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Pulmonology 2 > Clin Med - Asthma > Flashcards

Clin Med - Asthma Flashcards

1
Q

Define asthma

A

Chronic inflammatory disorder of the airways resulting in episodes of reversible inflammation causing airflow obstruction

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2
Q

Asthma pathology

A

Hypertrophy of the bronchial smooth mm, mucosal edema, mucous production, airway muscle tightening

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3
Q

Risk Factors for Developing Asthma

A
  • Family history: 40x more likely if parent has asthma
  • Family size
  • Socioeconomic factors
  • Race/Ethnicity
  • Gender: boys early, girls later
  • Prematurity/Birth weight
  • Atopy
  • Eczema
  • Obesity
  • Lower Respiratory Infection (RSV, PIV, Adenovirus, Chlamydia, Mycoplasma)
  • Diet: deficient in fruits and vegetables
  • Maternal smoking
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4
Q

Environmental risk factors

A

Allergans vs. irritants.

Allergans: dust mite, animal dander, cockroach, indoor/outdoor mold, pollen.

Irritants: tobacco smoke, other smoke, fumes, air pollution

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5
Q

Potential Triggers for Acute Symptoms

A
  • Viral Illnesses
  • Cold Air
  • Weather Changes
  • Emotions
  • Foods
  • Medications
  • Exercise
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6
Q

Signs & symptoms

A

-range from mild to severe, sometimes even fatal
-between attacks patient may have few, if any symptoms
-episodic wheezing, chest tightness, SHOB/DOE, cough
Severe attacks: use of accessory MM, nasal flaring, unable to talk in sentences, diminished breath sounds, audible wheezing, respiratory distress/anxiety/panic

Amount of wheezing is not a reliable indicator for severity of episode!!

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7
Q

Physical exam

A

tachypnea, tachycardia, hypoxemia, percussion often normal or hyperresonant, palpation normal, tripoding

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8
Q

What is the most important part of diagnosing asthma?

A

History & physical

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9
Q

What are the 4 causes of chronic cough?

A
  1. Lung disease
  2. Reflux
  3. Upper airway cough syndrome
  4. Drug side effects
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10
Q

Diagnosis of asthma

A

Some patients will report all three of the classic symptoms of asthma, while others may report only one or two:

  • -Wheeze (high-pitched whistling sound, usually upon exhalation)
  • -Cough (often worse at night)
  • -Shortness of breath or difficulty breathing
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11
Q

Asthma and Spirometry

A

A symptom pattern suggestive of asthma AND airflow limitation on initial spirometry, which completely reverses to normal following bronchodilator, virtually clinch the diagnosis of asthma.

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12
Q

What are peak flow meters used for?

A

To set an action plan based on your personal best.

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13
Q

When should you prescribe biologics?

A

When you max out therapy or you find a patient that’s a severe allergic asthmatic (via blood work)

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14
Q

Severity components of intermittent asthma

A
  1. Symptoms < once a week
  2. Nocturnal symptoms < 2x a day/month
  3. Interference with activity - brief exacerbations
  4. SABA use < = 2 days per week
  5. PFT: normal FEV1 between exacerbations, FEV1 > 80% predicted, FEV1/FVC normal
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15
Q

Recommended treatment strategy for intermittent asthma

A

Step-1:

Preferred - SABA PRN

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16
Q

Severity components of mild asthma

A
  1. Symptoms > than 2x per week, but not daily
  2. Nocturnal symptoms 3-4x/month
  3. Interference with activity - exacerbations may cause minor limitation of sleep and activity
  4. SABA use > 2 days per week, but not daily and not more than once on any day
  5. PFT: FEV1 > 80% predicted, FEV1/FVC normal
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17
Q

Recommended treatment strategy for mild asthma

A

Step-2:
Preferred: low-dose ICS
Alt: Cromolyn, LTRA, Nedocromil, or Theophyline

18
Q

Severity components of moderate asthma

A
  1. Symptoms daily
  2. Nocturnal symptoms more than once a week, but not every night
  3. Interference with activity - exacerbations more than 2x/week, may cause some limitation of activity and sleep
  4. SABA use daily
  5. PFT: FEV1 > 60%, but < 80% predicted, FEV1/FVC reduced 5%
19
Q

Recommended treatment strategy for moderate asthma

A

Step-3:
Preferred: low-dose ICS + LABA or medium-dose ICS
Alt: low-dose ICS + either LTRA, Theophiline, or Zileuton

Consider PO steroids

20
Q

Severity components of severe asthma

A
  1. Symptoms throughout the day
  2. Nocturnal symptoms often every night per week
  3. Interference with activity - frequent exacerbations with marked limitation of physical activity
  4. SABA use several times per day
  5. PFT: FEV1 < 60% predicted, FEV1/FVC reduced 5%
21
Q

Recommended treatment strategy for severe asthma

A

Step-4:
Preferred: Medium-dose ICS + LABA
Alt: Medium-dose ICS + either LTRA, Theophyline, or Zileuton

Step-5:
Preferred: high-dose ICS + LABA and consider Omalizumab for patients who have allergies

Consider PO steroids

22
Q

Beta2 agonists MOA

A

directly stimulate beta-adrenergic (beta2) receptors causing bronchial relaxation
*short/long acting beta agonist (SABA/LABA)

