PBL Case Flashcards
What are the characteristic symptoms of asthma?
-Wheezing
-Dyspnea
-Coughing
(these are variable both spontaneously and with therapy)
When might symptoms be worse for asthma patients?
At night - patients typically awake in the early morning hours.
What might some patients with asthma report?
- Difficulty filling their lungs with air
- Increased mucous production –> with tenacious mucus that is difficult to expectorate
- Increased ventilation and use of accessory muscles of ventilation
What are prodromal symptoms of asthma?
- Itching under the chin
- Discomfort between the scapulae
- Inexplicable fear (impending doom).
What are typical physical signs of asthma?
- Physical signs are inspiratory and to a GREATER EXTENT EXPIRATORY
- Rhonchi throughout the chest
- May be hyperinflation of the chest
When asthma is under control, what might the physical findings be?
There may be no abnormal physical findings!
What do some patients (particularly children) present with?
Predominant nonproductive cough (cough-variant asthma)
What does DVT present with?
Unilateral lower extremity swelling
What are risk factors for DVT?
- Hospitalization with confinement to bed for > 3 days
- Surgery or general anesthesia in last 3 months
- Trauma in last 3 months
- Pregnancy/recent childbirth
- Oral contraceptives (estrogen)
- Travel for more than 4 hours.
What does Pulmonary Embolism (PE) present with?
Sudden onset chest pain that is worse with inspiration, dyspnea, SOB, tachycardia.
What are the risk factors for PE?
Same at DVT:
- Hospitalization with confinement to bed for > 3 days
- Surgery or general anesthesia in last 3 months
- Trauma in last 3 months
- Pregnancy/recent childbirth
- Oral contraceptives (estrogen)
- Travel for more than 4 hours.
What does PERC rule stand for?
Pulmonary Embolism Rule-out Criteria
-It’s a “rule-out” tool and ALL variables must receive a ‘no’ to be negative
What are the criteria associated with the PERC rule?
Questions:
- Age > 50?
- HR > 100?
- O2 stat on room air
What is the pretest probability of PE if PERC rule out criteria was all answered “NO”?
What is the sensitivity and specificity of the PERC Rule-out criteria?
Sensitivity - 97%
Specificity - 23%
What is the MOST COMMON EKG finding with PE?
Sinus tachycardia
What is classically seen in EKG for 10% of PE patients?
-S1Q3T3 pattern of ACUTE COR PULMONALE
What is the McGinn-White sign?
S1Q3T3
- Large S wave in lead 1
- Q wave in lead III
- Inverted T wave in lead III
What does a large S wave in lead I signify?
Complete or incomplete RBBB
What does a Q wave in lead III signify?
Due to pressure and volume overload over right ventricle which causes repolarization abnormalities
What does an Inverted T wave in lead III signify?
Due to pressure and volume overload in the right ventricle which causes repolarization abnormalities.
What does S1Q3T3 all indicate together?
Acute Right Heart Strain
What can cause the S1Q3T3 finding?
Any cause of Acute Cor Pulmonale
-PE, acute bronchospasm, PTX and other acute lung disorders!!
Giving patients what molecule will directly mimic asthma?
Histamine!
What is NOT the CAUSE of asthma?
HISTAMINE
What drugs are NOT effective in treating asthma?
Antihistamines
What is the cause of Asthma?
Leukotrienes!!
What are first generation Antihistamines?
Oldest H1-antihistaminergic drugs and are relatively inexpensive and widely available. They are effective in the relief of allergic symptoms, but are typically moderately to highly potent muscarinic acetylcholine receptor (anticholinergic) antagonists as well.
Where do first generation antihistamines also have action?
They commonly also have action at alpha-adrenergic receptors and/or 5-HT receptors.
What are three first generation antihistamines?
- Diphenhydramine (Benadryl)
- Meclizine
- Chlorphenamine
What are second generation antihistamines?
Second generation H1-anti-histamines are newer drugs that are much more selective for peripheral H1 receptors as opposed to the central nervous system H1 receptors and cholinergic receptors.
What does the High Selectivity of 2nd generation Antihistamines significantly reduce?
The occurrence of adverse drug reactions: such as SEDATION, while still providing effective relief of allergic conditions.
What are examples of 2nd generation antihistamines?
- Cetrizine
- Loratidine
- Fexofenadine
What is the Stepwise Pharmacologic Therapy used for asthma patients?
Asthma medication should be added or deleted as the frequency and severity of the patients symptoms change!
What is Step 1 of asthma therapy?
Intermittent asthma
-A controller medication is not indicated. The reliever medication is a short-acting beta-agonist (SABA) as needed for symptoms
What is Step 2 of asthma therapy?
Mild Persistent Asthma
- The preferred controller medication is a low-dose inhaled corticosteroid.
- Alternatives include sodium cromolyn, nedocromil, or a leukotriene receptor antagonist (LTRA).
What is Step 3 of asthma therapy?
Moderate persistent asthma
- The preferred controller medication is either a low-dose inhaled corticosteroid plus a long-acting beta-agonist (LABA) (combination medication preferred choice to improve compliance) or an inhaled medium-dose corticosteroid.
- Alternatives include an inhaled low-dose ICS plus either a luekotriene receptor antagonist, theophylline, or zileuton (Zyflo).
What is Step 4 of asthma therapy?
Moderate-to-severe persistent asthma
- Preferred controller medication is an inhaled medium-dose corticosteroid plus a leukotriene receptor antagonist (combination therapy).
- Alternatives include an inhaled medium-dose corticosteroid plus either a leukotriene receptor antagonist, theophylline, or zileuton.
What is Step 5 of asthma therapy?
Severe persistent asthma
- The preferred controller medication is an inhaled high-dose corticosteroid plus a leukotriene receptor antagonist.
- Consider omalizumab for patients who have allergies
What is Step 6 of asthma therapy?
Severe persistent asthma
- The preferred controller medication is a high-dose inhaled corticosteroid plus an oral corticosteroid.
- Consider omalizumab for patients who have allergies.
What patients can quick relief medication be used for? What is that medication?
All patients and all severities.
-Short-acting beta agonist, used as needed for symptoms
What does intensity of treatment depend on?
Severity of symptoms!
How many treatments can be administered for quick relief?
Up to 3 treatments at 20-minute intervals as needed.
What does the use of a short-acting beta agonist more than 2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicate?
Inadequate control and the need to step up treatment.
What does the 2009 VA/DoD guideline emphasize?
That patients with persistent asthma should NEVER be treated exclusively with long-acting beta2 agonists.
What is the primary aim of therapy in patients with exercise-induced bronchospasm?
Prophylaxis to prevent acute episodes.
What is recommended for people with exercise induced asthma?
A warm-up period of 15 minutes is recommended prior to a scheduled exercise event and prophylaxis has been shown to have a duration of effect as long as 40 minutes.
–> This approach is not helpful for unscheduled events, prolonged exercise, or elite athletes.
What drugs are effective for repetitive exercise in patients with exercise-induced asthma?
Long-acting beta agonists such as Salmeterol (at least 90 min before exercise)
What other drugs have demonstrated an ability to prevent exercise-induced bronchospasm?
Newer agents like Leukotriene antagonists, inhaled heparin, and inhaled furosemide.
What has a limited role in the treatment of exercise-induced bronchospasm (except to control underlying asthma)?
Inhaled corticosteroids
