Asthma Flashcards
risk factors: bronchial hyperresponsivenss, genetic predisposition, gender, infections, atopy, exposure to indoor allergens, outdoor pollution, exposure to tobacco smoke, obesity, prematurity
these are all risk factors for which lung disease?
asthma
What is the defining feature of asthma symptoms and course?
They are variable, obstructive, reversible and episodic
which race or ethnicity is most affected by asthma in the US?
non hispanic black
Who experiences asthma remission more often: children or adults?
children
Which hispanic population is most affected by asthma?
puerto rican
Among children, are boys or girls more affected by asthma? among adults, are men or women more affected?
boys and women
Are atopy and airway hyperresponsiveness host or environmental factors that influence asthma?
host
Atopy, airway hyperresponsiveness, gender and obesity are risk factors for: asthma, COPD, or ILD?
asthma
What is “status asthmaticus”?
severe, life threatening asthma attacks
what kind of inflammation drives asthma?
TH2 predominance
Widespread use of antibiotics, western lifestyle, urban environment, diet and sensitization to household dust mites and cockroaches favor: TH2 or TH1 phenotypes in cytokine balance? What does this lead to?
TH2, asthma
The presence of older siblings, early exposure to day care, TB/measles/HepA infection, and rural environments predispose to a TH1 or TH2 balance? What does this mean for asthma?
TH1, protective immunity against asthma
Which cytokines drive TH2 activity? (3)
IL 13, IL 4, and IL 5
What mediators are released by mast cells in response to TH2 activation in asthma?
histamine, leukotrienes, and cytokines
What are the 3 characteristics of early response asthma attacks?
bronchospasm,, edema and airflow obstruction
In late response asthma, what are the 3 physiological effects driving symptoms?
airway inflammation
airflow obstruction
airway hyperresponsiveness
Is asthma a predominantly eosinophilic or neutrophilic disease?
eosinophilic
toluene diisocyanate, flour, wood dust and metal salts are occupational exposures that can lead to which airway disease?
asthma
Which leukotriene is involved in eosinophil attraction in asthma?
C4
What are the 3 airway change hallmarks of asthma?
- goblet cell hyperplasia
- thickened basement membrane
- smooth muscle hypertrophy
Nocturnal symptoms are common in which reversible airway disease?
asthma
colds that “go to the chest” and are accompanied by airflow obstruction that improves after bronchodilator administration is indicative of which disease?
asthma
Classically, which value changes the most on spirometry for asthma?
FEV1»_space; FVC, which lowers the overall ratio
What effect do smooth muscle bronchodilators have on FEV1 and FEV1/FVC in asthma?
they increase them
How does diffusing capacity change in asthma?
Diffusing capacity is normal or slightly increased owing to increased blood within the thoracic cage (new blood vessel growth within airway walls, red cells in airways)
How do you demonstrate airway hyperreactivity on spirometry? why is this important?
Methacoline challenging, which is indicative of AHR and is very common of asthma (but is non specific!)
What would a volume time curve look like for asthma?
obstructive “ramp” with long exhalation to compensate
What would a flow volume loop look like for asthma?
concave scooped expiratory limb
What is the HALLMARK of LFT’s with asthma?
there is variability with lung function!!
i.e. ask patient to take a peak flow meter home to see changes
What physical exam finding is compatible with asthma?
expiratory phase prolongation with diffuse expiratory ? inspiratory wheezes
Does a normal physical exam exclude asthma?
no
What are the two domains used to classify asthma severity?
impairment and risk
In the impairment domain of asthma severity classification, what is the cut off between intermittent and persistent asthma?
intermittent - any number 2 (symptoms, nighttime awakenings, use of meds, interference with ADLS) AND normal LFTs
How is persistent asthma classified along the impairment domain?
more than 2x symptoms, nighttime awakenings, med use or ADL limitation
with EITHER normal or abnormal LFTs
Is persistent or intermittent asthma more common?
persistent, which is important because it has a different control method and is rarely differentiated
What percentage (approx) of asthmatic adults have uncontrolled asthma?
