Asthma and COPD Flashcards
What is asthma (pathophysiology)?
Chronic reversible inflammatory disorder of the airways
- Increased responsiveness of tracheobronchial tree to stimuli → episode reversible narrowing and inflammation of airways
What are the clinical hallmarks of asthma?
- Episodic wheezing
- Breathlessness, anxiety
- Dyspnea
- Cough (most common symptom)
- Sputum production
True/false: Asthma is commonly diagnosed before 12 months of age
False - rarely diagnosed before 12 months because of high rates of viral bronchitis
- May be diagnosed with bronchiolitis
What is exercise-induced asthma?
Airway narrowing during or 5-10 minutes after vigorous exercise
- Typically resolves within 1-4 hours
What medications should patients with exercise induced asthma use if they exercise daily?
- Rescue inhaler
- Add ICS
What are the different types of asthma?
- Exercise induced
- Occupational/environment induced
- Allergen induced
What are the four classifications of asthma severity?
- Intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
Symptoms associated with intermittent asthma
- Symptoms occur 2x or less per week
- Asymptomatic and normal PEF between exacerbations
- Requires SABA 2 days/week
- Exacerbations are brief
- No interference with normal activity
How often do nighttime symptoms occur with intermittent asthma?
2x or less per month
Symptoms associated with mild persistent asthma
- Symptoms occur >2x/week but <1x/day
- Requires SABA >2 days/week but not more than 1/day
- Exacerbations may affect activity (minor)
How often do nighttime symptoms occur with mild persistent asthma?
3-4x/month
Symptoms associated with moderate persistent asthma
- Daily symptoms
- Daily use of inhaled SABA
- Some limitation
- Exacerbations affect activity, 2x or >/week, may last days
How often do nighttime symptoms occur with moderate persistent asthma?
>1/week but not nightly
Symptoms associated with severe persistent asthma
- Continual symptoms
- Requires SABA several times/day
- Extremely limited physical activity
- Frequent exacerbations
How often do nighttime symptoms occur with severe persistent asthma?
Often, 7x/week
How does asthma classification in severity differ between adults and pediatrics?
Similar classification, however poorly controlled asthma (mild, moderate, severe persistent) requires a step up in medication
Pediatric asthma physical exam findings
- Mild
- Wheezing at the end of expiration or no wheezing
- No or minimal intercostal retractions along posterior axillary line
- Slight prolongation of expiratory phase
- Normal aeration in all lung fields
- Can talk in sentences
- O2 saturation >92%
Pediatric asthma physical exam findings
- Moderate
- Wheezing throughout expiration
- Intercostal retractions
- Prolonged expiratory phase
- Decreased breath sounds at the base
- O2 saturation >92%
Pediatric asthma physical exam findings
- Severe
- Use of accessory muscles plus lower rib and suprasternal retractions
- Nasal flaring
- Inspiratory and expiratory wheezing or no wheezing heard with poor air exchange
- Suprasternal retractions with abdominal breathing
- Decreased breath sounds throughout base
- O2 saturation <92%
How would the provider manage a patient with chronic asthma?
- Reduce environmental/allergen exposures
- Treat rhinitis, sinusitis, GERD
- Yearly flu vaccine
- Medications: anticholinergics, cromolyn sodium, leukotriene modifiers, omalizumab
- Regular follow up with PCP after ED care
- Education (asthma action plan)
True/false: The severity of asthma attacks will determine the management approach
True - response to initial treatment determines subsequent treatment
When are antibiotics warranted for patients with asthma?
- Fever
- PNA
- Bacterial sinusitis
- Purulent sputum
What should the provider do if PEF values are 50-79% of personal best (asthma management)?
- Patient requires quick relief medication
- Depending on response to treatment, contact with pulmonologist may be indicated
What should the provider do if a patient has a PEF value <50% (asthma management)?
Need for immediate medical care
What are signs and symptoms of a serious asthma exacerbation?
- Marked breathlessness
- Inability to speak more than short phrases
- Use of accessory muscles
- Drowsiness
What is initial treatment for an asthma exacerbation?
- Inhaled SABA (rescue inhaler)
- Up to two treatments 20 minutes apart, 2-6 puffs by MDI, nebulizer
What is considered a good response to initial treatment of an asthma exacerbation? What further management is warranted at this time?
- No wheezing or dyspnea, PEF >80% (after rescue inhaler use)
- Contact PCP for follow up
- Continue inhaled SABA every 3-4 hours for 24-48 hours
- Consider short course of oral systemic corticosteroid
What is considered an incomplete response to initial treatment of an asthma exacerbation? What further management can the provider do?
- Persistent wheezing and dyspnea (tachypnea), PEF 50-79%
- Add oral systemic corticosteroid
- Continue inhaled SABA
- Same day referral to PCP for further instruction
What is considered a poor response to initial treatment of an asthma exacerbation? What further management should be done by the provider?
- Marked wheezing and dyspnea, PEF <50%
- Add oral systemic corticosteroid
- Repeat inhaled SABA immediately
- If distress is severe and non responsive to initial treatment: call PCP and head to ED
What important information should be gathered in health history for patients with asthma?
- Family history of asthma/atopy
- Conditions associated with asthma → GERD, sinusitis, chronic OM
- Chest tightness/dyspnea
- Cough/wheezing
- Seasonal or continuous symptoms
- Recurrent “bronchitis” symptoms or PNA
- Precipitation of symptoms
Physical examination findings for asthma
- Wheeze
- Cough
- Prolonged expiratory phase
- Diminished breath sounds
- Increased work of breathing/signs of distress
- VS
- Cyanosis
True/false: Asthma is a diagnosis of exclusion
True - must include the following…
- Episodic symptoms of airflow obstruction (wheeze, cough, SOB)
- Evidence that airflow obstruction is at least partially reversible (trial of bronchodilator)
- Exclusion of other conditions
Diagnostic tests for asthma
- Spirometry
- Done in patients 5 years or older
- PEFR and FEV1
- Peak flow meters
- Used to monitor symptoms
When should spirometry be used for asthma diagnosis?
