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Pulmonology > Asthma > Flashcards

Asthma Flashcards

1
Q

What are potential triggers for asthma?

A
  • Infections
  • Viruses
  • Cigarette smoke
  • Allergens
  • Pollutants
  • Cold air/changes in temperature
  • Excitement/stress
  • Exercise
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2
Q

What is asthma?

A
  • Reversible obstructive lung disease
  • Due to increased reaction of airwaus to triggers
  • Chronic inflammatory disease
  • Acute exacerbations or flare ups
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3
Q

What is the pathogenesis of asthma?

A
  • Inflammatory cell infiltration with eosinophils, neutrophils, and lymphocytes
  • Goblet cell hyperplasia
  • Plugging of small airways with mucus
  • Hypertrophy of smooth muscle
  • Airway edema
  • Mast cell activation

All lead to airway hyper-responsiveness and airflow limitation

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4
Q

What are the 2 primary pathophysiological factors contributing to asthma attacks?

A

Bronchoconstriction and inflammation

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5
Q

This is the strongest identifiable predisposing factor for development of asthma

A

Atopy

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6
Q

What are risk factors for the development of asthma?

A
  • Obesity
  • Pollutants
  • Respiratory irritants
  • Viruses
  • Aspirin/NSAIDS
  • Weather
  • GERD
  • Stress
  • Family history
  • Exercise
  • URIs
  • Beta blockers
  • Environment
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7
Q
A
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8
Q

When is the most common age for asthma to begin?

A

1-5 years

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9
Q

77% of asthma begins in children ____

A

<5 years old

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10
Q

What are types of asthma?

A
  • Extrinsic: allergic
  • Intrinsic: uncommon
  • Mixed: combo of extrinsic and intrinsic
  • Occupational
  • Drug induced: NSAIDs or ASA
  • Exercise induced
  • Cough variant: common, especially in children
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11
Q

How is asthma diagnosed?

A
  • clinical suspicion
  • History with focus on symptom patterns (triggers)
  • Physical exam for signs of allergies/asthma
  • Confirmed with spirometry
  • Allergy testing
  • Clinical response to bronchodilators
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12
Q

What are signs and symptoms of asthma?

A
  • Cough
  • Chest tightness
  • SOB/dyspnea
  • difficulty breathing
  • episodic wheezing

Frequency is variable

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13
Q

What can you see on physical exam for asthma?

A
  • Increased nasal secretion, mucosal swelling, and/or nasal polyps
  • Signs of atopy/allergic rhinitis
  • Wheezing or prolonged expiratory phase, hyperexpansion of thorax, use of accessory muscles, appearance of hunched shoulders
  • atopic dermatitis or eczem
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14
Q

What are signs of atopy/allergic rhinitis?

A
  • Conjunctival congestion
  • ocular shiners
  • salute sign
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15
Q

What should you inspect during the lung exam of a patient with potential asthma?

A
  • Shape (hyperinflated in severe asthma)
  • Movement of chest (silent is life threatening, retractions)
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16
Q

What should you palpate and expect to palpate during the lung exam of a patient who might have asthma?

A
  • Tactile fremitus may be decreased
  • Normal chest expansion may be decreased
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17
Q

What should you percuss/what do you expect to find during a lung exam of a patient who may have asthma?

A

normal to hyperresonant

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18
Q

What do you expect to hear on auscultation of a patient with asthma?

A
  • Rhonchi to wheeze (usually expiratory)
  • Prolonged expiratory phase
  • Silent chest in severe asthma
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19
Q

What are the spirometry criteria for diagnosis of asthma?

A
  • Less than lower limit of normal FEV1/FVC based on age, sex, height, and ethnicity AND increase in FEV1 >12% after bronchodilator
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20
Q

What adjunct diagnostic testing can be performed if spirometry is nondiagnostic?

A
  • Bronchoprovocation testing
  • Exercise challenge
  • Peak flow meters
  • Chest X ray
  • Skin testing
  • Measurement of sputum for eosinophils
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21
Q

What is bronchoprovocation testing and when would you not use it?

A

Use of inhaled histamine, methacholine, or mannitol to induce asthma attack

Do not use if FEV1 is <65% of predicted

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22
Q

What is a peak flow meter especially good for?

