Cardiopulmonary: Asthma Flashcards
Asthma is
a chronic, reactive, obstructive airway disorder characterized by narrowing of the airways due to bronchospasm, airway inflammation, and increased secretions.
Asthmatics cannot achieve ____, resulting in _____
cannot achieve normal air flow rates resulting in uneven lung aeration and VQ mismatch
VQ mismatch
decreased ventilation, normal perfusion
hallmark of asthma
inflammation, leading to bronchospasm
why are we aggressive in asthma treatment?
to prevent remodeling as much as possible
in asthma, wheezing is secondary to
turbulence and mucosal vibrations
Pathophysiology of asthma [structural]
airway obstruction and remodeling.
inflammation secondary to hyper responsiveness of airways
remodeling defined
& What does it lead to
structural changes as a result of constantly being “under attack”. this leads to decreased lung recoil and compliance.
management of chronic asthma begins with evaluating
FEV-1/FVC
pathophysiology of asthma [cellular]
mast cell degranulation, releasing histamine
inflammatory cytokines
eosinophil infiltration
leukotrienes
Forced Expiratory Volume (FEV1)
max amount of air one can exhale forcefully and rapidly in the first second after a deep inspiration (time based)
what is FEV1 based on?
body size and race
Forced Vital Capacity (FVC)
the maximum amount of air one can exhale forcefully and rapidly after a deep inspiration. Is there air remaining/trapped? (amount based)
FEV1:FVC Ratio is used for what?
to measure obstruction
Normal FEV1:FVC ratio
5-19 y/o
85%
Normal FEV1:FVC ratio
20-39 y/o
80%
Normal FEV1:FVC ratio
40-59 y/o
75%
Normal FEV1:FVC ratio
60-80 y/o
70%
goal FEV1/FVC ratio for someone being treated for asthma
80% or better
Categories of Asthma based on EPR-3 Guidelines: Step 1-6
1: intermittent
2: mild persistent
3, 4: moderate persistent
5, 6: severe persistent
At which step of asthma should specialist consultation occur?
Around step 4
Asthma treatment varies by
step of classification
As FEV1 goes down,
so does the FEV1/FVC ratio
The emphasis of asthma treatment is on
asthma control, reducing impairment and future risk
Initial asthma management is based off of
categorization of severity
subsequent asthma management is based off of
assessment of control using validated instrument
example of validated instrument used to assess asthma control
PFT
EPR: for patients in steps 2-4 with allergic asthma, what should be considered?
subQ allergen immunotherapy
budesonide is a
steroid
formoterol is a
LABA
albuterol is a
SABA
LAMA
muscurinic
Two major types of therapies for asthma treatment
bronchodilators
immunosuppressants
Benefits of inhalation therapies
doses are much smaller inhaled than if they were given systemically, so you have a reduction in adverse effects without a reduction in efficacy
what is the goal of long term control versus short term control of asthma?
prevention of exacerbation
long term asthma therapy
immunosuppresants
short term asthma therapy
bronchodilators
3 divisions of bronchodilators
beta 2 agonists
methylxanthines
anticholinergics
short acting beta 2 agonist bronchodilators
albuterol
levalbuterol
albuterol vs levalbuterol
isomer of albuterol, levalbuterol has less side effects than albuterol.
unfortunately, it is expensive and reserved for those who have failed or become refractory to albuterol.
long acting beta 2 agonist bronchodilator
formoterol
salmeterol
albuterol can be administered
po or inhaled
example of methylxanthine bronchodilator
theophylline
theophylline can be administered
oral or iv
examples of anticholinergic bronchodilators
ipratropium
tiotropium
(both inhaled)
Albuteral and levalbuterol are for ____ while formoterol and salmeterol are for _____
rescue ; maintenance
long acting beta 2 agonists are used in conjunction with
corticosteroids
you will see salmeterol or formoterol used in conjunction with ____ and why
corticosteroids ; because they are long acting beta 2 agonist bronchodilators.
what is the onset of short acting beta 2 agonist bronchodilators?
