Asthma

Question 1

Asthma is the most common chronic disease in …

Answer 1

childhood

Question 2

Asthma

Answer 2

chronic inflammatory disorder of the airways

partially or completely reversible with bronchodilators

controllable but not curable

Question 3

Symptoms

Answer 3

wheezing; usually only during asthma attacks/episodic

coughing

shortness of breath

tight chest

itchy or sore throat

rapid breathing

symptoms may be worse at night or wake the patient up

Question 4

Prevalence

Answer 4

8-10% of population; 1 in 12; 25 million in U.S>

increasing

Question 5

Inflammatory cells involved in the immunohistopathologic features of asthma

Answer 5

Neutrophils (especially in sudden-onset, fatal asthma exacerbations; occupational asthma, and patients who smoke)

Eosinophils

Lymphocytes

Mast cell activation

Epithelial cell injury

Question 6

Risk Factors

Answer 6

Atopy - the body’s predisposition to develop an antibody called immunoglobin E (IgE) in response to exposure to environmental allergens; can be measured in blood; includes allergic rhinitis, asthma, hay fever, and eczema

Obesity

Question 7

Triggers

Answer 7

environmental: dust mites, cockroach, animal dander, pollens
occupational: chemicals, fumes, smoke

cigarette smoke, upper respiratory infection, exercise, stress, post nasal drip, GERD (reflux)

Question 8

Samter’s Triad

Answer 8

aspirin sensitivity

asthma

nasal polyps

Question 9

Exam Findings

Answer 9

Vitals: May have elevated BP/ resp rate, decreased O2 sat

HEENT: allergic conjunctivitis, nasal swelling or polyps, throat erythema from PND (all atopy indicators)

LUNG: wheezing or prolonged expiratory phase; but normal if not having flare; wheezing may be absent during severe exacerbations; not moving enough air to even wheeze (‘silent chest’)

Chest inspection - using accessory muscles to breathe (rib/neck muscles show)

Heart: normal

Derm: cyanosis of lips or nails (if very bad)

Question 10

What will the Arterial Blood Gas show in people with asthma?

Answer 10

respiratory alkalosis

Question 11

What will tested sputum samples have in patients with asthma?

Answer 11

eosinophils or serum IGE level

Question 12

Pulmonary Function Tests in Asthma Patients

Answer 12

typically done pre- and post-bronchodilator to look for reversibility of airflow obstruction

significant reversibility is defined by in increase of 12% or more and 200 mL in FEV1 or FVC after inhaling a short-acting bronchodilator

may be normal if not having an asthma attack

Question 13

Bronchial Provocation Testing/Methacholine Challenge

Answer 13

done if asthma suspected but PFT not diagnostic.

A negative test has a negative predictive value for asthma of 95%

people whose airways do not narrow after inhaling methacholine are very unlikely to have asthma

Question 14

Peak Expiratory Flow (PEF)

Answer 14

personal monitoring tool; used at home; gross estimate of GVC; self-measured and recorded; if patient isn’t trying, the results are not accurate – effort dependent

Question 15

Fractional Exhaled Nitric Oxide (FeNO)

Answer 15

during inflammation, higher-than-normal levels of nitric oxide (NO) are released from epithelial cells of the bronchial wall; the concentration of NO in exhaled breath can help identify airway inflammation

usually used to determine if correct dose of anti-inflammatory is given

Question 16

• Increased probability that symptoms are due to asthma if:

Answer 16

more than one type of symptoms (wheeze, shortness of breath, cough, chest tightness)

symptoms often worse at night or in the early morning

symptoms vary over time and in intensity

symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells

Question 17

Decreased probability that symptoms are due to asthma if:

Answer 17

isolated cough with no other respiratory symptoms

chronic production of sputum

shortness of breath associated with dizziness, light-headedness or peripheral tingling

chest pain

exercise-induced dyspnea with noisy inspiration (stridor)

Question 18

Asthma severity and asthma control include two domains:

Answer 18

Current impairment: frequency and intensity of the patient’s symptoms and functional limitations (current or recent)

Risk: likelihood of untoward events (exacerbations, progressive loss of lung function, or medication side effects)

Question 19

Quick Relief or Rescue Treatment

Answer 19

Bronchodilators/(short acting beta agonists) SABAs

(albuterol - Ventolin, Pro Air, Proventil; and others) inhaler or nebulizer

Used to relieve or prevent symptoms (prior to exercise) SABAS FOR ALL

Question 20

Long-term Control Treatments

Answer 20

Corticosteroids: Inhaled: Many options, used frequently; Systemic: Oral prednisone, limit exposure

Long acting bronchodilators (LABA) - NEVER MONOTHERAPY, most often as combined inhaler

Question 21

Step Treatment System

Answer 21

Step 1 (Intermittent) – SABA PRN

Step 2 (Persistent) – Low dose ICS

Step 3 – Low dose ICS + LABA OR Medium dose ICS; consider consultation

Step 4 – Medium dose + LABA; consult with asthma specialist

Step 5 – High dose ICS + LABA

Step 6 – High dose ICS + LABA + Oral Corticosteroid

Question 22

Intermittent Asthma

Answer 22

symptoms: less than or equal to 2 days per week

night-time awakenings: less than or equal to 2 days a month

SABA use: less than or equal to 2 days a week

interference with normal activity: none

Lung Function:
FEV1: normal between exacerbations
FEV1 >80%
FEV1/FVC >85%

Question 23

Mild Asthma

Answer 23

symptoms: more than 2 days per week

night-time awakenings: 3-4 days a month

SABA use: more than 2 days a week, but not daily

interference with normal activity: minor

Lung Function:
FEV1 >80%
FEV1/FVC >80%

Question 24

Moderate

Answer 24

symptoms: daily

night-time awakenings: 1 time per week, but not nightly

SABA use: daily

interference with normal activity: some

Lung Function:
FEV1: 60-80%
FEV1/FVC : 75-80%

Question 25

Severe Asthma

Answer 25

symptoms: throughout the day

night-time awakenings: often; seven times per week

SABA use: several times per day

interference with normal activity: extreme

Lung Function:
FEV1 <60%
FEV1/FVC <75%

Question 26

Rules of Two

Answer 26

Do you have asthma symptoms or use your bronchodilator more than two times per week?

Do you refill your bronchodilator medication more than two times per year?

Do you have asthma symptoms that awaken you more than two times per month?

Does your peak flow drop more than 20% (2 X 10%) with symptoms?

NO – asthma is under control

YES to one of these questions – your asthma is not controlled

Question 27

Asthma Action Plan

Answer 27

guide for patient self-management effort

Includes:
daily management as well as early recognition and actions for exacerbations

medication names (trade or generic)

how much to take and when to take it

how to adjust medications at home as symptoms change

Question 28

When to Refer

Answer 28

when treatments are not working – suboptimal response, not meeting goals after 3-6 months

atypical presentation or uncertain diagnosis of asthma

complicating comorbid problems, such as rhinosinusitis, tobacco use, multiple environmental allergies, suspected allergic bronchopulmonary mycosis.

requires high-dose inhaled corticosteroids for control

more than two courses of oral prednisone therapy in the past 12 months

any life-threatening asthma exacerbation or exacerbation requiring hospitalization in the past 12 months

presence of social or psychological issues interfering with asthma management