Asthma Flashcards
what is the most common cause of recurrent wheezing in children under 5yrs
Asthma
Following bronchodilator inhalation, the minimum improvement in FEV1 or FVC consistent with reversibility is
12%
What is the most commonly used bronchoprovocative agent
methacoline
name a couple secondary bronchoprovocative agents that can be used
histamine and hypertonic (or hypotonic) saline used less commonly than methacoline
What defines a positive test for asthma in terms of decline in FEV1 in response to a bronchoprovocative agent?
A positive test is defined as a 20% decline in FEV1 but it does NOT diagnostic of asthma
Is a positive bronchoprovocative test diagnostic of asthma?
No, COPD, emphasema or even 8% normal pt’s can have a positive test
What severity category corresponds with an FEV1 of 70%
persistent moderate
Name 5 mediators linked to the pathophysiology of asthma include which of the following?
It is postulated that the allergic inflammation in asthma arises from an imbalance between T helper 1 (Th1) cells and T helper 2 (Th2) cells. Th2 cells release specific cytokines, including interleukin-4, -5, -9, and -13, which promote eosinophil growth and migration, as well as mast cell differentiation and IgE production. Inhaled antigens activate mast cells and Th2 cells in the airway, causing the release of histamine and cysteinyl leukotrienes (including leukotriene C4), leading to the rapid contraction of airway smooth muscle. Mast cells also can produce a variety of cytokines, including IL-1, -2, -3, -4, and -5, interferon-gamma, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor alpha which, being pro-inflammatory proteins, can mediate both acute and chronic inflammation.
What allergen is most likely responsible for the disproportionately high morbidity from asthma among inner-city residents?
cockroach allergen and current exposure to high levels of cockroach allergen in the bedroom
What is the pathophysiology that leads to the acute asthma reaction?
Mast cell activation triggered by antigen-IgE crosslinking releases asthma mediators (e.g., histamine, leukotrienes, thromboxanes), causing smooth-muscle contraction, edema, and enhanced mucus secretion, and leading to airflow obstruction and the manifestations of acute asthma symptoms.
While some facets of asthma are reversible, changes seen in chronic, uncontrolled asthma may be irreversible. Name 5Histologic features of the irreversible airway remodeling seen in patients with chronic asthma.
Features of airway remodeling seen in patients with asthma include goblet cell hyperplasia, subepithelial fibrosis with collagen deposition, smooth-muscle hypertrophy and hyperplasia, submucosal gland enlargement, and bronchial microvascular enlargement and proliferation.
For children younger than 3 years of age who have had four or more episodes of wheezing during the previous year, elevated level of IgE is a risk factor for the development of asthma, T or F?
False Elevated IgE is not an independent risk factor. Risk factors include the presence of any two of the following: evidence of sensitization to foods, peripheral blood eosinophilia ≥4%, or wheezing apart from colds.
What are independent risk factors for a child less than 3 yrs who had four or more episodes of wheezing during the previous year to develop asthma?
a parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens.
What defines Exercise Induced Asthma?
A 15% decrease in PEF or FEV1 after exercise is compatible with EIB. An exercise challenge test is used to establish the diagnosis of exercise-induced bronchospasm (EIB). This can be performed in a formal laboratory setting or a free-run challenge, or by simply having the patient undertake the physical activity that previously caused the symptoms.
Name 3 Nonpharmacologic measures that reduce the likelihood of exercise-induced bronchospasm.
Long warm-up, long warm-down, breathing through nose or covering face with something like a scarf
What medication that is helpful for treating acute asthma is NOT helpful for preventing EIB
Ipratropium
true or false, exercise induced asthma is not seen in patients with persistent asthma
False. All asthmatics are susceptible to EIB
Does EIB tend to occur during exercise or after it
Most often 10-15 minutes after exercise and usually resolves in 20-30 minutes
What is the initial home management of an asthma exacerbation?
Home treatment of asthma exacerbations begins with measurement of peak expiratory flow and initial treatment with an inhaled short-acting β2-agonist, up to two treatments at a 20-minute interval.
What is considered good response to home treatment of asthma exacerbation with albuterol MDI?
resolution of symptoms and improvement in PEF to at least 80% of personal best.
Which medication is most effective for reducing the frequency of exacerbations in adults with asthma?
ICS- Inhaled corticosteroids
How long should short term therapy with oral corticosteroids continue after an asthma exacerbation requiring oral steroids?
Following an exacerbation, the National Asthma Education and Prevention Program recommends that short-term therapy with corticosteroids should be continued until the patient achieves at least 70% of his or her personal best peak flow rate or symptoms resolve. This usually requires 3–10 days, but may take longer.
