Unit 3- Asthma Flashcards
Asthma definition
bronchoconstriction, airway inflammation, reversible airflow limitation
Asthma essentials of dx
episodic or chronic sx wheezing/dyspnea or cough
sx worse HS or early AM
prolong expiration and diffusse wheezing
limited airflow on PFT or positive bronchoprovacation challenge
reversibly airflow obstruction
Asthma more common in
males <14
blacks
asthma triggers
dust mites
cockroaches
cat dander
seasonal pollens
URI, rhinosinusitis, postnasal drip, aspiration, GERD, cold air, stress
tobacco, crack, coke, meth (increase sx and need for meds, decrease lung function)
air pollution
ASA/NSAID/tartazine dyes
workplace agents
catamenial- women during menses
exercise- during or 3 min after ends, peak 10-15 min, resolves by 60
cardiac- d/t HF
Cells present in asthma attack
eosinophils neutrophils lymphocytes (t-cells) IgE- central role in allergic asthma IL-5: promotes eosinophilic inflammation
goblet cell hyperplasia> plugs airway c mucus> collagen deposit under basement membrane, hypertrophy of bronchial SM> airways edena, mast cell activation
Asthma predisposing factors
genetics obsetiy atopy-strongest predictor tobacco exposure RSV or viruses
Lifestyle modifiatons for asthma
NO SMOKING pets humidity (keep indoor <50%) eliminate carpet limited stuffed toys (Wash weekly) encase pillow and mattress in dust-mite proof control cockroaches avoid outdoor activity when pollution index high avoid BB and sulfite- foods get annual FLU
Asthma s/sx
episodic wheezing difficulty breathing chest tightness cough excess sputum attacks variable occur spontaneously or triggers worse at night
Physical exam for asthma
nasal polyps nasal mucosal swelling increased secretion eczema atopic dermatitis
T or F: asthama has a prolonged inspiratory phase
FALSE
asthma has a wheezing or prolonged expiratory phase
Sign of severe asthma attack
globally diminished lung sounds
absent wheeze
use of accessory muscles (flaring and retractions)
asthma management steps
- eval severity (new dx, not on LABA)
a. assess pt recall of
previous 2-4wk and
spirometry> assign
severity
b. more frequent and
intense
exacerbation=greater
underlying disease
severity - iniate tx using stepwise approach
a. tx purpose: pt has
>=2 exacer. requiring
PO steroids in past
year> considered
same at pt w/
persistent asthma - assess asthma control and adjust tx PRN
T or F: 0-4yr can not do lung function test
TRUE
d/t not being old enough to cooperate
NAEPP asthma dx and management
- Assess and monitor asthma severity and asthma control
- Pt education to poster partnership for care
- control environment factors and comorbid conditions affecting asthma
- pharm agents (2 categories)
NAEPP asthma dx and management - pt education
all pt should have written action plan that includes instructions for daily management and measures to take in response to change in status
be taught to reconize sx and control need for therapy
NAEPP asthma dx and management - control environmental factors
reduce exposure to irritants and allergens= may reduce med need
comorbid conditions = rhinisinusitis, GERD, obseity , OSA
NAEPP asthma dx and management - pharm agents
quick relievers= act directly to relax SM
long term (controllers)= act to attenuate airway inflamm. and taken daily to achieve and maintain control
T or F: NAEPP recommend using weekly anti-inflammatory therpy w inhaled corticosteroids for persistent asthma
FALSE
they recommend DAILY
SABA medications
albuterol levalbuterol bitolrerol pirbuterol terbutaline
1-2 puffs
severe=6-12 q30-60min
SABA MOA:
relax SM> increase airflow and decrease sx
T or F: nebulized SABA are more effective
FALSE
DOES NOT offer more effective but DOES provide higher dose
What does repetitive ABA admin do
produces incremental bronchodilation
Alternative if SABA not working
Anticholinergics
corticosteroids
antimicrobials
Anticholinergic MOA
reverse bronchospasm but NOT allergen or exercise induced.
