Asthma Flashcards
what are the multiple contributing factors to the pathogenesis of asthma
- Inflammatory cell infiltration with eosinophils, neutrophils, and lymphocytes
- goblet cell hyperplasia
- plugging of small airways with thick mucus
- hypertrophy of smooth muscle
- airway edema
- mast cell activation
what is the strongest identifiable risk factor for the development of asthma
atopy - the genetic tendency to develop allergic diseases
what are other risk factors for asthma
obesity
aspirin and NSAIDS
GERD
Beta blockers
family hx
theres more but these are the ones im learning
what ages are asthma most likely to begin?
by 1 year - 26%
1-5 years - 51%
>5 years - 22%
what are the 7 types of asthma
- extrinsic (allergic)
- intrinsic (uncommon)
- mixed (ex and intrinsic combo)
- occupational
- drug induced (ASA/NSAID)
- exercise induced
- cough variant
what is the diagnostic approach to a suspected asthma patient
diagnosis is clinical
confirmed with PFTs (spirometry)
what are s/s of asthma
cough
chest tightness
SOB/Dyspnea
Difficulty breathing
episodic wheezing
what would the PE show in asthma
What would a lung exam show in asthma
- hyperinflation
- retractions
- decreased tactile fremitus
- rhonchi and wheeze
- prolonged expiration
- silent chest = severe asthma
what physical examination finding indicates a life threatening status
silent chest auscultations
what is the diagnostic criteria for asthma in children
what is the diagnostic criteria for asthma in adults
what is other testing that can be done in diagnostic testing for astham
- bronchoprovocation testing
- exercise challenge
- peak flow meters
- CXR
- skin testing
- measurement for sputum for eosinophils
what are the indications for a CXR in asthma
if diagnosis of asthma is uncertain
in acute asthma exacerbations, how often are abnormal findings present in CXR
- Abnormal findings at presentation - 5%
- Abnormal findings if no improvement in 12 hours - 34%
what does ABG show in acute exacerbation of asthma
- Hypoxemia
- hypercarbia with decompensation
what does a CBC show in acute exacerbation of asthma
- Eosinophillia may be present
- increased levels of IgE may be present
what does a Sputum sample show in acute asthma exacerbaiton
- casts of small airways
- thick mucoid sputum
- Curschmanns spirals
- Charcot-Leyden crystals
what are possible complications of asthma
- Exhaustion
- Dehydration
- Airway infection
- Tussive syncope
- Pneumothorax
- Respiratory Failure
- Chronic lung disease
what is considered severe persitent asthma
- symptoms of asthma throughout the day each day
- night-time awakenings nightly
- need for SABA multiple times/day
- extreme limitation in normal activity
- FEV1<60% predicted and FEV1/FVC below normal
what is the MC bronchoprovocation test in the US
the Methacholine Challenge - patients breathe in increasing amounts of methacholine and perform spirometry after each dose.
what is a positive methacholine challenge
Increased airway hyperresponsiveness with a ≥ 20% decrease in FEV1 up to 16 mg/mL max dose
what is considered mild persistent asthma
- symptoms occur more than 2 days/week but not daily
- aprox 3-4 night-time awakenings/month d/t asthma but not weekly
- use of SABA more than 2x week but not daily
- minor interference w normal activities
- FEV1 measurements w/i normal range and normal FEV1/FVC
- 2+ exacerbations/year requiring oral steroids
what is considered mild intermittent asthma
- daytime symptoms 2 or fewer days/week
- 2 or less night awakenings per month
- use of SABA inhaler 2 or fewer times/week
- no interference w normal activities between exacerbations
- FEV1 measurements between exacerbations are >80%
- FEV1/FVC ratio normal between exacerbations
- 0-1 exacerbations requiring oral steroids/year
what is considered moderate persistent asthma
- daily symptoms of asthma
- nighttime awakenings more than once per week
- daily need for SABA
- some limitation of normal activity
- FEV1 between 60-80% of predicted and FEV1/FVC below normal
which medications are referred to as “rescue inhalers”
albuterol
levabuterol
(SABAs)
what do SABAs do in asthmatic patients
work to relax the smooth muscle of the airway and cause prompt increase in airflow and decrease in symptoms
what are the SE of SABA?
tachycardia
shakiness
nervousness
what are the preferred long term controllers
inhaled corticosteroids
what are the common inhaled corticosteroids
pulmicort (budesonide)
Qvar (Beclometasone)
Asmanex(Mometasone furoate)
flowvent (fluticasone propionate)
what do inhaled corticosteroids do in asthmatic patients
reduce airway inflammation and reduces the airways exaggerated sensitivity to any and all triggers of asthma
What are the MC SE of inhaled corticosteroids
thrush
hoarsness
localized contact hypersensitivity
cough and throat irritation
what are the less common SE of inhaled corticosteroids
impaired growth in children
osteoporois in adults
cataracts
glaucoma
weight changes and adrenal suppression (cushings)
how can patients reduce the possibility of developing thrush when using inhaled corticosteroids
rinse your mouth out after using!
When do you use systemic corticosteroids
in acute asthma attacks
what are the oral systemic corticosteroids
prednisone
prednisolone
solumedrol (methylprednisolone)
What are SE of systemic corticosteroids
- skin and soft tissue Infections?
