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Asthma Flashcards

1
Q

Asthma is the ___________ in childhood

A

most common chronic disease

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2
Q

Hospitalization rates highest in _____ and _______ population

A

children & black population

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3
Q

Death rates highest in ______ y/o blacks

A

15-24

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4
Q

What are the risk factors of asthma?

A
  • ***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
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5
Q

What are the 3 main factors of Asthma pathophys?

A
  1. Airway hyperresponsiveness
  2. Inflammation
  3. Airflow obstruction & narrowing
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6
Q

What causes airway hyper-responsiveness?

A
  • inhalants/allergens
  • temp changes: humidity
  • stress
  • reflux: GERD
  • exercise
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7
Q

What causes inflammation in asthma?

A
  • eosinophils
  • lymphocytes: T cells
  • Neutrophils
  • mast cell act.
  • hyperplasia of goblet (mucus) cells
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8
Q

What causes airflow obstruction & narrowing?

A
  • smooth muscle abnormality
    • hypertrophy/hyperplasia
    • decreased relaxation
    • B-2 receptors
    • Muscarinic receptors
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9
Q

Classic symptoms of Asthma

A
  • wheezing
  • cough
  • dyspnea
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10
Q

Diagnosis of Asthma

A
  • Hx of respiratory symptoms AND variable, reversible expiratory airflow obstruction
  • AND H&P AND Spirometry
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11
Q

What will you see on a PE for a non-exacerbation pt?

A
  • pale, swollen nasal mucosa? -> allergic rhinitis
  • nasal polyps?
  • eczema
  • Cardiac: possible tachycardia
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12
Q

What is the GOLD STANDARD for dx asthma?

A

Spirometry/ Pulmonary Function Testing (PFT)

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13
Q

What is spirometry/PFT?

A

max inhalation followed by rapid and forceful, complete exhalation

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14
Q

“predicted values” are based on _____, _____ & ______

A

age, height, sex

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15
Q

What is FEV1?

A

Forced expiratory volume in 1 sec

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16
Q

FEV1 is _______ in obstructive dz

A

decreased

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17
Q

_____ is the normal value of FEV1

A

greater than or equal to 80% of predicted value

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18
Q

What is FVC?

A

forced vital capacity: amount of air forcefully exhaled after a maximal inhalation

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19
Q

FVC predicted value varies with ______ & ______

A

height & age

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20
Q

FVC normal value is…

A

greater than or equal to 80% of predicted

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21
Q

What does the FEV1/FVC ratio determine?

A

whether obstruction is present

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22
Q

What does an FEV1/FVC ratio <70% indicate?

A

obstructive disease

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23
Q

How does a normal pulmonary function graph differ from a severe airflow obstruction graph?

A

Normal pulmonary function is curved and severe airflow obstruction has a decreased slope

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24
Q

Predictive versus obstructive defect

A

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.

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25
Q

Pre and post bronchodilatory measurements are done to determine _______

A

reversibility

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26
Q

Describe the steps of a pre and post bronchodilator measurement

A
  1. 2-4 puffs of SABA (albuterol)
  2. Wait 15 minutes
  3. Perform spirometry again
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27
Q

FEV1 increase of ____% or more = positive response to reversibility

A

12%

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28
Q

Asthma is _____ so PFT values may vary depending on patient status, therefore __________ are important in asthma.

A

episodic

serial measurements

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29
Q

What are some additional tests a pulmonologist would do?

A
  • Bronchoprovication testing
  • Total lung volume
  • CBC: eosinophilia, anemia
  • Serum IgE levels
  • Allergy testing (IgE specific)
  • ABG’s for acute settings
  • Pulse O2
  • Imaging
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30
Q

What kind of patients would you use Bronchoprovocation testing for?

A

Pts who do not have any signs of FEV1/FVC being less than 70% but are still symptomatic

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31
Q

Describe Bronchoprovocation testing

A

Pt would inhale methacholine or mannitol, which challenges their airways

You would see how the patient reacts

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32
Q

How would you measure total lung volume?

A

Helium dilution

Plethysmography

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33
Q

Asthma therapy is based on severity of which 4 symptoms?

