asthma

Question 1

– Hyperresponsive airways
– Airway inflammation
– Reversible airway obstruction caused by bronchial smooth muscle
constriction (bronchospasm)
- more common in children

Answer 1

asthma

Question 2

Atopy:strongest identifiable predisposing factor
■ Inherited predisposition, body produces way too much IgE in response to antigen
■ Associated with atopic dermatitis (eczema), allergic rhinitis, asthma
– More common type
– Often diagnosed in childhood
– Family history

Answer 2

Extrinsic / Allergic / Atopic / Type 2 asthma

Question 3

– Normal serum IgE
– Often diagnosed in adulthood, no significant family history
– Exercise induced, medication induced, chronic infection, etc
- most likely diagnosed in adulthood

Answer 3

Intrinsic / Nonallergic / Nonatopic / Non-Type 2 asthma

Question 4

Exposure to allergens trigger a cascade of cellular activation in the airways resulting in inflammation.
– Antigen exposure activates IgE (main antibody responsible for allergic reaction)
– IgE binds to and activates mast cells
– Activation of mast cells leads to
release of mediators that cause
bronchoconstriction and inflammation
■ Histamine, leukotrienes,
prostaglandins
■ Mucus production

Answer 4

pathophysiology of asthma

Question 5

common triggers of asthma

Answer 5

■ Air pollution
■ Tobacco smoke
■ Certain occupational exposures / fumes
■ Mites, animal dander, cockroaches, fungi, mold, pollen
■ Infections – typically viral
■ Diet
■ GERD
■ Exercise induced
■ Menstruation
■ Medications
– Beta-blockers
– Aspirin

Question 6

Aspirin induced asthma / aspirin exacerbated respiratory disease
■ 3 main features:
– Aspirin / NSAID intolerance
– Asthma
– Nasal polyps / rhinitis
■ Nonallergic / intrinsic

Answer 6

Samter’s Triad

Question 7

■ Wheezing - expiratory
wheezes**
■ Dyspnea
■ Chest tightness
■ Cough
– Can be dry or productive
■ Symptoms worse at night***

■ Physical exam findings:
– Nasal polyps / swelling
– Eczema / dermatitis
– Prolonged expiratory
phase
– Accessory muscle usage

Answer 7

asthma symptoms

Question 8

how to diagnose asthma

Answer 8

1. get a thorough history
2. PFT: spirometry (gold standard)

Question 9

what is the FEV1/FVC ratio that indicates obstruction

Answer 9

less than 70%

Question 10

what % indicates reversibility after bronchodilator

Answer 10

more than 12%

Question 11

what percent indicates a positive asthma in bronchoprovacation testing

Answer 11

Decrease in FEV1 of more than 20%
after exposure to agent is +

Question 12

■ Inhaled agents trigger
bronchoconstriction to evaluate
responsiveness
■ Decrease in FEV1 of more than 20%
after exposure to agent is +
■ Methacholine (triggers inflammatory response and causes bronchoconstricition), histamine

Answer 12

Bronchoprovocation testing

Question 13

■ Handheld, portable way to assess severity of symptoms
■ ”normal” values are based on age, height, & biologic sex
– Patient’s have their own “normal”,
knowing their baseline is important

Answer 13

Peak Expiratory Flow Rate

Question 14

■ Measures exhaled Nitric Oxide, gas
produced by cells associated with
eosinophils
■ Can help determine efficacy of current regimen and guide medication management

Answer 14

FeNO testing

Question 15

adjunct diagnostics to asthma

Answer 15

■ Chest X-Ray
– May show hyperinflation over time, not specific to asthma
■ ABG
– More helpful in the acute setting w/ exacerbation
– Can help to assess impeding respiratory failure
■ Skin testing
■ Serum IgE

Question 16

asthma management: First steps

Answer 16

■ Goals of management:
– Maintain ADLs, reduce exacerbations / hospital visits
– Maintain lung function
■ Every asthmatic should be prescribed a rescue inhaler,
regardless of frequency of symptoms
■ Additional medication regimen based on classification /
severity of disease
■ Reduce risk factors
– Avoid known triggers
– Smoking cessation, weight loss, allergy treatment
■ Frequent reassessment

Question 17

– Albuterol (onset with minutes, lasts 6 hours) & Levalbuterol (Xopenex)
– Provide immediate relief of symptoms
– Binds to beta receptors, cause smooth muscle relaxation

Answer 17

Short Acting Beta Agonists (SABAs):

Question 18

– Formoterol (onset time 1-2 minutes, lasts 12 hours), Salmeterol
– Never used on their own, given with ICS (often combo inhaler)

Answer 18

Long Acting Beta Agonists (LABAs)

Question 19

– Mainstay of treatment. Indicated for all persistent asthmatics
– Strong anti-inflammatory properties.
– Improved lung function
– Slow onset, must be taken daily for several weeks for improvement

Answer 19

Inhaled Corticosteroids (ICS)

Question 20

■ Status asthmaticus
■ Very diminished lung sounds
■ Inability to speak in full sentences
■ Cyanosis
■ Accessory muscle usage
■ ABG
– Decreasing pH & PaO2, increasing PaCO

Answer 20

severe exacerbations

Question 21

Severe Exacerbations / ER treatment

Answer 21

■ ABCs always #1, ensure adequate IV access. Start treatment ASAP.
■ Maintain SpO2 >90%
– May need bipap for increased WOB
– Try and avoid intubation
■ Albuterol, lots of it. Often requires back-to-back or continuous nebulizer
treatments
– Commonly will add ipratropium bromide
■ Systemic Steroids
– Start immediately
-Methylprednisolone,dexamethasone
■ Magnesium Sulfate
– 2 g IV over 20 minutes

Question 22

Management: Patient Education

Answer 22

■ Asthma action plans
– Ensure patients have a
written asthma action plan
they can understand and
follow
■ MDI w/ Spacer technique:
– Drastically Improves delivery
of medication.
– No coordination required
■ Peak Expiratory Flow Rate
(PEFR) measurement:

Question 23

asthma complications:

Answer 23

■ Respiratory failure, hypoxia
■ Acidosis
■ Pneumothorax
■ Infection