Module 3- Adult asthma Flashcards
Asthma Pathognomonic
common findings are airway inflammatory cell infiltration with eosinophils, neutrophils, lymphocytes- TCELLs, goblet cell hyperplasia, plugging of small airway with mucus, collagen deposition beneath the basement membrane, bronchial smooth muscle hypertrophy, airway edema, mast cell activation, denudation of epithelium
Asthma Pathophysiology
Heterogeneous but divided into T2 high and T2 low
Allergic Asthma
childhood, and associated with eczema, allergic rhinitis, or food allergy
inhaled allergens may cause symptoms immediately or 4-6 hours after allergen exposure
T2- high endotype
reducing exposure reduces findings and symptoms
Common allergens
house dust mites, cockroaches, car dander and seasonal pollens
T2 High endotype
allergic asthma, Late-onset, aspirin/NSAID associated respiratory disease
T2 Low endotype
Non allergic asthma- Marked by neutrophils and inflammation and variable response to standard therapies
Asthma with persistent airflow limitation
due to airway remodeling
asthma with obesity
prominent respiratory symptoms on obese patients with little airway inflammation
nonspecific precipitants of asthma
upper respiratory tract infection, rhinosinututus, postnasal drips, aspiration, gastroesophageal reflux, changes in the weather, stress and exercise
Exercise- induced bronchoconstriction
begins during exercise or 3 min within 3 minutes after it ends, peaks within 10-15 minutes then resolves by 60 minutes
cough variant asthma
main symptom is cough rather than wheezing
Signs and symptoms of asthma
episodic wheezing, shortness of breath, chest tightness, and cough
often worst at nigh or morning,
prolong expiratory phase during normal breathing
chest examination btw exacerbation is normal during severe exacerbation airflow may be too limited to produce wheezing
Lab findings with asthma
ABG- normal with mild but severe hypoxemia develops but returns to normal
Pulmonary function testing
Spirometry, bronchoprovocation testing, Peak expiratory flow
spirometry
forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC
Before and after the administration of short acting bronchodilator test if reversible- increase of 12% or more and 200 ml FEV1 or FVC suggest asthma
Bronchoprovocation Testing
inhaled histamine or methacholine can help when spirometry test is negative, not recommended if FEV1 is less than 65%, Positive test is when FEV1 is 20% or more
Peak expiratory flow (PEF)
Handheld meters are devices designed as personal monitoring tools, quantify asthma severity and control
PEF values vary with age, height, and sex and are poorly standardized
Assessing control and severity of asthma
past 4 weeks
frequency of symptoms- days per week
awakening from sleep
frequency of SABA reliever use
severity is based of off level of control
Severe & uncontrolled asthma
assess inhaler technique, medication adherence, comorbities, after addressing theses if patient remains on step 4-5, referral to pulmonary or asthma
Inhaled corticosteroids
ICS
essential controller medication
as needed or Daily
Low-Medium- high doses
after symptom control for 3 months lower dose
mouth washing after to decrease systemic absorption and local side effects
SE of ICS
Local- cough, dysphonia, oropharyngeal candidiasis
systemic effects- adrenal suppression, osteoporosis, skin thinning, easily bruising, cataracts
Beta-adrenergic agonists
Short acting and Long
No one better than the other
SABA
relaxing smooth muscles with rapid onset, repetitive administration produces incremental bronchodilation- 1-2 usually sufficient for mild to moderate
Severe 6-12 puff Q30-60mins
LABA
Bronchodilation for up to 12 hours
salmetrerol formoterol
not to be used as mono-therapy
often used in combination with ICS
Systemic Corticosteroids
primary treatment for mod to severe asthma exacerbations for patients who don’t respond to SABA, early administration is key- patients with mod-severe asthma should have prescription for home
Systemic Corticosteroid dosing
Burst therapy- 0.5-1mg/kg/day up to 60mg in 1-3 doses for 3-7 days
long term administration require vit d and calcium supplements to prevent bone mineral loss
Anticholinergics
reverse vaguely medicated bronchospasm but not allergen or exercise induced bronchospasm
decreases mucous gland hyper-secretion
short and long acting- SAMA- LAMA
SAMA
Ipratropium bromide- can be added to SABA
less effective than SABA but used if pt are intolerance to SABA or bronchospasm due to beta-blocker medications
LAMA
cornerstone treatment of COPD, used with medium dose ICS and salmeteral improves lung function
Leukotriene modifiers
decreases leukotrienes, alternatives for ICS
phosphodiesterase inhibitor
theophylline- mild bronchodilation, effective in nocturnal asthma,
narrow therapeutic window
Mediator Inhibitors
cromolyn sodium and nedocromil- long term control for mild persistent or exercise-induced asthma
Monoclonal antibody agents
pulmonologist or allergist to give
omalizumab, eslizumab, Dupilumab
Vaccine for asthma
PNA vaccine and annul flu vaccine