A
  1. symptom frequency
  2. Nighttime awakenings
  3. need for SABA
  4. inferference with normal activity
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34
Q

Categorize pts symptoms by the _______ symptom/parameter

A

MOST SEVERE

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35
Q

What is the normal FEV1/FVC % for 8-19 y/o?

A

85%

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36
Q

What is the normal FEV1/FVC % for 20-39 y/o?

A

80%

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37
Q

What is the normal FEV1/FVC % for 40-59 y/o?

38
Q

What is the normal FEV1/FVC % for 60-80 y/o?

39
Q

Intermittent symptoms

A

less than or equal to 2 days

40
Q

Intermittent nighttime awakenings

A

1-2 times a month

41
Q

Intermitten SABA use

A

1-2 days a week

42
Q

Intermittent interference with normal activity

43
Q

Intermitten lung function

A
  • Normal FEV1 between exacerbations
  • FEV1 >80%
  • FEV1/FVC normal
44
Q

Mild

symtptoms

nighttime awakenings

SABA

Interference with normal activity

Lung Function

A
  • >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
45
Q

Moderate-Persistent

Symptoms

nighttime awakenings

SABA

interference with normal activity

lung function

A
  • daily
  • > 1x/week but not nightly
  • daily
  • some limitation
  • FEV1: 60-80
  • FEV1/FVC reduced 5 percent from normal
46
Q

Severe Persistent

Symptoms

Nighttime awakenings

SABA
interference with normal activity

lung function

A
  • throughout the day
  • often 7x/week
  • several times per day
  • extremely limited
  • FEV1 <60
  • FEV1/FVC reduced >5 percent from normal
47
Q

What are the 4 essential componenets of asthma management?

A
  • Monitor symptoms and lung function routinely
  • Educate patient
  • Control environmental factors ike triggers and comorbid conditions that contribute to asthma severity
  • pharmacologic therapy
48
Q

What are the two main goals of asthma treatment?

A
  • Reduction in impairment
  • Reduction of risk
49
Q

How do we reduce impairment?

A
  • 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
50
Q

How do we reduce the risk of asthma?

A
  • 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
51
Q

How do we control the triggers and contributing conditions of asthma?

A
  • 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
52
Q

B-2 Agonists (SABA) are _________ that relieve _______ by ________ bronchial smooth muscle.

A
  • bronchodilators
  • bronchospasm
  • RELAXING
53
Q

SABA

describe its usage

A
  • works immediately: used preventatively or emergently
  • Albuterol: HFA inhalers
  • Levalbuterol: causes less tachycardia
54
Q

LABA

Describe its usage

A
  • Used only for prevention
  • DO NOT USE AS RESCUE OR PRN INHALER
  • Examples:
    • Formoterol
    • Salmereol
    • Arformoterol
55
Q

What does the Black Box warning on LABA say?

A

LABAs may increase the risk of asthma death when used alone w/o an inhaled steroid simultaneously.

56
Q

Inhaled Corticosteroids

Describe usage

A
  • Decreases inflammation
  • Used as preventative therapy
  • Examples:
    • Beclamethasone
    • Fluticasone
    • Triamcinolone

Be a True Friend and give them an inhaler

57
Q

LABA & ICS combination inhalers

A
  • Long acting relief of bronchospasm PLUS decreased inflammation
  • Preventative only, not for PRN use
  • Examples
    • Salmeterol + fluticasone
    • Formoterol + budesonide
    • Formoterol + mometasone
58
Q

Leukotriene Receptor Antagonists (LTRA)

A
  • Leukotrienes cause inflammation & mucosal edema
  • Blocking the LT receptor mitigates this effect
  • Oral tablets, preventative only
  • treats allergic symptoms
  • Examples:
    • Montelukast
    • Zafirlukast
59
Q

Anticholinergics

Describe the usage

A

A for acute exacerbations only

  • decrease mucus
  • inhaler or solution for nebulization
  • Examples
    • Ipratropium
    • Trotropium
60
Q

Mast-cell stabilizer

A
  • Cromolyn sodium
  • inhibits the relase of histamine, leukotrienes, and other mediators from sensitized mast cells
61
Q

