Respiratory: Asthma 1 Flashcards
FENO
Fractional Exhaled Nitric Oxide
SCIT
Subcutaneous Immunotherapy
SLIT
Sublingual Immunotherapy
FEV1
Forced Expiratory Volume in 1 second
FVC
Forced Vital Capacity
PEF
Peak Expiratory Flow
wheezing
High pitched noise usually heard upon exhalation
“Personal best” is used to
monitor patients with asthma to monitor day to day asthma and if its under control
Take peak flow when asthma is under control, and then day to day peak flow is compared to that
EIB can be pre-treated with…
certain bronchodilators
Asthma definiton
characterized by chronic airway inflammation
defined by history of respiratory symptoms such as wheeze, SOB, chest tightness and cough that VARY OVER TIME AND INTENSITY, together with variable expiratory airflow limitation
Asthma Phenotypes
Allergic Non-alergic Adult-onset Asthma w/ persistent airflow limitation Asthma w/ obesity
Host risk factors for Asthma
Innate immunity (Hygiene Hypothesis)
Genetic factors
Age
Sex
Environmental risk factors Asthma
Allergens Pollution Infections Microbes Stress
Other Asthma Risk factors
Ethnicity- AA 2X as likely
Urbanization - living in city
Socioeconomic status - more common in low income
COPD vs Asthma
COPD - neutrophilic inflammation
Asthma - eosinophilic inflammation
Basic concept of Th1/2 cells in Asthma
Born with more Th2, and exposure to germs will cause an increase in Th1 cells
increasing Th2 = increase Asthma/Allergies
Pathophysiology of Asthma
Allergen presented to T cell, causing B cell to be activated.
Activated B cell will make IgE antibody for it, these will go onto mast cells and basophils.
Next time exposed to allergen, IgE antibodies will link on mast cell and cause mediatory release and a Bi-phasic inflammatory response
Eosinophilic Inflammation
Mast cells and Th2 cells release GM-CSF and IL-5.
This leads to differentiation of Eosinophil. These come to lungs and release inflammatory mediators that can cause airway injury
Repeat process of injury = issues
What happens in Asthma?
Bronchoconstriction - within min
Airway edema - over hours/days
Airway hyperresponsiveness - exaggerated bronchoconstrictor response that is present even when asymptomatic due to chronic inflammation
Airway remodeling - long term due to inflammation
Feno >50 or >35 (kids 5-12) is indicative of…
asthma and T2 inflammation
SABA info
Therapy of choice prior to exercise to prevent EIB
Albuterol preferred in pregnancy
Preferred rescue inhaler pts not on ICS/Formoterol
GINA doesn’t recommend SABA only therapy = inc mortality
SAMA info
longest onset of action to SABA
Alternative for pt who don’t tolerate SABA
Additive benefit to SABA in exacerbations in the ED setting
Preferred therapy for Asthma
ICS/ Formoterol
Budesonide/Formoterol (Symbicort)
Max ICS/Formoterol doses
8 puffs (36 mcg children) 12 puffs (54 mcg adults)
Systemic Corticosteroids
Prednisone
increased side effects compared to ICS
for moderate/severe asthma exacerbations
long term prevention of symptoms in severe, persistent, difficult to control asthma
Systemic corticosteroids are…
primarily used for treatment of asthma exacerbations and not as maintenance therapy in asthma
SAMA have benefit in the….
ED when used in conjunction with SABA during exacerbation
ICS/Formoterol combo can be used as…
maintenance and reliever inhaler in patients on ICS/Formoterol (only**)
Which Long-acting Bronchodilator is added first? Asthma
LABA - Salmeterol
1st line add-on therapy to ICS/Formoterol therapy
adding LABA = can decrease ICS dose
** cant use in ppl < 4 yrs old **
LAMA usage
Tiotropium
improvements in exacerbation rate when used in addition to ICS/LABA
preferred add on to ICS/LABA in Step 5 for >12 yrs old
Methylxanthine usage
Theophylline - usually used COPD
not recommended for ASTHMA, but alternate add-on therapy w/ ICS for NHLBI guidelines
ICS info
- most effective long term therapy for asthma
Budesonide preferred treatment in…
asthma in pregnant women
Beclomethasone is preferred treatment in….
pts with CYP3A4 inhibitor drugs… HIV therapy
Cromolyn Sodium info
Mast cell stabilizers
not recommended for routine use, weak efficacy
Leukotriene Modifiers info
less effective than ICS therapy
option for pts w/ co-morbid allergic rhinitis, ASA sensitive or EIB
Blackbox for neuropsychiatric risks
Macrolides info
Azithromycin
potential add on therapy in severe, difficult to control asthma despite moderate-high dose ICS/LABA
have to do risk/benefits
ICS/LABA info
- reduces use of SABA for quick relief
- Allows for lower doses of ICS, reducing risk of adverse effects
- More effective than ICS/LTRA combo
- preferred maintenance therapy for majority of steps in ages >4, + SABA PRN
BADGER trial
comparing ICS vs ICS/LABA vs ICS/LTRA
showed that patients did best on ICS/LABA
Benefits of biologic therapy in asthma
reduce exacerbations
improve symptoms/quality of life
decrease corticosteroids requirements
Biologics will be used as…
add on therapy
when on high ICS/LABA and uncontrolled and have TH2 based inflammation
Step 1: 1-5 yrs old
Intermittent/episodic wheezing
SABA q4-6h PRN until symptoms resolve
Step 2: 1-5yrs old
Preferred controller choice: Daily dose ICS
Other options: LTRA or short courses of ICS at onset
Reliever: SABA
Step 3: 1-5yrs old
Preferred controller therapy: Double “low dose” ICS
Other options: Low dose ICS + LTRA
Reliever: SABA
Step 4: 1-5yrs old
Preferred:Continue controller and refer for specialist assessment
Other option: Add LTRA, increase ICS freq, or add intermittent ICS
Step 4: 6-11 yrs old
Medium dose ICS-LABA or low dose MART
refer for expert advice
Step 3: 6-11 yrs old
Low dose ICS-LABA or medium dose ICS or very low dose MART
Step 2: 6-11 yrs old
Daily low dose ICS
Step 1: 6-11yrs old
Take ICS whenever SABA taken
Step4: >12yrs old
Track 1 (preferred): Medium dose ICS-formoterol maintenance and reliever (MART)
Track 2: Medium/high dose ICS-LABA + as needed SABA
When to use track 1 vs track 2
if think they will be adherent than track 2 is okay.
if don’t think they will be adherent better to do track 1 (preferred), less inhalers to worry about
Track 1 reliever: ICS-formoterol
Track 2 reliever: SABA
Step 3: >12 yrs old
Track 1: Low dose ICS-formoterol maintenance and reliever (MART)
Track 2: Low dose ICS-LABA + prn SABA
Step 2: >12 yrs old
Track 1: As needed low dose ICS-formoterol
Track 2: Low dose ICS + prn SABA
Step 1: >12 yrs old
Track 1: As needed low dose ICS-formoterol
Track 2: Take low dose ICS whenever SABA is taken
Step 5: >12 yrs old
Track 1: Add on LAMA, refer for phenotypic assessment
Consider high dose ICS-Formoterol
Track 2: Add on LAMA,refer for phenotypic assessment
Consider high dose ICS-LABA
What is MART therapy?
ICS-formoterol maintenance and reliever
