PULM Flashcards
asthma triad and hallmarks
triad:
1. airway inflammation
2. airway hyperresponsiveness
3. REVERSIBLE obstruction - seen w/ 12% or more reverse pre vs post BD tx on PFT or 20% or more w/ bronchoprovocation (w/ histamine or methacholine)
* *intermittent symptoms starting at any age (vs COPD more progressive, constant, older w/ hx smoking)
pres - asthma
INTERMITTENT sob, wheezing chest tightness, cough
- symptoms worse at night d/t increased bronchomotor tone b/n 3-4am!
- look for hx of ATOPY or family history of asthma, nasal polyps / mucosal swelling
- most attacks w/in 30 min
diagnosis - asthma
formal dx: PFT - restrictive pattern, 12% or more increase post-BD, increased diffusion capacity
other testing w/ asthma
- in acute exacerbation, use PEAK FLOW to assess airway NOT PFT or spirometry
- mild >300, mod 100-300 and severe <60%!!
- bronchoprovacation done w/ nondiagnostic PFT
- CXR - nl unless severe, use to r/o other lung dz
- ABG: expect respiratory alkalosis w/ increased A-a gradient
- **IF PAC02 IS NORMAL / LOW = sign of IMPENDING FAILURE - MUST INTUBATE (muscles fatigue, RR decreases so PAco2 falls!)
intermittent asthma
sx and SABA 2 or less / week, nighttime awakenings 2 or less/ month
no limitation in activity and PFT nl
STAGE 1 - SABA
persistent mild asthma
sx and SABA >2 / week, awaken 3-4 x mo, 0-1 exacerbations / yr, mild limitation
STAGE 2 - SABA + LOW ICS
persistent mod asthma
sx and SABA daily, awaken >1 / week, 01- exacerbations/ mod limitation
STAGE 3 - LOW ICS + LABA OR MOD ICS
persistent severe asthma
sx and saba >1/d, awaken every night, worsening exacerbations and severely limited
STAGE 4 OR 5 -
4: MOD ICS + SABA
5 HIGH ICE + SABA
*if must move up, add oral corticosteroids
what medication can you not give….
BB CONTRAINDICATED AND DO NOT USE LABA AS MONOTHERAPY - INCREASES MORTALIY!
1st line for persistent asthma?
INHALED CORTICOSTEROIDS
-use MDI + rinse mouth to decrease se (cough, dysphonia, candidiasis)
cromolyn and nedocromil
-mast cell stabalizers and affect eosinophil recruitment - good for preventing sx or for exercise induced but will NOT reduce symptoms already present!
tx mild exacerbation
-inhaled SABA q 3-4 hr x 24-48, may need to increase dose and may need oral corticosteroids (.5-1 mg / kg/d)
tx mod exacerbation
02 (>90%), SABA, systemic corticosteroids
*improvement after 30 minutes correlates w/ severity
tx severe exacerbation (PEF <60%)
*monitor peak flow and paco2!!
oxygen >90%, saba 2.5-5 albuterol q 20 min x 3 - at least 3 in the first hour, systemic corticosteroids IV and then oral
*when you begin to taper systemic, initiate inhaled!
*if not improved, ADMIT!
can add ipratropium to SABA
-mag sulfate - reduces bronchoconstriction
**mucolytic agents, anxiolytics and hypnotics contraindicated!
**response to initial treatment in ED = best predictor for need of hospitalization
what to use for intubation
ketamine or succylnylcholine
saba for asthma
albuterol, levalbuterol
anticholinergics
ipratropium bromide (atrovent) and tiotropium (spiriva)
laba
salmeterol (serevent) and formeterol (foradil)
combos
advair, dulera, symbicort - ICS + BD
duoneb = ipratropium and albuterol - for acute exacerbation or copd
zileuton
LT modifier - good for prophylaxis w/ exercise induced or as adjunct w/ saba for more severe to reduce need / dose of steroid
antibiotics for asthma
cover atypicals!!!
pt w/ daily symptoms, cough 4 x week, fev1 < 60…tx?
SABA, med-high ICS + LABA + oral steroids and maybe montelukast
sx twice / week w/ normal PFT…Tx?
saba only
sx daily, night cough 2 x week, PFT 60-80%…tx?
SABA, ICS + laba
sx 4 x week, night cough 2x mo, pft nl
albuterol + ICS
asthmatic bronchitis?…
combination of bronchitis in an asthmatic patient
persistent cough w/ progresively thick mucus, dyspnea, fever, chest pain w/ similar past episodes…
ASTHMATIC BRONCHITIS!! often viral!
