Asthma Flashcards
can you grow out of asthma
yes
can you feel fine with asthma
yes, do not feel the inflammation in the lungs
use of SABA
band aid for the condition
just a reliever/rescue med
shouldnt be filled monthly
what is the mainstay treatment for asthma
inhaled corticosteroids
controller/preventor
clinical presentation of asthma
episodic wheezing breathlessness chest tightness coughing intervals between symptoms can be days, weeks, onths, years
diagnosis of asthma
spirometry demonstrates obstruction
decreased FEV1/FVC
with reversibility following inhaled beta agonist at least a 12% improvement in FEV1 and a difference of 200mL *****
will you feel corticosteroids working
never
asthma control criteria
<4days/wk daytime sx <1nights/wk night sx normal physical activity infrequent exacerbations no absences need for a SABA <4doses/wk FEV/PEF >90% personal best PEF diurnal variation <15% sputum eosinophils <3% no acute care visits
for asthma control the need for a fast acting beta2 agonist is <4doses/wk, does this include exercise
yes***
what should you regularly reassess for asthma management
control spirometry or PEF inhaler technique adherence triggers comorbidities sputum eosinophils
which patients use SABA on demand only
very mild
what dose of flovent do you want people on
want to maintain on the lowest dose possible 250ug/day
can go on high doses shortly but not for long term chronic control
in adults always add on instead of increasing the dose to get control what do you do in kids
increase to a medium dose before adding on another agent
order of the asthma management continuum
SABA on demand inhaled corticosteroid LABA LTRA anti IgE prednisone long acting muscuranic agonist
when is leukotriene receptor antagonist used
second line to inhaled corticosteroid
should only be an add on not a replacement***
should you have to take extra doses to exercise
no
what other questions should you ask
feel like getting a cold/flu exposure to triggers limitation in activities referred to action plan rule out exacerbation
red flags for acute exacerbation
unable to speak SOB at rest reliver not working peak flow <60% predicted best patient knows from past experience
triggers for asthma attack
resp tract infection allergens environment food additives exercise drihs/preservatives - ASA, NSAIDS, beta blocker occupational - baker, farmer emotions
what is recommended once an individual is sensitized to a pet
avoidance recommended bc continued exposure is associated with worsening airway inflammation and detioration in asthma control
what is not recommended and recommended for patients with allergic rhinitis or asthma sensitive to house dust mite allergens
do not use single chemical or physical preventative methods aimed at reducing exposure to hourse dust mites, try environmental control programs (remove carpet, dust proof pillow and mattress cover)
how do symptoms occur
chronic inflammation
airway narrowing caused by contraction of smooth muscle, airway edema, mucus hypersecretion, airway thickening
**remodelling
what is airway remodelling
repair in response to chronic inflammation
increases the airway wall thickness - fibrosis, increase smooth muscle, increase mucous glands, increase number of blood vessels
early phase of acute asthma
bronchoconstriction within 10 min, mucous hypersecretion, edema
duration : 1 hr
last phase of acute asthma
6-9 hours later
continued inflammation, epithelial damage, intensified hyperresponsiveness
more severe, prolonged, and difficult to reverse
may last for weeks
what are the 2 major risk factors for severe exacerbations
underutilization of antiinflammatory drug
excesive reliance on short acting inhaled beta 2 agonists
recommended use of ventolin per year
1-2 inhalers per year
why are long acting beta agonist inhalers bad in asthma
increase in serious adverse events
not actually treating the problem
benefits of inhaled corticosteroids
decrease airway hyperresponsiveness decrease inflammation improving pulmonary function decrease asthma symptons, exacerbations, hospitalizations, death improve QOL
which corticosteroid is best and at what dose
doesnt matter
start low and adjust as needed
preferred device for children 0-3yoa
pressured metered dose inhaler plus spacer with face mask
preferred device for 4-5yrs
pressurized metered dose inhaler plus spacer with mouthpiece
how long for a response with inhaled corticosteroid
decrease symptoms in days to weeks
min improvement 2-4 weeks and max 4-8weeks
when should you do a follow up for ICS
1-3 months after starting, if stable every 3-12 months after
can you step down on the ICS dose
yes at 3 month intervals
can you stop controller treatment
if no sx for 6mon, no risk factors, spirometry, in very mild category could consider
choose an appropriate time then a written asthma action plan
components of the action plan
outlie recommended daily preventaive management strategies to maintain control
when and how to adjust therapy for loss of control
provide clear instruction when to seek urgent medical attention
the 3 zones of asthma action plan
green- sx free
yellow - sx
red - danger
see the action plan
k
can you quadruple advair for step up therapy
FP and salmeterol
no will have too much salmeterol and can cause anxiety etc.
