Atopic Child Flashcards
1
Q
Atopic Triangle
A
- Allergic Rhinitis
- Eczema
- Asthma
2
Q
What is Atopy?
A
- IgE mediated response
- Genetic and environmental factors
3
Q
Asthma Epidemiology
A
- Puerto Ricans have highest incidence
- African Americans have highest death rate
4
Q
Asthma PE
A
- Diaphoresis
- Anxiety
- Breathlessness
- Loss of breath sounds
- cyanosis
- Respiratory/cardiac collapse
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
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.
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
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
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
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
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
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
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
14
Q
Challenge Testing
A
- Methacholine
- Histamine
- Cold air
- Exercise challenge
- These cause bronchoconstriction
Use spirometry to measure lung function with challenge
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
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
17
Q
1) Assessing and Monitoring Asthma Severity and Control
A
-Must grade severity, functional limitations, and risks of asthma
18
Q
Asthma Severity Levels
A
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
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
Inhaled Corticosteroids
- 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
Oral Steroids
- 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
Mast Cell Stabilizers
- 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
Immunomodulators (anti-IgE)
- 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
Leukotriene Modifiers (LTRA: Leukotriene receptor antagonists)
- 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
Long-Acting Beta Agonists (LABAs)
- 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
Methylxanthines
- 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
Azithromycin (Zithromax) for Asthma
- 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
Anticholinergics (Acute Attack)
- 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
SABAs (Acute Attack)
- 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
Systemic Corticosteroids (Asthma)
- 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
Epinephrine Injection (Asthma)
- 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
Asthma in Pregnant Teens
- 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
Allergic Rhinitis: Basics
- 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
Allergic Rhinitis: Types
- 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
Allergic Rhinitis: Presentation
- 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
Allergic Rhinitis: PE
- 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
Allergic Rhinitis: Dx
- RAST/Immunocap
- Skin testing
- Eosinophils or nasal smear: may also be predictive of good clinical response to nasal corticosteroid sprays
43
Allergic Rhinitis: Tx
- Oral antihistamines
- Intransal corticosteroids
- Topical antihistamines
- Anticholinergics
- Nasal Cromolyn
- Decongestants
- Leukotriene antagonists
- Immunotherapy
44
Allergic Rhinitis: Antihistamines
- 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
2nd Generation Antihistamines
- Loratadine (Claritin)
- Desloratadine (Clarinex)
- Fexofenadine (Allegra)
- Cetirizine (Zyrtec)
- Levocetirizine (Xyzal)
