Asthma Flashcards
Asthma is the ___________ in childhood
most common chronic disease
Hospitalization rates highest in _____ and _______ population
children & black population
Death rates highest in ______ y/o blacks
15-24
What are the risk factors of asthma?
- ***Atopy (genetic tendency to develop allergies)
Atopic Triad:
- Eczema
- Asthma
- Atopic dermatitis
- Allergen exposure
- Fam hx
- Male child
- 20-40 M:F 1:1
- >40 F>M
- smoking
- viral illness
- obesity
What are the 3 main factors of Asthma pathophys?
- Airway hyperresponsiveness
- Inflammation
- Airflow obstruction & narrowing
What causes airway hyper-responsiveness?
- inhalants/allergens
- temp changes: humidity
- stress
- reflux: GERD
- exercise
What causes inflammation in asthma?
- eosinophils
- lymphocytes: T cells
- Neutrophils
- mast cell act.
- hyperplasia of goblet (mucus) cells
What causes airflow obstruction & narrowing?
- smooth muscle abnormality
- hypertrophy/hyperplasia
- decreased relaxation
- B-2 receptors
- Muscarinic receptors
Classic symptoms of Asthma
- wheezing
- cough
- dyspnea
Diagnosis of Asthma
- Hx of respiratory symptoms AND variable, reversible expiratory airflow obstruction
- AND H&P AND Spirometry
What will you see on a PE for a non-exacerbation pt?
- pale, swollen nasal mucosa? -> allergic rhinitis
- nasal polyps?
- eczema
- Cardiac: possible tachycardia
What is the GOLD STANDARD for dx asthma?
Spirometry/ Pulmonary Function Testing (PFT)
What is spirometry/PFT?
max inhalation followed by rapid and forceful, complete exhalation
“predicted values” are based on _____, _____ & ______
age, height, sex
What is FEV1?
Forced expiratory volume in 1 sec
FEV1 is _______ in obstructive dz
decreased
_____ is the normal value of FEV1
greater than or equal to 80% of predicted value
What is FVC?
forced vital capacity: amount of air forcefully exhaled after a maximal inhalation
FVC predicted value varies with ______ & ______
height & age
FVC normal value is…
greater than or equal to 80% of predicted
What does the FEV1/FVC ratio determine?
whether obstruction is present
What does an FEV1/FVC ratio <70% indicate?
obstructive disease
How does a normal pulmonary function graph differ from a severe airflow obstruction graph?
Normal pulmonary function is curved and severe airflow obstruction has a decreased slope

Predictive versus obstructive defect
Obstructive defect demonstrates scooping of the expiratory portion of the flow-volume curve compared with the predicted curve. The expiratory flow rate is reduced over most of the vital capacity.

Pre and post bronchodilatory measurements are done to determine _______
reversibility
Describe the steps of a pre and post bronchodilator measurement
- 2-4 puffs of SABA (albuterol)
- Wait 15 minutes
- Perform spirometry again
FEV1 increase of ____% or more = positive response to reversibility
12%
Asthma is _____ so PFT values may vary depending on patient status, therefore __________ are important in asthma.
episodic
serial measurements
What are some additional tests a pulmonologist would do?
- Bronchoprovication testing
- Total lung volume
- CBC: eosinophilia, anemia
- Serum IgE levels
- Allergy testing (IgE specific)
- ABG’s for acute settings
- Pulse O2
- Imaging
What kind of patients would you use Bronchoprovocation testing for?
Pts who do not have any signs of FEV1/FVC being less than 70% but are still symptomatic
Describe Bronchoprovocation testing
Pt would inhale methacholine or mannitol, which challenges their airways
You would see how the patient reacts
How would you measure total lung volume?
Helium dilution
Plethysmography
Asthma therapy is based on severity of which 4 symptoms?
- symptom frequency
- Nighttime awakenings
- need for SABA
- inferference with normal activity
Categorize pts symptoms by the _______ symptom/parameter
MOST SEVERE
What is the normal FEV1/FVC % for 8-19 y/o?
