Asthma Quiz Flashcards
What are some examples of obstructive airway disorders?
Asthma, COPD
What type of disorder leads to a decrease in airflow?
Obstructive; Asthma and COPD
Which type of airway disorder has no change in volume of air the lungs hold?
Obstructive disorders; Asthma and COPD
What are examples of restrictive disorder?
Kyphosis, chest wall deformities, pleural effusions (TB, CHF), and sarcoid
What type of airway disorder has no change in airflow?
Restrictive disorders: kyphosis, chest wall deformities, pleural effusions (TB, CHF), and sarcoid
What type of airway disorder has a decrease in volume of air the lungs can hold?
Restrictive disorders; kyphosis, chest wall deformities, pleural effusions (TB, CHF), and sarcoid
How does asthma make it hard to breathe?
The muscles of bronchial tubes tighten and thicken, and the air passages become inflamed, and mucus-filled, making it difficult for air to move
What is a normal bronchial tube like?
The muscles around the bronchial tubes are relaxed and the tissue is thin, allowing for easy airflow
What type of airway disorder involves recurrent episodes of coughing (particularly at night or early am), wheezing, breathlessness and chest tightness?
Asthma
Asthmatic episodes
Usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment
How can you do an initial assessment for asthma?
FEV1 of >200mL AND >12% increase from baseline measure after SABA
What else can be present in the initial assessment for asthma?
Increased bronchial hyperresponsiveness, presence of other risk factors (atopic conditions), wheezing, coughing, chest tightness
What are some examples of atopic conditions?
Eczema, allergic rhinitis, etc.
What are inhaled allergens?
Pollen, cockroaches, animal dander, house dust mites, damp rooms-mold
What are inhaled irritants?
Perfumes, tobacco smoke, cleaning agents, airborne chemicals, wood burning stoves
What are the interleukin-5 antagonists?
Cinqair (Reslizumab) and Nucala (Mepolizumab)
What is the class of Xolair (Omalizumab)
Inhibits binding of IgE to the high-affinity IgE receptor on surface of mast cells and basophils
Which monoclonal antibody is indicated for 6+ years, mod-severe asthma, not controlled on ICS + skin test or perennial allergies
Xolair (Omalizumab)
Which two monoclonal antibodies have a boxed warning for anaphylaxis?
Xolair (Omalizumab) and Cinqair (Reslizumab)
Which monoclonal antibody has hypersensitivity anaphylaxis as a boxed warning?
Nucala (Mepolizumab)
Which monoclonal antibody is used for 18+ with severe asthma eosinophilia phenotype?
Cinqair (Reslizumab)
Which monoclonal antibody is used for 12+ severe asthma with an eosinophilia phenotype?
Nucala (Mepolizumab)
How do you reduce allergen exposure to animal dander?
Keep animals out of bedroom, seal (filter) air ducts leading to bedroom, HEPA filters
How do you reduce exposure to dust mites?
Reduce humidity to <50%, remove carpets if possible, wash bedding weekly (>130F), encase mattress, pillow, and box springs in an allergen impermeable cover
How do you reduce exposure to cockroaches?
Use poison bait or traps, do not leave food or garbage exposed
How do you reduce exposure to pollens and outdoor molds?
Use air conditioning, stay indoors when pollen counts are high
How do you reduce exposure to indoor molds?
Fix all water leaks, clean moldy surfaces, reduce humidity to <50%
What are some important triggers/exacerbating factors for asthma?
GERD, rhinitis, sulfite sensitivity, ASA/NSAIDs, menstrual cycles, BBs
What is the staging of asthma for EPR 1?
Mild asthma, moderate asthma, severe asthma
What is the staging of asthma for EPR 2?
Mild intermittent asthma, mild persistent asthma, moderate persistent asthma, severe persistent asthma
What is the staging of asthma for EPR3?
Intermittent asthma, mild persistent asthma, moderate persistent asthma, severe persistent asthma
The staging severity for asthma is based on what two factors?
Impairment and risk
Impairment
Frequency and intensity of symptoms, functional limitations, effect on quality of life
Risk
Future exacerbations, loss of pulmonary function, risk of adverse effects from meds
What is a peak flow meter?
Measures how well lungs are able to expel air (peak expiratory flow rate or PEAFR -L/min)
What is the clinical utility for a peak flow meter?
