Mod 3 Asthma Flashcards
what do COPD and Asthma have in common?
Airflow limitations (Air trapping) and dynamic breathing
What are usual characteristic of asthma according to global initiative for asthma [gina]?
Chronic airway inflammation w/symptoms of:
-wheeze
-SOB
- chest tightness
-cough
-variable expiratory flow limitations (Big diff from COPD)
Generally describe an asthma episode
Extreme bronchoconstriction on inhalation and expiration
Why is it essential to pair a corticosteroid w/SABD for a asthma attack?
Bronchodilators open up the airways but do nothing to treat the underlying inflammation.
Assessing risk for severe exacerbation
History of severe asthma exacerbations; ED visit
Poorly asthma controlled asthma per CTS critera
Overuse of SABAs i.e > 2 a year (or no ICS use)
current smoker
What is the most effective controller for asthma?
What is the time frame of affect?
ICS
Improvement occurs within 1-2 weeks of starting daily use.
suppression of Asthma; what are the most affective controllers of asthma?
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Slide 17
ICS
Suppression of:
-inflammatory genes i.e cytokines and eosinophils
Are ICS affective for smokers
Nope.
Smoke generates oxidative stress that impairs activity of ICS.
Describe the ICS and B2 adrenergic receptors relationship
ICS can activate B2 receptors; enhancing B2 agonist effects
ICS can also prevent the down regulation of B2 receptors (increasing expression of them on the cell surface)
systemic corticosteroids vs. inhaled corticosteroids?
edit
need to check for accuracy
One is broader vs. the lungs itself
Inhaled have the same affect for asthma as systemic but w/o the issues that come with systemic use
GINA vs CTS
CTS; SABA only
GINA; subbing in budesonide/formatarol as a relievers (LABA w/a shorter onset (oxeze)
2021 asthma management pathway
- Confirm diagnosis
- environmental control, education, action plan
- SABA or budesonide/formeterol
- ICS -> followed by LTRA
- LABA
- LTRA or LABA
budesonide can be used for what?
A reliever and controller
Reliever meds for asthma
salbutamol, terbutaline, and budesonide/formoterol
What does regular use of a reliever looked like?
and why is it important
More than 2 doses per week.
identifies evaluation of use of and effectiveness
Risk factors of improper SABA use?
SABAs can increase risk of exaserbation
-not controlling the inflammation enough
-should be using a ICS more effecitly in conjunction w/saba
What do you do when a patient can’t tolerate ICS?
Switch to a LTRA
slide 27 won’t be tested. but the second line on gina is the general rule of thumb that we follow
don’t worry about slide 30
understand CTS step approach to treatment
How often should asthma be reviewed for the following scenarios:
- After diagnosis
- During Pregancy
- After an exacerbation
1. [1-3] months after treatment started, then every [3-12] months
2. During pregnancy: Every [4-6] weeks
3. After an exacerbation: within 1 week
3 strategies to manage asthma
Education
Environmental control; i.e allergies
pharmacotherapy
What is used to treat an anaphylactic reactions? (allergy based)
Epinephrine
w/asthma can produce a severe anaphylactic reaction
Asthma risk factors: How would a prenatal population get asthma?
Heredity
Maternal factors:
-smoking during pregnancy
-Low vit. D during pregnancy
-Cesarean delivery
Asthma risk factors: How would children get asthma?
-Eczema
-Allergic rhinitis
- Exposure to second hand smoke
-Air pollution
-Obesity
Asthma risk factors: for infancy, preschool, school, age etc.?
exposure to allergens (antigen)
i.e fungi, dust, etc.
Asthma risk factors for adulthood
Exposure to allergens
pollution/ Tobacco smoke/occupational exposure
drugs/additives
diet/obesity
Gender
What are some symptoms usually associated w/asthma?
Wheeze
SOB
Chest tightness
Cough
Asthma is primarily characterized by
variable expiratory airflow limitation
Symptoms of airflow limitation vary overtime and intensity; what factors can trigger incidents?
