Module 3 EB Asthma Flashcards
Essentials of asthma diagnosis (5)
-Episodic or chronic symptoms of wheezing, dyspnea, or cough
-Symptoms frequently worse at night or in the early morning
-Prolonged expiration and diffuse wheezes on physical exam
-Limitation of airflow on PFT or positive bronchoprovocation challenge
-Reversibility of airflow obstruction either spontaneously or following bronchodilator tx
Which sex is asthma more common in for the following age groups:
-children
-adults
-males (<14yrs)
-women
Which ethnicity has highest hospitalization rates related to asthma?
blacks (and children)
Which ethnicity has the highest death rate? (ages?)
blacks (ages 15-24yrs)
Asthma triggers
-Common allergens (4)
-Nonspecific precipitants (8)
-Exposures (3)
-house dust mites, cockroaches, cat dander, seasonal pollens
-exercise, URI, rhinosinusitis, postnasal drip, aspiration, GERD, exposure to cold air, stress
-tobacco, crack cocaine, meth (increases sx and need for meds, decreases lung function)
Asthma triggers
-Air pollution (how it impacts sx)
-Meds
-Occupational asthma (when may asthma sx occur d/t these triggers?)
-precipitates sx, increased ED visits/hospitalizations
-aspirin/NSAIDs/Tartrazine dyes - selected individuals experience sx
-triggered by various agents in the work place; may occur weeks-years after initial exposure
Catamenial asthma
women; occurs at predictable times during menstrual cycle
Exercise-induced bronchoconstriction
-def
-peak of EIB
-when does it resolve by?
-during exercise, or within 3 minutes after it ends
-peaks within 10-15min
-resolves by 60min
Cardiac asthma
-def
wheezing d/t decompensated HF
Cough-variant asthma
-def
cough is present instead of wheezing
Asthma
-def
-characterized by:
-chronic disorder of the airways
-bronchoconstriction, airway inflammation, reversible airflow limitation
common patho findings associated with asthma
-what type of inflammatory cells infiltrate the airway
-eosinophils, neutrophils, and lymphocytes (T-cells)
common patho findings associated with asthma
-what do goblet cells cause?
goblet cell hyperplasia leads to plugging small airways with mucus
common patho findings associated with asthma
-what deposits beneath basement membrane?
collagen
common patho findings associated with asthma
-what occurs to bronchial smooth muscle?
hypertrophy
common patho findings associated with asthma
-what type of edema occurs?
airway edema
common patho findings associated with asthma
-what cells are activated?
mast cell
common patho findings associated with asthma
-what occurs to epithelium?
denudation of airway epithelium
IgE role in asthma
central role in allergic asthma
IL-5 role in asthma
promotes eosinophilic inflammation
Predisposing factors for asthma (5)
-genetic predisposition : family hx or allergies, asthma
-obesity: 2nd leading cause
-Atopy: strongest predictor of asthma (genetic tendency to develop allergic disease such as allergic rhinitis, asthma, and atopic dermatitis - eczema)
-Tobacco exposure (2nd hand smoke in kids)
-RSV or other viruses during infancy
what is the strongest predictor of asthma?
atopy: genetic tendency to develop allergic disease such as allergic rhinitis, asthma, and atopic dermatitis - eczema
how quickly to asthma sx develop after exposure?
-immediate or 4-6hrs after exposure (late asthmatic response)
lifestyle modifications related to asthma (11)
-no smoking around child
-pets
-humidity (keep at <50%)
-Keep windows closed (air conditioner has air filter)
-eliminate carpeting in bedroom
-limit stuffed toys (wash weekly in hot water)
-encase pillows and mattress in dust-mite proof covering (wash bedding weekly)
-control indoor pests (cockroaches)
-avoid outdoor activities when air pollution index is high
-avoid beta blockers & sulfite-containing foods
-get annual influenza vaccine
S/S asthma
-4+
-episodic wheezing
-difficulty breathing
-chest tightness
-cough
-excess sputum production (common)
-frequency of attacks is variable
-may occur spontaneously or exacerbated by triggers
-sx worse at night (3-4am)
physical exam of asthma (6)
-nasal mucosa swelling
-increased secretions
-polyps (allergic asthma)
-eczema
-atopic dermatitis
-other allergic skin dx
what indicates the presence of airflow obstruction in asthmatic patient?
