Asthma

Question 1

What is asthma?

Answer 1

Widespread narrowing of peripheral airways, varying in severity over short periods of time

Question 2

What is the pathophysiology of asthma?

Answer 2

1. Irritation
2. Degranulation of mast cells
   - Histamine
   Contraction of smooth muscle, increase blood vessel permeability, increase bronchial secretions, attracts WBCs
   - Chemotactic factors, leukotrienes, prostaglandins and major basic protein released
   Inflammation
3. Bronchi mucosa swells and smooth muscle contracts
4. Goblet cells in alveoli secrete mucus in respnse to irritation
   - Narrows lumen
   - Plugs smaller airways

Question 3

What are the main symptoms of asthma?

Answer 3

• Wheeze
• Coughing
• Phlegm
• Dyspnoea
• Nasal polyps

Question 4

What are the risk factors for asthma?

Answer 4

• Recent upper respiratory tract infection
• Positive family Hx of asthma
• Allergen exposure
• Atopic Hx
• GORD
• Obesity

Question 5

What would you look for in a history to diagnose asthma?

Answer 5

• Symptoms
• Exacerbating factors
• Family/ Past medical Hx of exacerbating factors

Question 6

What might you find on examination of a patient with asthma?

Answer 6

• Can be normal
• Expiratory polyphonic wheeze on chest auscultation
  Has multiple pitches and tones heard over different areas of the lung when the person breathes out

Question 7

What is the test for airway inflammation?

Answer 7

Fractional exhaled nitric oxide (FeNO)

Question 8

What is a positive FeNO result?

Answer 8

• Adult : ≥ 40 ppb

- Children : ≥ 35 ppb

Question 9

What can decrease FeNO?

Answer 9

Smoking

Question 10

What are the tests for lung function?

Answer 10

• Spirometry
• Bronchodilator reversibility (BDR)
• PEFR

Question 11

What is a positive spirometry result?

Answer 11

FEV1/FVC ratio <70%

Question 12

What type of airway disease is asthma?

Answer 12

Obstructive

Question 13

What does brochodilator reversibility aim to show?

Answer 13

Reversibility of airway obstruction to a short-acting bronchodilator

Question 14

What is a positive bronchodilator reversibility test result?

Answer 14

• Improvement of FEV1 by ≥ 12%

- Increase in volume of 200ml

Question 15

What is PEFR?

Answer 15

The maximal rate that a person can exhale during a short maximal expiratory effort after full inspiration

Question 16

How do you predict PEFR?

Answer 16

Using a patients sex and height

Question 17

When would you ask a patient to measure PEFR for 2-4 weeks?

Answer 17

• Normal spirometry result
• Obstructive spirometry result and FeNO ≤ 39 ppb
• Negative bronchodilator reversibility

Question 18

What is an airway hyperreactivity measure?

Answer 18

Direct bronchial challenge test with histamine or methacholine

Question 19

What is a positive direct bronchial challenge test?

Answer 19

PC20 value ≤ 8mg/ml

Question 20

When patients present with symptoms for the first time, what other investigations would you order and why?

Answer 20

• CXR
• FBC

To exclude other differentials

Question 21

What happens if after treatment symptoms control remains poor?

Answer 21

• Step up the treatment ladder
  OR
• Review diagnosis after 6-10 weeks
  Do not rule out other diagnoses

Question 22

What are asthma triggers?

Answer 22

• Cold weather
• Dust
• Allergens - Tree pollen
  Exercise
• Infections
• Stress/anxiety

Question 23

What is a reliever inhaler?

Answer 23

Blue SABA inhaler

Relieves symptoms when they occur

Question 24

What is a preventer inhaler?

Answer 24

Brown inhaled corticosteroid (ICS) inhaler

Used everyday to decrease inflammation and sensitivity of the airways

Question 25

What happens to peak flow after a preventer inhaler is started?

Answer 25

- Peak flow improves - Less variation between peaks and troughs on a graph - Overall improvement

Question 26

What is the advice given to people with exercise-induced asthma?

Answer 26

SABA - Used shortly before exercise - May be helpful for 2-3 hours

Question 27

How long to LABAs last for?

Answer 27

Up to 12 hours

Question 28

What drugs should be avoided in asthma?

Answer 28

- Aspirin - NSAIDs Ibuprofen Naproxen - Beta-Blockers

Question 29

How is asthma managed in primary care?

Answer 29

- Individual self-management programme - Yearly asthma review - Advice on smoking cessation - Advice on exercise

Question 30

What questions would you ask in the yearly asthma review as a GP?

Answer 30

1. In the last month/week have you had difficulty sleeping due to your asthma? 2. Have you had your asthma symptoms during the day? 3. Has your asthma interfered with your usual daily activities?

Question 31

What vaccinations must asthmatics get?

Answer 31

- Flu vaccine Can prevent severe respiratory infections Can prevent further inflammation of airways Can prevent triggering of asthma attacks - Pneumococcal vaccine Childhood immunisation now People at high risk of infection get 23-valent pneumococcal polysaccharide vaccine

Question 32

How can people with asthma monitor their symptoms?

Answer 32

Regular PEFR readings

Question 33

How do you check an inhaler is working?

Answer 33

1. Shake inhaler 2. Check that the mouthpiece is not obstructed 3. Squirt twice

Question 34

What does SBAR stand for?

Answer 34

SBAR handover 1. SITATUON 2. BACKGROUND 3. ASSESSMENT 4. RECOMMENDATION

Question 35

What is the atopic triad?

Answer 35

Eczema, allergies and asthma

Question 36

What drugs can still be used in pregnancy for asthma?

Answer 36

Beta2-adrenergic agonists and inhaled steroids

Question 37

Can prednisolone be used to treat an asthma attack in a pregnant woman?

Answer 37

Yes | - Benefit outweighs risk

Question 38

How can anaesthetic potentially trigger an asthma attack?

Answer 38

1. Bronchodilation is controlled by sympathetic innervation (T2-T4) 2. Anaesthetic blocks the sympathetic NS

Question 39

Is spinal or general anaesthetic safer in a patient with asthma?

Answer 39

Spinal | - More localised