85%
What is the normal FEV1/FVC % for 20-39 y/o?
80%
What is the normal FEV1/FVC % for 40-59 y/o?
75%
What is the normal FEV1/FVC % for 60-80 y/o?
70%
Intermittent symptoms
less than or equal to 2 days
Intermittent nighttime awakenings
1-2 times a month
Intermitten SABA use
1-2 days a week
Intermittent interference with normal activity
none
Intermitten lung function
- Normal FEV1 between exacerbations
- FEV1 >80%
- FEV1/FVC normal
Mild
symtptoms
nighttime awakenings
SABA
Interference with normal activity
Lung Function
- >2 days/week but NOT DAILY
- 3-4x/mo
- >2 days/week but not >1x/day
- Minor limitation
- FEV1 greater than or equal to 80
- FEV1/FVC normal
Moderate-Persistent
Symptoms
nighttime awakenings
SABA
interference with normal activity
lung function
- daily
- > 1x/week but not nightly
- daily
- some limitation
- FEV1: 60-80
- FEV1/FVC reduced 5 percent from normal
Severe Persistent
Symptoms
Nighttime awakenings
SABA
interference with normal activity
lung function
- throughout the day
- often 7x/week
- several times per day
- extremely limited
- FEV1 <60
- FEV1/FVC reduced >5 percent from normal
What are the 4 essential componenets of asthma management?
- Monitor symptoms and lung function routinely
- Educate patient
- Control environmental factors ike triggers and comorbid conditions that contribute to asthma severity
- pharmacologic therapy
What are the two main goals of asthma treatment?
- Reduction in impairment
- Reduction of risk
How do we reduce impairment?
- Minimal need: 1-2 days/week of inhaled SABA
- <2 nighttime awakenings due to asthma
- Optimize lung function
- Maintain normal daily activities like work or school attendance and participation in athletics and exercise
How do we reduce the risk of asthma?
- prevent recurrent exacerbations
- prevent need for emergency services/hospital care
- prevent reduced lung growth in children
- prevent lost lung function in adults
- optimize pharmacotherapy with minimal or no adverse effects
How do we control the triggers and contributing conditions of asthma?
- Treat allergies
- Avoid respiratory irritants
- work on obesity, GERD, sleep apnea
- Control med triggers: NSAIDS, ASA
- Avoid dietary sulfides: beer, wine, processed potatoes, dried fruit, sauerkraut, shrimp
B-2 Agonists (SABA) are _________ that relieve _______ by ________ bronchial smooth muscle.
- bronchodilators
- bronchospasm
- RELAXING
SABA
describe its usage
- works immediately: used preventatively or emergently
- Albuterol: HFA inhalers
- Levalbuterol: causes less tachycardia
LABA
Describe its usage
- Used only for prevention
- DO NOT USE AS RESCUE OR PRN INHALER
- Examples:
- Formoterol
- Salmereol
- Arformoterol
What does the Black Box warning on LABA say?
LABAs may increase the risk of asthma death when used alone w/o an inhaled steroid simultaneously.
Inhaled Corticosteroids
Describe usage
- Decreases inflammation
- Used as preventative therapy
- Examples:
- Beclamethasone
- Fluticasone
- Triamcinolone
Be a True Friend and give them an inhaler
LABA & ICS combination inhalers
- Long acting relief of bronchospasm PLUS decreased inflammation
- Preventative only, not for PRN use
- Examples
- Salmeterol + fluticasone
- Formoterol + budesonide
- Formoterol + mometasone
Leukotriene Receptor Antagonists (LTRA)
- Leukotrienes cause inflammation & mucosal edema
- Blocking the LT receptor mitigates this effect
- Oral tablets, preventative only
- treats allergic symptoms
- Examples:
- Montelukast
- Zafirlukast
Anticholinergics
Describe the usage
A for acute exacerbations only
- decrease mucus
- inhaler or solution for nebulization
- Examples
- Ipratropium
- Trotropium
Mast-cell stabilizer
- Cromolyn sodium
- inhibits the relase of histamine, leukotrienes, and other mediators from sensitized mast cells
Monoclonal Antibody
-
Omalizumab
- Recombinant antibiody that binfs IgE without activating mast cells
-
Reslizumab & Mepolizumab
- Interleukin-5 antagonist monoclonal antibodies
- severe, recalcitrant asthma with eosinophilia
Oral corticosteroids
- systemic anti-inflammatory effect
- used for acute exacerbations or severe chronic symptoms
- many adverse effects
Examples of oral corticosteroids
Predinisone, methylprednisone
Methyxanthines/Phosphodiesterase inhibitors
- old, inexpensive
- may cause toxicity & adverse CV effects
- potential for drug-drug interactions
- benefit may be related to improved diaphragmatic function
- avoid use except in certain special cases
Example of methylxanthines/Phosphodiesterase inhibitors
Theophylline
What drugs are used for Bronchospasm?
