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Primary care of adults 2 > Asthma > Flashcards

Asthma Flashcards

1
Q

What is the airway pathology associated with asthma?

A
  • Chronic inflammation **** the cornerstone
  • Eventual airway remodeling and fibrosis d/t chronic inflammation
  • Airway wall edema
  • Mucus gland hypertrophy
  • Mucus hypersecretion/plugging
  • Smooth muscle hypertrophy
  • Bronchoconstriction
  • Airway hyperresponsiveness
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2
Q

What are the symptoms of asthma?

A

yspnea, wheezing, chest tightness, cough

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3
Q

Adult starts wheezing, what is your ddx?

A

COPD, asthma, vocal cord dysfunction

VCD is inspiratory. They can be discracted from it but it’s true pathology

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4
Q

Criteria for Dx of Asthma

A
  • Presence of episodic sx of airflow obstruction / airway hyperresponsiveness
  • Objective assessment - one of the following
    • at least partially reversible w/SABA
      • increase in FEV1, of > 12% from baseline
      • increase in predicted FEV1, of > 10% points from baseline
      • increase PEF of > 20% (or 60 l/min) from baseline
    • Diurnal variation in PEF (measured 2x daily) of >10%
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5
Q

What is FEV1?

A

Forced Expiratory Volume in 1 second

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6
Q

What is FVC?

A

Forced Vital Capacity (total volume of full exhalation after full inhalation)

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7
Q

FEV1/FVC normal values for 20-39yo

A

80%

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8
Q

FEV1/FVC normal value for 40-59yo

A

75%

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9
Q

FEV1/FVC normal value for 60-80yo

A

70%

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10
Q

Mild (intermittent or persistent) asthma: what is their FEV1/FVC?

A

may be normal

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11
Q

Pts w/moderate persisten asthma: what is their FEV1/FVC?

A

5% less than normal

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12
Q

Severe persistent asthma: what is their FEV1/FVC?

A

>5% less than normal

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13
Q

Goals of chronic asthma mgmt

A

Reduction of impairment

Reduction of risk

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14
Q

How can impairment d/t chronic asthma be reduced?

A
  • Minimizing intensity and frequency of symptoms
  • _<_2 days/week SABA use
  • _<_2 nights/month with symptoms
  • Maintenance of normal activity
  • Optimization of lung function
  • Improved patient satisfaction
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15
Q

How can risk d/t chronic asthma be reduced?

A
  • Prevention of exacerbations
  • Preservation of lung function
  • Tolerance of medications with minimal adverse effects
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16
Q

Characteristics of mild intermittent asthma

A
  • Sx ≤ 2d/ wk
  • Noct sx ≤ 2d/mo
  • FEV1>80%, 0-1 exac/yr
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17
Q

Characteristics of mild persistent asthma

A
  • Sx 3-6d/wk
  • Noct sx 3-4d/mo
  • FEV1>80%, _>_1 exac/yr
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18
Q

Characteristics of moderate persistent asthma

A
  • Daily sx
  • Noct sx >1d/wk
  • FEV1>60%, _>_1 exac/yr
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19
Q

Characteristics of severe persistent asthma

A
  • Constant sx
  • Noct sx often nightly
  • FEV1 ≤60%
  • Frequent exacerbations
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20
Q

Initial Tx: mild intermittent

A

no daily meds

SABA prn

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21
Q

Initial tx: mild persistent asthma

A

Preferred: low-dose ICS

Alternative: Cromolyn, LTRA, Nedocromil, Theophyline

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22
Q

Initial Tx: Moderate persistent asthma

A

Preferred: Low-dose ICS + LABA OR Medium Dose ICS

Alternative: Low-dose ICS + either LTRA, Theophyline, or Zileuton

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23
Q

Initial Tx: Severe persistent asthma (step 4)

A

Preferred: Medium-dose ICS + LABA

Alternative: Medium-dose ICS + either LTRA, Theopyline, or Zileuton

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24
Q

Initial Tx: Severe persistent asthma (step 5)

A

Preferred: High-dose ICS + LABA

AND

Consider Omalizumab for pts who have allergies

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25
Q

What is Step 6 for asthma?

