Asthma - Muthiah Flashcards
what is a treatment modality, comparable to the lower barometric pressure experienced at elevation, that is used in the ICU for patients having acute severe bronchospasm
give them Helium oxygen mixture - makes the air less dense, eases the work of breathing, allows the physician to work on correcting inflammation and spasm (probably not on test, he liked it though)
what is the clinical definition of asthma
chronic INFLAMMATORY disorder of the airways, characterized by EPISODIC REVERSIBLE (reversible in early stages) bronchospasm resulting from an exaggerated bronchoconstrictor response to various stimuli
airway inflammation in asthma contributes to what (another buzzword) - which results in what other symptoms
airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity
what occurs in some patients with asthma, regarding persistent changes in airway structure? - give name and examples
airway remodeling - in some pts, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis
why does airway remodeling happen? what is the end result?
it is a result of these inflammatory attacks happening many times, to where some of the changes get left behind permanently - results in narrowing of airway lumen
what is the prevalence of asthma?
2-7 %
what percentage of children will “outgrow” their asthma into adulthood? why?
30-50%
may have to do with increasing the size of airways (diameter) and something to do with maturing your exposure to allergens, becoming less hypersensitive over time
what race is associated with higher risk of asthma death (must know - exam)
black - may have to do w/ genetic factors
does asthma have a preference for affected population? sex race age etc
no - asthma is equal opportunity employer
what is the trend in asthma prevalence rates recently? and what epidemic associated with
rates have been steadily increasing
may be associated with obesity epidemic (keep this in mind)
what is the trend in asthma related death rates since 2000?
they have decreased - possibly due to Advair, the combined long acting B agonist and corticosteroid in one inhaler
compare extrinsic v intrinsic asthma
extrinsic - atopic, allergic, we know what is causing it
intrinsic - idiosyncratic, non-allergic, we do not know what is causing it
what drugs are associated with drug induced asthma
ASA, NSAIDs
what is cough variant asthma? How is it diagnosed?
diagnosed through therapy trial - do not know what is causing pt’s cough, treat w/ bronchodilator, cough goes away, call it cough variant asthma
what is the rare form of Asthma that is important for step
Allergic Bronchopulmonary Aspergillosis - ABPA
What are the two classifications of asthma at dx?
intermittent or persistent
what are the 3 classifications of asthma at follow up
controlled, partially controlled, uncontrolled
what is the only treatment for intermittent asthma? what is this medication type called?
albuterol - rescue therapy - use as needed
what is the treatment plan for persistent mild asthma?
inhaled steroids - for inflammation
treatment plan for persistent moderate asthma (2)
inhaled steroids + long acting beta agonist
tx plan for persistent severe asthma (3)
inhaled steroids + long acting beta agonists + leukotriene modifiers
what is the black box warning assoc w/ LABA
LABA are assoc w/ increased mortality - use cautiously
extrinsic asthma - what inflammatory mediators associated? what about pt history?
IgE mediated - eosinophils too
there will be a family history
for pts w/ extrinsic asthma, what things do they need to avoid?
house dust mites, cockroaches, pets, mold
intrinsic asthma - what will you not see?
serum IgE is NOT elevated and they do not have eosinophilia
drug induced asthma - ASA, NSAIDS - what triad do you see?
1) asthma
2) aspirin sensitivity
3) nasal polyps
what is pathogenesis of drug induced asthma?
arachidonic acid can either go through the cyclooygenase pathway or lipoxygenase pathway/ admin of NSAID will block COX, shunt more AA down leukotriene path. leukotrienes are potent bronchoconstrictors - this will precipitate the attack
why is the pathogenesis of drug induced asthma important from treatment perspective?
these patients work really well when you start them on leukotriene receptor antagonists - don’t have to give steroids and B agonists
what is typical presenting history of occupational asthma?
pt has asthma every weeknight evening. on weekends they feel better. they go on vacation and the asthma goes away entirely
(good, good, to know) - in exercise induced bronchospasm, when does the bronchospasm occur? pathogenesis?
immediately AFTER exercise (5-10 min after)
patho - it is due to cooling and mucosal drying of airways during exercise - thought to trigger mast cells to release histamine
what are two treatments (concurrent) for exercise induced bronchospasm
1) pre-treat w/ B-agonist
2) slow warm up period
REDBOX (test) - what is the cause of nocturnal asthma
common between midnight and 8AM - due to decline of circulating catecholamines (bronchodilator) and cortisol (anti-inflammatory)
what is type of hypersensitivity and mediator in allergic bronchopulmonary aspergillosis (ABPA)
astham due to specific fungi, aspergillus fumigatus
IgE mediated reaction and type III IgE mediated response
what are 4 main criteria for ABPA dx?
