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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
Should you use CXR during acute asthma exacerbations?
No
26
Why would a chest x ray be helpful during status asthmaticus or no improvement in acute asthma attack?
* Excludes CHF or pneumonia * Excludes pneumothorax, pneumomediastinum
27
What labs can be helpful for asthma diagnosis?
* ABGs * CBC * Sputum sample
28
What may be present on ABG of a patient with asthma?
* Hypoxemia * Hypercarbia with decompensation
29
What may be present on CBC of a patient with asthma?
* Eosinophilia * Increased levels of IgE
30
What may be present on a sputum sample of a patient with asthma?
* Casts of small airways * Thick, mucoid sputum * Curschmann's spirals * Charcot-Leyden crystals
31
What is the methacholine challenge?
* 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 ## Footnote Done in the hospital
32
How is asthma different from COPD?
* 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)
33
In addition to COPD, what diagnosis may be similar to asthma?
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
34
What is the golden rule related to asthma?
Not all wheezes are asthma?
35
What are some important diagnosis to consider with wheeze?
* Pulmonary edema * Pulmonary embolism * Anaphylactic reaction * COPD * pneumonia * Foreign body aspiration * Cystic fibrosis
36
What are complications of asthma?
* Exhaustion * Dehydration * Airway infection * Tussive syncope * Pneumothorax * Respiratory failure * Chronic lung disease
37
Once you have established a diagnosis of asthma, what should be done next?
* Determine severity * Develop treatment plan * Education of patient * Close monitoring
38
What are characteristics of mild intermittent asthma?
* 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
39
What are characteristics of mild persistent asthma?
* 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
40
What are characteristics of moderate persistent asthma?
* 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
41
What are characteristics of severe persistent asthma?
* 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
42
What are goals of treatment of asthma?
* 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
43
What are the classes of asthma medications?
* SABA * Inhaled corticosteroid * LABA * Combined agents * Inhaled anticholinergics * Theophylline * Leukotrienes * Cromolyn * Racemic epinephrine * Monoclonal antibodies
44
What medications are considered SABA's?
* Albuterol * Levalbuterol ## Footnote Usually referred to as rescue inhalers
45
Why might levalbuterol be helpful vs albuterol?
Levalbuterol has less tachycardia or cardiac SE but is more expensive
46
What is the mechanism of action of SABA's?
relax smooth muscle of airway and cause prompt increase in airflow and decrease symptoms
47
____ should be given to anyone diagnosed or experiencing asthma symptoms "___"
LABA, don't leave home without it
48
Side effects of LABA's
* Tachycardia * nervousness * shakiness
49
This medication is the preferred long-term controller in lowest doses possible to control your patient
Inhaled corticosteroids
50
What are common inhaled corticosteroids?
* Pulmicort (budesonide) * Qvar (beclometasone) * Asmanex (mometasone furoate) * Flovent (fluticasone propionate)
51
What is the mechanism of action of inhaled corticosteroids?
Reduces airway inflammation and airway's exaggerated sensitivity to triggers
52
Why are inhaled corticosteroids helpful?
Regular treatment: * Reduces frequency of symptoms * Improves quality of life * Decreases risk of serious exacerbations
53
What are the most common side effects of inhaled corticosteroids?
* Thrush * Hoarseness * Localized contact hypersensitivity * Cough and throat irritation
54
What are less common systemic side effects of inhaled corticosteroids?
* 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
What should you do to reduce risk of side effects with inhaled corticosteroids?
* 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
What is the recommended inhaler in pregnant women?
ICS * Budesonide * Proventil
57
What is used in acute asthma attacks?
Systemic corticosteroids
58
What are the systemic corticosteroids?
* Prednisone * Prednisolone * Solu medrol
59
This medication should be given to all moderate/severe asthmatics to keep at home in case of need
Systemic corticosteroids
60
What are contraindications to systemic corticosteroids?
* Hypersensitivity * Systemic fungal infections * varicella * superficial HSV keratitis * Administration of live vaccine if long term or consistent use
61
What are side effects of systemic corticosteroids?
* 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
This type of medication is used in combination with other medicatins, usually ICS and rarely as monotherapy for asthma
long acting inhaled beta-2 agonists
63
what are the long acting beta-2 agonists
salmeterol formoterol arformoterol
64
what are side effects of LABAs
* 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
What are the ICS + LABA medications
* Budesonide + formoterol (symbicort) * Fluticasone + Salmeterol (advair) * Fluticasone + vilanterol (Breo) * Mometasone + formoterol
66
What is the benefit and limitation of ICS + LABA medications?
* Benefit: bronchodilator widens airway + corticosteroid reduces inflammation of airway * Limitation: cost
67
What can be used if asthma is unresponsive to therapy in combination with SABA?
Anticholinergics
68
What are the anticholinergics?