Symptoms suggesting that respiratory arrest may be imminent in patients with a severe asthma exacerbation include
loss of pulsus paradoxus due to fatigue, drowsiness, loss of wheezing, paradoxical thoracoabdominal movement, bradycardia (late finding)
Risk factors for death from asthma include T/F
- Use of 1 MDI cannister per month
- Illicit drug use
- three or more emergency-care visits for asthma during the past year
- Hospitalization for Asthma in the past year
- past hx of sudden severe asthma attack
- False, 2 cannisters
- True
- True
- False, past month
- True but seems to conflict with 3,4
T/F Adjunctive treatment for an adult severe asthma exacerbation includes chest physical therapy.
Nope, has not been shown to be helpful
What characterizes asthma symptoms that are considered not well controlled?
-symptoms more than 2 days per week
-nighttime awakenings 1–3 times per week
-some limitation of normal activity
-use of a short-acting inhaled β2-agonist more than 2
days per week
-a peak flow or FEV1 that is 60%–80% of
predicted/personal best
-2 or more asthma exacerbations per year that require
systemic corticosteroid therapy
A 15 year old with mild persistent asthma is on zafirlukast (Accolate) and not well controlled. What should be done next for mediation?
Stop the “alternative tx” and go to standard or preferred treatment
What PCO2 level in a pregnant asthmatic patient signals respiratory failure?
Since minute ventilation rises 30%–40% by late pregnancy, normal pCO2 levels fall to 27–32 mm Hg, compared with 37–40 mm Hg in the nonpregnant state. If the pCO2 is 35 mm Hg or greater in a pregnant patient with an asthma exacerbation, it signals respiratory failure.
What is the triad of Aspirin induced asthma
Sampter’s triad-
- rhinosinuitis (first vasomotor them hyperplastic
- nasal polyps
- sensitivity to ASA and possibly other NSAIDS
Aspirin-induced asthma is the syndrome of rhinorrhea, nasal polyps, sinusitis, conjunctival edema, and asthma following aspirin ingestion. Aspirin-induced asthma usually begins with perennial vasomotor rhinitis, followed by hyperplastic rhinosinusitis with nasal polyps. Cross-reactivity may be seen with other NSAIDs, including indomethacin, naproxen, ibuprofen, fenoprofen, mefenamic acid, and phenylbutazone. Safer alternatives to aspirin include salsalate and acetaminophen.
What is the treatment of choice for Aspirin-induced Asthma
Leukotriene modifiers are regarded as the treatment of choice for patients with aspirin-induced asthma. Receptor Antaganists
montelukast (singulair), zafirlukast (accolate)
and Synthesis inhibitors- zileuton (zyflo)
Can you use Salsalate if you have ASA induced asthma?
Yes
What comorbid conditions should be treated also for difficult to treat asthmatics
- allergic bronchopulmonary aspergillosis (SOR A),
- gastroesophageal reflux disease (SOR B),
- obesity (SOR B)
- obstructive sleep apnea (SOR C),
- rhinitis/sinusitis (SOR B)
- chronic stress/depression (SOR C).
Is ABPA (bronchopulmonary aspergillosis) an infection?
How is it treated?
No. Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disease of the lungs related to colonization of Aspergillus (most commonly fumigatus) in the airways, and its proliferation in airway mucus.
ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid (steroid medicine) is used to treat inflammation and blocks the allergic reaction
Is occupational asthma permanent injury?
Early recognition and control of occupational asthma is important, since the likelihood of complete resolution decreases with time. Although improvement in symptoms is typically seen during vacations or days off, a week or more away from the sensitizer may be required.
Is occupational asthma due to chronic exposure?
sometimes can be traced to a high-level exposure
What foods should be avoided by patients with persistent asthma?
Sulfites
They are used to preserve foods and beverages. Use of these agents has been restricted, so heavy exposures now occur only with a limited number of foods, such as beer, wine, dried fruit, shrimp, and processed potatoes.
What is standard treatment for moderate persistent asthma
short and long beta-adrenergics + inhaled corticosteroids
i.e. SABA + LABA + ICS
What is better, symptom or peak flow based action plans?
Same except for those who do not perceive their symptoms well
What is the medication of choice for a pregnant patient with mild persistent asthma
inhaled corticosteroids
True or false. African Americans are particularly at risk for long term risks of long acting beta2 agonists
True
Does the use of inhaled corticosteroids reduce the risk of airway wall remodeling?
No- Clinical effects of inhaled corticosteroids (ICs) include a reduction in the severity of symptoms, improvement in peak expiratory flow and spirometry results, diminished airway hyperresponsiveness, and prevention of exacerbations. Whether ICs prevent airway wall remodeling is still unknown
Do oral corticosteroids reduce the rate of relapse in asthma patients?
