Asthma Flashcards
Explain pathophys of Asthma
-Inflammation: asthma irritate the lining of the bronchial tubes, causing them to become inflamed and swollen. excess mucus makes
breathing more difficult
-Bronchoconstriction: bands of muscle surrounding the bronchial tubes contract causing the airway to narrow
Pathophys of air flow obstruction
- air flow into lungs decreased by airway narrowing leading to increase resistance, potential respiratory depression.
- loss of elastic recoil in lung decreasing driving pressure
- inflammation
Contributors in the persistently inflamed airway
- inflamm cell (eosinophils, neutrophils, lymphocytes
- Goblect cell*
- mucus hypersecretion*
- loss of ciliated epithelium*
How do leukotrienes stimulate the inflamm response?
- increased vascular permeability»>edema
- increased mucus production
- decreased mucociliary transport
- LTD4- profoud bronchoconstriction, 1000x more potent than histamine.
Primary problem with asthma?
secondary?
inflamm.
bronchospasm
Characteristics of asthma
- variable and recurring symptoms***
- reversible airflow obstruction***
- bronchial hyper-responsiveness
- underlying inflamm
Asthma Triggers
- common allergens (house dust mites, cockroaches,cat and dog dander, seasonal pollens)
- non-specific: exercise, upper resp. infection, rhinosinusitis and post nasal drip (allergies), aspiiration and GE reflux (GERD), stress, tobacco smoke, aspirin, NSAIDS, hormones
Always obtain good pt Hx. What are some common symptoms of asthma?
- cough* (more likely than wheez)
- wheezing
- SOB
- season/diurnal (night/day)
What time of day would asthma symptoms be the worst and why?
typically between 3-4am d/t low levels of cortisol, more inflammation, eosinophils are most active at this time. Pollen counts are highest at this time too.
Classic Triad of Asthma Symptoms
- wheezing
- chronic episodic dyspnea
- chronic cough
Symptoms during Asthma attack
-tachypnea, tachycardia, systolic hypertension
- harsh respirations, prolonged expiration, wheezing
- air trapping-easier to get air in than out
- chest pain/tightness
- sputum production
- diminished breath sounds
Consider Dx of Ashtma when…
-wheezing or hx of chronic cough (gets worse w/ cold or exercise) or recurrent chest tightness
-Symptoms occur or worsen during.. exercise viral infection inhalant allergens change in weather stress strong laugh or cry menstrual cycles
Red flag sign*** symptoms occur or worsen at night, awakening the patient
Physical Exam finding in Ashtma pt
-usually pretty normal exam (they come in when stable)
- nasal mucosal swelling
- increased nasal secretions
- nasal polyps
- eczema
- atopic dermatitis
- wheezing/prolonged expiratory phase*
- body posture*
- accessory muscle use*
- fragmented speech pattern*
- last 4 require immediate care
- breathless while walking of going up stairs
- able to lie down
- can speak in sentences
- may be agitated
- no sweating
- slightly increase resp. rate
- usually no use of accessory muscles
- moderate wheeze; usually only end-expiratory
Mild Asthma Exacerbation
- breathless on minimal exertion
- prefers sitting
- speaks in phrases
- sometimes agitiated
- sweating
- increased resp. rate
- usually using accessory muscles
- loud wheeze throughout exhalation
Moderate Asthma Exacerbation
- breathless at rest
- hunched forward
- speaking in words
- usually agitated
- sweats profusely
- greater than 30 resp./min
- frequent accessory muscle use
- loud wheeze throughout inhalation and exhalation
Severe Asthma Exacerbation
- unable to speak
- drowsy or confused
- paradoxical thoracoabdominal movements
- weakened or absent wheeze
Respiratory Rest Imminent
Diagnosis of Asthma
- history (symptoms + personal/ family hx of asthma/atopy)
- signs and symptoms suggestive of asthma
- confirmation of variable expiratory airflow limitation, spirometry
- exclusion of alternative diagnoses
Pulmonary function testing
- spirometry**(used to diagnose asthma)
- order before and after bronchodilators, w/o bronchodilator result may be normal. if increase in 12-15% after bronchodilator then asthma.
- Bronchial provocation test
- methacholine challenge, if FEV falls by >20% you have a positive result»>asthma.
- peak flow (dont use this to diagnose asthma, just provides quick measurement)
- used to track asthma symptoms
- measures how fast air comes out of lungs w/ forceful exhalation after inhaling fully
Other asthma diagnostic testing
- chest xray (pneumonia may cause asthma)
- skin testing (helpful for finding allergic triggers)
Peak flow meters are helpful for….
- determining degree of airflow limitation
- learning asthma triggers
- used to build action plan
- determine if action plan working
- adjusting medications
- if peak flow starts to decrease you need to adjust medications
-knowing when to seek emergency care
How is normal peak flow determined?
