Respiratory (Asthma/COPD) Flashcards
What is Tidal Volume
Air exhaled during normal respiration
What is inspiratory reserve volume
Maximum air inhaled above TV
What is expiratory reserve volume
Maximum air exhaled below the tidal volume
What is residual; volume
Volume of air remaining the in lungs after maximal expiration
What sum equates to the total lung capactiy
Tidal volume. inspiratory reserve volume, expiratory reserve volume, residual volume
What is the airflow measure FEV1
Patient inspires to Total lung capacity and exhales maximally.
This value is the volume of air exhaled in the first second FEV1
What is the FEV1/FVC ratio
This helps to differentiate the restrictive from obstructive lung disease (Its a percent of the total air that an individual can breath out from TLC)
What is FVC or forced vital capacity?
Total volume of air expired as rapidly as possible from TLC
What are the 3 main Pulmonary function tests?
Spirometry
Peak Expiratory Flow Meter
Carbon monoxide diffusing capacity (DLCO)
What is the best tool we have for testing lung funciton/
Spirometry
What are the results compared to for spirometry for asthma
Predicted normals OR
Patients Personal Best
What indices are measured during a spirometry test?
FVC
FEV1
FEV1/FVC ratio
What contraindicates exist with spirometry
Intracranial or intraocular pressure
Increase in intrathoracic and intra abdominal pressure
Increases in myocardial demand or changes in BP
Risk of Infection
What happens to the FEV1/FEVC ratio in obstructive lung disease
FEV1 is decreased as well FVC is also decreased, but not as much. Hence, the FEV1/FEVC ratio is decreased
What happens to the FEV1/FEVC ratio during restrictive lung disease?
The ratio either increases or remains the same
What are pulmonary function tests?
They are generally tests used to determine the effects of an inhaled 2 agonist or similar therapy.
What is the considered reversibility in FEV1?
12% (Usually >0.2L)
What is Peak Expiratory Flow Rate?
This is usually a patient device that i used for self monitoring and use a comparison against personal bests or predicted values
What is the carbon monoxide diffusing capacity used to measure?
Generally medication side effects
How do we interpret Acid-Base Disturbances (5 steps)
Check the pH
Determine the primary cause of the disturbance
- Check the PaCO2
- Check the Bicarbonate
Check for compensation/correction
Calculate the Anion Gap (AG)
Check PaO2 and O2S
What is the formula for Anion Gap
AG= Na+ - (Cl + HCO3)
Normal range 3-11 mmol/L
What is the range for normal physiological pH
7.35-7.45 (7.40)
What is the normal paO2
90-100mmhg
What is the normal PaCO2
35-45 mmHg
What is the normal HCO-
22-26mmol/L
In respiratory acidosis what happens to the PH, HCO3, PaCO2, Compensation
Decrease Ph, Normal HCO3, Increase PaCO2, Increased HCO3
In Respiratory alkalosis what happens to the PH, HCO3, PaCO2, Compensation
Increased Ph, Normal HCO3, Decreased PaCO2, Decreased HCO3
In Metabolic acidosis what happens to the PH, HCO3, PaCO2, Compensation
Decrease Ph, Decreased HCO3, Normal PaCO2, Decreased PaCO2
In Metabolic Alkalosis what happens to the PH, HCO3, PaCO2, Compensation
Increased Ph, Increased HCO3, Normal PaCO2, Increased PaCO2
What is the general Etiology of asthma?
Genetics
Sex (Male over female childhood)
Females in later life
Obesity
What is atopic asthma?
Allergy to antigens
Offending allergens are suspended in the air
1/2 children and young adults
What is non-atopic asthma
Secondary to chronic/recurrent infections
Hypersensitivity to bacterial/viruses
What is Type 2 Asthma
(Atopy)
Early onset allergic
Later onset eosinophillic asthma
Excersize induced asthma
Type 1 Asthma?
