Asthma Flashcards
Asthma is the most common chronic dz in _____?
childhood
What are the underlying problems in asthma (4)?
airway hyper-responsiveness
inflammation
airflow obstruction
narrowed airway
What kinds of things cause airway hyper-responsiveness?
- particulate inhalants/allergens
- temp changes
- stress
- reflux
- exercise
Describe the inflammation in asthma (what kinds of cells?)
inflammatory cell infiltration w/ eosinophils, neutrophils, and lymphocytes
hyperplasia of goblet (mucus) cells
mast cell activation
What causes airflow obstruction in asthma?
- smooth muscle hypertrophy
- collagen deposition in basement membrane
- edema of airways
How is the airway narrowed in asthma? What receptors are involved?
Smooth muscle constriction and hyperplasia
Beta-2 receptors and Muscarinic receptors
Classic sx of asthma
are they constant/intermittent and specific/non-specific?
Wheezing
cough
dyspnea
Symptoms are intermittent and non-specific
How do you dx Asthma? (what is needed?)
History of respiratory sx
AND
demonstration of variable, reversible, expiratory airflow obstruction
AKA
History + Physical + Spirometry (PFTs)
What is the Atopic triad?
Allergy + asthma + eczema
What are some non-exacerbation patient clues?
- pale, swollen nasal mucosa= allergic rhinitis
- nasal polyps
- ecxema (atopic dermatitis)
- lung exam: usually nl
- cardiac: possibly tachy
What is the Gold Standard for diagnosing Asthma?
Spirometry / Pulmonary Function Testing (PFTs)
What is FEV1 and FVC?
FEV1= forced expiratory volume in 1 sec
FVC= forced vital capacity; amount of air forcefully exhaled after a maximum inhalation
What happens to the FEV1/FVC Ratio in Asthma?
decreased!
<70% indicates obstructive dz
After obstruction is identified (FEV1/FVC < 70%), the severity of obstruction is determined. What are the values that indicate mild, moderate, severe obstruction?
FEV1 >70% predicted = mild
FEV1 50-69% predicted= moderate
FEV1 <50% predicted= severe
if FVC is below 80% predicted then you have obstruction + low vital capacity
How do you determine reversibility in asthma?
pre- and post- bronchodilator measurements
- 2-3 puffs quick acting bronchodilator (albuterol)
- wait 15 mins
- perform spirometry again
FEV1 increase of 12% or more= positive response
Why must you take serial measurements in asthma pt?
because asthma is episodic! PFT values may vary depending on pt status!
What are the 4 components that are used to determine severity of asthma?
- Symptom frequency
- Nighttime awakenings
- Need for short acting beta-agonist inhaler
- Interference w/ normal activity
If you have symptoms in 2 different categories (ex. mild vs moderate), how do you categorize the pt?
by the MOST SEVERE symptom/parameter
What is the rule of 2’s?
More than 2 of any of the components of severity= persistent
Components of asthma management (4)
- Routine monitoring of sx and lung function
- Patient education to create a clinician and pt partnership
- Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity
- Pharmacologic therapy
What are the 2 goals of asthma tx?
reduction in impairment and reduction of risk
What is considered reducing impairment?
- freedom from sx
- minimal need (less than or equal to 2 days per week) of inhaled short acting beta agonists
- few night-time awakenings (<2 per month)
- optimization of lung fx
- maintenance of nl daily activities
- satisfaction w/ asthma care on the part of pts
What is considered reducing risk?
- prevention of recurrent exacerbation and need for ED or hospital care
- prevention of reduced lung growth in children, and off of lung fx in adults
- optimization of pharmacotherapy w/ minimal or no adverse effects
What are ways you can do environmental control for asthma?
controlling triggers and contributing conditions
- tx allergies
- avoid respiratory irritants
- address obesity, GERD
- control medication triggers
Goals of quick relief vs long-term control meds for asthma
Quick:
- direct relaxation of bronchial smooth muscle
- reversal of airflow obstruction
Long-term:
-decrease airway inflammation
How do B-2 agonists work?
bronchodilator- relive bronchospasm by relaxing bronchial smooth muscle
When is a SABA used?
work immediately, can by used preventatively or emergently
When can a LABA be used? Examples?
