Asthma Flashcards
The 2007 guidelines from NHLBI focus on what 4 components for asthma mgmt?
- Measures to assess and monitor asthma
- Patient education
- Control of environmental factors and comorbid conditions affecting asthma
- Pharmacologic therapy
Dx of asthma depends on what factors?
- Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present (medical hx, PE)
- Airflow obstruction is at least partially reversible (spirometry)
- Alternative diagnoses are excluded
Risk factors for asthma
- Family history of allergy, eczema, and asthma
- Smoking in the home
- Allergens including dust mites, pollen, pets
- Premature birth
Who is spirometry recommended for and what is its purpose?
Recommended for children 5 yrs. and older
Demonstrates obstruction and if it is reversible
Additional testing that may be considered in Dxing asthma?
- Chest x-ray
- Allergy testing
- Barium swallow (GER)
- Sinus films (chronic sinusitis?)
- Bronchoscopy
- Bronchoprovocation
DDx asthma
- Allergic Rhinitis
- Sinusitis
- Bronchiolitis
- Foreign body aspiration
- Vocal cord dysfunction
- Vascular rings
- Laryngotracheomalacia
- Tumor or enlarged lymph nodes
- Tracheal stenosis
- BPD
- CF
- Congenital Heart Disease
- CHF
- Aspiration
- PE
- GERD
Relationship between asthma impairment and risk
Independent
some patients can still be at high risk for frequent exacerbations even if they have few day-to-day effects of asthma.
what age groups does stepwise asthma mgmt specify for?
- 0-4 years
- 5-11 years
- 12 years and older
What do patients with persistent asthma need, in terms of Tx?
- both: long-term control medications and quick relief medications for symptoms
- Inhaled corticosteroids are the preferred method of treatment with persistent asthma
What is the Asthma Control Test (ACT)?
- Self rating questionnaire for the parents to assess asthma control
- Assess daily activities, shortness of breath, SABA use and nightly symptoms
Management of Exacerbations in the office
- Inhaled beta2-agonist x3 in office
- Systemic corticosteroids - 2 mg/kg/d not to exceed 60 mg/day
- O2 and hospitalization if needed
Short acting B2 agonists + anticholinergics: dosing and formulations
Short Acting Beta2-Agonist
- Albuterol 90mcg/actuation MDI 2 puffs with spacer or Albuterol nebulized solution (.083%) or 2.5mg (.5cc) with 3cc NS
- Levalbuterol (Xopenex®) 45 mcg/puff MDI 1-2 puffs or Nebulized solution: 0.025 mg/kg minimum 0.31 mg/3 ml unit dose; 0.63 mg/3 ml unit dose; 1.25 mg/3 ml unit dose
in combination with
Anticholinergics
- Ipratropium (Atrovent®) nebulized solution 0.25mg/ml 0.25-0.5 mg
Characteristics of mild exacerbation
dyspnea only w/activity (tachypnea in young kids)
PEF >70% predicted or personal best
Characteristics of Moderate Exacerbation
dyspnea interferes w/or limits usual activity
PEF 40-60% predicted or personal best
Characteristics of severe exacerbation
dyspnea at rest, interferes w/conversation
PEF <40 predicted or personal best
Characteristics of life-threatening exacerbations
Too dyspneic to speak, perspiring, PEF <25% predicted of personal best
Risk Factors for Death from Asthma
- Past history of severe exacerbations
- Prior ICU admission for asthma
- Prior Intubations from asthma
- 2+ hospitalization in the past year
- 3+ ED visits for asthma in the past year
- Hospitalization or ED visit in the last month
- Increase use of inhaled SABA
- Current or recent use of systemic corticosteroids
- Difficulty understanding severity of disease
- Comorbidity of cardiac or chronic respiratory disease
- Psychosocial issues, low socioeconomics, or urban living
- Psychiatric issues
- Illicit drug use
Adapted from NHLBI 2007
Exercise Induced Asthma: Dx
Hx of coughing, SOB, CP, or wheezing occurs during or after exercise.
Definitive Dx: spirometry or a decrease of 15% in peak flow with exertion
Exercise Induced Asthma: Tx
2-4 puffs SABA 5-60 minutes before exercise
or
Cromolyn or nedocromil before exercise
50% of patients respond to Leukotriene modifiers
Asthma triggers: drugs to avoid
Aspirin, NSAIDs, BBs
Asthma triggers: food and food additives
Avoid food products with sulfites if asthma symptoms associates with eating processed foods or drinking beer or wine
Nebulized Tx vs spacers for acute (non-life threatening asthma exacerbation
spacers equivalent to nebs + less time in ED, decrease hypoxia, lower HRs, lower cost of delivery
Metered Dose Inhalers (MDI): how to use
- 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 (5 sec) until you have taken a full breath.
