10-8 DSA Asthma by Kinder Flashcards
What is asthma? What are the 3 major components?
Clinical syndrome of unknown etiology with 3 distinct components:
- Recurrent airway obstruction: resolves spontaneously or with treatment
- Airway hyper-responsiveness: exaggerated bronchoconstriction in response to stimuli with little or no effect on non-asthmatic patients
- Airway inflammation
How common is asthma? When do most cases start?
Common disorder affecting 8% of adults.
Most cases start before age 25, but asthma can occur at any age.
What is the gender and age breakdown for asthma?
. Boys more common than girls, and after puberty women more often than men.
How many office and visits does asthma ‘cost’ each year?
Asthma is one of the most common reasons for seeking medical care. Fifteen million outpatient visits per year, and 2 million hospitalizations per year.
What is the pathology behind mild asthma?
Mild asthma:
edema and hyperemia of the mucosa plus mucosal infiltration with mast cells, eosinophils, and lymphocytes
What is the pathology behind moderate asthma?
Moderate:
chemokines eotaxin, RANTES, macrophage inflammatory protein 1 alpha, and interleukin 8 lead to inflammation and smooth muscle constriction
What is the pathology behind severe asthma?
Severe:
hypertrophy and hyperplasia of airway glands and smooth muscle lead to severe airway thickening
What is airway obstruction in asthma caused by?
Caused by a combination of:
1) Constriction of airway smooth muscle
2) Thickening of airway epithelium
3) Liquids in the airway
What are some common triggers in asthma?
atopy,
allergy,
cold air,
smoking or smoke in the environment,
pollution,
climate changes,
emotion,
medications,
occupational,
food
What are the asthma mediators?
AcH
Histamine
Leukotrienes and Lipoxins
Nitric Oxide
How does AcH mediate asthma?
Acetylcholine:
released from intrapulmonary motor nerves; stimulate M3 muscarinic receptors causing airway smooth muscle constriction
How does histamine mediate asthma?
Histamine:
released from mast cells – minor role
How do leukotrienes and lipoxins mediate asthma?
Leukotrienes and Lipoxins:
derived by the lipoxygenation of arachidonic acid released from target cell membrane phospholipids during cellular activation
How does NO mediate asthma?
Nitric Oxide:
produced by airway epithelial cells and by inflammatory cells found in the asthmatic lung. High levels found during asthma attack
(can act to dilate smooth mm, but also acts as a cytokine to upregulate inflammatory cells http://thorax.bmj.com/content/58/2/175.full )
What will you find in history of someone with asthma?
dyspnea, cough, wheezing, and anxiety.
Exercise induced, aspirin ingestion, extrinsic (allergen induced), or intrinsic (unknown).
Some patients may present with cough, hoarseness, or inability to sleep through the night.
Rapid changes in temperature or humidity may lead to an attack.
Must also consider occupational exposures.
What are some differential Dx’s for asthma?
COPD, CHF, Pneumothorax, Pulmonary Embolism, Large Airway Obstruction, Vocal Cord Dysfunction
What is mild intermittent asthma?
Mild intermittent: symptoms present for ≤ 2 days/week, or ≤ 2 nights/month
What is mild persistent asthma?
Mild persistent:
symptoms present for > 2 days/week but < once daily, or > 2 nights/ month
What is moderate persistent asthma?
Moderate persistent: symptoms present daily or > once/night
What is severe persistent asthma?
Severe persistent asthma:
symptoms are continual during the day and frequent at night
What will physical exam tell you in asthmatic patients?
Physical Examination: normal between attacks
During attacks:
Accessory muscle use, hyperinflation, prolonged expiratory phase
Wheezing loudest during expiration, but can also be heard during inspiration. Wheezing is polyphonic.
Decreased breath sounds in asthma patients is an indication of severe obstruction.
What are the vital signs in an asthmatic patient?
Vital Signs:
tachypnea with respiratory rate often between 25-40 breaths per minute,
tachycardia,
and pulsus paradoxus
What are some ominous physical findings in an asthmatic patient?
Ominous signs are inability to speak or drink, fatigue, drowsiness, confusion, and cyanosis.
What tests are helpful in the Dx of astha?
PFT
ABG
CBC
CXR
EKG
Sputum
What will the ABG reveal in asthma?
ABG:
often mild hypocapnea.
If PaCO2 normalizes during a severe attack, may indicate impending respiratory failure.
What will a PFT show with asthma?
obstruction
What will a CBC show with asthma?
CBC: Eosinphilia, Elevated IgE
What will a CXR show with asthma?
Chest X-ray:
often normal,
hyperinflation,
in severe asthma may have pneumothorax or pneumomediastinum
What will an EKG show with asthma?
EKG:
sinus tachycardia is usual,
may see right axis,
RBBB,
P pulmonale, and
even ST-T changes in a severe attack that will resolve after treatment.
What will sputum often show with asthma?
eosinophils
How is intermittent asthma managed?
No daily medication
Short-acting beta-2 agonist as needed
How is mild persistent asthma managed?
Mild Persistent Asthma
Short acting beta-2 agonist as needed
Inhaled corticosteroid
Alternate treatments mast-cell stabilizer, leukotriene-receptor antagonist, or theophylline
How is moderate persistent asthma managed?
Short-acting beta-2 agonist as needed
Low to medium dose inhaled corticosteroid
Long-acting beta-2 agonist
Alternate treatments: increase in inhaled corticosteroids within medium dose range; or low to medium dosed inhaled corticosteroids and either a leukotriene-receptor antagonist or theophylline
How is severe persistent asthma managed?
Step 4 Severe Persistent Asthma
Short-acting beta-2 agonist as needed
High-dose inhaled corticosteroid and long-acting beta-2 agonist
If symptoms persist, 2mg/kg/day of prednisone may be required, generally not to exceed 60mg/day
What is omalizumab?
Omalizumab:
monoclonal antibody in patients with moderate to severe persistent asthma who have shown reactivity to an allergen and whose symptoms are inadequately controlled by an inhaled corticosteroid.
