Asthma (wk 8) Flashcards
Stuff that's not highlighted
1) Define chronic cough
2) What are some common causes in adults?
1) > 8 weeks in adults, 4 weeks in kids
2) Upper airway cough syndrome (PND syndrome)
Asthma
COPD
Smoking
Post infectious – CAP, bronchitis, etc.
Rx – ACEi
GERD
Environmental triggers
1) What are some less common causes of chronic cough?
2) What are the least common causes?
Less common:
HF
Rx – opioids, sitagliptin, statin
OSA
Pertussis
Least common
Cancer
IPF, sarcoidosis
Lung abscess
PTX
MTB
What are some red flags for chronic cough in adults?
Abnormal findings on chest exam or imaging
Dysphagia
Hoarseness
Hemoptysis
New or worsening cough in > 45 y/o smoker
Prominent dyspnea at rest or at night
Vomiting
Weight loss
List 4 types of airway disease
Asthma
COPD
Acute exacerbations of Asthma and COPD
Bronchitis – covered in Pulmonary infections
Differentiate between vesicular and adventitious breath sounds
Vesicular BS = normal sounds
Adventitious BS = abnormal sounds (wheezing, crackles, rhonchi)
What provides USA recommendations on diagnosis, assessment, & treatment of chronic and acute exacerbations of asthma?
National Institutes of Health (NIH):
1) National Heart Lung Blood Institute (NHLBI)
2) National Asthma and Allergy Education Program (NAAEP)
What is endorsed by WHO and is a resource that addresses asthma diagnosis, assessment, management?
Global INitiative for Asthma (GINA)
Asthma:
1) How common is it?
2) What is it?
3) What is it characterized by?
4) ____% of adults with asthma do not have adequately controlled symptoms
1) 25 million in USA, 7.8% prevalence in adults and children
2) Chronic inflammatory lung disease
3) Episodic symptoms and reversible airway obstruction
4) 62%
What are the 3 main elements of asthma pathophysiology?
1) Airway hyperreactivity
2) Inflammation
3) Intermittent airflow obstruction
Episodic symptoms
Chronic airway inflammation
Increased mucus, swelling, and bronchial hyperreactivity
Reversible Airflow obstruction
Bronchiolar obstruction
Airway remodeling
1) Are asthma Sx episodic or chronic? Explain
2) Is the airway obstruction reversible? Describe what this obstruction is.
1) Episodic symptoms; chronic airway inflammation
-Increased mucus, swelling, and bronchial hyperreactivity
2) Reversible Airflow obstruction
Bronchiolar obstruction
Airway remodeling
Heterogeneous (phenotypes):
Allergic asthma (most common), cough-variant asthma, exercise induced bronchospasm, occupational asthma, aspirin sensitive asthma, reactive airway disease, virus induced bronchospasm (RSV)
Cough variant asthma (bedtime, morning)
Exercise induced bronchospasm (EIB) (formally EIA) – occurs during exercise or minutes afterward, peaks in 10-15 minutes, resolves within 60 minutes
True or false: risk factors and triggers are different things
True
List risk factors for asthma
1) Male kids, mid age female adults
2) Genetic predisposition: + FHx
3) Urban dwellers/pollution
4) History of RTI (resp. tract infections)
5) Triad: Infant atopic dermatitis, Childhood AR, asthma
6) Allergen exposure
7) Occupational triggers (farmers, miners)
8) Obesity
1) What can predispose a pt to asthma? Give 2 examples of this
2) What does the hygiene hypothesis suggest?
3) What is assoc. with reduced risk?
1) Exposure to indoor environmental allergens, tobacco smoke, and URI can predispose
-Maternal smoking and after delivery
-Rhinovirus in early childhood
2) That exposure to microbial diversity appears to protect against asthma (pets; outdoor activities/getting dirty)
3) Breast feeding
Define atopy
Tendency to produce an exaggerated immune response, IgE, to otherwise harmless substances in the environment
What is the Samter Triad?
1) ASA/NSAID sensitivity
2) Nasal polyp
3) Asthma
List and give examples of asthma
1) Respiratory tract infections (RTI), sinusitis
2) Allergens (SE USA, Smokey Mountains)
3) Aspiration, GERD
4) Weather changes, cold, air pollution, smoking
5) Physical activity
6) Emotional stress (PA school)
7) Hormonal fluctuations (puberty, menstrual cycle)
8) Medications – e.g., ASA and NSAID induced asthma
9) Occupational/inhaled respiratory irritants – may become symptomatic years after exposure
10) Cardiac “asthma” – refers to pulmonary edema in left sided HFrEF
1) What is the most common phenotype of asthma? When does it usually begin, and what is it assoc. with?
