Asthma Flashcards
is a syndrome characterized by airflow obstruction that varies markedly, both spontaneously and with treatment.
Asthma
approximately ____ of adults and ____ of children affected by the disease.
10–12% adults
15% children
Major risk factors for asthma deaths are
- poorly controlled disease with frequent use of bronchodilator inhalers
- lack of or poor compliance with ICS therapy
- previous admissions to hospital with near-fatal asthma.
Endogenous Risk factors for ASTHMA
Genetic predisposition ATOPY airway hyperresponsiveness Gender Ethnicity Obesity Early viral infections
Environmental Risk factors for ASTHMA
Indoor allergens Outdoor allergens Occupational sensitizers Passive smoking Respiratory infections Diet Acetaminophen (PARACETAMOL)
Asthma TRIGGERS
Drugs (BB & ASA) Allergens URT viral infx Exercise and hyperventilation Cold air Sulfur dioxide and irritant gases Stress Irritants (paints, sprays)
Mast cells release several bronchoconstrictor mediators including :
histamine
prostaglandin D2
cysteinyl-leukotrienes
several cytokines, chemokines, growth factors, and neurotrophins.
____ is an upstream cytokine released from epithelial cells of asthmatics that orchestrates the release of chemokines that selectively attract TH2 cells.
TSLP
Thymus stimulated lymphopoeitin
Th2 cytokines that mediates allergic inflammation
IL-4
IL-5
IL -13
Pro-inflammatory cytokines that amplify the inflammatory response and play a role in more severe disease
TNF-a
IL-1b
Inflammatory mediators
histamine
prostaglandin D2
cysteinyl-leukotrienes
Inflammatory mediators (histamine
prostaglandin D2
cysteinyl-leukotrienes)
Contract airway smooth
Asthma can present at any age, with a peak age of
3 years
is the major risk factor for asthma
Atopy
This is rarely useful in clinical practice, but can be used in the differential diagnosis of chronic cough and when the diagnosis is in doubt in the settingof normal pulmonary function tests.
The increased AHR is normally measured by methacholine or histamine challenge with calculation of the provocative concentration that reduces FEV1 by 20% (PC20).
is now being used as a noninvasive test to measure eosinophilic airway inflammation. The typically elevated levels in asthma are reduced by ICS, so this may be a test of compliance with therapy. It may also be useful in demonstrating insufficient anti-inflammatory therapy and may be useful in down-titrating ICS.
Fractional exhaled nitric oxide (FENO)
act primarily on airway smooth muscle to reverse the bronchoconstriction of asthma
Bronchodilators
Gives rapid relief of symptoms but has little or no effect on the underlying inflammatoryprocess. Thus, are not sufficient to control asthma inpatients with persistent symptoms.
bronchodilators
True or false
Anticholinergic are less effective than β2-agonists in asthma therapy as they inhibit only the cholinergic reflex component of bronchoconstriction, whereas β2-agonists prevent ALL bronchoconstrictor mechanisms.
True
These effects may account For the reduction in AHR that is seen with chronic ICS therapy.
ICS reduce eosinophils in the airways and sputum, and numbers of activated T lymphocytes and surface mast cells in the airway mucosa.
ICS are nowgiven as first-line therapy for patients with persistent asthma, butif they do not control symptoms at low doses, it is usual to add a _____ as the next step
LABA
is a depot preparation that is Occasionally used in noncompliant patients, but proximal myopathy is a major problem with this therapy.
IM triamcinolone acetonide
are asthma Controller drugs that appear to inhibit mast cell and sensory nerve activation and are, therefore, effective in blocking trigger-induced asthma such as EIA and allergen- and sulfur dioxide-induced symptoms.
Cromolyn sodium and nedocromil sodium or cromones
is a blocking antibody that neutralizes circulating IgE without binding to cell-bound IgE and, thus, inhibitsIgE-mediated reactions
Omalizumab
markedly reduce blood and tissue eosinophils and reduce exacerbations in patients who have persistentlyincreased sputum eosinophils despite maximal ICS therapy.
