Asthma Exacerbation and Chronic Asthma Management Flashcards
also includes aspirin exacerbated respiratory dx
duration and dosing of prednisone in mild to moderate asthma exacerbation
5-7 days of prednisone 40-60 mg daily appropriate for mild to moderate asthma exacerbation.
Do we use antibiotics for asthma exacerbations
no.
Do you use intranasal steroid therapy (budesonide) in exacerbation?
no.
what is the most common cause for ineffective inhalers
poor inhaler technique (45%) Need to exhale before inhalation or inhalation through the nose
Correct inhaler method
full exhalation followed by deep inhalation and then breath hold. Sometimes a metered dose inhaler should be slow 405 seconds for adults and inhalation with a dry poweder should be fast and start immediately.
IN treatment of a acute asthma exacerbation, what should pts be discharged on:
oral steroids for 3-10 days inhaled corticosteroids personalized asthma action plan
while hospitalized what is the ED protocol of management for acute asthma exacerbation?
inhaled beta agonist (repeated doses) corticosteroids IV or PO if able to tolerate maintain oxygen saturation for SaO2>92% ipratropium bromide if failure to improve with beta agonist.
severe asthma exacerbation is defined as
peak flow <200 L/min or <40% of normal peak flow
moderate asthma exacerbation is defined as:
<70% of normal peak flow
moderate to severe asthma exacerbations are treated with
systemic steroids. IV and PO are equivalent but prefer IV if in respiratory distress
indication for maintenance inhaled corticosteroids
one episode of asthma exacerbation severe enough to merit hospitalization
duration of steroid therapy in severe asthma exacerbations
3 to 10 days for most patinets no need to taper since it will be <3 weeks.
nocturnal asthma like symptoms could be the result of:
true nocturnal asthma, GERD, OSA, upper airway cough syndrome
symptoms suggestive of nocturnal asthma like symptoms that are actually: GERD
frequent regurgitation symptoms (worse at night) awakenings with heart burn possible cough and wheezing responds to PPI
symptoms suggestive of nocturnal asthma like symptoms that are actually: OSA
difficulty maintaining sleep and daytime sleepiness awakenings with cough responds to intranasal corticosteroids
symptoms suggestive of nocturnal asthma like symptoms that are actually: upper airway cough syndrome
daytime rhinorrhea or allergic symptoms awakenings with cough responds to intranasal corticosteroids
symptoms suggestive of nocturnal asthma like symptoms that are truly related to NOCTURNAL ASTHMA
symptoms usually are between 2-4am awakenings with cough and wheezing responds to albuterol or step up in asthma therapy
retrognathia is
lower jaw is set further back than upper jaw making it look like someone has a severe overbite.
step up therapy for asthma
nocturnal asthma symptoms
allergic rhinitis as a cause for nocturnal asthma would have findings of
inflamed nares, pharyngeal erythema and cobblestoning for signs of post nasal drip
tx with inhaled corticosterois (fluticasone)
chart with asthma severity levels
intermittent asthma is defined by:
<2 days/week or nighttime awakenings <2/month
Mild persistent asthma is defined as:
>2 days/week but NOT daily
or night time symptoms 3-4x/month
moderate persistent asthma definition of severity
daily symptoms
nighttime symptoms are >1 week/wk but not nightly
severe persistant asthma definition
symptoms throughout the day
nighttime awakenings symptoms: often 7x/week.
what do we see in allergic bronchopulmonary aspergillosis (ABPA) with persistent asthma
see episodes of bronchial obstruction, malaise, fever, expectoration of brownish mucous plugs, hemoptysis, peripheral blood eosinophilia and elvated serum IgE.
CXR in ABPA shows parenchymal infilitrates (often involving upper lobes) and/or bronchiectasis.
asthma step up therapy
what is the black warning about asthma treatment
it’s about the chronic use of LABA as it can cause severe exacerbations and asthma related deaths.
Effect of LABA is dminished or prevented by concomitant use of ICS. DO not use LABA agent alone as a single agent.
