Asthma Flashcards
Chronic respiratory condition characterized by wheezing, coughing, distress, and bronchospasm
Asthma
Pathophysiology of Asthma
Immune/allergic reaction (inflammation) in the basement membrane that causes permanent changes (airway remodeling)
Asthma can cause episodes of ____, ____, ____, ______. These episodes are reversible either spontaneously or with treatment.
wheezing, chest tightness, breathlessness, nighttime or early morning cough
Who is most likely to have asthma (location, race)
Low income, minority (black, American Indian, and some hispanic), inner city, children
Other chronic lung disease, CF, obesity (exercise intolerance), CV disease and immunodeficiency disorders are co morbidities of what?
Asthma
Asthma can cause smooth muscle dysfunction that leads to _______, bronchial ______, _______ of lung cells, and inflammatory mediator release
bronchospasm, hyperreactivity, hypertrophy/hyplerplasia of lung cells
Asthma can also lead to _____ ________, which causes inflammatory cell infiltration, mucosal edema, _____ damage, and basement membrane ______
airway inflammation; epithelial; thickening
So triggers lead to a immunohistopathologic response meaning:
shedding of epithelium and collagen deposition under basement membrane
-Edema occurs and mast cells are activated and then inflammatory cell infiltration occurs
Inflammation in asthma then leads to _____ and evolves into wheezing ____ _____, and cough
bronchospasm/constriction; chest tightness
_____ ______ occurs due to persistent inflammation that leads irreversible changes
such as abnormal airway diameter (caliber), decreased airflow
Airway remodeling
Triggers lead to airway inflammation, leading to ____ production, airway ____tightening, and swollen ___ ___, which leads to narrowing of breathing passages then ___, ___ and ______
mucous production, airway muscle tightening, and swollen bronchial membranes; wheezing, coughing, and SOB
Common asthma triggers include
Infections, viral respiratory illness (rhino/enterovisrus, parainfluenza, RSV, metapneumovirus), seasonal allergens, pets, cigarrette smoke, weather changes
Rule of 2’s (2 SABA canisters/years, 2 doses of SABA/wee, 2 nocturnal awakenings/month, 2 unscheduled visits/year, 2 PO steriod bursts/year)
Helps determine the need to add controller therapy in asthma (step 1 to STEP 2)
Medications: Reliever (Fast acting)
Taken as needed for rapid, short term relief
It is used to ____ or ____ an asthma attack.
Examples include albuerol or Xopenex ( less tachycardia than albuterol so consider in kids with heart issues)
Anticholinergic (Ipratropium or Atrovent) or Corticosteriods (systemic)
prevent or treat
Corticosteroids \_\_\_mg/kg per dose BID or 2-4mg/kg/day Liquid prednisone (poor taste) 15mg/5ml Pills (adult daily mac is \_\_\_\_\_mg) Oral dissolving tablets but insurance may be an issue
1-2
60
Controller Medications are taken _____ to control chronic symjpmtoms and prevent asthma attacks
Regularly
The most important type of medication for people with asthma is _______
controller medications
Controller medications are not _____, and one option during an exacerbation is doubling dose of _____ instead of giving steroids.
systemic; ICS
Example of a controller medication s______
Inhaled corticosteroids which are anti-inflammatory, most effective and commonly used for long term control; reduce swelling and tightening in airways, but can take several days/weeks to reach max. benefit
Inhaled corticosteroid examples
Fluticasone (Flovent), Beclomethasone (Qvar), Ciclesonide (Alvesco), Flunisolide (Aerobid)
Nebulizer (bedside (Pumicort), or even Mometasone.
- insurance helps determine.
