Asthma Exacerbation Flashcards

1
Q

What are the two types of asthmatic response?

A

Early asthmatic response

  • triggered by allergens
  • peak bronchoconstriction within 15-20minutes, lasts 1-2 hrs

Late asthmatic response

  • due to activation of inflammatory pathways
  • seen 4-12 hrs after initial challenge
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2
Q

Which class of medication does not inhibit or attentuate EAR?

A

Steroids

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3
Q

Which two drugs are able to decrease hyperresponsiveness?

A

Steroids

Cromolyn

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4
Q

Which drugs are good for EAR control?

A

SA, LA, Cromolyn, Theophylline, Ipratropium, Omalizumab, LKA

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5
Q

Which drugs are good for LAR control?

A

LA, Steroids, Cromolyn, Theophylline, Omalizumab, LKA

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6
Q

Which demographic and sex are a risk factor for asthma exacerbations?

A

Female, nonwhite

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7
Q

When measuring PEF at home, how do you assess the severity of asthma?

A

50-79% of best or predicted indicates need for quick relief med

<50% best or predicted indicates immediate medical care

Note for any SOB and speech in phrases

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8
Q

What is the treatment algorithm at home?

A

Initial treatment: inhaled SABA up to two doses every 20 minutes of 2-6 puffs via MDI or nebulizer treatments

If good response (>80% PEF) –> continue SABA and maybe add steroid

If incomplete response (50-79%) –> continue SABA and add steroid –> contact MD

If poor response ( immediate SABA repeat and steroid –> call 911

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9
Q

What are some things that are not recommended for asthma management at home?

A
  • Drinking large amounts of liquids
  • Breathing warm, moist air
  • OTC products like diphenhydramine
  • Pursed lip breathing
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10
Q

Which methods of spirometry are used to diagnose patients with asthma and its severity?

A

Forced expiratory volume in one second (FEV1)

Peak expiratory flow (PEF)

FEV1 is recommended because it is less susceptible to cheating

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11
Q

What other ways other than spirometry are available to diagnose asthma? When would you use them?

A

Pulse oximetry

- PEF < 25% after initial treatment

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12
Q

When measuring PEF at the ED, how do you assess the severity of asthma?

A

70% PEF -> mild
40-69% -> moderate
severe

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13
Q

What is the treatment algorithm at the ED?

A

If mild to moderate (FEV1 or PEF > 40%)

  • SABA MDI with VHC or neb up to 3 doses in 1 hr
  • Give O2
  • PO steroids

If severe (FEV1 or PEF < 40%)

  • Hi dose SABA and anticholinergic by MDI with VHC or neb q20minutes in 1 hr
  • Give O2
  • PO steroids
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14
Q

In terms of ingredients, compare albuterol and Levalbuterol.

A

Albuterol is a racemic mixture while levalbuterol has only the active isomer (R-isomer)

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15
Q

What is the dosing of Albuterol? (ADULT)

A

NEBULIZER
2.5-5mg q20 minutes for 3 doses
THEN 2.5-10mg q1-4 hours PRN

MDI
4-8 puffs q20 minutes up to 4 hours
THEN q1-4 hours PRN

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16
Q

What is the dosing of Levalbuterol? (ADULT)

A

NEBULIZER
1.25-2.5mg q20 minutes for 3 doses
THEN 1.25-2.5mg q1-4 hours PRN

MDI
4-8 puffs q20 minutes for 3 doses
THEN q1-4 hours PRN

17
Q

What is the dosing of Ipratropium? (ADULT)

A

NEBULIZER
0.5mg q20 minutes for 3 doses
THEN PRN

MDI
8 puffs q20 minutes PRN for up to 3 hours

18
Q

Can you mix ipratropium and albuterol in the same nebulizer?

A

YA

19
Q

What are the dosings of corticosteroids? (ADULT)

A

Prednisone
Methylprednisolone
Prednisolone

40-80mg/day in 1 or 2 divided doses

Give for 3-10days

20
Q

Treatment algorithm for continued management at the ED?

A

Moderate Exacerbation (FEV1 or PEF 40-69%)

  • inhaled SABA every 60 minutes
  • add oral corticosteroid

Severe Exacerbation (FEV1 or PEF<40%)

  • Give O2
  • Nebulized SABA + ipratropium hourly or continuous
  • Oral corticosteroids
  • Adjunctive therapies
21
Q

What are some adjunctive treatments?

A

Noninvasive ventilation
IV beta 2 agonists
Magnesium

22
Q

What are the dosings of IV epinephrine and terbutaline?

A

Epinephrine - 0.3-0.5mg SQ q20 minutes for 3 doses

Terbutaline - 0.25mg SQ q20 minutes for 3 doses

23
Q

What is not recommended for continuous therapy?

A
Methylxanthines
Antiobiotics
Aggresive hydration
Mucolytics
Sedation
Chest PT
24
Q

What are the categories of responses after treatment? What are the criteria for each category?

A

Good Response

  • PEV1 or PEF >70%
  • response is sustained for at least 60 minutes

Incomplete Response

  • PEV1 or PEF 40-69%
  • mild to moderate symptoms

Poor Response
- PEV1 or PEF 42mmHg

25
Q

What are some risk factors for death?

A

Previous exacerbations
2 or more hospitalizations for asthma in the past year
3 or more ED visits in the past year
Hospitalization or ED visit for asthma in past month
Using 2 or more canisters of SABA per month
Poor perception of asthma
Lack of a written action plan

26
Q

What did the SMART trial establish?

A

LABAs (salmeterol as an example in the study) can lead to respiratory and asthma death if used for long periods of time
- African americans were more susceptible to these warnings

27
Q

Which medications do you want to avoid in asthma patients?

A

Beta blockers (including eye drops)

28
Q

What step in the algorithm is omalizumab used in? What is its indication?

A

Step 5 and 6

Indicated in moderate or severe persistent allergy related asthma inadequately controlled with inhaled steroids if >12 YO

must have positive skin test to perennial allergen

29
Q

What does the dosing of omalizumab depend on?

A

Patient’s IgE concentrations and weight

30
Q

What is an important ADR with omalizumab? What can be done to account for this?

A

Anaphylaxis

Make sure patient is prescribed an EpiPen

31
Q

What did the EXCELS trial establish?

A

Omalizumab can increase the risk of:

  • MI
  • unstable angina
  • TIA
  • Pulmonary embolism/ venous thrombosis
  • Pulmonary hypertension
32
Q

What did the TALC trial establish?

A

Tiotropium might be of use with patients that are not able to take or have poor responses with LABAs

33
Q

What is bronchial thermoplasty? How many procedures are needed and what must be done before the procedure?

A

It is a surgical procedure that attempts to stop bronchospasms. Used in patients with severe asthma.

Must go through 3 procedures (left, right both lungs)
and prescribed 5 days of 50mg prednisone 2-3 days prior

34
Q

What did the DREAM trial establish?

A

Mepolizumab showed to be reduce exacerbation rates and increase FEV1 by reducing eosinophillic inflammation

35
Q

What did the SIRIUS trial establish?

A

Using mepolimuzab has shown to reduce the need for oral corticosteroid use