Early indicator for loss of control, may help pts identify triggers, determine how well regimen is working, may help indicate when to seek emergency care
How does a pt record and establish the “personal best”
When asthma is under “good control” over a 2-3 week period, take 3 readings daily and record highest reading
When do you take the daily readings to establish a personal best?
3 readings daily and record highest reading (mid-morning or afternoon) and record the HIGHEST VALUE obtained during 2-3 week period
What do you do AFTER a personal best is established?
Use atleast every morning upon awakening, use before any asthma meds, may use after taking a rescue med to determine impact
What is the GREEN zone?
When pt is 80-100% of personal best, can continue with regular activities, follow maintenance med plan
What are the directions for pts when they are in the green zone?
Continue with regular activity, follow maintenance med plan
What is the yellow zone?
50-80% of personal best
What are the directions for a pt when they are in yellow zone?
May require med adjustment, contact health care provider
What is the red zone?
<50% of personal best
What are the directions for a pt if they are in the red zone?
Emergency! Dial 911, contact health care provider
If the peak flow reading is >20% or more after using a SABA
Consider adjusting controller therapy
How often should a follow-up appointment be scheduled while gaining control for asthma?
Every 2-6 weeks
How often should a follow-up be scheduled for someone with controlled asthma?
Every 1-6 months
If a reduction in therapy in anticipated, how often should a follow-up be scheduled for asthma?
3 month intervals
What should be assessed at every follow-up for asthma?
Asthma control, med technique, asthma action plan, medication adherence, pt related concerns
What are some risk factors for death?
Prior severe exacerbation (intubation of ICU admission)
2+ hospitalizations or 3+ ED visits in the past year
>2 canisters of SABA per month
When should an asthma specialist be contacted?
If hospitalized, difficulties achieving or maintaining control, if immunotherapy is considered, if additional testing is indicated, if >2 oral steroids burst in past year
What are some other risk factors for death?
Poor perceived of symptoms, low SE status, illicit drug use, psyc disease, complicating co-morbidities
When can stepping down therapy be considered?
Must be “well controlled” for atleast 3 months
Stepping down therapy
Reduction should be gradual, must monitor closely, consider history or prior exacerbations
How often do you monitor when stepping down therapy?
2-6 weeks
Remember to use the ____ amount of meds needed for control
Least
What is ACT?
Asthma control test
An ACT score of _ means your pts asthma may not be under control?
<19
What needs to be provided to ALL pts?
Daily management and managing worsening asthma
What is included in daily management for asthma?
Controlled medication, environmental control measures
What is included for managing worsening asthma?
How to adjust medication, when to see medical care
Which domains should be assessed when monitoring asthma severity and control?
Impairment and future risk
What are the maintenance regimens?
ICS, long acting B2-agonists, long acting anticholinergics leukotriene antagonists, theophylline
What are the rescue regimens?
Short acting B2 agonists, short acting anticholinergics
What are some therapeutic considerations?
Cost and coverage, produce availability, adverse effects, pt population, lifestyle, pt preference, ability to use device, lung fxn, cognitive fxn, dexterity and strength
What are some advantages of an MDI without a spacer?
Less time (<1min), small/portable, no drug preparation, mechanical ventilation
What are some disadvantages for an MDI without a spacer?
Technique/timing essential, Freon effect (
What are some advantages of DPI?
Less time (<1min), less technique/timing, small/portable, usually less $$ than MDI counterpart
What are the disadvantages of using a DPI?
Some dose preparation, requires breath hold, requires faster inhalation, oropharyngeal deposition, no mechanical ventilation
What are some advantages of nebulizers?
Minimal technique/timing, no breath hold required, mechanical ventilation
What are some disadvantages of nebulizers?
More expensive, drug prep required, admin time (5-15min), bulky and less portable, requires power source, must clean regularly!
What are valves holding chambers used for?
MDIs only!!!
VHC valve doodling chambers
Requires less coordination to use, improves drug deposition into lungs, decreases oropharyngeal deposition, use one actuation per inhalation!
When should a face mask be considered if using an MDI and VHC?
For children <4 years
What is the mechanism for the quick relief medication?