A

Monitoring asthma

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23
Q

What would a chest x ray look like in an asthmatic patient?

A

Normal or hyperinflated, bronchial wall thickening, diminished peripheral lung vacular shadows

May not be able to see these findings

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24
Q

What are indications for CXR diagnostic testing?

A

Initial asthma diagnosis or uncertain diagnosis

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25
Q

Should you use CXR during acute asthma exacerbations?

A

No

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26
Q

Why would a chest x ray be helpful during status asthmaticus or no improvement in acute asthma attack?

A
  • Excludes CHF or pneumonia
  • Excludes pneumothorax, pneumomediastinum
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27
Q

What labs can be helpful for asthma diagnosis?

A
  • ABGs
  • CBC
  • Sputum sample
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28
Q

What may be present on ABG of a patient with asthma?

A
  • Hypoxemia
  • Hypercarbia with decompensation
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29
Q

What may be present on CBC of a patient with asthma?

A
  • Eosinophilia
  • Increased levels of IgE
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30
Q

What may be present on a sputum sample of a patient with asthma?

A
  • Casts of small airways
  • Thick, mucoid sputum
  • Curschmann’s spirals
  • Charcot-Leyden crystals
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31
Q

What is the methacholine challenge?

A
  • Patients breathe in methacholine and perform spirometry after each dose
  • Increased airway hyperresponsiveness with a >20% decrease in FEV1 up to 16 mg/mL max dose

Done in the hospital

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32
Q

How is asthma different from COPD?

A
  • Earlier onset
  • Symptoms vary from day to day (COPD is progressive)
  • Symptoms at night/early morning (COPD is during exercise)
  • Allergic/rhinitis/eczema also present (COPD is usually due to long smoking history)
  • Family history of asthma
  • Largely reversible (COPD irreversible)
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33
Q

In addition to COPD, what diagnosis may be similar to asthma?

A

Allergic rhinitis, sinusitis
FB in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, bronchostenosis
Enlargend lymph nodes or tumor
Viral bronchiolitis
CF
Bronchopulmonary disease
Heart disease
Recurrent cough
Aspiration from dysfunction of swallowing mechanism or GERD

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34
Q

What is the golden rule related to asthma?

A

Not all wheezes are asthma?

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35
Q

What are some important diagnosis to consider with wheeze?

A
  • Pulmonary edema
  • Pulmonary embolism
  • Anaphylactic reaction
  • COPD
  • pneumonia
  • Foreign body aspiration
  • Cystic fibrosis
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36
Q

What are complications of asthma?

A
  • Exhaustion
  • Dehydration
  • Airway infection
  • Tussive syncope
  • Pneumothorax
  • Respiratory failure
  • Chronic lung disease
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37
Q

Once you have established a diagnosis of asthma, what should be done next?

A
  • Determine severity
  • Develop treatment plan
  • Education of patient
  • Close monitoring
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38
Q

What are characteristics of mild intermittent asthma?

A
  • Daytime asthma fewer 2 or less days/week
  • <2 night awakenings per month
  • Use of SABA/rescue inhaler less than 2 times per week
  • No interference with normal activities between exacerbations
  • FEV1 measurements between exacerbations consistently within normal range (>80% predicted)
  • FEV1/FVC ratio between exacerbations is normal
  • 0-1 exacerbations requiring oral glucocorticoids per year
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39
Q

What are characteristics of mild persistent asthma?

A
  • Symptoms more than 2 days weekly
  • 3-4 night-time awakenings per month
  • Use of SABA to relieve symptoms more than 2 times/week
  • Minor interference with normal activities
  • FEV1 measurements within normal range and normal FEV1/FVC ratio
  • 2 or more exacerbations requiring oral glucocorticoids per year
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40
Q

What are characteristics of moderate persistent asthma?

A
  • Daily symptoms of asthma
  • Nighttime awakenings more than once per week
  • Daily need to SABA for symptom relief
  • Some limitation in normal activity
  • FEV1 between 60-80% of predicted and FEV1/FVC below normal
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41
Q

What are characteristics of severe persistent asthma?

A
  • Symptoms throughout day
  • Night-time awakenings nightly
  • Need for SABA several times per day
  • Extreme limitation in normal activity
  • FEV1 <60% predicted and FEV1/FEC below normal
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42
Q

What are goals of treatment of asthma?

