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Respiratory 3 > Asthma > Flashcards

Asthma Flashcards

1
Q

What is asthma?

A
  1. A syndrome – not a single disease
  2. Usually characterized by chronic airway inflammation
  3. Variable/reversible airway obstruction
  4. Airway hyperresponsiveness
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2
Q

What is the definition of asthma?

A
  • Asthma is a chronic inflammatory disease of the airways in which many inflammatory cell types play a role, in particular mast cells, eosinophils, T-lymphocytes, neutrophils, and epithelial cells
  • In susceptible individuals, the inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough—particularly at night and/or in the early morning
  • These symptoms are usually associated with widespread but variable airflow obstruction that is at least partly reversible either spontaneously or with treatment
  • This inflammation also causes an associated increase in airway responsiveness to a variety of stimuli
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3
Q

What are the intrinsic asthmas?

A

Exercise induced

Cough-variant

Occupational

Severe/Refractory

Eosinophilic

Noneosinophilic

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4
Q

What are the extrinsic asthmas?

A

Triad/AERD (aspirin exacerbated respiratory disease)

Difficult

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5
Q

Epidimiology of Asthma?

A
  • Common disease syndrome 1 to 18% of the population in different countries
  • Prevalence increasing
  • Highest in vulnerable population: children, people living below the poverty level, specific minority groups; Blacks, Puerto Ricans
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6
Q

Children vs. adults in asthma?

A

Children get asthma more than adults.

In children men more commonly get it.

In adults females more commonly get it.

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7
Q

Mortality of Asthma?

A

Estimates 300 million affected individuals

250,000 asthma related deaths each year worldwide

U.S. mortality 15 per million in 2009

Disproportionately affects Blacks (38.7/million) and Puerto Rican heritage (40.1/million)

Increased mortality in the elderly

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8
Q

Clinical features of asthma? Need to consider asthma in which patients?

A
  • Characterized by episodes of cough, wheeze, dyspnea and chest tightness
  • Large number of patients may not have classic symptoms and hence go undiagnosed.

Need to consider in: – Recurrent bronchitis – Dyspnea with exercise – Unexplained chronic cough

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9
Q

Questions to consider when thinking asthma?

A
  • Has the patient had an attack or recurrent attacks of wheezing?
  • Does patient have a troublesome cough at night?
  • Does patient have a cough or wheeze during or after exercise?
  • Does patient cough, wheeze, or complain of chest tightness after exposure to allergens or pollutants?
  • Does patient have frequent colds which last longer than 10 days?
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10
Q

Physical exam signs and history findings that may be suggestive of asthma?

A
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11
Q

Common asthma risk factors?

A
  1. Allergy history, a family history of asthma (the strongest)
  2. Respiratory viral infection (especially in childhood)
  3. “Hygiene Hypothesis” a reduction in bacterial exposure in childhood (↓TH1 resulting in ↑TH2)
  4. Air pollution
  5. Obesity
  6. Occupational exposure: Work-related asthma (WRA)
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12
Q

Asthma triggers?

A
  • Allergen exposure
  • Respiratory infections
  • Strong expressions of emotion (laughing, crying)
  • Vigorous exercise
  • Cold air
  • Dust
  • Air pollution
  • Cigarette smoke
  • Household products
  • Drugs
  • Pets
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13
Q

General pathogenesis of asthma?

A

Airway inflammation in asthma results from an interaction between susceptible genes and the environment

Airway Inflammation is a result of complex interaction between multiple cells and chemical mediators

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14
Q

What cells are involved in the asthma pathogenesis? leads to?

A

Inflammatory cells derived from the circulation (eosinophils, lymphocytes, mast cells, and macrophages) and Structural cells (epithelial and endothelial cells, fibroblasts and smooth muscle cells)

Results in structural changes called “airway remodeling”

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15
Q

How does asthma pathogenesis play into and feed itself?

A
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16
Q

what are the consequences of inflammation in asthma?

A
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17
Q

explain the shifts in asthma paradigms with time?

A
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18
Q

Cellular and molecular biology pathogenesis of asthma?

