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RC Test 2 > B4.032 - Big Case Asthma > Flashcards

B4.032 - Big Case Asthma Flashcards

1
Q
A

Type 1 HS - allergic asthma

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2
Q

what is a T1 HS reaction

A

Immediate hypersensitivity reaction

Involve IgE mediated relaesae of histamine and other mediators from mast cells and basophils

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3
Q

what are type 2 HS reactions

A

Cytotoxic hypersensitivity

Involve IgG or IgM antibodies bound to cell surface antigens, with subsequent complement fixation

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4
Q

what is a T3 HS reaction

A

immune complexc reactions

involve circulating antigen-antibody immune complexes tha teposit in post ca;illary venules, with subsequent complement fixation

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5
Q

what is a T4 HS reaction

A

delayed

cell mediated immunity

mediated by T cells rather than by antibodies

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6
Q

what is an arthrus reaction

A

type 3 immune complex mediate dHS that occurs following the intrdermal injection of antigen in the presence of a high level of circulating antibody. Within 4-12 hours the area becomes red and oedematous

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7
Q

which cell line is increased in patient with an acute asthma exacerbation, severe asthama or smokers with asthma?

A

in acute setting neutrophils are the major component

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8
Q

what is the 2007 definiton of asthma

A

Chronic inflammatory disorder of airway in whihc many cells an cellular elements play a role : mast cells, eosinophils, neutorphils, T lymphocyetes, macrophages, epithelial celsls. In susceptible indiviiduals this inflammation causes recurrent episodes of coughing (particularly at night or early in the morning), wheezing, breathlessness and chest tightness.

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9
Q

when do asthmatics wheeze

A

on expiration

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10
Q

describe the cause of inflammation in asthma

A
  1. inhaled antigen activates mast cells/Th2 cells in airway
  2. inflammatory mediators/cytokines
  3. bone marrow activation
  4. eosinophils migrate ot area of allergic inflammation
  5. eosinophils release inflammatory mediators
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11
Q

In pt with acute episode of asthma

A

Airway remodeling

why? hes 31, hopefully hes recieved treatment and had controlled asthma so he wouldnt have remodeling

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12
Q

what causes airway remodeling

A

chronic asthmatic episodes that are poorly controlled

the smooth muscle constricts during an asthmatic episode, if you have chronic constriction due to failure to control constant asthma then this smooth muscle hypertrophies

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13
Q

asthma pathogenesis

A
  1. airways infiltrated wiht eosinophils and mononuclear cells
  2. vasodilation and mocrovascular leakage
  3. airway smooth muscle hypertrophy
  4. new vessel formation
  5. increased numbrs of epithelial goblet cells
  6. deposition of interstitial collagens beneath epithelium
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14
Q

will giving bronchodilators help with airway remodeling

A

not if its already formed

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15
Q
A

All can play a role

A. gender is key here

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16
Q

describe gender and asthma prevalence

A

before puberty boys higher prevalence

after puberty girls higher

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17
Q

what factors initiate inflammation/asthma?

A
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18
Q

what factors favor Th1 phenotype

A

Presence of older siblings

Early exposure to daycare

TB, measles, hepA

Rural environment

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19
Q

what factors favor Th2 phenotype

A

widespread use of antibiotics

western lifestyle

Urban evironment

diet

sensitization to house-dust mites and cockroaches

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20
Q

What does the Th1 phenotype lead to

A

protective immunity

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21
Q

what does the Th2 phenotype lead to

A

Allergic diseases including asthma

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22
Q
A

A. currently available therapies (ICS) for asthma control symptoms, but do not modify disease severity

AKA if you give a beta agonist once they go off the medicine they will still have symptomes

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23
Q
A

ENT consultation

Classic - woman with PTSD –> vocal chords spasm

once you bypass obstruction with probe the symptoms should dissapate

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24
Q
A

Answer is A. Fibrotic stricture is going to result in flattening of both the inspiratory and expiratory flow-volume loop. The other three answers are extrathoracic issues that would result in flattening of the inspiratory limb like we see on the above loop. See next couple slides.