2) What are some common allergens?
1) Usually begins in childhood; assoc. w. atopic dermatitis and AR
2) House dust mites, cockroaches, cat dander (indoor allergens) and seasonal allergens (outdoor allergens
1) What can allergic asthma progress to?
2) Can adult-onset asthma occur without Hx of childhood asthma?
1) Some progress to chronic airflow obstruction with increasingly severe symptoms that persist into adulthood
2) Yes; adult-onset asthma may occur +/- history of childhood asthma
-May be missed
List the onset, duration & timing, and character of asthma presentation (OLDCARTS)
1) Onset – typically as child/teen but manifest in adults
2) Duration, Timing – chronic but episodic, variable severity (mild intermittent to persistent symptoms), daytime and or nighttime symptoms
Location - respiratory
3) Character – reversible episodic symptoms - tightness in chest, wheezing, dyspnea, coughing (usually dry cough)
List the aggravating factors, alleviating factors, radiation and assoc. Sx of asthma presentation (OLDCARTS)
1) Triggers (smoke, smells, allergens, stress, aspirin, exercise), to include RTI
2) Relaxation, avoidance of triggers
3) Typically isolated to respiratory system
4) Atopic dermatitis/eczema, allergic rhinitis, nasal polyps, snoring
What are some Sx less likely to be asthma?
1) Chest pain
2) Isolated cough
3) Chronic sputum production
4) Initial symptoms late in life
1) Can asthma Sx severity vary?
2) Is there tachypnea or tachycardia? Do they have a fever? What about hypoxia?
Variable based on severity
VS:
Tachypnea +/- accessory
Tachycardia
Usually afebrile unless concomitant RTI
May develop hypoxia
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Anxious
Expiratory wheezes – may progress to inspiratory/expiratory wheezing
Nasal polyps, eczema, allergic rhinitis
Asthma PE:
1) What would you see on PE?
2) What may you hear?
3) What may be normal between episodes?
4) How do you confirm Dx?
SOB, tachypnea/tachycardia, labored breathing
Diffuse wheezing correlates well with airflow obstruction
Typically, expiratory but may be throughout respiratory cycle
VS & Chest exam may be normal between episodes
Need to confirm diagnosis with spirometry
Severe asthma exacerbation
Airflow may be too limited to appreciate wheezing
Globally reduced breath sounds and prolonged expiration = concerning finding for impending respiratory failure
Patient in acute distress, cyanotic, hypoxic, and mental status changes (confusion)
Pulse oximetry indicating hypoxia < 90%
How do you make an Asthma Dx in patients with H&P consistent with differential including asthma?
1) Spirometry (PFT)
Should be performed in all patients at time of diagnosis
Key to confirm diagnose
2) NOTE: if patient < 5 yrs of age, a therapeutic trial of Rx is recommended as they can not perform spirometry
Define:
1) FEV
2) FEV1
3) FEV1%
4) FEV6
FEV = forced expiratory volume
FEV1 = forced expiratory volume 1st second
FEV1% predicted = FEV1 as % of predicted FEV1 using demographic data (age, Ht., gender, & race)
FEV1 25-75 = mid expiratory volume, mid 50% of FEV
FEV6 = force expiratory volume 6 seconds (nearly equivalent to FEV)
Define:
1) FVC
2) FEV1/FVC
3) FEV1%
4) Absolute change
1) Forced vital capacity
2) Measure of obstruction as %
3) (post SABA FEV1 – base FEV1)/ base FEV1
4) Post SABA FEV1 – base line FEV1
Office spirometry:
1) Airway obstruction suspected with decreased _______________.
2) Restriction is suspected with decreased ________.
don’t worry abt memorizing
1) FEV1/FVC ratio
2) FVC
Restriction is suspected with decreased FVC:
1) What % would you expect in adults with restriction?
2) What is predicted for children 5-18 y/o w. restriction?
don’t worry abt memorizing
1) < 5th % in adults
2) < 80%
1) FEV1/FVC ratio and FVC are used together to identify what 3 things?
2) What is FEV1 used for?
don’t worry abt memorizing
1) FEV1/FVC ratio and FVC used together to identify obstructive defects, restrictive, or mixed patterns
2) To subjectively determined severity of obstruction
List some studies you may use for specific patients to exclude alternate diagnosis/etiology
1) Allergy testing
2) CXR
3) Bronchial provocation testing
4) Sinus x-rays/CT
5) GERD evaluation
6) CBC with eosinophils, total IgE
7) Sputum exam
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NAEPP recommends recommends assessing degree of asthma control using validated clinical tools
E.g., Asthma Control Test (ACT)
Sens & Spec ~ 70% using cut off 19 for well controlled asthma
Based on severity and control of asthma symptoms, use a step wise approach for therapy
NAEPP guidelines
Global INitiate for Asthma (GINA)
1) When is asthma classified by severity? What are the classification groups?
