asthma Flashcards
1
Q
How can asthma be successfully managed?
A
- routine monitoring of lung function (PFTs and peak flow)
- pt education
- environment factors (avoid triggers)
- pharm: either start high or low dose
2
Q
What type of disorder is asthma?
A
- chronic inflammatory disorder of the airways
- reversible and obstructive disease
3
Q
Who is predominately effected by asthma?
A
- occurs in persons of all races
- ## occurs predominately in boys in childhood (2:1 ratio until puberty) then male to female ratio becomes 1:1
4
Q
Before what age are 2/3rd of all asthma cases dx?
A
- before age 18
- approx 1/2 of all children dx with asthma have a decrease or disappearance of sxs by early adulthood
5
Q
What is asthma?
A
- complex disorder characterized by variable and recurring sxs, airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation
6
Q
What are the airflow limitations in asthma?
A
- bronchoconstriction: bronchial smooth muscle contraction in response to exposure to a variety of stimuli
- airway hyperresponsiveness: exaggerated bronchoconstrictor response to stimuli
- airway edema: edema, mucus hypersecretion, formation of thickened mucus plugs
7
Q
What occurs chronically with asthma?
A
- 1: breakdown of epithelial cells
- 2: collagen deposition
- 3: massive airway edema, mast cells are activated and release histamine
- overtime this causes hypertrophy of airway: thick mucus is produced and more likely to develop pneumonia
8
Q
What is asthma characterized by?
A
- episodic, reversible bronchospasm resulting from an exaggerated bronchoconstrictor response to various stimuli
9
Q
How can asthma sxs vary?
A
- perennial versus seasonal
- continual versus episodic
- duration, severity, and frequency
- duirnal variations (nocturnal and early morning)
10
Q
What players are involved in the inflammatory response?
A
- the trigger or stimulus may be exposure to intrinsic or extrinsic host factors
- eosinophils: release granular protein that damages bronchial epithelium and promotes airway hyper-responsiveness
- lymphocytes: produce cytokines, leukotriene B-4, C-4, and prostaglandin and histamine
- Mast cells: initiate arousal condition in IgE receptors
11
Q
What are leukotrienes and what do they do?
A
- potent inflammatory mediators
- increased vascular perm/edema
- increased mucus production
- decreased mucociliary transport
- inflammatory cell recruitment (eosinophils - release inflammatory mediators)
- LTD 4: profound bronchoconstriction, about 1000x more potent than histamine
12
Q
Describe the early phase of asthma?
A
- IgE is secreted by plasma cells, binds to receptors on mast cells and basophils
- mast cells release mediators that contract airway smooth muscle directly
13
Q
Late phase of asthma?
A
- recruitment of inflammatory and immune cells, including eosinophils, basophils, neutrophils, and helper, memory T cells to site of allergen exposure
- dendritic cells are also recruited and plan an impt role
- the late phase rxn is more complex than just causing smooth muscle contraction
14
Q
What is intrinsic asthma?
A
- considered non-immune
- usually no personal or family hx
- *** serum IgE levels are normal
- usually develop in later life
- stimuli that have little or no effect in normal subjects can trigger bronchospasm: ASA, pulm infections (viral), cold, psychological stress, exercise, inhaled irritants, GERD, post nasal drip
15
Q
What is extrinsic asthma?
A
- initiated by type-1 hypersensitivity reaction
- atopic is most common
onset is usually the first 2 decades of life - associated with other allergic manifestations, family hx
- ** serum IgE and eosinophil count are usually elevated
- also is occupational asthma
- allergic bronchopulmonary aspergillosis
16
Q
What is exercise induced asthma?
A
- an asthma variant
- exercise or vigorous physical activity triggers acute bronchospasms in persons with heightened airway reactivity
- can be found in asthmatics, pts with atopy, allergic rhinitis or even healthy individuals
17
Q
What is tx for EIA?
A
- beta agonist 10-15 minutes before activity
- avoid activity in cold air if possible
18
Q
What are the classic triad of sxs for asthma?
A
- persistent wheeze, end expiratory wheeze
- chronic episodic dyspnea
- chronic cough
19
Q
What are the other associated sxs of asthma?
A
- tachypnea, tachycardia, and systolic HTN
- audible harsh respirations, prolonged expiration and wheezing
- sputum production
- chest pain or tightness
- hemoptysis
- diminished breath sounds during acute exacerbations
- pulses paradoxus
- sxs may be worse or only present at night (b/c of circadian rhythms)
20
Q
What is the DDx for asthma?
A
- COPD
- anaphylaxis
- FB ingestion
- CHF
- PE
- panic disorder, hyperventilation (heart attack sxs)
- pneumonia, bronchitis
- alpha1 -antitrypsin deficiency
- GERD
- sarcoidosis
- vocal cord dysfunction
- cough secondary to drugs (ACEI)
21
Q
What should you consider when pt presents with hemoptysis?
A
- allergic bronchopulmonary aspergillosis
- bronchiectasis
- lung carcinoma
- TB
22
Q
When should you consider a Dx of asthma?
A
- wheezing
- any hx of cough that is worse at night
- recurrent wheeze
- recurrent difficulty in breathing, recurrent chest tightness
-sxs occur or worsen in presence of:
exercise
viral infection
inhalant allergens and irritants
changes in weather, strong emotional expression, stress, menstrual cycles - sxs occur or worsen at night, awakening the pt
23
Q
What are the dx studies for asthma?
