Asthma Flashcards by Jas Jackson

Chronic respiratory condition characterized by wheezing, coughing, distress, and bronchospasm

Asthma

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Pathophysiology of Asthma

Immune/allergic reaction (inflammation) in the basement membrane that causes permanent changes (airway remodeling)

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Asthma can cause episodes of ____, ____, ____, ______. These episodes are reversible either spontaneously or with treatment.

wheezing, chest tightness, breathlessness, nighttime or early morning cough

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Who is most likely to have asthma (location, race)

Low income, minority (black, American Indian, and some hispanic), inner city, children

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Other chronic lung disease, CF, obesity (exercise intolerance), CV disease and immunodeficiency disorders are co morbidities of what?

Asthma

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Asthma can cause smooth muscle dysfunction that leads to _______, bronchial ______, _______ of lung cells, and inflammatory mediator release

bronchospasm, hyperreactivity, hypertrophy/hyplerplasia of lung cells

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Asthma can also lead to _____ ________, which causes inflammatory cell infiltration, mucosal edema, _____ damage, and basement membrane ______

airway inflammation; epithelial; thickening

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So triggers lead to a immunohistopathologic response meaning:

shedding of epithelium and collagen deposition under basement membrane
-Edema occurs and mast cells are activated and then inflammatory cell infiltration occurs

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Inflammation in asthma then leads to _____ and evolves into wheezing ____ _____, and cough

bronchospasm/constriction; chest tightness

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_____ ______ occurs due to persistent inflammation that leads irreversible changes
such as abnormal airway diameter (caliber), decreased airflow

Airway remodeling

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Triggers lead to airway inflammation, leading to ____ production, airway ____tightening, and swollen ___ ___, which leads to narrowing of breathing passages then ___, ___ and ______

mucous production, airway muscle tightening, and swollen bronchial membranes; wheezing, coughing, and SOB

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Common asthma triggers include

Infections, viral respiratory illness (rhino/enterovisrus, parainfluenza, RSV, metapneumovirus), seasonal allergens, pets, cigarrette smoke, weather changes

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Rule of 2’s (2 SABA canisters/years, 2 doses of SABA/wee, 2 nocturnal awakenings/month, 2 unscheduled visits/year, 2 PO steriod bursts/year)

Helps determine the need to add controller therapy in asthma (step 1 to STEP 2)

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Medications: Reliever (Fast acting)
Taken as needed for rapid, short term relief
It is used to ____ or ____ an asthma attack.
Examples include albuerol or Xopenex ( less tachycardia than albuterol so consider in kids with heart issues)
Anticholinergic (Ipratropium or Atrovent) or Corticosteriods (systemic)

prevent or treat

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Corticosteroids 
\_\_\_mg/kg per dose BID or 2-4mg/kg/day
Liquid prednisone (poor taste) 15mg/5ml
Pills (adult daily mac is \_\_\_\_\_mg) 
Oral dissolving tablets but insurance may be an issue

1-2

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Controller Medications are taken _____ to control chronic symjpmtoms and prevent asthma attacks

Regularly

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The most important type of medication for people with asthma is _______

controller medications

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Controller medications are not _____, and one option during an exacerbation is doubling dose of _____ instead of giving steroids.

systemic; ICS

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Example of a controller medication s______

Inhaled corticosteroids which are anti-inflammatory, most effective and commonly used for long term control; reduce swelling and tightening in airways, but can take several days/weeks to reach max. benefit

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Inhaled corticosteroid examples

Fluticasone (Flovent), Beclomethasone (Qvar), Ciclesonide (Alvesco), Flunisolide (Aerobid)
Nebulizer (bedside (Pumicort), or even Mometasone.

insurance helps determine.
encourage kids rinse mouth out

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LABA: _____ that opens up narrowed airways and reduces ____. They last for at least ___ hours and can control moderate to severe asthma and _____symptoms.

bronchodilators; swelling; 12; nighttime

*Salmerrol (Serevent) or Foradil

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Combination inhalers can increase the risk for __________ and contain both a corticosteroid and long acting beta agonist

Severe asthma attacks

*Advir, Symbicort, Dulera)

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Leukotrine modifiers (Antagonists) block the effect of leukotrienes which are: \_\_\_\_\_\_\_, \_\_\_\_\_\_ released by \_\_\_\_ cells,
These medications help prevent symptoms for \_\_\_\_hours

immune system chemicals that cause atopy symptoms and are released by mast cells. They help prevent symptoms for up to 24 hr.