What is aspirin exacerbated respiratory disease (AERD)?
what is the natural disease history for this syndrome?
this is seen in 20% of asthmatics and presents with classic triad of chronic rhinosinusitis with polyposis, asthma, and aspirin (or NSAID) sensitivity
They develop refractory rhinitis in their 30’s followed by chronic rhinosinusitis with anosmia and nasal polyposis. Then rhinosinusitis progresses to lower airway inflammation causing asthma. Aspirin and NSAID sensitivity develops during this progression. Then NSAIDs can cause lifethreatening asthma, nasal or ocular symptoms and facial flushing or erythema.
what are the metabolic pathways of NSAIDS that cause proinflammatory pathways
Arachidonic acid metabolic pathways chart
chart for aspirin exacerbated respiratory disease
what causes the aspirin exacerbated respiratory disease
likely a shift in the arachidonic acid metabolic pathway which leads to excesive leukotriene production and this is not a IgE mediated allergy response.
Diagnosis of Aspirin exacerbated respiratory disease
How to treat this?
diagnosis: made with clinical history of aspirin or NSAID reaction
Treatment: optimal asthma therapy and surgery for chronic rhinosinusitis, and advoidance of NSAIDS or aspirin.
Can also use montelukast (leukotriene receptor antagonist) per guidelines to improve pulmonary and sinus symtpoms.
Aspirin desensitization is considered in pts refractory to therapy or who require aspirin/NSAIDS for other condition (CAD or chronic headaches).
What is reactive airway disease syndrome?
form of occupational asthma that occurs in context of workplaces and subcategory of irritant induced asthma. Not a immunological asthma
this happens following a single high dosed exposure with inhaled irritant is termed reactive airway dx.
can be seen after chlorine, ammonia, paint, diesal fumes, bleach and other cleaning agents
need at least 3 months of asthmatic symptoms following exposure and confirmed with obstruction or bronchial hypersensitivity.
how to diagnose reactive airway disease?
methacholine challenge test is positive
spirometry may show obstruction but need the methacholine challenge test.
Prognosis with reactive airway disease?
variable. some may improve with steroids but others respond poorly to typical asthma therapy.
some will suffer from persistent asthma like symptoms (requiring inhaled glucocorticoids and bronchodilators) and others will have complete resolution in 2 years.
exercise induced bronchoconstriction:
transient form of upper airway hyperresponsiveness that occurs with strenous activity.
EIB can occur in pts who DON’T have history of asthma. due to increased minute ventilation during exercise and leads to increased exposure to environmental sitmuli (cool dry air, chlorine, outdoor allergens
Exertion is a common trigger for bronchoconstriction in pts with asthma,
how to treat exercise induced bronchoconstriction?
short acting beta 2 agonists like SABA (albuterol)
are useful in both treatment and prevention of EIB and should be given 5-15 minutes prior to exercise for prophylaxis
Frequent SABA use may lead to tolerance and paradoxical increased airway hyperresponsiveness
if this happens, need a second agent:
- inhaled corticosteroids: can take 4 weeks to reach peak effect but can be beneficial in pts with uncontrolled underlying asthma
- leukotriene receptor antagonists (LTRAs) - montelukast - rapid effect and avoid use of daily inhaler.
Need to get PFTs when not having an exacerbation.
what is allergic asthma?
it’s a subtype of asthma or phenotype seen with atopy
diagnosed with allergy skin prick tests and measurement of allergen specific IgE. Never measure total IgE levels because normal doesn’t mean that they don’t have allergic asthma
can see elevated serum or sputum eosinophils
important to diagnse becasue can benefit with omalizumab (monoclonal antibody for targeting IgE in severe atopic asthma) Can also need systemic steroids and antiinterluekin therapies like mepolizumab
what mimics exercise induced bronchospasm?
cardiac disorders and vocal cord dysfunction
need to make sure that there’s bronchial hyperreactivity to make accurate diagnosis
non pharmacological tx of exercise induced bronchospasm
wear a mask or scarf to warm up cold air before inhalation
what is cough variant asthma?
asthma whos primary symptom manifestation is chronic cough without other symptoms.
Diagnosis requires documentation of bronchial hyperreactivity as baseline spirometery will be normal. Need to have same therapy as other asthma.