A
- PFTs:
decreased FEV1 less than 80%
FEV1/FVC less than 65%, hyperventilation - establish reversibility: FEV1 increase of 12% and 200 ml after SABA
- or provocation testing with methacholine or histamine: detects bronchial hyperactivity, supports dx, sometimes done when asthma suspected but PFTs are near normal
- CXR: will help rule out pneumonia, CHF, pneumothorax, airway lesions or FBO
- GE reflux assessment
- skin tests: atopy
- blood tests: eosinophils and IgE elevations (absence doesn’t exclude asthma)
24
Q
What is the global strategy for asthma and prevention?
A
- achieve and maintain control of sxs
- prevent asthma exacerbations
- maintain pulmonary fxn as close to norm as possible
- maintain normal activity levels including exercise
- avoid adverse effect from asthma meds
- prevent development of irreversible airflow limitation
- prevent asthma mortality
25
Q
What does effective asthma management require?
A
- a proactive, preventative approach
- routine FU visits for pts with asthma, 1 to 6 months depending on severity
- FU should assess multiple aspects of pts asthma:
signs and sxs
pulmonary function
quality of life
exacerbations, adherence with tx and SEs and pt satisfcation with care
26
Q
What should be included in the sxs assessment?
A
- sxs over past 2-4 weeks should be assessed
- daytime sxs and nightime sxs
- use of SABA to relieve sxs (how often?)
- difficulty in performing normal activities and exercise
27
Q
What is the asthma action plan?
A
- pts normal peak flow value is used to construct a personalized asthma action plan which provides specific directions for daily managemnt and for adjusting meds in response to increasing sxs or decreasing PEFR
- PEF:
monitors airway obstruction, alter long term therapy for optimal control of sxs, keep diary, have clear plan in place for using peak flow info to intervene early in exacerbations
28
Q
What are the 4 classifications of asthma for the stepwise management approach?
A
- step 1: intermittent
- step 2: mild persistent
- step 3: moderate persistent
- step 4: severe persistent
29
Q
What qualifies a pt for step 1 intermittent?
A
- daytime sxs occurring 2 or fewer days/week
- 2 or fewer nocturnal awakening per month
- use of SABA agonists to relieve sxs fewer than 2x a week
- no interference with normal activities b/t exacerbations
- FEV1 b/t exacerbations are within normal range
- FEV1/FVC b/t exacerbations within normal limits
- one or no exacerbations requairing oral glucocorticoids per year
30
Q
Using what more than 2x a week may indicate the need to start long term control therapy?
A
- using SABA for resuce more than 2x a week
31
Q
What is mild persistent asthma?
A
- sxs more than 2x weekly (less than daily)
- 3-4 nocturnal awakenings a month
- use of SABA more than 2x a week
- minor interference with normal activities
- FEV1 measurements within normal range (80% of pred)
- FEV1/FVC normal
- 2 or more exacerbations requiring oral glucocorticoids/ year
- using SABA more than 2x a week may indicate start to long term therapy
- low dose inhaled steroids or cromolyn, or leukotriene inhibitors should be used
32
Q
What is step 3 moderate persistent sxs?
A
- daily sxs
- nocturnal awakening more than 1/week
- daily need for SABA for sx relief
- some limitation in normal activity
- FEV1 b/t 60-80%
- FEV1/FVC is 95-99% of normal
- 2 or more exacerbations requiring oral glucorticoids
- either inhaled steroid (medium dose) or low dose and either LABA or sustained release theophyline (no)
- if needed give inhaled steroids in a medium to high dose
- consider referral to specialist
33
Q
What sxs qualify for step 4 severe persistent asthma?
A
- sxs of asthma throughout the day
- nocturnal awakenings nightly
- need for SABA for sx relief several times a day
- extreme limitation in normal activity
- FEV1 less than 60%
- FEV1/FVC less than 95% of normal
- 2 or more exacerbations requiring oral steroids a year
- High dose inhaled steroid and either a long acting oral B2 agonist and oral steroids
- make repeated attempts to reduce systemic steroids and maintain control with high dose inhaled steroid
- refer to specialist!!
34
Q
How can we control asthma severity?
A
- ID and control contributing factors:
- inhaled allergens
- tobacco smoke
- rhinitis/sinusitis
- GERD
- occupational exposures
- viral respiratory infections
35
Q
How should asthma be monitored by both pt and clinician?
A
- pt self monitoring:
peak flow measurements, and self awareness of sxs - clinician:
frequent visits to achieve clinical control
assess achievement of therapy goals
prevention of chronic sxs/episodes - maintain normal activity levels
36
Q
What is status asthmaticus?
A
- severe bronchospasm that is unresponsive to routine therapy
- can be sudden and rapidly fatal
- most pts have hx of progressive dyspnea, over hours to days, with increasing bronchodilator use
37
Q
What is the presentation of status asthmaticus?
A
- difficulty talking
- using accessory muscles of inspiration
- orthopnea
- diaphoresis
- mental status changes
38
Q
What is the tx for status asthmaticus?
A
Want to get a CXR - oxygen - oximetry - ABGs - peak flows with txs: inhaled B2 agonists inhaled anticholinergics (reverse vago-mediated hyperresponse) oral or IV corticosteroids
39
Q
What should be done if there is an inadequate response to tx? a good response?
A
- inadequate respone:
hospital admission - if good response:
d/c with inhaled B2 agonist, inhaled anticholinergic, oral corticosteroids x 5 days (steroid burst), and a FU within 5 days
