asthma

Question 1

How can asthma be successfully managed?

Answer 1

• routine monitoring of lung function (PFTs and peak flow)
• pt education
• environment factors (avoid triggers)
• pharm: either start high or low dose

Question 2

What type of disorder is asthma?

Answer 2

• chronic inflammatory disorder of the airways

- reversible and obstructive disease

Question 3

Who is predominately effected by asthma?

Answer 3

• 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

Question 4

Before what age are 2/3rd of all asthma cases dx?

Answer 4

• before age 18

- approx 1/2 of all children dx with asthma have a decrease or disappearance of sxs by early adulthood

Question 5

What is asthma?

Answer 5

• complex disorder characterized by variable and recurring sxs, airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation

Question 6

What are the airflow limitations in asthma?

Answer 6

• 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

Question 7

What occurs chronically with asthma?

Answer 7

• 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

Question 8

What is asthma characterized by?

Answer 8

• episodic, reversible bronchospasm resulting from an exaggerated bronchoconstrictor response to various stimuli

Question 9

How can asthma sxs vary?

Answer 9

• perennial versus seasonal
• continual versus episodic
• duration, severity, and frequency
• duirnal variations (nocturnal and early morning)

Question 10

What players are involved in the inflammatory response?

Answer 10

• 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

Question 11

What are leukotrienes and what do they do?

Answer 11

• 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

Question 12

Describe the early phase of asthma?

Answer 12

• IgE is secreted by plasma cells, binds to receptors on mast cells and basophils
• mast cells release mediators that contract airway smooth muscle directly

Question 13

Late phase of asthma?

Answer 13

• 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

Question 14

What is intrinsic asthma?

Answer 14

• 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

Question 15

What is extrinsic asthma?

Answer 15

• 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

Question 16

What is exercise induced asthma?

Answer 16

• 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

Question 17

What is tx for EIA?

Answer 17

• beta agonist 10-15 minutes before activity

- avoid activity in cold air if possible

Question 18

What are the classic triad of sxs for asthma?

Answer 18

• persistent wheeze, end expiratory wheeze
• chronic episodic dyspnea
• chronic cough

Question 19

What are the other associated sxs of asthma?

Answer 19

• 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)

Question 20

What is the DDx for asthma?

Answer 20

• 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)

Question 21

What should you consider when pt presents with hemoptysis?

Answer 21

• allergic bronchopulmonary aspergillosis
• bronchiectasis
• lung carcinoma
• TB

Question 22

When should you consider a Dx of asthma?

Answer 22

• 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

Question 23

What are the dx studies for asthma?

Answer 23

• 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)

Question 24

What is the global strategy for asthma and prevention?

Answer 24

• 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

Question 25

What does effective asthma management require?

Answer 25

• 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

Question 26

What should be included in the sxs assessment?

Answer 26

• 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

Question 27

What is the asthma action plan?

Answer 27

• 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

Question 28

What are the 4 classifications of asthma for the stepwise management approach?

Answer 28

• step 1: intermittent
• step 2: mild persistent
• step 3: moderate persistent
• step 4: severe persistent

Question 29

What qualifies a pt for step 1 intermittent?

Answer 29

• 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

Question 30

Using what more than 2x a week may indicate the need to start long term control therapy?

Answer 30

• using SABA for resuce more than 2x a week

Question 31

What is mild persistent asthma?

Answer 31

• 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

Question 32

What is step 3 moderate persistent sxs?

Answer 32

• 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

Question 33

What sxs qualify for step 4 severe persistent asthma?

Answer 33

• 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!!

Question 34

How can we control asthma severity?

Answer 34

• ID and control contributing factors:
• inhaled allergens
• tobacco smoke
• rhinitis/sinusitis
• GERD
• occupational exposures
• viral respiratory infections

Question 35

How should asthma be monitored by both pt and clinician?

Answer 35

• 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

Question 36

What is status asthmaticus?

Answer 36

• 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

Question 37

What is the presentation of status asthmaticus?

Answer 37

• difficulty talking
• using accessory muscles of inspiration
• orthopnea
• diaphoresis
• mental status changes

Question 38

What is the tx for status asthmaticus?

Answer 38

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

Question 39

What should be done if there is an inadequate response to tx? a good response?

Answer 39

• 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