- encourage kids rinse mouth out
LABA: _____ that opens up narrowed airways and reduces ____. They last for at least ___ hours and can control moderate to severe asthma and _____symptoms.
bronchodilators; swelling; 12; nighttime
*Salmerrol (Serevent) or Foradil
Combination inhalers can increase the risk for __________ and contain both a corticosteroid and long acting beta agonist
Severe asthma attacks
*Advir, Symbicort, Dulera)
Leukotrine modifiers (Antagonists) block the effect of leukotrienes which are: \_\_\_\_\_\_\_, \_\_\_\_\_\_ released by \_\_\_\_ cells, These medications help prevent symptoms for \_\_\_\_hours
immune system chemicals that cause atopy symptoms and are released by mast cells. They help prevent symptoms for up to 24 hr.
*Montelukast (Sinfugulair)
1-5m=4mg, 6-14 = 5mg, >14 = 10mg
SE: nighttime terrors/hallucinations
Can use antihistamines, Leukotrine Antagonists, allergy shots, or omalizumab for _____
allergy-mediated symptoms
Spacers can help pt. with _________ and ________
difficulty using an inhaler/can reduce SE from medication.
*less thrush
If well controlled for 3-6m Improved spirometry Improved hx. and time of year is when they are not triggerd improved peak flow, what should you do?
Step Down
Acute exacerbation of asthma symptoms:
tachypnea, low 02 saturations, wheezing, retractions, tracheal tugging, breathlessness at rest, hunched forward, speaks in words vs. sentences, agitation, low peak flow (less than 60% of normal)
Acute exacerbation concerns
early tx. has better outcomes
identify pt. at risk for death
In an acute asthma attack:
SABA (you can double neb treatment or do an hour long neb tx.), oxygen, corticosteroid,
If there is concurrent illness present, give antibiotics
Azrithomycin has ______ effects that have actions on macrophages, COX-inhibitory effects
anti-inflammatory
Cystic Fibrosis is cause by abnormalities in the _____ protein that’s produced by mutations in the _____ gene
CFRT
CF presentation in utero
increased echogenicity on ultrasound
Newborn CF manifestations
Meconium ileus; delayed stool passage; jaundice
Infant and Children
Malabsorptive stools, rectal prolapse, failure to thrive, intusseption
CF presentation (Gastrointestinal)
Malabsorption of fat, protein, CHD, fat soluable vitamins, malabsorptive stools, FTT (but have a voracious appetite), recurrent abdominal pain, pancreatitis.
(hepatobiliary) electrolyte imbalance/abnormal liver enzymes
Respiratory CF presentation
Chronic cough (mucous production), Respiratory infections (recurrent), persistent and recurrent wheeze, prolonged symptoms of bronchiolittis, recurrent/chronic rhinosinusitis, bronchlectasis , finger clubbing
CF dx.
newborn screening; sweat test >60 mEq, malabsorptive studies, vitamin E, stool pancreatic elastase (<100)
Pneumonia
Effects_____ respiratory tractParticularly the ______ Lobar, interstitial, bronchial
Many viruses progress to secondary bacterial infection
lower; parenchyma
Pneumonia associated symptoms
Fever, cough, increased respiratory effort, dehydration, +/- wheezing
____, hypoxia, and____ are signs of worsening ____
nasal flaring; retrations; worsening pneumonia
Gold standard for diagnosing pneumonia
Crest X-ray (infiltrates/consolidation
Viral pneumonia is more common in _________. Symptoms include ___, _____, and tachypnea. We treat symptomatically and by ____, ____, _____, monitor and if suspecting possible bacterial thick about azithromycin
children; cough, fever; increasing water, isolation, and treating fever
Bacterial Pneumonia can be a ____ of vial pneumonia and is associated with ________. tx. includes ______, which is safest in neonates but if _____ or _______, give azithromycin. If influenza, use _______
secondary complication; influenza A. Amoxicillin; walking pneumonia or community acquired; Tamiflu
Bronchitis is associated with inflammation in the ____ airways vs. bronchiolitis in the ______
large; small
Bronchitis is associated with ___ and ____vs. bronchiolitis which is associated with ______
pharygitis and laryngitis; copious mucous secretion and upper wairway symptoms that move into lower airway
Bronchitis can be acute, chronic, viral or bacterial wheras bronchiolitis is ______ usually
acute
both bronchitis and bronchioltis are more prominent in the _____
Winter
Bronchitis can be treated with:
Cough suppressants in adults or expectorants in kids (Mucinex) and bronchodilators
