Asthma Flashcards
How do you successfully manage Asthma?
- routine monitor of lung function ***
- patient education
- environmental factors
- Pharm
Asthma Definition & pathophys
-variable and recurring sx, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation.
Pathophys:
- breakdown of airway epithelium
- collagen deposition in basement membrane
- airway edema
- as cell activation and inflamm mediators take over
- chronicity of disease remodels the lungs over time.
- airflow limitations
- -airflow limitations:
- bronchoconstriction
- airway hyperresponsiveness
- airway edema (mucus hypersecretions, thick mucus plugs)
WHat is asthma characterized by?
-episodic, reversible bronchospasm resulting from an exaggerated bronchoconstrictor response to stimuli,
What are some common irritants of Asthma?
-cold air, emotional upset, exercise, cigarette smoke, dust mites, cockroaches, cats, seasonal pollens, animal dander
What cells are involved during an asthmatic event?
- Eosinophils
- Lymphocytes CD4+
- Mast cells
- Leukotrienes (potent inflamm mediators, released by basophil) LTD4: profound bronchoconstriction 1000x more potent than histamine
Asthma has early and late phase, describe whats happening on a cellular level.
Early: IgE is secreted by plasma cells, mas cell release mediators that contract airway smooth muscle directly (bronchoconstriction)
Late: recruitment of eosinophil, basophil, neutrophil, and Tcells to site of allergen exposure. Dendritic cells also come.
Intrinsic Asthma
- immune/non-immune?
- IgE levels
- When does this develop?
- Stimuli
- NON-immune
- IgE levels are normal
- develops later in life and usually no family history
- Stimuli:
- ASA
- Pulmonary infections
- Cold
- Physiological stress
- Exercise
- Inhaled irritants (tobacco)
- GERD**
- Post nasal drip
What is Samters triad?
-nasal polyps, asthma, ASA allergy
-complex medical condition that causes pts to have asthma, chronic sinusitis, and nasal polyps
“asprin-sensitive asthma”
Extrinsic Asthma -initiated by what? -when does this develop? -IgE level -
- initiated by:
- Type 1 Hypersensitivity Rxn:
- Atopy(predisposition)
- Occupational asthma
- Allergic bronchopulmonary aspergillosis
- develops in first two decades of life
- elevated serum IgE & eosinophil
Exercise induced Asthma
- pathophys
- prophylaxis
- heat and water is dripped down the bronchotracheal tree, gets exaggerated if they are in cold leading to increased bronchospasm.
- Beta-Agonist 10-15minutes before activity, avoid cold air if possible, warm up really well before they start exercise.
Classic Triad of Asthma Sx, what are some other associated sx
- persistent wheeze (expiratory)
- chronic episodic dyspnea
- chronic cough (worse at night)
Associated sx:
- tachypnea, tachycardia
- prolonged expiration, wheeze
- sputum production
- chest pain/tightness
- hemoptysis
- diminished breath sound during acute exacerbations
- pulses paradoxus (also occurs with cardiac tampanode, pericarditis, and sleep apnea)
DDX of Asthma
- COPD
- Anaphylaxis
- foreign body ingestion
- PE
- CHF
- Panic disorder
- Pneumonia
- Alpha1-Antitrypsin deficiency
- GERD** (esp sx at night, could start taking prilosec and see if it goes away, will c/o heartburn)
- Sarcoidosis** young black american female, fibrotic lungs, hilar thickening on xray,
- vocal cord dysfunction
- Cough 2ndry ACE inhibitors
WHat are some anaphylaxis sx you wouldnt see in asthma?
-edema(facial), sweating, hives, itching, low BP.
Asthma with Hemoptysis DDX
- Allergic bronchopulmonary aspergillosis
- Bronchiectasis
- Lung Carcinoma
- TB
*any blood warrants a chest XRAY
Sx of asthma worsen in the presence of? (Triggers)
- exercise
- viral infection
- inhalant allergens and irritants
- changes in weather
- strong emotion expression
- stress
- menstrual cycles
WHat is needed to establish a dx of asthma?
-spirometry
Describe the PFT’s of asthma
- FEV1
- FEV1/FVC
PFT must reveal that the disease is _____.
How to establish reversibility?