A
  • Minimal or no chronic symptoms in the day, night, or after exertion
  • Minimal to no exacerbations
  • No limitations on activities
  • Near normal pulmonary function
  • Minimal use of rescue inhaler
  • Minimal or no adverse effects of medications
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43
Q

What are the classes of asthma medications?

A
  • SABA
  • Inhaled corticosteroid
  • LABA
  • Combined agents
  • Inhaled anticholinergics
  • Theophylline
  • Leukotrienes
  • Cromolyn
  • Racemic epinephrine
  • Monoclonal antibodies
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44
Q

What medications are considered SABA’s?

A
  • Albuterol
  • Levalbuterol

Usually referred to as rescue inhalers

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45
Q

Why might levalbuterol be helpful vs albuterol?

A

Levalbuterol has less tachycardia or cardiac SE but is more expensive

46
Q

What is the mechanism of action of SABA’s?

A

relax smooth muscle of airway and cause prompt increase in airflow and decrease symptoms

47
Q

____ should be given to anyone diagnosed or experiencing asthma symptoms “___”

A

LABA, don’t leave home without it

48
Q

Side effects of LABA’s

A
  • Tachycardia
  • nervousness
  • shakiness
49
Q

This medication is the preferred long-term controller in lowest doses possible to control your patient

A

Inhaled corticosteroids

50
Q

What are common inhaled corticosteroids?

A
  • Pulmicort (budesonide)
  • Qvar (beclometasone)
  • Asmanex (mometasone furoate)
  • Flovent (fluticasone propionate)
51
Q

What is the mechanism of action of inhaled corticosteroids?

A

Reduces airway inflammation and airway’s exaggerated sensitivity to triggers

52
Q

Why are inhaled corticosteroids helpful?

A

Regular treatment:
* Reduces frequency of symptoms
* Improves quality of life
* Decreases risk of serious exacerbations

53
Q

What are the most common side effects of inhaled corticosteroids?

A
  • Thrush
  • Hoarseness
  • Localized contact hypersensitivity
  • Cough and throat irritation
54
Q

What are less common systemic side effects of inhaled corticosteroids?

A
  • Impaired growth in children on long-term therapy
  • Osteoporosis in adults on long-term/high dose therapy
  • Cataracts
  • Glaucoma
  • Weight changes and adrenal suppression
55
Q

What should you do to reduce risk of side effects with inhaled corticosteroids?

A
  • Rinse mouth after use (decreases risk of thrush
  • Regular eye exams if h/o or family history of glaucoma
  • Monitor growth in children and cortisol levels
  • Watch calcium and vit D intake in women and children
56
Q

What is the recommended inhaler in pregnant women?

A

ICS
* Budesonide
* Proventil

57
Q

What is used in acute asthma attacks?

A

Systemic corticosteroids

58
Q

What are the systemic corticosteroids?

A
  • Prednisone
  • Prednisolone
  • Solu medrol
59
Q

This medication should be given to all moderate/severe asthmatics to keep at home in case of need

A

Systemic corticosteroids

60
Q

What are contraindications to systemic corticosteroids?

A
  • Hypersensitivity
  • Systemic fungal infections
  • varicella
  • superficial HSV keratitis
  • Administration of live vaccine if long term or consistent use
61
Q

What are side effects of systemic corticosteroids?

A
  • Skin and soft tissue infections
  • Cushingoid appearance/weight gain
  • cataracts/glaucoma
  • CV disease
  • GI disease-gastritis, ulcer formation, GI bleeding, pancreatitis
  • Hyperinsulinemia with insulin resistance
62
Q

This type of medication is used in combination with other medicatins, usually ICS and rarely as monotherapy for asthma

A

long acting inhaled beta-2 agonists

63
Q

what are the long acting beta-2 agonists

A

salmeterol
formoterol
arformoterol

64
Q

what are side effects of LABAs

A
  • can affect smooth muscle of heart –> tachycardia and palpitations
  • Shakiness
  • Cramping of hands, legs, and feet
  • May cause worsening of symptoms if used too often
65
Q

What are the ICS + LABA medications

A
  • Budesonide + formoterol (symbicort)
  • Fluticasone + Salmeterol (advair)
  • Fluticasone + vilanterol (Breo)
  • Mometasone + formoterol
66
Q

What is the benefit and limitation of ICS + LABA medications?

