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STEP 2 Pulmonary > Pulm. Asthma (08-05) > Flashcards

Pulm. Asthma (08-05) Flashcards

1
Q

asthma. Patohology?3

A

Bronchoconstriction and inflammation
Obstructive lung disease
IgE-mast cell mediated

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2
Q

Asthma. clinical presentation?

A

Wheezing from bronchoconstriction.

Shortness of breath.

Cough.

Worsens at night.

Atopy: eczema, seasonal allergies, and food. Response to triggers.

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3
Q

Asthma. diagnosis. ABG?

A

respiratory alkalosis

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4
Q

Asthma.diagnosis. spirometry used for diagnosing asthma in patients 5 years or more. findings?

A

o Decreased FEV1 to FVC ratio,
o Reversible by B agonist.
o Inducible with ach agonists.

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5
Q

Asthma. diagnosis. DLCO?

A

DLCO normal or increased. (vs decreased in COPD).

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6
Q

Asthma. algorithm. Do a PFT –> normal?

A

If normal –> methacholine challenge.
If positive –> asthma.

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7
Q

Asthma. algorithm. Do a PFT –> if OLD?

A

If OLD –> bronchodilator (albuterol) response.
If positive (>12% increase in FEV1) –> asthma.

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8
Q

Asthma. treatment. bronchodilators.

A

SABA (short acting)
LABA (long acting beta agonists)

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9
Q

Asthma. treatment. LABA adverse?

A

● Hypokalemia: muscle weakness, arrhythmias, and ECG changes.
● Tremor.
● Headache.
● Palpitations.

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10
Q

Asthma. treatment. anti-inflammatory. groups?

A

Inhaled corticosteroids.
Leukotriene antagonists - used interchangeably.
Oral corticosteroids.

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11
Q

Asthma. treatment. Inhaled corticosteroids. adverse?

A

● Oral thrush is the most common.
● Leukocytosis due to mobilization of marginated neutrophils, stimulation of release of immature neutrophils from the bone marrow, and inhibition of neutrophil apoptosis.
● Decreased lymphocytes and eosinophils.

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12
Q

Asthma. treatment. mast stabilizers? agents

A

Nedocromil.
Cromolyn.

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13
Q

Asthma severity. Intermitent. how often symtoms/use of SABA?

A

=<2 days a week

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14
Q

Asthma severity.Intermitent. nighttime awakenings?

A

=<2 times a month

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15
Q

Asthma severity. intermittent. what level treatment?

A

step 1

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16
Q

Asthma severity. mild persistent. Intermitent. how often symtoms/use of SABA?

A

> 2 days a week but not daily

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17
Q

Asthma severity. mild persistent. nighttime awakening.

A

3-4 times a month

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18
Q

Asthma severity. mild persistent. what level treatment?

A

Step 2

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19
Q

Asthma severity. moderate persistent. how often symtoms/use of SABA?

A

daily

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20
Q

Asthma severity. moderate persistent. nighttime awakening.

A

> 1 time a week but not nightly

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21
Q

Asthma severity. moderate persistent. what level treatment?

A

Step 3

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22
Q

Asthma severity. severe persistent. how often symtoms/use of SABA?

A

Throughout the day.

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23
Q

Asthma severity. severe persistent. nighttime awakenings.

A

4-7 times a week

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24
Q

Asthma severity. severe persistent. level treatment?

A

Step 4 or 5

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25
Q

Asthma. Step 1?

A

SABA pagal reikala

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26
Q

Asthma. Step 2?

A

Low dose inhaled corticosteroids (ICS)

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27
Q

Asthma. Step 3?

A

Low dose ICS + LABA

OR

medium dose ICS

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28
Q

Asthma. Step 4?

A

Medium dose ICS + LABA

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29
Q

Asthma. Step 5?

A

High dose ICS + LABA

AND

Consider omalizumab for patients with allergies

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30
Q

Asthma. Step 6?

A

High dose ICS + LABA + oral corticosteroid

AND

Consider omalizumab for patients with allergies

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31
Q

Asthma.
New recommendations: ICS for all steps including step 1 (taken as needed).

A

.

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32
Q

Asthma. Intermitent FEV1?

A

80 proc.

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33
Q

Asthma. mild FEV1?

A

80 proc.

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34
Q

Asthma. moderate FEV1?

A

60-80 proc.

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35
Q

Asthma. severe FEV1?

A

60 proc.

36
Q

Asthma.
Theophylline: PDE inhibitor that causes bronchodilation. Use as an alternative
to step 3.

what adverse? toxicity

A

Theophylline toxicity:
● CNS: headache, insomnia, and seizures.
● GI: nausea and vomiting.
● CVS: arrhythmia.