* Ipratropium bromide * Tiotropium bromide * Ipratropium and albuterol (Combivent, Duoneb)
69
What is the mechanism of action of anticholinergics in asthma?
Relax airways and prevent from getting narrower Reduce mucus in airway
70
What is the nonselective phosphodiesterase enzyme inhibitor used as an add on medicine for moderate to severe asthma?
theophylline
71
What is the mechanism of action of phosphodiesterase enzyme inhibitors in asthma treatment?
* Bronchodilation, anti inflammatory, enhances mucociliary clearance, strengthens diaphragmatic contractility
72
What should you keep in mind when using theophylline?
Monitor serum concentrations Not for acute exacerbations
73
What are the leukotriene receptor antagonists?
* Montelukast (Singulair) * Zafirlukast (Accolate)
74
What is the mechanism of action of leukotrienes?
blocks actions of cysteinyl leukotrienes at the CysLT1 receptor on target cells such as bronchial smooth muscle via receptor antagonism
75
What is the benefit of leukotriene receptor antagonists in asthma?
* Improves asthma symptoms * Reduces exacerbations * Limits markers of inflammation such as eosinophil counts in peripheral blood and bronchoalveolar lavage fluid
76
What are potential side effects of leukotriene receptor antagonists?
Boxed warning of suicidal thoughts and actions, nightmares, and night terrors
77
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
Cromolyn
78
What is the benefit of cromolyn?
It prevents both early and late responses to inhaled allergens and reduces airway reactivity to irritants like cold air and sulfur dioxide
79
What is the route of cromolyn?
nebulizer
80
What are side effects of cromolyn?
mild throat irritation and cough
81
When would you use nebulized epinephrine- racemic?
Severe asthma attacks, results in rapid improvement of upper airway obstruction
82
what is the mechanism of action of nebulized epinephrine- racemic?
sympathomimetic, beta and alpha agonist bronchodilator, decreases mucous membrane secretion, relieves subglottic edema duration of 1-3 hours
83
what are the side effects of nebulized epinephrine and how long do side effects of nebulized epinephrine usually last?
*restlessness * anxiety * tachycardia * no more than 2 hours
84
what monitoring must be done with children and nebulized epinephrine?
* monitor in hospital or ER for at least 3-4 hours due to rebound phenomenon
85
what is the monoclonal antibody used for asthma treatment?
omalizumab
86
what is the mechanism of action of omalizumab?
IgG antibody that binds to IgE mast cells and reduces mediator release
87
what is the population that may be given omalizumab for asthma?
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
what is the route/age of omalizumab?
injection only; 6 years and older
89
what is the black box warning for omalizumab?
anaphylaxis, monitor closely
90
What are the 6 steps of asthma treatment?
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
What is treatment other than medications for asthma?
* Desensitization with allergy shots * Vaccination: pneuomococcal, COVID, influenza
92
How do you monitor patients with asthma?
* 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
What should you assess in a asthmatic patient at follow up visits?
* Signs and symptoms * Pulmonary function * Quality of life * Exacerbations * Adherence * Satisfaction with treatment plan
94
What questions should you ask a patient with asthma?
* 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
What are assessment tools for asthma?
* Extensive questioning * Patient questionnaires * Peak flow meter ## Footnote Green = 80-100% Yellow = 50-80% (caution!) Red = below 50% (medical alert)
96
what is considered well controlled asthma?
symptoms less than 2 days a week
97
What is considered no well controlled asthma?
symptoms >2 days a week or multiple times a night
98
what is considered very poorly controlled asthma?
symptoms persist throughout the day, 20% change in value from AM to afternoon or day to day
99
What are goals of asthma treatment?
* 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
what is patient education to provide with asthma?
* 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
When should you refer/consult pulmonologist or allergist?
* 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
condition in which the airways narrow significantly during vigorous exercise
exercise induced asthma aka exercise induced bronchospasm
103
what are typical symptoms of exercise induced asthma
cough, wheezing, SOB, chest tightness starts at onset of exercise or 3 mins after; peaks 10-15 min; resolves within 60 min
104
what medication is helpful for exercise induced asthma?
SABAs: albuterol, pirbuterol, ipratropium and albuterol combo taken 15-30 min before exercise
105
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
Cough Variant Asthma
106
What is the treatment of cough variant asthma?
similar to other forms of asthma
107
what are warning signs for adults of acute asthma attack?
* 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
What are warning signs for an asthma attack in children?
* 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
Most severe form of asthma where lungs are no longer able to provide body with adequate oxygen or remove CO2
status asthmaticus
110
what happens in status asthmaticus?
* 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
what is treatment of status asthmaticus?
* intubation and ventilator support * maximum doses of medications * support to correct acidosis

Pulmonology (1 decks)

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