asthma Flashcards
define asthma
chronic disorder variable and recurring symptoms airflow obstruction bronchial hyperresponsiveness underlying inflammation
what are examples of airway hyper-responsiveness?
particulate inhalants/allergens temperature changes stress reflux exercise
what are examples of inflammation?
inflammatory cell infiltration with eosinophils, neutrophils and T lymphocytes
hyperplasia of goblet cells
mast cell activation
what are examples of airflow obstruction?
smooth muscle hypertrophy
collagen deposition in basement membranes
edema of airways
what are examples of narrowed airway?
smooth muscle constriction and hyperplasia
what are the main two receptors in asthma?
beta-2 receptors and muscarinic receptors for smooth muscle relaxation
what are the classic symptoms of asthma?
wheezing, cough, and dyspnea
how do you diagnose asthma?
hx of respiratory symptoms AND demonstration of variable, reversible, expiratory airflow obstruction as well has H&P AND spirometry
what in the pt’s hx could lead to increased risk for asthma?
atopy, obesity, allergies, smoking, atopy in family hx, respiratory disease
what might you see in the ROS for asthma?
general: fever, chills, night sweats, weight loss
skin: eczema, rashes, pruritis
HEENT: itchy eyes, nasal congestion, sneezing
Pulm: wheezing, cough, dyspnea
Cardiac: chest pain, palpitations, edema, orthopnea
what is the atopic triad?
allergy, asthma, and eczema
what are non-exacerbation pt clues?
allergic rhinitis nasal polyps eczema normal lung exam possible tachycardia
what is the gold standard for diagnosing asthma?
spirometry
what are normal FEV1 and FVC values?
80% or greater
what FEV1/FVC ratio indicates obstructive disease?
less than 70%
FEV1 tells us how ______ the obstruction is
severe
how to classify the obstructions?
over 70 = mild
50-69 = moderate
under 50 = severe
in spirometry, we look at _______
reversibility
FEV1 needs to increase by how much to indicate a positive response?
12% or more
in a bronchoprovocation test, what does the pt inhale to determine if he/she has a hyperresponsive response?
metacholine
what are the four categories of symptoms that therapy is based on?
- symptom frequency
- nighttime awakenings
- need for SABA inhaler
- interference with normal activity
choose the most severe symptom
intermittent asthma is classified how?
having symptom frequency 2 days or less per week
having nighttime awakenings 2 or less times per month
SABA use 2 days or less per week
no interference with normal activity
0-1 systemic steroid use per year
mild persistent asthma is classified how?
symptom frequency >2 days/week nighttime awakenings 3-4x/month SABA use > 2 days/week minor limitation with normal activity 2 or more systemic steroid use per year
moderate persistent asthma is classified how?
symptom frequency daily nighttime awakenings more than once per week but not nightly SABA use daily some limitation with normal activity 2 or more systemic steroid use per year
severe persistent asthma is classified how?
symptom frequency throughout the day nighttime awakenings often 7x/week SABA use several times per day extremely limited with normal activity 2 or more systemic steroid use per year
what are the four essential components in managing asthma?
- routine monitoring of symptoms and lung function
- patient education
- environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity
- pharmacologic therapy
the first goal of reducing impairment in asthma is?
keeping the symptoms under 2 times per week or month
what are possible medications that can trigger asthma?
ASA and NSAIDS
what are dietary sulfides to avoid?
beer wine processed potatoes dried fruit sauerkraut shrimp
in airflow obstruction, smooth muscle constriction could lead to?
bronchospasm
what does a B-2 agonist do?
bronchodilator - relieves bronchospasm by relaxing bronchial smooth muscle
what are the two types of B-2 agonists?
SABA and LABA
which B-2 agonist can you use in exercise induced asthma?
SABA
what are examples of SABAs?
albuterol
pirbuterol
levalbuterol (use this if pt has tachycardia or palpitations with albuterol)
LABAs are NOT for ________
emergencies
what are examples of LABAs?
formoterol
salmeterol
arformoterol
what is the black box warning for LABA
increase the risk fo asthma death when used alone without concurrent inhaled steroid (increased risk in black population)
inhaled corticosteroids are used in conjunction with LABAs, what are examples of inhaled corticosteroids?
beclamethasone
fluticasone
triamcinolone
what are examples of LABA and ICS combination inhalers?
salmeterol + fluticasone
formoterol + budesonide
formoterol + mometasone
leukotriene receptor antagonist (LTRA) is not a first line asthma/allergy medication, what are examples?
montelukast (singulair)
zafirlukast
what med class is only used for acute exacerbations?
anticholinergics examples: ipratropium tiotropium *can be combined with SABA
if someone has very severe asthma, what medication would you use?
monoclonal antibody
examples:
omalizumab
reslizumab and mepolizumab (use in eosinophilia)
when are oral corticosteroids used?
acute exacerbations or severe chronic symptoms
examples: prednisone or methylprednisolone
what meds are used for mucus production?
anticholinergics
what meds are used for bronchospasm?
SABA and LABA
what meds are used for mucosal edema (inflammation)?
inhaled corticosteroids
LTRA
5-lipoxygenase inhibitor, mast-cell stabilizers, monoclonal antibody
what med do you give if intermittent asthma?
SABA PRN
how do you treat persistent asthma with medications?
up the dose of the ICS (low, medium, high) + LABA
if high dose ICS and LABA are not working, what do you add?
oral systemic glucocorticoids
also be considering omalizumab in pts with allergies
what is the peak flow expiratory rate (PEFR)
helps pt determine need for rescue inhaler
predicted average PEFR based on age/height
PEFR has a color scale of green, yellow, and red, what does each color mean?
green = good to go yellow = caution, use SABA red = go to ER
what medication should you consider adding to a SABA for severe exacerbations?
ipratropium
if no immediate and marked response to the SABA, what should you start?
IV steroids
when should you consider admitting pts to the ICU if not responding to treatment?
4-6 hours
what are S&S of acute exacerbations?
inability to speak full sentences accessory muscle use tri-pod positioning inability to lie supine SpO2 < 90% PCO2 elevated
what are imminent respiratory arrest signs?
confusion
cyanosis
fatigue
agitation
how to treat mild-moderate exacerbations in hospital?
titrate O2 until SpO2 > 90%
albuterol + anticholinergic
IV or oral glucocorticosteroids (4-6 hr to work)
what are adjunct therapies for severe exacerbation?
IV magnesium IV epinephrine terbutaline heliox ketamine neuromuscular blockers
if pt does well with 2-3 treatments of SABA (20 minutes apart) at the office, what is the next step?
continue SABA q3-4h for the next 24-48 hours
can consider short course of oral systemic corticosteroids
if pt has incomplete response to the 2-3 treatments of SABA, what is the next step?
add oral systemic corticosteroid
continue SABA
contact clinician
if pt has no response to the 2-3 treatments of SABA, what is the next step?
call your doctor and proceed to the ED
define status asthmaticus
acute exacerbation of asthma unresponsive to initial treatment with bronchodilators
symptoms of dyspnea, CO2 retention, hypoxemia and respiratory failure
what are preventative measures for asthma?
pneumococcal vaccination
annual influenza vaccination