37
Q

Asthma. Refractory asthma treatment?

A

chronic oral steroids.

38
Q

Asthma. if patient is asks for more medications?

A

If someone comes in with need of more medications:
▪ Observe how they use inhaler.
▪ Use of spacer.
▪ Medication adherence.

39
Q

Asthma. Exercise-induced bronchoconstriction, prevention?

A

short-acting beta-adrenergic agonists
such as albuterol, used 10-20 minutes prior to exercise.

40
Q

Asthma. high performance athletes?

A

albuterol plus antileukotriene agent.

41
Q

Asthma. Exercise-induced bronchoconstriction.
Inhaled steroids can be used for those who exercise daily and require pre-treatment with albuterol.

A

.

42
Q

Asthma. Exercise-induced bronchoconstriction.
Montelukast can be used as an alternative to the daily steroids.

A

.

43
Q

Asthma. Exercise-induced bronchoconstriction
Asthma exacerbation –> limit daily activity.

A

.

44
Q

Severe life-threatening asthma.
table. risk factors?

A

Recent poor control (frequency of symptoms, albuterol use)

Frequent hospitalizations, emergency department visits or use of systemic glucocorticoids

prior intubation for asthma

45
Q

Severe life-threatening asthma.
symptoms?

A

RR >30 k/d
Pulse > 120 k/min
SpO2 < 90 proc.
incr. PaCO2 > 45
Peak expiratory flow =< 50 proc. predicted

46
Q

Severe life-threatening asthma.
examination findings?

A

Severe shortness of breath (eg inability to finish sentence or lie supine)

Marked accessory muscle use

Abscent wheezing (due to poor aeration)

Pulsus paradoxus

Mental status changes

47
Q

Severe life-threatening asthma.
5 steps?

A
  1. Give oxygen
  2. nebulizers
  3. IV steroids
  4. you can try epinephrine and MAGNESIUM
  5. Assess PEF rate
48
Q

Severe life-threatening asthma.
Give oxygen –> maintain SpO2 > 90 proc.

A

.

49
Q

Severe life-threatening asthma.
what nebulizers?

A

ipratropium and albuterol

50
Q

Severe life-threatening asthma.
assess PEF rate. 3 scenarios?

A

Get better –> go home (no need O2, no wheeze, PEF > 70 proc.)

Needs more time –> ward (nebulizers and they’ll transition to MDI; IV steroids and they’ll transition to oral prednisone)

Gets worse –> ICU, intubate (PEF < 50 proc.)

51
Q

Respiratory failure in asthma. table. clinical?

A

extreme fatigue, altered mental status, absent/minimal wheezing (poor air entry), cyanosis, chest wall retractions

52
Q

Respiratory failure in asthma. table. lab findings?

A

decr. PaO2 and pH (respiratory acidosis)
incr. CO2

53
Q

Normally in an asthma exacerbation: respiratory alkalosis.

Normal pH and normal or high PaCO2 indicates respiratory muscle fatigue and impending respiratory failure.

A

.

54
Q

Pharma for ACUTE asthma exacerbations

SABA = inhaled albuterol. use?

A

Bronchodilator
Continuous (if severe) or repeated dosing

55
Q

Pharma for ACUTE asthma exacerbations

anticholinergic = inhaled iptratropium bromide use?

A

bronchodilator
repeated dosing only in acute setting and in conjuction with albuterol

56
Q

Pharma for ACUTE asthma exacerbations

glucocorticoid = prednisone, methylprednisolone, dexamethasone (oral/iv) use?

A

anti-inflammatory
delayed effect (6h)
Multiday dosing for control of late-phase inflammation

57
Q

Occupational asthma.
pathogenesis?

A

Antigens –> Inflammation (lgE dependent or Independent) –> reversible bronchoconstriction

Animal proteins (eg, veterinary/laboratory animal workers, seafood processors), grain antigens (eg, bakers, food processors), isocyanates (eg. painters)

58
Q

Occupational asthma. clinical.
Onset?

A

asthmatic symptoms (cough, wheezing, dyspnea) closely linked lo workplace

59
Q

Occupational asthma. clinical.
chronic?

A

symptoms persist throughout workweek, abating after sustained absence

60
Q

Occupational asthma. diagnosis?

A

workplace-specific change in airway physiology (eg, serial PEFR (peak expiratory flow rate)
at home & work, serial sputum eosinophil counts)

61
Q

Occupational asthma. management?

A
  • Antigen avoidance (removal from the workplace preferred) or reduction (eg. management respirator use, rotation scheduling)
  • Bronchodilators & inhaled corticosteroids, desensitization & immunotherapy
62
Q

Occupational asthma. PEF measurement frequency?