A

Preferred: High dose ICS + LABA + PO corticosteroid

AND

Consider Omalizumab for pts who have allergies

26
Q

If a patient with asthma has coexisting allergic rhinitis, what is the recommended maintenance drug?

A

LTRA instead of ICS

27
Q

How should exercise indduced bronchoconstriction / asthma be treated?

A
  • Pretreat w/ SABA or MCS
  • Beware of masking symptoms. Consider controller
  • Warm up period in cold weather. Scarves, warm clothes.
28
Q

How should asthma be managed during pregnancy?

A
  • Albuterol = preferred bronchodilator
  • ICS = preferred controller. Budesonide (Pulmacort) is preferred.
  • No Singulaire
  • Risk of poor control outweighs risk of med adverse effects
29
Q

Metered Dose Inhalers (MDI): how to use

A
  • Shake the inhaler well before use; remove cap
  • Exhale away from inhaler
  • Bring the inhaler to your mouth.
  • Place it in your mouth between your teeth and close you mouth around it.
  • Start to breathe in slowly.
  • Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath.
  • Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
30
Q

Diskus (Dry powder inhaler): how to use

A
  • Hold Diskus in palm of hand (sandwich)
  • Push thumb grip until it clicks into place
  • Slide lever away from you
  • Place it in your mouth between your teeth and close you mouth around it.
  • Start to breathe in deeply and rapidly.
  • Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
  • Always check the number in the dose counter window to see how many doses are left
31
Q

Twisthaler (Dry powder inhaler): how to use

A
  • Twist white cap counter clockwise
  • Exhale away from Twisthaler
  • Hold horizontally
  • Place it in your mouth between your teeth and close you mouth around it.
  • Start to breathe in deeply and rapidly.
  • Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
  • Replace cap and twist clockwise.
  • Make sure it clicks to completely close it.
  • Rinse mouth and gargle
32
Q

Spacers: benefit

A
  • Enhanced drug delivery, highly recommended with ICS for pediatrics
  • Canister holds drug in place. Can inhale at own pace – good for pedi who may not have high lung capacity
33
Q

What controller medications are available for asthma tx?

A
  • Inhaled Corticosteroids
  • Leukotriene receptor antagonists (montelukast)
  • Long acting bronchodilators (b2-agonists)
  • Mast cell stabilizers (cromolyn and nedocromil) more in pedi
  • Methylxanthines (theophylline)
  • Biologics (omalizumab, trial therapies) new frontier
34
Q

What rescue meds are available for asthma tx?

A
  • short acting bronchodilators (b2-agonists, antichol) preferentially SABA, sometimes antichols, sometimes combo
  • corticosteroids: oral, IV
35
Q

Benefits of ICS

A
  • The cornerstone of “controller” therapy:
    • Decrease inflammation
    • Decrease AHR
    • Reduce risk of exacerbations
    • Reduce symptoms
  • More effective than LTRA for most stages
36
Q

When would you use an oral steroid with asthma?

A

acute exacerbation and severe dz

37
Q

Side effects of ICS

A
  • Inhaled: Thrush, dysphonia - thrush can be severe and refractory even to good technique
  • Oral (or high ICS with frequent OCS): cataracts, adrenal suppression, hyperglycemia, osteoporosis, skin fragility

If refractory to other methods, but reserved d/t side effects

38
Q

When are mast cell stabilizers used?

A
  • Frequently used in children, less in adults:
    • Seasonal, cold-induced sx
    • Exercise induced asthma
  • Mild to moderate anti-inflammatory effect

Not really used w/adults at all

39
Q

Mast cell stabilizer MOA

A
  • Prevents degranulation of mast cells
    • ↓ release of pro-inflammatory cytokines
40
Q

Side effects of mast cell stabilizers

A
  • Mild throat irritation, cough
  • Metallic taste
41
Q

Mast cell stabilizers: agents

A
  • Cromolyn sodium
  • Nedocromil sodium
42
Q

How do endogenous leukotrienes contribute to asthma?

A
  • Product of the arachadonic acid metabolic pathway
  • Potent proinflammatory effects: LTB4
  • Potent bronchoconstrictor effects: LTC4, LTD4
  • Increase mucus production while impeding mucociliary clearance
  • Promote vascular permeability
  • Receptors on respiratory mucosa, including nasal mucosa
43
Q

How do leukotriene inhibitors work?