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25
Q

what is vocal cord dysfunction, what does it mimic, epidemiology

A

an abnormal adduction of vocal cords durign respiratory cycle

Often mimics persistent asthma

more common in young females with psychiatric illnesses

localization of airflow obstruction to laryngela pharynx is an important clinical discriminatory feature wiht VCD

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26
Q

what type of lesion causes this

A

Fixed lesion

* neoplams of central airway

* vocal cord paralysis with fixed stenosis

* fibrotic stricture

27
Q

what type of lesion causes this

A

variable extrathoracic lesions

* vocal chord paralysis

* subglottic stenosis

* neoplasm

* goiter

28
Q

what type of lesion can cause this

A

variable intrathoracic lesion

* Tumor of lower trachea

* thracheomalacia

* strictures

* wegners granulomatosis or relapsing plychondrosis

29
Q
A

Everything essentially

30
Q

key indicators for considering diagnosis of asthma

A
31
Q

what is spirometry looking for

A

airflow obstruction

reversibility

32
Q

is there one single test to diagnose asthma?

A

no

33
Q

what is reversibility

A

when the patient blows the FEV1 is low, but when you give a bronchodilator in the clinic the FEV1 should open up

34
Q

whats methocholine challenge testing

A

Given to bronchocontrict and if it doesnt work think something else

35
Q
A

C - allay the spasm during the paroxysm

36
Q
A

B

37
Q

why does avoidance improve asthma symptoms?

A

decreased exposure means decreased reaction

38
Q

what is the best appraoch to asthma treatment

A

mutlifaceted. single steps are generally ineffective

39
Q
A

A. yes

40
Q
A

D. medium dose ICS

41
Q

what is mild intermittent asthma

A

* symptoms = 2 days / week

* Breif exacerbations

* SABA use <2x/month

* nighttime symptoms <2x / week

* asymptomatic with normal lung function between exacerbations

* FEV1 and PEF >/= 80% predicted

*PEF variablility

42
Q

what mediaction do you give someone with mild intermittent asthma

A

albuterol

43
Q

what is mild persistent asthma and how do you treat

A

inhaled cortico steroid (ICS) is the gold standard

*symptoms >2 d / wk but not daily

* minor limitations

* SABA >2d/week but not daily, not more than 1x /day

*nighttime asthma symptoms 3-4x/month

* FEV1 and PEF >/= 80% predicted

* PEF variability 20-30%

44
Q

how do you treat mild persistent asthma

A

ICS

45
Q

what is moderate persistent asthma

A

* daily symptoms

* exacerbations >2x/week

* affects activity

* nighttime symptoms >1x / week but not nightly

* daily use of short activng beta agonist

* FEV1 adn PEF > 60% and <80% predicted

* FEV1/FVC reduced 5%

*PEF variability

46
Q

what is severe persistent asthma

A

* continuous symptoms

* frequent exacerbations

* frequent nighttime symptoms

* limited activity

*FEV1 and PEF <60

* PEF variability >30%

47
Q
A

Answer is E. IV steroids are important but will not help in the acute exacerbation phase. They take 12 to 24 hours to work.

48
Q

what is the expert panel conclusion on sever asthma exacerbations in the ED

A

Ipratropium bromide (atrovent) , administered in multiple doses along with SABA provides additive benfit

49
Q
A

D. his LABA use

you need to have ICS with LABA always!!! Never just LABA

50
Q

why do patients start taking LABAs instead of ICS

A

because ICS dont make you feel good but dont bronchodilate, LABA makes you feel better sooner so patients tend to just use those

51
Q

what is bronchothermoplasty

A

burn airways/scar muscle layer so the muscle cant constrict

52
Q

You are taking care of Mr. Smith, a 35 yo veteran, who reports intermittent compliance issues with is asthma meds. You should be most concerned about what?

A. his dose of ICS

B. allergen avoidacen strategies

C. his occupational exposure risk

D. his LABA use

E. his inhaler technique

A

Answer is D. We don’t want asthmatics to use LABA’s alone. Need to be on inhaled steroid as well.

53
Q

Mrs. P. is a 35 yo female with moderate compliance with her asthma. Which of the following statements is correct in regards to her management of acute asthma exacerbations?

žA. A peak-flow-based plan may be particularly useful for patients who have difficulty perceiving airflow obstruction and worsening asthma (Evidence D).

žB. Appropriate intensification of therapy by increasing inhaled short-acting beta2-agonist (SABA) and, in some cases, adding a short course of oral systemic corticosteroids (Evidence C).

