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Clin Med II Exam 1 Pulm > Asthma > Flashcards

Asthma Flashcards

1
Q

The 3 Pathophysiological mechanisms behind asthma

A
  1. INFLAMMATION
    - mast cells, histamine release, interleukins (inflammatory), leukotrienes (AA pathway)
  2. constriction of the airway (via tightening smooth muscle) “bronchoconstriction”
  3. thickened secretions as a result of inflammation

(2 &3 = airway hyperresponsiveness)

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2
Q

what are the two triads to be aware of when thinking about asthma

A

Samters Triad
- Asprin sensitivity
-Asthma
- Nasal Polyps

Atopic Triad
- atopic dermatitis
- allergic rhinitis
- asthma

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3
Q

Epidemiology of Asthma

A
  • common: 25 million people in the US
    -highest prevalence is in Black people
  • most prevalent in kids (black kids 3x higher risk)
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4
Q

Define Asthma

A
  • an OBSTRUCTIVE disease state of the respiratory system due to increase inflammation
  • heterogenous in nature (multiple types of asthma and how it presents)
  • symptoms of SOB, cough, wheezing & chest tightness
  • EBB AND FLOW NATURE: symptoms can worsen and relieve over time
  • the variability in nature can be measured by expiratory airflow (spirometry)
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5
Q

Key points regarding history taking with asthma patients

A
  • what are the symptoms?
    wheeze (#1), cough, SOB, chest tight
  • how long are the symptoms lasting
    (intermittent v persistant?)
    (when are they occurring?)
  • known contact with allergens or triggers?
    (dust, pollen, animals, etc.)
  • IF ASTHMA KNOWN –>
    ask about length of time for
    rescue inhaler
    ask about # hospitalizations, ICU and intubations
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6
Q

Key points of the physical exam for pt. with asthma

A

** will appear normal between exacerbations**

when symptomatic –>
- vitals
- pulse ox
- color (lips and nail beds)
- accessory muscle use in breathing
- auscultation of lungs
listen for prolonged expiratory
phase

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7
Q

Key points of the physical exam for pt. with asthma

A

will appear normal between exacerbations

when symptomatic –>
- vitals
- pulse ox
- color (lips and nail beds)
- accessory muscle use in breathing
- auscultation of lungs
– listen for prolonged expiratory
phase
– listen for wheezing
- R/O others with cardiac and ENT exam

SILENT CHEST IS A BAD THING!!

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8
Q

how does pulmonary function test determine diagnosis of asthma

(what values are you testing)

A
  • must conduct a pulmonary function test (spirometry) to obtain FEV1 and FEV1/FCV ratio
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9
Q

what are the results of a pulmonary function test with asthma pt.

(abnormalities and reversibilities)

A
  • Abnormalities – asthma
    1. FEV1 DECREASED (to standard)
    2. FEV1/FVC DECREASED (to standard)
  • Reversibilities – asthma (KEY FINDING – because we know asthma comes and goes)
    1. increase of 12% or more (200ml increase in FEV1 after given SABA
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10
Q

when you do a pulmonary function test

A
  • to diagnose asthma
  • do twice –> 1st before given bronchodilator & then again after medicine
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11
Q

if no changes in FEV1 FEV1/FCV during pulm. test –> what test can you do if still suspicious?

A

broncoprovocation test

  1. administer METHACHOLINE
    * induces an exacerbation*
    • test result if FEV1 falls 20% from baseline read
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12
Q

what method is used to monitor asthma

A

peak flow monitoring

  • necessary to determine the LEVEL OF CONTROL of the patients asthma
  • “zones” or “amounts” pt. should be hitting is based on predictable values (height, weight and gender)
  • also based on the patients “best ever” reading

** NOT A DIAGNOSITC TOOL**

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13
Q

what are the 5 areas of asthma management

A
  • assess the severity and control the pt. has over the asthma
  • controlling environmental triggers
  • pharmacological management
  • pt. education
  • monitoring signs and sx. of lung function
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14
Q