Age, height, sex, race, from a standardized chart
Intermittent Asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
symptoms- 80% predicted, FEV1/FVC normal
step- 1
Mild persistent asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- symptoms- >2days/week, not daily
- nighttime awakenings- 3-4x/mo
- short acting B2 agonist use for symptom control- >2day/week, not daily or >1x/day
- interference w/ normal activity- minor limitation
- lung function- FEV>= 80% predicted, FEV1/FVC normal
- step #2
Moderate Persistent Asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- symptoms- daily
- nighttime awakenings- >1x/week, not nightly
- short acting B2 agonist use for symptom control- daily
-interference w/ normal
activity- some limitation
-lung function- FEV >60% but
Severe Persistent Asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- symptoms- throughout day
- nighttime awakenings- often 7x/week
- short acting B2 agonist use for symptom control- several times/day
- interference w/ normal activity- extremely limited
- lung function- FEV1 5%
- step # 4 or 5
- consider short course of oral systemic corticosteroids
Components of Asthma Management
- routine monitor symptoms and lung function
- pt education
- control triggers and comorbid conditions
- pharm. therapy
Stepwise Approach to Asthma Management: Step 1
Short acting beta agonist
Stepwise Approach to Asthma Management: Step 2
Preferred: low dose Inhaled corticosteroid (ICS)
Alternative: Cromolyn, Leukotriene antagonist (LTRA-singulair)
Stepwise Approach to Asthma Management: Step 3
Preferred: low dose inhaled corticosteroid (ICS) + Long acting beta agonist (LABA) or
medium dose ICS
Alternative: low dose ICS + LTRA
Stepwise Approach to Asthma Management: Step 4
Preferred: medium dose ICS + LABA
ALternative: medium dose ICS + LTRA
Stepwise Approach to Asthma Management: Step 5
Preferred: High dose ICS + LABA and consider Xolair for those w/ allergy
Stepwise Approach to Asthma Management: Step 6
Preferred: high dose ICS + LABA + Oral corticosteroid and consider Xolair if allergies
You can step up or down based upon pt symptoms, true or false?
TRUE.
What is the definitive test to confirm asthma? What does this test indicate?
Spirometry
Airflow obstruction
Quick Relief Medications (rescue)
- inhibit smooth muscle contraction: short acting beta 2-agonists (bronchodilators) and anti-cholinergics
- if using short acting beta 2 agonsits (SABA) >2x/week indicates inadequate control of asthma
Long term control (controller)
- prevent/reverse inflamm: Corticosteroids, leukotriene modifiers, and methylxanthines
- inhibit smooth muscle contraction: Long acting Beta 2 agonists (LABA)
Administration Techniques
MDI, Nebulizer, inhaled powder, systemin admin
MDI (meter dose inhaler)- aerosole particles, uses spacer
Neb- liquid medicine, moisturized airflow
Powder- disc inhaler, powder inhaled (advair)
Systemic- parenteral routes, gen. more side effects
Beta -2 Agonsist Effects
- produce airway dilation
- improve mucocilliary transport
- stimulate beta 2 adrenergic receptors in LUNGS (may be short or long acting)
*DO NOT affect inflammation.
Name Medication types that are short acting B2 agonists
Albuterol, Proventil, Ventolin, Levalbuterol (xopenex)
- use xopenex if albuterol allergy
- may bleed over to H1 heart receptors and make you tremor, tachycardic
Using more than 1 canister of MDI (metered dose inhaler) per month signal lack of adequate asthma control, true or false?
True
Name Medication type of Long acting beta 2 agonist
Salmeterol (Serevent)
Formoterol (Foradil) both are inhaled
oral- sustained release albuterol
*these are not rescue drugs
non-selective beta agonists
DONT use these, ex. epinepherine
Anticholinergic Bronchodilators
- enhances bronchodilation achieved by beta agonists, use this drug in combo with them.
- slow to onset, most common is Atrovent.
- Used for exacerbations, or pt in step 6
Methylxanthine Bronchodilators :
-Theophylline
*has narrow therapeutic index, more dangerous and require closer monitoring
Corticosteroid Function
- reduce airway inflamm, NOT a bronchodilator
* chronic use of oral corticosteroids is monitored/regulated by pulmonologist, allergist, or immunologist.
Why might Inhaled Corticosteroids are more favorable than oral?
they are more direct, less systemic circulation, drug is delivered to direct site of action (airways)
Side Effects of Inhaled Corticosteroids
- thrush–make sure to rinse mouth after use to prevent fungal infection
- dysphonia
- larger dose: adrenal suppression, cataract formation, decreased growth in children, bone metabolism interference, purpura
Benefits of Leukotriene Inhibitor
is the only other drug other than inhaled corticosteroids that can improve lung function.
Side effects of Leukotriene Inhibitors
- liver function test abnormalities, HA, depression, suicidal tendencies, childhood behavioral problems.
- these are reversible you just need to quit taking the meds.
Misc. treatment of Asthma
- identify trigger and control through avoidance or sensitization
- change environment (change of occupation or relocation of dwelling)
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