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Pulmonary: Clin Med II B > Obstructive Pulmonary Disease - Asthma > Flashcards

Obstructive Pulmonary Disease - Asthma Flashcards

1
Q

a REVERSIBLE obstructive lung disease caused by increased reaction of the airways to various stimuli or triggers

A

asthma
Chronic inflammatory disease with acute exacerbations or flare ups

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2
Q

triggers of asthma

A

infections
viruses such as colds
cigarette smoke
allergens
pollutants
cold air
changes in temperature,
excitement or stress and exercise.

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3
Q

pathogenesis of asthma

A
  1. No single pathognomonic factor but multiple contributing factors:
  • Inflammatory cell infiltration with eosinophils, neutrophils and lymphocytes (specifically T-lymphocytes)
  • Goblet cell hyperplasia
  • Plugging of small airways with thick mucus
  • Hypertrophy of smooth muscle
  • Airway edema
  • Mast cell activation
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4
Q

strongest identifiable predisposing factor for development of asthma is ?

A

atopy

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5
Q

other risk factors of asthma

A

obestiy
GERD
rsp irritants
viruses
stress
pollutants
Aspirin, NSAIDs, BBs
FHx
exercise
URIs
enivornment

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6
Q

when does asthma MC begin?

A

1-5 years - 51.4%

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7
Q

types of asthma

A
  1. extrinsic -allergic
  2. intrinsic - uncommon
  3. mixed - combo of ex and in
  4. occuptional
  5. drug-induced - NSAIDs, ASA
  6. exercise
  7. cough variant - common, esp in children
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8
Q

diagnostic approach for asthma

A
  1. Clinical Suspicion!
  2. Hx with focus on symptom patterns
  3. PE - Signs of allergies and asthma
  4. Confirm diagnosis with objective measure of pulmonary function (spirometry)
  5. Allergy testing
  6. Clinical response
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9
Q

symptoms of asthma

A

Cough
Chest tightness
SOB / Dyspnea
Difficulty Breathing
Episodic wheezing

Frequency is variable!

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10
Q

signs/general PE of asthma

A
  1. nasal secretion, mucosal swelling, and/or nasal polyps
  2. atopy / allergic rhinitis - conjunctival congestion, ocular shiners, salute sign
  3. Wheezing or prolonged expiratory phase, hyperexpansion of thorax, use of accessory muscles, appearance of hunched shoulders
  4. Atopic dermatitis or eczema
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11
Q

what does a focused lung exam of asthma consist of?

A
  1. Inspection
    - Shape
    — Hyperinflated - severe asthma
    - Movement of chest
    — Silent - life threatening
    — Retractions?
  2. Palpation
    - Normal chest expansion may be reduced (hyperinflated)
    - Tactile fremitus - may be decreased
  3. Percussion
    - Normal to Hyperresonant
  4. Auscultation
    - Rhonchi to wheeze (usually expiratory but may be inspiratory as well)
    - Prolonged expiratory phase
    - Silent chest - severe asthma
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12
Q

diagnostic testing + criteria for asthma

A

spirometry - showing reversible airway obstruction
- reduced FEV1/FVC AND increase FEV1 after BD or course of controller therpay
criteria:
1. > 6y/o - <LLN + >12%
2. adults - <LLN + >12% + >200mL

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13
Q

adjunct testing for asthma besides PFT

A
  1. Bronchoprovocation Testing
  2. Exercise Challenge
  3. Peak Flow Meters
  4. CXR
  5. Skin Testing
  6. Measurement of sputum for eosinophils
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14
Q

used If spirometry is nondiagnostic
Use of inhaled histamine, methacholine, or mannitol
what is this testing

A

bronchoprovocation testing

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15
Q

bronchoprovocation testing is NOT recommended for who?

A

FEV1 <65% of predicted

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16
Q

indications for CXR for asthma

A

initial asthma diagnosis or diagnosis uncertain
Low yield in acute asthma exacerbations
Status Asthmaticus or no improvement in acute asthma attack

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17
Q

CXR findings of asthma

A

Normal to hyperinflation

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18
Q

labs for asthma

A
  1. ABGs
    - Hypoxemia
    - Hypercarbia (or normal CO2) with decompensation
  2. CBC
    - Eosinophilia may be present
    - Increased levels of IgE may be present
  3. Sputum sample
    - May show casts of small airways
    - Thick, mucoid sputum
    - Curschmann’s spirals
    - Charcot-Leyden crystals
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19
Q