FEV1- decreased, less than 80% predicted
FEV1/FVC- less than 65% (70%)
- must reveal that the disease REVERSIBLE!!
- FEV1 increase of greater or equal to 12% and at least 200ml after using a short acting B2 agonist.
When is the Methacholine or histamine challenge test done?
- done when asthma is suspected but PFT’s are near normal.
Diagnostic Test of Asthma
- CXR; will help to rule out pneumonia, CHF, pneumothorax, and airway lesion
- GE refulx assessment (if have bad taste in their mouth, worse at night)
- Skin tests: demonstrate atopy
- Blood Tests: Eosinophils an IgE elevations (these support dx, absence does not exclude asthma)
Global Strategy for asthma and prevention
- control sx
- prevent exacerbation
- maintain pulmonary function close to normal levels
- maintain normal activity levels
- avoid advers effects from asthma meds
- Prevent development of irreversible airflow limitation
- prevent asthma mortality
- routine follow-up visits (q 6mo)
WHat are the aspects that should be assessed at each visit?
- signs and sx
- pulmonary function
- quality of life
- exacerbations
- adherance with tx and side effects
- patient satisfaction with care
Need to assess sx, what are some key question to ask?
- asthma awakened you at night or in early morning?
- have you needed your quick-acting relief medication more than usual?
- Have you needed any unscheduled care for your asthma? (ER visits, office visit)
- have you been able to participate in school/work and recreational activities as desired?
- Has your peak flow been lower than your personal best?
What is an Asthma Action plan and what is used to construct it?
-uses peak flow (PEF) values to provide specific directions for daily management and for adjusting medications in response to increasing sx or PEFR.
Purpose of Peak Flow
- monitor airway obstruction
- alter long term therapy for control of sx
- Have plan in place for using peak flow info to intervene early in exacerbations.
What are the 4 classifications of Asthma?
- Intermittent
- Mild persistent
- Moderate persistent
- sever persistent.
Intermittent Asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- tx
- sx: less than 2 days per week (daytime), 1 or no exacerbations/year requiring oral glucocorticoids
- nighttime awakenings 2 or few per mo
- Short acing B2 agonist use for sx control: few than 2x/week
- interference w/ normal activity: no interference with normal activity
- lung function: FEV1 normal between exacerbations, FEV1/FVC normal
- Step # 1
- Tx: SABA
Mild persistent asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- tx
- symptoms- >2days/week, not daily , 2 or more exacerbations/year requiring oral glucocorticoids
- 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
- Tx: Low dose ICS + SABA OR cromolyn or leukotriene inhibits
Moderate Persistent Asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- tx
- symptoms- daily, 2 or more exacerbations/year requiring oral glucocorticoids
- 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 less than 80% predicted, FEV1/FVC 95-99%
- Step 3
Tx: SABA + Low dose ICS + LABA or Medium dose ICS, OR theophylline
*consider refer to specialist
Severe Persistent Asthma
- symptoms
- nighttime awakenings
- short acting B2 agonist use for symptom control
- interference w/ normal activity
- lung function
- step #
- tx
- symptoms- throughout day, 2 or more exacerbations requiring oral glucocorticoids per year,
- 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 less than 60% predicted and FEV1/FVC less than 95% of normal.
- step # 4 or 5
- consider short course of oral systemic corticosteroids
Tx: SABA+
Step 4: medium dose ICS + LABA
Step 5: High dose ICS + LABA + consider omalizumab
Step 6: High dose ICS + LABA + oral glucocorticoid OR theophylline
Status Asthmaticus
- what is this
- presentation
-sever bronchospasm that is unresponsive to routine there, may be sudden and rapidly fatal.
Presentation
- difficulty talking
- using accessory muscle for inspiration
- orthopnea
- diaphoresis
- mental status changes
Tx of Status Asthmaticus
- Oxygen
- Oximetry
- ABG’s
- Peak flow w/ txs of:
- -inhaled beta 2 agonists
- -inhaled anticholinergics (works on vagal mediated bronchospasm)
- -oral or IV corticosteroids
- if inadequate response to above tx in ER admit to hospital.
- if good response d/c w/:
- -inhaled B2 agonist
- -inhaled anticholinergic
- -oral corticosteroids x5 days
- -follow up within 5 days.
