Asthma

Question 1

What is asthma?

Answer 1

• People with asthma have sensitive and inflamed airways that become narrower than normal
• Symptoms include coughing, weezing, shortness of breath and chest tightness
• Symptoms of asthma tend to come and go depending on ‘triggers’
• Important to take medication even when you don’t have the symptoms

Question 2

Reliever inhaler

Answer 2

Helps relieve asthma symptoms and attacks
- Relaxes the airways
- If asthma is well controlled shouldn’t need it more than three times a week

Question 3

Preventer inhaler

Answer 3

Helps long term at reducing inflammation in the airways and less likely to narrow in response to triggers

Question 4

Device test

Answer 4

Do this if inhaler hasn’t been used in more than 5 days
- Remove cap and shake inhaler well
- Point the mouthpiece away from you and press the canister to release a puff into the air

Question 5

pMDI Inhaler technique

Answer 5

• Remove the cap
• Shake the inhaler well
• Sit or stand up and tilt your chin slightly - this helps medication reach lungs better
• Breathe out gently and slowly away from the inhaler
• Put your lips on the mouthpiece
• Start to breathe in slowly and steadily whilst pressing the canister
• Continue to breathe in slowly until lungs feel full
• Remove inhaler from mouth and seal your lips
• Hold your breath for 10 seconds or as long as you comfortably can
• Breathe out gently away from your inhaler
• If inhaler contains steroid, then rinse mouth to avoid side effects
• If you require a second dose then wait 30 seconds to a minute until you repeat the steps

Question 6

Spacer inhaler technique

Answer 6

• Attach mouthpiece to spacer device
• Breathe out gently and slowly away from spacer
• Place your lips around spacer mouthpiece to create an effective seal
• Release one dose of the inhaler into the spacer device
• Breathe in and out deeply several times into the spacer device

Question 7

Spacer care instructions

Answer 7

Wash with detergent once a month and leave to air dry
- Never wipe dry as it can cause static causing the drug to stick to the sides
- Replace every year

Question 8

Pathophysiology of Asthma

Answer 8

• Excessive reaction from Type 2 helper cells
• Produce cytokines such as IL4 and IL5
• Smooth muscle spasm and increased mucuous production which narrows airways making it difficult to breathe

Question 9

Newly diagnosed/suspected asthma

Answer 9

• SABA as reliever therapy (in some patients this may be the only therapy required)
• Inhaled corticosteroid low dose as preventer therapy
• If still not controlled, add leukotriene and if still not controlled add LABA with ICS
• Next step is to increase ICS dose to moderate

Question 10

Beta adrenergics

Answer 10

SABA:
- Salbutamol, terbutaline
- Rapid onset of action - 15 mins
- Effects last up to 4 hours
- Four times daily use

LABA:
- Salmaterol
- Duration of action for 12 hours
- Start at low dose and monitor before increasing

Interact with corticosteroids, diuretics and xanthine derivatives to cause hypokalaemia

Interact with digoxin causing digoxin toxicity

Question 11

Overall pneumonia management

Answer 11

IV Fluids
Oxygen
Chest physiotherapy
Analgesia
May require respiratory support
VTE prophylaxis
Cultures>Antibiotics

Question 12

Community acquired pneumonia management

Answer 12

CURB 0-1 score
1st: Doxycycline PO
Alternative: Amoxicillin PO

CURB 2-5 score
1st: Benzylpenicillin IV + Doxycycline PO/Clarithyromycin IV\
Alternative: Levofloxacin IV/PO

Question 13

Hospital acquired pneumonia management

Answer 13

1st: Doxycycline PO
Severe: Benzylpenicillin IV + Gentamicin IV
Alternative: Levofloxacin IV/PO

Question 14

Aspiration pneumonia

Answer 14

1st: Doxycycline PO + Metronidazole PO
Severe: Benzylpenicillin IV + Metronidazole IV
Alternative: Levofloxacin IV + Metronidazole IV

Question 15

FEV1:FVC

Answer 15

FEV1 is the forced expiration volume in 1 second
FVC is the maximum amount of air out

If FEV1:FVC ratio is lower than 0.7 then this is an indicator

Question 16

Mechanism of action of Beta adrenergics

Answer 16

Beta 2 receptor is coupled to G protein which gets activated which in turn activated adenylate cyclase
Initiates ATP conversion to cAMP causing phosphorylation of myosin light chain kinase inhibiting its activity.

Phosphotase enzyme predominates leading to bronchiole smooth muscle relaxation

Question 17

Side effects of beta adrenergics

Answer 17

Tremor/nervousness/anxiety/excitement
Increased heart rate
Headache
Nausea and vomiting
Stuffy nose, coughs

Question 18

Side effects of beta adrenergics

Answer 18

Nervousness/anxiety/excitement
Tremors
Increased heart rate
Headaches
Nausea and vomiting
Stuffy nose, coughs

Question 19

Mechanism of action of inhaled corticosteroids

Answer 19

Have anti-inflammatory effects (glucocorticoids)
- Not to be used during asthma attack as they do not provide immediate relief

They bind to steroid receptors, which bind to DNA to induce synthesis of specific mRNA
- Reducing formation of cytokines
- Inhibiting prostaglandin synthesis
- Reducing eosinophil influx into lungs

Question 20

Side effects of ICS

Answer 20

• Cough
• Sore throat
• Difficulty speaking
• Bronchoconstriction
• Oropharyngeal Candidiasis

Question 21

Mechanism of action of leukotriene receptor antagonists

Answer 21

Bind to leukotriene receptors on bronchial smooth muscles to block smooth muscle contraction, reduce mucus production and preventing blood vessel permeability

• Have slower onset of action so cannot be used during an acute attack

Question 22

Side effects of LTRA

Answer 22

• Headache
• GI disturbances
• Fatigue
• Urticaria

Question 23

Mechanism of muscarinic antagonist

Answer 23

Blocks effects of Acetylcholinesterase which binds to muscarinic receptors