- Remove the inhaler from your mouth, and hold your breath for about 5-10 seconds, then breathe out.
Spacers: benefit
- 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
- Inhale 30 sec or 5-10 breaths
When to refer to asthma specialist?
- Hx Inbubation in ICU
- Multiple ED admissions
- Unable to control
- atypical sx
- >2 OCS in one year
- combo ICS + LABA/LTRA
- ICS if <5yo
- considering immunotherapy/omalizumab
- needs more testing
- comorbids affecting control, e.g. GER
How often should spirometry testing be done?
At Dx then Q1-2y once stabilized
What is FVC and what does it measure?
Forced Vital Capacity: total amt of air child can exhale forcibly after max inspiration
Decrease could indicate restrictive or severe obstructive Dz (often nl in asthma)
What is FEV1?
amt of air expelled in 1st second of FVC
Decreased in obstructive (st in restrictive)
How is reversibility shown in spirometry?
12-15% increase in FEV1 after inhalation of SABA
What is FEV1/FVC?
=% of lung volume can exhale in first one second
Decrease indicates airway obstruction
What is a normal FEV1/FVC?
85% up to 19yo
80% for 20-39yo
What is FEF?
FEF 25%-75%
measurement of FVC, excluding first 25% and last 25% of expiratory phase
Significance of FEF 25% to 75%?
measures small airway volume, may be decreased before changes in FEV1 or clinical sx are seen!
What are PEF values for Green, Yellow, and Red?
Green: 80-100% personal best
Yellow: 50-80% personal best
Red: <50% personal best
When is it appropriate to try step down therapy?
well controlled asthma at least 3mo
O-4yo
What are the components of intermittent asthma severity?
Impairment
- Sx: < 2d/wk
- Nighttime awakenings: 0
- SABA use: < 2d/wk
- Interference w/nl activity: None
Risk:
- exacerbations requiring OCS: 0-1/year
0-4yo Mild persistent
What are the components of severity?
Impairment
- Sx: > 2d/wk but not QD
- Nighttime awakenings: 1-2x/mth
- SABA use: > 2d/wk but not QD
- Interference w/nl activity: Minor limitation
Risk:
- exacerbations requiring OCS: >2 exac in 6mo OR > 4 wheezing episode in 1yr lasting > 1 day AND risk factors for persistent asthma
0-4yo
What are the components of severity for Moderate Persistent asthma?
Impairment
- Sx: Daily
- Nighttime awakenings: 3-4x/mth
- SABA use: Daily
- Interference w/nl activity: Some limitation
Risk:
- exacerbations requiring OCS: >2 exac in 6mo OR > 4 wheezing episode in 1yr lasting > 1 day AND risk factors for persistent asthma
0-4yo
What are you components of asthma severity for Severe Persistent Asthma?
Impairment
- Sx: Throughout day
- Nighttime awakenings: >1x/week
- SABA use: Several times/day
- Interference w/nl activity: Extreme limitation
Risk:
- exacerbations requiring OCS: >2 exac in 6mo OR > 4 wheezing episode in 1yr lasting > 1 day AND risk factors for persistent asthma
What step of therapy should be taken based on asthma severity?
- Intermittent: Step 1
- Mild P: Step 2
- Mod P: Step 3 or 4
- Severe P: Step 5 or 6
5-11yo
Components of severity for Intermittent Asthma?
Impairment
- Sx: < 2d/wk
- Nighttime awakenings: < 2x/mth
- SABA use: < 2d/wk
- Interference w/nl activity: None
- Lung Fx: Normal FEV1 btwn exac; FEV1 >80% predicted; FEV1/FVC >85%
Risk:
- exacerbations requiring OCS: 0-1/year
5-11yo
Components of Severity for Mild Persistent Asthma?
