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N827 > Atopic Child > Flashcards

Atopic Child Flashcards

1
Q

Atopic Triangle

A
  • Allergic Rhinitis
  • Eczema
  • Asthma
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2
Q

What is Atopy?

A
  • IgE mediated response

- Genetic and environmental factors

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3
Q

Asthma Epidemiology

A
  • Puerto Ricans have highest incidence

- African Americans have highest death rate

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4
Q

Asthma PE

A
  • Diaphoresis
  • Anxiety
  • Breathlessness
  • Loss of breath sounds
  • cyanosis
  • Respiratory/cardiac collapse
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5
Q

Asthma: Dx

A
  • Spirometry: before and after bronchodilation
  • Peak flow (PEFR)
  • Chest X-ray (hyperinflation, increased markings, translucent lung fields)
  • Sputum cultures
  • ABG
  • Bronchoprovocation (methacholine, histamine, cold air, or exercise challenge)
  • Eosinophils
  • IgE levels
  • Skin testing (Allergist)
  • RAST testing (blood test for allergies)/Immunocap
  • NO
  • SpO2
  • Sweat chloride test
  • PPD
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6
Q

Forced Expiratory Volume at 1 Second (FEV1)

A
  • The amount of air which can be forcibly exhaled from the lungs in the 1st second of a forced exhalation.
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7
Q

FEV1 in Asthma

A
  • NL: >80% of predicted
  • Mild obstruction: 60-70% of predicted
  • Moderate obstruction: 40-59% predicted
  • Severe obstruction: <40% predicted
  • ** An improvement of 12%+ w/rescue inhaler helps confirm the Dx
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8
Q

Forced Vital Capacity (FVC)

A
  • The amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible
  • NL adult: 3-5L
  • After 20yrs the FVC decreases by 250cc per 10 years
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9
Q

FEV1/FVC (FEV1%

A
  • The ratio of FEV1 to FVC
  • In healthy adults: 75-80%
  • In obstructive Dz, FEV1 is diminished and FVC may be NL or diminished (<80%)
  • In restrictive Dz (pulmonary fibrosis), FEV1 and FVC are both reduced proportionally and the value may be NL or even increased due to decreased lung compliance
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10
Q

Peak Flow

A
  • Measures Peak Expiratory Flow Rate (PEFR)
  • Maximum speed of expiration through the bronchi
  • Measures the degree of obstruction in the airways
  • Green: 80% (71-100%) of personal best
  • Yellow: 60% (50-70%) of personal best
  • Red: <50% of personal best
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11
Q

Exhaled Nitric Oxide (eNO)

A
  • Marker of eosinophilic inflammation of the airway mucosa
  • Marker for change in the clinical condition of asthma
  • NO is produced when airways become inflamed
  • Asthma = increased eNO
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12
Q

RAST

A
  • RadioAllergoSorbent Test (RAST): blood testing fro allergies
  • Looks for IgE in blood
  • Does NOT tell if patient will react oor how severely
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13
Q

Immunocap

A
  • Specific type of RAST
  • Different in that it allows measurement of exactly how much IgE is present to a specific food or allergen
  • More exact than RAST
  • May be used in addition to skin prick test (SPT)
  • Cannot tell severeity of reaction
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14
Q

Challenge Testing

A
  • Methacholine
  • Histamine
  • Cold air
  • Exercise challenge
  • These cause bronchoconstriction
    Use spirometry to measure lung function with challenge
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15
Q

Contraiindications to Challenge Test

A
  • Moderate-to-severe airway obstruction by FEV1
  • Mi in last 3mo
  • Uncontrolled HTN (SBP >200 or DBP >100)
  • Aortic aneurysm
  • pegnancy or nursing mother
  • Myasthenia gravis
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16
Q

4 Components of Asthma Care

A

1) Assessing and monitoring asthma severity and control
2) education for a partnership in care
3) Control of environmental factors and co-morbid conditions
4) Meds

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17
Q

1) Assessing and Monitoring Asthma Severity and Control

A

-Must grade severity, functional limitations, and risks of asthma

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18
Q

Asthma Severity Levels

A
  • Mild intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent
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19
Q

Exercise-Induced Bonchospasm (EIB)