Anti-IL-5 Antibodies that block IL-5
mepolizumab, reslizumab) or-it’s receptor (benralizumab
is a bronchoscopic treatment using thermal energy to ablate airway smooth muscle in accessible bronchi. It may reduce exacerbations and improve asthma control in highly selected patients not controlled on maximal inhaler therapy, particularly when there is no increase in inflammation.
Bronchial thermoplasty
True or false:
Anti-IL-13 blocking antibodies have little clinical effect, but-an antibody (dupilumab) against the common receptor for IL-4 and IL-13 (IL-4Rα) is more promising in reducing exacerbations and improving asthma control in severe asthma
True
A course of OCS (usually prednisone or prednisolone ____ once daily for 5–10 days) is usedto treat acute exacerbations of asthma; no tapering of the dose isneeded
30–45 mg
What dose is used For mild to moderate exacerbations, using repeated administrations of INHALED SABA is an effective and efficient way to achieved rapid reversal of airflow limitation.
4-10 puffs SABA every 20mins for the first hour
The recommended dose of OCS for adults is
1mg prednisolone/kg/day
Or equivalent up to a maximum of 50mg/day
OCS should usually be continued for how many days
5-7days
What are the SABA?
Saba AT
Albuterol
Terbutaline
What are the LABA?
LABAS F
Salmeterol
Formeterol
What are the ANTICHOLINERGICS?
ITsANTICHOLINERGICS
Ipratropium
Tiotropim
What are the oral corticosteroids?
Prednisone
Prednisolone
What are the ICS?
FLUTICASONE
BUDESONIDE
What are the relievers or Bronchodilators?
Beta 2 agonists SABA LABA
Anticholinergic ITS
Theophylline (aminophylline)
MOA OF B2 agonists
Inhibition of mast cell mediator release
Reduction in PLASMA EXUDATION
Inhibition of SENSORY NERVE ACTIVATION
NO EFFECT: dec of AHR & inflammation
Discharge management:
Patients currently prescribed ICS containing medication should generally have their treatment stepped up for how many days
2-4weeks
Discharge management:
Prescribe OCS at least now many days and dosages?
5-7 day course of OCS
Prednisone or equivalent 40-50mg / day
If the OCS is DEXAMETHASONE, how many days of treatments post discharge?
1-2days
The FEV1/FVC ratio is normally more than ____ in adults, and more than 0.85 in children.
0.75–0.80
FEV1 increases by >200mL and >12% of the baseline value (or in children, increases by >12% of the predicted value) after inhaling a bronchodilator. This is called
bronchodilator reversibility
Evidence of variability of expiratory airFlow limitation:
FEV1 increases by more than 12% and 200mL from baseline (in
children, by >12% of the predicted value) after
4 weeks of anti- inflammatory treatment (outside respiratory infections
True or false:
Bronchodilator reversibility may be absent during severe exacerbations or viral infections. If bronchodilator reversibility is not present when it is first tested, the next step depends on the clinical urgency and the availability of other tests.
True
What is the role of lung function in monitoring asthma?
Once asthma has been diagnosed, lung function is most useful as an indicator of future risk. It should be recorded at
diagnosis,
3–6 months after starting treatment, and periodically thereafter.
Over-use of SABA (e.g. ≥3 canisters dispensed in a year) is associated with an increased risk of severe exacerbations, and dispensing of ___ canisters in a year is associated with increased risk of asthma-related death.
≥12
given intravenously or by nebulizer is effective when added to Inhaled β2-agonists, and is relatively well tolerated but is not routinely recommended.