-wheezing or prolonged expiratory phase during normal breathing
***wheezing during forced expiration DOES NOT!
what is the only diagnostic clue on auscultation for a severe asthma attack?
globally diminished breath sounds (absent wheeze) and use of accessory muscles of respiration (nasal flaring and retractions)
what type of approach is used to manage asthma?
stepwise
-Asthma management is broken down into how many groups?
-ages of each group
-3 groups
1. 0-4yrs
2. 5-11yrs
3. 12 and over
for asthma management, what are the three steps to follow?
- evaluate asthma severity (new dx, not on long-term control medications)
- initiate treatment using the stepwise approach
- assess asthma control and adjust treatment as needed
Asthma management: (1) evaluate asthma severity (new dx, not on long-term control meds)
-how is this determined?
-parent/caregiver recall
-what does more frequent and intense exacerbations cause?
-determined by assessment of BOTH impairment and risk
-assess impairment domain by patient’s/caregiver’s recall of previous 204 weeks and spirometry –> assign severity to the most severe category in which any feature occurs
-more frequent and intense exacerbations = greater underlying disease severity
Asthma management: (2) initiate tx using Stepwise approach
-treatment purposes
patients who had >equal 2 exacerbations requiring oral systemic corticosteroids in the past year –> considered same as pts with persistent asthma (even in absence of impairment levels consistent with persistent asthma)
Asthma management
-what criteria exception exists for ages 0-4yrs
no lung function testing done (not old enough to cooperate), night-time awaking due to symptoms hold more weight
stepwise approach for asthma management
-newly diagnosed/tx naive: choose appropriate step diagram for person’s age; then, what needs to be considered?
-level of asthma impairment
-risk
stepwise approach for asthma management
-within a given step, preferred options are what?
-within a given step, alternative options are what?
-BEST MANAGEMENT CHOICES
-less effective
stepwise approach for asthma management
-when is it acceptable for patient to choose alternative therapy/tx?
-asthma that is currently receiving this therapy
-preferred treatment is not available or too costly
-if individual asthma prefers alternative tx
stepwise approach for asthma management
-when is treatment escalated or deescalated
-escalated: as needed
-deescalated: once individual’s asthma is well-controlled FOR AT LEAST 3 CONSECUTIVE MONTHS
when are asthma management steps deescalated?
the individuals asthma is well-controlled FOR AT LEAST 3 CONSECUTIVE MONTHS
persistent asthma (require tx at step 2 or above)
-what should the FNP be guided by?
-current step of treatment and individual’s response to therapy in both asthma control and adverse effects (currently and in past) –> use to decide if should step up, down, or continue current therapy
persistent asthma (using alternative treatment and have unsatisfactory/inadequate response to tx)
-what are next steps in asthma management?
-replace alternative tx with preferred tx within the same step BEFORE stepping up therapy
stepwise approach for asthma management
-what type of asthma is cared for in step 1?
intermittent asthma
stepwise approach for asthma management
-what type of asthma is care for in steps 2-6?
persistent asthma
stepwise approach for asthma management
-step 1 (0-4yrs)
-step 1 (5-11yrs)
-step 1 (>12yrs)
-SABA PRN and at start of RTI: add short course of ICS daily
-SABA PRN
-SABA PRN
stepwise approach for asthma management
-step 2 (0-4yrs)
-step 2 (5-11yrs)
-step 2 (>12yrs)
-Daily low-dose ICS + PRN SABA
-Daily low-dose ICS + PRN SABA
-Daily low-dose ICS + PRN SABA or PRN concomitant ICS + SABA
stepwise approach for asthma management
-step 3 (0-4yrs)
-step 3 (5-11yrs)
-step 3 (>12yrs)
-Daily medium-dose ICS + PRN SABA
-Daily and PRN combo Low-dose ICS-formoterol (LABA)
-Daily and PRN combo Low-dose ICS-formoterol (LABA)
stepwise approach for asthma management
-step 4 (0-4yrs)
-step 4 (5-11yrs)
-step 4 (>12yrs)
-Daily medium-dose ICS-LABA Combo + PRN SABA
-Daily + PRN combo Medium dose ICS-formoterol (LABA)
-Daily + PRN combo Medium dose ICS-formoterol (LABA)
stepwise approach for asthma management
-step 5 (0-4yrs)
-step 5 (5-11yrs)
-step 5 (>12yrs)
-daily high-dose ICS-LABA combo + PRN SABA
-daily high-dose ICS-LABA combo + PRN SABA
-Daily medium-high dose ICS-LABA combo + LAMA + PRN SABA
stepwise approach for asthma management
-step 6 (0-4yrs)
-step 6 (5-11yrs)
-step 6 (>12yrs)
-Daily high-dose ICS-LABA combo + oral systemic steroid + PRN SABA
-Daily high-dose ICS-LABA combo + oral systemic steroid + PRN SABA
-Daily high-dose ICS-LABA combo + oral systemic steroid + PRN SABA
To assess asthma control, what do you check first?