Most common bronchoprovocation test in US
Patients breathe in increasing amounts of methacholine and perform spirometry after each dose

A

Methacholine Challenge

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20
Q

diagnostic of Methacholine Challenge

A

Increased airway hyperresponsiveness with a ≥ 20% decrease in FEV1 up to 16 mg/mL max dose

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21
Q

asthma vs COPD

A
  1. Asthma
    - Onset early in life - childhood
    - sx vary from day to day
    - sx at night / early morning
    - Allergy / Rhinitis / and / or eczema also present
    - Family history of asthma
    - Largely reversible airflow limitation
  2. COPD
    - Onset in mid-life
    - Symptoms slowly progressive
    - Long smoking history
    - Dyspnea during exercise
    - Largely irreversible airflow limitation
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22
Q

golden rule of asthma

A

All that wheezes is not asthma!!

Pulmonary edema
Pulmonary embolism
Anaphylactic reaction
COPD
Pneumonia
Foreign body aspiration
Cystic fibrosis

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23
Q

complications with asthma

A

Exhaustion
Dehydration
Airway infection (pneumonia)
Tussive syncope
Pneumothorax
Respiratory Failure
Chronic lung disease

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24
Q

Daytime asthma sx occurring ≤2 d per wk
≤2 night awakenings per month
Uses SABA/rescue inhaler <2x per wk
No interference with normal activities between exacerbations
FEV1 ≥ 80% predicted value
FEV1/FVC ratio between exacerbations is normal
0-1 exacerbations requiring oral glucocorticoids per year
what is this classification

A

mild intermittment

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25
Q

Sx >2 weekly (less than daily)
3-4 night-time awakenings per month (but fewer than every week)
Use of SABA to relieve sx >2x a wk (but not daily)
Minor interference with normal activities
FEV1 measurements within normal range and normal FEV1/FVC ratio
2 or more exacerbations requiring oral glucocorticoids per year
what is this classification

A

mild persistent

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26
Q

Daily symptoms of asthma
Nighttime awakenings more than once per week
Daily need for SABA for symptom relief
Some limitation in normal activity
FEV1 between 60-80% of predicted and FEV1/FVC below normal
what is this classification

A

moderate persistent

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27
Q

Symptoms of asthma throughout the day
Night-time awakenings nightly
Need for SABA for symptom relief several times per day
Extreme limitation in normal activity
FEV1 ≤ 60% predicted and FEV1/FEC below normal
what is this classification

A

severe persistent

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28
Q

goals for asthma management

A

Minimal or no chronic symptoms in the day, night, or after exertion
Minimal to no exacerbations
No limitations on activities
Maintain near normal pulmonary function
Minimal use of rescue inhaler (less than or equal to 2 times a week)
Minimal or no adverse effects of medications

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29
Q

“Rescue Inhalers” and used as initial tx in intermittent asthma but every asthmatic should have one.

A

SABA
Should be given to ANYONE diagnosed or experiencing asthma sx
“Don’t Leave Home Without It”

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30
Q

MOA of SABA

A

Work to relax the smooth muscle of the airway and cause prompt increase in airflow and decrease in symptoms

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31
Q

Preferred long-term controller in lowest doses possible to control asthma

A

ICS

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32
Q

budesonide

A

ICS

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33
Q

beclometasone

A

ICS

34
Q

mometasone furoate

A

ICS

35
Q

fluticasone propionate

A

ICS

36
Q

MOA ICS

A

Works to reduce airway inflammation and reduces the airway’s exaggerated sensitivity to any and all triggers of asthma

37
Q

Regular treatment with ICS reduces ___ improves overall quality of life and decreases _____

A

the frequency of symptoms
the risk of serious exacerbations

38
Q

SE of ICS

A
  1. Most common
    - Thrush
    - Hoarseness (dysphonia)
    - Localized contact hypersensitivity
    - Cough and throat irritation
  2. Less common systemic
    - Impaired growth in children on long-term therapy
    - Osteoporosis in adults on long-term / high dose therapy
    - Cataracts
    - Glaucoma
    - Weight changes and adrenal suppression
39
Q

how to Cut down on the amount of steroid absorbed into the patient’s body
Decrease the risk of developing thrush with ICS