A

Type 2 immune responses – central immunologic abnormality Mediated by the CD4+cells and IgE

In Contrast Type 1 immune responses Mediated by Th1 CD4+, cytotoxic CD8+ T cells and IgG

The CD4+ cell prominence → think asthma The CD8+ cell prominence → think COPD

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19
Q

What do type 2 helper cells secrete?

A

Type 2 helper cells (TH2) → cytokines: Interleukin-4, Interleukin-5, and Interleukin-13

IL-4,5 help production of IgE and eosinophils

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20
Q

What are the two main types of asthma cellular phenotypes?

A
  1. Eosinophilic (Th2 high) 2

. Noneosinophilic (Th2 low) Seen in up to 25% of asthmatics not on treatment Seen in up to 50% of asthmatics on treatment and may account for why some patients respond poorly to inhaled corticosteroids

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21
Q

Explain the cellular classification of asthma based off of the sputum cytology?

A
  1. Eosinophilic (classic atopic asthma)
  2. Neutrophilic (acute and chronic infection, obesity, smoking)
  3. Mixed eosinophilic and neutrophilic (refractory asthma)
  4. Paucigranulocytic asthma: no observable inflammatory cells
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22
Q

Pathophysiological features associated with asthma?

A
  • Variable airflow obstruction
  • Bronchoconstriction
  • Edema
  • Airway hyperreactivity
  • Airway inflammation – Eosinophils – Mast cells – Lymphocytes – Neutrophils
  • Mucus hypersecretion – Goblet cell metaplasia – Submucosal gland hypertrophy
  • Impaired mucus clearance
  • Smooth muscle hypertrophy/ hyperplasia
  • Subepithelial matrix protein deposition
  • Collagen deposition
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23
Q

explain the pathophysiology of asthma?

A
24
Q

what are the ceullar components of asthma and what do they lead to?

A
25
Q

Full pathophysiology features, and airway changes of asthma?

A
26
Q

Explain the effects of asthma in different stages?

A
27
Q

How to make a clinical diagnosis of asthma?

A

Personal history: Family history of asthma, history of atopy, pets, etc.

Work history: Occupation, airborne irritants, symptoms improve away from work

Physical exam: Expiratory wheeze, prolonged expiration

PFT: Spirometry, ± provocative challenges

Radiographic imaging studies

Biomarkers: IgE, peripheral eosinophils, FeNO, Periostin

Sputum Eosinophils

28
Q

Key history points of asthma?

A
  • Symptoms
  • Pattern of symptoms
  • Precipitating factors (triggers)
  • Development of disease
  • Description of exacerbation
  • Living situation
  • Disease impact
  • Patient’s perception
  • Family & medical history
29
Q

Three cardinal findings of asthma?

A

Cough
Especially if: •After exertion • Breathing cold air •At night •After colds • Paroxysmal

Wheezing: • Tightness • Noisy breathing

Breathlessness:
Especially if: • Intermittent or variable •After exertion •At night

30
Q

Physical exam of Asthma? Should not see?

A
  • Expiratory wheeze – During normal breathing – Wheeze on forced expiration is not as reliable
  • Prolonged expiratory phase
  • Hyperexpansion of the thorax
  • Nasal polyps, edematous nasal turbinates
  • Atopic dermatitis

Note: Should not have cyanosis or clubbing of the nails

31
Q

Asthma airway hyperresponsiveness?

A
  • Airway resistance is related to airway radius
  • Asthmatic airway resistance will increase far more than in normals, for a given degree of smooth muscle shortening
  • Airway wall thickening in asthma may account for a large part of airway hyperresponsiveness

Airway resistance is proportional to 1/(airway radius^4)

32
Q

Common tests used to assess asthma?

A
  1. Spirometry
  2. Peak expiratory flow
  3. Asthma control questionnaire
  4. Exhaled nitric oxide (FeNO) in eosinophilic asthma
  5. Sputum eosinophil differential count
33
Q

Asthma will show what FCV, FEV1 and FEV1/FVC normally? during attacks?

