Asthma Flashcards
Asthma
characterized by either the intermittent or persistent presence of highly variable degrees of airflow obstruction from airway wall inflammation and bronchial smooth muscle constriction and in some persistent changes in airway structure.
More likely to be presenting with asthma if…
- > 1 type of sx (SOB, cough, chest tightness)
-sx often worse at night or in early morning
-sx vary over time and in intensity
-sx have identifiable triggers
Diagnosis of Asthma
-FEV1/FVC is reduced (normal: >0.75-0.80)
Types of delivery devices
-Dry powder inhaler (diskus, ellipta, twisthaler, handihaler, respiclick)
-MDI
-Softmist inhaler (respimat)
-nebulizer solutions
Short-acting beta 2 agonists (SABAs)
-rescue therapy only
-bronchodilator, does not address inflammation
-SE: tremor, palpitations, tachycardia
-onset: 5-15 min
-duration: 2-6 hrs
-Albuterol, Levalbuterol
Albuterol
-SABA
-MDI (ProAir HFA, Proventil HFA, Ventolin HFA, ReliOn Ventolin HFA, authorized generics)
-Inhalation powder (DPI) - ProAir Respiclick
-Neb solution (Accuneb, Albuterol sulfate solution)
-inhale 2 puffs every 4-6 hrs prn (max of 12 puffs per day)
exercise: inhale 2 puffs 5-20 min before exercise
Levalbuterol
-R isomer of albuterol
-MDI (Xopenex HFA, generics)
-Neb soln
-same rescue dosing as albuterol
-exercise: 2 puffs 10-30 min before exercise
ICS
-maintenance medication
-Alvesco (ciclesonide) -MDI
-(fluticasone)
-QVAR (beclomethasone) - MDI
-Asmanex (mometasone) - DPI or MDI
-Pulmicort (budesonide) - DPI or neb
-most effective anti-inflammatory meds for persistent asthma
-when using ICS mono therapy do not use for quick relief
ICS AE
-use lowest dose possible (step down dose when well controlled; dec dose of ICS 25-50% after 3 month stability period)
-hyperglycemia, inc risk of fractures (at higher doses w/ long term use)
-most common SE are oropharyngeal candidiasis and dysphonia
-counsel patients to rinse and spit after use to prevent oral thrush
-use of chamber/spacer for MDI
ICS clinical pearls
-avoid DPIs in children < 4 years old (they lack inspiratory force to get full dose)
-MDIs should usually be shaken
-DPIs should never be shaken (could lose some of the dose)
-DPIs should usually be avoided in those with milk protein allergies (budesonide DPI is an exception) - DPIs may contain lactose
ciclesonide (Alvesco)
-80 mcg, 160 mcg
-BID dosing
-not recommended in children < 12
-useful in patients with frequent thrush or horsiness form ICS bc drug is not activated until it reaches the lungs
Fluticasone (Flovent, Arnuity, ArmonAir)
-Flovent Diskus or HFA (propionate) - not rec in children < 4, shake before use, BID dosing
-Arnuity Ellipta (furoate) - not rec in children < 12, everyday dosing
-ArmonAir RespiClick (propionate) - not rec in children < 12, BID dosing
-higher risk of sore throat/hoarseness than others
beclomethasone (Qvar RediHaler)
-MDI
-BID
-do not shake
-not rec in children < 5
-better lung penetration
mometasone (Asmanex)
-MDI
-DPI
-can be given once or twice daily
-not rec in children < 4
-QD dosing admin in evening
budensonide (Pulmicort)
-DPI
-Neb
-QD-BID dosing
-neb preferred in children <4
-DPI not rec in children < 6
Long acting beta 2 agonist (LABAs)
-maintenance therapy
-MOA and SE same as SABA
-FDA labeled for asthma: salmeterol, formoterol, vilanterol)-F & V are not single agents
-can not be used as mono therapy for asthma (use in combo with ICS)
-Formoterol/ICS combo not rec as prn/reliever (as early as step 1)
-BBW: inc risk of asthma related death if used as mono therapy (effect not seen as mono therapy in COPD)
ICS/LABA combo
-budesonide/formoterol (symbicort) -also for COPD
-fluticasone propionate/salmeterol (advair/wixela) -also for COPD
-fluticasone propionate/salmeterol (AirDuo Respiclick)
-fluticasone furoate/vilanterol (breo ellipta) -also for COPD
-mometasone/formoterol (Dulera)
Long acting muscarinic antagonists (LAMAs)
-maintenance therapy
-bronchodilator
-FDA approved: Spiriva (tiotropium) - used for COPD also
Leukotriene receptor antagonists (LTRAs)
-maintenance medications for persistent asthma
-reduce airway constriction and mucous secretion
-Montelukast (Singulair), Zafirlukast (Accolate)
-not preferred
Montelukast
-LTRA
-10 mg tab QPM
-used for allergic rhinitis and EIB also
-For EIB dose is taken 2 hours before exercise, not more than once Q24H
BBW: mental health side effects
Methylxanthines
-Theophylline
-bronchodilator
-preg category C
-not freq used (narrow therapeutic range, high risk for AE, DDI)
-less effective than ICS LABA combo
-lots of DDI with CYP inhibitors and inducers
Systemic corticosteroids
-glucocorticoids used in severe asthma (cortisone, hydrocortisone; methylpred,prrdnisone; betamethasone, dexamethasone) - taper if treatment lasts longer than 10-14 days
-prednisone and methylprednisone used for asthma control
Mild asthma
controlled by step 1 or 2 treatment
Moderate asthma
controlled by step 3 or 4 treatment
Severe asthma
controlled by step 5 treatment
Assessing symptom control
- Daytime asthma symptoms more than twice/week?
-Any night waking due to asthma?
-Reliever (SABA) for sx more than twice/week?
-Any activity limitation due to asthma?
1-2 (partly controlled)
3-4 (uncontrolled)
*do not assess bullet #3 if patient is using an ICS/formoterol combo as their reliever
Risk factors for exacerbations
-ICS not prescribed
-Poor adherence
-incorrect technique
-high SABA use
-comorbidities
-exposure to smoking, pollution, allergens
-major socioeconomic probelms
-low FEV1 especially < 60%
Risk factors for developing fixed airflow limitation
-preterm birth/ low birth weight
-lack of ICS treatment
-exposure to tobacco smoke, noxious chemicals
-low FEV1
-sputum or blood eosinophilia
Stepping down asthma therapy
-good control achieved and maintained for >/= 3 months
-Reduce ICS dose by 25-50% at 2-3 month intervals
-If current therapy is low dose ICS or LTRA, PRN ICS/formoterol is a step down
-Do not completely stop ICS
Acute asthma treatment on discharge
-If not already on ICS, add one
-If on one increase (step up) dose for 2-4 weeks
-Use oral CS for 5-7 days total; re-evaluation should occur prior to d/c
-transition pt back to prn regimen
-if ipratropium was added inpatient, d/c
Managing exacerbation in primary care
-mild or moderate sx: start SABA, Prednisolone, controlled O2
-Worsening or life threatening: transfer to acute care facility and give SABA, ipratropium bromide, O2, systemic steroid
-at discharge: continue reliever prn, start controller if not on one already or step up, prednisolone continue for 5-7 days
managing exacerbation in acute care setting
-if pt is drowsy, confused or has a silent chest then consult ICU and start SABA and O2 and prepare for intubation
-SABA, consider ipratropium, O2, steroids
-In severe cases can also consider IV Mg2+ or high dose ICS
