Asthma

Question 1

Asthma

Answer 1

Chronic inflammatory disorder of the airways. Characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation. Airflow limitation is reversible, but over time may lead to airway remodeling.

Question 2

Asthma risk factors

Answer 2

Genetic: 60-80% susceptibility. Atophy or family history of atopic disease, parental history of asthma.
Environmental: Low socioeconomic status, family size, second hand smoke, allergen exposure, occupational exposure.

Question 3

Pathophysiology of asthma

Answer 3

Inflammation leads to airway obstruction and airway hyperresponsiveness, both of which contribute to symptoms.

Triggers: cold air, allergens, exercise, particulate, air pollution.

Cough, SOB, wheezing, chest tightness.

Question 4

Anatomy of an asthma attack

Answer 4

Smooth muscle found in lungs surrounding airway spasm, tightening of airway, swelling and inflammation of inner airway space. Occur due to fluid build up, infiltration by immune cells, excessive mucous secretions in airways. Airway becomes blocked.

Question 5

Signs & symptoms

Answer 5

Cough, recurrent wheezing, SOB, chest tightness, nocturnal cough, exercise-induced cough or wheezing, onset of symptoms after exposure to airborne allergens or stimuli, history of respiratory tract infections, associated conditions.

Evidence of bronchial obstruction: wheezing, prolonged expiration.
Airway obstruction at least partially reversible.
Evidence of atopy on physical exam (nose, eyes and skin).

Question 6

Spirometry

Answer 6

Objective test to assess severity of lung disease and responsiveness to treatment.
Ratio of FEV1/FVC gives useful index of airflow limitation. Measured before and after a short-acting bronchodilator.

A 12% increase in FEV1 after bronchodilator is consistent with asthma. A decrease in >15% FEV1 after an exercise test is consistent with exercise induced asthma.

Question 7

FEV1

Answer 7

Forced expired volume in one second

Question 8

FVC

Answer 8

Forced vital capacity

Question 9

Treatment goals

Answer 9

Reduce impairment, reduce risk.

Question 10

Initial visit

Answer 10

Diagnose asthma, assess asthma severity, initiate medication and demonstrate use, develop asthma aciton plan, schedule follow-up appontment

Question 11

Asthma triggers

Answer 11

Smoking (#1!), indoor allergens, outdoor allergens, exercise, cold air, pollutants, medications (b-blockers, aspirin, NSAIDs), sulfites, repiratory tract infections (#2!), medical comorbidities (GERD, depression/stress, rhinitis)

Question 12

Follow-up visit

Answer 12

Assess & monitor control, review medication technique & adherence; assess SE, review environmental control, maintain, step up or step down medication, review asthma action plan, revise if needed, schedule next follow-up appointment.

Question 13

Modifying therapy per CONTROL

Answer 13

Stepwise approach:

Well controlled: maintain or consider step down if well controlled x3 months.
Not well controlled: step up at least 1 step,
Very poorly controlled: step up 1-2 steps and consider short term course of oral steroids.

Always review adherence to meds, technique and environmental control before stepping up.

Question 14

Rescue medications

Answer 14

SABA’s (B2), systemic corticosteroids (acute exacerbation)

Question 15

Controller medications

Answer 15

Inhaled corticosteroids, LABA’s, leukotriene receptor antagonists, mast cell stabilizers, methylxanthines

Question 16

SABA’s

Answer 16

“-terol”
Increase cAMP, relax airway smooth muscle.
Relief of bronchospasm during exacerbation, pretreatment for exercise induced asthma.
Every patient should have one!
1 puff Q4-6 hours

SE: tachycardia, tremor, palpitations, dizziness, headaches

Question 17

Inhaled corticosteroids

Answer 17

“-sonide”, “-asone”
Main treatment.
Decrease inflammation and hyperresponsiveness.
Reduce symptoms, improve quality of life, and improve lung function. Reduce severity and frequency of exacerbations, reduce asthma mortality.
Available in MDI and dry-powder inhalers

SE: cough, dysphonia, oral thrush, minimal systemic effects.

Question 18

LABA’s

Answer 18

Relax airway smooth muscle with longer duration of action
NOT for monotherapy or exacerbations
Increase risk of asthma-related deaths
*Add-on therapy to ICS

SE: tachycardia, skeletal muscle tremor, hypokalemia

Question 19

Salmeterol

Answer 19

LABA

Question 20

Formoterol

Answer 20

LABA

Question 21

Leukotriene receptor antagonists

Answer 21

Interfere with pathway of leukotriene mediators, which are released from mast cells, eosinophils, and basophils.
Alternative to inhaled steroids in mild persistent
Can be adjunct to ICS but not preferred in children >12 and adults compared to addition of LABA

SE: headache, GI upset, hepatotoxicity

Question 22

Singulair

Answer 22

Leukotriene receptor antagonists

Question 23

Zafirlukast

Answer 23

Leukotriene receptor antagonist

Question 24

Zileuton

Answer 24

Leukotriene receptor antagonist

Question 25

Mast cell stabalizers

Answer 25

Stabilize mast cells and interfere with chloride channel function. Weak anti-inflammatory effects.
Alternative, not preferred. Can be used for exercise-induced bronchospasm. May need 4-6 week trial to determine max benefit. Used 3-4 times daily.

SE: unpleasant taste, dry throat, headache, N/V

Question 26

Cromolyn

Answer 26

Mast cell stabalizer

Question 27

Methylxanthines

Answer 27

Relax smooth airway muscle, modest anti-inflammatory properties.
May be beneficial add on therapy to ICS, but less effective than LABA

SE: n/v, diarrhea, tachycardia, cardiac arrhythmias, seizures, headache

Lots of drug interactions. Oral, inhalation not effective.
MONITORING REQUIRED: narrow therapeutic range, 5-15 mcg/mL

Question 28

Theophylline

Answer 28

Methylxanthine

Question 29

Follow-up care

Answer 29

Every 2-6 weeks while gaining control, every 1-6 months to monitor control, every 3 months if step down is anticipated.

Question 30

Oral corticosteroids

Answer 30

Rescue med during acute asthma exacerbations, use short oral burst over 3-10 days, may or may not need a taper.

Question 31

SE of oral corticosteroids

Answer 31

Acute use:
Fluid retention, mood changes, sleep disturbances, appetite increase, hypokalemia, hyperglycemia, hypertension

Chronic use:
cushingoid changes, growth suppression in children, cataracts, osteopenia, osteoporosis, HPA axis suppression

Question 32

Quality measures

Answer 32

Adults: flu shot, pneumonia vaccine, tobacco use
Pediatric: flu shot
PERSISTENT: controller meds, asthma action plan, admissions/er visits prior year