Asthma/COPD Flashcards
Obstructive Chest Conditions:
disturbance of ventilation due to increased resistance to airflow in the airways (Asthma/COPD
Restrictive Chest Conditions:
disturbance of ventilation due to decreased chest wall or lung movement (fibrosis)
What are the selected obstructive chest disorders?
- Asthma
- COPD-Chronic Bronchitis, Emphysema
- Atelectasis
- Consolidation
What are the first five symptoms of obstructive chest disease?
- Chest pain
* 2. Dyspnea*
* 3. Wheezing*
* 4. Cough* - Hemoptysis
What is the etiology of dyspnea?
difficulty breathing
1. CV (left-sided heart failure)
2. Lungs (asthma, COPD, pneumonia)
3. Anxiety
SOB related to activity vs. difficulty taking deep breaths, smothering sensation, paresthesia
What is the etiology of wheezing?
- relatively high pitched adventitious sounds with hissing or shrill, musical quality*
1. May be audible without stethoscope
2. Etiology: narrowed bronchi
What is etiology of cough?
Reflex response to endogenous or exogenous irritants in larynx, trachea, or large bronchi (lung/heart disease)
- Dry vs. productive cough
- If productive, volume, color, odor, consistency important
What are pulmonary function tests used for?
- help d/x and determine severity of chest conditions
2. monitor patients with chest conditions (disease progression, effect of treatment)
What does a pulmonary function test assess?
- Lung volumes
- Air flows rates
- Gas exchange
What is spirometry?
- Measurement of breathing*
1. Used to measure volumes/capacities and flow rates
How do you complete spirometry?
- Pt. inhales maximally, then exhales forcibly and completely into spirometer
- May continue through maximal forced inspiration, depending on test performed
- May record volume as function of time as function of volume
Why use spirometry in obstruction?
individuals have a reduced ability to move air through the conducting airways of the lung (Asthma, COPD)
Why use spirometry in restriction?
individuals have most difficulty getting air into the lung and typically have decreased lung volumes (fibrosis)
Spirometry: FEV1
forced expiratory volume in first second of expiration
- -pre/post bronchiodilator
- ->12% improved = asthma
Spirometry: FVC
forced vital capacity
-helpful to determine fixed obstruction
Spirometry: TLC
total lung capacity
Spirometry: RV
residual volume (left after FVC)
Spirometry: DLco
diffusing capacity for carbon monoxide
Spirometry: FEV1/FVC
ratio to standardized and interpret results
Normal: > 75%
What effective do obstructive processes have on spirometry parameters?
decrease airway flow rates with relative preservation of forced vital capacity
What effective do restrictive processes have on spirometry parameters?
decreased forced vital capacity with relative preservation of flow rates
If disease is likely check the spirometry % FEV1/FCV:
- If the ratio 88-90% or higher = restrictive disease likely
- If the ratio is <75% = obstructive disease likely
What occurs with FEV1/FVC in asthma?
<75%
What occurs with FEV1/FVC in COPD?
<75%
What is asthma?
- a heterogenous clinical disorder characterized by episodic wheezing and hyper-responsiveness of the airway to a variety of stimuli
- largely reversible obstruction of the airways
- inflammation is present in the airways and over time remodeling may occur that in turn can cause permanent structural changes and decline liver function
What are the smooth muscle dysfunctions that occur during asthma?
- bronchoconstriction
- bronchial hyperreactivity
- hypertrophy/hyperplasia
- inflammatory mediator release
What airway inflammation occurs during asthma?
- inflammatory cell infiltration/activation
- mucosal edema
- cellular proliferation
- epithelial damage
- basement membrane thickening
What factors can lead to pre symptomatic/early disease and then onto clinical asthma?
- Genetic/host susceptibility for asthma
2. Environmental exposures, allergens, air pollutants, viral infections
what happens to the lung morphology in asthma?