58%
Because nearly half of all patients have uncontrolled asthma, what should you be asking patients about their symptoms?
FREQUENCY, not just whether or not they have them currently
How do you define intermittent asthma along the risk domain?
0 to 1 exacerbations (i.e. any time oral systemic corticosteroids were required)
How do you classify persistent asthma along the risk domain?
2+ episodes where oral systemic corticosteroids were used
A patient can be classified for having persistent asthma (yes or no) if they: use albuterol > 2 days per week?
Yes
A patient can be classified for having persistent asthma (yes or no) if they: had asthma symptoms less than 2 days per week?
no - must be more than 2
A patient can be classified for having persistent asthma (yes or no) if they: had nightime awakenings > 2 times per month?
yes
A patient can be classified for having persistent asthma (yes or no) if they: no limitation in physical activity
no - must have at least minor
A patient can be classified for having persistent asthma (yes or no) if they: 2 or more exacerbations per year
yes
If a patient has FEV1 > 80% of predicted, but symptoms and exacerbations are severe and frequent, they do NOT have persistent asthma, true or false
False - asthma severity is guided by symptoms and exacerbation frequency, NOT by FEV 1
What is the first line treatment for asthma?
inhaled corticosteroids
Of the following, which one blockes eosinophil and mast cell recruitment: inhaled CS, leukotriene modifiers, long acting B agonists, systemic CS, theophylline, cromones, or anti IgE ab?
leukotriene modifiers
inhaled CS, leukotriene modifiers, long acting B agonists, systemic CS, theophylline, cromones, or anti IgE ab.
Which ones are used for very severe asthma?
theophylline, cromones, and Ab (very rarely used)
inhaled CS, leukotriene modifiers, long acting B agonists, systemic glucocorticosteroids, theophylline, cromones, or anti IgE ab
which ones are used for flare ups?
systemic glucocorticosteroids
If inhaled corticosteroids are not enough to control asthma, what is added to treatment?
long acting inhaled beta 2 agonists
What are 2 examples of asthma rescue medications?
rapid acting inhaled beta agonists and inhaled anticholinergics
On the asthma control test screen, what score is considered an indication for changing therapy? (regardless of severity)
< 19 - the goal is control, regardless of intermittent v. persistent asthma
if someone has well controlled asthma, can you try to step down their therapy?
yes - dynamic therapy and appropriate dosing are the goal
When should you pay a lot of attention to risk in a patient with an asthma exacerbation?
did they almost die, ever? do they have poor access or social determinants of poor outcomes? have they ever had a severe exacerbation?
Name some common triggers for asthma flare ups?
allergens RTI weather changes exercise air pollution food/additives/drugs
Repetitive administation of rapid acting inhaled beta agonists and early introduction of systemic glucocorticosteroids with or without O2 are primary therapies for what kind of asthma?
management of a flare up
Pulmonary function tests in asthma classically do NOT demonstrate:
a) a concave or scooped expiratory flow volume loop b) increased residual volume c) a normal or slightly elevated diffusing capacity for carbon monoxide d) a flattened inspiratory loop
d- flattened inspiratory loop
this is suggestive of variable extra thoracic airway obstruction, which is NOT a feature of asthma
Which of the following statements best describes the pathologic findings of asthma?
a) granulomatous airway inflammation b) eosinophilic inflammation with epithelial cell disruption c) perivascular mononuclear cell inflammation d) smooth muscle hypertrophy without inflammation.
b - eosinophilic inflammation with epithelial cell disruption
A 4 year old presents with sudden onset respiratory distress. She is found to have unilateral wheeze with volume loss on the same side on chest X-ray. The leading diagnosis in this case is:
a) asthma b) vocal cord paralysis c) tumor d) foreign body aspiration
d- foreign body aspiration
Unilateral wheezing with volume loss of chest x-ray is highly suspicious for an aspirated foreign body in patients at risk (like young children)