Decrease mucus gland secretions
IPORATROPIUM BROMIDE
With intolerance to Beta 2 agonist of bronchospasms d/t BB what do you give
ANTICHOLINERGICS
Iporatropium bromide
Corticosteroid MOA
systemic steroids are PRIMARY for pt w mod-severe exacer who dont respond promptly and completely to SABA
reduce rate of relapse and speed resolution of obstruction
Prednisone, methylprednisone
Antimicrobial MOA
consider likihood of acute bacterial RTI
Long term controllers examples
anti-inflammatory
long term bronchodilators
Inhaled corticosteroids
PREFERRED 1st LINE for persistent asthma
use twice daily
max response not usually observed for months
dry powder inhales:not used w/ inhalation chamber
systemic effects may be seen w/ high dose of steroids
Systemic corticosteroids
most effective in achieving prompt control of asthma during exacerbation in child and adult
alternating days is preferred than daily tx
requires concurrent tx w/ Ca and Vit D to prevent bone mineral loss
avoid rapid discontinuation to prevent adrenal insufficiency
When do bone density test need to be done with systemic steroids
after 3 months
Mediator inhibitors (long term broncho)
Cromolyn sodium and nedocromil
prevent sx, improve function with mild persistent or exercise induced
effective before allergen exposure, dont relieve sx once present
Long acting beta 2 agonists (LABA)
Salmetrol and Formoterol
Delivery: dry powder device
MOA: bronchodilate up to 12 hr after single dose
prevent sx, nocturnal sx, and prevent exercise induced
SHOULD NOT BE used as monotherapy
T or F: LABA should be used as monotherapy
FALSE
They have no anti-inflammatory effects need to be used with steroids
Anticholinergics, short acting muscarinic agents, long acting muscarinic agents
reverse vagally mediated spasms but not allergen or exercise
- Ipratroprium bromide (SAMA): less effective than SABA
- Tiotropium add on therapy: improve lungs and reduce frequency of exacerbation
Phosphodiesterase inhibitor
Theophylline
use for mild dilation
MOA: anti-inflammatory and immunodilator properties>enhances mucociliary clearance and strengthens diaphragmatic contracions
MONITOR serum concentractions d/t narrow therapeutic range
Leukotriene modifiers
Zileutonn or Zafirlukast or montelukast
Alt to low-dose inhaled steroids in pt with mild persistent, but as monotherapy are less effective than inhaled steroids
Omalizumab and Reslizumab
recombinant antibody that binds IgE without activating mast cells:
TREATS severe asthma in 18 or older
Vaccinations for asthma
pneumovac and flu
Oral sustained release beta 2 agonists
reserved for pt with nocturnal asthma or persistent mod-severe who DO NOT respond to other therapies
Mild exacerbation
minor changes in airway function
PEF>80%
pt respond quick and full to inhaled SABA
Can initiate inhaled steroid if not one one
T or F: doubling the dose of steroids is helpful in mild asthma
FALSE
is not effective or recommended
Moderate asthma exacerbation
goal: correct HYPOXEMIA, reverse obstruction and reduce reoccurrence
T or F: systemic steroids should be given if peak flow if <50% baseline
FALSE
should be given if <70% baseline or pt doesnt respond to several SABA tx
The improvement of ___ after ___ minutes correlates to the severity of asthma
FEV1
30 minutes
Acute (severe) asthma exacerbation
all pt should IMMEDIATELY get O2, high dose of inhaled SABA and systemic corticosteroids
Albuterol repeat in 20 minutes x3
Ipratropium bromide:: reduce rate of hospitalization when added to inhaled SABA
Short course PO steroids
IV mag FEV1<25
When can you D/C pt home with severe asthma
when PEF or FEV1 has returned to 60% or more
What is contraindicated in severe asthma
mucolytic agents (may worsen cough and airflow) Hypnotics (d/t resp depression)
Tx for all asthma
SABA
Albuterol as MDI 1 puff repeat q20 x3
How to dx <5 with PFT/spirometry
clinical judgement and assessment of sx
How to determine is obstruction is reversible
test before and after short acting dilator
FEV1
FVC
FEV1/FVC
FEV1
forced expiratory volume in 1 sec
FVC
forced vital capacity
FEV1/FVC
compared to reference norms for age, weight and gender
Airflow indicated by reduced
A positive or negative response to bronchodilators confirms asthma
positive
Peak expiratory flow meters
handheld devised for personal manageent
usually lowest when awakening
highest several hours before midpoint of day
measures in the AM before taking dilator and in afternoon after taking dilator
20% change in PEF suggest inadequate control
When to refer for asthma
atypical presentation or uncertain dx
comorbid conditions: rhinosinusitis, tobacco, environmental allergies, bronchopulm mycosis
suboptimal response to therapy
not meeting goads after 306 months
requires high dose steroids for control
>2 course of prednisone in past 12 months
life-threatening exacerbation require hospitalization in last 12 mo
social or psych issues interfering with asthma
When to admit asthma to hospital
Poor response to SABA after 2 tx 20 min apart
O2 <95 on RA
inability to speak in sentences
accessory muscles
change in alertness
PEF <50%
