Asthma Flashcards
The 3 Pathophysiological mechanisms behind asthma
- INFLAMMATION
- mast cells, histamine release, interleukins (inflammatory), leukotrienes (AA pathway) - constriction of the airway (via tightening smooth muscle) “bronchoconstriction”
- thickened secretions as a result of inflammation
(2 &3 = airway hyperresponsiveness)
what are the two triads to be aware of when thinking about asthma
Samters Triad
- Asprin sensitivity
-Asthma
- Nasal Polyps
Atopic Triad
- atopic dermatitis
- allergic rhinitis
- asthma
Epidemiology of Asthma
- common: 25 million people in the US
-highest prevalence is in Black people - most prevalent in kids (black kids 3x higher risk)
Define Asthma
- 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)
Key points regarding history taking with asthma patients
- 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
Key points of the physical exam for pt. with asthma
** 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
Key points of the physical exam for pt. with asthma
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!!
how does pulmonary function test determine diagnosis of asthma
(what values are you testing)
- must conduct a pulmonary function test (spirometry) to obtain FEV1 and FEV1/FCV ratio
what are the results of a pulmonary function test with asthma pt.
(abnormalities and reversibilities)
- 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
when you do a pulmonary function test
- to diagnose asthma
- do twice –> 1st before given bronchodilator & then again after medicine
if no changes in FEV1 FEV1/FCV during pulm. test –> what test can you do if still suspicious?
broncoprovocation test
- administer METHACHOLINE
* induces an exacerbation* - test result if FEV1 falls 20% from baseline read
what method is used to monitor asthma
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**
what are the 5 areas of asthma management
- 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
5 asthma phenotypes
- Allergic Asthma
- Non-allergic Asthma
- Adult Onset
- Asthma with persistant airflow limitations (pulmonologist monitors these pts.)
- Asthma with obesity
Allergic Asthma – specifics
- begins in childhood
- family history of atopy
- examination of the sputum shows eosinophilia
- GOOD RESPONSE TO ICS meds
Non- allergic Asthma – specifics
- few granulocytes (because its not an allergy)
- less of a short term response to ICS
How do the stepwise classifications of asthma correlate with severity
step 1 & 2: mild asthma
step 3: moderate
step 4 & 5: severe asthma
Symptoms the patient will complain about that can identify their level of control over their asthma
- daytime asthma sx. > 2x/weekly
- nighttime wakening due to asthma
- using SABA reliever > 2x/weekly
- limiting their activities due to asthma
Levels of control of asthma classifications (well, partly or uncontrolled)
- no symptoms of asthma issues = well controlled
- 1-2 symptoms of asthma issues = partly controlled
- 3-4 symptoms of asthma issues = uncontrolled
9 risk factors for poor asthma outcomes
- asthma is uncontrolled
- medication issues
-
using their SABA 3+ canisters in
a year, or using 1 canister a
month
- inadequate use of the ICS
-
using their SABA 3+ canisters in
- co-morbid medical conditions
- obesity
- chronic rhinosinusitits
- GERD
- confirmed food allergy
- pregnancy - exposures (polluntants, smoke)
- context (socioecon, psychological)
- lung function
- low FEV1 <60% of predicted - type 2 inflammatory markers
- eosinophils in the blood
- elevated FeNO - ever been intubated in ICU
- severe exacerbation in last 12 months
what are some triggers of asthma
- tobacco smoke
- e-cigs
- dust mites
- outdoor air pollution
- pests (mice)
- pet hair/dander
- molds
- household product fumes
- occupational exposures
what are the 3 categories of asthma medications
- long-term controllers (maintenance)
- ICS
- LABA
-Theophylline - reliever medications ( as needed)
- SABA
- ICS + formoterol
- oral (systemic corticosteroids) - add-on therapy for severe asthma
- LAMA (muscarinic)
- immuno-therapies
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
-
Assess
- their severity & dx.
- their ability to control symptoms and risk factors
- their co-morbid conditions
- their technique for medication administration
- patient preferences -
Adjust
- medications (up and down in step-wise)
- co-morbid conditions (treat if it will help!)
- non-pharm strategies (avoidance)
- education and adherence -
Review
- symptoms @ each visit
- exacerbations and frequency
- side-effects
- lung function
- patient preferences
What are SABA and when are they used?