2) List some Sx that help determine classification
interventions require OCS/year
1) At initial evaluation/diagnosis; intermittent asthma or mild, moderate, or severe persistent asthma
2) Daytime symptoms
Nighttime symptoms
Need for SABA
Limitations on QOL
Lung function
Risk
Initial therapy dependent on classification of asthma
What 2 things help determine asthma severity classification?
Sx and risk
Define risk regarding asthma
interventions require OCS/year
What determines initial therapy?
Classification of asthma severity and Sx
Low FEV1/FVC or reduced FEV1 % predicted are not typically seen in __________ or ________________ asthma
intermittent or mild persistent
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Define:
1) Intermittent asthma
2) Mild
3) Moderate
4) Severe
1) Less than 2x/ month
NAEPP recommendations:
1) What is step 2? What is the Tx?
2) What is step 3+? What is the Tx in pts 4 y/o or older?
1) Mild persistent asthma
-PRN ICS + SABA
2) Moderate to severe asthma
-SMART therapy should be considered as daily and rescue Rx
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For uncontrolled asthma despite daily ICS
therapy, adding a LABA is preferred
over LAMA (may replace daily ICS with
SMART Rx)
SQ immunotherapy can reduce the
severity of mild or moderate asthma
over time in patients with proven
allergies
Benefits and harms of major classes of asthma Rx:
1) What is a reliever (rescue) Rx used to Tx?
2) What are the goals of using a Maintenance (control) Rx on a scheduled dosing to?
1) Acute symptoms (PRN)
2) Improve airflow & decrease hospitalizations, exacerbations, and frequency of reliver Rx use
Give some examples of drug classes to Tx asthma
1) SABA
2) SAMA
3) ICS
4) LABA
5) LAMA
6) LTRA
What do ICSs do for asthma?
Reduce inflammation
Short acting beta agonist(SABA):
1) Give an example
2) What is it used for?
3) What does it do?
1) Albuterol (Ventolin)
2) Preferred monotherapy for PRN/acute symptoms
3) Increases FEV1 in 3-5 minutes - Short onset of action, but short half-life +/- 2 hours
Preferred monotherapy for PRN/acute asthma symptoms is what?
SABA
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SABA
B2-adrenergic receptor agonist relax bronchial smooth muscle
Minimum adverse affects – tachycardia, tremor (spill over to B1-adrenergic receptors in heart that increase heart rate and contractility)
Frequent use may result in down regulation of receptors
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Example: Ipratropium (Atrovent)
Increases FEV1 but slower onset of action than SABA when used as monotherapy , ~ 15 minutes, short half-life like SABA
Block cholinergic receptors in bronchial smooth muscle relaxing airways
Minimum side effects
SABA + SAMA combination synergistic, often used for combined effects in more severe exacerbations
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Example: Flovent (fluticasone), Pulmicort (budesonide), Asmanex (mometasone)
Most effective maintenance Rx – addresses inflammatory component of asthma
Decreased exacerbations, hospitalizations, & reliever Rx use
PRN or scheduled use + SABA OR part of SMART Rx
ICS:
1) What do all common adverse affects have in common?
2) What may increase risk for cataracts in adults?
3) What can it do in kids? (mixed evidence)
1) Common adverse affects are localized (pharyngeal thrush)
2) Prolonged use high dose ( >1 mg daily for > 3+ years) may increase risk for cataracts in adults
3) Adrenal suppression and decreased linear growth
Long-acting Beta agonist(LABA):
1) Give an example
2) How long does it take to work? What abt how long it lasts?
Example: Salmeterol (Serovent)
Typically takes ~1 hour to reach peak efficacy, lasts 8-24 hours
Preferred choice for add on controller therapy (to ICS)
Decrease exacerbations, reliever Rx use, & nocturnal awakening
Not typically recommended as monotherapy has FDA warning of increased hospitalization, Intubation, & death
Used on scheduled Rx with ICS
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Example: Tiotropium (Spiriva)
LAMA + ICS has similar results to LABA + ICS, but increased hospitalizations associated with LAMA
Triple Rx with LABA + ICS + LAMA may improve symptom control for some severe persistent asthma patients – typically reserved for symptomatic COPD patients
Avoid in patients @ risk for urinary hesitancy (anticholinergic) and glaucoma
Not typically recommended as monotherapy or 1st line add on to ICS for asthma
Leukotriene modulators:
1) What are they used for? How are they taken (inhaled, orally, IV, etc)?