5 asthma phenotypes

A
  1. Allergic Asthma
  2. Non-allergic Asthma
  3. Adult Onset
  4. Asthma with persistant airflow limitations (pulmonologist monitors these pts.)
  5. Asthma with obesity
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15
Q

Allergic Asthma – specifics

A
  • begins in childhood
  • family history of atopy
  • examination of the sputum shows eosinophilia
  • GOOD RESPONSE TO ICS meds
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16
Q

Non- allergic Asthma – specifics

A
  • few granulocytes (because its not an allergy)
  • less of a short term response to ICS
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17
Q

How do the stepwise classifications of asthma correlate with severity

A

step 1 & 2: mild asthma
step 3: moderate
step 4 & 5: severe asthma

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18
Q

Symptoms the patient will complain about that can identify their level of control over their asthma

A
  • daytime asthma sx. > 2x/weekly
  • nighttime wakening due to asthma
  • using SABA reliever > 2x/weekly
  • limiting their activities due to asthma
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19
Q

Levels of control of asthma classifications (well, partly or uncontrolled)

A
  • no symptoms of asthma issues = well controlled
  • 1-2 symptoms of asthma issues = partly controlled
  • 3-4 symptoms of asthma issues = uncontrolled
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20
Q

9 risk factors for poor asthma outcomes

A
  1. asthma is uncontrolled
  2. medication issues
    • using their SABA 3+ canisters in
      a year, or using 1 canister a
      month
      - inadequate use of the ICS
  3. co-morbid medical conditions
    - obesity
    - chronic rhinosinusitits
    - GERD
    - confirmed food allergy
    - pregnancy
  4. exposures (polluntants, smoke)
  5. context (socioecon, psychological)
  6. lung function
    - low FEV1 <60% of predicted
  7. type 2 inflammatory markers
    - eosinophils in the blood
    - elevated FeNO
  8. ever been intubated in ICU
  9. severe exacerbation in last 12 months
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21
Q

what are some triggers of asthma

A
  • tobacco smoke
  • e-cigs
  • dust mites
  • outdoor air pollution
  • pests (mice)
  • pet hair/dander
  • molds
  • household product fumes
  • occupational exposures
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22
Q

what are the 3 categories of asthma medications

A
  1. long-term controllers (maintenance)
    - ICS
    - LABA
    -Theophylline
  2. reliever medications ( as needed)
    - SABA
    - ICS + formoterol
    - oral (systemic corticosteroids)
  3. add-on therapy for severe asthma
    - LAMA (muscarinic)
    - immuno-therapies
23
Q

What are the 3 steps of asthma care we want to consider when treating our patients

first we _____ the severity

then we ____ the meds if needed

then we _____ to make changes

A
  1. Assess
    - their severity & dx.
    - their ability to control symptoms and risk factors
    - their co-morbid conditions
    - their technique for medication administration
    - patient preferences
  2. Adjust
    - medications (up and down in step-wise)
    - co-morbid conditions (treat if it will help!)
    - non-pharm strategies (avoidance)
    - education and adherence
  3. Review
    - symptoms @ each visit
    - exacerbations and frequency
    - side-effects
    - lung function
    - patient preferences
24
Q

What are SABA and when are they used?

MOA

names

indication for use

A

short acting beta agonists

  • MOA: act on the beta-2 agonists to simulate SNS & bronco-dilate the airway by relaxing the smooth muscle
  • albuterol & levalbuterol
  • GINA 2020 –> only use SABA when in combo with an ICS

SABA alone shown to increase asthma exacerbations

25
Q

Formoterol

MOA

indication for use

name (combo)

A

LABA (long acting –> shorter onset to act)

  • used for both controller and reliever of asthma
  • MOA: relaxes the smooth muscle by acting on beta 2 receptors

** DOES NOT HAVE ANY ANTI-INFLAMMATORY PROPERTIES –> so it must be used alongside a ICS**

  • ICS/LABA —> budesonide & formeterol (symbacort!)

** other LABA (like salmeterol) should not be used long term**

26
Q

Corticosteroids (Inhaled)

MOA

Indication

Side Effects

A

the Key of asthma treatment!!

