Asthma And COPD - Dr. Miller Flashcards
Prevalence in the Asthma
Boys childhood (genetics), women adult and puberty (maybe sex hormones) (Also farther away from equator and rural places have higher rates)
Risks of asthma
- GI microbiome —> pulmonary microbiome
- Lung function
- Delayed immune maturation
- Viral and LRTI
Prenatal risks for asthma
Ethnicity, C section, Stress, Low Socioeconomic, tobacco use mother
Postnatal risks for asthma
- Endotoxins and allergens at home (duct mites)
- Viral and bacterial infection (RSV, adenovirus)
- Pollution
- ABs, acetaminophen
- Obesity
Inflammation in asthma consists of what
- T2 type inflammation (M2 cells)
- Allergens (dust, fungi, pets, pollen) cause inflammation = Eosinophils
- Defect in resolution of inflammation
Airway remodeling in asthma consists of
- SM proliferation in airway
- Mucous cells production increased + more mucous production
- Thickened subepithelial reticular lamina
Asthma SX
- Exacerbations
- Worse at night, exercise, viral inf, allergen exposure, weather changes, laugh/crying, stress
- Chest tightness, SOB
- Wheezing
Asthma DX
SPIROMETRY (does not exclude disease if normal)
- FEV1 <80%
- FEV1/FVC <75%
- obstruction of airway is reversible (12% improvement in FEV1, at least 200mL improvement total)** ——> you know its not COPD
Asthma with normal spirometry what do you do
- Give bronchodilator or corticosteroids and see improvement
- Give give methocholine or menatol and see hyperrespnsive reaction (you need to be prepared for severe attack)
Classifying Asthma (what are the 2 types)
Intermittent and persistent
Intermittent asthma is what
- Sx less then 2d / week
- Night time awakening < 2d/month
- Asthma exacerbation needing corticosteroids 0-1/year
- Normal activity no sx
- Rescue inhaler < 2days/week
Persistent Asthma MILD
- More then 2d/week sx
- Minor limitation in normal activity
- <2/month awake from night
- 2 or more exacerbation needing tx/ year
Persistent Asthma moderate
- Sx daily
- 3-4 nights / month awake
- Daily inhaler need
- > 2 exacerbation per year
Persistent Asthma severe
- Sx throughout day
- Several times a week awake night
- Inhaler multiple times a day
- Extreme limitation in normal activity
- More then 2 exacerbation per year
Most severe and risky effect of asthma
Exacerbations
Intermittent asthma TX
SABA as needed (inhaler), short-acting beta agonist = ALBUTEROL
Persistent asthma TX step 2-6
STEP 2 : SABA + LOW ICS (inhaled corticosteroids)
STEP 3 : + LABA (long acting beta agonist) or MEDIUM ICS
STEP 4 : + LABA (long acting beta agonist) and MEDIUM ICS
STEP 5 : + HIGH ICS + LABA + omalizumab
STEP 6 : + HIGH ICS + LABA + corticosteroid
SABA more then 2 times a week
Inadequate therapy and need more therapy
Asthma TX not responding appropriately causes
- Correct inhaler use
- Infections
- Obesity
- GERD, exposure to smoke
- Low VIT D
- Anxiety Depression, sleep apnea
TX exacerbations
- Bronchodilator
- Glucocorticoids
- O2
- MgSO4 = relax SM
- Epinephrine
- Iprotropram
Preventing asthma
- Breastfeeding
- Avoid tobacco and secondary smoke
- Prevent obesity
- Vit D
- Vaccinations
COPD is what
Persistent airflow limitation progressive, and chronic inflammation response
= irreversible airflow limitation (more in men, 3rd leading cause of world death)
Genetics playing in COPD
A1-antitrypsin deficiency = 1% of COPD (only one we know right now)
What happens in COPD
- Obstructive bronchitis (inflammation, bacteria colonization)
- Emphysema (elastic walls destroyed)
- Hypersecretion of mucous
= lung is like a paper lunch bag
COPD FEV
Acceleration in decline of FEV1
COPD SX
- Dyspnea, SOB (progressively worsening, worse with exercise)
- Sputum and purulence chronic
- Cough (unproductive)
- Wheezing
- Tiggers in Day by day variation
COPD TX
- ABs
- Steroids = lower inflammation
- Bronchodilators
- Pulmonary rehabilitation = increase pulmonary function
Pink puffers
COPD more like emphysema
- Expanded lung, low BMI
- Fewer cardiac + comorbidities probs
- Hyperinflation
- Low CO capacity
- More SOB + lower exercise tolerance
- Worse health
Blue Bloaters
COPD less emphysema 1. High BMI 2. More comorbidities 3. Cardiac probs 4. Chronic bronchitis 5. High IL6 and CRP 6 more exacerbations + sleep apnea
How to DX COPD
SPIROMETRY :
- FEV1/FEV < 0.7
- FEV1 LOW (classified by GOLD)
- <12% reversibility
GOLD classification
Classify COPD 1-4 (4 being worse FEV1 <30%)
GOLD 1
FEV 1 > 80% + FEV1/FVC < 0.7
GOLD 2-4
FEV1 = <80% + FEV1/FCV = <0.7
No pharmacology TX COPD
- pulmonary rehab : exercise, breathlessness, mental and physical health
- lung volume reduction surgery + transplant :
TX COPD pharm
- LABA and LAMA improve sx and lung function (if both are given lung function 2x improvement only sx don’t improve x2)**
- Inhaled corticosteroids (ICS not always helpful) ——> exacerbation risk pts
- Oxygen (15hours per day) = reduced mortality **
Group A - D COPD
GROUP A : bronchodilator
GROUP B : LAMA or LABA (no hospitalization)
GROUP C : LAMA ( more then 2 exacerbations hospitalized pts)
GROUP D : LAMA or LAMA + LABA or ICS + LABA
Acute exacerbation TX in COPD
- Oral corticosteroids **
2. ABs + O2
Some things that can improve COPD SX
- Opiates = air hunger improvement
- Fans and O2 blowing
- Nutrition supplements
- Pulmonary rehabilitation
When to use ICS in COPD
**frequent exacerbations + reactive airway component (Eosinophils >300 cells)
When to definitely not use ICS in COPD
- Repeated pneumonia
- E < 100 cells
- Mycobacterium infection history
Normal FEV1/FVC
Above 0.70
Asthma with bronchodilator should do what
Increase FEV1 more then 200ml + increase FEV1/FVC
Long-acting B- Agonist should always be used with
ICS
When do you not do spirometry
Unstable acute patients
GOLD 2 and GOLD 3
GOLD 2 : 50%-80% FEV1 predicted
GOLD 3 : 30% - 50% FEV1 predicted
Acute COPD TX
Managements COPD TX
- Oral Corticosteroids + O2 + bronchodilator + ABS (if sx of consolidation or type of inflammation/infection shown)
- LABA OR LAMA OR SABA
+ ICS (frequent exhasterbaitons only or hospitalizations)
