Arfoosh: Asthma Flashcards
What are 5 common triggers of asthma?
Allergens Exercise Cold Air SO2 Particulates
What are the 4 things that occur in airway remodeling due to asthma?
FIBER, MUSCLE, BLOOD, and BOOGERS Sub-epithelial fibrosis Increased muscle mass Angiogeness Mucus gland hyperplasia
In asthmatic patients, is peak air flow (FEF) higher or lower in the morning compared to the evening?
Lower in the AM
What will be common physical exam findings of an asthmatic patient?
- Increase in RR, HR
- Pulsus Paradosux (systemic drops by 10 or more on inhalation)
- Hypoxia
- accessory ventilation muscle use
- hyper-inflated chest
- prolonged inspiratory phase with ronchi and wheezing
What is the standard workup for an asthmatic patient to assess their level?
CBC with diff IgE Peak Expiratory flow or Spirometry CXR Allergy skin test (not routine) ABG (in severe cases)
What are some complaints your patient may have that will clue you in on a dx of asthma?
- frequent wheezing
- cough at night
- cough/wheeze after exercise
- colds “go to chest” or take >10d to clear
If your patient has a normal FEV or FEV/FVC, does that rule out asthma?
Nnnnnope.
To see if your patient is asthmatic, what test can you perform to trigger its effects?
Metacholine test: positive will show a 20% drop in FEV and will be reversed with bronchodilator.
(this is a somewhat weak positive predictor and a strong negative predictor. if there’s a 20% drop after the first or second dose = asthma. if there’s a 20% drop or less after 3,4,ot5th dose, you might have asthma but probably not.)
Ipratropium is a (short or long-acting?) reliever that acts on which receptors?
Muscarinic
What is the response of inhaled corticosteroids?
Anti-inflammatory Upregulate B Agonist receptors Decrease airway hyper-responsiveness reduce exacerbation reduce asthma-related mortality
What are salmeterol and formoterol?
Long-acting B2 agonists (meter/motor)
How long does bronchodilation last with long-lasting B2 agonists?
12 h
Can you use B2 agonists as a rescue medication?
No
What should always be used together with a long-acting B2 agonist?
ICS
In order to treat asthma in aspirin-sensitive patients or patients with virus-induced-wheezing, what can you use?
Leukotriene modifiers
How does Theophyline work and why must you be careful with dosage?
Phosphodiesterase Inhibitor; narrow therapeutic window (GI and cardiac SE)
How can you treat your patient that is already on a higher corticosteroid dose and continues to have attacks, and is showing elevated IgE?
Omizulab: binds IgE
What can you use in your patient (hospitalized, non-hospitalized) that has severe, persistent uncontrolled asthma?
Prednisone (non-hospital)
Methylprednisone (hospital)
Your patient has daytime sx and need for rescue inhaler less than twice a week, normal lung function, and no limitations of activities or sleep disturbance. Is this patient’s asthma controlled, partly controlled, or uncontrolled?
Controlled
Your patient has daytime sx and need for rescue inhaler more than twice a week, less than 80 of personal best lung function, and occasional limitations of activities and/or sleep disturbance. Is this patient’s asthma controlled, partly controlled, or uncontrolled?
Partly controlled; 3 or more of these factors is uncontrolled
List the 5 characteristics that describe the level of control in an asthma patient.
Daytime sx, activity limitation, sleep disturbance, need for rescue inhaler, and lung function (3 or more in any week is considered uncontrolled)
***Treatment options for asthma in steps 1-5.
Step 1, select one: rapid-acting B2 agonist as needed
Step 2, select one: low-dose ICS or Leukotriene modifier (cheaper)
Step 3, select one: Low-dose ICS plus LABA, OR med or high-dose ICS OR low-dose ICS plus leuko OR low-dose ICS plus sustained release theophylline
Step 4, select one or more: med or high-dose ICS plus LABA OR leuko OR sustained release theophylline
Step 5, add either to step 4 tx: oral glucocorticosteroid (lowest dose) OR anti-IgE tx
ED asthma management, initial assessment shows FEV or PEF >40%. What is your treatment and follow-up?
- O2 (need >90%)
- SABA (inhaled, nebulizer or MDI with valved holding chamber, up to 3 doses in first hour)
- oral systemic corticosteroids if no response (or if patient recently took that already)
F/U: repeat assessment
ED asthma management, initial assessment shows FEV or PEF
- O2 (need >90%)
- high-dose SABA plus ipratropium (inhaled, nebulizer or MDI with valved holding chamber, every 20 mins continuously for 1 hour)
- oral systemic corticosteroids
F/U: repeat assessment
ED asthma management, initial assessment shows impending or actual respiratory arrest. What is your treatment and follow-up?
- intubation and mechanical ventilation (100% o2)
- nebulized SABA and ipratropium
- IV corticosteroids
- consider adjunct therapies
F/U: admit to ICU
ED asthma management, repeat assessment shows FEV or PEF 40-69% (moderate exacerbation). What is your treatment and follow-up?
- inhaled SABA every 60m
- oral systemic corticosteroid
F/U: continue tx for 1-3h; make an admit decision in
ED asthma management, repeat assessment shows FEV or PEF
- O2
- nebulized SABA
- oral systemic corticosteroids
- consider adjunct therapies
ED asthma management, after your repeat assessment, what is your follow-up?
- If good response (>70% and sustained 60m after last tx, no distress, normal PE): D/C home, con’t with SABA, corticosteroid, consider ICS initiation, patient education
- If incomplete response (40-69%): Hospital Ward, O2, inhaled SABA, corticosteroid (oral or IV), monitor (once they improve, step down to D/C home with the above tx)
- If poor response (