A

rinse mouth

40
Q

pt education about ICS

A
  1. rinse mouth
  2. Regular eye exams with h/o or family h/o glaucoma
  3. Monitor growth in children on ICS (BMI <15%); cortisol levels
  4. Watch calcium and Vit D intake in women and children on ICS
41
Q

what asthma tx is recommended for pregnancy

A

ICS
Budesonide (Pulmicort)
Proventil

42
Q

SE of systemic corticosteroids

A

Skin and soft tissue
Cushingoid appearance / weight gain
Cataracts / glaucoma
CV disease
GI disease - gastritis, ulcer formation, GI bleeding, pancreatitis
Hyperinsulinemia with insulin resistance

42
Q

what corticosteroid is used for acute asthma attacks
Given to all moderate to severe asthmatics to keep at home in case of need

A

systemic corticosteroids
Prednisone - oral
Prednisolone (Prelone, Orapred) - liquid
Solu Medrol (Methylprednisolone) - IV

42
Q

Used in combination with other medications - usually ICS - rarely a monotherapy

A

LABA
Salmeterol, Formoterol, arformoterol

43
Q

MOA of LABA

A

Affects smooth muscle not limited to the airways and therefore can affect smooth muscle in the heart causing tachycardia and palpitations

44
Q

why are ICS+LABA beneficial for asthma?

A

bronchodilator working to widen the airway
inhaled corticosteroid reduces and prevents inflammation of the airway

45
Q

limitations of ICS+LABA

A

Limitations - COST - 2nd tier on most insurance plans

46
Q

Not used as first line but can be used if unresponsive to therapy in combination with SABA
Relax the airways and prevent them from getting narrower
Also reduce the amount of mucus in the airway

A

LAMA+SAMA
Ipratropium bromide, Tiotropium bromide, Ipratropium + albuterol

47
Q

Add on medicine for moderate to severe asthma; Not for acute exacerbations
Mild bronchodilation, anti inflammatory, enhances mucociliary clearance, and strengthens diaphragmatic contractility
Nonselective phosphodiesterase enzyme inhibitor

A

Theophylline

48
Q

Montelukast

A

Leukotrienes

49
Q

zafirlukast

A

Leukotrienes

50
Q

MOA of leukotrienes

A

Blocks actions of cysteinyl leukotrienes at CysLT1 receptor on target cells such as bronchial smooth muscle via receptor antagonism
Improves asthma symptoms and reduces exacerbations and limit markers of inflammations such as eosinophil counts in the peripheral blood and bronchoalveolar lavage fluid proving they have antiinflammatory properties

51
Q

BBW of leukotrienes

A

behavioral issues, wakeful nights, suicidal ideations

52
Q

Not used first line - may be an option if someone fails or can’t tolerate ICS
Alternate initial controller therapy in mild asthma in national and international guidelines
Mast cell stabilizer

A

Cromolyn

53
Q

MOA of Cromolyn

A

Prevents both early and late asthmatic responses to inhaled allergens and reducing airway reactivity to a range of inhaled irritants such as cold air and sulfur dioxide

54
Q

cromolyn is only available as a ?

A

neb

55
Q

Used in patients with severe asthma attacks and results in rapid improvement of upper airway obstruction
Sympathomimetic
Alpha and beta agonist (slightly more Beta2)

A

Nebulized Epinephrine - Racemic

56
Q

why must you monitor with neb EPI -racemic

A

Onset <5 min; peak 5 - 15 min; duration 1 - 3 hrs
monitor for 3-4 hrs for rebound

57
Q

SE of racemic tx

A

Side effects usually last no more than 2 hours
- Restlessness, anxiety, tachycardia, rebound

58
Q

Omalizumab (Xolair) is available only as a

A

injection
>6 y/o

59
Q

DNA-derived, IgG antibody which binds to IgE mast cells and reduces the mediator release that produces the allergic response
Also indicated for those w/ chronic idiopathic urticaria

A

Omalizumab (Xolair)

60
Q

this tx is used for Moderate-severe uncontrolled asthma in person w/ positive skin prick testing to perennial allergies who is inadequately controlled on max dose of other meds

A

Monoclonal Antibodies - Omalizumab

61
Q

BBW for Omalizumab

A

anaphylaxis

62
Q

6 steps of asthma tx

A

SABA + low dose ICS when symptomatic or low dose ICS daily
SABA + low dose ICS
SABA + low dose ICS + LABA OR medium dose ICS alone
SABA + medium dose ICS + LABA
SABA + high dose ICS + LABA (or montelukast)
SABA + high dose ICS + oral steroids + LABA (or montelukast); consider monoclonal antibody