MOA: multi-fold
- potent anti-inflammatory
- reduces edema
- blunts airway hyperresponsiveness
- reduces secretions & mucus

indications
- used in low, moderate or high doses depending on severity of asthma in combo with SABA or LABA

Names (to be aware)
- budesonide
- beclometasone
- Flunisolide
- momentasone
- trimcinolone

Side Effect
- oral thrush –> ensure patient rinses mouth

27
Q

GINA Guidelines for…
Steps 1-2

A

Controller: as needed low dose ICS - formoterol (combo)

Reliever: as needed low dose ICS- formoterol

28
Q

GINA Guidelines for…
Step 3

A

Controller: maitnence low dose ICS-formoterol combo

Reliever: as needed low dose ICS- formoterol

29
Q

GINA Guidelines for..
Step 4

A

Controller: maintenance medium dose ICS-formoterol

Reliever: as needed low dose ICS- formoterol

30
Q

GINA Guidelines for…
Step 5

A

Controller: High dose ICS-formoterol AND LAMA

  • phenotype testing for asthma
  • consider addition of immuno-therapy agents
31
Q

When do you step-up treatment?
When do you step down treatment?

A

Step Up:
- persistently poor symptom control
- exacerbations despite ICS treatment for 2-3 MONTHS

Step Down:
- when patient has good symptoms control
AND
- stable lung function for 3 MONTHS

** always ensure pt. has asthma treatment plan about when to administer meds & when to call 911**

32
Q

Leukotriene Receptor Antagonists
MOA

A

MOA
- work to stop leukotriene involvement in…
1. bronchoconstriction
2. mucus secretion
3. mast cell activation
4. lymphocyte activation
5. eosinophil and basophil recruitment

33
Q

Leukotriene Receptor Antagonists
Names

A

Names
- montelukast
- zafirlukast
- sileuton

34
Q

Leukotriene Receptor Antagonists
Indications

A

Indications
- when pt. also has allergic rhinitis
- when pt. has inadequate response to ICS

35
Q

Leukotriene Receptor Antagonists
Efficacy

A

Efficacy
modest at best –> 50% have no response

36
Q

Mast Cell Stabilizers

Name
Use
Efficacy

A
  • cromolyn
  • limited use with current recommendations
  • moderate benefit in those with exercise-induced
37
Q

What is an asthma exacerbation?
what are some triggers?

A

episodes of worsening of asthma symptoms (subjective or objective)

triggers (many)
- viral URI (MOST COMMON)
- exposure to allergens/irritants
- lack of adherence to usual controller medications

38
Q

Assessment & Treatment of Asthma Exacerbation - Steps to treatment decisions

A
  1. early intervention and recognition is KEY!
  2. assess severity and risk of death
  3. use rescue inhaler early & often
  4. no immediate response –> can start oral corticosteroids
  5. frequently assess Peak Flow
  6. no response with above steps –> seek ER acute care
39
Q

signs and symptoms of asthma exacerbation

A
  • PERV decreases more than 20% personal best
  • wheezing, cough, chest pain & breathlessness
  • exercise fatigue (not common)

Severe sx.
- intractable coughing
- sensation of air hunger
- inability to speak in full sentences
- worsening respiratory distress when laying down

40
Q

risk factors for individuals at increased risk of a fatal asthma attack

A

** these people should initiate home treatment and immediately go to ER**

  • previous life-threatening exacerbation (ICU or intubation)
  • hospitalized 1+ times in last year
  • 3+ ED visits in last year
  • using more than 1 can/ month of rescue
  • cardiovascular or respiratory abnormalities s
  • drug use
  • psychosocial issues (depression)
  • IgE mediated food allergy
  • not on ICS
  • cannot perceive their symptoms
  • history of poor adherence
41
Q

Home Management of Exacerbation

A
  • advise pt. to take fast acting inhaled bronchodialators
  • determine need for OCS
    if no improvement with dialators
    if PEFR less than 80% of best
  • waiting for ambulance –> 4-6 puffs (albuterol, formoterol) and oral prednisone

** NO INHALED EPINEPHRINE**

  • pt. not on ICS –> initiate medium-high dose
  • pt. on combo SMART –> can take 4x amount of maintenance dose (can take as soon as VURI starts)
42
Q

When should home managers go to the ED?