Used for Prevention!!
not for use as rescue or PRN inhaler
ex:
Formoterol
Salmererol
Arformoterol
Black box warning on LABAs?
may increase risk of asthma death when used alone (w/o concurrent inhaled steroid)
What do inhaled corticosteroids do? When to use? Examples?
decrease inflammation
- not for use as rescue or PRN inhaler
- Used for Preventative
Ex:
Beclamethasone
Fluticasone
Triamcinolone
What is the purpose of combining LABA + ICS? Examples?
Long acting relief of bronchospasm + decrease inflammation
prevention only
Ex:
salmeterol + fluticasone
formoterol + budesonide
formoterol + mometasone
What do Leukotriene Receptor Antagonists (LTRA) do? When do you use it? Examples
- Leukotrienes cause inflammation and mucosal edema
- blocking the LT receptor mitigate this effect
- oral tables, prevention only
- also indicated to tx allergic sx
Ex:
Montelukast
Zafirlukast
How do anticholinergics work? When do you use? Examples?
- decrease secretions (mucus)
- generally used for acute exacerbations only
- inhaler or nebulization
Ex:
Ipratropium
Tiotropium
How do Mast-cell stabilizers work? ex
inhibits the release of histamine, leukotrienes, and other mediators from sensitized mast cells
Cromolyn sodium (Intal)
How do Monoclonal antibodies work? Ex
Recombinant antibody that binds IgE w/o acting mast cells
Omalizumab
Reslizumab
How do oral corticosteroids work? When to use? Ex
- Systemic anti-inflammatory effect
- used for acute exacerbation or severe chronic sx
- many adverse side effects
Ex: prednisone, methylprednisone
If your patient has sx of bronchospasm, what are med options?
- Short-acting beta-agonist
- Long-acting beta-agonist
Asthma pt has mucosal edema (inflammation), what are med options?
- inhaled corticosteroids (and oral)
- leukotriene receptor antagonists
- (5-Lipoxygenase inhibirto, mast-cell stabilizers, monoclonal antibody)
Asthma pt has mucus production, what is med option?
Anticholinergics
Explain step-therapy
- start w/ highest step based on pt’s sx, severity categorization and spirometry
- re-assess control every few weeks
- step up or down as needed
- All pts are on SABA prn
What medication do ALL asthma pts need to be on?
SABA prn!
In persistent asthma, what meds are given for steps 2-4?
2: low-dose inhaled glucocorticoids
3: low-dose inhaled glucocorticoids + LABA
OR
Medium-dose inhaled glucocorticoids
4: medium-done inhaled glucocorticoids + LABA
What are the benefits of monitoring Peak Flow?
- simple, inexpensive
- helps pt determine need for rescue inhaler
- peak flow diary helps clinician eval sx control and determine “personal best”
What is predicted average PEFR based on?
Age and height
When so you instruct your pts to use their peak flow meter?
- every morning before taking rx as part of daily routine
- during asthma sx or attack
- after taking meds for an attack
What do the colors on the peak flow monitor indicate? (green, yellow, red)
green= good yellow= caution, use SABA red= go to ER
When do you admit pts with asthma exacerbation?
pts who do not respond well after 4-6 hrs to ICU
Signs/sx of serve exacerbation
- inability to speak full sentences
- accessory muscle use
- tripod position
- inability to lie supine
- tachycardia
- tachypnea
- O2 sat < 90%
Signs of imminent respiratory arrest
- confusion
- cyanosis
- fatigue
- agitation
How do you tx a pt with mild-moderate exacerbation?
- O2= titrate up > 90%
- Albuterol + anticholinergic
- IV or Oral glucocorticoids
In addition to tx given for mild-moderate exacerbation, what else can be given to a pt w/ severe exacerbation?
- IV magnesium
- IV epinephrine
- Terbutaline
- Heliox
- ketamine
- Neuromuscular blocks
What is status asthmatics? Sx?
- acute exacerbation or asthma unresponsive to initial tx w/ bronchodilators
- mild-severe form w/ bronchospasm, airway inflammation, and mucus plugging
- difficulty breathing, carbon monoxide retention, hyperemia, and respiratory failure
Preventative care given to asthma pts?
Pneumococcal vaccine
Annual influenza vaccine
When do you refer to Pulmonology?
when sx do not respond to therapy at Step 3 or 4, or if sx are severe
