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    Asthma

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    SUSHIL KUMAR OLI
    Asthma is a chronic inflammatory disease of the airways characterized by reversible and variable airflow obstruction, airway hyperresponsiveness, and inflammation. It has an increasing prevalence and is caused by factors like atopy, allergies, infections, pollution, and drugs. Presentations include cough, wheeze, breathlessness and chest tightness. Diagnosis involves objective tests like peak flow monitoring, spirometry showing reversibility, and exclusion of other differential diagnoses. Management consists of pharmacological treatments through a stepwise approach depending on severity, involving relievers, preventers like inhaled corticosteroids, and add-on therapies. Complications include pneumonia, respiratory failure, and side effects from long-term treatment.

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    Asthma

    Uploaded by

    SUSHIL KUMAR OLI
    8 views7 pages
    Asthma is a chronic inflammatory disease of the airways characterized by reversible and variable airflow obstruction, airway hyperresponsiveness, and inflammation. It has an increasing prevalence and is caused by factors like atopy, allergies, infections, pollution, and drugs. Presentations include cough, wheeze, breathlessness and chest tightness. Diagnosis involves objective tests like peak flow monitoring, spirometry showing reversibility, and exclusion of other differential diagnoses. Management consists of pharmacological treatments through a stepwise approach depending on severity, involving relievers, preventers like inhaled corticosteroids, and add-on therapies. Complications include pneumonia, respiratory failure, and side effects from long-term treatment.

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    Oxfordmedicaleducation.com Asthma

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    Asthma is a chronic inflammatory disease of the airways characterized by reversible and variable airflow obstruction, airway hyperresponsiveness, and inflammation. It has an increasing prevalence and is caused by factors like atopy, allergies, infections, pollution, and drugs. Presentations include cough, wheeze, breathlessness and chest tightness. Diagnosis involves objective tests like peak flow monitoring, spirometry showing reversibility, and exclusion of other differential diagnoses. Management consists of pharmacological treatments through a stepwise approach depending on severity, involving relievers, preventers like inhaled corticosteroids, and add-on therapies. Complications include pneumonia, respiratory failure, and side effects from long-term treatment.

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    © All Rights Reserved
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    8 views7 pages

    Asthma

    Uploaded by

    SUSHIL KUMAR OLI
    Asthma is a chronic inflammatory disease of the airways characterized by reversible and variable airflow obstruction, airway hyperresponsiveness, and inflammation. It has an increasing prevalence and is caused by factors like atopy, allergies, infections, pollution, and drugs. Presentations include cough, wheeze, breathlessness and chest tightness. Diagnosis involves objective tests like peak flow monitoring, spirometry showing reversibility, and exclusion of other differential diagnoses. Management consists of pharmacological treatments through a stepwise approach depending on severity, involving relievers, preventers like inhaled corticosteroids, and add-on therapies. Complications include pneumonia, respiratory failure, and side effects from long-term treatment.

    Copyright:

    © All Rights Reserved
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    of 7

    Oxford Medical Education

    Asthma
    oxfordmedicaleducation.com/respiratory/asthma/

    10 January 2015

    Asthma
     

    Definition of asthma
    Chronic inflammatory disease of the airways
    3 components:
    Reversible and variable airflow obstruction
    Airway hyper-responsiveness to stimuli
    Inflammation of the bronchi

     Epidemiology of asthma
    Increasing prevalence – estimates of prevalence range from 3 to 5.4 million
    Approximately 235 million people worldwide affected
    Approximately 250,000 people die per year from the disease

     Aetiology of asthma
    Atopy and allergy – pets, pollen
    Cold air
    Exercise
    Pollution
    Occupational
    e.g. isocyanates (paint sprayers), latex, flour and grain dust

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    Viral infections
    Drugs
    e.g. NSAIDs, Beta blockers
    Emotion

     Presentations of asthma
    Cough
    Wheeze
    Breathlessness
    Chest tightness

    Features which increase the probability of asthma include:


    Diurnal variation (worse at night and early morning)
    Triggered by or made worse by above aetiologies
    Recurrent and frequent symptoms
    Family history of atopy or asthma

     Differential diagnosis of asthma


    Respiratory
    Churg-Strauss
    Look for high eosinophils
    Allergic bronchopulmonary aspergillosis
    Allergy testing for common moulds
    COPD (exacerbation)
    Chronic cough syndromes
    Rhinitis
    Bronchiectasis
    Sarcoidosis
    Lung cancer
    In chidren
    Croup and epiglottitis
    Obliterative bronchiolitis
    Cystic fibrosis/ Ciliary dyskinesia
    GORD
    Heart failure
    Tracheomalacia
    Narrow trachea on bronchoscopy, obstructive picture on spirometry
    Vocal cord dysfunction

    2/7
     Investigation of asthma
    Peak flow charts
    Lung function tests
    FEV1/FVC <0.7
    Reversibility/ improvement after treatment trial
    CXR
    In patients presenting atypically or with additional symptoms or signs
    Tests of atopy
    Skin prick testing
    Blood eosinophilia
    Raised specific IgE

    Further investigations
    Methacoline PC20 – the provocative concentration of methacholine required to
    cause a 20% fall in FEv1. .
    FENO –  Exhaled NO concentration
    Indirect challenges – e.g. exercise challenge
    Sputum eosinophil count

    In acute asthma (see Acute Asthma pages for full details on acute asthma)
    CXR
    Recommended in the presence of suspected pneumothorax,
    consolidation, life threatening asthma, requirement for ventilation, failure
    to respond to treatment
    Pulse oximetry
    ABG

    It is important to obtain objective support for the diagnosis of asthma given the potential
    long-term treatment implications. Repeated assessment and measurements may be
    needed. Whether or not this should happen before starting treatment depends on the
    certainty of the initial diagnosis and the severity of presenting symptoms.

