Module 3: Respiratory Disorders Flashcards
The asthma updates’ most highly pediatric-relevant recommendations involve three treatment options: (1) intermittent ICS dosing with -A- for quick-relief therapy, (2) -B- and reliever therapy, and (3) -C-
A. as-needed short-acting b2-agonist (SABA)
B. single maintenance (SMART)
C. add-on LAMA therapy
In children 0 to 4 years with intermittent asthma, clinicians may now conditionally recommend a -1- course of -2- with as-needed SABA at the start of a -3- for children who have had -4- of similar wheezing or >1 episodes in the past year and who are -5-.
- short (7–10 days)
- daily ICS
- viral URI
- > 2 lifetime episodes
- asymptomatic between episodes
In those >11 years with -1-, clinicians and families may jointly decide to use -2- -3- instead of daily ICS with as-needed SABA.
- mild persistent asthma
- intermittent as-needed concomitant
- ICS with SABA
For patients >3 years with mild to moderate persistent asthma who are likely adherent with daily ICS alone, a short-term increase in the ICS dose (eg, doubling, tripling, or quadrupling the daily dose) -1-. It -2- for patients whose adherence is less certain.
- is not recommended
2. may be considered
SMART is treatment with -1- and a specific LABA (-2-) for both -3- therapy
- ICS
- formoterol
- daily and rescue
Formoterol is the LABA of choice for SMART because it has a -1- onset of action and can be used -2- daily.
- rapid
2. more than twice
Individuals whose asthma is uncontrolled on daily ICS-LABA maintenance therapy should receive the preferred … before moving to a higher-step level of therapy
SMART
-1- or -2- (in liquid or tablet form) reduces the -3- allergic response associated with asthma.
- Subcutaneous immunotherapy (SCIT)
- sublingual immunotherapy (SLIT)
- immunoglobulin E–mediated
In children ages -1- with -2-, the Expert Panel recommends -3- to predict the future development of asthma.
- 0–4 years
- recurrent wheezing
- against FeNO measurement
Asthma is characterized by variable and recurring symptoms of: -1-, -2-, and -3-
- Airflow obstruction
- Bronchial Hyperresponsiveness
- Underlying inflammation
What is the most common trigger for an asthma exacerbation in a 4 year old child? A. Upper respiratory infection B. Exercise C. Cold air D. Cigarette smoke E. Allergic rhinitis
A
Pathophysiology of asthma is a cycle of -1-, -2- in response to triggers, -3-, and -4-
- Airway remodeling
- Hyperresponsiveness and inflammation
- Obstruction
- Partial recovery (compared to full recovery in healthy lungs)
Difficulty breathing/SOB, chronic cough, cough after exercise, chest pain, wheezing, and/or night cough
Symptoms of childhood asthma
Early phase of asthmatic response is characterized by -1- and responsive to -2-. Begins in -3- in response to a trigger and abates in -4- to 2 hours. Common triggers include animal dander, pollen, mold, dust, -5-, exercise
- Inflammation and bronchoconstriction
- Albuterol
- 10-20 min
- 30 min
- cold air
Late phase asthmatic response is characterised by -1-. Caused by an ongoing production of the -2-. Usually begins in -3- after initial attack, reaches a maximum in -4- and disappears within -5-
- obstruction of airflow
- mediators of inflammation and bronchoconstriction
- 4-12 hrs
- 6-12 hrs
- 12-24 hrs
Late phase asthmatic response: May be more severe and occur -1-. -2- are not effective for this late phase, but -3- are.
- at night
- Bronchodilators
- anti-inflammatory medications, like steroids,
A 3 year old child with multiple episodes of wheezing, which of the following is a major risk factor for the future development of asthma? • A. History of bronchiolitis • B. Atopic dermatitis • C. History of food allergy • D. 10% peripheral eosinophilia • E. Uncle with asthma
B
Asthma Diagnosis (0-4): Major Criteria: -1- history of -2-; physician diagnosis of -3-; Minor Criteria: physician diagnosed -4-, wheezing unrelated to colds, -5- >3%
- parental
- asthma
- atopic dermatitis
- allergic rhinitis
- Eosinophils
What is considered the “gold standard” for diagnosing asthma in children 6 years and up?
