Asthma Flashcards
What FEV1/FVC value signifies obstruction?
< 0.70
Normal FEV1/FVC = ?
> 0.70
What are common triggers for asthma?
Allergens, humidity, exercise, smoke
What is the preferred route for SABAs?
Inhaled
Why? Gets to site quicker and less ADEs
Exercise induced asthma - DOC
SABA - Albuterol 2 puffs 15 min before exercise
LABA - Formoterol DPI 1 puff 15 min before exercise
What is the preferred inhaled SABA?
Albuterol
Inhaler or neb
Albuterol - indications
Reversible bronchospasm (BBW) and EIA
*What are some oral SABAs?
Albuterol syrup and tabs
Metoproterenol syrup and tabs
Terbutaline tabs
Beta 2 agonists - side effects
Tremor
Palpitations
Reduction in o2 sat (b/c opens unused spaces)
What is considered a “good candidate” for bronchodilators?
Increase of 200 mL or 12% in FEV1 compared to baseline
Formoterol - class and dosing
LABA
1 puff bid
Onset 5-15 min x 12 hrs
When should LABA be used?
Only in combo with an asthma controller med -> never alone!
Use in long term patients that are not adequately controlled with other meds
Who requires a LABA in combination formulation with a corticosteroid?
Peds and adolescents
ex. Budesonide + Formoterlol (Symbicort) and Fluticasone +Salmeterol (Advair)
Why do LABAs have a black box warning?
Increased risk of asthma related deaths -> Taper off ASAP
Not for acute exacerbations!
*ICS - MOA
Inhibits cytokine-induced production of pro inflammatory proteins
Indirect: suppresses inflammation, increased production of beta 2 receptors (improves response), decrease mucous
When should corticosteroids be stepped down?
Once controlled, decrease dose by 25% q 2 weeks for 8 weeks
Corticosteroids - side effects
Effects in bone growth (slower but catches up)
Adrenal suppression
Osteoporosis
Thrush (inhaler)
What classes can be used in patients that need/want to avoid steroids?
Mast cell stabilizers (cromolyn and nedocromil)
Leukotriene modifiers (montelukast)
*Corticosteroids - counseling
Inhaler technique
Right order (bronchodilator first)
Daily use (not for exacerbations)
Rinse mouth to prevent thrush
Mast cell stabilizers - ADEs
Bad taste, GI
Which drug can be given for mod-severe persistent allergic asthma NOT controlled with inhaled steroids?
Omalizumab (xolair)
> 12 yrs
Acts as a receptor to IgE
Given in clinic q 2-4 wks
Expensive!
Why isn’t theophylline used much?
Narrow therapeutic window (5-15 mcg/mL)
Lots of DDI
Treatment for acute asthma exacerbation
Albuterol (quick) + ipratropium (long acting)
Acute asthma exacerbation - DOC and dosing
Albuterol
MID: 4-8 puffs q 20 min x 4 hrs
Neb: 2.5-5 mg q 20 min x 3 2.5-10 mg q 1-4 hrs prn
+
Ipratropium (Never use alone…always w/albuterol)
MDI: 8 inhalations q 20 min prn up to 3 hrs
Neb: 0.5 mg or 500 mcg q 20 min x 3
*When are steroids given during acute asthma exacerbation?
Early in the attack if incomplete response to inhalers
Steroids for acute asthma exacerbation - DOC and dosing
Adults - Prednisone 60 mg PO or methylprednisone 80 mg IV
Peds - prednisolone 2 mg/kg PO x 5 days
What are the 3 alternative treatments (meds) for acute asthma exacerbation?
- Mgso4 if not responding and trying to prevent intubation
- Racemic epi if not responding to albuterol (SQ or neb)
- Antibiotics if evidence of infection
*Asthma exacerbation - Treatment steps
- Albuterol
- Oral steroid
- O2 (goal sat >95%)
- Short acting theophylline if beta 2 agonist not available
- If unresponsive to steroid + albuterol -> MgSO4
If a pedi RR > 60, what should you do?
Admit
An asthma attack is considered severe if…
Breathless at rest, hunched forward and/or talking in words
Infant - stops feeding, agitated, drowsy, confused, bradycardia or resp >30
Budesonide Inhln Powder (pulmacort) - indication
ICS for asthma prophylaxis
*Montelukast (Singulair) - class
Leukotriene receptor antagonist
Albuterol - dosing
2 puffs q 4-6 hrs prn
Onset 5-8 min x 3-6 hours
Which is more effective…oral or inhaled SABA?
inhaled
why? oral takes longer (onset 30 minutes) and needs regular dosing (generally TID-QID)
What is the only ICS approved for pregnancy?
Pulmacort (cat B)
Pulmacort - dosing
Adults - qd for mild asthma
Peds - bid
Onset 24 hrs, max benefit 1-2 wks
Montelukast (Singulair) - dosing
Qd in evening
*Corticosteroids - MOA
Inhibits cytokine-induced production of pro-flammatory proteins
*Mast cell stabilizers - MOA
no bronchodilation…prevents mast cells from releasing histamine
*Omalizumab (Xolair) - class?
IgE Antibody Inhibitor
*Omalizumab - MOA
inhibits the binding of IgE to the high-affinity IgE receptor on the surface of mast cells and basophils
*Omalizumab - only FDA approval
mod-severe persistent allergic asthma
*Formoterol and salmeterol - class?
LABA
*Albuterol and levalbuterol - class?
SABA
*Budesonide + Fomoterol (Symbicort) and Fluticasone + Salmeterol - class?
LABA + ICS
*Budesonide and Beclomethasone - class?
ICS
*Level of asthma control - “controlled”
daytime symptoms < 2 times/week, no limitations, no night symptoms, rescue inhaler < 2 times/week, normal lung function, no exacerbations
*Level of asthma control - “partly controlled”
any of the following in past week: symptoms > 2 times, any limitations, any night symptoms, rescue inhaler > 2 times, lung function <80% of personal best, any exacerbation this year
*Level of asthma control - “uncontrolled”
3+ features from partly controlled in last week
*Asthma - approaches to treatment based on control
controlled - maintain lowest controlling step
partially controlled - consider stepping up
uncontrolled - step up until controlled
exacerbation - treat as exacerbation
