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MS2 Respiratory > 9/21- Asthma > Flashcards

9/21- Asthma Flashcards

1
Q

T/F: Mortality rates of asthma have decreased over recent years

A

True

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2
Q

T/F: Mortality rates of COPD have decreased over recent years

A

False???

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3
Q

What are some basic characteristics of asthma?

A
  • Chronic inflammatory disorder of the airways
  • Associated with increased airway responsiveness leading to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
  • Particularly at night or in the early morning
  • Episodes typ associated with widespread but variable airflow obstruction
  • Often reversible either spontaneously or with treatment
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4
Q

T/F: There has been a recent increase in asthma prevalence in the past decade?

A

True; 15% increase

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5
Q

What are the risk factors that lead to asthma development?

  • Predisposing Factors
  • Causal Factors
  • Contributing Factors
A

Predisposing Factors

  • Atopy
  • Gender

Causal Factors

  • Indoor Allergens: Domestic Mites, Animal Allergens, Cockroach Allergens, Fungi (esp Aspergillus)
  • Outdoor Allergens: Pollens, Fungi
  • Occupational Sensitizers

Contributing Factors:

  • Respiratory Infections
  • Small Size at Birth
  • Obesity
  • Air Pollution: outdoor and indoor pollutants
  • Smoking: passive and active
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6
Q

T/F: You can “outgrow” asthma

A

False

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7
Q

What is the pathogenesis of asthma?

A
  • Starting factors: genetically susceptible host + risk factors (viral infection, smoke exposure, allergen exposure…)
  • Hormones; aggravated by nonallergen exposure (irritants like smoke, infections, exhaust)
  • Chronic allergen exposure -> chronic symptoms (i.e. congestion) -> established disease
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8
Q

What is the early phase response of asthma?

A

Allergen-Mediated IgE Cross-linking Triggers Mast Cell Degranulation

  • Prostaglandins (CCL2, IL-8)
  • Histamine
  • Leuokotrienes Results in characteristic asthma airway effects
  • Vasodilation, edema, increased mucus
  • Recruitment of inflammatory cells
  • Bronchospasm
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9
Q

What is the late phase response of asthma?

A

Allergen Recognition by Mast Cells or T Cells Drives Inflammatory Cell Recruitment and Synthesis of Additional Mediators

  • Inflammatory cytokines (IL-4, 5, 13)
  • Inflammatory cell recruitment and activation: eosinophil, TH2 cell, basophil, neutrophil
  • Increased production of cytokines and inflammatory mediators

Symptoms of chronic asthma:

  • Thickened basement membrane
  • Epithelial injury
  • Increased mucus
  • Airway obstruction
  • Recruitment of inflammatory cells
  • Bronchospasm
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10
Q

Chronic airway inflammation leads to what?

A

General increase in sensitivity to triggers

  • Regular exposure of allergic asthma pts to allergens -> chronic inflammation
  • Increases in immune cells in the lung, resulting in additional hypersensitivity
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11
Q

Typical inflammation in asthma involves what cell?

A

Eosinophilic inflammation

  • May involve neutrophils as well (subset; not as common as in COPD)
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12
Q

What is the pathology behind airway obstruction and related symptoms?

A
  • Bronchoconstriction
  • Mucus Plugs
  • Mucosal Edema
  • Inflammatory Cell Infiltration/Activation
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13
Q

What is remodeling in asthma?

A
  • Increased vascularity
  • Epithelial cell disruption
  • Increased airway smooth muscle mass (hyperplasia)
  • Reticular basement membrane thickening
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14
Q

What are the major symptoms of asthma and characteristics of the disease?

A

Wheezing

  • During cold/illness, when laughing/crying, in response to allergens or irritants

Breathlessness

Chest tightness

Cough

  • Frequent (esp at night)*
  • May be only sign in children
  • When laughing/crying or in response to allergens/irritants Likely to occur at night and early in the morning*

Likely to increase with activity and exercise

  • Esp during cold weather

*Lowest airflow occurs at night; fluctuation in cortisol levels; GERD may also play a role

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15
Q

What is the differential diagnosis for asthma in pediatric pt?

A

“Active Airway Disease” used in pediatrics to refer to asthma or one of these other diagnoses (not used in adults)

  • Distinguish chronic cough from acute cough, which may correspond to viral infections
  • Congenital abnormalities
  • Cystic fibrosis
  • Gastroesophageal reflux
  • Airway obstruction
  • Bronchopulmonary dysplasia
  • Upper airway noise
  • Immunodeficiency
  • Congenital heart disease
  • Vocal cord dysfunction
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16
Q

What is the differential diagnosis for asthma in adult pts?

A
  • Chronic obstructive pulmonary disease
  • Congestive heart failure
  • Gastroesophageal reflux
  • Mechanical obstruction
  • Medication
  • Vocal cord dysfunction: more in healthcare fields, more in women, “pseudo-asthma”; may see inspiratory loop abnormality and upper airway symptoms
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17
Q

What are some key differences between the presentation of asthma and COPD?

A
  • Age: asthma presents early in life (often childhood) while COPD onset is in midlife
  • Symptoms vary from day to day in asthma but are slowly progressive in COPD
  • Timing: night/early morning (acid reflux) Sx in asthma
  • Reversability: asthma is largely reversible airflow limitation while COPD is only partially reversible
  • Allergic rhinitis and/or eczema may also be present in asthmatics
  • Asthmatics may have family history of asthma
  • COPD may involve dyspnea during exercise or a long smoking history
18
Q

What clinical evaluation method is key to the diagnosis of asthma?

A

Spirometry

  • Assess severity of airflow obstruction; symptoms alone are insufficient to determine asthma severity
  • Helps rule out restrictive airway disease and may show reversability of asthma
  • Confirms home PEFR msmts
19
Q

What are the expected spirometry results in asthma?