- Bronchial inflammation
- Edema, mucus plugging
- Bronchospasm
- Obstruction
- Over inflation/atelectasis
- Characteristic of COPD
What is the notable micro pathology of asthma?
- Patchy necrosis of epithelium
- Sub-mucosal glandular hyperplasia
- Hypertrophy of bronchial SM
- Eosinophils, mast cells, lymphocytes
- Mucous plugs
What happens in the bronchial tissue in patients with asthma?
- Inflammation
- Eosinophils
- Gland hyperplasia
- Mucous plug in lumen
- Hypertrophy of muscle layer
What happens at the cellular level in asthma?
- Initiated by allergens
- Recruited to airway by other inflammatory cells
- Perpetuate tissue damage and inflammation (mast, Th2, eosinophils, neutrophils)
What are characteristic features of persistent asthma?
- Denudation of airway epithelium
- Collagen deposition beneath basement membrane
- Mast-cell degranulation
- Lymphocyte and eosinophil infiltration
- Release of cytokines and chemokines
What are the most common predisposing factors associated with asthma?
- History of atopy
- Initiation of asthma in early life
- Respiratory viral infections
- Exposure to airborne allergens
- Positive family history
Normal FEV1
> 80%
Normal FVC
> 80%
Mild obstruction FEV1/FVC and FEV1
<75%
70-100%
Moderate obstruction FEV1/FVC and FEV1
<75%
60-70%
Moderate/severe obstruction FEV1/FVC and FEV1
<75%
50-60%
Severe obstruction FEV1/FVC and FEV1
<75%
34-50%
well controlled asthma
- symptoms
- nighttime awakenings
- interference with normal activity
- SABA use
- FEV1 or peak flow
- exacerbations
- <2 days/week
- <2/month
- none
- <2 days/week
- > 80% predicted/personal best
- 0-1 per year
Not well controlled asthma
- symptoms
- nighttime awakenings
- interference with normal activity
- SABA use
- FEV1 or peak flow
- exacerbations
- > 2 days/week
- 1-3 per week
- some limitation
- > 2 days/week
- 60-80% predicted/personal best
- 2-3 per year
Very poorly controlled asthma
- symptoms
- nighttime awakenings
- interference with normal activity
- SABA use
- FEV1 or peak flow
- exacerbations
- Throughout the day
- > 4/week
- extremely limited
- several times per day
- <60% predicted/personal best
- > 3 per year
Questionnaires for asthma
ATAQ (asthma therapy assessment questionnaire)
ACQ (asthma control questionnaire)
ACT (asthma control test)
Well controlled asthma
- ATAQ
- ACQ
- ACT
- 0
- <0.75
- > 20
Not well controlled asthma
- ATAQ
- ACQ
- ACT
- 1-2
- > 1.5
- 16-19
Very poorly controlled asthma
- ATAQ
- ACQ
- ACT
- 3-4
- N/A
- <15
Indirect costs of asthma
$5 billion
- lost productivity at work
- schooldays lost
- mortality
Direct costs of asthma
$14.7 billion
- hospital care
- physical and other health services
- Rx meds
Treatment success of asthma
- no missed school/work days
- no sleep disruption
- maintain normal activity levels
- no (or minimal) ER visits
- normal or near normal lung function
Severity
intrinsic intensity of disease
Control
degree to which asthma is minimized
Responsiveness
ease with which asthma control is achieved
impairment
frequency and intensity of symptoms and functional limitations
risk
likelihood of either exacerbations, progressive decline in lung function or risk of ADEs from meds
When is spirometry recommended for asthma?
- at initial assessment
- during stabilization phase PRN
- after treatment has stabilized symptoms
- at least every 1-2 years
When FEV1 increases ____% after using SABA this is reversible
12
Additional tests for asthma
- bronchoprovocation (Histamine challenge, methacholine challenge)
- exercise/treadmill testing
Alternative strategies for asthma
- FENO
- sputum eosinophils
- videolaryngostroboscopy
- chest X ray
- allergy skin test
What are common comorbidities that can aggravate asthma?
