Asthma Clinical Approach Flashcards
3 populations most commonly affected by asthma
- adult
- female
- hispanic or white
Asthma is caused by a release of inflammatory mediators that lead to which 4 physiologic responses?
- increased airway secretion
- mucous plugging
- bronchospasm
- bronchoconstriction
What is the main differences between aeroallergens and animal allergens?
- aero: mites, pollen, grass, etch
- animal: dog, cat, zoonotic animals
(other category is non-allergic)
non-allergic asthma triggers (5)
- viral/bacterial infection
- tobacco
- strong odors (perfume)
- cold air
- medicine
6 Risk factors for asthma
- fam hx
- presence of IgE
- lower socioeconomic status
- infantile obesity
- low exposure to microbes
- vit D defiiency in utero
asthma sx (4)
other than wheezing
- non-productive cough
- SOB
- Cp
- fatigue
List the corticosteroids used to tx asthma (5)
- fluticasone
- baclomethasone
- mometasone
- budesonide
- ciclesonide
“-asone” or “-esonide”
List the 4 LABA - ICS combos that are used for moderate to severe asthma
this improves compliance = better asthma control
- advair
- breo
- dulera
- symbacort
List the 2 LABA-ICS combo meds that contain fluticasone. What are they paired with?
- advair: salmeterol
- breo: vilanterol
List the 2 LABA - ICS combos that contain fomoterol. What is it paired with?
tx moderate - severe asthma
- symbacort: budesonide
- dulera: mometasone
list the 2 rescue inhalers for asthma
- symbacort (fomoterol + budesonide)
- albuterol
SLIT
sublingual immunotherapy
used for allergic rhinitis
Which immuno therapy is recommended for allergic asthma? Which for allergic rhinitis?
aeroallergen or allergen
- immunotherapy shots
- SLIT
How can patients avoid asthma triggers (2)?
- allergy testing
- checklist at home
60% have allergic asthma
How does ashma lead to airway obstruction (decreased lumen diameter) (3)?
- adaptive immune response
- smooth msk contraction –> bronchospasm & constriction
- viscous mucus secretions
non-allergic asthma inflammatory response is aka
neutrophilic
Describe the early and late allergic asthma response.
- 30 min: immediate IgE-induced mast cell degranulation
- 12 hours: immune cell infiltration
In the “doorway view” of an asthma c/c, what should you notice first (4)?
- can they speak in full sentences
- what position are they in (tripod?)
- retractions (substernal)
- nasal flaring
DDx for asthma (10)
- vocal cord dysfxn
- pneumonia
- bronchitis
- URI
- FB obstructino
- CHF
- PE
- COPD
- anxiety
- GERD
C/C asthma: pert +/-
- dyspnea at rest? w/exertion?
- cough (non-productive)?
- exposure (new house, pet)
- chest pain
(must distinguish from MI)
C/C asthma: fam hx questions (3)
- asthma
- atopy
- seasonal allergies
How can asthma become fatal?
prolonged expirations overtime = acidosis
4 s/sx severe asthma attack
- retractions
- difficulty speaking full sentences
- altered mentation
- prolonged expiratory phase
note in Objective findings under lungs, not MSK (retractions)
3 findings on physical exam: asthma
- hyper-resonance (increase vocal fremitus)
- diminished breath sounds
- wheezing
What does expiratory wheezing indicate?
obstruction
what does monophasic wheezing indicate?
obstruction
describe monophasic wheeze
high-pitched squeak
best heard over lower neck
what does polyphonic wheezing indicate?
multiple airways obstructed
asthma
polyphonic wheeze is only heard on exhalation/inhalation. monophonic wheeze is only heard on exhalation/inhalation.
polyphonic = exhalation
monophonic = both
polyphonic wheezing is also heard in bronchitis, CHF and ______.
PE
What does asymmetric wheezing suggest (3)?
- pneumothorax
- pneumonia
- foreign body
management of acute dyspnea following asthma trigger for mild or moderate exacerbation?
(O2>94%, tachycardia, tachypnea)
- prednisone
- O2
- SABA
management of acute dyspnea following asthma trigger for severe exacerbation (8)
- ABC
- O2 (>92%)
- high dose SABA
- muscarinic antagonist (ipratropium)
- duo-neb (atrovent)
- IV corticosteroid (oral just as good)
- magnesium sulfate (relax sm. msk)
- intubate (if impending failure)
Define Duo-neb (atrovent)
albuterol + ipratropium
SABA + Antimuscarinic
If the patient is hyperventilating, how do they become acidodic?
- ABG low CO2 at first
- then they fatigue & retain CO2
this leads to altered mentation & death
Which dx testing for asthma can be done in the office
primary care
- peak flow
- spirometry
normal FEV1/FVC ratio
70%
Why are PFTs normal in asthma patients at times?
asthma is episodic/reversible
Lab findings for asthma (2)
- charcot-leyden crystals
- curshmann spirals
what are curshmann’s spirals?
spiral-shaped mucus plugs
what are charcot-leyden crystals?
indicative of eosiniphilic infiltration
co-morbidities of asthma (5)
- GERD
- OSA
- allergic rhinitis
- sinusitis
- nasal polyps
poor prognosis factors of asthma
- fatigue
- pulsus paradoxus
- diaphoresis
- decreased breath sounds
- cyanosis
- bradicardia
- acidosis
aspirin nasal-polyposis syndrome
(samter’s triad)
- bronchial asthma
- nasal polyps
- intolerance to COX-1 inhibitors
non-allergic hypersensitivity rxn (non-IgE mediated)
Eosinophilia and cross-reactivity between ASA (and other NSAIDs) is seen in which condition?
Aspirin sensitiviy-nasal polyposis syndrome
What is the correlation between asthma and GERD?
stomach acid aspiration irriates airways –> bronchospasm
When might you suspect GERD in an asthma patient?
not responding to steroids
put them on PPI
What is included in astham action plan (3)?
- increrase controller & reliever meds if worsening
- take short-course oral steroids for severe exacerbation
- when to seek medical help
Why are nebulizers not recommended? What is the alternative?
- dissemination of virusespressurized metered dose
- inhaler via spacer (mouth piece or tightly fitting mask
define fractional exhaled nitric oxide test. when is it used?
- measures NO2 (increased w/airway inflammation
- confirms asthma
What is bronchial thermoplasty (BT)
heat application to relax msk around airways
used for persistant asthma in adults