Monoclonal Antibody

A
  • Omalizumab
    • Recombinant antibiody that binfs IgE without activating mast cells
  • Reslizumab & Mepolizumab
    • ​Interleukin-5 antagonist monoclonal antibodies
    • severe, recalcitrant asthma with eosinophilia
62
Q

Oral corticosteroids

A
  • systemic anti-inflammatory effect
  • used for acute exacerbations or severe chronic symptoms
  • many adverse effects
63
Q

Examples of oral corticosteroids

A

Predinisone, methylprednisone

64
Q

Methyxanthines/Phosphodiesterase inhibitors

A
  • 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
65
Q

Example of methylxanthines/Phosphodiesterase inhibitors

A

Theophylline

66
Q

What drugs are used for Bronchospasm?

A

SABA & LABA

67
Q

What drugs are used for Mucosal edema (inflammation) ?

A
  • inhaled and corticosteroids
  • Leukotriene Receptor antagonists (LRA)
  • 5-lipoxygenase inhibitor, mast-cell stabilizers, monoclonal antibodies
68
Q

What drugs are used for Mucus production?

A

Antibholinergics

69
Q

Step Therapy:

Start with the ________ step based on the patient’s _______, ________ & ________

A
  • highest
  • symptoms
  • severity categorization
  • spirometry
70
Q

Step therapy:

Reassess control every _______

71
Q

Step _____ or ______ as needed

72
Q

All patients are on _______

73
Q

Step 1

A

Preferred: SABA PRN

74
Q

Step 2

A
  • Preferred:* low-dose inhaled glucocorticoids
  • Alternative:* cromolyn, LTRA or Theophylline
75
Q

Step 3

A

Preferred: Low-dose inhaled GC + LABA

OR

Med-dose inhaled GC

Alternative: Low-dose inhaled GC + either [LRTA or theophylline or Zileuton]

76
Q

Step 4

A

Preferred: med-dose inhaled GC + LABA

Alternative: med-dose inhaled GC + either [LRTA or theophylline or Zileuton]

77
Q

Step 5

A

Preferred: High-dose inhaled GC + LABA

AND

consider omalizumab for pts w/allergies

78
Q

Step 6

A

Preferred: High-dose inhaled GC + LABA + oral systemic GC

AND

consider omalizumab for pts who have allergies

79
Q

Peak Flow (Peak Expiratory Flow Rate/PEFR)

A
  • 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
80
Q

When do you use the PEFR?

A
  • every morning before taking rx as part of daily morning routine
  • during asthma symptoms or an attack
  • after taking medicine for an attack
81
Q

What do the following mean on PEFR?

Green

Yellow:

Red:

A

Green: good to go

Yellow: caution, use SABA

Red: Go to ER

82
Q

What would you use on top of a SABA for a severe exacerbation?

A

ipratropium

83
Q

When should you start systemic steroids?

A

if there is not an immediate and marked response to the inhaled SABA

84
Q

Which patients with acute exacerbations do you admit and after how long?

A

Those who do not respond well; after 4-6 hours

85
Q

Signs/sx of severe exacerbations

A
  • inability to speak full sentences
  • accessory muscle use
  • tri-pod positioning
  • inability to lie supine
  • tachypnea
  • tachycardia
  • O2 <90%
  • PCO2 elevated (hypercapnia)
  • PEFR
86
Q

Imminent respiratory arrest

A
  • confusion
  • cyanosis
  • fatigue
  • agitation
87
Q

Rx treatment of Acute exacerbation (mild-moderate)

A
  • SABA use
  • Oral glucocorticoids
  • Increase controller meds (step up)
  • review adherence
  • patient education
88
Q

Adjunct therapies for severe exacerbations

A
  • IV mag
  • IV epinephrine
  • Terbutaline
  • Heliox
  • Ketamine
  • Neuromuscular blockers
89
Q

Preventative care for Asthma

A
  • pneumococcal vaccination
  • annual influenza vaccination

these infections can complicate or exacerbate asthma

91
Q

Which receptor is responsible for bronchodilation?

A

Beta Receptors (B2)

92
Q

Which receptor is responsible for bronchoconstriction?

A

Muscarinic Receptors

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