Exercise
Allergen/irritant exposure
Changes to weather
Viral resp. infections
How long can asthma symptoms be absent for?
Weeks or months at a time.
List some Asthma phenotypes
-Allergic asthma
-non-allergic asthma
-adult-onset (late-onset) asthma
-Occupational asthma
-Asthma w/obesity
-Asthma w/persistent airflow limitation
Define common traits of Allergic asthma:
- History
- Sputum profile
- Best Treatment Plan
Associated w/past or fam. allergic disease
-i.e eczema
Sputum profile: Treatment reveals eosinophilic airway inflammation
Usually responds well to ICS
Sputum profile/Traits of non-allergic asthma?
- response to treatments?
Sputum profile: may be neutrophilic, eosinophilia, or contain a few inflammatory cells
Demonstrates less short term response to ICS
Traits of adult-onset (late-onset) asthma
Effects women > Men
- tend to be non-allergic
- Require higher doses of ICS, relatively refractory to ICS treatment
Define occupational asthma
repeat exposure to a sensitized in the workplace or asthma worsens in the workplace
i.e dusts, plants, animal substances
How is occupational asthma checked?
Patient history;
—ask if symptoms improve away from work
Peak expiratory flows
Define asthma w/persistent airflow limitation
Due to airway remodeling
-develop airflow limitation that is persistent or incompletely irreversible
Traits of Asthma w/obesity
Prominent respiratory symptoms and little eosinophilia airway inflammation
Anatomic alterations of the lungs;
what traits would be present/affected by Asthma inflamed bronchial tubes
Increased eosinophils
excessive secretions
hyperinflation
bronchospasm
Bronchial inflammation
Anatomic alterations of the lungs; Bronchial inflammation
Inflammation throughout the submucosa of airways; but not the alveoli/lung parenchyma.
Describe Primary and stimulated eosinophils during bronchial inflammation
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Slide 23
CTS Typical Severity Classification: Very mild
AKA well controlled
PRN SABA
CTS Typical Severity Classification: mild
Low dose ICS (or LTRA -> Montelukast)
+
PRN SABA or PRN bud/form [Symbicort]
CTS Severity Classification plan for:
Moderate + well controlled asthma
Low dose ICS
+
Second controller (LABA) and PRN SABA
CTS Typical Severity Classification: Moderate w/increasing severity
Moderate dose ICS +/- second controller
AND
PRN SABA or PRN low-mod. dose of Symbicort
CTS Typical Severity Classification: HIGH
High dose ICS + second controller
For previous year or systemic steroids for 50% of the previous year to prevent asthma from being uncontrolled to prevent asthma from being uncontrolled, or is uncontrollable despite this therapy.
True or False:
Asthma is characterized by inflammatory changes throughout the submucosa of the airways, alveoli, and lung parenchyma?
False
(not the alveoli or lung parenchyma)
What is responsible for bronchial inflammation?
Primary eosinophils
Inflammatory molecules are recruited by cytokines
inflammation causes a positive feedback loop for more inflammation
bronchial tissue degranulate and the pro inflammatory contents induce
Airway inflammation for asthma can lead to structural changes in the airway called airway remodeling:
list 3 changes/anatomic alterations of the lung airway remodeling causes
hypertrophy/hyperplasia of smooth muscles
increased goblet cells
neovascularziation/angiogenesis
What does hypertrophy/hyperplasia of smooth muscles mean?
Narrowed airways
What does it mean when goblet cells increase?
more secretions
hat does angiogenesis mean?
new vessels remove excess inflammatory mediators away from airways
can backfire and increased perfusion can bring new inflammation
What are 5 anatomic alterations of the lungs asthma cause?
Bronchospasm
Bronchial inflammation
increased eosinophils
hyperinflation
Excessive secretions
smoke, Dust mites, animal allergies, mild, pollen and viral infections are examples of
Inflammatory triggers
Non-inflammatory triggers cause
smooth muscle constriction
and NOT inflammation in the airways
What are 2 non-inflammatory triggers?
