asthma

Question 1

what is asthma?

Answer 1

heterogenous disease characterised by chronic airway inflammation with variable airflow obstruction

Question 2

what causes the airflow obstruction? 3

Answer 2

• bronchoconstriction= contraction of the smooth muscle in the bronchial wall
• bronchial secretions and plugs of mucus= due to inflammation of the bronchial wall
• oedema of the bronchial wall= due to inflammation of the lining mucosa in the bronchial wall

Question 3

describe asthma and atopy? 3

Answer 3

• asthma in young people is generally linked to atopy
• tendency to form IgE antibodies to allergens
• often associated hay fever of eczema in the personal and family history

Question 4

what are the symptoms of asthma? 6

Answer 4

• cough
• wheeze
• breathlessness
• chest tightness
• occurs in episodes with periods of minimal symptoms
• diurnal variability so worse at night or early morning

Question 5

what medications can trigger asthma? 3

Answer 5

• aspirin
• ibuprofen
• beta blockers

Question 6

how do we diagnose asthma? 5

Answer 6

• history is critical, need more than one symptom
• symptom free periods
• past medical history, family history, social history
• alternative diagnosis- what else could this be?
• physical examination may be normal except during an attack

Question 7

how do investigate asthma? 3

Answer 7

• GP= peak flow 2x a day for 2 weeks or spirometry
• GP/hospital= CXR, increased blood eosinophils, fraction exhaled nitric oxide
• hospital= skin prick or blood test

Question 8

describe a lung function test ? 3

Answer 8

• is there an airflow obstruction? FEV1/FVC ration <70
• does it vary over time? peak flow monitoring- 20% diurnal variation
• is it reversible? with bronchodilators, 15% improvement

Question 9

what is fractional exhaled nitric oxide? 4

Answer 9

• measure of airways eosinophilic inflammation
• performed on patients not on any treatment, positive test supports diagnosis of asthma
• GP of hospital clinics
• used to monitor treatment and look at compliance

Question 10

how do we manage asthma? 5

Answer 10

• smoking cessation
• weight reduction
• pollution may provoke acute asthma or aggravate existing asthma, but effects from allergens, smoking and infection are more significant
• inhaled corticosteroids
• inhaled long acting beta 2 agonists (in combination with ICS)

Question 11

what are the long term pharmacological treatments? 3

Answer 11

• oral leukotriene antagonist- montelukast
• oral theophylline
• low dose long term oral steroids

Question 12

what is maintenance and reliever therapy? 5

Answer 12

• LABA formoterol has short onset of action
• equivalent of salbutamol
• so certain specific ICS/LABA combinations can be used as relievers as well as preventers
• so patients can take additional doses for short periods to rapidly treat any worsening asthma symptoms
• aim to address and treat the inflammatory aspect of the disease by having both ICS and LABA

Question 13

what are the 2 different types of inhalers?

Answer 13

• dry powder- activated by inspiration of the patient, drug is dispersed into particles by the inspiration
• pressurised metered dose inhalers- drug dissolved in propellant hydrofluorocarbons under pressure valve system, which releases a metered dose

Question 14

how do we pick which inhaler to prescribe? 6

Answer 14

• what treatment are they on
• what device can they use
• side effects
• what do they want to use
• counter so they know how many doses are left
• cost

Question 15

what are the 3 key questions to ask an asthma patient?

Answer 15

• have you had any difficulty sleeping because of your symptoms
• have you had your usual asthma symptoms during the day
• has your asthma interfered with your usual activities

Question 16

describe monoclonal antibody treatment? 3

Answer 16

• anti-IgE injections
• anti IL-5 treatment
• bronchial thermoplasty

Question 17

what is done on a personal asthma action plan? 6

Answer 17

• daily medication to take and why
• which triggers to avoid
• signs of asthma deterioration
• names and doses of treatment for worsening asthma
• indicators of how and when to seek medical attention
• 2-3 action point

Question 18

what are the features of severe asthma? 6

Answer 18

• PEFR <33%
• SpO2 <92%
• silent chest, feeble respiratory effort
• arrhythmia or hypotension
• exhaustion
• > 110 HR

Question 19

how do we manage severe asthma? 5

Answer 19

• oxygen
• corticosteroids
• nebulised bronchodilators
• if poor response, then intravenous MgSO4
• exceptionally intubation and ventilation

Question 20

when do we discharge asthma patients from the hospital? 7

Answer 20

• been on discharge medication for 24 hours
• inhaler technique checked
• PEFR >75% of best
• treatment with oral and inhaled steroids in addition to bronchodilators
• own peak flow metre
• GP follow up after 2 days
• respiratory clinic follow up in 4 weeks