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Junior - Pulm Mod 1 COPY > 3 - Asthma > Flashcards

3 - Asthma Flashcards

1
Q

High prevalence of asthma in which patient population? (For US)

A

Black patients age 15-24 yrs

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2
Q

Briefly describe asthma:

A

Chronic inflammatory disorder

Reactive, obstructive airway disease

Hyper-responsive airways lead to edema, mucus production, collagen deposition

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3
Q

What is the strongest predisposing factor to asthma?

A

Atopy (atopic derm)

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4
Q

During which phase of the respiratory does wheezing most commonly occur?

A

Expiration - obstructed airways lead to air trapping

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5
Q

Two primary mechanisms by which asthmatic obstruction occurs?

A

Mucus production
Inflammation

Both lead to narrowed lumen

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6
Q

Common pathologic changes in all asthmatics:

A

Infiltrates within the bronchial walls (especially in allergic asthma)

Epithelial damage

Hypertrophy and hyperplasia of smooth muscle

Collagen deposition

Increase in goblet cells

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7
Q

Chronic inflammation in asthma leads to:

A

Airway remodeling

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8
Q

Name three features of airway remodeling:

A
  1. Epithelial damage
  2. Airway fibrosis
  3. Smooth muscle hyperplasia
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9
Q

Factors that will precipitate or exacerbate asthma:

A 
House allergens
Outdoor allergens
Exercise
URTI’s
GERD
Stress
Tobacco
Air pollution
ASA/NSAIDs
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10
Q

What are the four MC asthma precipitants?

A
  1. Allergen exposure
  2. Inhaled irritants
  3. Infection
  4. Exercise
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11
Q

Describe allergic asthma:

A

IgE-mediated

Mast cells release histamines and leukotrienes

Increased epithelial permeability

Bronchoconstriction and inflammation

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12
Q

MC irritant that precipitates asthma?

A

Cigarette smoke

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13
Q

Mechanism by which exercise precipitates asthma?

A

Heat and moisture loss -> rapid cooling of the airway

The lungs prefer to have warm, humidified air

This is fine for normies, but for asthmatics it can lead to severe reactions

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14
Q

What is the asthma triad? (Aka Samter Syndrome)

A

Asthma
ASA sensitivity
Nasal polyps

Not to be confused with the atopic triad (AR, asthma, eczema)

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15
Q

In asthmatics, what happens to the residual volume (RV)?

A

It goes UP, because of air trapping (so now you have stagnant, shitty gas exchange - air that’s just sitting in the lungs)

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16
Q

What would you expect to see on ABG’s in the initial stages of an asthma attack? Why?

A

Lower pO2 and pCO2 (alkalosis)

The body responds with tachypnea

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17
Q

How would the flow-volume loop appear for asthma?

A

Scooped (obstructive)

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18
Q

S/S of asthma:

A

Episodic wheezing, dyspnea, tightness, cough

Increased sputum

Variable frequency

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19
Q

What are the three red flag questions for asthma? (I actually use these for every asthma pt i’ve ever had - let’s me know whether i wanna get ready to RSI)

A
  1. Have you every been hospitalized for your asthma?
  2. Have you ever been intubated because of your asthma?
  3. Have you ever been on oral systemic steroids for your asthma?
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20
Q

PE L/S for asthma will reveal:

A

Diffuse expiratory wheezes

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21
Q

What if your asthma pt ISN’T wheezing but still looks like shit?

A

Late finding - BAD! Their airways are so obstructed they’re not even producing a wheeze anymore

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22
Q

Other late findings for asthma (ominous)

A

Hunched shoulders
Accessory muscle use
Unable to lie back

(You’ll know - these guys are looking at you with terror like they’re about to die)

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23
Q

Criteria by which you can assess severity of exacerbation:

A

Dyspnea (position)

Speech (able to speak in sentences versus words)

Orientation

RR

Accessory muscle use

Wheeze

HR

Pulsus paradoxus

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24
Q

ABG in a mild asthma attack: (pCO2)

A

Decreased

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25
Q

ABG in a severe asthma attack: (pO2)

A

Decreased

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26
Q

If pCO2 is increased, suggests:

A

Respiratory acidosis and impending failure (either late finding or early finding in severe case)

This pt is getting put on a vent

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27
Q

Is asthma a reversible or irreversible defect?

A

Reversible

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28
Q

How will the FEV1/FVC ratio appear in asthma?

A

Reduced

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29
Q

During pulmonary function tests, if bronchodilators produce greater than ___ percent improvement in FEV1 or FVC, the disease is considered reversible

A

11

30
Q

What is bronchial provocation testing?

A

We are inducing an asthma attack in a controlled setting

Use histamine or methacholine

31
Q

A positive methacholine test would be an FEV1 drop of greater than ___ percent after exposure:

A

20

32
Q

Is a positive bronchial provocation test confirmatory for asthma?

A

NO! It can rule it OUT with a negative test, but a positive BPT does not necessarily mean the pt has asthma

33
Q

What is the peak flow meter?

A

Personal monitoring tool

Helps guide decisions in their action plan

34
Q

When is peak flow normally the lowest?