Bronchiolitis is most common lower respiratory infection in kids ages ________
1 month to 2ys
Bronchiolitis is caused by 5 viruses (name them) and has the symptoms of edema and necrosis of lining in small airways, ___ mucous production, and _____
RSV, adenovirus, influenza, para influenza, human metapneumovirus
___ is the most common agent for bronchiolitis with the greatest incidence between ____ and March. 90% of kids are infected in the first 2 years of life
RSV; December
RSV’s incubation period is _ to _ days. It is transmitted by _____ contact, _____ ____ droplets, and can survive for ___ on hands and fomites
4-6; direct contact (nasopharyngeal or ocular mucous membranes, large aerosol droplets; hours
RSV Risk factors include
premature birth (less than 37w), young child (6-12 weeks), development of apneic episodes, hemodynamically significant heart disease, chronic lung disease, immunocpromised, non-breastfed
RSV symptoms: _____ is the presenting symptom in 20% of infants admitted to the hospital, significant _____, tachypea (over ____ RR), wheezing, coughing, crackles, nasal flaring, use of accessory muscles, and 50-75% also have ______
Apnea; rhinitis; 70; Acute otitis media
RSV dx.
Clinical features; virologic nasopharyngeal testing; pulse oximetry <90, chest X-ray (r/o pneumonia) , CBC
RSV management incudes: supportive nutrition/hydration. Insert an IV PRN ; Pulse oxyden PO is _____, antibiotics only is ____ present. Suction the nares
<90%; AOM
___ should not routinely be used for RSH (modest short term improvement), _____ not okay if <24m, ____ only used in immosuppressed patients with RSV, and if _____ and on Synagis they may continue
Bronchodilators; Corticosteriods; premature
RSV is worse on day ___
4
____ is also known as ____ or ____ and is cause by the bacterium ______ _______
Pertussis; Bordetella pertussis
symptoms of Pertussis include a ______ _______ cough that is accompanied by an ____ whoop and patients may often have a ___ worsening or subsequent encounter ; reportable to local health department
prolonged paroxysmal; inspiratory; second
Pertussis mode of transmission is ___ to ____ by ____ ____ or ___ contact with sections from respiratory tract. 80% have a secondary attack rate, and older adults and kids are a source for infants and young children. Kids ______m are at greatest risk for complications and death
<12m
Incubation for pertussis ____ days. Most infectious period is during the catarrhal stage or ______w ____ cough and first ___ weeks ____ cough onset.
Duration is _____ or ___ in adolescents
7-10 days; 3 weeks before cough or 2 weeks after cough onset.
Duration is 6-10w or 10+ in adolescents
Pertussis is dx. without labs if patient has COUGH LASTING ____ WEEKS WITHOUT LIKELY DX. AND 1 OF THE FOLLOWING:
> 2; paroxysm of cough, inspiratory whop, post tussive vomitting, apnea without or without cyanosis (if <1y)
Cough that is not improving, rhinorrhea with steady watery mucous, apnea, seizures, cyanosis, vomitting, or poor weight gain; ____ (WBC > 20,000) with lymphocytosis ( ____% lymphoctyes), pneumonia, subconjunctival hemorrhage, sleep disturbance, or
leukocytosis; 50%
Labs for Pertussis
CBC with Diff (WBC/lymphocytes are directly related to severity in infants) , Chest X-ray )could be normal/r/o pneumonia), PCR and culture if <4 or PCR and serology is ?4 ( IgG is >1 if vaccinated)
Syncope, rib fractures, incontinence, sleep disturbance, (pneumonia, seizures, encephalopathy in infants) and death (unvaccinated infants) are complications of
Pertussis
If child is < ____m, in respiratory distress, may have PNA, unable to feed, cyanotic or apnea with or without cough, or has a seizure, send them to the _____
At home, ___ and ___. ___ aren’t recommended
HOSPITAL
Nutrition/fluids; cough suppressants
Antimicrobial therapy may be given to kids with pertussis if given within ___ days of symptom onset because it can shorten duration and decrease transmission, espically if
7; 6
tx. includes azithromycin, erythromycin, clarirothymic, and TMP-SMX
T or F: Treat close contacts pending PCR and isolate the patient for 5 days after giving antibiotics or 21 days if no antibiotics
T
laryngotracheitis or laryngotracheobronchitis typically effects ____m to ____y
Croup; 3m-3y
Croup is _____; most common causes : Parainfluenza, adenovirus, RSV.