     Staging of acute asthma (Table from BTS 2014 asthma guidelines)

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     Initial management of acute asthma (see Acute Asthma pages for


    full details on acute asthma)
    Oxygen: aim sats 94-98%
    Inhaled/Nebulised high dose Beta 2 agonists
     e.g. 2.5-5mg nebulised salbutamol at 15-30 min intervals
    Steroid therapy
     40mg prednisolone po daily for 5 days. If oral route not possible – IV
    hydrocortisone 400mg daily or IM methylprednisolone 160mg daily.

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    In patients failing to respond to initial treatment or with acute severe or life
    threatening asthma:
    Nebulised ipratropium bromide
    0.5mg 4-6 hourly
    Magnesium sulphate
    1.2-2g IV infusion over 20 minutes
    IV aminophylline
    5mg/kg loading dose IV over 20mins (unless already on oral therapy),
    then infusion of 0.5-0.7mg/kg/hr.
    If on oral maintenance therapy – check level on admission
    Monitor levels whilst on infusion (Aim 10-20mg/l)
    Early referral to ITU. Indications include:
    Deteriorating PEF
    Persisting or worsening hypoxia
    Hypercapnia
    Fall in pH in ABG
    Exhaustion
    Reduced GCS

    Management of chronic asthma (See BTS 2014 asthma


    guidelines for full guidelines)

    Non-Pharmacological

    Self-management plan
    Allergen avoidance
    Smoking cessation
    Immunisations
    Immunotherapy

    Pharmacological: Stepwise Drug Treatments (see BTS/SIGN Guidelines) – move


    both up and down the steps

    Step 1: Reliever therapy


    Short acting beta-2 agonist as required: Salbutamol 100-200mcg
    Step 2: Regular preventer therapy
    Introduce inhaled steroid if: exacerbations in last 2 years; using salbutamol
    3x/wk; symptomatic 3x/week; waking one night/wk
    Usual starting dose 200mcg bd (Budesonide – alternatives include
    beclomethasone and fluticasone)

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    Step 3: Add-on therapy
    Trial long acting beta 2 agonist (LABA): Salmeterol 50mcg/12h
    If no response to LABA: stop LABA and increase inhaled steroid dose to
    800mcg/day
    If some, but inadequate, response to LABA: increase inhaled steroid dose to
    800mcg/day. And if still inadequate response consider alternative add-on
    therapy:
    Leukotriene receptor antagonist (first choice add-on therapy in children)
    Theophyllines
    Slow release beta 2 agonist tablets
    Step 4: Additon of a 4th drug
    If control remains inadequate, consider the following interventions:
    Increasing inhaled steroids to 2000 micrograms/day
    Adding 4th drug e.g. leukotriene receptor antagonist; theophylline; slow
    release β2 agonist tablets (caution in patients already on long-acting β2
    agonists
    Step 5: Oral steroids
    Add regular oral prednisolone (at lowest dose for symptom control)
    Monitor for systemic side effects: BP, blood glucose, bone mineral
    density, cholesterol
    Continue high dose inhaled steroid
    Refer to specialist asthma clinic

    Other medications and potential steroid sparing agents (only for use by specialist
    centres):
    Anti IgE monoclonal antibody: Omalizumab
    Immunosuppressants (methotrexate, ciclosporin, gold)

     Good asthma control can be defined as:


    No daytime symptoms
    No night-time awakening due to asthma
    No need for rescue medication
    No exacerbations
    No limitations on activity including exercise
    Normal lung function (in practical terms FEv1 and/or PEF>80% predicted or best)
    Minimal side effects from medication.

     Complications of asthma
    Pneumonia
    Lobar collapse
    Pneumothorax
    Respiratory failure

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    Side effects from treatment
    e.g. hypokalaemia, arrhythmias
    Fatigue
    Psychosocial problems: depression, difficulties at work

     Markers of poorer prognosis in asthma


    Poor adherence
    Previous acute admissions and/or intubation
    3+ different classes of asthma medication
    Psychosocial dysfunction
    Inadequately treated disease
    Smoking

    Click here for medical student OSCE and PACES questions about


    asthma

    Common asthma exam questions for medical students, finals, OSCEs and MRCP
    PACES

    Click here to download free teaching notes on asthma: Asthma

    Perfect revision for medical students, finals, OSCEs and MRCP PACES

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