Chronic Respiratory- Adults Flashcards
asthma
“Asthma is a complex disorder characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation..”
o Acute inflammation that is reversible. As reaction continues, the airway lumen becomes obstructed by thick secretions and infiltration of lymphocytes and eosinophils which go on to form mucus plugs →death
asthma: s/s
o Wheezing, recurrent
* Shortness of breath, recurrent
o Chest tightness
* Cold often “goes to the chest” and takes more than 10 days to improve
o Cough
* May be the only symptom in up to 57% of patients(“cough variant”)
* Asthma should be considered in the differential diagnosis of all patients with a chronic cough
* Clue: Cough is worse at night
* Nighttime awakening
o Other
* Symptoms that worsen with exercise, viral infection, inhalant allergens, irritants, weather changes, strong emotions, menses
asthma: taking a history
o Symptoms/Triggers:
* Pattern is important
* Night time, in response to irritants, related to exercise, potential triggers at home/work/school, change in environment
* Are symptoms episodic?
o Personal/Family History:
* Personal or family history of atopy
* Prior personal hx of inhaler use, frequent chest colds, etc
* History of childhood asthma/asthma symptoms
o Social History
* Occupational history, smoking history
o Concomitant symptoms
* Symptoms such as chest pain, lightheadedness, syncope or palpitations are concerning for alternative cardiac etiology
physical exam
o Vital signs: T, P, R, BP, SpO2
o General survey: Breathlessness(able to speak in full sentences?), alertness, preferred position (sitting, hunched forward)
o HEENT: Nasal polyps? allergic rhinitis? infection? Med SE’s like thrush?
o Cardiac:
* Tachycardia (may reflect med SE’s or stress response)
* Bradycardia (may precede respiratory arrest in severe asthma)
o Skin: Diaphoresis? Cyanosis? Concurrent eczema(atopic dermatitis)?
o Respiratory
* Rate? Accessory muscles? Retractions?
* Wheezing:
* expiratory at first, with worsening exacerbation inspiratory and expiratory may be heard
* In a severe exacerbation with significant obstruction wheezing may not be appreciated due to lack of air movement
* Respiratory exam may be normal in a person with asthma not experiencing an exacerbation
confirmation of dx of asthma
The demonstration of variable expiratory airflow limitation, preferably by spirometry
* Reduced FEV1
* Increase in FEV1 >15 percent after bronchodilator
* If normal spirometry: Repeat when symptomatic, serial home PEF, bronchoprovocation testing
peak flow measurement
- Often used after diagnosis to objectively monitor symptoms and response to treatment
- Commonly used in sites where spirometry is not available
- Requires adequate training on proper use and motivation to self monitor
- Predicted values based on age/gender/height
- Always record a baseline “personal best” reading when asthma is under reasonable control.
- Use this for comparison during exacerbations.
- Not reliable in children under 5 or with mild asthma
- Green Zone: Good: 80-100% Best
- Yellow Zone: Caution: 50-80%
- Red Zone: Danger <50%
Asthma: Treatment
GINA Option 1: for pts using ICS as a reliver
Mild intermittent asthma
* Low dose ICS with LABA (formoterol)
Mild persistent asthma
* Low dose maintenance ICS with LABA
Moderate persistent asthma
* Medium dose maintenance ICS with LABA
Moderate severe persistent asthma
* Add LAMA, consider high dose ICS maintenance with LABA
GINA Option 2: for pts using SABA as a reliver
Mild intermittent asthma
* ICS whenever SABA taken
Mild persistent asthma
* Low dose ICS
Moderate persistent asthma
* Low dose ICS and LABA
Moderate severe asthma
* Add on LAMA
asthma: pt education
- Smoking cessation
o Motivational Interviewing - Proper use of inhalers
o Check expiration dates of inhalers.
o Renew inhalers at annual PE - Asthma Action Plan
o Every patient with asthma should have an asthma action plan
o Many schools will ask for one - Spacers
o Use of spacer for children, elderly or poor technique - Allergy Avoidance
allergies
o IgE Antibody is produced by plasma cells beneath the mucosal surfaces of the eyes, upper and lower respiratory tracts, skin and gut
o Enter circulation & binds to receptors on mast cells
o Once the binding occurs, the person is sensitized.
allergies: s/s
- Skin –> atopic dermatitis (eczema)
- Nasal Mucosa –> allergic rhinitis
- Respiratory Tract –> asthma
- GI Tract –> vomiting, diarrhea
- Blood Vessels (systemic i.e. anaphylaxis) –> vasodilation, loss of blood pressure, bronchoconstriction, death.
atopy
Refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema).
o Associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.
