Asthma FINAL EXAM Flashcards
What does AIR stand for?
-AIR: Anti-Inflammatory Reliever
f.e. ICS-formoterol (formoterol is long-acting but has quick onset -> can be used for rescue), ICS-SABA (not in USA)
-AIR only: ICS-formoterol used as needed for symptom relief (not for therapy)
How is AIR better than SABA alone for rapid symptom relief?
Reduces risk of exacerbation, compared to SABA alone
What does MART (SMART) stand for?
-MART: Maintenance and Reliever Therapy with ICS-formoterol for daily use; used for treatment (every day) + as needed
-SMART: same as MART, S stands for a single device
-ICS-formoterol can also be used before exercise or allergen exposure
What is Asthma?
-Airflow obstruction (like in COPD, but reversible)
-Bronchial hyperresponsivness
-Symptoms are variable and recurring
What is the hallmark of Asthma?
-Bronchial hyperresponsivness
-overreaction (constriction) of bronchioles to triggers (allergens, cold air, etc)
Which cells/molecules are involved in causing Asthma?
-Immune cells: T-lymphocytes, Macrophages, Eosinophils, Neutrophils, Mast cells, Epithelial cells
-Inflammatory mediators: Interleukin (f.e. IL-5), IgE (omalizumab), Chemokines, Leukotrienes, TNF-α, Nitric oxide
Pathophysiology of Airways in Asthma
-Constriction of the airway
-Wall inflamed and thickened
-Air trapped in Alveoli
What causes Asthma?
-Not proven
-Hygiene Hypothesis: less exposure of babies to microbes leads to less Th1 and more Th2 inflammatory profile
-Genetics: 60-80% of susceptibility related to genes
Atopy -> genetic predisposition to IgE-mediated response environmental antigens (strongest predisposing factor)
What are the long-term consequences of asthma?
-Airway remodeling leading to fibrosis and scarring of parenchyma (long tissue) -> can lead to COPD or other irreversible pathology
-Mucus overproduction: hyperplasia and hypertrophy of Goblet cells, epithelial cells slough off to mucus -> mucus plugs (can be deadly)
-Airway smooth muscle hypertrophy and hyperplasia - may contribute to hyperresponsiveness of bronchioles - treatment counteracts the hyperresponsiveness
Clinical presentation of asthma patients
-diverse: some pt with severe and some with mild asthma
-symptoms vary from complete remission to severe exacerbation (you never know when a pt will have an asthma attack)
How to diagnose asthma
-Pulmonary function test (PFT)
-Family history
Chronic Asthma Symptoms
-Shortness of breath (may be exercise-induced -> take puffs before exercising)
-Wheezing
-Chest tightness
-Chronic cough (at night)
-Dermatologic (eczema, inflammation of the skin)
-Allergic rhinitis
-symptoms worsen due to exercise or cold air, dry air
Acute asthma Symptoms
-Anxiety
-Severe shortness of breath
-chest tightness/burning
-tachypnea, tachycardia
-using accessory muscles for breathing
-pale skin
-doesn’t respond well to usual treatment
What are the different manifestations of asthma?
-chronic, underlying
-acute exacerbation: can occur in a few minutes and symptoms may persist for days
-exercise-induced: often triggered by cold and dry air
-nocturnal asthma: can be worsened by uncontrolled comorbidities: GERD, OSA (obstructive sleep apnea), sinusitis, environment, allergies, diurnal pattern of cortisol release
What are the risk factors for increased severity of asthma?
-Viral respiratory infections!!!
-Environmental exposure
-lower socioeconomic status
-Stress, depression
-Rhinitis/sinusitis
-Pregnancy, female hormones
-GERD
-Food allergies, Obesity
-Drugs
What are common drugs causing increased severity of asthma?
-Aspirin
-NSAIDs
-Non-selective ß-blocker
What are important questions to ask to assess for asthma (GINA guidelines)
-Daytime asthma symptoms more than twice a week?
-any night awakening due to asthma?
-SABA reliever for asthma more than twice a week?
-activity limitation due to the asthma?
Yes: 1-2x -> partially controlled asthma
Yes: 3-4x -> uncontrolled asthma
What are the goals of treatment?
-Symptom control
fewer asthma symptoms
no sleep disturbance
no exercise limitation
-Risk reduction
maintain normal lung function
reduce flare-ups (exacerbation)
prevent asthma deaths
reduce drug side effects
Peak Flow meter
-adjustable red light system (individual breathing performance)
-green: 80% of personal best, continue current therapy
-yellow: 50-80%, make changes to prevent worsening
-red: <50%, seek medical attention
How to use the Peak flow meter
-measures how fast and hard the air can be blown out of the lung
1. The marker should be at the bottom of the scale
2. stand or sit up straight, chin up, and look straight ahead
3. blow out and empty the lungs
4. breath in as much as possible
5. put the mouthpiece between teeth and close with lips tightly
6. blow out as hard and fast as you can
7. repeat 3x times and record the highest score
8. keep a record for two weeks (same time of the day when feeling well)
2Non-pharmacological approach for asthma
-reduce triggers
-control comorbidities
-education of self-management
-Health maintenance:
->vaccines: Influenza (anyone under 6), pneumococcal (before 65 with asthma), COVID, RSV
What is the long-term treatment of asthma?
