Lecture 10 (pulm)-Exam 5 Flashcards
Pathophysio
Asthma:
* Allergen from an environmental trigger picked up by what?
* What do the cells present them to?
* What is released after that?
- Allergen from an environmental trigger picked up by dendritic cells
- Dendritic cells present them to TH2 cells
- TH2 cells release cytokines causing inflammation-> Cytokines (IL4 and IL5)
Pathophysio
What does IL4 and IL5 cause?
IL4
* Stimulates B-cells to produce IgE which binds to Fc€RI receptors on mast cells
* Mast cells use phospholipase A2 to produce arachidonic acid (AA)
* AA metabolized by:
* COX to prostaglandins
* 5-LOX to leukotrienes
IL5
* Activates eosinophils
* Promotes immune response by releasing more cytokines and leukotrienes
Asthma
* Airway obstruction caused by what? (irreversible or not?)
* Part of what triad?
ASTHMA – GOALS OF TREATMENT
* Reduce impairment: Prevent what, require what, normal what?
- Prevent chronic symptoms (if no txt: damage)
- Require minimal use of reliever (ex: SABA)
- Normal or near normal lung function and activity levels
Asthma: goals of treatment:
* Reduce risk: Prevent what? (2) Minimize what? (2)
- Prevent exacerbations
- Minimize need for emergency care and hospitalization
- Prevent decreased lung function
- Minimize pharmacotherapy adverse effects
What are the Nonpharmacologic treatment of asthma? (4)
- Avoidance of environmental triggers
- Avoidance of dietary triggers
- Weight loss
- Breathing exercise programs->Adults
Medication definitions
* What is a reliever?
* What is a controller? Use with what?
* What is maintenance treatment?
Reliever
* For symptom relief or before exercise or allergen exposure
Controller (kinda like a mix of reliever and maintence)
* For symptom control and exacerbation risk
* Used with ICS-containing treatment
Maintenance treatment
* Used daily to prevent symptoms and exacerbations (e.g., twice a day)
NIH treatment guidelines
* All asthma guidelines follow what?
* Specific steps of the ladder depend on what?
Asthma classification
* Classification based on what?(2)
* What is each one based on?
What is the classification of intermittent asthma? (Symptoms, nighttime awakings, SABA use, asthma excerbations for ages 0-4, 5-11, over 12)
This is step one
What is the step one or intermittent astma txt?
SABA (reliever) as needed for symptoms
* All ages
* Use throughout all steps for symptom control in addition to other therapies
What is new step one or intermittent asthma txt for 0-4 years old?
Consider short course ( 7 to 10 days) ICS at start of respiratory tract infection
What are the two SABA choices?
Albuterol and levalbuterol
Albuterol:
* What are the dosage forms?
* Usual dose rang for mild symptom control?
* Usual dose range for exacerbations?
Need to know the dosages for albuterol
Levalbuterol:
* What are the dosage forms?
* What is the usual dose range for mild symptom control?
* What is the usual dose range for excerbations?
What are the beta 2 adverse effects?
What is the classifcation for Mild persistent asthma? (Symptoms, nighttime awakings, SABA use, asthma excerbations for ages 0-4, 5-11, over 12)
Mild persistent or step 2:
* What is the preferred txt for all patients?
* What is the alternative txt for all patients?
* What do you with the controller? What does it not work as?
All Patients:
* Preferred treatment : low-dose ICS (controller)+ SABA for sx
* Alternative: montelukast
Controllers
* Take everyday regardless of symptomatic or not
* Will not work as rescue therapy
For mild persistent asthma or step two:
* What should you consider for allergic asthma (adults+children over five)
Consider SC immunotherapy for patients with allergic asthma
What are the different ICS? (you need to be able to recognize them)
- Beclomethasone HFA (Qvar)
- Budesonide DPI (Pulmicort)
- Fluticasone propionate DPI (Flovent Diskus)
- Fluticasone furoate DPI (Arnuity Ellipta)
- Mometasone DPI (Asmanax Twisthaler)
- Mometasone HFA (Asmanax HFA)
BE BUDs with FLUTtering MOM
ICS:
* What are the different doses?
* When does the dose change?
- Low – Med – High dose ICS
- changes with age groups
Multiple strengths exist
What is the classifcation for moderate persistent asthma? (Symptoms, nighttime awakings, and SABA use for ages 0-4, 5-11, over 12)
Moderaten persistent asthma or step 3:
* What is the txt for patients 0-4 years old?
- Preferred: medium dose ICS + saba for sx
- Consult asthma specialist
Moderaten persistent asthma or step 3:
* What is the txt for patients over 5 years old?
* What should you consider?
Preferred:
* Medium dose ICS or
* Low-dose ICS + LABA or LTRA (LTRA best for allergy or exercised indused asthma)
* plus SABA for sx
Consider SC immunotherapy for patients with allergic asthma
What are the different types of ICS/LABAs?
- Fluticasone-salmeterol
- Budesonide-formoterol
- Mometason-formoterol
What is the classifcation for severe persistent asthma? (Symptoms, nighttime awakings, and SABA use for ages 0-4, 5-11, over 12)
Severe Persistent asthma:
* What is the treatment for patients of ages 0-4?