Spirometry (PFT)
Major differential for asthma in the newborn/early infant
bronchopulmonary dysplasia
Top 3 differentials for asthma
Tracheo-bronchomalacia, GER, CF
Four Components of Care: 1. Assessment and Monitoring
Four major factors used for classification of Asthma
Age
Phenotypes
Severity
Control
Four Components of Care: 1. Assessment and Monitoring
Guiding Asthma Principle I: Reduce -1-
• -2- chronic and troublesome symptoms
• Minimize the need to use -3- of asthma symptoms to ≤two days/week, maintain (near) normal pulmonary function
• Maintain normal -4- levels
• Prevent -5-
- impairment
- Prevent
- SABA for relief
- activity
- reduced lung growth
Four Components of Care: 1. Assessment and Monitoring
Guiding Asthma Principle II: Reduce -1-
• Prevent recurrent -2-
• Provide optimal -3- or -4-
• Step-down therapy: -5- to maintain control
- Risk
- exacerbations
- pharmacotherapy with minimal
- no adverse effects
- minimum medication necessary
Four Components of Care: 1. Assessment and Monitoring
Guiding Asthma Principle III: Optimize -1-
• Provide initial and ongoing -2- and family
• Educate patient and family to recognize -3-
• -4- and family to identify treatment goals and achieve well-controlled asthma that allows patient to fully and safely participate in activities (eg,
physical education, recess, sports, etc)
• Maintain patient’s and family’s -5- care
- Health and Function
- education to patient
- and avoid triggers
- Partner with patient
- satisfaction with asthma
Four Components of Care: 1. Assessment and Monitoring
Asthma severity is the -1- of the disease process and dictates which step -2-
Level of severity is determined by both -3-.
- intrinsic intensity
- to initiate treatment
- impairment and risk
Four Components of Care: 1. Assessment and Monitoring
The stepwise approach is meant to -1- the clinical decision making required to meet -2-
- assist, not replace,
2. individual patient needs
Four Components of Care: 1. Assessment and Monitoring
For treatment purposes, patients who had -1- oral systemic corticosteroids in the -2-, or -3- in the past year, and who have risk factors for -4- may be considered the same as patients who have -4-, even in the absence of -5- with -4-
- ≥2 exacerbations requiring
- past 6 months
- ≥4 wheezing episodes
- persistent asthma
- impairment levels consistent
Four Components of Care: 1. Assessment and Monitoring
PFT Classificaiton of Asthma - FEV1 & FEV1/FVC:
1. >80% predicted & > 85% (80/85)
2. > 80/80
3. 60/75 - 80/80
4. <60/75
- Intermittent
- Mild Persistent
- Moderate Persistent
- Severe Persistent
Four Components of Care: 1. Assessment and Monitoring
-1- is the degree to which manifestations of asthma are minimized and the goals of therapy are met (e.g., prevent symptoms/exacerbations, maintain normal lung
function and activity levels).
A guide to either -2- therapy
- Asthma control
2. maintain or adjust
Four Components of Care: 1. Assessment and Monitoring
Asthma control classified into 3 categories:
well controlled, not well controlled, and poorly controlled
Four Components of Care: 1. Assessment and Monitoring
The classification of severity or level of control is based on the -1- or -2- in which any feature occurs.
- most severe impairment
2. risk category
Component of Care 2: Control -1- Factors and Comorbid Conditions
a. Identify -2- factors
b. Recommend measures to control
exposures to -3- that make asthma worse.
c. Identify -4- that may adversely affect asthma
management
d. -5-
- Environmental
- precipitating and exacerbating (ie, asthma triggers, including those in the home, school, and child care settings)
- allergens and pollutants/irritants
- comorbid medical conditions
- Treat comorbid conditions
Component of Care 3: Education
Integrate education into all -1- where health professionals interact with patients.
Provide -2-
Knowledge: -3- asthma; Role of medications; Skills
-4- to control asthma
-5- in response to signs of worsening asthma
- points of care
- self-management education.
- Basic facts about
- Take daily actions
- Adjust medication
Component of Care 3: Education
Develop a written -1- in partnership with the patient.
Take medications correctly, use appropriate type of -2- with proper technique
Identify and avoid asthma triggers
-3- of asthma control
Recognize early -4- of worsening asthma & seek medical care as appropriate
Communicate asthma information to -5- center, and other caregivers
- asthma action plan
- inhaler and spacer
- Self-monitor level
- signs and symptoms
- school, child care
Component of Care 4: Medications
a. Select -1- devices to meet patient’s need and circumstances.
b. Periodically inspect -2- to verify appropriate type
- medication and delivery
2. medications and inhaler/spacer
When to consult:
0-4 years and -1- or higher is required
5 years or older and -2- or higher is required
Difficulty in -3- asthma control
- Step 3 care (may consider consultation at Step 2)
- Step 4 care (may consider consultation at Step 3)
- achieving or maintaining
- What are Beta adrenergic agonists?