VCD
GERD
allergic rhinitis
Symptom history for asthma should be based on what?
2-4 week recall period
How do you monitor lung function in asthma?
peak flow monitoring
Red zone
<50%
Yellow zone
50-80%
Green zone
80-100%
t/f partnership in asthma care is important
true
A key principle of pharmacologic care in asthma is
regulation of chronic airway inflammation
In general ____ medication is superior to ____ in asthma control
inhaled
Oral or IV
Low dose fluticasone MDI
88-24 mcg
44 mcg per puff = 1-3 puffs/day
Medium dose fluticasone MDI
264 - 440 mcg
110 mpg/puff = 2 puffs BID
220 mcg/puff = 1 puff BID
High dose fluticasone MDI
> 440mcg
110mcg/puff = 3 puffs BID
220 mcg/puff = 2 or more puffs BID
Low dose fluticasone DPI
100 - 300mcg
50mcg per inhaler = 1-3 BID
Medium dose fluticasone DPI
300-500 mcg
100mcg per inhalation = 2 BID
250 mcg per inhalation = 1 BID
High dose fluticasone DPI
500 mcg
100 mcg per inhalation = 3 or more BID
250 mcg per inhalation = 2 or more BID
What is the most effective long term anti-inflammatory controller therapy for persistent asthma?
ICS
T/f all patients respond adequately to ICS
false!
smokers, neutrophilic patients may not
1/3 nonresponders
Benefits of daily use of ICS
- fewer symptoms
- fewer severe exacerbations
- reduced use of quick relief meds
- improved lung function
- reduced airway inflammation
potential ADE of ICS
thrush
osteoporosis or stunted bone growth
HPA axis suppression (at high doses)ty
What is typical dosing of ICS?
BID typically
QD may be enough for mild
- based on severity
How is cromolyn used in asthma?
- mild persistent asthma
- used as controller, not rescue
Who is cromolyn typically used for?
- meds
- seasonal allergies
- steroid intolerant
- pregnant
Typical dosing of cromolyn
TID to QID
side effects of cromolyn
virtually none
T/f LABA can be a substitute for anti-inflammatory meds
false!
Not for monotherapy
When is LABA used?
in combo with ICS
What are leukotriene modifiers used for?
long term therapy in mild persistent asthma
or add on in moderate to severe persistent asthma
What asthma med can be used in children as young as 2 and take at bedtime?
leukotriene modifiers
When would you use a combo asthma med?
persistent asthma
require daily anti-inflammatory and bronchodilation therapy
How do combo products help with compliance?
- decrease frequency of use
- decrease need for coordination
- improve patient inventory control
T/f it is okay to use a combo product even if you only need one of the meds
false!!
only use if both are necessary for treatment
Who would you use Omalizumab in?
persistent asthma >1 year
- inadequately controlled on combo therapy
- controlled on high dose ICS
What should your IgE level be to take omalizumab?
30-700
T/f you can take omalizumab at home
false
- must be administered by provider in office
Which drug targets IgE for asthma?
omalizumab (Xolair)
Which drugs target the IL-4/5 receptors for asthma?
eosinophil modifiers
What is the most effective medication for PRN relief of asthma?
SABA
Why is regular schedule of SABA not recommended?
may lower effectiveness
may increase airway hyperresponsiveness
Should SABA be B1, B2 or nonselective?
B2
What type of drugs can be used for long term control of asthma?
ICS Cromolyn LABA methylxanthines Leukotriene modifiers Combo Anti-IgE IL-5 agents
What type of drugs can be used for short term control of asthma?