(Non-Atopic)
Obestiy
Late onset
Smoking related
Comorbidities
What is the adult criteria for asthma?
FEV1/FVC ratio <75-80%
Where it improves 12% and 0.2L imporvement post SABA or Beta 2 quick acting agonist
What are we looking for post treatment with a SABA for indicating asthma?
We are looking for an increase in FEV1 after a bronchodilator or after course of controller therapy
What are the number of daytime symptoms deemed acceptable for asthma control?
<2 days/week
What is the definition of controlled asthma for the need for a reliever (SAB or BUD/FORM)
<2 doses per week
What is the primary reliever medication that is utilized?
SABA (Shorta acting beta adrenergic agonists)
What are the main SABA therapies?
Salbutamol
Terbutaline sulfate
What are the main LABA therapies?
Sameterol (Partial agonist)
Formoterol (Full agonist)
(Vilanterol +Fluticasone)
(Indacterol+ mometasone)
What is central to all pathogenesis of asthma?
Chronic Inflammation is central with ICS as the most effective anti-inflammatory management
What are some examples of ICS? (6)
Fluticasone Proprionate
Fluticasone Furoate
Budesonide
Ciclesonide
Beclomethasone
Mometasone
S/E of ICS
Dysphonia/throat irritation
URTI increase
Candidal oral infections
Growth retardation in kids
What is the only available Leuokotriene Receptor antagonist?
Montelukast
What are the side effects asociated with LRA?
Usually none it just must be taken regularly and do not abruptly substitute for inahled or oral steroid
Who are LTRA therapy for?
Usually used for individuals who have suboptimal adherence to inhaled steroid or do not want to use an inhaled steroid
What are the general combination products for asthma treatment?
This would be our LABA and ICS
What are the 5 inhaled ICS and LABA combination products that we discussed in class?
Salmeterol+ Fluticasone (Advair)
Formoterol+ Budesonide (symbicort)
Formoterol + mometasone (Zenhale)
Vilanterol+Fluticasone (Breo)
Indacaterol+mometasone (Atectura)
What is special about symbicort?
Symbicort is the combination product of formoterol and budesonide. (LABA + ICS) which can be used too as a resucue inhaler as opposed to using the SABA
SMART
What are methylxanthines?
These are an add on in patients therapy who already require high dose CS.
Reserved for severe asthma
Requires consistent monitoring
What is Omalizumab?
This is a S/C injection that is an anti- IgE antibody, hence reducing inflammation
What are the current IL-5 inhibitors in the market?
Mepolizumab (Which is approved for asthma coverage in sask)
What are some other therapies for severe asthma?
Tiotropium (LABA) and chronic use of macrolides
What is considered overuse of SABA according to current guidelines?
2 inhalers of SABA in a year
What is conisdered higher risk for an exacerbation is defined by (4)
History of severe asthma exacerbation
Poorly controlled asthma as per CTS
Overuse of SABA
Current smoker
What is considered a severe asthma exacerbation?
Requires systemic steroid
an ED visit
Hospitalization
What is considered a mild exacerbation?
an increase in asthma symptoms from baseline that does not require ED visit or hospitalizaton
What is the severity classification treatment for very mild asthma? (Therapy)
PRN SABA only (Salbutamol or Terbutaline sulfate)
What is severity classification treatment for mild asthma (Therapy)
SABA and ICS
if >12 they can use Symbicort PRN
What is the severity classification for moderate controlled asthma (What therapy?)
Low dose ICS + second controller (LTA possibly) +prn SABA
OR
Moderate dose of ICS +- second controller medication and SABA prn
OR
Low moderate dose of Bud/form +prn bud/form
How often should asthma be reviewd?
1-3 months after treatment started, then 3-12 months post
How often during pregnancy should asthma be reviewed?
4-6 weeks
What is a Peak expiratory flow meter used for?
Used in patients to monitor and measure their symptoms
Daily preventive management strategies
How long after an exacerbation should asthma be reviewed?