A
  • Zileuton inhibits leukotriene production, while LTRAs (Montelukast, zafirlukast) inhibit receptors → mild bronchodilator/anti-inflammatory effects
44
Q

Side effects of leukotriene inhibitors

A
  • mostly well tolerated
    • Mildly elevated LFTs
    • +/- Mild sedation (give in evening)
45
Q

Main limiting factor of leukotrien inhibitors?

A

main limiting factor is not SEs, but whether accomplishes goal

46
Q

How do beta 2 agonists work?

A
  • Stimulate β2-adrenergic receptor –> smooth muscle bronchodilation
  • Decreased sensitivity of β2 receptor with age
47
Q

When do you use LABAs?

A

Only in combo with ICS!

many given combo first now - but you should start w/ICS to avoid risks, per speaker

48
Q

Onset and duration of SABAs

A

rapid onset (minutes), 4-6h duration

49
Q

Onset and duration of LABAs

A

variable onset (2-5min formoterol, >20min salmeterol), 12h duration

50
Q

Side effects of beta agonists

A
  • Common: Tachycardia, tremor, nervousness (β1 effect)
  • Hypokalemia – if given very frequently, e.g., in acute setting
  • Vasodilation: stimulation of β2-receptor on vascular smooth muscle
    • mild hypoxia (pulmonary vasodilatation –> shunt)
    • Hypotension
    • Reflex tachycardia
    • increased cardiac output
51
Q

Methylxanthines (Theophylline): how does it work & why is it not often used?

A
  • good drug, works for many, but many issues w/it
    • Multiple mechanisms (BD, anti-inflammatory, etc)
    • Narrow therapeutic window – monitoring essential
    • Multiple drug interactions
    • High occurrence of side effects/toxicity
52
Q

Anti-IgEs: what are the agents?

A

omalizumab (Xolair)

53
Q

How do Anti-IgEs work?

A
  • Monoclonal Ab blocking binding of IgE to receptors on mast cells and basophils – e.g., allergic to dust mites
  • Injections every 2-4 wks, small risk of anaphylaxis
54
Q

Who is at high risk for acute exacerbations of asthma?

A
  • Prior ICU/intubation
  • > 2 hospitalizations or >3 ED visits in past year
  • High SABA use
  • Poor symptom perception – don’t recognize until crisis point. PFMs at home can be helpful in training.
  • Low SE status, urban residence
  • Comorbid drug use, psychiatric disease, heart/lung disease
55
Q

Characteristics of mild / moderate asthma exacerbation

A
  • SOB with activity that may limit some normal activities
  • Usually treated at home; may require UV or ED
  • PEF>40% personal best
  • Symptoms relieved temporarily with SABA use
56
Q

Tx for mild / moderate exacerbation

A
  • Frequent SABA
  • Oral systemic steroids
    • 40-60mg “bursts”
    • 5-10 days
    • <1wk course no need to taper – commonly taper but not necessary
  • Should expect improvement in 24-48hrs
57
Q

Characteristics of severe/life threatening exacerbation

A
  • SOB at rest, unable to converse
  • Requires hospitalization, possibly ICU
  • PEF<40% personal best
  • Incomplete improvement with SABA
58
Q

Tx of severe/life threatening exacerbation

A
  • Oral/IV steroids
    • ~40-80mg/d equivalent
    • Oral = IV if absorbed
    • No data for higher doses – unless absorption problem
  • Frequent SABA/SAMA, possibly continuous SABA
  • IV Magnesium
  • Heliox –inhaled helium & oxygen. Improves laminar flow through tight airway
  • Careful ventilator management
59
Q

Important co-morbidities in asthma (may lead to exacerbation)

A
  • Rhinosinusitis (and consider evaluation for ABPA/AF disease)
  • GERD - often missed
  • Sleep disordered breathing
  • Depression
  • Anxiety
  • Obesity
  • Cardiac disease
60
Q

Two important factors to monitor in deciding asthma therapy

A

severity

control

61
Q

What must asthma Tx include

A

First line pharm therapy + constant education, prevention, trigger control, and co-morbid management to optimize care

Primary care of adults 2 (15 decks)

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