63
Q

management for asthma pts (besides inhalers)

A

Desensitization - Allergy shots
Vaccination - Influenza, Pneumococcal, COVID

64
Q

monitoring/follow ups for asthma

A

2-6 wks after new med
1-6 months for routine f/u
If asthma is stable for 3 months or more, you may consider stepping down in your treatment

65
Q

routine for each asthma visit

A

Assessment of s/s
Pulmonary function
Quality of life
Exacerbations
Adherence with treatment
Medication side effects
Overall patient satisfaction with his/her treatment plan

66
Q

extensive questioning for asthma pts

A

Questions about nighttime awakening or early morning awakenings
How often they need rescue inhaler
How often they or a family member hears wheezing
Unscheduled care for asthma / called in sick
Participation in school / work activities
Questions about peak flow readings if they are measuring them
Systemic steroid since last visit

67
Q

determination of asthma control (3)

A

Well controlled - sx ≤ 2 days a wk

Not well controlled - sx > 2 days a wk or multiple times a night

Very poorly controlled - sx persist throughout the day; 20% change in value from AM to afternoon or day to day

68
Q

goals of asthma tx

A

Relief from symptoms
Minimal need of SABAs to relieve symptoms
Few night-time awakenings
Optimal lung function
Normal ADLs - work, school, athletics, etc.
Satisfaction of care among patients and families
Prevent recurrent exacerbations, including ED and hospital care
Optimal treatment plan (pharmacotherapy) with minimal SEs

69
Q

when to refer/consult to pulm or allergist for asthma

A

If patient experienced life threatening asthma attack
The patient has been hospitalized or on more than 2 rounds of oral corticosteroids
The patient over 5 yrs old requires step 4 care or higher; a patient under 5 yrs old requires step 3 or higher
Unresponsive to treatment or uncontrolled therapy after 3 - 6 months of active therapy and monitoring
Diagnosis is uncertain
Other conditions complicate management
Additional diagnostic tests needed
Patient may be a candidate for allergen immunotherapy

69
Q

pt education about/for asthma

A

Patient needs to understand and become an active partner in managing their asthma
Patients must learn how to monitor their symptoms and pulmonary function
Possible triggers
How to take their medicine properly
Instruction on how to use peak flow meters and a detailed treatment plan should be given to all patients especially when first starting a treatment plan or if changes are made “Asthma Action Plan”

70
Q

A condition in which the airways narrow significantly during vigorous exercise

A

Exercise Induced Asthma (EIA)

71
Q

Cough, wheezing, SOB, chest tightness
Starts at onset of exercise or 3 min after; peaks 10 - 15 min; resolves within 60 min
what is this condition?

A

EIA

72
Q

tx for EIA

A

trial albuterol
Usually bronchodilators - SABA
Albuterol (Ventolin, Proventil)
Pirbuterol (Maxair)
Ipratropium and Albuterol combo (Combivent)
Taken 15 - 30 min. before exercise

73
Q

Chronic cough
> 3 weeks
Non-productive
Usually nocturnal, but can occur anytime
Any age group
what is this condition

A

Cough Variant Asthma

74
Q

work-up + tx for Cough Variant Asthma

A

PFT / spirometry normal
R/O other causes of chronic cough
tx - Similar to other forms of asthma

75
Q

adult pt is experiencing
Increased SOB or wheezing
Disturbed sleep caused by SOB, coughing or wheezing
Chest tightness or pain
Increased need to use bronchodilators (SABAs)
A fall in peak flow rates as measured by a peak flow meter
what are they experiencing?

A

acute asthma ttack

76
Q

child pt is experiencing
An audible whistling or wheezing when the child exhales
Coughing, especially when the cough is frequent and occurs in spasms
Waking at night with coughing or wheezing
SOB, which may or may not occur when the child is exercising
A tight feeling in the child’s chest
what are they experincing?

A

acute asthma attack

77
Q

The most severe form of asthma
The lungs are no longer able to provide the body with adequate oxygen or remove carbon dioxide
Many organs begin to malfunction
what is this condition

A

Status Asthmaticus

78
Q

Status Asthmaticus leads to a build-up of CO2 leading to what state?

A

acidosis

79
Q

tx/managment for Status Asthmaticus

A

Require intubation and ventilator support as well as maximum doses of several medications
Support is also given to correct acidosis

Pulmonary: Clin Med II B (10 decks)

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