Bronchial Asthma: Made Incredibly Easy with Q&As
By using the Q&A method, you will review a vital topic in medicine: bronchial asthma.
Tip: To get the most out of this post, try to brainstorm questions before you proceed to look at the answer.
What is the mechanism of symptoms in bronchial asthma?
There is reversible airway narrowing in asthma.
The feature of reversibility differentiates it from other obstructive airway diseases like COPD.
What are the characteristic symptoms of asthma?
Typical symptoms of asthma include cough, wheezing, and dyspnea.
What factors contribute to airway narrowing?
Three factors contribute to the airway narrowing:
1. Bronchial smooth muscle contraction
2. Mucosal inflammation & swelling
3. Increased mucus production.
What are the congenital causes that result in the development of bronchiectasis?
Congenital causes include:
– Cystic fibrosis (commonest)
– Young’s syndrome
– Primary ciliary dyskinesia (Immotile cilia syndrome)
– Kartagener syndrome
What is the characteristic time of coughing in asthma?
Nocturnal cough is more common in asthma.
What are the possible precipitants or triggers of asthma symptoms?
Asthma triggers include allergens (pets, house dust mites), irritants (smoke), infections (viral), drugs (aspirin, ß-blockers), cold air, exercise, and stress.
Is there any variation in the symptoms of asthma during different parts of the day?
Yes, there is a diurnal variation. Symptoms or peak flow may vary over the day. Marked morning dipping of peak flow is common.
What are the signs found in asthma patients?
Signs include
– Tachypnoea
– Audible wheeze
– Hyperinflated chest
– Hyper-resonant percussion note
– Reduced air entry
– Widespread, polyphonic wheeze
What are the characteristics of acute severe asthma?
In acute severe asthma, there is
– Inability to complete sentences
– Pulse >110/min
– Respiratory rate >25/min
– Peak expiratory flow (PEF) rate 33–50% predicted
What are the features of a life-threatening asthma attack?
Features of life-threatening asthma include
– Silent chest
– Confusion
– Exhaustion
– Cyanosis (PaO2 < 60 mmHg but PaCO2 34 – 45 mmHg, SpO2 <92%)
– Bradycardia
– PEF <33% predicted
When do you call an acute attack of asthma "near-fatal"?
An asthma attack is said to be near-fatal if PaCO2 is raised in ABGs.
What is the diagnostic test for asthma?
A compatible clinical history plus either/or:
- FEV1 ≥12% (and 200 mL) increase following administration of a bronchodilator/trial of glucocorticoids. Greater confidence is gained if the increase is >15% and >400 mL
- >20% diurnal variation on ≥3 days in a week for 2 weeks on PEF diary
- FEV1 ≥15% decrease after 6 mins of exercise
What are the important differential diagnoses of bronchial asthma?
D/D of asthma shall include:
– Congestive heart failure (called ‘Cardiac asthma’)
– Vocal cord dysfunction
– Chronic obstructive pulmonary disease (COPD)
– Foreign body aspiration
– Allergic bronchopulmonary mycosis
– Churg-Strauss syndrome
What are the principles of management of chronic asthma?
Provide patients with lifestyle advice. e.g., quitting smoking, avoiding triggers, and weight loss if overweight.
Educate about inhaler technique, using peak flowmeter to monitor PEF, and altering their medications according to symptoms or PEF.
Breathing exercise.
Start at the higher step of treatment and step down to the lower step if the control is good for >3 months.
Moving to higher steps when needed.
Rescue courses of prednisolone may be used at any time.
What are the five management steps for bronchial asthma according to BTS guidelines?
Step 1: Regular preventer therapy. Low-dose inhaled glucocorticosteroid (ICS) e.g., beclomethasone dipropionate 400 mcg/day. Higher doses may be required in smokers.
Step 2: Inhaled add-on therapy: Add long-acting beta-agonist (LABA), if asthma remains poorly controlled despite regular preventer therapy.
Step 3: Additional add-on therapies: If asthma control is poor despite compliance, good inhaler technique, and avoidance of triggers, choose from any of the choices mentioned:
- If there has been no response to the LABA, then it should be stopped and an increase of the ICS to a medium dose (800 μg) considered.
- If there is a benefit from the LABA, but control is poor then the ICS should be increased to a medium dose.
- Alternatively, a trial of a leukotriene antagonist (LTRA) or a slow-release theophylline preparation should be considered.
Step 4: High-dose therapies: the dose of ICS be increased up to a high dose (2000 μg BDP or equivalent) daily. Trials of LTRA, long-acting antimuscarinic agents (LAMA), theophylline or a slow-release oral β2-agonist may be considered. If the trial of add-on therapy is ineffective, it should be discontinued.
Step 5: Continuous or frequent use of oral glucocorticoids: Oral corticosteroids such as prednisolone (usually administered as a single daily dose in the morning) should be prescribed at the lowest dose necessary. Patients who are on long-term glucocorticoid tablets (>3 months) or are receiving more than three or four courses per year will be at risk of systemic side effects. The risk of osteoporosis is reduced by giving bisphosphonates. These patients should be considered for biological therapy to minimize long-term harm from oral glucocorticoids.
What is Omalizumab?
Omalizumab is an anti-IgE monoclonal antibody and is used in highly selected patients with persistent allergic asthma with high serum IgE levels.
What are the biological treatment options for a patient having severe eosinophilic asthma?
Benralizumab (anti-IL5r), Mepolizumab (anti-IL5), Reslizumab (anti-IL5) or Dupiliumab (anti-IL4/13).
What other conditions need to be considered and looked for in a patient with uncontrolled asthma?
Acid reflux disease (GERD), Allergic bronchopulmonary aspergillosis (ABPA), polyarteritis nodosa (PAN), and Churg–Strauss syndrome.
What is brittle asthma?
Brittle asthma is the term given to patients having difficulty controlling asthma symptoms and having acute attacks with little or no warning.