SABA
anticholinergics
systemic corticosteroids
What type of drug is ipratropium?
anticholinergic
What type of drug is tiotropium?
anticholinergic
When is prednisone burst therapy recommended?
short term use during moderate to severe exacerbations
T/f you can use regularly scheduled prednisone for asthma
false!
not recommended, increase risk of ADE
Step 1 treatment of asthma
mild intermittent
- SABA PRN
Step 2 treatment of asthma
mild persistent
- low dose ICS
alt: cromolyn, nedocromil, LTRA or theophylline
Step 3 treatment of asthma
moderate persistent
- medium dose ICS
OR Low dose ICS + LABA
alt: low ICS + either LTRA, theophylline or Ziluetin
Step 4 treatment of asthma
moderate persistent
- Medium dose ICS + LABA
Alt: med ICS + either LTRA, theophylline or zileuton
Step 5 treatment of asthma
Severe persistent
- high dose ICS + LABA
AND Consider omalizumab (allergies)
Step 6 treatment of asthma
severe persistent
- high dose ICS + LABA + oral corticosteroid
AND Consider omalizumab (allergies)
When should you step down on asthma treatment?
if well controlled for at least 3 months
t/f you should start higher and more aggressive in treatment for asthma
true
step down as needed
What steps should you consider a referral to a specialist?
3-4
What steps should you recommended a referral to a specialist?
5-6
2 main goals of asthma treatment
reduce impairment
reduce risk
How often should you follow up with well controlled asthma patients?
every 6 months
more frequently if needed
When should you step up asthma treatment?
- awakens at night
- urgent care visit
- evidence of deceased PEF
- SABA >2/week
Before increasing medications for asthma what should you check?
- inhaler technique
- adherence to prescribed regimen
- environmental changes
- reconsider alternative diagnosis
What should an action plan include?
- signs, symptoms, peak flow levels
- how to adjust meds in response to deteriorating asthma
- when to seek help
- emergency phone numbers
Home treatment of exacerbation initially
inhaled SABA up to 2 treatments of 2-6 puffs at 20 min intervals
Good response to initial therapy for exacerbation for home treatment
contact clinician
continue SABA
consider oral steroids
Incomplete response to initial therapy for exacerbation for home treatment
contact clinician urgently
continue SABA
add oral steroid
Poor response to initial therapy for exacerbation for home treatment
proceed to ER
repeat SABA immediately
add oral steroid
systemic corticosteroids in elderly
can provoke confusion, agitation, changes in glucose metabolism
ICS in elderly should also be treated with what?
calcium supplement
Vitamin D
estrogen replacement
What other medications may exacerbate asthma?
NSAIDs
nonselective B blockers
B blockers in some eye drops
What shots should you get if you have asthma?
flu vaccine
pneumovax
prevnar 13: routine 2-59 months
Diagnosis of exercise induced bronchospasm (EIB)
history of symptoms
exercise challenge or do task that provokes symptoms
How long can SABA last in EIB?
2-3 hours
Salmeterol and EIB
can prevent for 10-12 hours
NOT PRN use!!
t/f you can use cromolyn for EIB?
true
Managing seasonal asthma symptoms
- start anti-inflammatory before allergy season
- continue during allergy season and use step wise approach to control symptoms
Patients with asthma going into surgery are at risk for what type of complications?
perioperative
How can you reduce risk in asthma patients going into surgery?
- pre-op eval with PFT
- improve lung function before (consider steroid)
Maternal asthma can increase risk of
perinatal mortality
pre-eclampsia
pre-term birth
low birth weight infants
T/f it is safer to be treated with asthma meds than to have asthma symptoms in pregnancy
true
What is the preferred bronchodilator in pregnancy?
albuter
What are the preferred controlled therapy in pregnancy?
ICS
t/f montelukast can be used in pregnancy
true
t/f you can use burst steroids in pregnancy
true
Who are high risk asthma patients?