A

Normal: FVC, FEV1 and FEV1/FVC
Attack: drops in FVC, FEV1 and FEV1/FVC
Decline responds to bronchodilators e.g., reversible airway obstruction

34
Q

What is exhaled nitric oxide (FeNO)?

A
  • Measurements easy to obtain
  • Results immediately available
  • Reasonable close relationship between FeNO and eosinophilic airway inflammation – Independent of age, gender, atopy
  • Not closely related to other measures of asthma morbidity
35
Q

Differential diagnosis of airway diseases in the consideration of asthma, Localized?

A

– Vocal cord paresis

– Laryngeal carcinoma

– Thyroid enlargement

– Relapsing polychondritis

– Tracheal carcinoma

– Bronchial carcinoma

– Post tracheostomy stenosis

– Foreign bodies

– Bronchopulmonary dysplasia

– Obstructive sleep apnea

36
Q

Differential diagnosis of airway diseases in the consideration of asthma, diffuse or generalized?

A

– Asthma

– COPD

– Bronchiectasis

– Cystic fibrosis

– Obliterative bronchiolitis

37
Q

Factors in making an asthma diagnosis?

A

History of Recurrent Symptoms Wheeze Cough Shortness of breath

Then:
Rule Out Other Causes of Symptoms

Then:
Document Presence of Airflow Obstruction PEFR Spirometry

Then:
Demonstrate Reversibility of Obstruction/Symptoms

38
Q

Goals of asthma management?

A
  1. Control of asthma symptoms
  2. Prevention of an asthma attack
  3. Preservation of normal lung function
39
Q

General Asthma treatment plan?

A
  • Reduce impairment – Limit number of symptomatic episodes – Reduce medication needs – Maintain/improve quality of life – Optimize lung function
  • Reduce risk – Prevent exacerbations – Prevent loss of lung function/remodeling – Optimize therapy
  • Patient education – Identify possible triggers develop asthma education plan
  • Monitor pulmonary function
  • Pharmacotherapy
40
Q

What are the therapeutic targets of asthma treatment?

A
41
Q

Treatment highlights of asthma?

A
  • Emphasis is on asthma control
  • Achieving and maintaining control are among the goals of therapy
  • Treatment options are organized to achieve control
  • Consider stepping up therapy, if control is not achieved on a current regimen
  • Consider stepping down once control is maintained, to identify the lowest treatment step required to maintain control
42
Q

Five esstential steps to assess control of asthma?

A
  • Symptoms
  • Reliever medication use
  • Recent exacerbations
  • Lung function
  • Evaluate risk of future adverse outcomes
43
Q

Comorbid conditions in asthma? What are they?

A

Evaluate for comorbid conditions in the history and when asthma cannot be well controlled.

Treating comorbid conditions may improve overall control of asthma and lessen requirements for asthma medications.

– Allergic bronchopulmonary aspergillosis (ABPA)

– Gastroesophageal reflux disease (GERD)

– Obstructive sleep apnea (OSA)
– Obesity – Rhinitis/sinusitis – Stress/depression

44
Q

Assess what?

A
  • Severity: measure of disease intensity – Measured most easily in a patient not currently receiving long-term control therapy
  • Control: extent to which manifestations of disease are minimized – Level of control will guide decisions to either maintain or adjust therapy • Severity and control involve 2 domains: current impairment and future risk
45
Q

Treatment of asthma?

A
  • Disease heterogeneity requires individualized therapy: one size does not fit all.
  • Disease assessment and treatment plans are tailored to 3 age groups: ≤4 years, 5–11 years, ≥12 years.
  • Panel consensus: “Evidence to date indicates that daily long-term control medication does not alter the underlying severity of the disease.”
46
Q

Control of asthma involves?

A
  • Reduce impairments –Prevent daytime/nighttime symptoms. –Reduce use of short-acting rescue medications (≤2 days per week) –Maintain (near) normal lung function –Maintain normal activity levels –Deliver satisfactory asthma care
  • Reduce risks –Prevent exacerbations and minimize need for urgent care –Prevent progressive loss of lung function; in children, prevent reduced lung growth –Minimize possible side effects of medication
47
Q

Reducing impairment means?