A

Confirm that there is airflow obstruction and at least partially reversible

  • Obstruction: FEV1 under 80% predicted; FEV1/FVC under 70%
  • Reversibility: FEV1 OR FVC increases > 12% AND at least 200 mL after using a short-acting inhaled B2 agonist
20
Q

What are additional tests you can do with asthma (in addition to spirometry) if pt has asthma symptoms but normal/near normal spirometry?

A
  • Assess diurnal variation of peak flow over 1 to 2 weeks
  • Refer to a specialist for bronchoprovocation/methacholine, histamine, or exercise; negative test may rule out asthma
21
Q

What are additional tests if you suspect infection, large airway lesions, heart disease, or obstruction by foreign object?

A

CXR

22
Q

What are additional tests if you suspect coexisting COPD, restrictive defect, or central airway obstruction?

A
  • Additional pulmonary fct studies
  • Diffusing capacity test
23
Q

What are additional tests if you suspect other factors that contribute to asthma?

A
  • Allergy tests: skin or in vitro
  • Nasal examination
  • Gastroesophageal reflux assessment
24
Q

What are the goals of asthma mgmt?

A

“ACHIEVE OVERALL ASTHMA CONTROL”

Reduce Impairment

  • Symptoms
  • Reliever use
  • Activity
  • Lung infection

Reduce future risk

  • Instability/worsening
  • Exacerbations
  • Loss of lung function
  • Adverse effects of medication
25
Q

Whatare the 4 “legs” of asthma mgmt?

A
  1. Initial Assessment and Continuous Monitoring
  2. Control of Triggers
  3. Pharmacotherapy
  4. Asthma education
26
Q

What are the key elements of assessment and monitoring?

A

Severity

  • Intrinsic intensity of dz during pt’s initial presentation
  • Application: used for initiating appropriate meds

Control

  • Degree to which manifestations are minimized and goals of long-term control therapy
  • Application: guides decisions to maintain/adjust therapy
  • Responsiveness to treatment ease with which asthma control is achieved by therapy

Severity and Control are defined in terms of current impairment and future risk.

27
Q

Skim: what are the characteristics of intermittent asthma?

A
  • Sx fewer than 2 days/wk
  • Nighttime awakenings under 2 times/mo
  • Short B2 agonist for control under 2 days/wk
  • No interference with normal activity
  • Lung function: normal FEV1 between exacerbations; FEV1 > 80%, FEV1/FVC normal
28
Q

Skim: what are the characteristics of severe asthma?

A
  • Sx throughout the day
  • Nighttime awakenings often (7x/wk)
  • Short B2 agonist for control several times/d
  • Extremely limited normal activity
  • Lung function: FEV1 under 80%; FEV1/FVC reduced > 5%
29
Q

What should be done after Initial Assessment?

A

Assessment of Control

  • Current impairment
  • Future risk
30
Q

When should you assess comorbid conditions? Examples?

A

Evaluate for comorbid conditions during Hx and when asthma cannot be well controlled

  • Allergic bronchopulmonary aspergillosis (ABPA)
  • GERD
  • Obstructive sleep apnea (OSA)
  • Obesity
  • Rhinitis/sinusitis
  • Stress/depression
31
Q

What are some pharmacological treatments for long-term control?

A
  • Inhaled

Corticosteroids

  • Cromolyn/nedocromil
  • Leukotriene modifiers
  • Long-acting beta2-agonists
  • Methylxanthines
32
Q

What are some pharmacological treatments for quick relief?

A
  • Short-acting inhaled beta2-agonists
  • Anticholinergics
  • Systemic corticosteroids
33
Q

T/F: All persistent asthmatics should be on a controller medication?

A

True

  • Inhaled corticosteroids (ICSs) are the most potent and consistently effective long-term control med for asthma
  • Leukotriene agents are alternatives to steroids in children
34
Q

What are some key educational messages for asthma education?

A
  • Basic Facts About Asthma: contrast normal and asthmatic airways
  • Roles of Medications with Long-term-control and quick-relief medications
  • Relevant Environmental Control Measures
  • When and How To Take Rescue Actions
  • Skills: Inhalers, spacers, symptom and peak flow monitoring, early warning signs of attack
35
Q

What should all pts with asthma receive to guide their self-management efforts?

A

A written Asthma Action Plan (AAP)

  • Daily Rx
  • How to recognize worsening asthma
36
Q

What are features of an “ideal” Asthma Action Plan?

A
  • Lays out specific steps that patients can take under changing clinical conditions
  • Provides guidelines for when to seek urgent or emergency medical care
  • Constructed in collaboration with patient and family to be incorporated into daily activities and consistent with patient goals
  • Presented in a way that is convenient and easy to visualize
37
Q

What is PEFR?

A

Peak expiratory flow rate

38
Q

What is the importance of PEFR in asthma monitoring?

A
  • Monitors response to therapy
  • Important for those with poor perception of symptoms
  • Identifies variation in disease severity, >20% suggests worsening asthma
  • May help identify environmental /occupational triggers
  • Important clinical tool in home
39
Q

What are components of the Well Asthma visit?

A
  • Review control/severity questions
  • Review history of exacerbations (and effect on quality of life)
  • Directed physical exam (need to look at skin, esp in kids for ectopic dermatitis)
  • Record spirometry results
  • Education: Review medication / spacer use, and patient adherence to medical regimen
  • Review patient satisfaction
  • Schedule return visit
40
Q

Epidemiology of asthma:

  • Which gender is most affected
  • What races are most affected?
A

Gender: women > men

Race:

  • African American
  • Hispanic/Puerto Rican

MS2 Respiratory (26 decks)

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