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Rosens > 59. Asthma > Flashcards

59. Asthma Flashcards

1
Q

What factors contribute to mortality and morbitidy of asthma

A

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

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2
Q

Asthma physiology: what is the defn?

A

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

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3
Q

Asthma: allergen stimuli

A

environment
virus
occupation

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4
Q

Asthma: nonallergic stimulic

A

exercise
aspirin induced
mentraual related

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5
Q

What causes bronchoconstriction, airway obsruction, airway inflow limitation in asthma?

A

edema inflamm mucus production and airwau smoothm hypertrophy

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6
Q

Rapid onset fatal asthma - what signs on histology?

A

greater degranulated mast cells
less mucus in airway lumens

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7
Q

RF for asthma - demographics -

A

did not grad from high school

<15000 per year

obese

current daily smoker

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8
Q

What wbc subsets do do airways reveal?

A

neitrophils
eosinophils
mast cells
subbasement membrane thickening
epithelial cell integrity loss
goblet cell hyperplasia
mucuous plugs

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9
Q

Asthma: allergic vs non allergic type - differentiater?

A

presnece of abscence IgE antibodies to common environmental antigens and microbiologic antigens

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10
Q

Regardless of asthma type, what is the common feature (immunology)

A

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

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11
Q

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?

A

prolonged bronchial sm m spasm
edema
mucus production

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12
Q

Common symptoms of asthma

A

wheeze
cough
sob

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13
Q

Slow onset asthma (deterioration over 6 hours) - what demographics/triggers predominate?

A

female
URTI
airflow inflamm response slower to tx

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14
Q

Sudden onset asthma (deterioration < 6 hours) - what demographics/triggers predominate?

A

male predom
triggers by resp allergens
exercise psych stress

more severe response with faster tx improvement

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15
Q

What comorbidities may worsened by CS if used in asthma?

A

db
pud
htn
psychosis

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16
Q

Med triggers for asthma include?

A

nsaid
aspirin
beta blocker (these sp incr hospitalizations and EDvisits
topical agents for glaucoma bb
acei

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17
Q

RF of death from asthma

A

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

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18
Q

RF for asthma exacerbations

A

female
history of one or more exacerbations past year
poor adherence to plan or uncontrolled sx
incorrect inhaler use
chronic sinusitis
smoking
African american

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19
Q

Cough variant of asthma - ddx of cause chr cough?

A

gerd
acei
chronic sinusitis
postnasal drip
inducible laryngeal obstruction

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20
Q

Why do people get exercise induced bronchoconstriction?

A

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

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21
Q

Prophylaxis of airway induced asthma

A

face mask/nasal breathing pre warm up

inhaled GC, SABA 5-10 min prior

LABA with inh GC if above GC not useful alone

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22
Q

What outcomes does obesity negatively effect in pt with asthma?

A

poorer control of asthma
higher admission rate
greater risk of complications

*NOT influence severity or resolution of an acute exacerbation

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23
Q
A
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24
Q

What must be measured in order to diagnose someone with asthma?

A

Peak flows, this is often not done in the emergency department

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25
Q

What peak expiratory flow is concerning for a acute severe asthma, exacerbation versus signifying, life-threatening or near fatal asthma (percent)

A

Less than 50%
Less than 33%

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26
Q

Peros Enns, what pulse oximetry should asthma patients be maintained between?

A

94 and 98%

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27
Q

What will a blood gas look like in Asma exacerbations? (General)

A

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

28
Q

When does Rosen recommend doing an arterial blood gas in asthma?

A

SPO2 less than 92% or PEF is less than 50% of personal best or predictive value

29
Q

What is the pathophysiology of aspirin, exacerbated respiratory disease?

A

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

30
Q

Differential diagnosis of asthma: other disease categories

A

Cardiovascular
Pulmonary
G.I.
Psychogenic
Endocrine
Parasitic.
Iatrogenic from medication.
Neoplastic

31
Q

Differential diagnosis of asthma: cardiac conditions

A

Valvular heart disease.
Heart failure.
Non-cardiogenic pulmonary edema.
Related – adverse reaction to a drug including ace inhibitors

32
Q

Differential diagnosis of asthma – other lung or pulmonary disease causes

A

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

33
Q

Differential diagnosis of asthma – other lung or pulmonary disease causes

A

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

34
Q

What is Loefler syndrome?

A

: A type of eosinophilic pneumonia mimicking community-acquired pneumonia and asthma that arises from Ascaris lumbricoides in a child.

35
Q

What is Churg Strauss syndrome?

A

Eosinophilic granulomatosis with poly angitis

36
Q

What endocrine disease can mimic asthma?

A

Addison’s

37
Q

Frequent SABA treatments can cause what kind of electrolyte abnormalities?

A

Hyperkalemia
Hypo magnesia.
Hypo phosphataemia
Hyper Lactatemia

38
Q

Should I get a chest x-ray in asthma?

A

Not unless I think I need to diagnose pneumonia, pneumothorax, pneumomediastinum, subcutaneous, emphysema, or heart failure

39
Q

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?

A

Comet tail sign

40
Q

In severe asthma, what might your EKG show?

A

RVH that improves with airflow management

41
Q

Key treatment in an acute asthma exacerbation:

A

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

42
Q

Why does magnesium work for asthma?

A

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

43
Q

Are methylxanthines, including Theophylline filling useful to treat acute asthma?

A

No

44
Q

Are leukotriene modifiers useful, and acute asthma?

A

No

45
Q

When should you give antibiotics in an asthma exacerbation?

A

When do you think there’s an infection?

46
Q

Why might ketamine be useful in asthma?

A

Potent bronco dilator effects, only use in the intubated patient or for intubation

47
Q

Why might a blend of 60 to 80% helium with 20 to 40% oxygen help an asthma?

A

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

48
Q

Why might non-invasive ventilation be useful in certain asthma patients?

A

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

49
Q

What might symptoms and signs of acute severe asthma be?

A

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

50
Q

If an asthmatic patient arrests what might pocus useful to find?

A

Unrecognized barotrauma

Therefore consider bilateral tube thoracostomy

51
Q

What increases the risk of relapse after discharge from ED for an asthma patient?

A

Numerous asthma related ED visits within the previous year.
More outpatient medication’s
Longer duration of symptoms before the ED visit

52
Q

What are indicators for disposition home for asthma patients?

A

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

53
Q

When considering disposition what factors might increase the likelihood of admission?

A

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

54
Q

Discharge instructions for patients going home on corticosteroids for asthma treatment

A

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

55
Q

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?

A

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

56
Q

When does follow-up need to be arranged for a family doctor if a patient with asthma is being discharged home?

A

Within 3 to 5 days to contact them and follow up medical appointment within 1 to 4 weeks

57
Q

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

A

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

58
Q

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?

A

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

59
Q

What might be a reasonable induction and paralytic plan for intubation of an asthmatic?
Etomidate and such
Ketamine succ
Midazolam, Pancuronium
Propofol and Rocuronium

A

Be ketamine

60
Q

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

A

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

61
Q

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

A

Give more albuterol

Per Rosens, really not severe enough for Iv mag

62
Q

ECMO consider when?

A

near fatal asthma consideration

63
Q

PRAM score peds asthma mild vs mod vs sever

A

1-3
4-7
8-12

64
Q

PRAM score peds asthma - findings?

A

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%

65
Q

DOPES mneumonic for ventilation

A

displ
obstruction
ptx
equipm issue
stacked breathes

Rosens (19 decks)

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