Increased adenyl cyclase -> increases CAMP which activates PKA -> Ca+ leaves the cell -> smooth muscle relaxes
When should the quick relief medication be used?
Acute symptoms and exacerbations
Treatment of choice for exercise induced asthma
What are the take home points about quick relief medications?
SABAs are preferred
Weekly cleaning is recommended
Regularly scheduled, daily, chronic use is not recommended
What are some examples of quick relief medication?
Albuterol, Levalbuterol, Pirbuterol (discontinued)
Should all patients with asthma have an albuterol inhaler?
Yes
What are some indications for the RespiClick device?
Treatment or prevention of bronchospasms in 4 years+
Prevention of exercise-induced bronchospasms in 4 years +
What are some features of the RespiClick device?
Dose counter, “click” open loads dose, expires 13 mos after opening, counts down by even numbers only
Does the RespiClick need to be primed or cleaned?
No
How is the RespiClick device activated?
Breath activated device (Dry Powder)
What are some examples of products that have a dose counter?
Proair HFA, Ventolin HFA
What are the two types of Albuterol for adults?
Albuterol Sulfate 0.5% solution 5mg/ml (concentrated)
Albuterol Sulfate 2.5mg/3mL (0.083%) (pre-mixed)
Which Albuterol Rx for adults requires two prescriptions?
Albuterol Sulfate 0.5% solution 5mg/ml (concentrated)
What are the SABAs via nebulizer?
Albuterol for adults and children, Xopenex (Levalbuterol)
When is the nebulizer preferred?
When pt is unconscious
What are examples of oral beta-2 agonists?
Albuterol immediate release tablets and syrup, Vospire ER extended release tablets
When should you use inhaled corticosteroids?
Preferred long-term control therapy for all ages
How often should ICS be cleaned?
Weekly
What should be done after each use of ICS?
Rinse mouth and expectorate after using, wash around childs mouth if using a mask
What is mild-mod asthma most managed with?
Low-medium ICS doses
What do ICS do to lung function?
Improves lung function and reduced need for quick relief medications
What are some examples of ICS?
Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone proportionate and furoate, Mometasone
Oral candidiasis can be from ICS, how could you reduce it?
Spacer, rinse mouth, decrease dose/frequency if possible
What % of pts can get oral candidiasis?
34%
What % of pts can get dysphonia from ICS?
5-50%
What can dysphonia be reduced by?
Spacer, rinse mouth, decrease dose/frequency if possible
What can reflex cough and bronchospasms be reduced by from ICS?
Spacer, decreased rate or inspiration, pre-treat with albuterol
Low dose ICS has no significant effects on
Bone mineral density in children
Incidence of cataracts or glaucoma
HPA axis function
What is the preferred therapy for asthma?
ICS therapy
Implications of ICS
Minimal effects ICS dose is recommended be used in all children with asthma, trails should be required to monitor height
What is Arnuity or Ellipta?
Fluticasone Furoate
Clinical pearls fo Arnuity/Ellipta/Fluticasone Furoate
1st once daily ICS, cleaning NOT required, unable to double load dose, discard 6 weeks after opening tray
What are some potential drawbacks for Arnuity/Ellipta/Fluticasone Furoate
See DPI limitations, dosing may be less flexible
What is another name of ArmonAir or RespiClick?
Fluticaonse Propionate
What are some clinical pearls of ArmonAir/RespiClick/Fluticasone Proprionate
12+ asthma maintenance, not interchangeable with Flovent, unable to double load dose, discard 30 days after opening
A temporary increase in anti-inflammatory therapy may be indicated to reestablish asthma control
“Burst”
What MUST BE used concomitantly with anti-inflammatory medications for long-term control of asthma symptoms
Long acting B2 agonists
What can be used to prevent exercise-induced bronchospasm?
Long acting B2 agonists
Long acting B2 agonists do NOT eliminate the need for what?
An anti-inflammatory agent when used for asthma
What should not be used to treat acute symptoms or exacerbations?
Long acting B2 agonists
The use of LABAs is contraindicated without the use of what?
OF an asthma controlled medication such as an ICS
LABAs should be used for what?
The shortest duration of time required to achieve control of asthma symptoms and D/C, if possible, once asthma control is achieved
Pediatric and adolescent pts who required the addition of a LABA to an ICS should use what?
