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95 Cards in this Set
- Front
- Back
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True or false: asthma affects boys more than girls in childhood
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True
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How does the prevalence of asthma change during puberty
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Decreases very slightly in boys, and increases in girls
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Which four factors affect Peak Flow readings?
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-Age
-Sex -Height -Ethnicity |
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How many people have asthma in the UK?
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8 million
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How much does asthma cost the NHS/year?
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£850m/year
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How many new episodes of asthma present to GPs each week?
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18000
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Give the three main components of asthma's clinical definition.
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-Chronic airway inflammation
-Airway hype-rresponsiveness -Functionally variable and reversible with treatment |
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Which two factors contribute to the variable lung function associated with asthma?
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-Bronchospasm
-Bronchial hyper-reactivity |
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Name three features of the chronic airway inflammation associated with asthma
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-Smooth muscle hypertrophy
-mucosal inflammation & oedema -luminal mucous production |
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Name the main symptoms of asthma
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-Wheeze
-Chest tightness -Breathlessness -Cough |
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When do asthmatic symptoms commonly present?
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Diurnal variation: worse in mornings than evenings.
Provoking factors e.g. exercise or allergen exposure |
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What is atopy?
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Tendency to overproduce IgE in response to allergen/provoking factor.
Atopy has a genetic element and is associated with: -eczema -hayfever -rhinitis (ask if they ever get a runny nose) -urticaria (hives) People who have some mild atopic tendencies can become fully asthmatic if they are constantly exposed certain environmental factors e.g. smoke exposure. |
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Why can aspirin and other NSAIDs cause asthma?
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As arachidonic acid metabolism is forced from the COX pathway down the lipoxygenase pathway. Accumulation triggers asthmatic response.
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Which provoking factor is the most common cause of asthma exacerbations?
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Viral upper respiratory tract infections (cause 70%) of exacerbations.
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True or false: thunderstorms are associated with lower asthma admissions post storm.
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False: thunderstorms seem to trigger increased emergency asthma admissions.
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Which cells in sputum are sometimes predictive of serious asthma exacerbations?
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Eosinophils.
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What is 'intrinsic' asthma?
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Intrinsic asthma is that with no obvious IgE response. (sometimes called 'non-allergic asthma') It may be triggered by non-allergic causes e.g. exercise, stress, anxiety, cold air etc.
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Describe the immediate and late asthmatic responses
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Immediate response: binding of allergen to mast cells releases preformed mediators e.g. histamine, proteases, leukotrienes and pro-inflam cytokines.
Late response: further airway narrowing may occur once other inflam cells have been chemotactically attracted to site. Cause longer period of airway narrowing |
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Is the late response always preceded by an immediate response?
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No!
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How does asthma's prevalence alter during puberty?
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Decreases in boys. Increases in girls. Asthma doesn't really ever 'go away' fully.
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How common is asthma in children?
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20% have asthma-like symptoms at some time.
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How common is asthma in adulthood?
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5%
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True or false: adult onset asthma tends to persist
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True
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With a suggestive clinical history, how is asthma diagnosed using respiratory function testing?
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VC or FEV1 must increase by over or equal to 15% original and vol must increase by at least 200ml following bronchodilator/corticosteroid therapy
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On exercise testing, what change in FEV1 is suggestive of asthma?
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After 6 minutes of exercise, a decrease of over or equal to 15% in FEV1 is suggestive of exercise-induced asthma.
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Which is not suggestive of asthma?
-Colds which go to the chest (taking >10 days to clear) -Excessive sputum production -Troublesome cough at night |
Excessive sputum production. You often do have sputum production in asthma, but large volumes are often other things e.g. bronchiectasis
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What pattern of symptoms may suggest an occupational cause to asthma?
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Obstructive lung diseases which get better at the weekends or on holiday are suggestive of asthma.
Occupational asthma is characteristically worse at the end of the week than at the beginning. |
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Give 4 factors which predispose to asthma not resolving in adolescence/returning in later life.
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-Airway hyperresponsiveness
-Sensitisation to dust mite (or other common allergens) -Female sex -Smoking (at age 21) |
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What is the hygiene hypothesis?
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That lack of exposure to infections and allergens in childhood mean T cells (which are mainly Th2 in utero) are not forced down the normal, non allergic Th1 path in childhood. Th result is that T cells have a Th2 bias, and subsequently are predisposed to producing excess IgE (atopy).
The Th2 pathway is characterised by IL 4,5 and 13 production. |
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True or false: smoking in pregnancy is a risk factor for asthma in the child?
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True: as is passive smoking during the child's early years.
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Name the most commonly used inhaled corticosteroids?
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Budesonide (BUD)
Beclomethosone dipropionate (BDP) |
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Which inhaled corticosteroids are more potent than BUD and BDP, but still short acting? What does this mean for their dose?
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-Fluticasone propionate
-Mometasone furoate Means you can take half the dose of BUD or BDP for the same effect. |
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Name an ICS which is a pro-steroid?