- history of sudden severe exacerbations
- prior intubation or admin to ICU for asthma
- 2 or more hospitalizations in past year
- 3 or more ER visits in past year
- use >2 canisters per month of SABA
t/f males are more likely to have COPD than women
false
Women >men
What is the main environmental risk factor for COPD?
cigarettes
what is a permanent air space enlargement with weakened and collapsed air sacs with excess mucus?
emphysema
What is it when a patient has chronic productive cough for 3 months during 2 consecutive years?
chronic bronchitis
classic symptoms of COPD
- cough
- dyspnea
- wheezing
- sputum production
Emphysema
- age
- dyspnea
- cough
- sputum
- bronchial infections
- respiratory episodes
- chest x ray
- 60+
- severe dyspnea
- cough after dyspnea
- scanty, mucoid sputum
- bronchial infection < frequent
- respiratory episodes often terminal
- increased diameter, flattened diaphragm
Chronic bronchitis
- age
- dyspnea
- cough
- sputum
- bronchial infections
- respiratory episodes
- chest x ray
- 50+
- mild dyspnea
- cough before dyspnea
- copious, purulent sputum
- bronchial infection > frequent
- respiratory episodes repeated
- broncovascular mar, enlarged heart
Prednisone burst dose
60mg QD for 7 days
Is cor pulmonate more common in chronic bronchitis or emphysema?
chronic bronchitis
Pulmonary HTN in COPD leads to ____
death!
symptoms of COPD
cough
sputum
SOB
_____ is the gold standard for diagnosis of COPD
spirometry
Chronic symptoms of COPD
cough
sputum
production
What stage is someone who has normal spirometry with chronic symptoms of COPD?
stage 0: at risk
What stage is someone who has FEV1/FVC <70%, FEV1 >80% and with or without chronic symptoms of COPD?
stage 1: mild COPD
What stage is someone who has FEV1/FVC <70%, FEV <80% and with or without chronic symptoms of COPD?
stage 2: moderate COPD
What stage is someone who has FEV1/FVC <70%, FEV1 between 30-50% with or without chronic symptoms of COPD?
stage 3: severe COPD
What stage is someone who has FEV1/FVC <70%, FEV1 <30% or <50% with chronic respiratory failure?
stage 4: very severe COPD
2 assessments in COPD
mmrc (medical research council questionnaire)
cat (COPD assessment test)
Gold 1
FEV1 >80%
Gold 2
FEV1 50-79
Gold 3
FEV1 30-49
Gold 4
FEV1 <30
Category A COPD
- less risk (< 1exacerbations/year)
- less symptoms (<10 CAT; 0-1 mMRC)
- GOLD 1-2
Category B COPD
- less risk (< 1 exacerbations/year)
- more symptoms (>0 CAT; >2mMRC)
- GOLD 1-2
Category C COPD
- High risk (>2 exacerbations/year)
- Less symptoms (<10 CAT; 0-1 mMRC)
- GOLD 3-4
Category D COPD
- High risk (>2 exacerbations/year)
- More symptoms (>10 CAT; >2 mMRC)
- GOLD 3-4
Group A COPD treatment
bronchodilator
Group B COPD treatment
LAMA or LABA
Group C COPD treatment
LABA + ICS
Group D COPD treatment
LABA + LAMA + ICS
COPD comorbidities
CVD osteoporosis Respiratory infections anxiety depression diabetes lung cancer
additional screenings for COPD
- chest x ray (co-morbidities)
- lung volume capacity
- oximetry
- a-1 antitrypsin deficiency screening
Salmeterol, formoterol and tiotropium are what type of drug?
bronchodilator
ALL DPI
What is the GOLD guideline recommendation for first line in management of symptomatic COPD?
bronchodilators
Long acting inhaled bronchodilators vs short acting
long: more convenient, more costly
short: less convenient, less costly
T/F ICS withdrawal may lead to COPD exacerbation
true
Vaccines recommended in COPD
flu
pneumovax
When should you use antibiotics in COPD?
if suspected infection
- azithromycin, erythromycin
What are some non-pharmacologic ways to treat COPD?
- exercise training
- pulmonary rehab
- oxygen therapy
- surgical treatments