Yes
Should oral steroids be tapered to prevent relapse
No evidence for it
What is the recommended dose for oral prednisone
40-80 mg per day for adults or 1 mg/kg in children
Which one of the following can reduce corticosteroid requirements in asthmatics by reducing free circulating IgE?
Omalizumab is a murine monoclonal antibody directed against circulating IgE. In patients with moderate to severe asthma, the use of omalizumab can improve symptoms and reduce exacerbations, and may reduce corticosteroid requirements. Omalizumab is administered subcutaneously and is generally well-tolerated.
true or false
Leukotriene inhibitors are particularly useful in both Exercise and Aspirin induced asthma?
True
Leukotriene modifiers can be used effectively in acute asthma exacerbations
Leukotriene modifiers have no intrinsic smooth-muscle–relaxing ability, and therefore should not be used as quick-relief medications.
T/F. The full benefits of IC (inhaled corticosteroids) may not be seen for 2-3 weeks
False- Although some benefit can be seen within weeks after starting inhaled ICs, the full benefit typically occurs within 1–2 months.
For what conditions should Inhaled steroids be avoided or used with caution
inhaled corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infection of the respiratory tract; untreated systemic fungal, bacterial, parasitic, or viral infections; or ocular herpes simplex.
What is considered the most effective “alternative” agent for moderate persistent asthma
Of these alternatives, leukotriene modifiers offer several advantages, including efficacy against allergic rhinitis, ease of use, high rates of compliance, and a good safety profile. Furthermore, a recent pragmatic trial found leukotriene modifiers to be equivalent to inhaled corticosteroids as a first-line controller therapy.
Accolate, singulair, zyflo
What is the only therapy thought to add efficacy to high dose corticosteroids?
Omalizumab (zolair)
Reduces circulating IgE
A 19-year-old male has severe persistent asthma treated with high-dose inhaled corticosteroids and a long-acting inhaled β2-agonist. What would you add if he was not having adequate control?
Omalizumab (zolair)
What is considered well controlled asthma?
Well-controlled asthma is defined as symptoms that occur 2 days or less per week, nighttime awakening 2 nights or less per month, use of a short-acting inhaled β2-agonist 2 days or fewer per week, a peak flow (or FEV1) >80% of predicted/personal best, and no more than one asthma exacerbation requiring oral corticosteroids per year, with no interference with normal activity
t/F Only oral steroids are associated with bone density loss
False also high dose inhaled
Which cardiac chemical stress test agents are associated with bronchospasm
Both (persantine) dipyridamole and (adenocard) adenosine can cause severe bronchospasm in patients with asthma or chronic obstructive lung disease.
B2 Agonists can cause a temporary reduction in PaO2 in patients with severe asthma. T/F
True- Because they produce a transient increased ventilation-perfusion mismatch, β2-agonists can cause a temporary reduction in arterial oxygen tension in patients with severe acute asthma. This reduction generally lasts less than 10 minutes and can be managed with the administration of oxygen.
What are the symptom hallmarks of intermittent asthma
Rule of 2 symptoms < 2d/wk night time awakenings < 2x/month NO symptoms with normal activity FEV1 > 80%
What is the treatment for intermittent asthma
SABA PRN (Step 1)
Describe symptoms of persistent asthma
It is divided into Mild, Moderate and Severe
More than 2 uses of SABA, 2 night episodes and it is exacerbated with activity
Symptoms of mild/persistent asthma
Wheezing > 2 days/wk 3-4/ Month night time episodes minor limitation of activity Use SABA > 2 times per week ***FEV1 >80% predicted***
Symptoms of moderated /persistent asthma
Wheezing daily >1 night wheezing episode per week moderate limitation activity using SABA daily FEV1 > 60% < 80% FEV1/FVC reduced 5% from predicted
symptoms of severe / persistent asthma
Wheezing throughout the day Wheezing most nights Activity extremely limited FEV1 < 60% predicted FEV1/FVC reduced >5% Using SABA several times per day
Name 3 alternative medications that can be used in step 2, 3,4 of Asthma treatment
Mast Cell stabilizer (cromolyn) step 2
LTRA (antagonist- singulair, accolate) add step 3/4
Leukotriene inhibitor (zyflo/zilueton) step 3/4
What is the new severe asthma alternative drug that is crazy expensive
Omalizumab
What is considered a positive reversibility response to SABA
12% increase in FEV1
A 20% change in PEF indicates poorly controlled asthma. Below what level is considered severe obstruction?
What is Life threatening?
< 200 L/min
25-40% of predicted
Life threatening is < 25% predicted
What are the % predicted values of PEF that define
Mild, moderate and severe asthma
Mild > 70%
Moderate < 70%
Severe < 40%
how common is occupational asthma?
Occupational asthma accounts for up to an estimated 5%–20% of new asthma diagnoses in adults