-Inhaled Corticosteroids
-3 categories: Low, Medium, High dose (use to the lowest possible dose)
-patients concerned about linear growth in children (no risk according to literature)
-counsel on oral care (candidiasis)
Steroid dose-depending effect
-the dosing is not linear to the magnitude of the effect
-no doubling of effect when increasing the dose
-low dose preferred
QUESTION
-should asthma be treated by regular drug intake (like COPD)
-any harm in taking too much of bronchodilators
-is the efficacy reduced after time, when taking the drug more often than directed
-What is a good way to help in acute asthma episodes that could not be controlled by albuterol? give IV prednisone -> PO Prednisone
-When is it appropriate to recommend a nebulizer? -> EXACERBATION
-Can ICS-Formoterol be used for Stage 3 as MERT and as a short term reliever at the same time, or should DIFFERENT bronhodialtor be used for rescue treatment?
When are Leukotrienes appropriate to use?
-often used for kids with allergies or asthma
-alternative treatment for persistent asthma (not preferred over ICS)
-can be used as an adjunct therapy in addition to ICS (addition of LABA to ICS is more preferred in those older than 12y)
What are the Leukotriene Modifiers used/not used for kids
-Montelukast (6 mo) and zafirlukast (5 yr)
-5-lipoxygenase inhibitor (zileuton) (no peds)
Why is Zileuton (Leukotriene synthesis inhibitor) less preferred than Leukotriene receptor antagonist?
-limited efficacy data
-need for liver function monitoring
What are the common side effects of Leukotriene Modifiers?
-Headache is a common side effect
-Some experience neuropsychiatric effects (suicidal or homicidal thoughts)
How is LABA supposed to be used in patients with Asthma?
-as an adjunct to ICS for providing long-term control – NEVER used alone!! (preferred in pt older than 12)
-not for quick relief (except for formoterol)
When to use Oral Corticosteroids
-only short-term- WHY??? -> because we dont want systemic exposure for a long period of time
-in case of moderate to severe exacerbation
-prescription on hand for early treatment of exacerbations (part of the asthma action plan to start oral steroids right away and call the provider)
How often are oral steroids appropriate to use before reevaluation of oral asthma controller therapy?
3 times a year
When is Tiotropium used for asthma treatment?
-the patient is on ICS/LABA + rescue (SAMA) and still not controlled
-only approved for SoftMist inhaler
MOA for Omalizumab (Xolair)
-Anti-IgE antibody which prevents the binding of IgE to receptors on mast cells and basophils
-Leads to a decreased release of inflammatory mediators upon allergen exposure
When is Omalizumab (Xolair) used?
QUESTION Do we need to know the brand names for the Antibody drugs
-high-dose ICS and LABA and still not controlled allergies and severe persistent asthma
Dosing for Omalizumab (Xolair)
-Given SubQ every 2 – 4 weeks
-dosed on IgE serum levels
-dosed on the body weight
Things to consider for Omalizumab (Xolair)
-Boxed warning for anaphylaxis (life-saving environment: EpiPen - for all -mabs)
-approved for those 6 or older
MOA for Mepolizumab (Nucala)
-antibody against interleukin-5 (IL-5)
-IL-5 most specific cytokine in eosinophil regulation
-uncontrolled asthma with steroids, as adjunct (high eosinophils in asthma patients)
Dosing for Mepolizumab (Nucala)
-SubQ injection
-Dose: 100 mg Q4 weeks SubQ
-NO adjustment for age, weight, or organ function
-FDA indicated for those 12 and older
MOA for Reslizumab (CINQAIR)
-IL-5 Antibody
Dosing for Reslizumab (CINQAIR)
Difference to Mepolizumab
-IV
-3 mg/kg dosed Q4 weeks
-based on weight!
-approved for eosinophilic asthma and 18 years of age or older
MOA for Benralizumab
-Targets IL-5 (Fasenra)
-Specifically leads to apoptosis of eosinophils
IL-5 drugs
-Mepolizumab (Nucala)
-Reslizumab (CINQAIR)
-Benralizumab (Fasenra)
MOA for Dupilumab (Dupixent)
-Targets IL-4/IL-13 complex
-IL-4/IL-13 seen in many allergic conditions
-Effective for eczema/atopic dermatitis as well
SABA - indication
-Albuterol (or Formoterol - LABA w/ fast onset)
-used for rescue therapy
-used for exercise-induced-bronchoconstriction
-improvement within 5 minutes
SABA - Contraindication
-Regular, scheduled use of SABA is not recommended -WHY -> TOLERANCE??