1) symptoms
2) antigen test
3) CBC value
4) another level of something in the blood
1) poorly controlled asthma
2) A. fumigatus positive skin antigen test
3) significant Eosinophilia (huge)
4) IgE greater than 1000ng/mL (this is also huge)
what is mainstay of tx for ABPA
prednisone
what are some other criteria for dx of ABPA (probably not test, but still seems impt)
1) proximal bronchiectasis
2) fleeting chest infiltrates
3) peripheral eosinophilia w/ chest infiltrates
recall the general pathophysiology for asthma
airway hyperresonpsiveness due to inflammation, epithelial injury, neural mechanism (too much vagal tone) - all this leads to airflow obstruction
what mediator do we use to modulate each of the following? (this is must know)
1) eosinophils
2) mast cells
3) Eosinophilic Cationic Protein (ECP)
4) Histamine
5) leukotrienes
6) IgE
7) vagal afferent and efferent
8) IL-5
1) steroids
2) Cromolyn
3) (not sure)
4) H1 blockers
5) LTRAs
6) Omalizumab
7) Anticholinergics
8) Mepolizumab
what crystal is associated with asthma?
Charcot-Leyden Crystals
what happens to the epithelium in asthma?
disruption - loss of ciliated cells to complete denudation of epithelium
increased permeability to inhaled allergens promotes hyperresponsiveness
increased mucous and resp secretions
nerual mechanisms - what autonomic tone predominates in asthma? how do we treat
elevated parasympathetic tone (vagal tone - thus bronchoconstriction) - anticholinergics attenuate this - cause bronchodilation
memorize - compare asthma and COPD w/ onset
asthma - younger age
COPD - older age
memorize - compare asthma and COPD w/ type of inflammation
asthma - eosinophilic
COPD - neutrophilic
memorize - compare asthma and COPD w/ relevant lymphocytes
asthma - CD-4
COPD - CD-8
memorize - compare asthma and COPD w/ relevant interleukins
asthma - IL-5
COPD - IL-8
memorize - compare asthma and COPD w/ allergy history
asthma - usually present
COP - not usual
memorize - compare asthma and COPD w/ reversibility of bronchospasm
asthma - usually present
COPD - variable, and limited
memorize - compare asthma and COPD w/ what predominates during exacerbation
(MUST KNOW)
asthma - neutrophils
COPD - eosinophils
(note the diff from initial type of inflammation)
what symptoms clue you in to dx of asthma
SOB or wheezing that is seasonal/after exposure to allergens etc
what does death from asthma usually result from
diffuse mucous plugging of airways
asthma diagnostic tests -PFTs - FEV1 and FEV1/FVC
reduction of FEV1, FEV1/FVC - this reverse with bronchodilators
MUST KNOW - reversibility criteria
12% improvement AND 200cc increase in FEV1 and/or FVC
what is the lung volume status of asthma during attack
hyperinflated
REDBOX (exam) - what is the clinical utility of the Methacholine Challenge test?
it has a high negative predictive value - use it to rule out asthma (a positive result on methacholine test is much less useful than a negative one)
what is one random trigger of asthma?
GERD - even acid refluxed into part of esophagus is enough to trigger bronchospasm (b/c of common embryological origin or something)
what medication should you not use for asthma?
Primatene Mist - epinephrine, should not use
asthma medications, what are the 2 relievers? (need to know)
1) short acting Beta 2 agonists
2) short acting Anticholingergics
asthma meds - what are the 7 controllers? (need to know)
1) inhaled corticosteroids
2) inhaled LABA
3) LAMA
4) leukotriene modifiers
5) systemic steroids
6) Anti IgE
7) Anti IL-5
