Asthma Review Flashcards
What is asthma?
chronic inflammatory disease of airways with:
- airway obstruction that may or may not be reversible either spontaneously or with meds
- airway inflammation caused by many cellular components
- increased ariway hyper responsiveness
- airway remodeling
Development of asthma?
- genetics + environmental factors lead to airway inflammation and then to bronchoconstriction and then manifest as asthma sxs
Asthma PP?
- inhaled trigger leads to release of histamine leukotrienes from mast cells which lead to bronchospasm and this then leads to late asthmatic response and chronic inflammation
- this leads to neural and vascular effects, there is recruitment and activation of inflammatory cells (cytokines) which cause mast cells to release histamine leukotrienes - leading to bronchospasm
Common allergens and irritants of asthma? other triggers?
- allergens: dust mites, pet dander, pollen, rodents, mold, natural oils
- irritants: smoke, strong fumes, pollutions, ozone, chemicals, petroleum, VOCs
other triggers:
-URI - rhinovirus
-tobacco and other smoke exposure
-exercise
-cold air
-GERD
-chronic sinus disease
What is more prevalent: GERD or asthma?
- GERD
- may be present in up to 70% of asthma pts
- physiology of asthma and meds for asthma may increase risk for GERD
- GERD may worsen asthma through direct irritation or nervous system reaction
Correlation b/t NSAIDs and asthma?
- up to 20% of adult asthmatics may experience asthma sxs after ingestion of aspirin or NSAIDS
- rare in kids
- usual presentation: adult with chronic rhinitis, nasal polyps, asthma
- pts usually present with malaise, rhinnorhea, bronchospasm, productive cough, and occasionally angioedema within 20 min to 3 hrs of aspirin or NSAID ingestion
When should you suspect asthma?
- persistent cough
- recurrent pneumonia
- responds to albuterol
Impt findings in hx of asthma pt?
- recurrent cough, wheeze, SOB esp at night or with exercise
- improvement with bronchodilator
- clear triggers: exercise, cold air, allergens, colds
- PMH: allergic child (atopic dermatitis, allergic rhinitis)
- family hx: esp maternal
positive asthma sxs during physical?
- wheezing: inspiratory, expiratory or both
- could have clear lung exam
- tripod breathing
- tachypnea
- hypoxemia
- dyspnea
- retractions
- poor aeration
- prolonged I:E ratio
- think of other things if there is clubbing or crackles
DDx of asthma?
upper/central airways:
- allergic rhinitis/ sinusitis
- fb
- vascular ring or sling
- laryngo/tracheo/bronchomalacia
- vocal cord dysfxn
lower airways:
- bronchiolitis
- CF
- bronchopulmonary dysplasia
- heart disease
- aspiration/GERD
- asthma
Simple goals of tx ped asthma pt?
- sleep: prevent chronic coughing, asthma sxs, and asthma exacerbations during day and night
- learn: eliminate missed school days
- play: maintain normal activity levels
Classification of intermittent asthma in peds?
- less than 2 days/week sxs
- no nighttime awakenings
- less than 2 days a week using SABA for sx control
- no interference with normal activity
- 0-1/year requiring oral steroids
- in kids 5-11: normal FEV1 b/t exacerbations, FEV1 greater than 80% of predicted and FEV1/FCV is greater than 85%
Mild persistent asthma in peds?
- more than 2 days/week of sxs but not daily
- 1-2x a month nighttime awakenings
- use SABA more than 2 days a week but not daily
- minor limitation with normal activity
- more than 2 exacerbations in 6 months requiring oral steroids
- 5-11:
FEV1= greater than 80% predicted
FEV1/FVC= greater than 80%
Moderate persistent asthma in peds?
- daily sxs
- 3-4x a month nightly awakenings
- daily use of sx SABA use
- some limitation with normal activity
- more than 2 exacerbations in 6 months reqring oral steroids
- 5-11:
FEV1= 60-80% predicted
FEV1/FVC= 75-80%
Severe persistent asthma in peds?
- sxs throughout the day
- more than 1 nighttimes awakening within a week
- seveal times a day of SABA sx relief
- extremely limited normal activity
- more than 2 exacerbations in 6 months requiring oral steroids
- ages 5-11:
FEV: less than 60% predicted
FEV/FVC= less than 75%
Who is at risk for future exacerbations?
- severe obstructive disease
- 2 or more ED/hosp in last year
- pts frightened by exacerbations (esp peds)
- demographics: nonwhite, women, no ICS, lower SES
- psych: depression, stress
ICS mechanism
- anti inflammatory
- block late rxn to allergen and inhibit inflammatory cascade
- reverse beta2- receptor down regulation
Most effective tx in those with moderate persistent asthma?
- low dose ICS with LABA
better than:
med dose ICS
low dose ICS+LTRA
Does low dose ICS affect ht?
- nope!
Mechanism of leukotriene blockers?
- inhibit inflammation through diff pathway
- may help toddlers who wheeze with viruses
- may help spare steroids
- pill versus inhaler or neb
- not as effective as ICSs
- may have psych side effects
- ex: singulair (montelukast)
Peak flow recommended in which asthma pts?
– in severe, those with hx of severe exacerbation and trouble with sx perception
F/U schedule?
- regular - 3-6 month follow up
- education
- meds
- spirometry annually
Step up and step down therapy?
- step up if no response in 4-6 wks
- step down if good control for 3 months
When are spacers recommended?
- always recommended for MDI delivery in kids
- also strongly recommended in adults
How often should spacers be cleaned?
- weekly
How old should ped pt be before starting dry powder inhalers?
- 7-8
- should be able to correctly perform PFTs
What does an asthma action plan include?
- written plan of care includes zones and sxs
- how to tx asthma sxs
- med information, usual triggers, and special instructions
Green zone of asthma action plan?
- controlled asthma:
no sxs, active, eating and sleeping well - peak flows at least 80% of personal best
- may be on daily controller med
- goal: participate in all activities, and not be limited by asthma
Yellow zone of asthma action plan?
- some coughing, wheezing, chest tightness, or SOB
- peak flow: 50-80%
- give quick relief med as directed for sxs
- continue daily controller meds
- if child in yellow zone for 12-24 hrs or breathing sxs increase - call PCP
Red zone?
- quick relief med isn’t effective, or not available
- bluish lips, pale
- diff. talking, walking or drinking
- skin areas of neck, throat or chest sucked in
- nasal flaring on inhalation
- obvious distress
- alt LOC/ confusion
Acute management of asthma attack?
3 back to back neb tx with albuterol and atrovent
- oral steroids
On d/c an asthma ped pt should have what?
- asthma education
- asthma action plan
- controller meds
- re-label meds for home use