-Use > 2 d/wk for symptoms usually indicates
inadequate control and need for intensified therapy
How to prevent Exercise-induced Bronchoconstriction (EIB)?
-Recommend a SABA 15 minutes before
-LTRAs need to be taken a few hours before exercise (helps half of patients)
-Recommend a warm-up period
-Cover your mouth with a mask or scarf to warm the air
Patients with Asthma before Surgery
-for moderate to severe asthma, may use stress dose hydrocortisone perioperatively
Asthma during Pregnancy
-Negative outcomes for baby if not well-controlled
-Monitor regularly
-Albuterol for SABA and budesonide for ICS are preferred
Asthma regimen GINA guidelines
TRACK 1
Step 1-2: As needed: low dose of ICS-formoterol
Step 3: Maintenance: Low dose ICS -formoterol
Step 4: Maintenance: Medium dose ICS-formoterol
Step 5: Add LAMA and refer to a specialist (phenotype assessment) or
Maintenance: high dose ICS-formoterol +- anti-IgE, IL-5/IL-4
CONCURRENT USE OF AIR: low-dose ICS-FORMOTEROL as needed
Asthma regimen GINA guidelines
TRACK 2
Step 1: Take ICS whenever SABA is used
Step 2: Maintenance: low dose of ICS
Step 3: Maintenance: low dose of ICS-LABA
Step 4: Maintenance: Medium/high dose of ICS-LABA
Step 5: Add LAMA and refer to a specialist (phenotype assessment) or
Maintenance: high dose ICS-formoterol +- anti-IgE, IL-5/IL-4
CONCURRENT USE OF AIR: ICS-SABA or SABA as needed
Asthma Myths
LABA needs to be stopped ASAP - FALSE
Spare initiating ICS therapy - FALSE
-the earlier the better
-stopping ICS in adults is not advised due to the
increased risk of exacerbations
-Consider stopping controller only if no symptoms for 6-12 months, no risk factors, asthma plan and close follow-up with provider
Asthma Myths II
-Ashtma plans are only for those with uncontrolled asthma - FALSE
-Low inhaler adherence due to complex regimens -False - once daily regimen available (Budesonide, ciclesonide, mometasone)
Asthma Myth - Height
-Budesonide v. placebo: shorter by -1.2 cm (~0.5 inches)
-Differences occurred during the first 2 years of treatment, but all had normal growth velocity after 2 years
-Longer history of asthma and atopic asthma: a risk factor for reduced height
Risk factors for Asthma exacerbation
-no access to ICS, ICS not prescribed; poor adherence; incorrect technique; excessive SABA use (Albuterol - more than one inhaler a month (200 inhalations or more than 12 inhalations a day (maintenance + reliever)
-Comorbidities
-Allergen exposure: smoking, air pollution
-low lung function
-Setting: socioeconomic status
-History: intubation related to asthma
Treating Asthma Exacerbation
-Oxygen
-Bronchodilator (Albuterol)
-Systemic Steroids (PO, IV, IM)
Dosing Albuterol - Asthma Exacerbation
-4 puff every 20 mins x 1hr
-then 2-4 puffs every 3-4 hr
-or 6-10 puffs every 1-2 hr
-inpatient: Ipratropium (LAMA) added
Dosing Steroid - Asthma Exacerbation
-1mg/kg per day
-40-50 mg prednisone or equivalent for 5 days (3-5 days for kids)
Action Plan Stage YELLOW
-Asthma Flare-ups
-over a period of 2-3 days: symptoms are getting worse or no improvement
-more than 6 budesonide/formoterol rescue inhalations a day
What to do at Stage YELLOW
-GOAL is to prevent Asthma EMERGENCY (RED)
-Continue using everyday treatment + 1 inhalation of budesonide/formoterol as needed (reliever)
-start a course of prednisone (on-hand prescription)
-contact doctor
-if more than 12 budesonide/formoterol in a day is needed: see the doctor or go to the hospital on the same day
Signs of asthma emergency
-Symptoms getting worse quickly
-Extreme difficulty speaking or breathing
-little or no improvement with budesonide/formoterol inhalation
What to do in an asthma emergency
-call 911
-sit upright and stay calm
-take 1 inhalation of budesonide/formoterol - wait 1-3 min and take another one if needed (max 6)
-if only albuterol is available - take 4 puffs as often as needed
-start a course of prednisone
-even if symptoms settle quickly, see doctor after a serious asthma attack
Agent to use to treat moderate to severe asthma perioperatively?
stress dose of hydrocortisone
Max dose for budesonide a day?
12 inhalations
Max dose albuterol per month
not more than 1 inhaler (200 inhalations)
