Dubin Asthma Flashcards
Asthma relievers - immediate
SABA, Ipratroprium (anticholinergics), Oral or injected steroids.
Asthma controllers - long term
ICS, LTRAntag, LAB2A, Methlxanthines (Theophylline), Omalizumab (anti ige)
Classifications for intermittent asthma
- Symptoms less than once per week
- Brief exacerbations
- Nocturnal s/s 2 or less per month
- FEV1 greater than 80% predicted
Classifications for mild Persistent asthma
- Symptoms MORE than 1/week, but LESS than 1/day
- Exacerbations may affect activity/sleep
- Nocturnal s/s 2 or MORE per month
- FEV1 greater than 80% predicted
Classifications for Moderate Persistent asthma
- Symptoms DAILY
- Exacerbations may affect activity/sleep
- Nocturnal s/s MORE than 1/per week
- FEV1 60-80% predicted
Classifications for Persistent asthma
- Symptoms DAILY
- FREQUENT exacterbaations
- FREQUENT nocturnal asthma symptoms
- LIMITATION of physical activity
- FEV1 less than 60% predicted
Short Acting Beta 2 Agonists (SABA) MOA
SAB2A relax bronchial smooth muscle by activating Adenylate Cyclase and STIMULATION cAMP PRODUCTION.
Preferential SAB2A for tx of asthma bronchospasm.. If this doesn’t work, try what?
Albuterol.
If albuterol doesn’t work, the try isomer Levalbuterol.
Name 5 SAB2A
Albuterol, Pirbiterol, Terbutaline, Metaproterenol, Levalbuterol
Name 3 LAB2A.
Use these when?
- Use as CONTROLLERS for DAILY SYMPTOMS (moderate persistent/Severe Persistent)
- Salmeterol, Formoterol, Fluticasone/Salmeterol (Advair)
What is the PREFERRED controller LAB2A?
Advair = Solmeterol (LAB2A) + Fluticasone (ICS)
What is an extremely potent inhaled B1 and B2 agonist? Used frequently?
Isoproterenol
- Dangerous SE if used too much (Death)
Name 2 Mast Cell stabilizers
- CROMOLYN (use with albuterol)
- Nedocromil
Name 2 Leukotriene Modifiers
- MONTELUKAST
- Zafirlukast
Name the most common methylxanthine and its MOA.
THEOPHYLLINE (IV)
- MOA: phosphodiesterate inhiitor that PREVENTS cAMP BREAKDOWN
Therapeutic blood range for theophylline.
If blood level too high, what happens?
10-20
SE - seizures.
When should theophylline be added to therapy regimen?
When person has difficulty breaking asthma with LABA (especially night time asthma).
- To achieve maximal bronchodilation and diaphragm contraction.
Name of anticholinergic and MOA.
Ipratroprium.
- Anticholinergic that decreases ACh release to decrease PSNS vagal stimulation to airway smooth muscle.
Name of 5 inhaled steroids
Beclomethasone, budesonide, flunisolide, fluticasone, triamcinolone acetonide.
Uses of inhaled steroids.
- ONLY IN ASTHMATICS. as relievers.
- Never in hospitals - only use oral or IV steroids.
Use for IV steroids.
Steroid burst for status asthmaticus.
Adverse effects of long term use or oral steroids.
Adrenal suppression, buffalo hump, moon facies, purple stria, posterior capsule cataracts, necrosis of femoral head, thin skin, blood sugar elevation.
When is immunotherapy used?
- When ALLERGIES ARE THE MAIN TRIGGER of asthma
- In patients with severe anaphylaxis.
- Indicated in kids with SEVERE persistent asthma exacerbated by allergies.
Name and MOA of immunotherapy.
Omalizumab - monoclonal antibody developed against IgE to decrease total serum IgE levels.
In 85% of deaths due to asthma, what is the duration of the final episode?
12 hours or longer
Four main causes of death in asthmatics.
- Asphyxia
- Barotrauma/Ventilator
- Nosocomial Infection
- Unexpected
Three components of “Sudden Asphyxic Asthma”
- Rapid decomposition
- Extreme hypercapnia (CO2 in blood) with metabolic and respiratory acidosis.
- Silent chest on auscultation.
(also, airway devoid of inspissated mucus; more neuts than eosino in submucosa @ autopsy)
Do previous admissions in the past year and life threatening attacks in the past increase risk of asthmatic death?
What are other risk factors?
Yes
- 3+ meds, marked circadian cariation in lung function, physiological abnormalities)
Important physical findings to identify High-Risk asthmatics for unexprected deaths.
- Tachycardia (120+)
- Tachypnea (20-30bpm)
- RONCHI/WHEEZING (or COT to lack of wheeze)
- Hyperinflation of chest
- ACCESSORY MUSCLE USE.
- PULSUS PARADOXUS
- Cyanosis
What condition can wheezing and then lack of wheezing indicate?
STATUS ASTHMATICUS - air exchange gets so bad that no air is moving and you have a silent chest.
What do you look for in accessory muscle use
Skin over thorax retracted into intercostal spaces during inspiration. Expiratory phase prolonged relative to inspiratory phase.
What is pulsus paradoxus?
Exaggerated inspiratory decrease in systolic pressure.
- Drop exaggerated about 15 because CO is restricted.
Four important signs of development of status asthmaticus.
- SaO2 less than 90%
- Normal of high PaCO2 with hyperventilation
- Metabolic acidosis
- Severe obstruction/Bronchoconstriction that does not improve 30% with B2-agonists.
Treatment of status asthmaticus
- High dose, IV, systemic steroid burst.
- Inhaled bronchodilators
Describe PFTs in asthma
- Reduced FEV1 during acute attack, resulting in decreased FEV1/FVC ratio
- FEV1 increases with bronchodilator (SAB2A)
- Increased RV/TLC due to air trapping.
- FEV25-75 at 45%??
DLCO in asthma
decreased
ABG for asthma
PaO2 between 55-70
PaCO2 between 25 and 35
Lab findings that indicate allergic asthma (IGE mediated).
In sputum - Curschmann Spirals, Charcot-Leyden Crustals, eosinophils.
Define extrinsic asthma, intrinsic asthma, occupational, cough variant asthma, and refractory asthma.
- Extrinsic - dyspnea post-exposure to known allergen
- Intrinsic - dyspnea for unknown reason
- Occupational - asthma brough on by occupational expssure
- Cough variant - cough (or hoarseness/inability to sleep) is only symptom
- Refractory - refractory to standard care
What is this?
A 42yo woman with no hx of asthma is exposed to acetic acid at work. She develops persistent asthma-like pheontype.
RADS - Reactive Airway Dysfunction Syndrome.
- Not IgE mediated, so NOT an allergic occupational asthma
What happens to RV/TLC% in asthma?
- increased - increased RV
- AIR TRAPPING
What is a methacholine challenge and what does a positive test indicate?
(+) if FEV1 decreaes by 12-20% or more.
- Indicates bronchial hyper reactivity.
Stepwise Approach to Asthma Control
- SAB2A prn
- Low dose ICS
- Low does ICS+LABA or med dose ICS
- Med dose ICS + LABA
- High dose ICS + LABA
- High dose ICS + LABA + Oral CS
What does this woman have?
35yoF with urticarial, SOB, wheezing. She ate tuna fish and took aspirin for HA prior to onset. PE reveals nasal polyps.
She has NSAID induced asthma, part of SAMTER’S TRIAD of:
- Nasal Polyps
- Asthma
- NSAID allergy
Urticaria and anaphylactic allergic reaction - give what?
Epinephrine