Recommended at the time of initial assessment, after treatment is initiated and symptoms and PEF have been stabilized, and at least every 1-2 years
True/false: Peak flow monitoring helps individuals to follow the course of their disease, predict exacerbations, identify triggers, assess response to treatment
True - should be used as the basis for an asthma action plan
How would a patient determine their personal best PEF with peak flow monitoring?
Can be estimated after a 2-3 week period
- PEF is recorded at least once/day in early afternoon when asthma is well controlled
What are the cut offs for peak flow meter zones (green, yellow, red)?
Green → >80% (90% for patients who decompensate quickly)
Yellow → 50-80% (can be 60-80%)
Red → <50% (or 60%)
Management considerations for yellow zone (50-80%) readings on peak flow meter
- Continue with green zone medication and add quick relief medication
- Temporary increase in medication dose or frequency
- Increase bronchodilator therapy, increase or add corticosteroid, add short course of oral corticosteroid
Yellow zone (peak flow meter) signs
- First signs of a cold
- Exposure to known trigger
- Cough
- Mild wheeze
- Tight chest
- Coughing at night
Red zone (peak flow meter) management
- Immediate use of inhaled rescue bronchodilator
- Start or increase oral corticosteroid therapy
- If symptoms persist, call 911 or go to ED
True/false: If asthma has been well controlled for 6 months, can “step down” in management
False - if well controlled for 3 months, can “step down”
What are some forms of reliever medications for asthma?
All patients need a reliever medication (bronchodilator)
- Short acting beta agonist bronchodilator (SABA)
- Low dose ICS/formoterol
- Short acting anticholinergic
Examples of controller medications used for asthma control
- Inhaled ICS and long acting beta agonist bronchodilator combinations (ICS/LABA)
- Long acting anticholinergic
- Systemic corticosteroid
True/false: If a patient requires a rescue inhaler 4x/week or more, they will need controller medication
False - if using rescue inhaler 2x/week or more, will need controller medication
Stepwise approach to asthma management
- Step 1
Reliever medication
- As needed short acting beta agonist (SABA) for relief
Stepwise approach to asthma management
- Step 2 (mild)
- Reliever medication: as needed SABA
- Preferred controller medication: low dose ICS
Stepwise approach to asthma management
- Step 3
- Reliever medication: as needed SABA or low dose ICS/formoterol
- Preferred controller medication: low dose ICS/LABA
Stepwise approach to asthma management
- Step 4
- Reliever medication: as needed SABA or low dose ICS/formoterol
- Preferred controller medication: medium high dose ICS/LABA
Stepwise approach to asthma management
- Step 5
Pulmonologist consultation
When are follow up visits warranted for patients with asthma?
- 1-3 months after starting treatment then every 3-12 months afterwards
- If pregnant, follow up every 4-6 weeks
When is a referral to a pulmonologist warranted for patients with asthma?
- Diagnosis of asthma-related hospitalization
- Poorly controlled asthma (e.g. frequent missed days of work and/or school)
- Unresponsiveness to therapy
- Second opinion
- Periodic patient evaluation
What is COPD?
- Preventable and treatable disease characterized by airflow limitation
- Progressive, not fully reversible
- Predominately a smokers disease
COPD is a term used to describe two related lung disease. What are they?
- Chronic bronchitis
- Emphysema
What is the difference between chronic bronchitis and emphysema?
Chronic bronchitis - frequent cough with mucus
Emphysema - SOB
When in the lifespan does COPD typically present?
Usual onset in midlife and associated with long history of smoking
- Slow progressing symptoms
COPD clinical presentation (symptoms)
- Dyspnea on exertion
- Persistent and progressive
- Worse with exercise
- Cough
- Sputum production
COPD physical examination findings
Suspected based on history and examination, but can be confirmed physiologically with simple spirometry
- Skin → tobacco stains on fingers, clubbing
- Pulmonary → inspiratory crackles, hyperinflation, forward sitting posture
- Cardiac → RVH (cor pulmonale)
Gold standard diagnostic test for COPD
Spirometry
- Forced expiratory time
- FEV1/FVC <0.70 (or <70%)
- FEV1 <80%
Other diagnostic tests used to diagnose COPD (other than spirometry)
- Pulse oximetry
- COPD assessment test
- Chest x-ray
- Hct and hbg
- Blood gas measurements (if O2 sat <92%)
- Alpha-1 antitrypsin deficiency
- Biomarkers
- EKG (cor pulmonale)
What medication class should not be prescribed to patients with asthma or COPD?
Beta blockers
COPD management considerations
- Encourage smoking cessation
- Oxygen therapy
- Pulmonary rehabilitation
- Exercise training
- Psychological support
- Nutrition → small frequent meals
- Flu and pneumococcal vaccines
- Palliative care (if end stage)
Pharmacotherapy management for patients with COPD
- Inhaled bronchodilators to relieve bronchospasm
- Methylxanthine therapy to enhance bronchodilator therapy
- Corticosteroids to reduce inflammation
- Antibiotics for infection
COPD exacerbation medication management
- Mild
SABA prn
COPD exacerbation medication management
- Moderate
- SABA
- Oral corticosteroid (prednisone)
- Antibiotic (if indicated)
COPD exacerbation medication management
- Severe
Go to ED for hospitalization