Need to rule out other causes of chronic cough like GERD, upper airway cough syndrome from rhinitis
Occupational asthma is seen with
direct exposure by sensitizing or irritant substances in the work place and preexisting asthma that is exacerbated the same factors.
seen with animal, plant allergens, latex, grains and diisocyanates.
people at risk for occupational asthma
farmers, animal workers, healthcare workers, latex glove users, bakers, manufacturerers of polyurethane products
treatment of occupational asthma
and how to diagnose?
diagnosis: spirometry before and after workplace eposure is cost effective way to confirm
- can see bronchial hyperrreactivity through bronchial challenge testing
Tx: reduce exposure to offending agent through workplace modifications or removing pts from the workplace entirely
classic triad of
chronic rhinosinusitis with polyposis (nasal polyps),
airway and peripheral eosinophilia
persistent severe asthma,
Seen in a young adult and develops severe life threatening bronchospasm after NSAID or aspirin
Aspirin exacerbated respiratory dx
Chronic management is no NSAIDs, and no leukotriene receptor antagonists
May need aspirin desensitization.
Chronic eosinophilic pneumonia is
rare idiopathic disorder with abnormal accumulation of eosinophils in lung. See asthma preceding diagnosis in 50% of cases. Peripheral eosinophilia and elevated IgE are present.
See bilateral upper lobe opacities or peripheral or pleural based opacities often called a “photographic negative” of pulmonary edema.
Chronic Eosinophilic Pneumonia presentation: insidious onset of fever, cough, progressive dyspnea, wheezing, weight loss. NO respiratory failure unlike AEP.
see peripheral eosinophilia>6% and elevated ESR and CRP, thrombocytosis.
BAL>25% eosinophils suggests this
lung biopsy will show interstitial and alveolar eosinophils with multinucleated giant cells and associated bronchiolitis obliterans with organizing pneumonia.
Respond to steroids within 48 hrs. lack of improvement point to different etiology.
Tx of steroids continues for 3 months until tapered over following 3 months.
some is complaining of wheezing that is intermittent and varying intensity and sometimes happening at night. What is the differential for wheezing and how to evaluate for this?
interimittent wheezing - a course whistling sound caused by airflow in a narrow airway
differential diagnosis: asthma, bronchospasm, CHF (cardiac asthma), vocal cord dysfunction, post nasal drip and both intra and extrathoracic obstruction
Initial evaluation of stable pts for wheezing: PFTs (spirometry)
CXR can be obtained for focal or persistent wheezing
CT chest is based on those initial findings.
Chronic Eosinophilic Pneumonia presentation
labs:
BAL findings?
Chronic Eosinophilic Pneumonia presentation: insidious onset of fever, cough, progressive dyspnea, wheezing, weight loss. NO respiratory failure unlike AEP.
see peripheral eosinophilia>6% and elevated ESR and CRP, thrombocytosis.
BAL>25% eosinophils suggests this
lung biopsy will show interstitial and alveolar eosinophils with multinucleated giant cells and associated bronchiolitis obliterans with organizing pneumonia.
Treatment of Chronic Eosinophilic Pneumonia
Both acute and chronic eosinophilic pneumonia respond to steroids within 48 hrs
continue for 3 months with steroids and t_hen taper gradually over following 3 months_ (6 months of steroids)
how to treat pregnant women with asthma?
same way you treat non pregnant woman
easier to treat than to deal with asthma symptoms or exacerbations because of increased perinatal complications and maternal morbidity
management while pregnant:
objective monitoring of lung function,
avoiding controlling asthma triggers,
educating pts on minimal amount of drug necessary to control symptoms.
If you have asthma pt who presents with an asthma exacerbatio nand appears to be in moderate respiratory distress
breathing shallow and no wheezing or rales or rhonchi. Stat CXR is clear. What do you do next?
intubate. If in asthma exacerbation and he is not wheezing and normal lung exam means he is not moving much air and needs to be intubated or has impending respiratory failure.
most typical acid base disturbnce in asthma exacerbation?
respiratory alkalosis is typical
respiratory acidosis and high CO2 is sign of respiratory failure and needing intubation.
can see normal pH which is an omnious sign of fatigue.