SABA & LABA
What drugs are used for Mucosal edema (inflammation) ?
- inhaled and corticosteroids
- Leukotriene Receptor antagonists (LRA)
- 5-lipoxygenase inhibitor, mast-cell stabilizers, monoclonal antibodies
What drugs are used for Mucus production?
Antibholinergics
Step Therapy:
Start with the ________ step based on the patient’s _______, ________ & ________
- highest
- symptoms
- severity categorization
- spirometry
Step therapy:
Reassess control every _______
few weeks
Step _____ or ______ as needed
Up, down
All patients are on _______
SABA prn
Step 1
Preferred: SABA PRN
Step 2
- Preferred:* low-dose inhaled glucocorticoids
- Alternative:* cromolyn, LTRA or Theophylline
Step 3
Preferred: Low-dose inhaled GC + LABA
OR
Med-dose inhaled GC
Alternative: Low-dose inhaled GC + either [LRTA or theophylline or Zileuton]
Step 4
Preferred: med-dose inhaled GC + LABA
Alternative: med-dose inhaled GC + either [LRTA or theophylline or Zileuton]
Step 5
Preferred: High-dose inhaled GC + LABA
AND
consider omalizumab for pts w/allergies
Step 6
Preferred: High-dose inhaled GC + LABA + oral systemic GC
AND
consider omalizumab for pts who have allergies
Peak Flow (Peak Expiratory Flow Rate/PEFR)
- simple and inexpensive monitoring
- helps pts determine need for rescue inhaler
- peak flow diary helps clinican evaluate sx control AND determines “personal best”
- Predicted average PEFR based on AGE & HEIGHT
When do you use the PEFR?
- every morning before taking rx as part of daily morning routine
- during asthma symptoms or an attack
- after taking medicine for an attack
What do the following mean on PEFR?
Green
Yellow:
Red:
Green: good to go
Yellow: caution, use SABA
Red: Go to ER
What would you use on top of a SABA for a severe exacerbation?
ipratropium
When should you start systemic steroids?
if there is not an immediate and marked response to the inhaled SABA
Which patients with acute exacerbations do you admit and after how long?
Those who do not respond well; after 4-6 hours
Signs/sx of severe exacerbations
- inability to speak full sentences
- accessory muscle use
- tri-pod positioning
- inability to lie supine
- tachypnea
- tachycardia
- O2 <90%
- PCO2 elevated (hypercapnia)
- PEFR
Imminent respiratory arrest
- confusion
- cyanosis
- fatigue
- agitation
Rx treatment of Acute exacerbation (mild-moderate)
- SABA use
- Oral glucocorticoids
- Increase controller meds (step up)
- review adherence
- patient education
Adjunct therapies for severe exacerbations
- IV mag
- IV epinephrine
- Terbutaline
- Heliox
- Ketamine
- Neuromuscular blockers
Preventative care for Asthma
- pneumococcal vaccination
- annual influenza vaccination
these infections can complicate or exacerbate asthma
Which receptor is responsible for bronchodilation?
Beta Receptors (B2)
Which receptor is responsible for bronchoconstriction?
Muscarinic Receptors