EXAM #1: ASTHMA Flashcards
What is asthma?
Chronic inflammatory lung disease characterized by REVERSIBLE airway bronchoconstriction
What are the hallmark clinical features of asthma?
1) Non-productive cough
2) Dyspnea (episodic typically)
3) Wheezing
*Typically triggered by an environmental trigger
What is the current emphasis in the treatment of asthma?
Control of the underlying INFLAMMATION
What patient population has the worst prognosis with asthma?
Young African Americans
What are the two major risk factors associated with future fatal or near-fatal asthma?
1) History of recent uncontrolled asthma
2) History of prior near-fatal asthma (ICU or intubation)
*Thus, for every patient with asthma, you should be asking them, “Have you ever been hospitalized for your asthma?” and “Have you ever been intubated because of your asthma?”
What classes of medications classically exacerbate asthma?
1) Beta-blockers
2) Aspirin/ NSAIDs*
*7% of asthmatics have ASA/NSAID exacerbated asthma
What is the primary pathophysiologic mechanism of asthma?
Airway obstruction
What are the three identifiable components of the inflammation seen in asthma?
1) Normal cells are upregulated to a proinflammatory state
2) Airway infiltration with eosinophils and lymphocytes
3) Anatomical remodeling of the airway wall
What inflammatory mediators that are implicated in asthma?
1) Histamine
2) Leukotriene (C4, D4, and E4)
3) Kallekrein
4) Platelet activation factor
What are the components of airway obstruction seen in asthma i.e. what obstructs the airway?
1) Inflammation
2) Smooth m. contraction and hypertrophy
3) Mucus gland hypersecretion/ plugging
4) Airway remodeling
What is “cough variant asthma?”
Asthma where cough is the only complaint
What are the typical physical exam signs associated with asthma?
1) Wheezing
2) Tachypnea/ tachycardia
3) Decreased breath sounds (ominous)
4) Accessory muscle use
What diagnostic tests are indicated for a patient with a history and physical consistent with asthma?
1) Methacholine-challenge i.e. bronchoprovocation
2) Pre/post bronchodilator spirometry
3) Serial peak flow measurements
What are the pitfalls of bronchoprovocation testing?
1) Recent viral infection leading to false positive
2) False negative if tested on asthma meds
What are the criteria for the NHLBI classification of asthma severity?
1) Days with sx.
2) Nocturnal sx.
3) Peak flow rates
4) Peak flow rate variability
What are the two major categories of asthma classification?
Intermittent vs. persistent
What classification of asthma can be treated with rescue inhalers only?
Intermittent asthmatics i.e. patients with:
1) Sx. less than 2 days per week (daytime)
2) 2x episodes or less of nocturnal asthma per MONTH**
3) Use of rescue inhaler less than 2x per week
- Patients with MORE sx. than this require anti-inflammatory medications
- *“Does your asthma wake you up at night?”**
What are the categories of persistent asthma?
1) Mild
2) Moderate
3) Severe
List the medication classes that are used to treat asthma.
- Beta agonists
- Anticholinergics
- Theophylline
- Leukotriene modifiers
- Inhaled/ systemic corticosteroids
- Omalizumab*
*IgE antagonist (v. expensive and restricted for refractory asthma)
Is there any difference in the efficacy of a MDI vs. nebulizer for administration of beta-agonists for acute asthma exacerbation?
No
What type of medication should never be used as a monotherapy for asthma?
Long-acting beta agonist
*Black-box warning b/c of associated with cardiac death
What are the three leukotriene inhibitors used in the treatment of asthma?
1) Zileuton
2) Zafirlukast
3) Montelukast
If that patient has persistent asthma (post- step 1), what medication do they need?
Inhaled corticosteroid
What drugs should be used in the setting of an acute asthma exacerbation?
Systemic steroids
*Note that IV does NOT have any benefit vs. PO
If a patient has not responded to aggressive therapy for an hour in the ED, in the setting acute asthma exacerbation, what drug should you add?
Mg++