Within 1 week
When would we consider stepping up therapy for astham?
sustained step up for at least 2-3 months if asthma is poorly controlled
Short term for 1-2 weeks (Infection)
What is short term step up?
When we increase therapy due to things like infections or increased presence of allergen
What is sustained step-up?
When asthma is poorly controlled we will increase therapy for 2-3 months
When should we consider stepping down therapy?
Only considered if >3 months of control and the goal is to find the lowest effective dose
What steps/ general principles should be employed for stepping down controller treatment?
Record the level of symptom control and consider risk factors
Make sure patient has a written asthma action plan
Book a follow up appointment
What can occur during ASA/NSAID induced asthma?
Chronic rhinitis, chronic nasal congestion
Inflammation in lower airway
Acute sensitization ot NSAIDS
What is a Peak expiratory flow meter used for?
Used in patients to monitor and measure their symptoms
Daily preventive management strategies
What medications should we avoid in patients with a severe asthma exacerbation?
Sedatives and hypnotics
What is the treatment of acute severe asthma? (4)
SABA or Short Acting Anticholinergic agent every 20 minutes for 4-6 doses
Corticosteroids PO to improve symptoms within 2 hours. 7-10 day course
Oxygen
Maybe magnesium
What is the peak expiratory flow for a mild to moderate exacerbation?
> 60% from person (PEF)
What PEF should someone be admitted to hospital?
<60% personal best and is Deteriorating
What are some none pharmacological asthma treatments we can utilize?
Scarf/Mask
Enhanced level of physical fitness
In respiratory acidosis Ph ___ while paCO2 ___. In compensation HCO3 will ___
Decrease, Increase, Increase
What can occur during ASA/NSAID induced asthma?
Chronic rhinitis, chronic nasal congestion
Inflammation in lower airway
Acute sensitization ot NSAIDS
What is the management for ASA/NSAID induced asthma?
Leuokotriene antagonists
Low dose acetaminophen as tolerated
Why are Beta blockers not generally warranted for asthamtics
Decreased response of beta agonists
Increased airway hyper responsiveness
Is asthma control in pregnancy safe?
Yes. Basic therapies, with little evidence though for newer biologics
What can uncontrolled asthma in pregnancy lead to?
Premature birth
Low birth weight
Maternal blood pressure changes
What is Pulse Oximetry?
Utilizes light absorptive characteristics of hemoglobin to determin oxygenation levels
In respiratory acidosis Ph ___ while paCO2 ___. In compensation HCO3 will ___
Decrease, Increase, Increase
In respiratory alkylosis Ph ___ while paCO2 ___. In compensation HCO3 will ___
Increase, Decrease, Decrease
In Metabolic acidosis Ph ___ while HCO3 ___. In compensation PaCO2 will ___
Decrease, Decrease, Decrease
In Metabolic Alkylosis Ph ___ while HCO3 ___. In compensation PaCO2 will ___
Increase Increase Increase
What are endogenous stimuli for asthma triggers?
Generated inside the body
Caused by stress gastroesophageal reflux disease (GERD), rhinitis
What are Exogenous stimuli for asthma triggers?
those stimuli generated outside the body
What are the side effects with inhaled corticosteroids
Dysphonia, hoarseness, throat irritation, cough
URTI increase
Candida oral infections
Growth retardation in kids
What are the precautions of Inhaled corticosteroids
HPA-Axis suppression upon withdrawal
Long term steroid effects at high doses
Possible URTI increase risk
When do we see an increase in asthma related hospitalization in children?
September. Back to school!
Triggers of Asthma (Meds)
ASA/NSAIDS
Radiocontrast media
Beta blockers
Sulfites, benzalkonium, MSG
Adult criteria for asthma diagnosis?
FEV1/FVC <75-80% predicted AND
12% improvement + 0.2L from baseline post quick acting 2 agonist
children criteria for asthma diagnosis?
Reduced FEV1/FEV with a >12% increase in FEV1 post bronchodilator