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Ciclesonide is a pro-steroid which is metabolised to a more active substance.
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What is name for the mechanism of action of ICS?
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Transactivation.
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Which ICS is most widely used, globally?
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Fluticasone propionate
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Which ICS has a long duration of action and is taken nasally?
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Fluticasone furoate
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What is step 1 asthma treatment?
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-Inhaled short acting beta 2 agonist
-use when required Stage 1 given to people with 'mild intermittent asthma' |
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List the indications for step 2 asthma treatment
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-recurrent exacerbations
-nocturnal asthma -impaired lung function -using inhaled beta 2 agonist more than twice a week |
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Give two examples of step 1 asthma medications, and give their class.
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-Salbutamol
-Terbutaline -Class: short acting beta 2 agonists |
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What is step 2 asthma treatment? and the common starting dose?
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-Add in regular preventer therapy
-This is an inhaled corticosteroid at least once a day. -400 micrograms is a common starting dose -They may still use the reliever medication (short acting beta agonist) occasionally, but if using lots, they should be reassessed. |
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Give two examples of step 2 asthma medications, and give their class.
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-Beclomethasone dipropionate (BDP)
-Budesonide (BUD) -Class: inhaled corticosteroids |
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What is step 3 asthma treatment? and give two examples.
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-Add inhaled LABA
-Salmeterol -Formoterol |
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If there is no response to LABA in step 3, what should you do?
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-Stop LABA
-Increase ICS to 800 micrograms/day -If control is still inadequate, trial other therapies: *Leukotriene receptor antagonist e.g. montelukast 10mg/day, orally *Theophylline: difficult to use bronchodilator which requires plasma monitoring |
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What should you do if LABA has an effect in step 3, but you still haven't got good control?
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-Maintain LABA
-Increase ICS up to the maximum 800 micrograms/day |
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What are the advantages (3) of combination inhalers?
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-Improved compliance
-Avoids patient using LABA as monotherapy -More effective in reducing exacerbations than using higher doses of ICS alone |
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What are combination inhalers?
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Combination of LABA and ICS in one inhaler for people in step 3 treatment.
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True or false: Theophylline is good for acute exacerbations of asthma?
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False - it is very hard to control.
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Name three combination inhaler tradenames and their generic compositions
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-Fostair: formoterol & beclomethasone
-Seretide: salmeterol & fluticasone -Symbicort: formoterol & budesonide |
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What is step 4 asthma management?
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-Persistent poor control
-consider: *increasing inhaled steroids up to 2000 micrograms/day *addition of fourth drug (leukotriene receptor antagonist, theophylline, anticholinergic, slow release beta 2 agonist tablet) |
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What are the additional medications you can try in stage 4?
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-leukotriene receptor antagonist
-theophylline -anticholinergic -slow release beta 2 agonist tablet |
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Give two examples of anticholinergic medication
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-Ipratropium bromide
-Atropine |
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What percentage of asthma patients require step 5 treatment?
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5%: the most difficult to gain control
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What is step 5 asthma management?
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-oral steroid tablet in lowest dose to maintain adequate asthma control
-High dose ICS (up to 2000 micrograms/day) -Consider steroid-sparing agents e.g. DMARDs -Refer patient for specialist care |
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When is oral prednisolone indicated in the management of asthma? (2 situations)
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-As step 5 of chronic asthma
-In emergency acute asthma attack |
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Give the 6 treatment goals defined by GINA for 'well controlled asthma'
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-no (or minimal) daytime symptoms
-no nocturnal symptoms or awakenings -no (or minimal) need for 'rescue' treatment (SABAs) -no limitations on activities (including exercise) -(near) normal lung function -no exacerbations |
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Here are 4 GINA goals for 'well controlled' asthma:
-no (or minimal) daytime symptoms -no nocturnal symptoms or awakenings -no (or minimal) need for 'rescue' treatment (SABAs) -no limitations on activities (including exercise) Give the other two. |
-(near) normal lung function
-no exacerbations |
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If a patient has limitations of their physical activity, are they controlled, partly controlled or uncontrolled?
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partly controlled
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If a patient needs to use reliever medication more than twice a week, are they controlled, partly controlled or uncontrolled?
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Partly controlled
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If a patient experiences minimal daytime symptoms, are they controlled, partly controlled or uncontrolled?
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Controlled, providing it is less than twice a week.
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A patient has a lung function of <80% predicted or personal best. Is this controlled, partly controlled or uncontrolled?
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Partly controlled.
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If a patient has an exacerbation of asthma every week, are they controlled, partly controlled or uncontrolled?
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Uncontrolled
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Bob is woken three times a week with a wheezy cough. Is his asthma controlled, partly controlled or uncontrolled?
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Uncontrolled
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What is the Asthma Control Test, and what score is considered good?
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-A reasonably objective measure of asthma's effect on quality of life and the control of symptoms
-A score over or equal to 20/25 is considered 'well controlled' asthma |
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Which is the first sign of asthma control to recover once appropriate treatment is started?
