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)