A

Right when you wake up

35
Q

When is peak flow normally highest?

A

Right after you suck on that beautiful albuterol MDI….

But normally, a few hours before midday.

36
Q

Is CXR required to Dx asthma?

A

Nah. It’s clinical.

37
Q

DDx for asthma?

A

Vocal cord paralysis or dysfunction

COPD

Bronchiectasis

CF

Psych - conversion d/o

38
Q

4 recommendations for approach to asthma tx:

A
  1. Assess severity vs control
  2. Patient education
  3. Control of environmental factors and comorbidities
  4. Pharm
39
Q

Which is more important to assess overall - severity or control?

A

Control

Severity may be helpful in early management, but we wanna know how well CONTROLLED they are

40
Q

Asthma action plan:

A

Detailed guide for patients, based on their peak flow and/or symptoms

Green/yellow/red (red = call 911)

41
Q

Quick review of the steps:

A
  1. SABA as needed
  2. Low-dose ICS
  3. Low-dose ICS and LABA or medium-dose ICS
  4. Medium-dose ICS and LABA
  5. High-dose ICS and LABA
  6. High-dose ICS and LABA and oral steroids

4/5 consider omalizumab (if allergic)

Can sub LABA’s for LTRA’s if you want

42
Q

If well-controlled asthma, you can try to step down after ____ months

A

3

43
Q

Meds for long-term asthma control include:

A

ICS
LBA
LTM

44
Q

What’s the preferred 1st line for long-term asthma tx?

A

ICS

45
Q

How long until you see full benefit of ICS?

A

Could take months - be patient before stepping up

46
Q

Systemic steroids in asthma:

A

Only for exacerbations or severe cases

47
Q

Salmeterol and Formoterol are examples of:

A

LABA’s

48
Q

Can LABA’s be used as monotherapy in asthma?

A

Hellllll no.

But they can be in COPD.

49
Q

Cromolyn and Nedocromil are examples of:

A

Mediator inhibitors

Useful BEFORE exposure or exercise (not for acute relief - that’s what your SABA is for)

50
Q

Use of tiotropium in asthmatics?

A

LAMA - can be an ADD-ON if uncontrolled on ICS + LABA

More commonly seen in COPD

51
Q

Theophylline may be useful for:

A

Persistent night awakenings

Narrow therapeutic range, difficult to control - not an ideal med

52
Q

Zileuton, Zafirlukast, Montelukast - what are these?

A

LTM’s

Alternative to ICS in mild-persistent

Less effective than ICS

53
Q

With Zileuton you need to monitor:

A

LFT’s

54
Q

What is omalizumab?

A

Recombinant antibody

For allergic asthma

Expensive, injection q 2-4 wks

55
Q

Best drug for acute relief of symptoms?

A

SABA (albuterol)

56
Q

What drug is indicated to prevent EIB?

A

Albuterol

57
Q

Which is more effective, MDI or nebulizer?

A

Neb, by far, but requires a machine

58
Q

If you’re using a SABA more than twice a month:

A

Your asthma is poorly controlled - it’s a RESCUE inhaler - should only need it rarely

59
Q

Describe prednisone burst:

A

For exacerbation

40-60mg in 1-2 doses x 3-10 days

60
Q

For severe attacks, what steroid do we go for?

A

Methylprednisolone (Solu-Medrol) IV

61
Q

Empiric ABZ in asthma?

A

No. Only if S/S support infective process

62
Q

Features of mild exacerbation

A

Still responds to SABA

If not already on ICS, maybe consider starting one (a low-dose, step 2)

If already on ICS - consider oral prednisone burst

63
Q

Features of moderate exacerbation

A

Supplemental O2 requires (SpO2<94)

Continuous SABA (either 3 MDI puffs in an hour or nebulizer txt)

Early systemic steroids

Serial PFT’s

64
Q

Features of severe exacerbation

A

Life-threatening

SpO2<90

Systemic steroids (IV Solu-Medrol)

Continuous high-dose SABA

Consider mag-sulfate IV

AVOID ANXIOLYTICS

65
Q

In the ED, repeat assessments:

A

After initial bronchodilator

After 3 doses of inhaled bronchodilator

66
Q

If after tx, FEV1 > 70:

A

Send em home

67
Q

If after tx, FEV1 40-69:

A

Consider admission or continued tx in ED

68
Q

If after tx, FEV1 < 40

A

Dude’s getting admitted, no arguing.

69
Q

Admission disposition based on:

A

Duration and severity of sxs

Severity of obstruction (FEV1, FVC)

ABG’s (serial)

Prior Hx

Current Rx’s

Access to care / support

Psych concerns

70
Q

When to refer?

A 
Atypical presentation
Complicated comorbidities
Suboptimal response
High-dose ICS
2+ systemic steroids in 12 mos
Any life threatening hospitalizations in the last 12 months
Psych issues interfering
71
Q

Trust me. They have one thats called a meat tornado. Literally killed a guy last year.

A

You had me at meat tornado

Junior - Pulm Mod 1 COPY (6 decks)

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