-if step up is needed, when do you reassess?
-how do you know if step down is needed?
check adherence, inhaler technique, environmental factors, and co-morbid conditions
-step up if needed; reassess in 4-6 weeks (ages 0-4yrs) and 2-6 weeks (>equal 5yrs)
-step down if possible if asthma is well controlled for at least 3 consecutive months
At what step do you consult an asthma specialist for ages 0-4yrs?
if step 3 or higher is required
-consider consultation at step 2
At what step do you consult an asthma specialist for ages >equal 5yrs?
if step 4 or higher is required
-consider consultation at step 3
Asthma
-quick relief (relievers) def
-long term (controllers) def
-act by directly relaxing bronchial smooth muscles
-act primarily to attenuate airway inflammation and that are taken daily independent of sx to achieve and maintain control of persistent asthma
NAEPP asthma dx and management guidelines (4)
- assessing and monitoring asthma severity and asthma control
- patient education designed to foster a partnership for care
- control of environmental factors and comorbid conditions that affect asthma
- pharmacologic agents (two categories)
what do NAEPP recommendations emphasize with therapy?
recommendations emphasize daily anti-inflammatory therapy with inhaled corticosteroids as the cornerstone of treatment of persistent asthma
asthma: quick relief medications
-SABA: types (meds), use, MOA, mild/mod sx, severe sx, nebulized tx
-albuterol, levalbuterol, bitolterol, pirbuterol, terbutaline
-most effective bronchodilators; most effective during exacerbations
-relaxes the smooth muscles –> prompt increase in airflow and decrease in sx
-1-2 puffs usually sufficient
-higher doses of 6-12 puffs every 30-60min of albuterol by MDI or 2.5mg neb is equivalent bronchodilation
-DOSE NOT offer more effective delivery but providers higher doses (usually nebulized tx doses are 25-30x higher; single activation MDI 0.09mg-albuterol. Standard dosing of inhalations from an MDI will often be insufficient in the setting of an acute exacerbation)
SABA administration before exercise
-what does it prevent?
prevents exercise induced bronchoconstriction
what does repetitive ABA administration promote?
produces incremental bronchodilation
alternatives if SABA doesn’t work for asthma
-anticholinergics: ipratropium bromide is the inhaled drug of choice for pts with intolerance to beta 2 agonist or with bronchospasms due to beta blockers meds despite being less effective than beta 2 agonists (decreases mucus gland hypersecretions; reverse mediated bronchospasm but NOT allergen or exercise induces asthma)
-corticosteroids: systemic steroids are PRIMARY tx for patients with moderate to severe asthma exacerbations who do not respond promptly and completely to SABA. Reduces rate of relapse and speeds resolution of airflow obstruction
*outpatient burst therapy: 0.5-1mg/kg/d (typically 40-60mg) in 1-2 doses for 3-10d
*severe exacerbations: require 1mg/kg of prednisone or methylprednisone every 6-12hrs for 48 hrs or until FEV1 returns to 50% predicted
-antimicrobials: multiple studies suggest infections with viruses (rhinovirus) and bacteria (M pneumoniae and C pneumoniae) predispose exacerbations. Consider when likelihood of acute bacterial RTI. Routine use in asthma exacerbations is not recommended.