A combo product
What is another name for Breo/Ellipta
Fluticasone Furoate + Vilanterol
What are some clinical pearls for Breo/Ellipta/Fluticasone Furoate + vilanterol
1st once daily ICS/LABA combo, unable to double load dose, discard 6 weeks after opening tray, cleaning NOT required
What are some potential drawbacks for Breo/Ellipta/Fluticasone furoate +vilanterol
See DPI limitations
What is another name fo AidDuo/RespiClick
Fluticasone Propionate + Salmeterol
What are the clinical pearls for AirDuo/RespiClick/Fluticasone propionate + salmeterol
12+ asthma maintenance not controlled on ICS alone, not interchangeable with Adair, unable to double load dose, discard 30 days after opening
When should long acting antimuscarinics be used?
As an add-on for pts with a hx of exacerbations, once-daily, maintenances treatment of asthma in pts 6+ years
What are the long acting antimuscarinics?
Spiriva, Respimat (Tiotropium)
Clinical pearls for long acting antimuscarinics
Cost, expires 90 days after loading, dose = two half turns once daily, Respimat only LAMA approved for asthma
What are some potential drawbacks for the long acting antimuscarinics?
Initial load and priming, coordination between dose release and inhalation
When should Theophylline be used?
Alternative therapy for Step 2 care (not preferred), adjunctive therapy with ICS in patients >5 years old
Take home points for Theophylline
Monitor serum Theophylline concentration, consider adverse effect profile, DDIs
What should the serum Theophylline concentration be at?
5-15mcg
What are the adverse effects similar to for Theophylline
Caffeine
Smoking induces metabolism, so if a pt on Theophylline stops smoking,
The levels in serum will go very high
What are some dose-related acute toxicities from Theophylline?
Tachyarrhythmias, CNS stimulation, seizures, hyperglycemia and hypokalemia
What are the Theophylline drug inducers?
Smoking, Rifampin, Phenytoin, Omeprazole, Phenobarbital, Carbamazepine
What are the Theophylline drug inhibitors
ETOH, Zileuton, Cimetidine, Zafirlukast, Propranolol, Ciprofloxacin
Leukotrienes
Produced and release from multiple sources, contract smooth muscle, increase vascular permeability and mucus secretions
When to use leukotriene inhibitors
Alternative therapy for Step 2 care (not preferred), adjunctive therapy with ICS
What are some clinical pearls for leukotriene inhibitors
Montelukast and Zafirlukast block at recept level (LTRA)
Zileuton blocks production
What needs to be taken on an empty stomach?
Zafirlukast
Which leukotriene inhibitor must liver function be monitored?
Zileuton
Which leukotriene must be administer once daily at bedtime?
Montelukast
Which leukotriene inhibitors must be taken atleast 2 hour before or 2 hours after meals?
Zafirlukast
What did the FDA find an association between in 2008?
Montelukast and behavior/mood changes, suicide
What is an example of a mast cell stabilizer?
Intal (Cromoly sodium)
Adverse effects of Intal (Cromolyn sodium)
Bad taste, cough/irritation
Clinical pearls fo mast cell stabilizers
Long-term prevention of symptoms in mild persistent asthma, presentation treatment prior to exercise or known allergies, dosed 3-4x/day
Mast cell stabilizers can be used for long term prevention fo what?
Symptoms in mild persistent asthma
How many times a day are mast cell stabilizers dose?
3-4x/day
Which vaccinations are required?
Influenza and pneumococcal
What can be used to assess and monitor asthma severity and control?
EPR-3 table and validated questionnaires to assess impairment and risk
Budesonide DPI
Pulmicort Flexhaler
Budesonide Neb
Pulmicort
Flunisolide HFA
Aerospan
Fluticasone HFA
Flovent HFA
Mometasone DPI
Asmanex, Twisthaler
Ciclesonide HFA
Alvesco
Albuterol
Proair HFA, Proair RespiClick, Proventil HFA, Ventolin HFA
Levalbuterol
Xopenex
Pirbuterol
Maxair Autohaler (Discontinued)
Advantages Diskus
Fluticasone + Salmeterol
Advair HFA
Fluticasone + Salmeterol
Symbicort HFA
Budesonide + Formoterol
Dulera HFA
Mometasone + Formoterol
