59. Asthma Flashcards
What factors contribute to mortality and morbitidy of asthma
under treatment of acute episodes by emerg physicians, overuse of otc meds to delay in are
more ED visits
life threatening episodes
Failure to initiate CS early
Asthma physiology: what is the defn?
chr resp disease characterized by periods of variable and recurring sx, airflow obstruction, bronchial hyperresponsiveness manifests as attacks of impaired breathing
repetitive episodes of acute superimposed on chronic airway inflamm are responsible for alterations in airwau fnction and reesult in irreersible structural airway changes
Asthma: allergen stimuli
environment
virus
occupation
Asthma: nonallergic stimulic
exercise
aspirin induced
mentraual related
What causes bronchoconstriction, airway obsruction, airway inflow limitation in asthma?
edema inflamm mucus production and airwau smoothm hypertrophy
Rapid onset fatal asthma - what signs on histology?
greater degranulated mast cells
less mucus in airway lumens
RF for asthma - demographics -
did not grad from high school
<$15000 per year
obese
current daily smoker
What wbc subsets do do airways reveal?
neitrophils
eosinophils
mast cells
subbasement membrane thickening
epithelial cell integrity loss
goblet cell hyperplasia
mucuous plugs
Asthma: allergic vs non allergic type - differentiater?
presnece of abscence IgE antibodies to common environmental antigens and microbiologic antigens
Regardless of asthma type, what is the common feature (immunology)
T helper cells in ariway releasing IL 4, 5 and 13 to sitmulate basophil, eosinophil, mast cell and leukocyte migration to airways enhancing IgE production so airways are more inflammatory and remodel irreversibly
Mast cells and eosinophils contain and release intracellular medi- ators and cytokines (histamine, prostaglandins, leukotrienes, tumor necrosis factor alpha [TNF-α]) that contribute to … what 4 signs?
prolonged bronchial sm m spasm
edema
mucus production
Common symptoms of asthma
wheeze
cough
sob
Slow onset asthma (deterioration over 6 hours) - what demographics/triggers predominate?
female
URTI
airflow inflamm response slower to tx
Sudden onset asthma (deterioration < 6 hours) - what demographics/triggers predominate?
male predom
triggers by resp allergens
exercise psych stress
more severe response with faster tx improvement
What comorbidities may worsened by CS if used in asthma?
db
pud
htn
psychosis
Med triggers for asthma include?
nsaid
aspirin
beta blocker (these sp incr hospitalizations and EDvisits
topical agents for glaucoma bb
acei
RF of death from asthma
hx near fatal RQ intubation and mech ventilation
at least 1 hosp/ED visit for asthma in past year
currently/recently stopped using oral CS
not using inhaled CS
over use of SABA (>1 cannister per mo)
Poor adherence to meds or action plan
psychosocial issues
psych disease
asthma with food allergen
RF for asthma exacerbations
female
history of one or more exacerbations past year
poor adherence to plan or uncontrolled sx
incorrect inhaler use
chronic sinusitis
smoking
African american
Cough variant of asthma - ddx of cause chr cough?
gerd
acei
chronic sinusitis
postnasal drip
inducible laryngeal obstruction
Why do people get exercise induced bronchoconstriction?
airway dehydration from increased ventilation, increased osmolarity of airway lining fluid and this can trigger airway inflammatory cell mediators so sm contract and airway edemas
Prophylaxis of airway induced asthma
face mask/nasal breathing pre warm up
inhaled GC, SABA 5-10 min prior
LABA with inh GC if above GC not useful alone
What outcomes does obesity negatively effect in pt with asthma?
poorer control of asthma
higher admission rate
greater risk of complications
*NOT influence severity or resolution of an acute exacerbation
What must be measured in order to diagnose someone with asthma?
Peak flows, this is often not done in the emergency department
What peak expiratory flow is concerning for a acute severe asthma, exacerbation versus signifying, life-threatening or near fatal asthma (percent)
Less than 50%
Less than 33%
Peros Enns, what pulse oximetry should asthma patients be maintained between?
94 and 98%
What will a blood gas look like in Asthma exacerbations? (General)
Initially the hyperventilation will lead to a fall in the partial pressure of carbon dioxide.
With hypo ventilation the partial pressure of carbon dioxide will normalize and increase – resulting in hypercapnia and a respiratory acidosis
When does Rosen recommend doing an arterial blood gas in asthma?
SPO2 less than 92% or PEF is less than 50% of personal best or predictive value
What is the pathophysiology of aspirin, exacerbated respiratory disease?
Inhibition of the enzyme COX decreases production of prostaglandin E2. This then causes five Lipo oxygenate to be diminished and produces more leukotrienes.