alternatives if SABA doesn’t work for asthma
-anticholinergics
-anticholinergics: ipratropium bromide is the inhaled drug of choice for pts with intolerance to beta 2 agonist or with bronchospasms due to beta blockers meds despite being less effective than beta 2 agonists (decreases mucus gland hypersecretions; reverse mediated bronchospasm but NOT allergen or exercise induces asthma)
alternatives if SABA doesn’t work for asthma
-corticosteroids
-outpatient burst therapy
-severe exacerbations
-corticosteroids: systemic steroids are PRIMARY tx for patients with moderate to severe asthma exacerbations who do not respond promptly and completely to SABA. Reduces rate of relapse and speeds resolution of airflow obstruction
*outpatient burst therapy: 0.5-1mg/kg/d (typically 40-60mg) in 1-2 doses for 3-10d
*severe exacerbations: require 1mg/kg of prednisone or methylprednisone every 6-12hrs for 48 hrs or until FEV1 returns to 50% predicted
alternatives if SABA doesn’t work for asthma
-antimicrobials
-antimicrobials: multiple studies suggest infections with viruses (rhinovirus) and bacteria (M pneumoniae and C pneumoniae) predispose exacerbations. Consider when likelihood of acute bacterial RTI. Routine use in asthma exacerbations is not recommended.
Quick relief medications for asthma (4)
SABA (short acting beta agonist)
Anticholinergics
Corticosteroids
Antimicrobials
Long term controllers for asthma (7)
-inhaled corticosteroid
-systemic (oral) corticosteroids
-mediator inhibitors
-long acting beta 2 agonists (LABA)
-Anticholinergics agents, short acting muscarinic agents (SAMA) and long acting muscarinic agents (LAMA)
-phosphodiesterase inhibitor
-leukotriene modifiers
long term controllers: anti-inflammatory agents
-inhaled corticosteroids
-systemic (oral) corticosteroids
long term controllers: long term bronchodilators
-mediator inhibitors
-long-acting beta 2 agonists (LABA)
-Anticholinergics agents, short acting muscarinic agents (SAMA) and long acting muscarinic agents (LAMA)
-phosphodiesterase inhibitor
purpose of anti inflammatory agents used to treat asthma
-long term control
-corticosteroids reduce acute and chronic inflammation –> improved airflow, decreased airway hyper responsiveness and fewer asthma exacerbations and potentiate the action of beta-adrenergic agonists
what is the 1st line treatment agent used for patients with persistent asthma?
inhaled corticosteroids
inhaled corticosteroids (asthma treatment)
long term controller; anti-inflammatory agent
-preferred first line tx for all pts with persistent asthma
-most pts use twice daily dosing –> provides adequate control
-maximum response from inhaled corticosteroids may not be observed for months
-dry powder inhalers: not used w/ an inhalation chamber (chamber with mouth rinsing DECREASES side effects)
-systemic effects may be seen w/ high dose of steroids
systemic (oral) corticosteroids (asthma treatment)
long term controller; anti-inflammatory agent
-most effective in achieving prompt control of asthma during exacerbations in children and adults
-alternating days (treatment plan) is preferred than daily tx
-requires concurrent treatment with calcium and vit D to prevent corticosteroid induced bone mineral loss; check bone density after 3 months
-avoid rapid discontinuation to prevent adrenal insufficiency
-
what (med) is the most effective in achieving prompt control of asthma during exacerbations in children and adults?
systemic (oral) corticosteroids
mediator inhibitors (asthma treatment)
-examples
-MOA
long term controller; long term bronchodilators
-cromolyn sodium and nedocromil
-effective before allergen exposure or exercise but do not relieve asthmatic sx once present
long acting beta 2 agonists (LABA)
-meds
-delivery
-MOA
-helpful with?
-SHOULD NOT BE USED AS…?