A

good response:
- maintain therapy until symptoms resolve
- PEFR goes above 80% of best

incomplete response:
- take high dose ICS or oral CS

Ambulance when…:
- worsening symptoms despite 3x doses of rescue inhaler
- PEFR < 50 of personal best
- concerning co-morbid condtions

43
Q

Manage the exacerbation in out-patient office
- indications for 911

A
  1. breathlessness at rest, tripoding
  2. drowsy, confused
  3. unable to speak in full sentences
  4. RR > 30
  5. HR > 120
  6. PEFR <50 of personal best
  7. arterial O2 <90%
44
Q

Manage the exacerbation in out-patient office

medications

A

Inhaled SABA
- consider nebulizer

systemic glucocorticoids
- all pts.
- administer in office and send home with 5day supply

  • after admin –> reassess need for ED or sent home, etc. *
45
Q

Manage the exacerbation in out-patient office

discharge home instructions

A

can discharge when…
- improved clinically
- PEFR > 70%
-SpO2 >94%

Discharge Instructions
- monitor @ home 2x daily PEFR
- continue OCS
- use reliever 2 puffs q 4-6 hours then taper
- continue controller meds

46
Q

Manage the exacerbation in the ED

steps to take

A
  • assess signs and symptoms of exacerbation and comorbidities
  • PEFR if possible
    can predict hypercapnia ( only
    happening if PEFR < 25% of
    best)
  • assess oxygenation
  • chest x-ray USELESS
47
Q

Manage the exacerbation in the ED

Treatment (Meds)

A

** no particular order**

  1. Oxygen
    - for pts. with SpO2 < 90% (want to get above 92%)
  2. inhaled beta agonists
    - nebulizer usually necessary
    - short acters–> albuterol, levalbuterol
  3. inhaled muscarinic antagonists
    - iprotropium
    - inhaler or nebulizer
    - in combo with SABA
  4. systemic CS
    - MUST GIVE!! if refractory to other therapy
    - oral and IV effects are similar
    - IM slower onset
  5. high dose inhaled corticosteroids
    - can be used but DO NOT REPLACE the need for systemic ones!!!
  6. magnesium sulfate
    - for LIFE THREATENING exacerbations
    - for nonresponders to other treatments
    - brochodilator (strong)
48
Q

when to intubate in ED setting for exacerbation of asthma

A
  • slowing respirations without clinical improvement
  • depressed mental status
  • inability to comply with ED treatments
  • worsening hypercapnia, acidosis
  • inability to maintain O2 sat > 92 on mask O2

** can try positive pressure masks first prior to intubation**

49
Q

“Last Ditch” Efforts for exacerbation in ED

A

parenteral beta agonists
- epinephrine
- terbutaline
** NEVER COMBINE THE TWO**

anestetic agents
- ketamine
- isoflurane

helium oxygen mix

ECMO

50
Q

Management of exacerbation in the patient setting (admitted)

Benefit & Goals

A

Benefit
- forced tobacco cessation
- avoidance of allergen at home
- continuous monitoring

Goals
- continue ED or ICU treatment then transition to home-replicated management

51
Q

Management of exacerbation in the patient setting (admitted)

Medications

A
  • majority improve with SABA 24-48 hours after –> taper off
  • continue glucocorticoids (oral if still needed)
  • begin/resume ICS

** alwasy start new inhaler inpatinet before D/C

52
Q

Management of exacerbation in the patient setting (admitted)

Discharge instructions

A
  • follow-up meds are critical!!
    oral CS & step-up therapy
  • patient education on meds, therapy, triggers, and follow up
53
Q

when are biologic therapies indicated for asthma?

Classses (not drug names)

A
  • for moderate, severe asthma as add-on therapy
  • NEVER for acute use
  • manage via pulmonology

names
- anti-IgE
- anti-interleukins
- anti-thymic stromal

Clin Med II Exam 1 Pulm (9 decks)

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