- Beta-adrenergic agonists or Beta-agonists -1- muscle and may -2- from -3- and basophils
- They are a class of -4- which act upon the -5-.
- relax airway smooth (bronchodilation)
- modulate mediator release (i.e. histamine)
- mast cells
- sympathomimetic agents
- beta adrenoceptors
What is the difference between Beta-1 (β1) receptors, beta (β2) receptors and beta (β3) receptors?
• Beta-1 (β1) receptors are found in the -1- and kidneys while beta (β2) receptors are found in the -2-, liver, -3-, and skeletal muscle.
• The third type, beta (β3) receptors are found in -4-
- heart, eye,
- lungs, gastrointestinal tract
- uterus, blood vessels
- fat cells.
Short acting beta (β2) agonist (SABAs) recommended in -1- asthma to be administered -2- to -3- for -4- or -5-
- mild to moderate
- before exposure
- known allergens
- symptom relief
- rescue therapy
Inhaled beta 2 agonists delivered -1- are preferable to -2-; inhaled therapy causes fewer -3- has -4- with similar -5-, and achieves results at lower doses
- directly to airways
- oral agents
- systemic adverse effects (CV stimulation, anxiety, skeletal muscle tremor)
- faster action onset
- duration of action
Treatment for patient under 5 with:
- intermittent asthma
- mild persistent asthma
- moderate persistent asthma
- SABA PRN
- Low-dose ICS > Cromolyn or Montelukast; consider referral
- Medium-dose ICS; refer
Inhaled Corticosteroids (ICS) MOA: suppression of -1-
• Decreased synthesis and release of -2-
• Decreased infiltration and activity of -3-
• Decreased -4-
• Block -5- to allergen
• Diminishes airway reactivity to histamine, methacholine, and cold air
• May take 1-3 months to decrease -3-, decrease shedding of epithelial cells and reduce hyperplasia of epithelial goblet cells.
- inflammation, reduce hyperresponsiveness
- inflammatory mediators (prostaglandins, leukotrienes)
- inflammatory cells (eosinophils, leukocytes)
- airway mucosal edema
- late phase reaction
ICS Therapy:
True or False: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis
True
- Pediatric Patients Aged 4 - 11 Years: Dosage for FLOVENT HFA
- Recommended dosage: -1- daily, approximately -2-
- 88 mcg twice
2. 12 hours apart
The starting dosage for QVAR Redihaler is based on -1- and -2-, including consideration of the patients’ current -3- and risk of -4-. -5- are not used with QVAR, as it may interfere with delivery.
- previous asthma therapy
- disease severity
- asthma symptom control
- future exacerbation
- Spacers
Oral Corticosteroids
• Gain initial control of acute asthma or -1-
• May cause -2- suppression, -2- function returns rapidly
• Suppression may be prolonged with -3- short courses of oral corticosteroids per year
- severe persistent exacerbations
- adrenal
- > 4
Cromolyn sodium. Drug class: -1- • Not useful for -2- • Prevent asthma attacks with -3- • Also used to prevent -4- • MOA: suppresses inflammation (is not a bronchodilator). Stabilizes -5- membranes and prevents release of histamine and other mediators.
- mast cell inhibitor
- acute attack
- bronchial asthma
- bronchospasm (wheezing, chest tightness, trouble breathing)
- mast cell cytoplasmic
[Leukotriene Receptor Antagonist (LTRA), e.g. singulair]
Effective for:
• Preventing asthmatic responses to -1—important esp. in children with unpredictable schedule of -1-
• -2- exposure and -2- rhinitis
• Additive effect with inhaled -3- and may be able to use lower -3- dose
MOA:
• Blocks/Inhibits -4- mediators
• Can decrease -5- mucous secretion, and recruitment of eosinophils and other inflammatory cells
- exercise/physical activity
- Allergic
- corticosteroid
- leukotrienes: inflammation synthesis
- inflammation, bronchoconstriction, edema,
Anticholinergics prevent the increases in intracellular
concentration of -1- that are caused by -2- with the -3- on -4-
- cyclic guanosine monophosphate (cyclic GMP)
- interaction of acetylcholine
- muscarinic receptor
- bronchial smooth muscle
Cystic Fibrosis Diagnostic studies
• -1- screening
• -2- test
• Genetic -3- mutation
- Newborn
- Sweat
- analysis for CFTR
Newborn screening for CF
• Many newborns will have a -1- for the disease, fewer than 10 percent will -2-
•Infants diagnosed with CF through newborn screening and -3- begin are healthier
- positive newborn screen
- actually have it
- treated before symptoms
The newborn screen for CF is a two-tier process
• The first tier is the analysis of -1- using the Guthrie card.