A
  • A Hx of cough, SOB, chest pain or tightness, wheezing, or endurance problems during exercise suggests EIB
  • During exercise challenge, 15% decrease in PEF or FEV1
  • SABA and leukotriene receptor antagonist can attenuate EIB
20
Q

Asthma Action Plan

A
  • Used to know when and how to take meds, adjust meds in response to asthma worsening, and tailor care to cultural and ethnic practices
21
Q

3) Control of Environmental Factors and Co-morbid Conditions

A
  • Cockroaches
  • Dust-mites
  • Rodents
  • Animals (saliva and fur)
  • Indoor plants and molds
  • Smoking
22
Q

Co-Morbidities of Asthma: Aspergillus

A
  • Allergic aspergillosis (ABPA): considered in pateints who have asthma & Hx of pulmonary infiltrates, IgE sensitization to Aspergillus, and/or are steroid dependent
  • Dx: +skin test; elevated IgE/IgG to Aspergillus; central bronchiecstasis
  • Tx: Predisone; Azole antifungals
23
Q

Co-Morbidities of Asthma: Others

A
  • GERD
  • Obesity
  • Occupational exposure
  • OSA
  • Rhinitis/Sinusitis
  • Stress and depression
  • Vocal cord dysfunction
24
Q

AIRESMOG Mnemonic

A 
A: allergy and adherence to therapy
I: infection/inflammation
R: rhinitis/sinusitis
E: exercise and error in diagnosis
S: smoking and psychogenic factos
M: medications (B-Blockers, ASA, ACE)
O: Occupational exposure, OSA, Obesity
G: GERD
25
Q

Inhaled Corticosteroids

A
  • Reduce airway hyperresponsiveness, inhibit inflammation, and block late phase reaction to allergens
  • The most consistent, effective long-term control med at all stages of care for persistent asthma
  • Safe for long-term use
  • SIGNIFICANTLY less potential for side effects than oral steroids
26
Q

Oral Steroids

A
  • Used long-term to treat patients who require step 6 med therapy (severe persistent asthma)
  • More side effects than ICSs: adrenal suppression, weight gain, immunocompromise, avascular necrosis of hip, cataracts, decreased bone density, decreased vitamin D and calcium
27
Q

Mast Cell Stabilizers

A
  • Cromolyn and Nedocromil
  • Stabilize mast cells and interfere with chloride channel function
  • Used as an alternative med for step 2 (mild persistent)
  • Can also be used for preventative Tx before exercise or unavoidable exposure
28
Q

Immunomodulators (anti-IgE)

A
  • Omalizumab (Xolair): monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells
  • Must have elevated IgE to be candidate
  • Used as an adjunct therapy for patients 12+ with allergy to relevant allergens and who require step 5-6 care (sev. persistent)
  • Providers should be prepared to deal with anaphylaxis
  • Slight increase of lymphoma with Xolair
29
Q

Leukotriene Modifiers (LTRA: Leukotriene receptor antagonists)

A
  • Interfere with the pathway of leukotriene mediators, which are released from mast cells, eosinophils, and basophils
  • Alternative, but not preferred, therapy for the Tx of patients who require step 2 care (mild persistent)
  • Can be used as an adjunct with ICSs
  • LTRAs can attenuate exercise-induced asthma
  • Montelukast (singulair) is preferred; Zafirlukast (Accolate) has caused cases of life-threatening hepatic failure
30
Q

Long-Acting Beta Agonists (LABAs)

A
  • Inhaled bronchodilators that have a duration of >12hr after single dose
  • Not to be used as monotherapy
  • BLACK-BOX WARNING: Asthma-related death
  • Used in combination with ICSs for long-term control and prevention of symptoms is moderate or severe-persistent
  • May be used as separate or combined products with ICSs
  • Included salmeterol (Serevent) and formoterol (Foradil)
  • Daily use should not exceed 100mcg Salmeterol or 24mcg formoterol
31
Q

Methylxanthines

A
  • SR theophylline: mild-to-moderate bronchodilator used as an alternative, not preferred, therapy for step 2 care (mild persistent) or as an adjunct therapy
  • May have anti-inflammatory effects
  • Monitoring of serum theophylline concentration is essential
  • Not used often; absorption is affected by many factors
32
Q