MOA
names
indication for use
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
Formoterol
MOA
indication for use
name (combo)
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**
Corticosteroids (Inhaled)
MOA
Indication
Side Effects
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
GINA Guidelines for…
Steps 1-2
Controller: as needed low dose ICS - formoterol (combo)
Reliever: as needed low dose ICS- formoterol
GINA Guidelines for…
Step 3
Controller: maitnence low dose ICS-formoterol combo
Reliever: as needed low dose ICS- formoterol
GINA Guidelines for..
Step 4
Controller: maintenance medium dose ICS-formoterol
Reliever: as needed low dose ICS- formoterol
GINA Guidelines for…
Step 5
Controller: High dose ICS-formoterol AND LAMA
- phenotype testing for asthma
- consider addition of immuno-therapy agents
When do you step-up treatment?
When do you step down treatment?
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**
Leukotriene Receptor Antagonists
MOA
MOA
- work to stop leukotriene involvement in…
1. bronchoconstriction
2. mucus secretion
3. mast cell activation
4. lymphocyte activation
5. eosinophil and basophil recruitment
Leukotriene Receptor Antagonists
Names
Names
- montelukast
- zafirlukast
- sileuton
Leukotriene Receptor Antagonists
Indications
Indications
- when pt. also has allergic rhinitis
- when pt. has inadequate response to ICS
Leukotriene Receptor Antagonists
Efficacy
Efficacy
modest at best –> 50% have no response
Mast Cell Stabilizers
Name
Use
Efficacy
- cromolyn
- limited use with current recommendations
- moderate benefit in those with exercise-induced
What is an asthma exacerbation?
what are some triggers?
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
Assessment & Treatment of Asthma Exacerbation - Steps to treatment decisions
- early intervention and recognition is KEY!
- assess severity and risk of death
- use rescue inhaler early & often
- no immediate response –> can start oral corticosteroids
- frequently assess Peak Flow
- no response with above steps –> seek ER acute care
signs and symptoms of asthma exacerbation
- 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
risk factors for individuals at increased risk of a fatal asthma attack
** 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
Home Management of Exacerbation
- 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)
When should home managers go to the ED?
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
Manage the exacerbation in out-patient office
- indications for 911
- breathlessness at rest, tripoding
- drowsy, confused
- unable to speak in full sentences
- RR > 30
- HR > 120
- PEFR <50 of personal best
- arterial O2 <90%
Manage the exacerbation in out-patient office
medications
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. *
Manage the exacerbation in out-patient office
discharge home instructions
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
Manage the exacerbation in the ED
steps to take
- 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
Manage the exacerbation in the ED
Treatment (Meds)
** no particular order**
- Oxygen
- for pts. with SpO2 < 90% (want to get above 92%) - inhaled beta agonists
- nebulizer usually necessary
- short acters–> albuterol, levalbuterol - inhaled muscarinic antagonists
- iprotropium
- inhaler or nebulizer
- in combo with SABA - systemic CS
- MUST GIVE!! if refractory to other therapy
- oral and IV effects are similar
- IM slower onset - high dose inhaled corticosteroids
- can be used but DO NOT REPLACE the need for systemic ones!!! - magnesium sulfate
- for LIFE THREATENING exacerbations
- for nonresponders to other treatments
- brochodilator (strong)
when to intubate in ED setting for exacerbation of asthma
- 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**
“Last Ditch” Efforts for exacerbation in ED
parenteral beta agonists
- epinephrine
- terbutaline
** NEVER COMBINE THE TWO**
anestetic agents
- ketamine
- isoflurane
helium oxygen mix
ECMO
Management of exacerbation in the patient setting (admitted)
Benefit & Goals
Benefit
- forced tobacco cessation
- avoidance of allergen at home
- continuous monitoring
Goals
- continue ED or ICU treatment then transition to home-replicated management
Management of exacerbation in the patient setting (admitted)
Medications
- 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
Management of exacerbation in the patient setting (admitted)
Discharge instructions
- follow-up meds are critical!!
oral CS & step-up therapy - patient education on meds, therapy, triggers, and follow up
when are biologic therapies indicated for asthma?
Classses (not drug names)
- for moderate, severe asthma as add-on therapy
- NEVER for acute use
- manage via pulmonology
names
- anti-IgE
- anti-interleukins
- anti-thymic stromal