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Nocturnal awakenings are the first to go
-Important to realise, as measure of success in asthma control can depend on what measure you use. |
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Which sign of asthma control takes the longest to recover once appropriate treatment is started?
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Bronchial hyperresponsiveness takes the longest to recover
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What are most exacerbations triggered by?
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Viral upper respiratory tract infection (70% cases)
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If asthmatic patients get a cold, what should they do?
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-Act early & have an action plan.
-When they notice runny nose, at least double ICS dose to control the inflammation -Extra bronchodilator therapy (SABA puffs) will control symptoms. Increase up to 4 times/day if not on ICS combination inhaler -Current evidence is poor |
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List the three features of airway remodelling/fixed airflow limitation
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-fibrosis of the airway wall
-fixed narrowing of the airway -reduced response to bronchodilator medications |
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Give two risk factors for developing fixed airflow limitation
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-older age (especially in asthma with adult onset)
-longer duration of asthma |
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How does smoking affect asthma management?
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-need higher doses of treatment to have same effects
-much more likely to get exacerbations of asthma if smoker or previous smoker |
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Describe the effect of cardioselective beta-blockers on the action of beta agonists
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They blunt the effect of bronchodilators (will require higher doses to achieve same relief)
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What do kinins cause? As a result, what is the effect of ACE inhibitors?
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-bronchoconstriction
-vasodilatation -vascular leak -mucus hypersecretion -Effect of ACE inhibitors is to cause a nasty cough (especially in women) |
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In acute asthma, what PEF is 'mild?'
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>75% predicted
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In acute asthma, what PEF is 'severe?'
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33-50% predicted
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In acute asthma, what PEF is 'moderate?'
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50-75% predicted
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In acute asthma, what PEF is 'life-threatening?'
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<33% predicted
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Define 'mild' acute asthma attack and describe its management.
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-PEF >75% predicted
-give usual bronchodilator therapy -observe for 60 mins. -discharge if PEF >70% and stable Important to: -ensure patient has adequate supply of treatment and knows how to use inhaler -write letter to GP & get patient to consult -advise patient to return if symptoms worsen |
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Define 'moderate' acute asthma and describe its first step of management
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-PEF 50-75% predicted
-nebulised beta 2 agonist |
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In moderate acute asthma, what do you do if after the beta 2 agonist is administered, the patient's PEF is >50-75% predicted?
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-Patient is stable and improving
-Give repeat nebulised beta 2 agonist -Give oral prednisolone -Wait 60 minutes -After 60 mins, if PEF is >60%, discharge -Continue course of prednisolone for the first week whilst waiting for ICS to kick in -Boost regular inhaled steroid -Consider referring to respiratory doctor -ensure supply of meds is okay and inhaler technique is adequate -write letter to GP and advise early consultation -advise to return if symptoms worsen |
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In moderate acute asthma, what do you do if after 60 minutes post nebulised beta 2 agonist, the PEF is <50%?
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Arterial Blood Gasses
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Give 4 key signs of severe acute asthma. What is your immediate management?
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-Pulse >110 b.p.m
-can't complete sentences in one breath -PEF: 50% or less of predicted or best. Or <100 -Respiratory rate of >=25b.p.m. -Immediate management is to do ABGs. |
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Give three respiratory clinical signs of life threatening asthma
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-silent chest
-feeble respiration -cyanosis |
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What would a PEF of <33% predicted suggest?
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Acute, life-threatening asthma
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True or False: people with life threatening asthma often have a tachycardia and hypertension
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False: they typically have bradycardia and hypotension
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How will the mental state of someone with life-threatening asthma be?
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Confused, coma, exhausted
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What is the PaCO2 likely to be in acute life-threatening asthma?
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Normal or high
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What is the PaO2 likely to be in acute life-threatening asthma?
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Low: below 8kPa
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What kills people in acute life-threatening asthma?
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Acidosis
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What is the immediate management of someone with life-threatening asthma?
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-Hospital admission
-Immediate high flow oxygen, nebulised beta 2 agonist and steroid -Check ABGs -Add ipratroprium bromide to nebuliser -CXR |
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What second line treatments may be considered in life-threatening asthma, if the first line ones are proving ineffective?
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-IV Aminophylline (mixture of theophylline & ethylenediamine (to increase solubility)
-IV Magnesium sulphate -IV beta 2 agonist |
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Is the pulse and respiratory rate higher or lower in children than in adults with severe life threatening asthma?
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Higher.
Pulse rate >140 is alarming Respiratory rate >50/min is alarming |
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What PEF level is considered 'severe' for acute asthma in children?
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PEF <50% predicted or best
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True or false: children with severe asthma always look distressed
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False: children with severe asthma attacks may not appear distressed.
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True or false: Blood gas estimations are useful in children with acute life threatening asthma
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False: they are rarely helpful in deciding initial management
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What PEF is considered 'life-threatening' in children?
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PEF <33% predicted or best
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