*Montelukast (Sinfugulair)
1-5m=4mg, 6-14 = 5mg, >14 = 10mg
SE: nighttime terrors/hallucinations

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Can use antihistamines, Leukotrine Antagonists, allergy shots, or omalizumab for _____

allergy-mediated symptoms

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Spacers can help pt. with _________ and ________

difficulty using an inhaler/can reduce SE from medication. *less thrush

``` If well controlled for 3-6m Improved spirometry Improved hx. and time of year is when they are not triggerd improved peak flow, what should you do? ```

Step Down

Acute exacerbation of asthma symptoms:

tachypnea, low 02 saturations, wheezing, retractions, tracheal tugging, breathlessness at rest, hunched forward, speaks in words vs. sentences, agitation, low peak flow (less than 60% of normal)

Acute exacerbation concerns

early tx. has better outcomes | identify pt. at risk for death

In an acute asthma attack:

SABA (you can double neb treatment or do an hour long neb tx.), oxygen, corticosteroid, If there is concurrent illness present, give antibiotics

Azrithomycin has ______ effects that have actions on macrophages, COX-inhibitory effects

anti-inflammatory

Cystic Fibrosis is cause by abnormalities in the _____ protein that's produced by mutations in the _____ gene

CFRT

CF presentation in utero

increased echogenicity on ultrasound

Newborn CF manifestations

Meconium ileus; delayed stool passage; jaundice

Infant and Children

Malabsorptive stools, rectal prolapse, failure to thrive, intusseption

CF presentation (Gastrointestinal)

Malabsorption of fat, protein, CHD, fat soluable vitamins, malabsorptive stools, FTT (but have a voracious appetite), recurrent abdominal pain, pancreatitis. (hepatobiliary) electrolyte imbalance/abnormal liver enzymes

Respiratory CF presentation

Chronic cough (mucous production), Respiratory infections (recurrent), persistent and recurrent wheeze, prolonged symptoms of bronchiolittis, recurrent/chronic rhinosinusitis, bronchlectasis , finger clubbing

CF dx.

newborn screening; sweat test >60 mEq, malabsorptive studies, vitamin E, stool pancreatic elastase (<100)

Pneumonia Effects_____ respiratory tractParticularly the ______ Lobar, interstitial, bronchial Many viruses progress to secondary bacterial infection

lower; parenchyma

Pneumonia associated symptoms

Fever, cough, increased respiratory effort, dehydration, +/- wheezing

____, hypoxia, and____ are signs of worsening ____

nasal flaring; retrations; worsening pneumonia

Gold standard for diagnosing pneumonia

Crest X-ray (infiltrates/consolidation

Viral pneumonia is more common in _________. Symptoms include ___, _____, and tachypnea. We treat symptomatically and by ____, ____, _____, monitor and if suspecting possible bacterial thick about azithromycin

children; cough, fever; increasing water, isolation, and treating fever

Bacterial Pneumonia can be a ____ of vial pneumonia and is associated with ________. tx. includes ______, which is safest in neonates but if _____ or _______, give azithromycin. If influenza, use _______

secondary complication; influenza A. Amoxicillin; walking pneumonia or community acquired; Tamiflu

Bronchitis is associated with inflammation in the ____ airways vs. bronchiolitis in the ______

large; small

Bronchitis is associated with ___ and ____vs. bronchiolitis which is associated with ______

pharygitis and laryngitis; copious mucous secretion and upper wairway symptoms that move into lower airway

Bronchitis can be acute, chronic, viral or bacterial wheras bronchiolitis is ______ usually

acute

both bronchitis and bronchioltis are more prominent in the _____

Winter

Bronchitis can be treated with:

Cough suppressants in adults or expectorants in kids (Mucinex) and bronchodilators

