10-8 DSA Asthma by Kinder

Question 1

What is asthma? What are the 3 major components?

Answer 1

Clinical syndrome of unknown etiology with 3 distinct components:

1. Recurrent airway obstruction: resolves spontaneously or with treatment
2. Airway hyper-responsiveness: exaggerated bronchoconstriction in response to stimuli with little or no effect on non-asthmatic patients
3. Airway inflammation

Question 2

How common is asthma? When do most cases start?

Answer 2

Common disorder affecting 8% of adults.

Most cases start before age 25, but asthma can occur at any age.

Question 3

What is the gender and age breakdown for asthma?

Answer 3

. Boys more common than girls, and after puberty women more often than men.

Question 4

How many office and visits does asthma ‘cost’ each year?

Answer 4

Asthma is one of the most common reasons for seeking medical care. Fifteen million outpatient visits per year, and 2 million hospitalizations per year.

Question 5

What is the pathology behind mild asthma?

Answer 5

Mild asthma:

edema and hyperemia of the mucosa plus mucosal infiltration with mast cells, eosinophils, and lymphocytes

Question 6

What is the pathology behind moderate asthma?

Answer 6

Moderate:

chemokines eotaxin, RANTES, macrophage inflammatory protein 1 alpha, and interleukin 8 lead to inflammation and smooth muscle constriction

Question 7

What is the pathology behind severe asthma?

Answer 7

Severe:

hypertrophy and hyperplasia of airway glands and smooth muscle lead to severe airway thickening

Question 8

What is airway obstruction in asthma caused by?

Answer 8

Caused by a combination of:

1) Constriction of airway smooth muscle
2) Thickening of airway epithelium
3) Liquids in the airway

Question 9

What are some common triggers in asthma?

Answer 9

atopy,

allergy,

cold air,

smoking or smoke in the environment,

pollution,

climate changes,

emotion,

medications,

occupational,

food

Question 10

What are the asthma mediators?

Answer 10

AcH

Histamine

Leukotrienes and Lipoxins

Nitric Oxide

Question 11

How does AcH mediate asthma?

Answer 11

Acetylcholine:

released from intrapulmonary motor nerves; stimulate M3 muscarinic receptors causing airway smooth muscle constriction

Question 12

How does histamine mediate asthma?

Answer 12

Histamine:

released from mast cells – minor role

Question 13

How do leukotrienes and lipoxins mediate asthma?

Answer 13

Leukotrienes and Lipoxins:

derived by the lipoxygenation of arachidonic acid released from target cell membrane phospholipids during cellular activation

Question 14

How does NO mediate asthma?

Answer 14

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 )

Question 15

What will you find in history of someone with asthma?

Answer 15

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.

Question 16

What are some differential Dx’s for asthma?

Answer 16

COPD, CHF, Pneumothorax, Pulmonary Embolism, Large Airway Obstruction, Vocal Cord Dysfunction

Question 17

What is mild intermittent asthma?

Answer 17

Mild intermittent: symptoms present for ≤ 2 days/week, or ≤ 2 nights/month

Question 18

What is mild persistent asthma?

Answer 18

Mild persistent:

symptoms present for > 2 days/week but < once daily, or > 2 nights/ month

Question 19

What is moderate persistent asthma?

Answer 19

Moderate persistent: symptoms present daily or > once/night

Question 20

What is severe persistent asthma?

Answer 20

Severe persistent asthma:

symptoms are continual during the day and frequent at night

Question 21

What will physical exam tell you in asthmatic patients?

Answer 21

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.

Question 22

What are the vital signs in an asthmatic patient?

Answer 22

Vital Signs:

tachypnea with respiratory rate often between 25-40 breaths per minute,

tachycardia,

and pulsus paradoxus

Question 23

What are some ominous physical findings in an asthmatic patient?

Answer 23

Ominous signs are inability to speak or drink, fatigue, drowsiness, confusion, and cyanosis.

Question 24

What tests are helpful in the Dx of astha?

Answer 24

PFT

ABG

CBC

CXR

EKG

Sputum

Question 25

What will the ABG reveal in asthma?

Answer 25

ABG:

often mild hypocapnea.

If PaCO₂ normalizes during a severe attack, may indicate impending respiratory failure.

Question 26

What will a PFT show with asthma?

Answer 26

obstruction

Question 27

What will a CBC show with asthma?

Answer 27

CBC: Eosinphilia, Elevated IgE

Question 28

What will a CXR show with asthma?

Answer 28

Chest X-ray:

often normal,

hyperinflation,

in severe asthma may have pneumothorax or pneumomediastinum

Question 29

What will an EKG show with asthma?

Answer 29

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.

Question 30

What will sputum often show with asthma?

Answer 30

eosinophils

Question 31

How is intermittent asthma managed?

Answer 31

No daily medication

Short-acting beta-2 agonist as needed

Question 32

How is mild persistent asthma managed?

Answer 32

Mild Persistent Asthma

Short acting beta-2 agonist as needed

Inhaled corticosteroid

Alternate treatments mast-cell stabilizer, leukotriene-receptor antagonist, or theophylline

Question 33

How is moderate persistent asthma managed?

Answer 33

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

Question 34

How is severe persistent asthma managed?

Answer 34

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

Question 35

What is omalizumab?

Answer 35

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.