Impairment
- Sx: > 2d/wk but not QD
- Nighttime awakenings: 3-4x/mth
- SABA use: > 2d/wk but not QD
- Interference w/nl activity: Minor Limitation
- Lung Fx: FEV1 >80% predicted; FEV1/FVC >80%
Risk:
- exacerbations requiring OCS: > 2 in 1 yr
5-11yo
Components of asthma severity for Mod Persistent Asthma
Impairment
- Sx: Daily
- Nighttime awakenings: >1x/wk but not nightly
- SABA use: Daily
- Interference w/nl activity: Some Limitation
- Lung Fx: FEV1 60-80% predicted; FEV1/FVC 75-80%
Risk:
- exacerbations requiring OCS: > 2 in 1 yr
5-11yo
Components of asthma severity for Severe Persistent Asthma
Impairment
- Sx: throughout the day
- Nighttime awakenings: Often 7x/wk
- SABA use: Several x/day
- Interference w/nl activity: Extreme Limitation
- Lung Fx: FEV1 <60% predicted; FEV1/FVC <75%
Risk:
- exacerbations requiring OCS: > 2 in 1 yr
_>_12yo
Components of severity for Intermittent Asthma?
Impairment
- Sx: < 2d/wk
- Nighttime awakenings: <2x/mth
- SABA use: <2d/wk
- Interference w/nl activity: None
- Lung Fx: Normal FEV1 btwn exac; FEV1 >80% predicted; FEV1/FVC normal
Risk:
- exacerbations requiring OCS: 0-1/year
_>_12yo
Components of Severity for Mild Persistent Asthma?
Impairment
- Sx: > 2d/wk but not QD
- Nighttime awakenings: 3-4x/mth
- SABA use: > 2d/wk but not >1x/day
- Interference w/nl activity: Minor Limitation
- Lung Fx: FEV1 >80% predicted; FEV1/FVC normal
Risk:
- exacerbations requiring OCS: > 2 in 1 yr
_>_12yo
Components of asthma severity for Mod Persistent Asthma
Impairment
- Sx: Daily
- Nighttime awakenings: >1x/wk but not nightly
- SABA use: Daily
- Interference w/nl activity: Some Limitation
- Lung Fx: FEV1 >60 but <80% predicted; FEV1/FVC reduced 5%
Risk:
- exacerbations requiring OCS: > 2 in 1 yr
_>_12yo
Components of asthma severity for Severe Persistent Asthma
Impairment
- Sx: throughout the day
- Nighttime awakenings: Often 7x/wk
- SABA use: Several x/day
- Interference w/nl activity: Extreme Limitation
- Lung Fx: FEV1 <60%; FEV1/FVC reduced >5%
Risk:
- exacerbations requiring OCS: > 2 in 1 yr
Characteristics of well controlled asthma, 0-4yo
Impairment
- Sx: < 2d/wk
- Nighttime awakenings: < 1x/mth
- SABA use: < 2d/wk
- Interference w/nl activity: None
Risk:
- exacerbations requiring OCS: 0-1/year
*Consider med SEs in assessment, but intensity not correlate to control
0-4yo
Recommended Tx action for well-controlled asthma
Maintain current tx, regular f/u q1-6 mths, consider step down if w-c at least 3mo
Characteristics of NOT well controlled asthma, 0-4yo
Impairment
- Sx: >2d/wk
- Nighttime awakenings: >1x/mth
- SABA use: >2d/wk
- Interference w/nl activity: Some
Risk:
- exacerbations requiring OCS: 2-3/year
*Consider med SEs in assessment, but intensity not correlate to control
0-4yo
Recommended Tx action for NOT well-controlled asthma
Step up 1 and reevaluate in 2-6wks
If no clear benefit in 4-6wks, consider alternative dx or adjusting Tx
For SEs consider alternative tx options
Characteristics of very poorly controlled asthma, 0-4yo
Impairment
- Sx: througout day
- Nighttime awakenings: >1x/wk
- SABA use: several x/day
- Interference w/nl activity: Extremely
Risk:
- exacerbations requiring OCS: >3/year
*Consider med SEs in assessment, but intensity not correlate to control
0-4yo
Recommended Tx action for very poorly well-controlled asthma
Consider short course OCS
Step up 1-2 steps and reevaluate in 2wks
If no clear benefit in 4-6wks, consider alternative dx or adjusting Tx
For SEs consider alternative tx options
5-11yo Characteristics of well controlled asthma
Impairment
- Sx: <2d/wk but _<_1 each day
- Nighttime awakenings: _<_1x/mth
- SABA use: _<_2d/wk
- Interference w/nl activity: None
- Lung fx: FEV or Peak Flow >80% PPB; FEV1/FVC >80%
Risk:
- exacerbations requiring OCS: 0-1/year