- cushings/weight gain
- cataracts/glaucoma
- CV disease
- GI disease
- hyperinsulinemia w insulin resistence
when are the LABA medications used in treatment for asthmatic patients
in combination with other medications - usually ICS - rarely a monotherapy
what are the LABAs used in asthmatic patients
salmeterol
formeterol
aformeterol
what are the SE of LABAs
tachycardia
palpitations
shakiness
cramping
worsening of symptoms (if used too often)
what are the ICS plus LABA combo medications used in asthmatic patients
budesonide + formoterol
fluticasone + salmeterol
Fluticasone + Vilanterol
Mometasone + formoterol
Why are ICS plus LABA combos beneficial
the bronchodilator works to widen the airway + inhaled corticosteroid reduces and prevents inflammation of the airway
What are limitations of ICS plus LABA therapy in asthmatic patients
COST
most insurance plans have them as 2nd tier
when do you use LABA + SAMA in asthmatic treatment
not first line, but can be used if unresponsive to therapy in combination with SABA
what are the LABA + SAMA therapies
ipratropium bromide
tiotropium bromide
ipratropium and albuterol
How do LABA + SAMA aid in the treatment of asthma
- relax the airways and prevent them from getting narrower
- also reduce the amount of mucous in the airway.
what is theophylline used for in the treatment of asthmatic patients
add on medication for moderate to severe asthma
what is the drug class of theophylline
nonselective phosphodiesterase enzyme inhibitor
what does theophylline do to treat asthma
- mild bronchodilation
- anti inflammatory
- enhances mucociliary clearance
- strengthens diaphragmatic contractility
what should theophylline NOT be used for
acute exacerbations of asthma
what is the MOA of leukotrienes
blocks actions of leukotrienes at the CysLT1 receptor on target cells such as bronchial smooth muscle via receptor antagonsism
what effect do leukotrienes have on asthma
- improves symptoms/reduces exacerbations
- limits inflammatory markers like eosinophils
what is the black box warning for leukotrienes (specifically montelukast)
serious mental health side effects.
What are the leukotrienes
montelukast
zafrilukast
When is Cromolyn used in asthmatic treatment
not used first line
may be an option if someone fails or cant tolerate ICS
What is the MOA of Cromolyn
Mast cell stabilizer -
prevents asthmatic responses and reduces airway reactivity to a range of inhaled irritants.
What are the down falls of Cromolyn
not available in inhaler form and is only available in nebulizer solution.
When is nebulized epinephrine used as a asthma treatment
in patients with severe asthma attacks. Results in rapid improvement of upper airway obstruction.
What is the MOA of nebulized epinephrine
a sympathomimetic alpha and beta agonist. this results in bronchodilation, decreased edema, and decreased mucous.
what are the SE of nebulized epinephrine
restlessness
anxiety
tachycardia
usually lasts no more than 2 hours.
what should be monitored when giving children nebulized epinephrine
when taking nebulized epinephrine, children can suffer from the “rebound” effect and therefore should be monitored in an ER or hospital setting for at least 3-4 hours after a single dose.
What is the monoclonal antibody medications used in asthma that we learned
Omalizumab
what is the MOA of monoclonal antibodies in asthma treatment
this is DNA-derived IgG antibodies which bind to IgE mast cells and reduce mediator release which therefore decreases allergic response.
who can receive monoclonal antibodies
children 6 years and older (injection only)
what type of patient is indicated for treatment with monoclonal antibodies
- Moderate-severe uncontrolled asthma in person w/ positive skin prick testing to perennial allergies who is inadequately controlled on max dose of other meds
- also in those with chronic urticaria
what is the black box warning for monoclonal antibodies
anaphylaxis! so monitor closesly!!!
what are the 6 steps of asthma treatment
How often should you follow up with a patient with asthma
- every 1-6 months depending upon the severity of the asthma
- every 2-6 weeks after any new med admin
when should stepping down from treatment be considered in patients with asthma
if their asthma is stable for 3 months or more
what are the peak flow values that indicate asthma severity
what is considered well controlled asthma
less than 2 days a week with symptoms
what is considered not well controlled asthma
more than 2 days a week of symptoms or multiple symptoms during the nighttime
what is considered very poorly controlled asthma
- symptoms persist throughout the day.
- a 20% change in peak flow from AM to afternoon or day to day shows poor control
When should you refer/consult a pulmonologist or allergist
- life threatening asthma attacks
- hospitalized or 2+ rounds of oral steroids
- over 5 with step 4 care or more, or younger than 5 and step 3 care or more
- unresponsive/uncontrolled after 3-6 mo of active therapy
- diagnosis uncertain
- additional diagnostic tests needed
- if pt is candidate for allergen immunotherapy
What is exercise induced asthma
a condition in which the airways narrow significantly during vigorous exercise
what are symptoms of exercise induced asthma
cough
wheezing
SOB
chest tightness
what is the timeline for exercise induced asthma
starts at onset or 3 min after
peaks at 10-15 minutes
resolves within 60 minutes
what medications are typically used to treat exercise induced asthma
usually bronchodilators - SABA
* albuterol
* pirbuterol
* ipratropium and albuterol combo
take 15 min prior to exercise!
what is cough variant asthma
chronic cough
>3 weeks
non productive
usually nocturnal
what are warning signs of an impending asthma attack
- Increased SOB or wheezing
- Disturbed sleep caused by SOB, coughing or wheezing
- Chest tightness or pain
- increased need to use bronchodilators
- afall in peak flow rates as measured by a peak flow meter
what are warning signs for symptoms for children prior to an asthma attack
- audible wheeze/whistle with exhale
- coughing in spasms
- waking at night with coughing/wheezing
- SOB w or w/o exercise
- tight feeling in chest
what is status asthmaticus
the most severe form of asthma during which lungs can no longer provide oxygen and remove CO2
leads to multi organ damage, acidosis, hypotension, and narrowed airways.
what is the treatment for status asthmaticus
requires intubation and ventilator support as well as maximum doses of several medications
also meds for acidosis correction.