Leads to _____ and _____ of larynx and subglottic area & decreased mobility of the ______ ______
viral;
inflammation and infection; vocal chords
Croup is ______, beginning with nasal irritation, coryza, and congestion. Generally progresses over ___ to ___ hours to include fever, _____, ___ cough, and stridor
Respiration distress ___ as upper airway obstruction becomes more severe.
gradual; 12-48; hoarseness, barking; increases
Cough resolves in ___ days, other symptoms may persist for ____ and gradually return to normal
3; 7
- deviations in course suggest different diagnosis
occasional barking cough, no stridor at rest, mild to no suprasternal retractions
Mild croup disease
Moderate Croup disease:
____cough, ____audible stridor at __, and retractions _____
Severe Croup presents as ____ cough, inspiratory/expiratory ______, retractions, cyanosis, lethargy, distress, and agitation
frequent; stridor
Croup dx.
Clinical presentation, A/P neck x-ray will show subglottic _____ (steeple), CBC might show ______
Croup management at home;
humidity, cool air mist, steam from bathroom, exposure to outdoor cool air, adequate hydration, fever reducation, and oral fluids
Outpatient management of Croup;
Glucocorticoids: single dose of oral or IM dexamethasone (0.6mg/kg)
Prednisolone (2mg/kg per day for three days)
Tell parents to seek medical attention:
Stridor at rest, difficulty breathing, pallor or cyanosis, suprasternal retractions, severe coughing spells, drooling, difficulty swallowing, fatigue, worsening course, fever >38.5 and prolonged symptoms greater than 7 days
Severe Croup management
Send to ER; Nebulized Racemic epinephrine (NOT GIVEN OUTPATIENT), dexamethasone (+/- prednisolone for 3 days)
Moderate/severe croup with persistent or deteriorating respiratory distress after treatment with racemic epinephrine and corticosteroids (In ER or office)
Severe croup with poor air entry, altered consciousness, or impending respiratory failure
Dehydration
Significant respiratory compromise
Signs of respiratory failure
”Toxic” appearance or clinical picture suggesting serious secondary bacterial infection
Need for supplemental oxygen
Severe dehydration
Hospitalization Indications
____ is an acute inflammation of the ___, cartilaginous structure covered with mucous membrane, and pharyngeal structures
epiglottitis; epiglottis
Epiglottitis affects kids _ through __ and is caused by ____, S. pneumoniae, H parainfluenzae, S. aureus, and beta hemolytic streptococci
2-7; HIB
Epiglottitis Manifestations: There is a tyriad of ____, dysphagia,____; also high ___, ___positioning, dyspnea, inspiratory stridor, accessory muscle use, ____ voice, and ___ cough
drooling; distress/ high fever; tripod positioning; muffled; brassy
CALL 911
Epiglottitis Dx.
Lateral neck is enlarged, edematous epiglottis, Laryngoscopy (direct inspection of epiglottis under controlled circumstances), leukocytosis, and + blood cultures for staph/strep.
Epiglottits management
ER HOSPITALIZATION
-Secure airway with intubation or cricothyroidotomy, sit child upright, humidifed oxygen, no tongue blades, IV antibiotics (ROCEPHIN)
If a child is younger than 5, they cannot have a ___ infection
sinus