Emotions
Temperature
Exercise
What is GERD, what does it mean in relation to airways?
non-allergic intrinsic subgroup of asthma
Happens when there is a issue with the gastric sphincter causing inhalation of acidic contents causing irritation and bronchoconstriction
Symptoms of Asthma are
mono/poly wheezes, SOB, Cough, and/or chest tightness
How does asthma increase venous return?
increased airway resistance and dynamic hyperinflation raise intrathoracic pressure. This can:
- Decrease left ventricular preload (reducing stroke volume)
- Increase afterload (due to compressed pulmonary vasculature)
- Changes are acute, if chronic it is more likely a RV dysfunction
What are 4 prenatal asthma risk factors?
Hereditary
maternal smoking during pregnancy
low vitamin D during pregnancy
C section
What are 4 childhood asthma risk factors?
Eczema
Allergic Rhintis
Second hand smoke
Air pollution
Obesity
What are 4 adult asthma risk factors?
allergens
tobacco
occupational exposure
drugs
pollution
obesity
In asthma pt, induced sputum before treatment is indicative of
eosinophilic airway inflammation
In terms of vitals, would you expect from someone with asthma (when symptomatic)?
They would most likely have increased RR and HR
Asthma is usually associated to what?
airway hyper responsiveness to direct/indirect stimuli.
In pulsus paradoxus, what happens to BP during inspiration and during expiration?
Inspiration: BP decreases
Expiration: BP decreases
How do you confirm that someone has asthma w/spirometers?
FEV1/FVC = < 0.75-0.8
After applying bronchodilator;
-Incrase of >12% and >200mL
How do you confirm a asthma diagnosis with a peak expiratory flow [PEF]?
> 20% increase after bronchodilator
If pt answers 1-2 symptoms these, their asthma is considered
Daytime asthma symptoms more than twice a week?
Any night waking due to asthma
Reliever needed for symptoms * more than twice a week?
any activity limitation due to asthma
Partially controlled (uncontrolled)
If pt answers 3-4 symptoms these, their asthma is considered?
Daytime asthma symptoms more than twice a week?
Any night waking due to asthma
Reliever needed for symptoms * more than twice a week?
any activity limitation due to asthma
Uncontrolled
If pt answers 3-4 symptoms these, their asthma is considered?
Daytime asthma symptoms more than twice a week?
Any night waking due to asthma
Reliever needed for symptoms * more than twice a week?
any activity limitation due to asthma
Uncontrolled
Reliever therapy:
Should bud/form be used as a reliever when controller medications other than bud/form are used
Yes
- as of 2022 Symbicort is a used reliever
Which pharm. treatments would be the most appropriate for acute symptoms?
Salbutamol, terbutaline, budesonide/formoterol [Symbicort]
Well controlled asthma on PRN SABA or no med w/higher risk of exacerbation should be on which pharmacological treatment?
ICS + SABA PRN
How often should patients on PRN SABA w/uncontrolled asthma take ICS + PRN?
Dailey
Which age group is not recommended symbicort?
12 and below.
bc of poor adherence + education
Indicators to step up asthma treatments: if poorly controlled?
at least 2-3 months
be sure to check for common causes
Indicators to step up asthma treatments: short term
1-2 weeks, may be initiated by pt
Indicators to step up asthma treatments: day to day
adjust as needed by pt for the prescribed low-dose ICS/formoterol maintainer and reliever regimen
Indicators to step down asthma treatments?
Good control maintained for 3 months
3 strategies to manage asthma
Education
environmental control: reduce need for asthma med
pharmacotherapy meds: treat/prevent worsening symptoms
What is used to treat anaphylactic reactions?
Epinephrine
Where are Beta 1 receptors are found
Heart and kidneys
Beta 1 cause increase in?
Inotrophy (rhythm)
HR
Renin in kidneys
What does renin in the kidneys do?
Balance NA+ AND K+ LEVELS
Balance BP
Beta 3 receptors are located in?
