PULMO-Asthma Flashcards
Asthma
narrowing (obstruction/reacive) of bronchial airways
bronchoconstricat, hyperreactive= dyspna
reversible
Prevlaance
8-11% us population
1/2 chidren. Inc AA- leave in polluted city, mold, old buildings, fast food, stressful, close prox,
<10y male to female 2:1
>10y female to male 2:1
Risk factors
Rarely truth behind growing out of ashtma
many adults have asthma excbaeration w/ illness
Smoking parents
Work place bacteria
Extrinsic Atopic Asthma
Pt response to IgE antibody. inc IGE Atopy= common triad of eczema, allergy, asthma FH age <30y Seasonal sx Males
Intrinsic
No Atopy No triggers Asthma w/ URI Older age onset No FH *Normal serum IgE No repsponse to bronci changes *less respons to therapy persistent and progressive
Pahtophysiology
Breathing throough a straw c/c
Narrowing of airway
Inflammotory-mast cells, baophil eosnphils, reacte and, vessels enlarge, mucus produce w/ WBC, narrow
Inc. resisetance
Aireway edema
Pt breath at high volume to keep airway open, hyperinflation
Bronchoconstriction
Exercise Allergens Pollutants URI Aerosols GERD Food persever-sulfates Aspirin, NSaids Dry, cold air
Pathophysiology
Inflammatory mediators:
cause bronchial smooth muscle contraction resulting in airway edema, inflammation and narrowing
increase mucus production- edema and mucus plugging leads to narrowing of peripheral airways causing increased resistance to inspiratory and expiratory air flow and trapping of air
patient must breathe at high volumes to keep the airway open, causing hyperinflation
What is the Dx of a patient who has episodic bronchoconstriction that follows exercise?
Exercise Induced Bronchoconstriction (EIB)
Intermittent paroxysms of cough
chest tightness
wheezing
dyspnea
Cough variant asthma
May or may not report associated provoking factors
slowly progressive over a period of hours or days
Describe a patient with Asthma: Clinical Characteristics
Cough variant asthma
cough may be sole presenting sx of asthma, in pts with or without h/o asthma;
may progress to include wheezing, SOB;
must be considered in pts with subacute or chronic cough
Describe Asthma Physical Exam
Tachypnea
Tachycardia
SOB
diffuse inspiratory and/or expiratory wheezes
Use of accessory muscles
Hyperinflation,
HYPER-resonance
Position helps indicate severity
mild – supine
moderate – sitting
severe – tripod
Between exacerbations PE should be normal
Look for evidence of triggers (allergic rhinitis, URI, sinusitis)
WBCs maybe elevated d/t: prednisone, infection, received epinephrine, or stress
ASX-lab normal – may have elevated serum IgE with atopic disease
Eosinophilia: useful in diagnosing asthma in NEW onset wheezing reversible by β-2 agonists
Pulse oximetry: baseline & measure desaturation with exertion; acute exacerbations
Peak Expiratory Flow Rate (PEFR) -Baseline gives indication of severity, or control of asthma
document response to tx
Maximal flow rate achieved in the FVC
Describe Diagnostics of Asthma Pt
diffusing capacity of the lungs for carbon monoxide; measures ability of lungs to transfer gas from inhaled air to RBC in pulmonary capillaries; helps narrow ddx of lung disease
Quantitation of diffusing capacity of CO (DLCO
Forced Vital Capacity: FVC
Volume of gas that can be forcefully expelled from the lungs after maximal inspiration
Spirometry
FEV1
Volume expelled in the first second of the FVC
Forced Expiratory Volume:
TLC
Volume of gas in lungs after a maximal inspiration
:RV
Volume remaining after maximal expiration
Total Lung Capacity:
Residual Volume
Spirometry Results
RAD- all low, except TLC normal and Vol N
Narrow curver
Obstrucive- wider curve
Performed in PFT laboratory
Inhaled methacholine MC stimulus - histamine, mannitol
Indicated in patients with unusual presentation (cough variant asthma, EIB) of asthma or unclear diagnosis
What is used for a Bronchoprovocation Test?
