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820 > Chronic Asthma - Diagnosis/Assessments > Flashcards

Chronic Asthma - Diagnosis/Assessments Flashcards

1
Q

Chronic Asthma Guidelines

A
  • GINA 2019 - Global Initiative for Asthma

- EPR-3 - Diagnostic/Management of Asthma

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2
Q

Asthma Defintions

A
  • Heterogeneous disease
  • Chronic airway inflammation
  • History of symptoms that vary over time and in severity
  • Variable expiratory airflow limitation
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3
Q

Asthma Presentations

A
  • Episodes of dyspnea
  • Episodes of wheezing
  • Tightness in chest
  • Chronic daily OR intermittent symptoms
  • Intervals between symptoms - weeks, months, year
  • Characterized by recurrent exacerbations/remissions
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4
Q

Asthma Clinical Phenotypes

A
  • Allergic asthma
  • Non-allergic asthma
  • Adult-onset asthma
  • Asthma with persistent airflow limitation
  • Asthma with obesity
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5
Q

Asthma Diagnosis - Need to determine…

A
  • History of variable respiratory symptoms
  • Confirm expiratory airflow limitation
  • Make sure alternative diagnoses are excluded
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6
Q

Asthma Diagnosis Methods

A
  • Detailed medical history
  • Physical exam
  • Spirometry
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7
Q

Asthma - Medical History questions

A
  • Types of symptoms
  • Pattern of symptoms
  • Precipitating/aggravating factors
  • Development of disease/treatment
  • Family history
  • Social history
  • Profile of typical exacerbation
  • Impact of asthma on patient/family
  • Assessment of patient/family perceptions
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8
Q

Asthma Triggers

A
  • Respiratory infections - viral
  • Environment factors - smoke, bakers, farmers
  • Psychological factors - stress, depression
  • Obesity - may increase prevalence and decrease control
  • Rhinitis/sinusitis
  • Gastroesophageal reflux - noctural symptoms associated with reflux
  • Female hormones - increase symptoms during periods and premenstrual times
  • Preservatives - benzalkonium chloride, sulfite sensitivity
  • Medications
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9
Q

Asthma Physical Exam Findings

A

The following increases the probability of asthma…

  • Hyperexpansion of thorax
  • Wheezing
  • Atopic dermatitis/eczema
  • Can also be noctural
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10
Q

Pulmonary Function Tests

A
  • Used to establish diagnosis of asthma
  • Spirometry to establish reversibility
  • FEV1 increases by more than 12% after using a SABA
  • Perform initial visit, then retest 3-6 months afterwards
  • Then perform test every 1-2 years once treatment is established
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11
Q

<5 y.o. Diagnosis - Asthma

A
  • Challenging
  • Recurrence of wheezing is common in large portion of kids due to viral URI
  • Certain factors that increase or decrease asthma probability
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12
Q

< 5 y.o. Increased Asthma Factors

A
  • Wheezing/coughing occurs with exercise, laughing, or crying with no infection
  • History of other allergic diseases (eczema, allergic rhinitis)
  • Asthma in primary relatives
  • Clinical improvement over 2-3 months of controller treatment and worsening after cessation
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13
Q

< 5 y.o. Decreased Asthma Factors

A
  • Isolated cough with no other respiratory symptoms
  • Chronic production of sputum
  • SOB with dizziness, light headed, peripheral tingling
  • Chest pain
  • Exercise-induced dyspnea with noisy inspiration (stridor)
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14
Q

2 Domains to Control with Asthma

A

Symptom Control

  • Burden to patients
  • Increases risk of exacerbations if they aren’t controlled

Future Risk of Adverse Asthma Outcomes

  • Exacerbations/Flare-ups
  • Loss of lung function
  • Medication SE
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15
Q

Severe Risk Factors - Exacerbations

A
  • Uncontrolled asthma symptoms
  • Inadequate ICS: not prescribed, adherent, or incorrect technique
  • > = 1 exacerbation in past year
  • Higher bronchodilation reversibility
  • Major psychological or socioeconomic problems
  • Comorbidities: chronic sinusitis, obesity, confirmed food allergy
  • Sputum or blood eosinophilia
  • Pregnancy
  • Increased fractional concentration of exhaled NO (FNEO)
  • Exposures: smoking, allergens, pollution
  • Low FEV1 (<60% of predicted)
  • High SABA use
  • Ever intubated or ICU for asthma
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16
Q

Risk Factors: Decreased Lung Function

A
  • Preterm birth
  • Lack of ICS treatment
  • Exposures: tobacco smoke, noxious chemicals, occupational exposure
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17
Q

Risk Factors: Medication SE

A
  • Systemic rises from frequent oral CS use
  • Long term, high dose ICS can also cause it
  • Taking P450 inhibitors increases the risk for systemic SE as well
  • Local SE rise from high dose ICS and poor inhaler technique
18
Q

Asthma Goals of Therapy

A
  • Avoid daytime and noctural symptoms
  • Need little or no reliever medication
  • Maintain normal activity levels
  • Normal or near normal lung function
  • Avoid serious asthma flare-ups
  • Patient specific goals
  • Minimize adverse effects
19
Q