Magnesium sulfate
The preferred treatment in step 1 in patient’s who have symptoms less than twice a month
As needed Low dose ICS + formoterol (LABA)
Off label controller options at step 1
Low dose ICS taken whenever SABA is taken
Preferred controller in step 2
DAILY low dose ICS plus as needed SABA
Off label: As needed low dose ICS-FORMOTEROL (LABA)
True or false:
Daily low dose of ICS + LABA as initial therapy leads to faster improvement in symptoms and FEV1 than ICS ALONE but more costly and the exacerbation rate is similar
True
Preferred controller in step 3
Low dose ICS-LABA maintenance plus as needed SABA
or
Low dose ICS FORMOTEROL maintenance and reliever therapy
For adult patients with rhinitis who are allergic to house dust mite, consider adding — provided FEV1 is >70% predicted
sublingual immunotherapy (SLIT)
When should patient follow up after starting treatment?
Patient should preferably be seen at 1-3 months after starting treatment and every 3-12 months after that.
When should pregnant patient follow up after starting treatment?
In pregnancy, asthma should be reviewed every 4-6 weeks
In a well controlled asthma, Step down thru available formulations to reduce the ICS dose by 25-50% is done at how many months of interval?
2-3 months
If asthma is well controlled on low dose ICS or LTRA, what is a step down option?
As needed Low dose ICS -formeterol
Value of FEV1/FVC that is diagnostic of obstruction?
<70%
Value of total lung capacity that defines restrictive pathophysiology
<80%
Although most patients with asthma are easily controlled with appropriate medication, a small proportion ofpatients (~5%) are difficult to control despite maximal inhaled therapy
Refractory Asthma
It is defined by a failure to respond to a high dose of oral prednisone/prednisolone (40 my once daily over 2 weeks), ideally with a 2-week run-in with matched placebo
Corticosteroid-Resistant Asthma
Some patients show chaotic variations in lung function despite taking appropriate therapy. Some show a persistent pattern of variability and may require OCS or, at times, continuous infusion of β2-agonists
type I brittle asthma
generally normal or near-normal lung function but precipitous, unpredictable falls in lung function that may result in death
type 2 brittle asthma
The most effective therapy in brittle asthma, which suggests that the worsening islikely to be a localized airway anaphylactic reaction with edema
subcutaneous epinephrine
In Pregnancy, drugs that have been used for many years in asthma therapy have now been shown to be safe and without teratogenic potential. Thesedrugs include
SABA, ICS, and theophylline
If an OCS is needed, it is better to use this drug rather Than prednisolone as it cannot be converted to the active prednisolone by the fetal liver, thus protecting the fetus from systemic effects
prednisone
In asthma,a patients undergoing surgery,Patients who are treated with OCS will have adrenal suppression and should be treated with an___ dose of OCS immediately prior to surgery.
increased
For patients with mild, intermittent asthma, what meds is all that is required
SABA
The treatment of choice for all patients is an ___ give twice daily.
ICS
Seen in 10% of patients, normal serum IgE, later onset, commonly with nasal polyps, may be ASA sensitive, usually more severe persistent asthma, increased local production of IgE In The airways
Intrinsic asthma
Implicated antigen in intrinsic asthma
Staphylococcal enterotoxin
Airway edema + acute infallmatory response with increased eosinophils and neutrophils that is not reversible with bronchodilators
Late phase allergic reaction
In exercise induced asthma the best prevention is
Regular tx with ICS
Other prevention: B2 agonist and antileukotrienes
Environmental air pollutants that inc asthma symptoms
Ozone
NO2
So2 sulfur dioxide
Diesel particulate
Characteristic pathological finding in asthma
Thickening of the basement membrane due to subepithelila COLLAGEN deposition
Inflammation of the respiratory mucosa extends from the trachea to the terminal bronchioles with the PREDOMINACE of inflammation located at the?
BRONCHI (cartilaginous airway)
What is the physiologic abnormality is asthma
Airway hyperresponsiveness AHR
Inflammatory mediators released by mast cells
Histamine
Cysteinyl leukotrienes
Asthma is associated with a specific chronic inflammation of the mucosa of the
lower airways.