- Same as Step 3 therapy: medium dose ICS
- Consult asthma specialist
Severe Persistent asthma:
* What is the treatment for patients of ages 5-11?
Continue with Step 3 medium ICS option
OR
Step 4
* Preferred: medium dose ICS plus LABA
* Alternative: medium dose ICS plus montelukast
Severe persistent asthma
* What is the txt for 12+?
Step 4:
* Preferred: medium-dose ICS + LABA
* Alternative: medium-dose ICS + LTRA
* Consult asthma specialist
What is the txt for step 5 Severe persistent asthma?
- High-dose ICS + LABA
- Consider omalizumab for patients with allergies
What is the txt for step 6 severe asthma?
Same as step 5 with addition of oral corticosteroids
GLOBAL INITIATIVE FOR ASTHMA (GINA) GUIDELINES
* What is this?
* What is the evidence?
New evidence published in the last few years showing the benefit of ICS used with reliever agents
* Strongest evidence with adults and adolescents ≥ 12 years
* Some evidence and recommendations for 6 to 11 years
* Minimal evidence for 5 and under
GINA guidelines:
* What has been shown When compared to SABA alone, SABA + daily ICS, or daily ICS alone?
- Decrease severe exacerbations
- Decrease systemic corticosteroid use
- Decreased ED visits / hospitalizations
What is an anti-inflammatory reliever (AIR)
- E.g., ICS-formoterol, ICS-SABA
- Provides symptom relief plus small dose of ICS
What is MART?
Maintenance And Reliever Therapy with ICS-formoterol = MART
* ICS-formoterol used as maintenance therapy AND PRN symptom relief
* One inhaler
Global initiative for Asthma (GINA) Guidelines
* What age group is it for?
* What is Step one and two?
Adults and adolescents ≥ 12 years
Steps 1 and 2
* As needed low dose ICS-formoterol
What is step 3 of gina?
Low-dose maintenance ICS-formoterol
plus PRN ICS-formoterol
What is step 4 of gina?
Same as step 3 but medium dose ICS-formoterol
What is step 5 of gina?
Same as step 4 (medium dose ICS-formoterol) but add LAMA
Give an example of the GINA stepwise
FOLLOW-UP ASSESSMENTS
* When do you re-evaluate?
* Control based on what? (What does the pt recall and what measurements?)
Re-evaluate every 2 to 6 weeks until well-controlled then every 3 to 6 months
Control based on most severe impairment
* Patient / caregiver recall of events over last 2 to 4 weeks
* Spirometry / peak flow measurements
Follow up assessment:
* Explain the use of stepwise approach?
Step down if symptoms controlled for at least 3 months
Step up if needed
* Check compliance, inhaler technique, environmental control and comorbidities first (before switching)
* If alternative therapy was used; switch to preferred therapy for current step before increasing a step
EXERCISE-INDUCED ASTHMA
* What does it describe?
* Exercise-induced bronchoconstriction occurs in how many people?
* Can be an indicator of what?
- Exercise-induced bronchoconstriction (EIB) describes a transient airway narrowing occurring during physical exertion
- Exercise-induced bronchoconstriction occurs in 40% to 90% of people with asthma and up to 20% of the general population without asthma
- Can be an indicator of poorly controlled asthma
Exercise induced asthma:
* What is the txt?
ASPIRIN SENSITIVE ASTHMA
* Blocking the COX pathway increases what?
* What is the pathway/ what does this cause?
* What is there a cross reactivity between?
- Blocking the COX pathway increases the production of lipoxygenase
- Increases the production of leukotrienes
- Induces bronchospasm
- Cross reactivity between NSAIDS exists
PEAK FLOW METERS
* What does it measure? (2)
* What can it help determine?
- Measures how fast a patient can push air out of lungs when blowing out as hard as they can
- Helps measure how open the airways are
- Helps determine when adjustments to home regimen are necessary
Peak Flow Meter
* May start to decrease when?
* Part of what?
* Zones can be set up initally based on what?
* Individualized zones can also be set up if what?
- May start to decrease before other identifiable symptoms
- Part of asthma action plan
- Zones can be set up initially based on height and sex
- Individualized zones can also be set up if patient healthy
What is an asthma action plan?
ASTHMA EXACERBATIONS
* What is it?
* Management may occur where? Depends on what?
Worsening of asthma symptoms requiring temporary increase in treatments
Management may occur at home or in the hospital
* Depends on severity of exacerbation and underlying
disease
Asthma exacerbations:
* What are the sxs of more severe exacerbation?
- No breath sounds (no air mvt)
- Taking in single words or no talking
- Tachycardia / bradycardia
- Perioral cyanosis
- Hypoxemia
- Hypotension
- Patients at high-risk of poor outcomes->hospitalization
- Most institutions – treatment protocolized
What are the factors that increase asthma related death?
MILD – MODERATE EXACERBATIONS
* What is the txt?
asthma
What are the sxs of mild-moderate exacterbations?
asthma
SEVERE EXACERBATION
* What are the first line initial therapies?
asthma
What are the sxs of servere exacerbation