Adipose tissue
They activate lipolysis (breakdown of fats and lipids)
Adrenergic receptors are typically associated w/which receptors ?
Alpha and Beta
Difference between Alpha 1 and 2 receptors?
A1 = contraction
A2 = inhibit
Beta 1 receptors generally affect the which organs?
Heart and kidney
Beta 2 receptors affect the?
pulmonary system
(bronchial smooth muscle)
PNS only uses which 2 neurotransmitters?
Acetylcholine and Norepinephrine
Somatic motor neurons release what NT?
Acetylcholine
How do LAMA’s work?
LAMAs affect muscarinic agents located on smooth muscles; muscarinic agents active AcH which constricts airways.
preventing AcH activation via inhibition of muscarinic agents relaxes airways
what would the neurotransmitter AcH normally do to the body?
Affect vessel tone; [PNS] releases AcH to stimulate muscarinic receptors in the airway smooth muscle, causing contraction and narrowing of the airway.
What is the function of anticholinergic drugs?
Prevent AcH binding to/blocking muscarinic receptors (that respond to AcH)
-AcH is involved w/vessel tone, HR, and glandular secretions; factors that increase airway resistance.
Can improve breathing for COPD and Asthma because airway constriction is reduced
What traits does Asthma have in terms anatomic alterations of the lungs?
(3)
- Reversible bronchial airway smooth muscle constriction
- Airway inflammation
- increased airway responsiveness to stimuli
What happens to airways when they become inflamed and infiltrated with eosinophils and goblet cells?
mucous all edema bc goblet cells increase,
Become filled w/mucous which can lead to plugging and atelectasis
Define Extrinsic asthma
Hypersensitivity reaction to stimuli (allergic/atopic)
Define intrinsic asthma
Nonallergenic/non-atopic asthma
can’t be linked to a specific antigen/extrinsic inciting factor
not hypersensitive and develops in adult years
What is a Biphasic response?
An early asthmatic response followed by a late asthmatic response
GINA classification for asthma symptoms?
(4)
- cough
- recurrent wheeze
- recurrent difficult breathing
- recurrent chest tightness
other = worsening symptoms over night
colds that go to chest or take more than 10 days to clear
2 main diagnostic/monitoring tests for asthma
Spirometers
Peak expiratory flow [PEF]
4 levels/classes of asthma severity (4)
Intermittent: < 1 a week
mild: > 1 a week but < once a day
moderate: occurs dailiy
severe: daily w/nocturnal symptoms. limits physical activity
Describe the asthma mnemonic plan [SOAP]
Structured method of documenting pt progress/plan of treatment
S: Subjective [Pt symptoms]
O: Objective [vitals]
A: Assessment [i.e bronchospasm, metabolic acidosis etc.]
P: Plan
[SOAP] - discussion/example
what protocol could be followed for the following plan?
- o2 therapy protocol
- aerosolized medication therapy protocol
Oxygen therapy protocol [FiO2 80-100% via NRB]
-monitor w/SpO2 oximeter
Aerosolized med therapy
-med. neb q30m w/saba
-monitor PEFR and breath sounds
-review abgs
What is Asthma typically characterized by?
Inflammation and narrowing of the airways in the lungs, which can cause breathing difficulties
What diagnostic tools are the accepted standard to establish the diagnosis of bronchiectasis?
- CT
- PFT
- Sputum culture
- Bronchoscopy
All the following are a prenatal risk factor for asthma except:
a. low vitamin D during pregnancy
b. Cesarean delivery
C. Maternal smoking
D. low progesterone during pregnancy
D
what type of asthma responds the best to ICS?
Atopic (allergic) asthma
Asthma with persistent airflow limitation is due to what?
Airway remodeling and chronic inflammation of airways
Asthma with variable airflow limitation is due to what?
- Environmental factors
- Asthma w/obesity
- irritants
- exercise
Gold standard for diagnosing asthma?
Spirometry test
Asthma criteria if patient has 0 symptoms to questions?
Well controlled
After making changes to a therapy, when should you reassess the effectiveness?
After 1-3 months