3 Asthma Medication Categories

A
  1. Controlled - ICS, LABA
  2. Reliever (Rescue) - SABA, SA anticholinergics, SCS
  3. Add-on (Severe asthma)
20
Q

Controller Medications

A
  • Regular maintenance treatment
  • Decreased inflammation
  • Controls symptoms
  • Decreases future risk of exacerbations and decreased lung function
21
Q

Reliever Medications

A
  • All patients with asthma should have one
  • Relieve breakthrough symptoms
  • Prevention of exercise-induced bronchoconstriction
22
Q

Add-On Medications

A

-Severe Asthma
-For those with persistent symptoms/exacerbations with high dose controller meds
EX: leukotriene modifiers, long-acting mus. antagonists, OCS, methylxanthones, cromolyn, biologics

23
Q

Presenting Symptom: Infrequent Symptoms

A

Initial Treatment: PRN low dose ICD - formoterol

Controversial

24
Q

Presenting Symptom: Asthma symptoms/reliever needed 2 times+/month

A

Initial Treatment: Low dose ICD or LTRA (less effective, theophylline)

25
Q

Presenting Symptom: Troublesome asthma symptoms most days or waking asthma 1 times+/week

A

Initial Treatment: Medium dose ICS or Low dose ICD + LABA

26
Q

Presenting Symptom: Severely uncontrolled asthma or acute exacerbations

A

Initial Treatment: Short course OCS AND high dose ICS
OR
Medium dose ICS + LABA

27
Q

How severe is the asthma?

A
  • Assessed retrospectively from level of treatment required to control symptoms and exacerbations
  • Assessed once controller treatment for severe months and, if appropriate, after step down therapy has been attempted
28
Q

Step 1 Therapy

A
  • Preferred Controller: None, PRN ICS + Formoterol
  • Other Controller Options: Low dose ICS
  • Reliver: PRN SABA
  • Mild asthma
29
Q

Step 2 Therapy

A
  • Preferred Controller: Low dose ICS
  • Other Controller Options: LTRA
  • Reliever: PRN SABA
  • Mild asthma
30
Q

Step 3

A
  • Preferred Controller: Low dose ICS + LABA OR Medium dose ICS (preferred for 6-11 y.o.)
  • Other Controller Options: Medium dose ICS, low dose ICS + LABA
  • Reliver: PRN SABA
  • Moderate asthma
31
Q

Step 4

A
  • Preferred Controller: Medium dose ICS + LABA and a specialist
  • Other controller options: Add-on tiotropium, high dose ICS, add-on LTRA
  • Reliever: PRN SABA
  • Severe asthma
32
Q

Step 5

A
  • Preferred Controller: High dose ICS + LABA and a specialist
  • Other controller options: Low dose OCS, tiotropium, LTRA, biologics
  • Reliever: PRN SABA
  • Severe asthma
33
Q

Step Down Therapy

A
  • Considered after 3 months of control and lung function hits a plateau
  • Few data on optimal timing, sequence, or magnitude
  • Decrease ICS dose by 25-30% at 3 months intervals is safe for MOST
  • Step-down approach based on patient’s current medications and doses
34
Q

Step Down Option: High dose ICS/LABA + OCS

OR High dose ICS/LABA + other add-on

A
  • Continue high dose ICS/LABA, reduce OCS
  • Alternate-day OCS
  • Refer for expert advice
35
Q

Step Down Option: Medium-high dose ICS/LABA

OR High dose ICS + second controller

A
  • Continue combination; reduce ICS by 50%
  • Discontinuing LABA may lead to deterioration
  • Reduce ICS by 50% and continue second controller
36
Q

Step Down Option: Low dose ICS/LABA

OR Moderate or high dose ICS

A
  • Reduce ICS/LABA to once daily
  • Discontinuing LABA may lead to deterioration
  • Reduce ICS dose by 50%
37
Q

Step Down Option: Low Dose ICS

A
  • Once daily dosing

- Adding LTRA may allow ICS step down

38
Q

Non-Pharm for Asthma

A
  • Smoking cessation and environmental tobacco smoke avoidance
  • Avoid occupational exposures
  • Avoid medications that worsen asthma
  • Avoid indoor/outdoor allergnes
  • Weight loss
  • Dealing with emotional stress
39
Q

Check Following before Increasing Meds

A
  • Inhaler technique
  • Adherence to prescribed medications
  • Environment changes
  • Consider alternative diagnosis
40
Q

Basic Asthma Educations

A
  • Provide to ALL asthmatics
  • Contrast normal and asthmatic airways
  • What happens during an attack
41
Q

Role of Medication Education

A
  • Provide to ALL asthmatics

- Controller v.s. relievers

42
Q

Skills Asthma Education

A
  • Provide to ALL asthmatics
  • Inhaler technique/device use
  • Avoid environmental exposures
  • Self-monitoring
  • How to use written action plan

820 (19 decks)

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