A
  • Prevent chronic and troublesome symptoms –Coughing –Breathlessness in the daytime/nighttime/after exertion
  • SABA use 2 or less days a week (not including EIB prevention)
  • Maintain near-normal pulmonary function
  • Maintain normal activity levels –Exercise and physical activity –Attendance at work/school
  • Meet patient’s and family’s expectations
48
Q

Reducing the risk in asthma control?

A
  • Prevent recurrent exacerbations of asthma
  • Minimize the need for emergency department visits or hospitalizations
  • Prevent loss of lung function
  • Prevent reduced lung growth in children
  • Determine the appropriate therapy while balancing its potential benefits and risks
49
Q

Explain the different asthma severities, what is found and what we do?

A
50
Q

Pharmocotherapy treatment of asthma?

A
  • Bronchodilators
  • Anti-inflammatory drugs (1˚corticosteroids)
  • Bronchial thermoplasty
  • Agents with specific targeted action: Monoclonal antibody therapies – Omalizumab (Xolair) – Mepolizumab (Nucala) – Reslizumab (Cinqair) – Benralizumab (Fasenra) – Dupilumab (Dupixent)
51
Q

Explain Omalizumab? Mepolizumab? Reslizumab? Benralizumab? Dupilumab?

A

A. Omalizumab: Xolair MOA: Monoclonal antibody Blocks the interaction of IgE with mast cells and basophils

B. Mepolizumab: Nucala MOA: Monoclonal antibody Blocks IL5 a key cytokine responsible for eosinophil maturation and recruitment

C. Reslizumab: Cinqair MOA: Monoclonal antibody Prevents IL5 from binding to the alpha chain of the IL5 receptor

D. Benralizumab: Fasenra MOA: monoclonal antibody IL5 cytolytic antibody, leads to apoptosis of eosinophils and basophils through antibody-dependant cell-mediated cytotoxicity

E. Dupilumab: Dupixent MOA: A monoclonal antibody inhibits interleukin-4 and interleukin-13 signaling, appears especially good for severe asthma

52
Q

What is a new drug to treat severe/refractory asthma?

A

Tezepelumab (in the pipeline) MOA: Monoclonal antibody targets the epithelial cell

Thymic Stromal Lymphopoietin (TSLP) reduces eosinophilic count and fraction of exhaled nitric oxide

53
Q

Explain the stepwise approach to treatment of asthma? Before stepping up? Consider stepping down?

A
  • Stepwise approach recommended to gain/maintain control – Severity assessment used to initiate controller or maintenance therapy – Control assessment used to adjust controller or maintenance therapy
  • Before stepping up: – Assess medication adherence, inhaler technique, environmental control measures, comorbid conditions – If alternative treatment is being used, discontinue; initiate preferred treatment instead
  • Consider stepping down therapy: – Once control has been maintained for >3 months – To identify minimum medication necessary to maintain control
54
Q

summarize asthma management?

A
  • Asthma assessment is now described by severity and control; each includes domains of impairment and future risk.
  • Current evidence indicates that intervention with available long-term control medication does not alter the underlying severity of the disease.
  • Use a stepwise approach to treatment, focused on individualized therapy with frequent monitoring.
  • Once control is achieved, step down to minimal treatment step if possible.
  • The clinician needs to develop individualized treatment plans tailored to the specific needs and circumstances of the patient.
55
Q

What are the four compnents of care for asthma?

A
  1. Assessment and Monitoring a) Assess asthma severity to initiate therapy b) Assess asthma control to monitor and adjust therapy c) Schedule follow-up care
  2. Education a) Provide self-management education b) Develop a written asthma action plan in partnership with the patient c) Integrate education into all points of care where health professionals interact with patients
  3. Control Environmental Factors and Comorbid Conditions a) Recommend measures to control exposures to allergens and pollutants or irritants that make asthma worse b) Treat comorbid conditions
  4. Medications a) Select medication and delivery devices to meet patient’s needs and circumstances

Respiratory 3 (10 decks)

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