*Consider med SEs in assessment, but intensity not correlate to control
5-11yo
Recommended Tx action for well-controlled asthma
Maintain current tx, regular f/u q1-6 mths, consider step down if w-c at least 3mo
5-11yo Characteristics of NOT well controlled asthma
Impairment
- Sx: >2d/wk or multiple x on < 2days/wk
- Nighttime awakenings: _>_2x/mth
- SABA use: >2d/wk
- Interference w/nl activity: Some
- Lung fx: FEV1 or peak flow 60-80% PPB; FEV1/FVC 75-80%
Risk:
- exacerbations requiring OCS: _>_2/year
*Consider med SEs in assessment, but intensity not correlate to control
5-11yo
Recommended Tx action for NOT well-controlled asthma
Step up at least 1 and reevaluate in 2-6wks
For SEs consider alternative tx options
5-11yo Characteristics of very poorly controlled asthma
Impairment
- Sx: througout day
- Nighttime awakenings: _>_2x/wk
- SABA use: several x/day
- Interference w/nl activity: Extremely
- Lung fx: FEV1 or Peak Flow <60% PPB; FEV1/FVC <75%
Risk:
- exacerbations requiring OCS: _>_2/year
*Consider med SEs in assessment, but intensity not correlate to control
5-11yo
Recommended Tx action for very poorly well-controlled asthma
Consider short course OCS
Step up 1-2 steps and reevaluate in 2wks
For SEs consider alternative tx options
_>_12yo Characteristics of well controlled asthma
Impairment
- Sx: <2d/wk
- Nighttime awakenings: <2x/mth
- SABA use: < 2d/wk
- Interference w/nl activity: None
- Lung fx: FEV or Peak Flow >80% PPB
- Questionnaires: ATAQ, ACQ, ACT
Risk:
- exacerbations requiring OCS: 0-1/year
*Consider med SEs in assessment, but intensity not correlate to control
_>_12yo
Recommended Tx action for well-controlled asthma
Maintain current tx, regular f/u q1-6 mths, consider step down if w-c at least 3mo
_>1_2yo Characteristics of NOT well controlled asthma
Impairment
- Sx: >2d/wk
- Nighttime awakenings: 1-3x/wk
- SABA use: >2d/wk
- Interference w/nl activity: Some
- Lung fx: FEV1 or peak flow 60-80% PPB
- Questionnaire: ATAQ, ACQ, ACT
Risk:
- exacerbations requiring OCS: _>_2/year
*Consider med SEs in assessment, but intensity not correlate to control
_>_12yo
Recommended Tx action for NOT well-controlled asthma
Step up 1 and reevaluate in 2-6wks
For SEs consider alternative tx options
_>_12yo Characteristics of very poorly controlled asthma
Impairment
- Sx: througout day
- Nighttime awakenings: _>_4x/wk
- SABA use: several x/day
- Interference w/nl activity: Extremely
- Lung fx: FEV1 or Peak Flow <60%PPB
- Questionnaire: ATAQ, ACQ, ACT
Risk:
- exacerbations requiring OCS: _>_2/year
*Consider med SEs in assessment, but intensity not correlate to control
_>_12yo
Recommended Tx action for very poorly well-controlled asthma
Consider short course OCS
Step up 1-2 steps and reevaluate in 2wks
For SEs consider alternative tx options
0-4yo
Steps 1-6
- Step 1: SABA prn
- Step 2: Low-dose ICS (or cromolyn, montelukast)
- Step 3: Medium dose ICS
- Step 4: Med dose ICS + LABA/Montelukast
- Step 5: Hight Dose ICS + LABA/Montelukast
- Step 6: Hight Dose ICS +LABA/Montelukast, OCS
5-11yo
Steps 1-6
- Step 1: SABA prn
- Step 2: Low-dose ICS (or cromolyn, LTRA, Nedocromil, Theophylline)
- Step 3: Either low dose ICS + LABA/LTRA/theophy OR Medium dose ICS
- Step 4: Med dose ICS + LABA (or med dose ICS + LTRA/Theo)
- Step 5: Hight Dose ICS + LABA (or high dose ICS + LTRA/theo)
- Step 6: Hight Dose ICS +LABA +OCS (or high dose ICS + LTRA/theo + OCS)
_>_12yo
Steps 1-6
- Step 1: SABA prn
- Step 2: Low-dose ICS (or cromolyn, LTRA, Nedocromil, Theophylline)
- Step 3: Either low dose ICS + LABA OR Med dose ICS (or low dose ICS + LTRA/Theo/Zileuton)
- Step 4: Med dose ICS + LABA (or med dose ICS + LTRA/Theo/zileuton)
- Step 5: High Dose ICS + LABA AND consider omalizumab if allergies
- Step 6: High Dose ICS +LABA +OCS AND consider omalizumab if allergies