15 minutes
true or false, everyone diagnosed with asthma gets a SABA
true
SABAs are also used for
prevention of exercise induced asthma
as a rule of thumb, what would insight would you gain if your patient tells you they have used one small canister of their SABA in one month?
that they are well controlled
as a rule of thumb, what would insight would you gain if your patient tells you they have used two or more small canisters of their SABA in one month?
that they need more anti inflammatory effects
beta-2 agonists and MAOIs or tricyclic anti depressants
HTN crisis
Beta-2 agonists plus corticosteroids
more effective than increased doses of corticosteroids on their own
adding beta-2 agonists to an ICS corticosteroid regimen can do what to ICS dose?
decrease by 50%
T or F, beta-2 agonists have no appreciable anti-inflammatory action
true
long term use of beta-2 agonists may result in
tolerance
if pt is getting tolerant to beta2 agonist, what should provider do
change agents or increase dose/freq.
if someone has an asthma exacerbation, what should provider ask them to demonstrate
how they use their inhaler/if their technique is incorrect
Per FDA, LABAs should only be used
in combo with other agents such as corticosteroids
Theophylline is generally not recommended for
exacerbations
anticholinergic bronchodilators are aka
muscarinics
Ipratropium is a
short acting muscarinic antagonist (SAMA)
___ includes anticholinergics, while ___ does not
GINA, EPR
Ipatropium is not actually indicated for asthma but
it is used all of the time, especially in first 24 hours via neb and is part of the GINA guideline.
why give beta 2 agonist with an anticholinergic in asthma exacerbation?
they both bronchodilate but via different mechanisms, you’ll have a more effective bronchodilator.
tiotroprium is a
long acting muscarinic antagonist (LAMA)
tiotroprium is not
in the EPR but is FDA approved for asthma
4 immunosuppressant groups used for long term asthma control
corticosteroids
mast cell antagonists
leukotriene antagonists
monoclonal antibodies/biologics
PO corticosteroids used for asthma (2)
prednisone
methylprednisolone
inhaled corticosteroids used for asthma (2)
beclomethasone
flunisolide
inhaled mast cell antagonist
cromolyn
PO leukotriene antagonists (3)
zafirlukast, montelukast, zileuton
corticosteroids are first line treatment starting at what asthma step, typically?
step 2
t or f - corticosteroids are not for acute attacks
true, ok for an exacerbation.
inhaled steroids are best for
long term use - control
what route of steroids for acute attack?
IV or Oral
short term oral corticosteroids use of 3-10 days is indicated for what?
to gain control of inadequately controlled persistent asthma.
long term inhalation of corticosteroids is
used for prevention. the preferred long term control therapy for all ages.
adverse effects of inhaled corticosteroids (4)
cough
dysphonia
thrush
headache
what should patient take with po corticosteroid?
h2 blocker
adverse effects of PO corticosteroids (4)
reversible glucose increase
increased appetite
fluid retention
peptic ulcer
adverse effect of high dose PO glucocorticoid
adrenal axis suppression
how to maximize effect of inhaled corticosteroids?
use of spacer
how to minimize local side effects of inhaled corticosteroids?
rinse mouth after
t or f - preparations of each type of inhaled steroid are NOT interchangeable
true
corticosteroids are NOT
for acute attacks
what to look for in long term corticosteroid use?
growth issues
if growth issues occur in long term corticosteroid use, what is a proper alternative?
mast cell agents
MoA of Cromolyn sodium, a mast cell stabilizer
acts as an anti inflammatory, stabilizing mast cell membranes, inhibiting activation and release of mediators from eosinophils and epithelial cells like histamine and leukotrienes.
mast cell stabilizers are used mainly in __ , why?
children
weaker drug and does not have growth issues like steroids do
mast cell stabilizers as compared to beta agonists
less side effects but takes longer to get results. should never be used as a rescue.
