Asthma Flashcards
Where?
Conducting airways
Bronchoconstriction
From?
- vagal innervation (para)
- Ach, Methacholine
- histamine
- decrease in PACO2
Bronchodilation
From?
Difference night vs. day?
B2 adrenergic receptors, circulating catecholamines
Less catecholamines at night, so worse s/s
Obstructive Ventilatory Defect
Which diseases?
- Asthma,
- chronic obstructive bronchitis,
- bronchiectasis,
- emphysema
Up turbulence = _______ pressure needed?
More
MMEFR (FEF25-75)
Use?
Smaller airway dz
Maximum mid-expiratory flow rate
Forced expiratory flow over the middle half of FVC
PEFR (FEFmax)
Name?
Use?
Peak expiratory flow rate
Highest expiratory flow achieved
Good for home monitoring
Normal FEV/VC
80%
Obstructive FEV/VC
40%, total amount of both down
Types of airway obstruction in asthma
Secretions
Wall inflammation
Bronchoconstriction
Lower FEV1/FVC % =
Obstruction
Type of expression in asthma cell
Th2
Chronic _______ bronchitis
Eosinophilic
Low V/Q mismatch –>
Low V/Q units –> localized alveolar hypoxia
Induce bronchoconstriction
What?
Why?
Methylcholine
Resembles Ach
How to show hyperresponsiveness?
Earliness of Fall of FEV1 w/ methacholine
s/s of asthma
- cough
- wheezing
- dyspnea
- chest tightness
Asthma s/s with no respiratory inflammation?
Obesity
- childhood onset
- FH = atopy
- preceeded by allergic rhinitis, urticaria, eczema
- triggered by environment
- prick test
Allergic (atopic) asthma
*up to 4 weeks
*AWHR up
*w/ RSV, Rhinovirus
*NEUTROPHIL RESPONSE 1st, then eosinophil
*
Respiratory virus asthma
Exercise-induced asthma
Mech?
From amount of heat energy needed to humidify + warm air
Comorbid conditions that can trigger
Sinusitis
GERD
Obstructive Sleep Apnea
ABPA
Asthma evaluation
- ID triggers
- ID comorbid conditions
- Med treatment hx
- severity
Asthma Dx
Spirometry b/f and after spirometry w/ bronchodilator
If normal but suspect = methacholine challenge
Long term goals Tx
- Symptom control
- Risk reduction
NEED GOOD RELATIONSHIP w/ Patient
control =
- s/s
- airway obstruction
- effect on life
SYMPTOM + FUTURE RISK
Severity categories
Mild
Moderate
Severe
Severity
Impairment =
Patients recall of symptoms
Activity levels
Lung function
Control
key s/s
- Daytime s/s
- nocturnal wakening
- frequency of SABA use
- inability to perform activity
Asthma control
- 4 key s/s
- monitoring pulmonary function
- monitoring history of AE/asthma
- monitor pharmacology (compliance/technique)
- adjust therapy as needed
Rescue inhalor use in controlled asthma
2x per week
Inhalor lasts 50 weeks
When should see follow-up to reassess?
Every 3 months
If stepped up :
(sustained) 2-3 months
(Short term) 1-2 weeks
Asthma
Nasal Polyps
ASA/NSAID allergy
Samter’s Triad = atopic dermatitis
Path
Airway hyperreactivity
Cell type? 2 types?
Early IgE –> T cell
- Extrinsic - allergic triggers
- Intrinsic - non-allergic triggers (infection/URI, Rx, occupation, cold)
Path
Bronchoconstriction
physics? result?
airway narrowing, up resistance, down EXPIRATORY flow
result : airway remodeling
Path
Inflammation
Why?
cellular infiltration (T lymph, neutro, eosino = leukotrienes)
UP histamine (igE)
S/s
classic triad
dyspnea
wheezing
cough
=/- chest tightness
- inability to complete sentence
- altered mental
- pulsus paradoxicus (inspiratory DOWN SBP>10)
- cyanosis
- tripod
- silent chest
- tac = cardio pulm
Severe asthma
Status asthmaticus
SABAs
Albuterol
Levalbuterol
Terbutaline
Epi
Antichol short term
ipatroprium
Corticosteroids long term
Beclomethasone,
Flunisolide,
Triamcinolone
1st line - long term
LABAs
Salmeterol
Symbicort (Budesonide/Formoterol)
Advair (fluticasone/Salmeterol)
Mast cell modifiers
Cromolyn
Nedocromil
Leukotriene inhibitors
Monteleukast
Zafirlukast
Zileuton
Theophylline
Asthmatics w/ aspirin induced/allergic rhinitis
- less than 2 attacks per day/week
* Normal FEV1
intermittent
Inhaled SABA as needed
- 2+ days a week, but NOT daily or +1 in a day (same SABA)
- FEV1 > 80%
- FEV1/FVC normal
- 3-4 night awakenings/month
Mild
Inhaled SABA
Low dose ICS
- Daily s/s ~ SABA daily
- > 1 night awakening / week (not daily)
- FEV1 = 60-80%
- FEV1/FVC = DOWN 5%
Moderate
*Low ICS + LABA OR *UP ICS dose OR *+ LTRA
- s/s throughout day
- SABA several times a day
- night awakening usually every night
- FEV1= <60%
- FEV1/FVC= DOWN 5%
Severe
High dose ICS + LABA
+/- Omalizumab (anti - IgE)
GINA Stepwise treatment
*Step 2= low dose ICS OR LTRA/Low theophylline
*Step 3=Low dose ICS/LABA
Step 4= Med/high ICS/LABA
Setp 5= Add-on Tx (tiotropium, anti-IgE, Anti-IL5
Asthma Interview
- S/S + pattern
- Triggers
- Dz developtment/treatment
- FH
- Social (home//tobacco/occupation)
- Exacerbation profile
- impact on patient/family
- Patient’s perception of dz
Essential to Dx?
Spirometry
Show AWO
Anti IgE Rx
Omalizumab
*severe, uncontrolled
