Pulm-Asthma Flashcards

1
Q

Pathophys of allergic asthma

A

Mast cell degranulation and initiation of the inflammatory cascade with the Th-2 response, release of histamine and interleukins

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2
Q

Pathophys of nonallergic asthma

A

Epithelial stimulation and initiation of inflammation can occur with viral or bacterial infections or exposure to noxious chemicals

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3
Q

Symptoms of asthma

A

Episodes of coughing, chest tightness, SOB, and wheezing. Cough may be spastic and dry or productive of mucus.

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4
Q

How is COPD on differential for asthma? How tell difference?

A

Airway obstruction is less reversible, typically seen in older patients with a smoking history

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5
Q

How is vocal cord dysfunction on differential for asthma? How to tell the difference?

A

Abrupt onset and end of symptoms; monophonic wheeze; most common in younger patients; confirm with laryngoscopy or flow-volume loop

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6
Q

How is allergic bronchopulmonary aspergillosis like asthma? How tell difference?

A

Recurrent infiltrates on chest radiograph; eosinophilia; positive skin testing to Aspergillus antigens, high IgE levels, positive to Aspergillus; frequent need for glucocorticoid treatments

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7
Q

How is mechanical obstruction like asthma? How tell difference?

A

More localized wheezing; if central in location, flow volume loop may provide a clue

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8
Q

How is Churg-Strauss like asthma? How tell difference

A

Churg strauss is eosinophilic granulomatosis with polyangiitis. It is an autoimmune small-vessel vasculitis that presents with a PERIPHERAL eosinophilia, lung symptoms similar to asthma; skin changes such as purpura and sensory or motor neuropathy, +ANCA, usually p-ANCA

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9
Q

How is asthma diagnosed with testing? What is the first step?

A

The first step is spirometry to assess for obstruction as indicated by a REDUCED FEV1/FVC ratio and its reversibility (with a 12% or greater improvement in FEV1 after administration of a bronchodilator)

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10
Q

What are the different types of asthma? How to treat each?

A

Allergic asthma: avoid trigger, step up/down, treat allergy

Cough-variant asthma-same as guideline based therapy for asthma

Exercise-induced bronchospasm-beta2 agonist 5-20 min before exercise

Occupational asthma-guidelines and avoid allergy triggers if able

ASA sensitive asthma-avoid ASA or NSAIDS with guidelines asthma management

Reactive airways dysfunction syndrome-guidelines, avoid irritan

Virus-induced bronchospasm-step-up, guidelines

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11
Q

Treatment of ABPA

A

systemic glucocorticoids, inhaled glucocorticoids; may try anti fungal therapy such as fluconazole and anti-IgE therapy (omalizumab)

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12
Q

What is the anti-IgE monoclonal Ab

A

omalizumab

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13
Q

What are non-asthma mimics of asthma?

A

GERD, vocal cord dysfunction, post-nasal drip, OSA, vocal cord dysfunction, obesity

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14
Q

Describe the symptoms of vocal cord dysfunction

**HY

A

(1) mid chest tightness when exposed to triggers
(2) difficulty with breathing in
(3) partial response to asthma medications

*Often misdiagnosed as severe asthma and ppl get intubated

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15
Q

Gold standard for the diagnosis of vocal cord dysfunction?

A

Adduction of vocal cords on laryngoscope

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16
Q

What does the flow-volume loop of vocal cord dysfunction look like when symptomatic?

A

Look up. There is a flat inspiration curve.

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17
Q

What are some SABAs?

A

albuterol, salbutamol

18
Q

What are some anticholinergics?

A

ipratropium –less effective than beta-agonists, short acting agent can be used as adjunctive quick-relief

19
Q

When is asthma considered persistent?

A

When symptoms happen more than twice per week or more than one night per week

20
Q

What is the mainstay treatment for persistent asthma?

A

Inhaled glucocorticoids

21
Q

When is a LABA used in persistent asthma?

A

If inhaled glucorticoids aren’t working, then add a LABA as this has been proven to be effective for step-up therapy

22
Q

Name some LABAs

A

Salmeterol, formoterol

23
Q

What if inhaled glucocorticoids and LABA not enough?

A

Add leukotriene receptor antagonists: LTRAs like tiotropium

24
Q

What do you do following inhaled glucocorticoid, LABA, LRTA?

A

oral glucocorticoids

25
Q

Why not use theophylline any more?

A

Toxicity!

26
Q

What happens if patients are refractory to short courses of oral glucocorticoids and are on inhaled glucocorticoid, LABA, LRTA?

A

Chronic oral steroids, then Omalizumab

27
Q

What is the monoclonal antibody used for severe refractory asthma?

A

Omalizumab

28
Q

What can be used for the treatment of refractory ABPA?

A

Omalizumab!

29
Q

What has omalizumab been shown to do?

***HY

A

Reduce ED visits and is cost effective in:
(1) symptoms inadequately controlled with inhaled glucocorticoids; (2) allergies to perennial aeroallergens; (2) serum IgE levels high

30
Q

Intermittent asthma:

  • symptoms
  • nighttime awakenings
  • SABA use
  • interference with normal activity
  • lung function
A

-symptoms: < or equal to 2 days/week
-nighttime awakenings: <2x per month
-SABA use: <2 days per week
-interference with normal activity: None
-lung function: Normal FEV 1 between exacerbations, FEV1 > 80% predicted
FEV1/FVC normal

31
Q

Mild asthma:

  • symptoms
  • nighttime awakenings
  • SABA use
  • interference with normal activity
  • lung function
A
  • symptoms: >2 days per week
  • nighttime awakenings: <2x per month
  • SABA use: <2 days per week
  • interference with normal activity: minor limitation
  • lung function: FEV1 >80% of predicted, FEV2/FVC normal
32
Q

Moderate asthma:

  • symptoms
  • nighttime awakenings
  • SABA use
  • interference with normal activity
  • lung function
A
  • symptoms: Daily
  • nighttime awakenings: >1x per week but not nightly
  • SABA use: daily
  • interference with normal activity: some limitation
  • lung function: FEV1 > 60% but <80% of predicted, FEV1/FVC reduced <5%
33
Q

Severe asthma:

  • symptoms
  • nighttime awakenings
  • SABA use
  • interference with normal activity
  • lung function
A
  • symptoms: throughout the day
  • nighttime awakenings: often 7x per week
  • SABA use: several times a day
  • interference with normal activity: extremely limited
  • lung function: FEV1<60% of predicted, FEV1/FVC reduced >5%
34
Q

Step Treatment for Intermittent Asthma

A

Step 1: SABA PRN

35
Q

Step Treatment for Mild Asthma

A

Step 2: Low dose inhaled GC

36
Q

Step Treatment for Moderate Asthma

A

Step 3: Low dose inhaled GC + LABA; OR medium-dose inhaled GC…. may need a short course of systemic GC

37
Q

Step Treatment for Severe Asthma

A

Step 4 or 5: Medium dose inhaled GC+LABA; OR high -dose inhaled GC + LABA; consider short courses of GCs

38
Q

When can you step down on therapy?

A

asthma is well controlled at least 3 months

39
Q

What increases the risk for a poor outcome in asthma exacerbation?

A

frequency of ED visits, need for intubation in the past, high work of breathing

40
Q

How do you treat pregnant women with asthma?

A

inhaled glucocorticoids! Budesonide is also okay .Most LTRAs are also ok.