23
Q

Give examples of SABA and LABA

A

SABA: Albuterol and Levalbuterol
LABA: Salmeterol

24
Q

Anticholinergics MOA

A

produces bronchodilation by relaxing airway smooth muscle by blocking acetylcholine-induced bronchoconstriction
*short/long acting muscarinic antagonist (SAMA/LAMA)

25
Q

Give examples of anticholinergics

A

SAMA: Ipratropium (Atrovent), Ipratropium + albuterol (Combivent or Duoneb)

LAMA: Tiotropium (Spiriva), Aclidinium (Tudorza), Umeclidinium (Incruse)

LAMA/LABA: Umeclidinium/Vilanterol (Anoro Ellipta), Tiotropium/Olodaterol (Stiolto)

26
Q

Inhaled corticosteroid (ICS) MOA

A

nonspecific anti-inflammatory

27
Q

Examples of ICS

A

ICS: Ciclesonide (Alvesco), Beclomethasone (Qvar), Mometasone (Asmanex), Fluticasone (Flovent), Budesonide (Pulmicort)

28
Q

Combination ICS/LABA

A

Fluticisone/salmeterol (Advair), Budesonide/Formoterol (Symbicort), fluticasone/vilanterol (Breo Ellipta), Mometasone/formoterol (Dulera)

29
Q

What biologics are prescribed for asthma?

A
  1. Omalizumab (Xolair) - IgG monoclonal ab
  2. Mepolizumab (Nucala)
  3. Benralizumab (Fasenra)
30
Q

What is IL-5?

A

IL-5 is the major cytokine responsible for the growth and differentiation, recruitment, activation, and survival of eosinophils (a cell type associated with inflammation and an important component of the pathogenesis of asthma).

31
Q

Which biologics inhibit IL-5?

A

Mepolizumab (Nucala) & Benralizumab (Fasenra)

32
Q

Quick relief plan is same for all classifications…

A
  1. Short acting inhaled B2 agonist as needed
  2. Intensity of treatment will depend on severity of exacerbation
  3. Use of short-acting B2 agonist >2 times a week may need to move to long-term control therapy
  4. If on long-term control therapy and using short-acting B2 agonist on daily basis, or increasing frequency of use indicates need to move to next step (“step up”)
33
Q

What role does IgE play in asthma?

A

IgE binds to allergens and triggers the release of substances from mast cells that can cause inflammation.

34
Q

What immunocaps should you draw?

A
  • Midwest Panel: trees, grass, weeds
  • Perinneal Panel: molds, cat/dog dander, dust mites, cockroaches
  • Could they be a Xolair candidate? IgE > 35 with multiple allergens
35
Q

What is considered good asthma control?

A
  • Daytime symptoms < 4 times/week
  • Night-time symptoms < 1time/week
  • Normal physical activity
  • Mild, infrequent exacerbations
  • No asthma-related absence from work/school
  • B-agonist use < 4 times/week
  • Peak expiratory flow without much diurnal variation
36
Q

Characteristics of mild exacerbation

A
  • Minor changes in airway function
  • Minimal signs and symptoms
  • Most patients respond quickly and fully to inhaled short-acting B2 agonists (may need to administer every 3-4 hours for 24-48 hours)
  • If not taking inhaled corticosteroid, initiation may be indicated
  • If taking inhaled corticosteroid, double dose until peak flow returns to normal
  • 3-10 days of systemic steroid may be indicated if no response to initiation of, or increased dose of, inhaled steroid
37
Q

Moderate-to-Severe Exacerbations -

Need for hospitalization is based on…

A
  • Response to initial treatment
  • Duration and severity of symptoms
  • Severity of airflow obstruction
  • Course and severity of prior exacerbations
  • Access to medical care
  • Adequacy of social support and home conditions
38
Q

Mod-to-Severe exacerbation discharge criteria

A
  • PEF or FEV1 is >70% of predicted or personal best
  • Minimal to absent symptoms
  • Monitor patient for 30 minutes after last bronchodilator treatment to ensure stability of patient
39
Q

Pediatric Asthma Meds

A

Albuterol inhaled: (short acting)
<2yo- 0.05-0.15 mg/kg NEB q4-6h
2-5yo – 0.1-0.15 mg/kg NEB q4-6h
>5yo – 2.5mg NEB q4-6h

Salmeterol inhaled: (long acting)
>4yo – 50mcg/blister 1 puff inhaled q12h

Cromolyn sodium:(mast cell stabilizer)
>2yo – 20mg/2ml NEB one vial qid then bid

Budesonide: (inhaled corticosteroid)
1-8yo – 0.25-0.5 mg/day NEB div qd-bid

40
Q

Pediatric Asthma Exacerbation Treatment

A
  • Increase frequency of NEB albuterol to q2-4 hrs
  • 5 day course of oral steroid (Prednisolone 15mg/5ml 1mg/kg q24 hours)
  • Continue/begin oral antihistamine
  • If s/s last > 7 days and/or pt develops fever, fatigue, sputum production, etc = consider antibiotic treatment.
41
Q

When to worry…

A

Nasal flaring
Retractions of stomach/chest muscles
Lack of wheeze (Silent Chest)
Fatigue (Floppy Baby)

42
Q

Before this exam make sure you….

A

Review the asthma tables from lecture :)

Pulmonology 2 (17 decks)

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