2) Is it well tolerated?
1) anti-inflammatory, PO tablets
2) Well tolerated (but * Montelukast has FDA warning regarding behavior, mood, & suicide)
Leukotriene modulators: List and describe the 2 types
Leukotriene inhibitors (LTI) – block production of 5-Lipoperoxigenase
Zyflo (zileuton)
Leukotriene receptor antagonist (LTRA) – block action of leukotriene at receptor
Singular (montelukast) *
Accolate( zafirlukast)
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1) What does SMART stand for?
2) What is the most common SMART medication? What does it contain?
1) Single medication for Maintenance And Rescue Therapy
2) Symbicort: budesonide (ICS) + Formoterol (LABA) combinate in single inhaler
1) Why are Formoterol (and now others) are unique LABAs? Explain
2) How may it be used as for asthma?
1) Have quick onset of action like SABA, but long half life like LABA
2) Reliever and controller medications; current evidence indicates using ICS along with quick acting bronchodilator works better than bronchodilator alone as it addresses the inflammatory component.
What 3 things do you need to assess at follow-up asthma visits?
1) Assess with validated clinical tools for asthma control
-Asthma control test (ACT)
-GINA assessment of asthma control
2) Assess for patient compliance with current therapy
3) Assess for inhaler technique
Asthma Control Test (ACT) assesses for what factors?
Impact on QOL
Symptoms
SOB
Nighttime symptoms/awakenings
Rescue inhaler use
Patient rating of control
When you assess Sx control with GINA, what are you taking into consideration? (4 things)
1) Daytime symptoms
2) Nighttime symptoms/awaking
3) Rescue Rx use
4) Impact on QOL
What are 2 options when ICS monotherapy Rx is not enough?
Increase dose of ICS
Best: add LABA (formoterol) to ICS for maintenance and rescue
What is the dosing of LABA (formoterol) to ICS for maintenance and rescue when monotherapy isn’t enough?
4+ y/o, SMART therapy with increased dosing for controller and rescue
4-11 y/o max dose is 8 puffs daily
12 + y/o max dose is 12 puffs daily
1) When using just ICS (i.e. not using formoterol as LABA) what else do you need to Rx?
2) Why would you not use LAMA instead?
Will need SABA for rescue if not using formoterol as LABA
LAMA has similar affects but increased rate of hospitalizations, especially in black adult patients, therefore not recommended
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For allergic asthma, subcutaneous immunotherapy may be considered for adjunct therapy in patients 5 + y/o with mild to moderate persistent asthma with proven allergies
Avoid in severe persistent asthma
Asthma should be optimally controlled during all phases of therapy
Medically supervised
Shared decision
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Immunotherapy has limited utility due to slight risk of harm and variable access
Sublingual immunotherapy is not recommended or FDA approved for asthma
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Home monitoring & patient education:
1) Subjective monitoring?
2) Objective monitoring?
3) What else needs to be included?
1) Symptoms
2) Peak flow meter
3) Written asthma action plan (hope for the best, plan for the worse
What does PEF stand for?
2) What is the best method for PEF?
Peak expiratory flow;
2) Personal best – when at base line, average values over 1-2 weeks
Define green, yellow, and red in an asthma action plan
1) Green: Usual activity; PEF > 80% of personal best
2) Yellow: Some of usual activity; PEF 50-80% of personal best
3) Red: Can not do usual activities; PEF < 50% of personal best
List 2 parts of asthma prevention
1) Vaccinations
2) Smoking cessation
Pneumococcal conjugate vaccines:
1) How does it work?
2)
Durable immunity by stimulating T-cell dependent MOA resulting in memory B-cell formation providing mucosal immunity
PCV-15 = Vaxneuvance
PCV-20 = Prevnar-20
PCV-21 = Capvaxive
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Pneumococcal polysaccharide vaccine
Induces immunity via release of Ig from B-cells, does not result in mucosal immunity, and protection wanes in 5-6 years
PPSV-23 (Pneumovax 23)
Current recommendations for pneumococcal vax
NEW! … routine - Adults 50+
Either PCV 20 or PCV 21 alone
Or
PCV 15 followed in 1 year by PPSV 23
Current recommendations for pneumococcal vax
High risk patients after childhood vaccination
PCV 20 or 21 alone
Or
PCV 15 followed in 8 weeks by PPSV 23
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Market forces will likely result is disappearance of PCV 15 and PPCV 23 combination as single dose vaccines are easier and PCV 20 or 21 will be the standard
However, new vaccines are being developed
2 vax that are 24 valent
1 vax that is 31 valent
1) RSV vax is FDA approved for who?
