Pulm-Asthma Flashcards
Pathophys of allergic asthma
Mast cell degranulation and initiation of the inflammatory cascade with the Th-2 response, release of histamine and interleukins
Pathophys of nonallergic asthma
Epithelial stimulation and initiation of inflammation can occur with viral or bacterial infections or exposure to noxious chemicals
Symptoms of asthma
Episodes of coughing, chest tightness, SOB, and wheezing. Cough may be spastic and dry or productive of mucus.
How is COPD on differential for asthma? How tell difference?
Airway obstruction is less reversible, typically seen in older patients with a smoking history
How is vocal cord dysfunction on differential for asthma? How to tell the difference?
Abrupt onset and end of symptoms; monophonic wheeze; most common in younger patients; confirm with laryngoscopy or flow-volume loop
How is allergic bronchopulmonary aspergillosis like asthma? How tell difference?
Recurrent infiltrates on chest radiograph; eosinophilia; positive skin testing to Aspergillus antigens, high IgE levels, positive to Aspergillus; frequent need for glucocorticoid treatments
How is mechanical obstruction like asthma? How tell difference?
More localized wheezing; if central in location, flow volume loop may provide a clue
How is Churg-Strauss like asthma? How tell difference
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
How is asthma diagnosed with testing? What is the first step?
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)
What are the different types of asthma? How to treat each?
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
Treatment of ABPA
systemic glucocorticoids, inhaled glucocorticoids; may try anti fungal therapy such as fluconazole and anti-IgE therapy (omalizumab)
What is the anti-IgE monoclonal Ab
omalizumab
What are non-asthma mimics of asthma?
GERD, vocal cord dysfunction, post-nasal drip, OSA, vocal cord dysfunction, obesity
Describe the symptoms of vocal cord dysfunction
**HY
(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
Gold standard for the diagnosis of vocal cord dysfunction?
Adduction of vocal cords on laryngoscope
What does the flow-volume loop of vocal cord dysfunction look like when symptomatic?
Look up. There is a flat inspiration curve.
What are some SABAs?
albuterol, salbutamol
What are some anticholinergics?
ipratropium –less effective than beta-agonists, short acting agent can be used as adjunctive quick-relief
When is asthma considered persistent?
When symptoms happen more than twice per week or more than one night per week
What is the mainstay treatment for persistent asthma?
Inhaled glucocorticoids
When is a LABA used in persistent asthma?
If inhaled glucorticoids aren’t working, then add a LABA as this has been proven to be effective for step-up therapy
Name some LABAs
Salmeterol, formoterol
What if inhaled glucocorticoids and LABA not enough?
Add leukotriene receptor antagonists: LTRAs like tiotropium
What do you do following inhaled glucocorticoid, LABA, LRTA?
oral glucocorticoids
Why not use theophylline any more?
Toxicity!
What happens if patients are refractory to short courses of oral glucocorticoids and are on inhaled glucocorticoid, LABA, LRTA?
Chronic oral steroids, then Omalizumab
What is the monoclonal antibody used for severe refractory asthma?
Omalizumab
What can be used for the treatment of refractory ABPA?
Omalizumab!
What has omalizumab been shown to do?
***HY
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
Intermittent asthma:
- symptoms
- nighttime awakenings
- SABA use
- interference with normal activity
- lung function
-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
Mild asthma:
- symptoms
- nighttime awakenings
- SABA use
- interference with normal activity
- lung function
- 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
Moderate asthma:
- symptoms
- nighttime awakenings
- SABA use
- interference with normal activity
- lung function
- 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%
Severe asthma:
- symptoms
- nighttime awakenings
- SABA use
- interference with normal activity
- lung function
- 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%
Step Treatment for Intermittent Asthma
Step 1: SABA PRN
Step Treatment for Mild Asthma
Step 2: Low dose inhaled GC
Step Treatment for Moderate Asthma
Step 3: Low dose inhaled GC + LABA; OR medium-dose inhaled GC…. may need a short course of systemic GC
Step Treatment for Severe Asthma
Step 4 or 5: Medium dose inhaled GC+LABA; OR high -dose inhaled GC + LABA; consider short courses of GCs
When can you step down on therapy?
asthma is well controlled at least 3 months
What increases the risk for a poor outcome in asthma exacerbation?
frequency of ED visits, need for intubation in the past, high work of breathing
How do you treat pregnant women with asthma?
inhaled glucocorticoids! Budesonide is also okay .Most LTRAs are also ok.