These cause bronchoconstriction, mucus, production, and airway, eel migration
Differential diagnosis of asthma: other disease categories
Cardiovascular
Pulmonary
G.I.
Psychogenic
Endocrine
Parasitic.
Iatrogenic from medication.
Neoplastic
Differential diagnosis of asthma: cardiac conditions
Valvular heart disease.
Heart failure.
Non-cardiogenic pulmonary edema.
Related – adverse reaction to a drug including ace inhibitors
Differential diagnosis of asthma – other lung or pulmonary disease causes
COPD
Pneumonia.
Allergic bronchi pulmonary aspergillosis
Loffler syndrome
Chronic eosinophilic pneumonia
Lauren, edema, neoplasm, foreign body, vocal cord disfunction
Endobronchial disease: neoplasm, foreign body.
Bronchial stenosis
Pulmonary embolism
Cystic fibrosis
Carcinoid tumour
Anaphylaxis
Differential diagnosis of asthma – other lung or pulmonary disease causes
COPD
Pneumonia.
Allergic bronchi pulmonary aspergillosis
Loffler syndrome
Chronic eosinophilic pneumonia
Lauren, edema, neoplasm, foreign body, vocal cord disfunction
Endobronchial disease: neoplasm, foreign body.
Bronchial stenosis
Pulmonary embolism
Cystic fibrosis
Carcinoid tumour
Anaphylaxis
What is Loefler syndrome?
: A type of eosinophilic pneumonia mimicking community-acquired pneumonia and asthma that arises from Ascaris lumbricoides in a child.
What is Churg Strauss syndrome?
Eosinophilic granulomatosis with poly angitis
What endocrine disease can mimic asthma?
Addison’s
Frequent SABA treatments can cause what kind of electrolyte abnormalities?
Hyperkalemia
Hypo magnesia.
Hypo phosphataemia
Hyper Lactatemia
Should I get a chest x-ray in asthma?
Not unless I think I need to diagnose pneumonia, pneumothorax, pneumomediastinum, subcutaneous, emphysema, or heart failure
What ultrasound finding of the lung has high diagnostic accuracy in differentiating, acute heart failure from COPD or asthma as it causes of acute dyspnea?
Comet tail sign
In severe asthma, what might your EKG show?
RVH that improves with airflow management
Key treatment in an acute asthma exacerbation:
Monitoring a pulse ox.
Short, acting beta to agonist via MDI or nebulized 6 to 12 puffs every 20 minutes times three doses versus nebulized 2.5 mg Q 20 minutes times three doses
Oral prednisone 40 to 50 mg or if unable to take oral methyl prednisone 125 mg IV daily
Also, can you consider ipatropim 0.5mg if severe: similar puffs as above, but will take longer to affect i.e. 30 to 120 minutes after administration up to six hours
Add magnesium sulphate 2 g over 20 minutes severe asthma concern
Why does magnesium work for asthma?
Bronchial, smooth muscle, relaxation and dilation of asthmatic airways by calcium channel blocking properties inhibition of cholinergic, neuromuscular transmission, stabilization of mass cells and teal lymphocytes stimulation of nitric oxide and prostaxyxlin
Are methylxanthines, including Theophylline filling useful to treat acute asthma?
No
Are leukotriene modifiers useful, and acute asthma?
No
When should you give antibiotics in an asthma exacerbation?
When do you think there’s an infection?
Why might ketamine be useful in asthma?
Potent bronco dilator effects, only use in the intubated patient or for intubation
Why might a blend of 60 to 80% helium with 20 to 40% oxygen help an asthma?
Heliox reduces resistance associated with flow through the airway and reduces priory muscle work, also increases diffusion of carbon dioxide and may improve alveolar ventilation
Why might non-invasive ventilation be useful in certain asthma patients?
Continuous positive pressure airway improves oxygenation, and reduces respiratory muscle fatigue by increasing the functional residual capacity and lung compliance, supplying some of the inflating pressure required during inspiration
What might symptoms and signs of acute severe asthma be?
Assume an upright position and appeared to be in severe respiratory distress.
High respiratory rate, diaphoresis and accessory muscle user evident
Fragmented speech.
Absence of wheeze
Altered mental status and change to low slow breaths, indicate hypercarbia and impending arrest
If an asthmatic patient arrests what might pocus useful to find?
Unrecognized barotrauma
Therefore consider bilateral tube thoracostomy
What increases the risk of relapse after discharge from ED for an asthma patient?
Numerous asthma related ED visits within the previous year.
More outpatient medication’s
Longer duration of symptoms before the ED visit
What are indicators for disposition home for asthma patients?
Improved peak, expiratory, flow rate greater than equal to 60%
Have one or no of the following risk factors: history of near fatal, asthma, requiring intubation, or mechanical ventilation, hospitalization or ED visit for asthma in the past year, currently using a recently stopped oral steroids.