A
  • Benefit: bronchodilator widens airway + corticosteroid reduces inflammation of airway
  • Limitation: cost
67
Q

What can be used if asthma is unresponsive to therapy in combination with SABA?

A

Anticholinergics

68
Q

What are the anticholinergics?

A
  • Ipratropium bromide
  • Tiotropium bromide
  • Ipratropium and albuterol (Combivent, Duoneb)
69
Q

What is the mechanism of action of anticholinergics in asthma?

A

Relax airways and prevent from getting narrower
Reduce mucus in airway

70
Q

What is the nonselective phosphodiesterase enzyme inhibitor used as an add on medicine for moderate to severe asthma?

A

theophylline

71
Q

What is the mechanism of action of phosphodiesterase enzyme inhibitors in asthma treatment?

A
  • Bronchodilation, anti inflammatory, enhances mucociliary clearance, strengthens diaphragmatic contractility
72
Q

What should you keep in mind when using theophylline?

A

Monitor serum concentrations
Not for acute exacerbations

73
Q

What are the leukotriene receptor antagonists?

A
  • Montelukast (Singulair)
  • Zafirlukast (Accolate)
74
Q

What is the mechanism of action of leukotrienes?

A

blocks actions of cysteinyl leukotrienes at the CysLT1 receptor on target cells such as bronchial smooth muscle via receptor antagonism

75
Q

What is the benefit of leukotriene receptor antagonists in asthma?

A
  • Improves asthma symptoms
  • Reduces exacerbations
  • Limits markers of inflammation such as eosinophil counts in peripheral blood and bronchoalveolar lavage fluid
76
Q

What are potential side effects of leukotriene receptor antagonists?

A

Boxed warning of suicidal thoughts and actions, nightmares, and night terrors

77
Q

This medication for asthma is not used first line. It may be an option if someone fails or cannot tolerate ICS. It is a mast cell stabilizer

A

Cromolyn

78
Q

What is the benefit of cromolyn?

A

It prevents both early and late responses to inhaled allergens and reduces airway reactivity to irritants like cold air and sulfur dioxide

79
Q

What is the route of cromolyn?

A

nebulizer

80
Q

What are side effects of cromolyn?

A

mild throat irritation and cough

81
Q

When would you use nebulized epinephrine- racemic?

A

Severe asthma attacks, results in rapid improvement of upper airway obstruction

82
Q

what is the mechanism of action of nebulized epinephrine- racemic?

A

sympathomimetic, beta and alpha agonist
bronchodilator, decreases mucous membrane secretion, relieves subglottic edema
duration of 1-3 hours

83
Q

what are the side effects of nebulized epinephrine and how long do side effects of nebulized epinephrine usually last?

A

*restlessness
* anxiety
* tachycardia
* no more than 2 hours

84
Q

what monitoring must be done with children and nebulized epinephrine?

A
  • monitor in hospital or ER for at least 3-4 hours due to rebound phenomenon
85
Q

what is the monoclonal antibody used for asthma treatment?

A

omalizumab

86
Q

what is the mechanism of action of omalizumab?

A

IgG antibody that binds to IgE mast cells and reduces mediator release

87
Q

what is the population that may be given omalizumab for asthma?

A

moderate-severe uncontrolled asthma in person w/ positive skin prick testing to perennial allergies who is inadequately controlled with max dose of other meds

88
Q

what is the route/age of omalizumab?

A

injection only; 6 years and older

89
Q

what is the black box warning for omalizumab?

A

anaphylaxis, monitor closely

90
Q

What are the 6 steps of asthma treatment?

A
  1. SABA + low dose ICS when symptomatic or low dose ICS daily
  2. SABA + low dose ICS
  3. SABA + low dose ICS + LABA or medium dose ICS alone
  4. SABA + medium dose ICS + LABA
  5. SABA + high dose ICS + LABA
  6. SABA + high dose ICS + oral steroids + LABA
91
Q

What is treatment other than medications for asthma?