-when added to low or med doses of inhaled corticosteroids
-combo inhalers
-salmeterol and formoterol
-dry powder delivery devices
-bronchodilation for up to 12 hours after a single dose
-long term prevention of asthma sx, nocturnal sx and prevention of exercise induced bronchospasm
-SHOULD NOT be used as monotherapy (linked to fatal asthma when used alone; have no anti-inflammatory effects thus, needs to be used with corticosteroid)
-provide the equivalent to what would be if doubled the inhaled corticosteroids
-combo inhalers of formoterols short onset and budesonide
anticholinergics agents, short acting muscarinic agents (SAMA) and long acting muscarinic agents (LAMA)
-action
-meds
-reverse vagally mediated bronchospasm but not allergen or exercise induced bronchospasms
-Ipratropium bromide (SAMA): less effective than SABA for relief of acute bronchospasm
-Tiotropium: add on therapy to bronchodilator (salmeterol) or inadequately controlled low-dose inhaled; improved lung function and reduce frequency of asthma exacerbation
phosphodiesterase inhibitor
-meds
-use
-MOA
-drug levels
-theophylline
-mild bronchodilation in asthmatic patients
-anti-inflammatory and immunodilator properties –> enhances mucociliary clearance and strengthens diaphragmatic contractility
-MONITOR serum concentrations due to narrow therapeutic range
Use of leukotriene modifiers
-examples
-alternatives to low-dose inhaled corticosteroids in patients w/ mild persistent asthma, but as monotherapy are usually less effective than inhaled corticosteroids
-zileutonn or zafirlukast or montelukast
desensitization
immunotherapy for specific allergens
omalizumab and reslizumab
recombinant antibody that binds IgE without activating mast cells
-TREATS severe asthma in 18 and older
what vaccines should an asthmatic receive?
pneumovac and influenza
what are oral sustained release beta 2 agonists used for?
reserved for patients with nocturnal asthma or persistent mod-severe asthma who DO NOT RESPOND to other therapies
Mild asthma exacerbation
-characterized by…
-4 components to exacerbation
-**doubling dose
-characterized by only minor changes in airway fx (PEF (peak expiratory flow) >80%)
-many patients respond to quick and fully to inhaled SABA
-sometimes need continuous SABA at increased doses
-if not taking an inhaled corticosteroid, can initiate one
-if patient is taking inhaled steroid –> can initiate oral corticosteroid
-**doubling dose of inhaled corticosteroid is not effective and not recommended
Moderate asthma exacerbation
-goal of treatment
-SABA and corticosteroid role
-what correlates to severity of asthma exacerbation
-correct hypoxemia, reverse airflow obstruction, and reduce likelihood of reoccurrence of obstruction
-MAIN IMPORTANCE is correction of hypoxemia through supplemental oxygen
-Continue inhaled SABA and early administration of corticosteroids
-systemic corticosteroids should be given if peak flow is >70% of baseline or patient who doesn’t respond to several SABA treatments
-improvement of FEV1 after 30 minutes
-regardless of severity, all pts should be provided necessary meds and education, instruction in self-assessment and follow up with an action management plan
what does FEV1 improvement after 30 minutes correlate to?
severity of asthma exacerbation
do providers utilize pulmonary function tests/spirometry in <5yr olds?
-if not, what is dx based on?
NO
-clinical judgment and assessment of sx
FEV1
forced expiratory volume in 1 second
FVC
forced vital capacity
FEV1/FVC ratio
-how is airflow indicated
compared to reference norms for age, weight, and gender
-airflow is indicated by reduced FEV1/FVC
Pulmonary function tests/spirometry
-what should it include?
-when should testing be done (and for what purpose)?
-FEV1, FVC, FEV1/FVC
-test before and after administration of short acting bronchodilator to determine if obstruction is reversible
Pulmonary function tests/spirometry
-what value confirms the dx of asthma?
a positive bronchodilator response (increase in FEV1) strongly confirms the diagnosis of asthma
Peak expiratory flow (PEF) meters
-def
-when is it usually lowest?
-when is it usually highest?
-when should it be measured?
-what percent change suggest inadequately treated asthma?
-handheld devices for personal management
Assessing Asthma Control
Age: 0-4yr; wake-ups
-Well controlled
-Not well controlled
-Very poorly controlled
-<1x/month
->1x/month
->1x/week
Assessing Asthma Control
Age: 5-11yrs; wake-ups
-Well controlled
-Not well controlled
-Very poorly controlled
-<1x/month
->2x/month
->2x/week
Assessing Asthma Control
Age: >12 years
-Well controlled
-Not well controlled
-Very poorly controlled
-<2x/month
-1-3x/week
->4x/week
Assessing Asthma Control
SABA use
-Well controlled
-Not well controlled
-Very poorly controlled
<2x weekly
>2x weekly
Several times each day
Assessing Asthma Control
Activity problems
-Well controlled
-Not well controlled
-Very poorly controlled
None
Some limitation
Very limited
Assessing Asthma Control
Validated questionnaires (ACT) >equal 12yr
-Well controlled
-Not well controlled
-Very poorly controlled
> equal 20
16-19
<equal 15
Assessing Asthma Control
Exacerbations requiring oral meds (0-4yrs)
-Well controlled
-Not well controlled
-Very poorly controlled
0-1/year
2-3/year
>3/year
Assessing Asthma Control
Exacerbations requiring oral meds (>5yrs)
-Well controlled
-Not well controlled
-Very poorly controlled
0-1/year
>2/year
>2/year
Assessing Asthma Control
Recommended actions:
-Well controlled
-Not well controlled
-Very poorly controlled
maintain - f/u in 1-6 months
Step up 1 step - reevaluate in 2-6 weeks
Oral meds + step up 1-2 steps - reevaluate in 2 weeks
AIRQ
-definition
-what is it used along side?