Bronchiolitis is most common lower respiratory infection in kids ages ________

1 month to 2ys

Bronchiolitis is caused by 5 viruses (name them) and has the symptoms of edema and necrosis of lining in small airways, ___ mucous production, and _____

RSV, adenovirus, influenza, para influenza, human metapneumovirus

___ is the most common agent for bronchiolitis with the greatest incidence between ____ and March. 90% of kids are infected in the first 2 years of life

RSV; December

RSV's incubation period is _ to _ days. It is transmitted by _____ contact, _____ ____ droplets, and can survive for ___ on hands and fomites

4-6; direct contact (nasopharyngeal or ocular mucous membranes, large aerosol droplets; hours

RSV Risk factors include

premature birth (less than 37w), young child (6-12 weeks), development of apneic episodes, hemodynamically significant heart disease, chronic lung disease, immunocpromised, non-breastfed

RSV symptoms: _____ is the presenting symptom in 20% of infants admitted to the hospital, significant _____, tachypea (over ____ RR), wheezing, coughing, crackles, nasal flaring, use of accessory muscles, and 50-75% also have ______

Apnea; rhinitis; 70; Acute otitis media

RSV dx.

Clinical features; virologic nasopharyngeal testing; pulse oximetry <90, chest X-ray (r/o pneumonia) , CBC

RSV management incudes: supportive nutrition/hydration. Insert an IV PRN ; Pulse oxyden PO is _____, antibiotics only is ____ present. Suction the nares

<90%; AOM

___ should not routinely be used for RSH (modest short term improvement), _____ not okay if <24m, ____ only used in immosuppressed patients with RSV, and if _____ and on Synagis they may continue

Bronchodilators; Corticosteriods; premature

RSV is worse on day ___

____ is also known as ____ or ____ and is cause by the bacterium ______ _______

Pertussis; Bordetella pertussis

symptoms of Pertussis include a ______ _______ cough that is accompanied by an ____ whoop and patients may often have a ___ worsening or subsequent encounter ; reportable to local health department

prolonged paroxysmal; inspiratory; second

Pertussis mode of transmission is ___ to ____ by ____ ____ or ___ contact with sections from respiratory tract. 80% have a secondary attack rate, and older adults and kids are a source for infants and young children. Kids ______m are at greatest risk for complications and death

<12m

Incubation for pertussis ____ days. Most infectious period is during the catarrhal stage or ______w ____ cough and first ___ weeks ____ cough onset. Duration is _____ or ___ in adolescents

7-10 days; 3 weeks before cough or 2 weeks after cough onset. Duration is 6-10w or 10+ in adolescents

Pertussis is dx. without labs if patient has COUGH LASTING ____ WEEKS WITHOUT LIKELY DX. AND 1 OF THE FOLLOWING:

>2; paroxysm of cough, inspiratory whop, post tussive vomitting, apnea without or without cyanosis (if <1y)

Cough that is not improving, rhinorrhea with steady watery mucous, apnea, seizures, cyanosis, vomitting, or poor weight gain; ____ (WBC > 20,000) with lymphocytosis ( ____% lymphoctyes), pneumonia, subconjunctival hemorrhage, sleep disturbance, or

leukocytosis; 50%

Labs for Pertussis

CBC with Diff (WBC/lymphocytes are directly related to severity in infants) , Chest X-ray )could be normal/r/o pneumonia), PCR and culture if <4 or PCR and serology is ?4 ( IgG is >1 if vaccinated)

Syncope, rib fractures, incontinence, sleep disturbance, (pneumonia, seizures, encephalopathy in infants) and death (unvaccinated infants) are complications of

Pertussis

If child is < ____m, in respiratory distress, may have PNA, unable to feed, cyanotic or apnea with or without cough, or has a seizure, send them to the _____ At home, ___ and ___. ___ aren't recommended

