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
