food
Drugs (aspirin/NSAIDS)
How do we diagnose asthma? What 6 things can we look for?
Investigations can support - no single test to diagnose asthma
Look for:
-Recurrent episodes of symptoms
-Symptom variability
-Absence of symptoms of alternative diagnosis
- Recorded observation of wheeze
- Personal history of atopy
- Historical record of variable PEF or FEV1
What 3 past medical history can we look for if suspecting asthma?
- Childhood asthma, bronchitis or wheeze in infancy
- Eczema
- Hayfever
In a clinical history of asthma, which 3 things should you ask, relating to drugs?
Current inhalers (check technique), other asthma therapies, compliance
Beta blockers, aspirin, NSAIDS
Effects of previous drugs/inhalers
In a clinical history of asthma, what 4 things should you ask relating to social history?
Tobacco, recreational drugs, vaping
Pets
Occupation (past and present)
Psychological effects
What 6 signs suggest it’s probably not asthma?
Finger clubbing
Cervical lymphadenopathy
Stridor
Asymmetrical expansion
Dull percussive note
Crepitations
What is the first line objective testing for asthma, and why?
For whom is this test less reliable, and what does the test do?
Fractional exhaled nitric oxide (FeNo). It’s cheaper.
FeNo is an eosinophilic inflammatory marker in lungs and nose.
The test is less reliable in smokers
What will spirometry results look like for someone asthmatic?
Less than 70% FEV1 if symptomatic
Normal spirometry if asymptomatic
If a spirometry test shows less than 70% FEV1, what other 3 tests can be done and what illnesses can they exclude?
Full pulmonary function test - exclude COPD/emphysema
Carbon monoxide gas transfer test - exclude COPD if reduced
Reversibility test - exclude COPD if no change
What does a carbon monoxide gas transfer test do?
Measures gas transfer of CO to Hb across alveoli
What does a reversibility test entail?
User B2 agonist (or oral steroid). After 15 mins for agonist, or 2 weeks for steroids, check FEV1
If a spirometry test returns a normal value but you still suspect asthma, what other 6 tests can you do?
Peak flow monitoring
Airway responsiveness
Exhaled nitric oxide
Chest x-ray
Skin prick test
Total and specific IgE
Name the 4 “types” of asthma
Moderate
Severe
Life Threatening
Near Fatal
What does ability to speak, heart rate, resp rate and peak flow look like for: Moderate asthma, severe asthma and life threatening asthma?
Ability to speak
Moderate: Complete sentences
Severe: Unable to speak sentences in one breath
Severe: Grunting, confusion
Heart rate:
Mod: <110
Sev: >110
LT: Bradycardia/arrhythmia
Resp rate:
Mod: <25
Sev: >25
LT: Cyanosis/silent chest
Peak flow:
Mod: 50-75%
Sev: 33-50%
LT: <33%
What do oxygen saturation and arterial blood gas/PaCO2 look like for moderate, severe, life threatening and near-fatal asthma?
Moderate
>92%
No need for ABG
PaCO2 reduced
Severe
>92%
PaCO2 reduced
Life threatening
SaO2 <92%
PaCO2 normal
Near fatal
PaCO2 raised
Need for mechanical ventilation
Name 5 non-pharmacological management for acute asthma
Exercise
Weight loss
Patient education and self-management plans
Smoking cessation
Flu/pneumococcal vaccination
What are the 6 aims of treatment for asthma?
- No daytime symptoms
- No night-time wakening
- No need for rescue medication
- No asthma attacks
- No limitations on activity including exercise and normal lung function
Minimal side effects from medication
Outline the stepwise approach to managing asthma
- Monitor with low-dose ICS
- Regular preventer - Low dose ICS
- Low dose ICS + inhaled LABA
- Increase ICS. If LABA works keep it otherwise stop. Consider LTRA, S R theophylline, LAMA
- Increase ICS. Add forth drug, e.g. LTRA, SR theophylline, beta agonist tablet, LAMA. Refer to specialist
What indicates that you may need to escalate an asthma patient’s medication?
If they’re using 3+ doses of short acting B2 agonists a week
Name the 3 broad categories of pharmacological management of asthma
Inhaled therapy
Oral therapy
Specialist treatments
Name 3 types of oral therapy
Leukotrine receptor antagonist
Theophylline
Prednisolone
Name 3 types of specialist treatment
Omalizumab
Mepolizumab
Bronchial thermoplasty
Name 4 types of inhaler
pMDI (Metered Dose Inhaler)
pMDI with spacer
Dry Powder Inhaler (DPI)
Short-Acting B2 Agonists (SABA) Relievers
SABA used for flare ups and exposure to triggers
What 5 ways should you treat a mild/moderate asthma attack?
Increase inhaler use
Oral steroid
Treat trigger
Early follow up
Back up plan
What 4 drugs can you give in hospital for moderate/severe asthma attack
Nebulisers - salbutamol/ipratropium
Oral/IV steroid
Magnesium
Aminophylline