Not using inhaled, steroids, overuse of SABAS especially more than one cannister monthly.
Poor adherence with medication’s or plan
Psychosocial problems.
Psychiatric disease.
Food allergy and patient with asthma
When considering disposition what factors might increase the likelihood of admission?
Peak expiratory flow rate less than 50% after treatment
Female sex, older age, non-white race.
Use more than eight beta. Agnes pops in previous 24 hours.
Severity of exacerbation i.e. need for rapid medical intervention on arrival, respirate greater than 22, oxygen saturation less than 95%
Past history of intubation or asthma admission.
Previous use of oral cortical steroids
Discharge instructions for patients going home on corticosteroids for asthma treatment
Oral corticosteroid for 5 to 7 days once daily
If patients have less than two episodes of asthma symptoms per month, can consider discharging on a low-dose ICS full motor inhaler or take a low-dose inhale corticosteroid whenever using
If a patient has more than two episodes, they need to be discharged on those medications as above
What are considered persistent symptoms of asthma that a patient would need to be discharged home on a controller medication such as a moderate dose inhaled corticosteroid with SAB or combination inhaled cortical steroid and LABA?
Symptoms of rescue therapy more than twice a week.
Interference with sleep more than twice per month.
Activity, limitation caused by asthma exacerbations requiring oral cortical steroids more than once in the past year
When does follow-up need to be arranged for a family doctor if a patient with asthma is being discharged home?
Within 3 to 5 days to contact them and follow up medical appointment within 1 to 4 weeks
Which of the following is a risk factor for sudden death from asthma
A hospitalization from asthma in the past year but not within past 30 days.
Emergency department visit for asthma within the last year, but not within the last 30 days.
Use of systemic cortical steroids.
Patient perception that current exacerbation is very severe
C
Factories for sudden death are current or recent corticosteroid use, ED or hospitalization with the last 30 days, more than two hospitalizations for Jasmine in the last year, more than three ED visits for Asma in the past year, more than two beta agonist canisters per month, previous intubation or ICU visit and difficulty perceiving symptoms of the severity
A 23-year-old male with known severe asthma comes to the hospital with an acute asthma flare over two hours. Physical exam shows that he is in marked respiratory distress with the heart rate of 120, oxygen saturation of 90%, respiratory rate of 26 and blood pressure of 140/92 he is not feral. Current medications are albuterolvia MDI and a Fluzone inhaler twice daily what therapy would you recommend for the acute flare?
Short acting, inhaled, beta agonist with ipratropium, corticosteroids, magnesium sulphate 2 g should be considered, and given that his respirate is so high you may want to give the cortical steroids IV
What might be a reasonable induction and paralytic plan for intubation of an asthmatic?
Etomidate and such
Ketamine succ
Midazolam, Pancuronium
Propofol and Rocuronium
Be ketamine
Which of the following is a risk factor for death and patient’s presenting with an asthma attack
A taking methylxanthine
B family, history of asthma.
C presence of roots for a week
D use of three albuterol MDI per month
D
Past history of sudden severe exacerbation.
Prior intubation for asthma.
Prior asthma admission for ICU
Two or more hospitalizations for asthma in the last year
Three or more emergency emergency department care visits for asthma in the past year
Hospitalization or ED care visit for asthma within the past month.
Use of more than two MDI short acting beta two agonist canisters per month.
Current use or or withdrawal of systemic steroids
Difficulty perceiving severity of obstruction.
Such as cardiovascular disease or other systemic problem.
Psych disease
Psychosocial problems.
IV drug use especially cocaine and heroin
A 25-year-old woman presents with wheezing and shortness of breath from asthma. She recently was exposed to cigarettes smoke. She find it difficult to speak and complete her sentences. She has concerning symptoms of a severe asthma exacerbation. Over one hour she gets nebulized albuterol times three doses, ipratropium the same or prednisone 50 mg she said she feels better but can’t speak complete sentences. She has a repeat peak flow of 60% predicted. What is your next step?
A Gimme More albuterol.
B of magnesium
C methyl prednisone IV
D give montekulast
Give more albuterol
Per Rosens, really not severe enough for Iv mag
ECMO consider when?
near fatal asthma consideration
PRAM score peds asthma mild vs mod vs sever
1-3
4-7
8-12
PRAM score peds asthma - findings?
suprasternal indrawing 0 -3 for each
scalene retractions
wheezing: absent vs expir only vs inspir +/- expir, adubile without steth or silent chest
air entry: Nbase vs decr base vs widesp vs absent
room air o2 sat >/95%, 92-94%, <92%
DOPES mneumonic for ventilation
displ
obstruction
ptx
equipm issue
stacked breathes