Azithromycin (Zithromax) for Asthma

A
  • Being used by pulmonologists as an immunomodulator in asthma q.o.d. for 1-several months
  • Not done in general practice
  • anti-inflammatory modes of action
33
Q

Anticholinergics (Acute Attack)

A
  • Inhibit muscarinic receptors and reduce intrinsic vagal tone of the airway
  • Ipratropium bromide provides additional benefit to SABA in moderate-to-severe exacerbations in the emergent setting, not in the hospital setting
  • Impratropium may be used as an alternative bronchodilator for those who do not tolerate SABAs
  • Includes ipratropium and DuoNeb (Ipratropium + Albuterol)
34
Q

SABAs (Acute Attack)

A
  • Albuterol (ProAir, Ventolin, Proventil), levalbuterol (Xopenex), & pirbuterol (Maxair, being d/c’d this year)
  • Bronchodilators relax smooth muscle
  • TOC for relief of acute symptoms
  • Use of SABA >2x/wk indicates inadequate control
  • Regularly schedule, daily, chronic use NOT RECOMMENDED
  • Now all are free of fluorocarbons (HFA)
  • Albuterol inhalers are no longer generic
35
Q

Systemic Corticosteroids (Asthma)

A
  • Used for moderate-to-severe exacerbations in addition to SABA to speed recovery and prevent recurrence
  • Short courses of oral steroids used to gain prompt control
  • Generally 5d course given
36
Q

Epinephrine Injection (Asthma)

A
  • Not recommended in beta 2 agonists are available
  • 1:1,000 solutions (1mg/mL)
  • 0.01mg/kg up to 0.3-0.5mg q 20min x 3
37
Q

Asthma in Pregnant Teens

A
  • Albuterol is preferred SABA
  • ICSs are preferred long-term control
  • Budesonide is preferred ICS because more data is available on its use in pregnancy
  • No data indicate that other ICSs are unsafe during pregnancy
38
Q

Allergic Rhinitis: Basics

A
  • Inflammation of the nasal epithelium characterized bu sneezing, itching, rhinorrhea, and congestion
  • “Hay fever”
  • Rare under 6mo; Typically found in 3+yrs
  • Requires repeated sensitization to allergens
  • 40% of all children
39
Q

Allergic Rhinitis: Types

A
  • Seasonal: caused by airborne pollens of trees, grasses, and weeds with seasonal patterns
  • Perennial: Caused by indoor allergens such as cockroaches, dust mites, animal dander, and mold
  • Episodic: Intermittent such as home where pets dwell
40
Q

Allergic Rhinitis: Presentation

A
  • Clear, thin rhinorrhea
  • Nasal congestion
  • Sneezing
  • Itchiness of nose, eyes, ears, & palate
  • Postnasal drip
  • Clearing of the throat
  • Coughing
  • Hoarseness
  • Disrupted sleep patterns
  • Poor school performance
41
Q

Allergic Rhinitis: PE

A
  • Pale pink or bluish-gray swollen, boggy nasal turbinates with clear water nasal secretions
  • Nasal salute/Allergic salute
  • Lymphoid hyperplasia of the soft palate or posterior pharynx with visible mucous
  • Allergic shiners, dark periorbital swollen areas, with swollen eyelids and conjunctival injection
  • Retracted tympanic membranes, non-mobile
42
Q

Allergic Rhinitis: Dx

A
  • RAST/Immunocap
  • Skin testing
  • Eosinophils or nasal smear: may also be predictive of good clinical response to nasal corticosteroid sprays
43
Q

Allergic Rhinitis: Tx

A
  • Oral antihistamines
  • Intransal corticosteroids
  • Topical antihistamines
  • Anticholinergics
  • Nasal Cromolyn
  • Decongestants
  • Leukotriene antagonists
  • Immunotherapy
44
Q

Allergic Rhinitis: Antihistamines

A
  • Have been found to be effective and safe for controlling most allergic rhinitis symptoms and are recommended as 1st-line
  • Older antihistamines can produce cholinergic side effects
  • Newer antihistamines do not cross blood-brain barrier resulting in less sedation
45
Q

2nd Generation Antihistamines

A
  • Loratadine (Claritin)
  • Desloratadine (Clarinex)
  • Fexofenadine (Allegra)
  • Cetirizine (Zyrtec)
  • Levocetirizine (Xyzal)

N827 (19 decks)

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