HOSPITAL Nutrition/fluids; cough suppressants

Antimicrobial therapy may be given to kids with pertussis if given within ___ days of symptom onset because it can shorten duration and decrease transmission, espically if

7; 6 tx. includes azithromycin, erythromycin, clarirothymic, and TMP-SMX

T or F: Treat close contacts pending PCR and isolate the patient for 5 days after giving antibiotics or 21 days if no antibiotics

laryngotracheitis or laryngotracheobronchitis typically effects ____m to ____y

Croup; 3m-3y

Croup is _____; most common causes : Parainfluenza, adenovirus, RSV. Leads to _____ and _____ of larynx and subglottic area & decreased mobility of the ______ ______

viral; inflammation and infection; vocal chords

Croup is ______, beginning with nasal irritation, coryza, and congestion. Generally progresses over ___ to ___ hours to include fever, _____, ___ cough, and stridor Respiration distress ___ as upper airway obstruction becomes more severe.

gradual; 12-48; hoarseness, barking; increases

Cough resolves in ___ days, other symptoms may persist for ____ and gradually return to normal

3; 7 | - deviations in course suggest different diagnosis

occasional barking cough, no stridor at rest, mild to no suprasternal retractions

Mild croup disease

Moderate Croup disease:

____cough, ____audible stridor at __, and retractions _____

Severe Croup presents as ____ cough, inspiratory/expiratory ______, retractions, cyanosis, lethargy, distress, and agitation

frequent; stridor

Croup dx.

Clinical presentation, A/P neck x-ray will show subglottic _____ (steeple), CBC might show ______

Croup management at home;

humidity, cool air mist, steam from bathroom, exposure to outdoor cool air, adequate hydration, fever reducation, and oral fluids

Outpatient management of Croup;

Glucocorticoids: single dose of oral or IM dexamethasone (0.6mg/kg) Prednisolone (2mg/kg per day for three days)

Tell parents to seek medical attention:

Stridor at rest, difficulty breathing, pallor or cyanosis, suprasternal retractions, severe coughing spells, drooling, difficulty swallowing, fatigue, worsening course, fever >38.5 and prolonged symptoms greater than 7 days

Severe Croup management

Send to ER; Nebulized Racemic epinephrine (NOT GIVEN OUTPATIENT), dexamethasone (+/- prednisolone for 3 days)

Moderate/severe croup with persistent or deteriorating respiratory distress after treatment with racemic epinephrine and corticosteroids (In ER or office) Severe croup with poor air entry, altered consciousness, or impending respiratory failure Dehydration Significant respiratory compromise Signs of respiratory failure "Toxic" appearance or clinical picture suggesting serious secondary bacterial infection Need for supplemental oxygen Severe dehydration

Hospitalization Indications

____ is an acute inflammation of the ___, cartilaginous structure covered with mucous membrane, and pharyngeal structures

epiglottitis; epiglottis

Epiglottitis affects kids _ through __ and is caused by ____, S. pneumoniae, H parainfluenzae, S. aureus, and beta hemolytic streptococci

2-7; HIB

Epiglottitis Manifestations: There is a tyriad of ____, dysphagia,____; also high ___, ___positioning, dyspnea, inspiratory stridor, accessory muscle use, ____ voice, and ___ cough

drooling; distress/ high fever; tripod positioning; muffled; brassy CALL 911

Epiglottitis Dx.

Lateral neck is enlarged, edematous epiglottis, Laryngoscopy (direct inspection of epiglottis under controlled circumstances), leukocytosis, and + blood cultures for staph/strep.

Epiglottits management

ER HOSPITALIZATION -Secure airway with intubation or cricothyroidotomy, sit child upright, humidifed oxygen, no tongue blades, IV antibiotics (ROCEPHIN)

If a child is younger than 5, they cannot have a ___ infection

sinus