2) What does Tdap protect against?
1) All patients 60+, pregnant women 32-36 EGA, passive immunity in at risk infants
2) Pertussis (replace Td at least once as adult to boost pertussis)
Assist – with FDA approved Rx
Nicotine replacement – gum, lozenges, patches
Wellbutrin SR (Zyban)
Varenicline (Chantix)
Exercise induced bronchoconstriction(EIB):
1) What do most pts with this have?
2) What triggers Sx?
3) Who does it occur in?
4) How is it diagnosed?
Most have underlying asthma
Symptoms (dyspnea, cough, wheezing) triggered by exercise
Occurs in 90% of asthmatics and 10% of athletes (cross country skiers)
Diagnosed by demonstration of reversible airway obstruction
Exercise induced bronchoconstriction (EIB) preferred diagnosis?
Exercise challenge – treadmill/ergometer to get HR 80-90% max
+ test = decrease FEV1 10% (15%) base line
Reversed by SABA
EIB treatment recommendations: what are the 4 steps?
- If underlying asthma, gain good control
- Improved CV fitness
- Warm up prior to exercise ??
- Medications: quick relief SABA for relief and prevention, alt. ICS-formoterol (Symbicort) & LTRA
EIB:
1) How do you Tx for quick relief?
2) How do you prevent episodes? What are alternatives ?
Quick relief
SABA, 2 puffs prn.
Prevention:
Pre-exercise treatment with SABA about 5-20 minutes prior to activity
Alternative
ICS-formoterol (Symbicort)
LTRA
How does asthma react to pregnancy?
Asthma is associated with increases in what 6 pregnancy-related things?
Extremely variable: symptom severity often changes with pregnancy compared to pre-gravid state
1) Asthma associated with Increased:
2) Perinatal mortality
3) Preeclampsia
4) IUGR
5) Preterm birth
6) LBW infants
Asthma Tx in pregnancy:
1) What should you pt avoid?
2) What should they recognize and manage?
Inadequate control of asthma poses a greater risk to the fetus than asthma medications!!
Avoid allergens and irritants – smoking
2) Comorbid conditions: for Seasonal Allergic Rhinitis (SAR)
ICS
Antihistamines – loratadine and cetirizine preferred
Sinusitis –treat
GERD – treat
Asthma in pregnancy:
1) Do all pregnant asthma pts need a monthly evaluation of asthma history and pulmonary function?
1) No; just high risk
Albuterol is the preferred rescue (CAT C – uncertain safety, no human studies, animal studies show adverse effects)
ICS are preferred controller medication
Budesonide is preferred, most reliable safety profile
Cromolyn, LTRAs, LABAs, and theophylline may be alternatives, but have lower efficacy or less safety data
LABA should NOT be used as monotherapy
1) ~ 40% of patient with asthma experience exacerbation
~ 1.8 million ER visits and 170,000 hospitalizations/yea
~ 40% of patient with asthma experience exacerbation
~ 1.8 million ER visits and 170,000 hospitalizations/year
Asthma exacerbation = a deterioration of baseline symptoms or lung function in a patient with asthma
Asthma action plans help patients triage and manage symptoms at home
What are 5 risk factors for asthma exacerbation?
1) Poor symptom control
2) Exacerbation in the past year requiring OCS
3) Poor compliance
4) Poor inhaler technique
5) Comorbid conditions: RTI; Chronic sinusitis; AR; Smoking
1) What are the 3 subjective criteria for an AE?
2) What are the 2 objective criteria?
1) a) Dyspnea and chest tightness
b) Cough
c) Wheezing
2) a) Decreased FEV1 or PEF
b) Decreased SpO2
Give the short definition of asthma exacerbation
Worsening of baseline symptoms or lung function in patient with asthma
(probably not on test)
Goal home-based care:
Control symptoms
Reduce asthma related M & M
Guidelines recommend ALL patients have written asthma action plan (AAP)
Written instructions
Based upon patients personal best PEF and or S/S
Address use of rescue therapy, inhaled and oral corticosteroids
(probably not on test)
If symptoms don’t improve by end of first hour, (per written asthma action plan)
Start OCS = equivalent dose of 40-60 mg prednisone daily for 3-5 days
Repeat SMART Rx
Call clinic/urgent care, ER to discuss
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Asthma exacerbation office based management: What are the basics?
(probably not on test)
1) Assess
2) S
What 4 things are not recommended for acute asthma exacerbations?
Mucolytics
Chest PT
Methylxanthines
Sedation
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