can help you and your patient determine whether their asthma is well controlled
Asthma impairment and risk questionnaire
-for patients age >equal 12 years, only the AIRQ is validated as a single instrument assessing both impairment and control
-10 yes or no questions that evaluate sx, social and physical activities, exacerbations, related healthcare resources utilization, perception of asthma control, and use of rescue (reliever) medications
-a score of 0 or 1 indicates asthma is well controlled
-score of 2-4 indicates asthma is not well controlled
-score of 5-10 indicates asthma is very poorly controlled
*identifies patients with exacerbations requiring treatment with oral corticosteroids or emergency department/unplanned office visits or hospitalizations for asthma that are not assessed by many other asthma control tools
*used along side the asthma checklist
asthma checklist
a management assessment checklist used in conjunction with an asthma control questionnaire can facilitate a thorough investigation and optimization of asthma control
-this checklist includes factors such as medication adherence, use of an action plan, psychological issues, vaccination, and suggestions for specialty care referral
Assessing Asthma Control
-Asthma Control Test
Questionnaire that assesses a patient’s asthma control. For patients 12 years and older who have been diagnosed with asthma. If score is 19 or less, asthma may not be controlled as well as it should be. Talk to your doctor.
Acute (severe) asthma exacerbation
-how serious is this?
-what three things should patient be immediately put on?
-can be life-threatening
-all patients should immediately get O2, high dose of inhaled SABA and systemic corticosteroids
Acute (severe) asthma exacerbation
-management: oxygen, SABA, regular control meds, oral corticosteroids, IV mag, assess
-when can you D/C patient home?
-what is contraindicated?
-oxygen saturation >90% or PaO2>60mmHg
-frequent delivery of high-dose SABA: albuterol inhaler 2-6 puffs, repeat in 20 min x3 (may need to continue SABA q 3-4 hours for 24-48hrs)
-continue/adjust regular control meds (stepwise) –> ipratropium bromide reduces rate of hospitalizations when added to inhaled SABA in pts with mod to severe asthma
-start short course oral corticosteroids (prednisone, methylprednisolone, or prednisolone in either single dose or divided BIDx7days (no need to taper)
-IV magnesium: FEV1<25%
-assess use of regular medications –> EDUCATE
-assess immunization status: influenza, pneumococcal vaccine
-can discharge to home if PEF or FEV1 has returned to 60% or more of predicted
-contraindicated: mucolytic agents (may worsen cough and airflow; anxiolytic and hypnotics (due to resp depression)
Treatment for all cases of asthma
-quick acting
quick acting “rescue” inhaler = SABA
albuterol can be given as a MDI (90mcg/spray) or nebulized (available as 0.63 or 1.25mg/3mL of saline)
-dose: 0.05mg/kg (max 5mg) 20kg = 1 mg
-use 1 puff of MDI or 1 neb - may repeat q 20 min x 3 for acute exacerbation of sx
how does a patient use an asthma action plan?
used for daily management that includes instructions and measures to take in response to specific change in status
reasons to refer someone with asthma
-atypical presentation
-comorbid conditions
-suboptimal response to therapy
-not meeting asthma goal after 3-6 months
-requires high dose corticosteroids for control
-more than 2 courses of oral prednisone in past 12 months
-any life-threatening asthma exacerbation requiring hospitalization in last 12 months
-social/psych issues interfering with asthma management
when to admit patient with asthma to the hospital
poor response to SABA after 2 treatments 20 minutes apart
-hypoxia: O2 sat <95% on RA
-marked breathlessness: inability to speak in sentences
-use of accessory muscles
-changes in alertness
-PEF of <50% personal best!!!!!!!
