Asthma

Question 1

Asthma

Airflow obstruction due to bronchial spasm, inflammation, mucous hypersecretion

Sign and Symptoms: Sudden onset (esp night), dyspnes, wheezing, cough, chest tightening, flushing. Usually self-limiting with productive cough

Answer 1

Extrinsic/allergic 35%

Children, young adults

Inhaled seasonal allergens

IgE mediated >> mast cell degranulation >> histamine, leukotrienes >> SM contractions

Intrinsic 30%

Middle-aged adults

Normal IgE

emotional stress, GERD, vagally mediated responses

Drug-induced

aspirin, NSAIDs, B-blockers, ACEI, sulfite

Exercise-induced

Infectious asthma

some respiratory viral infec during infancy/childhood can result in asthma

Question 2

Aspirin-Sensitive Asthma

National Asthma Council Australia:

Aspirin/NSAID-intolerant asthma (AIA)* affects about 3-11% of adults with asthma.

Highest risk:

• severe asthma
• recurring nasal polyps
• adulthood asthma

Prevalence

• much less common in children
• 2% children with mild-to-moderate asthma (challenge study)

ASA/NSAID Contraindication

• previous AIA diagnosis
• experience of runny nose or wheezing 1-3 hours after taking aspirin or NSAIDs.

Answer 2

Triad Asthmaticus = Samter’s Triad

• Asthma
• Aspirin sensitivity
• Nasal polyps

due to overproduction of leukotriene from arachidonic acid pathway (shunted from COX)

Sheehan et al 2016 Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma The New England Journal of Medicine

Multicenter, prospective, randomized, double-blind, parallel-group trial

300 children with mild persistent asthma enrolled

Result: NSD Ibuprofen vs Tylenol in higher incidence of asthma exacerbations or worse asthma control

Question 3

Medical Management

Inhaled corticosteroids (maintenance) - systemic adverse effects rare

Systemic steroids if inhaled ineffective

Long-acting B2-adrenergic bronchodilator in combo

• salmeterol, formoterol

Short-acting B2-adrenergic agonist (acute)

• albuterol
• epi (0.3-0.5 ml, 1:1000) IM injection (status asthmaticus > 24h)

Answer 3

Dental Management

Inhaler: bring to appt, prophylatic use

Pulse Ox < 91% need intervention, 97-100% healthy

Anxiety: ok N2O (not resp depressent/irritant), low dose short-acting BNZ

Drugs to avoid:

• NSAIDs
• narcotics / barbiturates
• Sulfite preservatives (epi-containing LA)

Oral Health Considerations

Xerostomia >> Caries _{(B2 agonist reduce salivary flow by 20-35%)}

GERD common - dental erosion

Candidiasis - steroid inhalation spacer use/water rinse

Antifungal therapy: Nystatin (swish-swallow), clotrimazole, fluconazole

Question 4

Severe Attack: Sign and Management

• Inability to finish sentences with one breath
• Bronchdilators ineffective in relieving dyspnea
• Tachypnea > 25 breaths/min
• Tachycardia > 110 BPM
• Diaphoresis
• Accessory muscle usage
• Paradoxical pulse

Answer 4

Management

• Administer fast acting bronchodilator
• Administer O2
• Give 0.3 to 0.5 ml of sub Q epi 1/1000 or epi inhalation
• Activate EMS
• Repeat fast acting bronchodilator every 5 mins until EMS arrives