Asthma Flashcards
What are the features of asthma on history
Wheeze
Cough
SOB
Chest tightness
Sx worse at night or early in AM
Atopic disorder - eczema, allergic rhinitis
Triggers: cold, exercise, viral illness, allergens, irritants, BB, NSAIDs, ASA, emotions
What are the features of asthma on exam
Usually normal
Prolonged expiration + expiratory wheeze
Silent chest = medical emergency
Kids - linear nasal creases, swollen nasal turbinates = allergic rhinitis
Features of asthma on spirometry
Pre and post bronchodilation = should see 12% improvement in FEV1 for Dx of asthma (250ml difference from baseline after bronchodilator)
FEV1/ FVC = less than 0.8 in kids, less than 0.7 in adults = restrictive airway disease
Can only be done >6 y/o
If under, trial inhaled corticosteroid for 8-12 weeks + PRN SABA
Dx if responsive
Only reliable when pt symptomatic - repeat if spiro negative
Other tests: peak flow (>20% change after bronchodilation), methylcholine solutions - can provoke bronchial restriction - watch for decrease in FEV1 by 20%, post-exercise decrease in FEV1 by 20%
CXR not indicated in diagnosis of asthma
Mild - mod - severe classification
Mild - PEF >70%
Moderate - PEF 50-70%, does not reverse
Severe - PEF <50%, RR >30, tachy >120, inability to finish sentences, pulsus paradoxus, cyanosis, silent chest, decreased LOC, ABG normal or elevated CO2
well controlled asthma features
Daytime sx <4 times weekly
Rescue puffer <4 times weekly
Nighttime sx <1 time a week
Physical activity unimpaired by sx
No asthma related absences from school or work
Exacerbations are mild and infrequent
FEV1/ PEF >90% of personal best
Diurnal PEF variation <10%
RF for severe asthma
Hx of severe exacerbation
Poorly controlled asthma
Comorbid atopic dz
Current smoker
Vit D deficiency
Rx for exacerbation
O2 if sats <92%
All: SABA - salbutamol w/ MDI, q20 mins in first hour
Mod-Severe: Ipratropium (short acting anti-cholinergic) 500mcg via neb or 4-8 puffs by MDI, q20mins for 1 hr then PRN for up to 3 hrs
If no response to initial rx: Prednisone 40-60mg PO in 1st hr. Can take 6 hrs to effect. Kids - 1mg/kg day
Severe + unresponsive: IV Magnesium sulphate 2g over 20 mins
Equipment + personnel for rapid intubation on hand
Criteria for admission
Unable to speak sentences
Tachypnea >25
Tachy >110
PEF <40%
Silent chest
Cyanosis
Confusion
Pharmacotherapy steps for asthma + what to ensure before stepping up
1) SYMBICORT (LABA/ ICS) PRN
2) BETHAMETHASONE (ICS) daily or MONTELUKAST (LTRA) daily
3) ADVAIR (LABA/ ICS)
4) ADVAIR + MONTELUKAST (ICS/ LABA + LTRA)
5) ADVAIR + MONTELUKAST + SPIRIVA (ICS/ LABA + LTRA + tiotropium)
Confirm correct dx
Continuing education
Check triggers + lifestyle interventions (pets, smoking)
Ensure compliance w/ meds + proper technique
As well as meds, what else is included in an asthma management plan
Self-monitoring - asthma plan w/ sx + at home PEF % of personal best (green, yellow, red zone)
Self-adjustment of medication
When to consult back (1-6 months depending on control)
When to refer
Children 1-5 w/ >2 exacerbations needing steroids
Children 6-11 who fail control on medium dose ICS
Recurrent need for oral steroids (>8/mo)
Diagnostic uncertainty
Need for environmental allergy testing
Suspected occupation related asthma
What is included in education and lifestyle adjustments?
Adherence w/ meds (barriers = cost, inhaler burden)
Ensure correct technique
Avoiding irritants/ triggers (smoking, wt loss, personal triggers (smoke, dust, viral URTIs, pet dander, NSAIDs, BB, emotions, exercise, cold air, GERD)
SABA - name, device, dose + SE
Salbutamol (Ventolin)
MDI = 1-2 puffs QID
Diskus = 1 puff QID
Tremor, tachycardia, HA
SAMA - name, device, dose + SE
Ipratropium (Atrovent)
MDI = 2 puffs TID-QID
Dry mouth, constipation, urinary retention
LABA - name, device, dose + SE
Formoterol
Turbuhaler = 6-12mcg BID
Salmeterol
Diskus = 1 puff BID
Tremor, tachycardia, HA