Cromolyn, a mast cell stabilizer, is most useful in
younger and allergic asthmatics with mild persistent asthma
patient education re: cromolyn sodium, a mast cell stabilizer
most patients take a while to see clinical effect.
adverse effects of cromolyn, a mast cell stabilizer (2)
cough and congestion
rare
Mast cell stabilizer (Cromolyn) as compared to corticosteroid
considered weak in comparison
why are mast cell stabilizers (cromolyn) used more frequently in children?
they pose no risk of growth suppression
indication for cromolyn, a mast cell stabilizer
prevention of exercise induced asthma
Montelukast is a
leukotriene modifier
MoA of montelukast and zafirlukast (leukotriene modifiers)
Blocks leukotriene receptors on inflammatory cells and smooth muscle
when should leukotriene modifiers be used?
in maintenance when a patient is stable. is not a tx for acute asthma.
leukotriene modifiers in asthma exacerbation
no help
MoA of zileuton, a leukotriene modifierwh
stops the synthesis of leukotrienes via lipoxygenase inhibition
Leukotriene modifiers are given
PO as systemic treatment
Leukotriene modifiers as compared to corticosteroids
well tolerated and have minimal side effects but are less effective
drug interactions involving leukotriene modifiers
these drugs are enzyme inhibitors
-lukast drugs: enzyme inhibition
will inhibit warfarin metabolism
zileuton: enzyme inhibition leads to
will inhibit warfarin and theophylline metabolism
What lab should be monitored when someone is on a leukotriene modifier?
LFT - baseline and q6 months
Which monoclonal antibody is indicated for asthma?
omalizumab, an IgE-binder
MoA of Omalizumab
forms complexes with IgE and prevents binding to receptors, thus limiting inflammatory mediator release.
Omalizumab is indicated in
patients >12 y/o with moderate to severe asthma who have failed all other traditional agents.
Example of a novel asthma therapy
dupilumab
MoA of dupilumab
Inhibits IL-4 and IL-13, reducing symptoms
Dupilumab is indicated in
patients with eczema
in patients with asthma, it is similar indication as omalizumab - patients in steps 5 or 6 who have failed other therapies.
Goal of ED care: asthma
oxygen management
emergency asthma care is comprised of
anti inflammation, frequent bronchodilation, and potential for antibiotic
What meds would you anticipate being administered in an acute asthma exacerbation in the ED?
- IV corticosteroid methylprednisolone before switching to PO prednisone
- albuterol/ipatropium for first 24 hours, then albuterol alone,
- magnesium
rationale for antibiotics in asthma exacerbation
want to avoid CAP superimposed on exacerbation
Empiric antibiotics and asthma
avoid unless you have a reason to r/o pneumonia
What asthma meds should be avoided in acute asthma exacerbation? (3)
- leukotriene based agents because they will not have an effect
- theophylline because of AEs and narrow levels
- empiric abx
Monitoring of chmronic asthma
assess control and set up action plan
what modifiable factors which make asthma worse can be controlled? (5)
tobacco smoke dust mites animal dander cockroaches mold
What tools can be used to assess progress in chronic asthma?
peak flow meter
asthma diary
Metered dose inhalers and soft mist inhalers administration characteristics
slow and deep inhalation
dry powder inhaler characteristic of administration
rapid and deep
what is the purpose of an inhaler spacer?
disperses aerosol into the spacer, decreasing the droplet size and thus decreasing oral deposition of the aerosol.
skipping slide 64 until lecture
ok
LABAs are used in conjunction wit
tolerance to beta-2 agonists may necessitate what from the provider?
change in beta-2 agonist or increased steroid dose
tolerance to beta-2 agonists may necessitate what from the provider?
change in beta-2 agonist or increased steroid dose
tolerance to beta-2 agonists may necessitate what from the provider?
change in beta-2 agonist or increased steroid dose