A

Serial PEF measurement: 4 times a day for 2 or more weeks.

63
Q

Occupational asthma.

Other diagnostic tactics: in-workplace spirometry, serial methacholine bronchoprovocation testing, and serial sputum eosinophil count.

A

.

64
Q

Asthma treatment is based on the severity of asthma in the patient

A

.

65
Q

Once a patient begins asthma controller therapy (eg, Inhaled corticosteroids) they are evaluated
based on symptomatic assessment of asthma control.

A
66
Q

Patients whose condition remains well controlled on the same therapy for 3 months
should be considered for a step down in medication management, pvz Step 3 –> step 2

A
67
Q

In patients with poorly controlled symptoms, medication therapy should be increased
by 1 or 2 steps, and a short course of oral prednisone should be considered, pvz step 4 -> step 5

A

.

68
Q

Exercise-induced bronchoconstriction (EIB) pathophysiology?

A

Passage of high volumes of dry, cold air –> triggering of mast cell degranulation –> Bronchoconstriction

69
Q

EIB can occur in asthmatic patients but may also cause bronchospasm in those without a preexisting diagnosis of asthma

A

.

70
Q

EIB.

Treatment
a. SABA (eg, albuterol) 10-20 minutes prior to exercise
b. Antileukotriene agent 15-20 minutes prior to exercise - It is used in patients who can’t tolerate beta agonists
c. Inhaled corticosteroids
d. Combination of SABA and antileukotriene agents is used in high-performance athletes

A

.

71
Q

EIB. SABA is first-line treatment if it is required only a few times a week (ie, less than daily). If the
patient exercises daily, use inhaled corticosteroids or antileukotriene agents

A

.

72
Q

Algorithm. Suspected asthma: intermitent resp symptoms (cough, dyspnea, wheezing, chest tightness) –> DO SPIROMETRY –> NORMAL?

A

NORMAL –> do metacholine bronchoprovocation test

73
Q

Algorithm. Suspected asthma.

metacholine bronchoprovocation test –> positive?

A

Asthma possible

74
Q

Algorithm. Suspected asthma.

metacholine bronchoprovocation test –> negative?

A

asthma unlikely (seek alternative diagnosis - eg CHF, PH, vocal cord dysfunction)

75
Q

Algorithm. Suspected asthma: intermitent resp symptoms (cough, dyspnea, wheezing, chest tightness) –> DO SPIROMETRY –> OBSTRUCTION (FEV1/FVC < 70 proc) –> ?

A

Inhale bronchodilator (SABA)

76
Q

Algorithm. Suspected asthma.

Inhale bronchodilator (SABA) –> nonreversible?

A

COPD

77
Q

Algorithm. Suspected asthma.

Inhale bronchodilator (SABA) –> reversible?

A

Asthma confirmed

78
Q

Algorithm. Suspected asthma.
Inhale bronchodilator (SABA) –> reversible.

what is ,,reversible”?

A

at least 12 proc. and 200 ml increase FEV1 or FVC, with postbronchodilator FEV1/FVC rise to >=70 proc.

79
Q

Ventilatory response in asthma exacerbation.

A

During asthma exacerbation, the initial physiologic response is an increase in respiratory drive
and resultant hyperventilation

80
Q

Ventilatory response in asthma exacerbation. what metabolic change?

A

respiratory alkalosis

81
Q

Ventilatory response in asthma exacerbation.

what metabolic shows impending respiratory failure?

A

However, a normal or elevated PaCO2 is an alarming and extremely important finding that suggests impending respiratory failure

82
Q

Ventilatory response in asthma exacerbation.
symptoms (jau dahuja kartoti)

A

i. Markedly decreased breath sounds
ii. Absent wheezing
iii. Decreased mental status
iv. Marked hypoxia with cyanosis

83
Q

Ventilatory response in asthma exacerbation.
management. mild to moderate asthma exacerbation?

A

i. Oxygen
ii. SABA
iii. Systemic corticosteroids (for those who don’t respond to the above-mentioned therapy)

84
Q

Ventilatory response in asthma exacerbation.
management. severe asthma exacerbation?

A

i. SABA
ii. Ipratropium nebulizer
iii. Systemic corticosteroids
iv. One-time IV MgSO4 infusion (indicated for additional bronchodilation if the asthma exacerbation shows no improvement after an hour of therapy)

85
Q

Ventilatory response in asthma exacerbation.
management. Impending or actual respiratory arrest?

A

i. Endotracheal intubation

86
Q

Asthma. Unlike COPD exacerbation, abs are not recommended for asthma exacerbations as viral infections are the most common trigger

A

.

STEP 2 Pulmonary (19 decks)

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