Pts EIB without documented asthma, adult onset
Treadmill exercise to raise HR 85% of predicted max, look for fall in FEV1 of 10-15% = dx EIB
Measured at 2.5, 5, 10, 15, 30 mins after exercise, correlate with symptoms
Alternatively do bronchoprovocation test
Exercise Testing
Normal or hyperinflation-uncommon
Pt w/ asthma presentatino and feibril, R/O pneumonia
Pt w/ pleuritic chest pain or subcutaneous emphysema, r/o pneumothorax or pneumomediastinum
Sinus CT may be useful to r/o sinusitis
CXR
Classification of Asthma Severity
Step 1: Intermittent
Sx <2 days/wk
Night wakes <2x/mo
SABA use <2 days/wk
No interferece w/ acivity
PFT- Normal FEV1
FEV1 >80 predicted
FEV1/FVC normal
Step 2: Mild Persistent
Sx >2 days/wk
Night wakes 3-4x/mo
SABA use >2 days/wk
Minor interference w/ acivity
FEV1 >_80 percent predicted
FEV1/FVC normal
Step 3: Mod Persistent
Sx Daily
Night wakes >1x/wk
SABA use Daily
some limits interference w/ activity
FEV1 >60 but <80 percent predicted
FEV1/FVC reduced 5%
Step 4: Severe Persistent
Sx throughtout day
Night wakes >7x/wk
SABA use several times/day
extremely limited interference w/ activity
FEV1 >_60, <80 percent predicted
FEV1/FVCr educed 5%
Short term vs long term management
Rescue vs controller medications
Supplemental O2 if pulse oximetry < 93%
Cardiac monitoring in acutely ill patients
Management
Stepwise approach
LABA- Salmeterol, formoterol recommended only as add-on therapy to inhaled corticosteroids as controller medications
Smooth muscle relaxant
short term treatment
Blocks muscular contraction
Increases ciliary motion
Decreases mediator release from basophils and mast cells
ADR-tremor, tachycardia, headache
#1 SABA-Albuterol, levalbuterol exacerbations of asthma, EIB Oral inc. ADR
β-adrenergic (β2) Agonists
SABA
Components of Controls
Well
Sx- <2d/wk Night wakes <2x/mo Activity- none SABE use- <2d/wk FEV1 or PF> 80/personal best Questionnaires- 0, 20
Components of Controls
NotWell
Sx- >2d/wk Night wakes 1-3x/mo Activity- some limits SABE use- >2d/wk FEV1 or PF 60- 80/personal best Questionnaires- 2, 19
Components of Controls
Poor
Sx- thorughout day Night wakes >4x/mo Activity- extremely limit SABE use- several /day FEV1 or PF <60/personal best Questionnaires- 4, 15
PS ActylCholinergic receptor blockade promotes bronchodilation by removing tonic vagal input to the smooth muscle of the airway
ipratropium bromide (Atrovent): less side effects; added therapeutic effect when combined with LABA
Atropine: effective anticholinergic but numerous side effects (HA, flushing, palpitations, delerium)
Anti-Cholinergic Agents
LAMA
Anti-inflammatory therapy
Topical local effect while minimizing systemic
Indicated Systemic steroids
Frequent ER visits
Hx of admissions for recurrent asthma exacerbations
Hx of intubation for acute asthma
Currently on inhaled steroids
Experiencing symptoms > 3 days per week- continue
INhaled Corticosteroids
Long term controller
oral
Anti-inflammatory and bronchodilatory effects by blocking leukotrienes in bronchial smooth muscle cells, macrophages, and eosinophils
allergic disease
70% +
30% -
Montelukast and Zafirlukast
Leukotriene Receptor Antagonists
frightened and fatigued
pattern deep and slow with progression to rapid shallow breathing; expiratory grunting heralds the onset of respiratory failure
Coughing is ineffective
Absent breath sounds in one hemithorax with wheezing in another suggests possible pneumothorax
Emergency Management
Step up if needed But considere resources enviroment, comorbid Adhereance Step down-only if well controlled 3mo.
SABA PRN
Stepwise RX
Step 1
Intermintent Mild
Stepwise RX
Step 2
Mild Mod
Low dose ICS
Alt- LTRA, Nedocciman
Stepwise RX
Step 3
Mod
Low dose ICS + LABA
or Med dose ICS
or
Low dose ICS + LTRA, Zileuton
Stepwise RX
Step 4
Mod- Severe
Med. dose ICS + LABA
or Med dose ICS
or
Med dose ICS + LTRA Like Zileuton (less diserabel
Stepwise RX
Step 5
High dose ICS + LABA AND Ige Omalizumab (w/ Allergies need EPI
Stepwise RX
Step 6
1stHigh dose ICS + LABA+ (Oral steroid, if needed) AND Ige Omalizumab (w/ Allergies
Arterial blood gas
O2 treatment for POx < 90% after tx (hypoxia)
acute asthma-hypoxemia; arterial pO2 < 80 (ideal 95)
dec CO2 hypocapneic as a result of reflex hyperventilation (breathing in bag bc inhale CO2 back in)
ABG in moderately ill pt: pO2=67 pCO2=32 pH =7.47 Severe asthma: hypoxemia worsens and pCO2 increases
Hypoxia and Hypoxemia
WHAT IS A NORMAL ABG?
HYPOXIA (O2 sat) VS HYPOXEMIA (ABG)
pH 7.35-7.45,
PaO2 80-100
PaCO2 35-45
Allergen Avoidance
Refer pts for allergy testing if indicated
H/o eczema, allergic rhinitis
Asthma occurs seasonally, assoc with specific exposures
Patient notes improvement in different locations
Asthma not well controlled, especially children
Pollens, molds, fungi, dust – common allergens,
educate pts
Cats/animals: avoid in the home, especially on bedding and clothing
Smoke: discourage smoking and second-hand smoke exposure, wood burning stoves
Serum eosinophils/IgE elevate
Annual influenza vaccine
Tdap vaccine:
1st dose at 11-12 yrs
Every pregnancy 27-36
one booster in adulthood
Zoster vaccine (>60 yrs)
Prevention: Vaccines in Asthma
Adults who smoke or have chronic lung disease: 1 dose PPSV23
•Give 1 dose of PPSV23 to all adults 65 years or older at least 1 year after any prior PCV13 dose and at least 5 years after any prior PPSV23 dose.
◦Adults who received one or two doses of PPSV23 before age 65 should receive one final dose of the vaccine at age 65 or older.
Pneumococcal vaccines