can you quadruple symbicort
budenoside/formalderol
form is more flexible and can give more
good to quadruple up to max 8puffs/day, 6 at a time
advantage of ciclesonide
comes as prodrug so not active untill it gets into the lungs so dont get thrush
reasons for a lack of response to ICS
erroneous diagnosis of asthma comorbidities (GERD, sinusitis, vocal cord dysfunction) poor inhaler device technique poor adherence exposure to environmental triggers
do ICS stunt growth
no will still reach same height
uncontrolled severe asthma also adversely affects growth
could measure height yearly in kids on ICS
AE for ICS
dose dependent thrush dysphonia (change in voice) - switch steroids
how to prevent thrush
spacer with mouthpiece instead of mask
rinse with water SWISH SWISH SPIT
adding LABA instead of increasing dose of ICS benefits
decrease rate of exacerbations increase morning and evening PEF decrease time take to achieve wel controlled asthma improve exercise response little evidence for children
formoterol (LABA) onset of action
1-3 min making it fast acting
what is SMART dosing (symbicort maintenance and reliver therapy)
LABA and ICS combo
SMART dosing concept
asthma exacerbations evolve over a few days and recent evidence that ICS begins reducing airway inflammation as early as 6 hours
by using as needed ICS and formoterol instead of SABA only gives an immediate intervention with on einhaler to control symptoms and prevent exacerbation
benefit from timing of higher ICS relative to worsening in sx
advantages of SMART dosing
long acting effect of formoterol
even at max dose lower corticosteroid exposure overall compared to tradational protocols
only one inhaler
what does the CTS say about single inhaler therapy
use of bud/form as a reliever and controller at the same ICS dose in patients with asthma uncontrolled on fixed dose ICS/LABA combo instead if increasing ICS dose
most common AE of beta2 agonists
tremor excitement nervous palpitation tachycardia can also decrease potassium causing heart problems
what do you use to treat the nose (always first step)
second gen antihistamines or intranasal corticosteroids
what is the peak expiratory flow meter
used for self monitoring
to help patient see where they are at
when should you recommend a peak expiratory flow meter
poor symptom percievers or severe asthma
can use for 2 weeks when a worsening or change in therapy
3 early therapies for exacerbations
repetitive admin of rapid acting inhaled beta2agonist
oral systemic glucocorticoids if dont respond in 6hr or histry of severe
oxygen supplement
reasons not to use prednison long term
causes osteoporosis, diabetes, cataracts
what is exercise induced bronchoconstriction
develops 5-10min after completing exercise
resolves spontaneous in 30min
how is exercise induced bronchoconstriction diagnosed
rapid improvement after inhaled beta 2 agonist
fall in FEV >15% after 6 min of near max exercise
what to do if someone is experiencing exercise induced broncoconstriction
if underlying asthma step up controller therapy
in no asthma have spirometry test
if need SABA >3x per week need an ICS as well
whne should biologics be used
severe allergic client as last resort
indication for tiotropium
add on for over 12with severe asthma uncontrolled with ICS/LABA combo
recommended inmmunizations
influenza for everyonw
pneumococcal for COPD and other comorbidities