A
  • Desensitization with allergy shots
  • Vaccination: pneuomococcal, COVID, influenza
92
Q

How do you monitor patients with asthma?

A
  • Follow up visits every 1-6 months (depends on severity)
  • 2-6 week follow up after new med
  • Consider stepping down treatment if stable for 3 months
93
Q

What should you assess in a asthmatic patient at follow up visits?

A
  • Signs and symptoms
  • Pulmonary function
  • Quality of life
  • Exacerbations
  • Adherence
  • Satisfaction with treatment plan
94
Q

What questions should you ask a patient with asthma?

A
  • Nighttime or early morning awakenings?
  • How often need rescue inhaler
  • How often wheezing
  • Unscheduled care for asthma or called in sick
  • participation in school/work activities
  • questions aout peak flow readings if measuring
  • systemic steroids since last visit
95
Q

What are assessment tools for asthma?

A
  • Extensive questioning
  • Patient questionnaires
  • Peak flow meter

Green = 80-100%
Yellow = 50-80% (caution!)
Red = below 50% (medical alert)

96
Q

what is considered well controlled asthma?

A

symptoms less than 2 days a week

97
Q

What is considered no well controlled asthma?

A

symptoms >2 days a week or multiple times a night

98
Q

what is considered very poorly controlled asthma?

A

symptoms persist throughout the day, 20% change in value from AM to afternoon or day to day

99
Q

What are goals of asthma treatment?

A
  • Relief from symptoms
  • Minimal need of SABAs to relieve symptoms
  • Few night-time awakenings
  • optimal lung function
  • normal ADLs
  • satisfaction of care among patients and families
  • prevent recurrent exacerbations, including ED and hospital care
  • Optimal treatment plan with minimal SEs
100
Q

what is patient education to provide with asthma?

A
  • Help patient be active in managing
  • Teach to monitor symptoms and pulmonary function
  • possible triggers
  • how to take medication properly
  • how to use peak flow meters and treatment plan/”Asthma action plan”
101
Q

When should you refer/consult pulmonologist or allergist?

A
  • Life threatening asthma attack
  • Hospitalized or on more than 2 rounds of oral corticosteroids
  • Step 4 care or higher over 5 or 3 or higher under 5
  • unresponsive to treatment or uncontrolled therapy after 3-6 months of active therapy and monitoring
  • diagnosis is uncertain
  • other conditions complicate management
  • additional diagnostic tests needed
  • patient may be candidate for allergen immunotherapy
102
Q

condition in which the airways narrow significantly during vigorous exercise

A

exercise induced asthma aka exercise induced bronchospasm

103
Q

what are typical symptoms of exercise induced asthma

A

cough, wheezing, SOB, chest tightness
starts at onset of exercise or 3 mins after; peaks 10-15 min; resolves within 60 min

104
Q

what medication is helpful for exercise induced asthma?

A

SABAs: albuterol, pirbuterol, ipratropium and albuterol combo taken 15-30 min before exercise

105
Q

chronic cough for >3 weeks that is non-productive, usually nocturnal in any age group. PFT/spirometry normal and no other causes of chronic cough

A

Cough Variant Asthma

106
Q

What is the treatment of cough variant asthma?

A

similar to other forms of asthma

107
Q

what are warning signs for adults of acute asthma attack?

A
  • increased SOB or wheezing
  • Disturbed sleep caused by SOB, coughing, or wheezing
  • Chest tightness or pain
  • Increased need to use bronchodilators
  • A fall in peak flow rates
108
Q

What are warning signs for an asthma attack in children?

A
  • audible whistling or wheezing when the child exhales
  • Coughing, especially when cough is frequent and in spasms
  • Waking at night with coughing or wheezing
  • SOB, which may or may not occur when child is exercising
  • Tight feeling in child’s chest
109
Q

Most severe form of asthma where lungs are no longer able to provide body with adequate oxygen or remove CO2

A

status asthmaticus

110
Q

what happens in status asthmaticus?

A
  • organs malfunction
  • build up of carbon dioxide leads to acidosis
  • blood pressure may fall
  • airways so narrowed that is difficult to move air in and out
111
Q

what is treatment of status asthmaticus?

A
  • intubation and ventilator support
  • maximum doses of medications
  • support to correct acidosis

Pulmonology (1 decks)

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