-This report is then sent to the -2-
•If the IRT is -3-, the second tier is diagnostic for
CF with either -4- by the State Lab or -5- at a CF center
• Positive screening with either an -3- IRT or CF
-4- needs follow up at a CF center facilitated by the -2-
- immunoreactive trypsinogen (IRT)
- PCP
- elevated
- gene analysis
- sweat chloride testing
PCP actions given:
- Elevated IRT w/o mutation
- Elevated IRT w/ 1 mutation
- Elevated IRT w/ 2+ mutations
- monitor for signs of CF: persistent diarrhea, poor weight gain, chronic cough or other respiratory problems - any of these are call for CF specialist referral
- Sweat chlorine test at a CF center (under 30, negative; 30-59, refer for further assessment; >60 positive Dx)
- Positive diagnosis, refer for CF care
-Cystic Fibrosis Clinical findings-
Pulmonary
• Chronic lung disease, -1-, dysfunctional mucociliary transport, obstruction, chronic infections
• Chronic -2-, respiratory failure
• Progressive disease – -3-
GI/nutrition
• -4- insufficiency, rectal prolapse
• Thick, fat-laden stools, failure to thrive
• -6-, GER, A, K, E, D deficiencies
• Distal intestinal obstructive syndrome (DIOS) -blockage or bowel obstruction, seen only in people with CF
- inflammation, viscous mucus
- cough, sputum production
- respiratory failure, death
- Meconium ileus, pancreatic
- Volvulus, duodenal inflammation
Cystic Fibrosis Clinical findings Hepatobiliary tract • -1-, ascites, hematemesis Endocrine • Recurrent -2- Musculoskeletal • Vitamin -3- Reproductive • -4- • -5-
- Biliary cirrhosis, jaundice
- pancreatitis, diabetes mellitus
- D deficiency – osteoporosis
- Delayed sexual development
- Male sterility
CF inheritance pattern
autosomal recessive
Cystic Fibrosis
The defective gene and its protein product cause the body to produce -1- mucus that:
• -2- and leads to life-threatening bronchiectasis
• Affects the pancreas and stops enzymes from -3-
• Impacts other organ systems affecting -4-
- unusually thick, sticky
- Obstructs the airway
- facilitating food absorption
- quality of life
CF Mgmt:
• PCP manages -1- and -2- care, including immunizations
• -3- managed at a CF-accredited center with multidisciplinary team
- Anticipatory guidance
- routine well-child
- Complicated treatment regimens
Cystic Fibrosis Management
Pulmonary
• -1- – for airway clearance
• Ivacaftor – transmembrane conductance regulator
• High-dose -3- inflammation
• -4-
GI
• Replacement of -5-
• -6- replacement
• Management of cystic fibrosis liver disease
• Distal intestinal obstruction syndrome (DIOS) management – osmotic laxatives
Endocrine
• Diabetes mellitus – management/diagnosis
- Inhaled dornase alfa
- ibuprofen reducing chronic
- Manage chronic pneumothoraces
- pancreatic enzymes
- Fat-soluble vitamin
- PROTEINURIA,
- HYPOALBUMINEMIA, HYPERLIPIDEMIA
- +/- EDEMA
NEPHROTIC SYNDROME
- UA results
- CMP/Lipid Panel results
- Phy’l Exam
- Excessive excretion of protein in urine from increased -1-
- Selective (albumin only) or non-selective (most serum proteins) proteinuria
- Massive proteinuria (3-4+) or protein-creatinine ratio greater than 2-3:1
- Edema formation from decreased -2-
- Liver -3- – hyperlipidemia and lipiduria
- Reduced -4- – increased reabsorption of water
.Nephrotic Syndrome
- glomerular filtration permeability
- plasma oncotic pressure
- increases protein synthesis
- volume stimulates ADH