allergic rhinitis
- Inflammation of nasal sinus cavity
- Response to viruses, allergens, environmental or occupational irritants
- Increased irritation to the epithelial lining of nasal cavity leads to increased nasal congestion and secretion
risk factors: allergic rhinits
o Family hx of atopy
o Male sex
o Birth during pollen season
o Early antibiotic use
o Exposure to indoor allergens
o Serum IgE >100 int. units / mL before age 6
o Presence of allergen-specific immunoglobulin E (IgE)
triggers allergic rhinits
o Exposure to indoor / outdoor allergen leads to symptoms
seasonal allergic rhinitis
o Pollen, trees, flowers in spring
o Grasses in summer
o Ragweed in fall
perennial: allergic rhinitis
o Not seasonal
o Triggered by environmental triggers
o Animal dander, dust mites, foods, insect stings, cockroach droppings, mold spores, chemicals
history of allergic rhinitis
o Detailed symptom history
o Social review
* occupation, home environment, new pets, tobacco or drug use
o Medication review
o Environmental history
* Dust mites, animal dander and indoor allergens should be suspected (heating systems disseminate dust particles)
o Seasonal symptoms
* Late spring / early summer – grass pollen
* Later summer / early fall – weed pollen
* Later winter / early spring – tree pollen
s/s allergic rhinitis
o Paroxysmal Sneezing
o Nasal congestion
o Rhinorrhea
o Post-nasal drip
o Taste / smell disturbance
o Mucosal Swelling
o Obstruction
o Conjunctivitis
o Nasal-ocular and pharyngeal itching
o Dry mouth
o In more severe cases – fatigue, headache
exam findings: allergic rhinits
o Pale nasal mucosa with turbinate enlargement
o Clear nasal secretions
o TM effusion
o Mucus, crusting or bleeding
o Allergic shiners heavy bags under eyes
o Enlarged tonsils
o Post-nasal drip
o “Allergic salute”
diagnostics allergic rhinits
o Not typically necessary
o History can provide much information
o Allergy skin testing
* Performed if symptoms persist and diagnosis is not clear, or not responding to pharmacologic treatment
tx allergic rhinits
o Environmental conrol
* Outdoor allergens
* Indoor allergens
o Intranasal glucocorticoids
* Considered 1st line after environmental control
* Low systemic exposure
* Both relieves and prevents nasal congestion
* May take days to weeks for full effect
* Side effects include nasal burning, dryness, epistaxis, pharyngitis
* Available options: fluticasone propionate (flonase), mometasone furoate (Nasonex), fluticasone furoate (flonase sensimist) (2nd generation preferred)
o Oral antihistamines
* Less effective for nasal congestion, but do help with sneezing, pruritis and rhinorrhea
* May be useful for patients who don’t respond to intranasal steroid
* 1st generation: less preferred – diphenhydramine (Benadryl), hydroxyzine
* 2nd Generation: preferred - cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra)
o Saline irrigation
* Spray bottle, neti pot, plastic bottle
o Other nasal sprays
* Antihistamine sprays, cromolyn sodium spray less effective
anaphylaxis
An acute life-threatening systemic event associated with a potentially life-threatening hypersensitivity reaction.”
o Multiple systems involved (CV, Respiratory, Skin, GI, CNS)
anaphylaxis triggers
o Common: foods, medications, insect venom, latex, occupational inhalants, IV dye, blood products
o Non-immunologic triggers: cold air, exercise, heat
s/s anaphylaxis
o Hives, itching, low BP, high HR, SOB, wheezing, flushing, vomiting, anxiety, lightheadedness
o Symptoms usually occur within 5-30 minutes
o Biphasic reactions (2nd acute reaction) occur hours after the first despite no re-exposure
Usually, 8 hours later but can be up to 72 hours later.
o Intensity of hypersensitivity reactions are not related.
o Clinical presentation pruritic dermal rashes severe systemic manifestation.
red flags anaphylaxis
MI, Foreign body aspiration, Pulmonary embolism, Seizure disorder, Hypoglycemia, Shock
labs and diagnostic testing: anaphylaxis
o Any diagnostics ordered should be used to monitor or eliminate other conditions that the presentation of your patient.
o Anaphylaxis is a clinical diagnosis
o Cardiac monitoring/O2 saturation, ABGs, ECG, CXR
* Used for monitoring patient response, exclude differentials
* Likely in the ED setting
o Skin testing is not predictive of anaphylaxis but may be helpful in identifying causative agent post-anaphylactic episode.
management of anaphylaxis
o Allergen: remove irritating allergen if possible
o Airway: Assess airway, breathing, circulation, and orientation; if needed, support the airway using the least invasive but effective method (eg, bag-valve-mask)
o CPR: Start chest compressions (100/min) if cardiovascular arrest occurs at any time
o Epinephrine: Inject epinephrine 0.3–0.5 mg intramuscularly in the vastus lateralis (lateral thigh)
* Repeat intramuscular epinephrine every 5–15 min for up to 3 injections if the patient is not responding
o Get Help: Call for assistance
o Position: Place adults and adolescents in recumbent position, pregnant people on left side
o Oxygen: Give 8–10 L/min through facemask or up to 100% oxygen as needed;
monitor by pulse oximetry if available
o EMS: Activate EMS (call 911 or local rescue squad) if no immediate response
to first dose of IM epinephrine or if anaphylaxis is moderate to severe
o Fluids: Establish IV line. Keep open with 0.9NL saline