žC. Recognition of early signs of worsening asthma and taking prompt action (Evidence B).

žD. Patient education, including a written asthma action plan to guide patient self-management of exacerbations at home, especially for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations

(Evidence D).

A

Answer D: This slide speaks to the importance of pt education and providing an asthma action plan so pt’s can initiate a therapy plan from home if and when they start to develop an exacerbation. These plans often direct them to contact their physician if they are not improving with specified therapy.

54
Q

Mrs. P. does not recognize her asthma has worsened and ends up being admitted to unit 66 for an acute asthma exacerbation. She reports dyspnea, cough, and wheeze and believes her trigger is the humidity. Which therapy below has not been shown to have significant benefit for the hospitalized asthma patient?

žA. Oxygen to keep sats>92%

žB. Prednisone 60mg po

žC. Levaquin 500mg qd

žD. SABA

žE. Atrovent

A

E. Atrovent

Remember, this has been shown to be beneficial on arrival to the ER during an exacerbation. If the pt does not improve and is admitted then albuterol is the drug of choice for bronchodilation but not both.

55
Q

You return to check on Mrs. P after admitting 2 other patients from the ER. She appears less tachypnic than before, but is still using her accessory muscles to breath. She appears mildly confused and is having a difficult time speaking. Her oxygen levels are stable on 2 liters. The most important next step in her care is?

žA. Check an ABG

žB. Intubate the patient

žC. Start heliox stat

žD. Add magnesium infusion to her management

žE. Call a rapid response

ž

A

A. check ABG

Answer is A. This pt is showing signs of respiratory fatigue. Don’t be fooled by less tachypnea. As an asthmatic pt. fatigues they start to become more hypercapnic (retain CO2). This is likely contributing to her confusion. You need and ABG to assess her acid-base status and to see if she is developing a respiratory acidosis. If she is then you would call a rapid response, move her to the ICU and provide her with NIV or intubation. Additional magnesium is used for bronchodilation. Heliox is used for worsening hypercapnia when you are trying to clear CO2. Changes gas flow dynamics in the airway.

56
Q

Mrs. P. just can’t catch a break and gets intubated. You are asked by the respiratory therapist for ventilator settings. Your recommended ventilator strategy will be which of the following?

žA. Active hyperventilation to remove C02.

žB. Shortened expiratory phase to improve ventilation

žC. Moderate tidal volume ventilation to maintain plateau pressures below 40.

žD. Controlled hypoventilation

žE. Permissive hypocapnia

A

Answer is D. We ventilate pt’s with asthma at low lung volumes, slow rates (hypoventilation) and prolonged expiratory times. Remember, when they are obstructed with severe bronchial constriction during status asthmaticus they struggle to get the air out of their lungs. They are at increased risk of stacking breaths and air-trapping which will make the pressure in their thorax go up. This can result in hemodynamic compromise and shock. You don’t want them to hyperventilate, we always want to maintain plateau pressures below 30 to protect against ventilator-induced lung injury. We allow for permissive hypercapnia. Allow their PCO2 to run a little on the high side (pH of 7.20 to 7.25) until their bronchoconstriction improves with therapy.

57
Q

what is step one of treatment for asthma patients

A

SABA PRN

58
Q

what is step 2 for persistent asthma

A

Low dose ICS

alternative:

Cromoly, LTRA, Nedocromil, theophyline

59
Q

what is step 3 in treatment for persistent asthma patients

A

ICS + LABA

OR

Medium dose ICS

Alternative:

Low dose ICS

and LTRA, theophylline or zileutron

60
Q

what is step 4 in treatment for persistent asthma

A

medium dose ICS + LABA

alternative:

medium dose ICS, adn LTEA, theophylline or zileuton

61
Q

what is step 5 in treatment for persistent asthma

A

High dose ICS + LABA

AND

consider omalizumab for patients with allergies

62
Q

what is step 6 for treatment of persistent asthma

A

High dose ICS + LABA + oral corticosteroid

AND

consider Omalizumab for patients who have allergies

63
Q

what should you check before stepping up asthma treatments

A

adherance, environmental control, comorbid conditions

64
Q

when can you step down mediactions

A

when asthma is well controlled at least 3 months

RC Test 2 (19 decks)

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