Asthma Flashcards
Syndrome characterized by airflow obstruction that varies markedly, both spontaneously and with treatment
Asthma
Heterogenous disease characterized by chronic airflow inflammation that varies markedly both spontaneously and w/ treatment
Asthma
Asthma
AIRWAY HYPERRESPONSIVENESS
AIRFLOW INFLAMMATION
Measures how much air an individual can EXHALE during a forced breath during the first second
FEV 1
Total amount of air exhaled during the FEV test
FVC
Should be 75-80 %
REDUCED in obstructive diseases
May be NORMAL or INCREASED in restrictive diseases
FEV 1/FVC ratio
Major risk factor for asthma
atopy
Most consistent findings in asthma have been associated with polymorphisms of genes on
chromosome 5q
Hygiene hypothesis
Proposes that LACK OF INFECTIONS in early childhood PRESERVES THE TH2 CELL BIAS at birth whereas EXPOSURE TO INFECTIONS and endotoxin results in a shift toward a predominant PROTECTIVE TH1 IMMUNE RESPONSE
Mast cells
Important in initiating the ACUTE BRONCHOCONSTRICTION responses to allergens and several other indirectly acting stimuli (exercise, hyperventilation and fog)
Dendritic cells
Specialized macrophage-like cells in the airway epithelium which are major antigen presenting cells –
Characteristic feature of asthma airways
Eosinophil infiltration
Eosinophils
Linked to the development of AHR through the release of basic proteins and oxygen derived free radicals
Neutrophils
Resistant to the anti-inflammatory effects of corticosteroids
T-lymphocytes
Play a very important role in coordinating the inflammatory response in asthma through the release of specific cytokines
IL-4, IL-5 and IL-13
Mediate allergic inflammation
Chemokines
Involved in ATTRACTING INFLAMMATORY CELLS from the bronchial circulation into the airways
TNF-α and IL-1β
Proinflammatory cytokines that amplify the inflammatory response and has a role in SEVERE DISEASE
IL-13
Induces MUCUS HYPERSECRETION
Airway remodeling
Increased airway smooth muscle, fibrosis, angiogenesis and mucus hyperplasia
Major pathology of asthma
airway hyperresponsiveness
Symptoms of Asthma
wheezing
shortness of breath
chest tightness
cough
2 key defining features of asthma
history of respiratory symptoms such as wheeze, SOB, chest tightness and cough that vary over time and intensity
AND
variable expiratory airflow limitation
Most frequent PE finding in px with asthma
wheezing on auscultation esp on forced expiration
Provide quick relief of asthma symptoms and bronchoconstriction
SABA - Salbutamol (Albuterol), Terbutaline
Adverse effects of SABA
tremor tachycardia (palpitations) hyperglycemia hypokalemia hypomagnesemia restlessness hypoxemia
Preferred reliever for patients prescribed as-needed controller therapy for mild asthma
Low dose ICS (Budesonide)-Formoterol
Adverse effects of LABA – Formoterol, Salmeterol
tachycardia
headache
cramps
Adverse effects of SAMA (Ipratropium bromide, Oxitropium bromide)
dry mouth (MC)
bitter taste
glaucoma
urinary incontinence
The most effective anti-inflammatory medications for asthma
Inhaled corticosteroids (ICS) – Beclomethasone, Budesonide, Ciclesonide, Fluticasone propionate, Fluticasone furoate, Mometasone, Triamcinolone
Local adverse effects of ICS
oropharyngeal candidiasis
hoarseness/dysphonia
Systemic side effects of ICS
osteoporosis
glaucoma
cataract
Adverse effects of LAMA (Tiotropium bromide)
dry mouth
Anti IgE that neutralizes circulating IgE without binding to cell-bound IgE
Omalizumab
An add-on option for px with SEVERE ALLERGIC ASTHMA uncontrolled on high dose ICS-LABA
Anti-IgE - Omalizumab
An add-on option for px with SEVERE EOSINOPHILIC ASTHMA uncontrolled on high dose ICS-LABA
Anti-IL5- Mepolizumab or Reslizumab and anti-IL5R - BenRalizumab
An add-on option for px with SEVERE EOSINOPHILIC OR TYPE 2 ASTHMA uncontrolled on high dose ICS-LABA
Anti-IL4R – Dupilumab
Short term adverse effects of oral corticosteroids – prednisone, prednisolone, methylprednisolone, hydrocortisone
sleep disturbance reflux appetite increase hyperglycemia mood changes
Long term adverse effects of oral corticosteroids
cataract glaucoma hypertension diabetes adrenal suppression osteoporosis
Preferred reliever for step 1 and 2
as needed LOW DOSE ICS-FORMOTEROL
other reliever
SABA
Preferred reliever for step 1 and 2
as needed LOW DOSE ICS-FORMOTEROL
other reliever
SABA
Preferred controller for step 1
as needed LOW DOSE ICS FORMOTEROL
other controller options
LOW DOSE ICS taken whenever SABA is taken
Preferred controller for step 2
daily LOW DOSE ICS or as needed LOW DOSE ICS-FORMOTEROL
other controller options
daily LTRA
OR
LOW DOSE ICS taken whenever SABA is taken
Preferred reliever for step 3,4 and 5
as needed low dose ICS - formoterol for patients prescribed maintenance
Preferred controller for step 3
LOW DOSE ICS-LABA
other controller options
MEDIUM DOSE ICS or LOW DOSE ICS +/- LTRA
Preferred controller for step 4
MEDIUM DOSE IC-LABA
other controller options
HIGH DOSE ICS, add on TIOTROPIUM or add on LTRA
Preferred controller for step 5
HIGH DOSE ICS LABA
refer for phenotypic assessment +/- add on therapy i.e. tiotropium, anti IgE, anti IL5/5R, anti IL4R
other controller options
add LOW DOSE OCS
SABA
stimulate adenycyl cyclase –> inc cAMP –> bronchodilation
Procaterol
Salbutamol
Terbutaline
Albuterol
Adverse effects of SABA
tremor
palpitation
mild hypokalemia
SAMA
(-) cholinergic reflex components
Ipratropium
Adverse effects of SAMA
dry mouth
urinary retention
glaucoma
Methylxanthines
(-) PDE activity –> inc cAMP –> bronchodilation
Theophylline
Aminophylline
Doxofylline
ICS
Beclomethasone
Budesonide
Fluticasone
Adverse effects of ICS
hoarseness
dysphonia
oral candidiasis
pneumonia
Systemic Steroids
Prednisone
Methylprednisone
Hydrocortisone
Adverse effects of systemic steroids
truncal obesity easy bruisability osteoporosis DM HPN ulcers proximal myopathy cataracts depression
LABA
should NOT be given in the absence of ICS
Formoterol Salmeterol Bambuterol Vilanterol Indacaterol Olodaterol
LAMA
blocks acetylcholine’s effects on muscarinic receptors
Tiotropium
Leukotriene Modifying Drugs
BLOCK LEUKOTRIENE RECEPTORS
Montelukast
Zafirlukast
INHIBIT LIPOXYGENASE
Zileuton
Cromones
(-) mast cells and sensory nerve activation
Cromolyn sodium
Nedocromil sodium
Anti-IgE
Omalizumab
