2 - Asthma Flashcards
Main sx of asthma
- 4 main sx = coughing, wheezing, tightness in chest, shortness of breath (sometimes children will only present w/ a dry cough)
- Can send for spirometry test when 6 & older
- Worsening doesn’t necessarily mean exacerbation (exacerbation = hospitalization)
- *Asthma + smoking = COPD (airways are inflamed, so continuously irritating them will lead to irreversible damage)
Jana is 7 y/o female w/ 4-year hx of asthma. Since her diagnosis she has been using salbutamol 100 ug, 2 puffs prn to manage her symptoms. Over the last while her sx have mainly been intermittent including SOB once or twice weekly & no nighttime awakenings. She effectively uses 1-2 doses of her salbutamol inhaler per week. She is able to participate in normal physical activity. What signs/sx does Jana have that are consistent w/ chronic asthma?
Intermittent SOB, reversible w/ salbutamol inhaler
- Can’t get spirometry until age 6, so only had asthma-like sx for 4 years (spirometry is only diagnostic tool so can’t truly have asthma until diagnosis)
Jana is 7 y/o female w/ 4-year hx of asthma. Since her diagnosis she has been using salbutamol 100 ug, 2 puffs prn to manage her symptoms. Over the last while her sx have mainly been intermittent including SOB once or twice weekly & no nighttime awakenings. She effectively uses 1-2 doses of her salbutamol inhaler per week. She is able to participate in normal physical activity. How would you describe Jana’s current asthma control?
Still technically under “control”
Jana is 7 y/o female w/ 4-year hx of asthma. Since her diagnosis she has been using salbutamol 100 ug, 2 puffs prn to manage her symptoms. Over the last while her sx have mainly been intermittent including SOB once or twice weekly & no nighttime awakenings. She effectively uses 1-2 doses of her salbutamol inhaler per week. She is able to participate in normal physical activity. Is she receiving the appropriate treatment?
Add a steroid; also think about non-pharms
Over the next 4-6 weeks Jana begins experiencing increased episodes of SOB, up to 3 days each week. She also finds that she needs to take her salbutamol inhaler 2 puffs, 15 minutes before gym class (3x/week). She currently doesn’t have any shortness of breath at night. What is Jana’s current level of asthma control?
Not in control b/c needs salbutamol w/ exercise & now using 6x/week
Describe the clinical presentation of asthma
- Episodic wheezing, breathlessness, chest tightness, & coughing
- Wheezing = high-pitched, whistling sound created by turbulent airflow through an obstructed airway, usually when breathing out
- Intervals between sx can be days, weeks, months, or years
- Spirometry demonstrates obstruction (decreased FEV1/FVC) w/ reversibility following inhaled beta 2-agonist (at least 12% improvement in FEV1 & a difference of 200 mL)
- Just b/c someone goes months w/o sx doesn’t mean it isn’t a big deal – it is still chronic!!
Describe the asthma control criteria
- Daytime sx = < 4 days/week
- Night-time sx = < 1 night/week
- Physical activity = normal
- Exacerbations (any acute care visit indicates poor control) = mild, infrequent
- Absence from work/school due to asthma = none
- Need for fast-acting beta 2-agonist = < 4 doses/week (includes exercise!!)
Describe the general rules for asthma management
- Regularly reassess inhaler technique, adherence, & triggers!!
- For those 6-11 y/o we increase ICS
- For those 12 years & older, we add a LABA (don’t get more benefit from increasing steroid, only get more adverse effects)
- LRTAs help w/ allergic component in upper airways, so prevent further inflammation (better at prevention than tx)
- *Focus of asthma therapy is prevention & suppression of the underlying inflammation
What are some other questions we should ask about asthma?
- Feel like you’re getting a cold/flu?
- Exposure to triggers?
- Limitation in activities?
- Referred to action plan?
- Rule out exacerbation
Asthma red flags
- Unable to speak
- SOB at rest
- Reliever not working
- Peak flow < 60% predicted best
- Pt knows from past experience they are having a serious attack
What are some triggers for asthma?
- Respiratory tract infections
- Allergens (pollens, house dust mites, animal dander, fungal spores)
- For pet dander, best recommendation is avoidance, but if they can’t get rid of the pet at least get it out of the bedroom; pet dander can remain in a house for years
- Environment
- Food additives
- Exercise
- Drugs/ preservatives
- Occupational
- Emotions
How do asthma sx occur?
- Inflammation is chronic; symptoms are episodic
- Airway narrowing is variable & caused by:
- Contraction of airway smooth muscle (increased responsiveness to certain triggers)
- Airway edema
- Mucous hypersecretion
- Airway thickening
Describe what happens in the body during an acute asthma attack
- Trigger => release of inflammatory mediators (histamine, leukotrienes, prostaglandins)
- Early phase = bronchoconstriction (w/in 10-20 min), mucous hypersecretion, edema (duration ~ 1 h)
- Late phase (6-9 h later) = continued inflammation, epithelial damage, intensified hyperresponsiveness; more severe, prolonged, & difficult to reverse; may last for weeks
Risk factors for a severe asthma exacerbation?
- Under-utilization of anti-inflammatory drugs
- Excessive reliance on short-acting inhaled beta 2-agonists
Describe the use of ICS for asthma
- Always start at lowest possible dose (250 mcg/day is baseline low dose fluticasone or beclomethasone equivalents)
- Ciclesonide breaks down & activates into true anti-inflammatory in the lungs so less thrush issues – very good in children
- Most px see decreased sx in days to 1-2 weeks & often achieve minimum improvement use 2-4 weeks & maximum symptomatic improvement w/in 4-8 weeks
- Follow-up 1-3 months after starting tx, then every 3-12 months if stable
- *Always assess technique, adherence, & triggers
- Adverse effects (dose dependent; more common w/ dry powder inhaler DPIs) = thrush (uncommon in children), dysphonia
- Can minimize w/ aerochamber & rinse w/ water after use
