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Clin Med IIB Pulmonology > Asthma > Flashcards

Asthma Flashcards

1
Q

What is the biggest difference between acute bronchitis/pneumonia and asthma?

A

Asthma has thickening of bronchioles

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2
Q

What is asthma?

A

Chronic inflammation with exacerbations is a REVERSIBLE lung disease that has triggers that stimulate it

-infections
-colds
-chemicals

any irritant

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3
Q

What causes asthma?

A

Not a single factor

But there is eosinophils (also sometimes neutrophils and T-lymphocytes)
-goblet cell hyperplasia
-increased mucous leads to plugging of airway
-inflammation

All of these lead to airway edema and mast cell activation leading to hyper-reposniveness

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4
Q

What causes hypersensitivity and what is the hypersensitivity

A

Antigens
Leading to bronchoconstrition and inflammation

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5
Q

What are the factors that cause asthma?

A

Environmental factors (more allergens)
Genetic factors

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6
Q

What is the strongest identifiable predisposing factor for asthma?

A

Atopy

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7
Q

What is atopy?

A

combination of runny nose, allergy like symptom, rash, eczema

if eczema and runny nose, they will likely have asthma

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8
Q

What are the risk factors for asthma?

A

Obesity
Respiratory irritants
Pollutants (2nd hand smoke)
Environment
Weather (often cold)
GERD
Virus
Exercise-induced
Beta-blockers
Stress
Aspirin
NSAIDs
Family history

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9
Q

When does asthma begin?

A

1-5 years MC (51.4%)

77% <5 years old

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10
Q

What are the types of asthma?

A

Extrinsic (allergic)
Intrinsic (something inside)
Mixed
Occupational
Drug-induced
Exercise induced
Cough variant (after ruling things out, improved with bronchodilator)

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11
Q

What is the diagnostic approach that you start with for asthma?

A

Clinical suspicion
History
PE with s/s of allergies (wheezing, eczema)

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12
Q

How do you confirm dx of asthma?

A
  • PFT (spirometry) typically at 5

perhaps allergy testing
sometimes just try bronchodilator and see if it works

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13
Q

What are the s/s of asthma

A

Dry hacking cough
Wheezing
Chest tightness
SOB
Episodic wheezing with virus/cold

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14
Q

What are the PE of asthma?

A

Increased nasal secretion
Mucosal swelling
Nasal polyps
Wheezing or just prolonged expiratory
Use of accessory muscles
Silent chest (no air movement at all)
Mild, severe,

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15
Q

What do you focus on for PE of lung exam

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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16
Q

What is the diagnostic testing of choice for asthma, and what are the criteria?

A

Spirometry shows reduced FEV1/FVC < 70% in adult < 85% in adult

Bronchodilator trial: FEV1 OR FVC improves by 12% for kids (just need one) and adults need 200 mL as well (it is reversible)

REVERSIBILITY IS SEEN IN ASTHMA, not COPD

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17
Q

If you are not able to catch asthma on spirometry, what can you do?

A

Bronchoprovocation test (induce an asthma attack with histamines, needs to have greater than 65% FEV1 otherwise dmg)

exercise test
peak flow measures
CXR (typically normal though)

Skin allergen testing
Measure sputum for eosinophils

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18
Q

Why would you order a CXR for asthma?

A

Undiagnosed
Low yield in acute asthma exacerbation (abnormal after repeat)

Status asthmaticus or no improvement

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19
Q

What do you see in CXR for asthma?

A

MC = nothing
Sometimes hyperinflation

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20
Q

What do you see on labs for asthma?

A

ABGs may show hyoxemia, hypercarbia
CBC = eosinphilia
Sputum: casts, thick sputum, Curschmann’s spirals and Charcot-Leyden crystals (both only seen in asthma)

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21
Q

What is a methacholine challenge test?

A

Breathe in excessive methacholine and perform spirometry after each dose

If we see decrease >20% in FEV1 up to 16 mg/mL max dose

very expensive though, very rare, very dangerous

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22
Q

Differences in asthma and COPD

A

Onset: asthma = early, COPD = late
s/s: asthma = vary from day/day based on exposure COPD = slowly progressing symptoms
Allergy, family history, reversible
COPD is not reversible

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23
Q

What is a golden rule of asthma?

A

Not all wheezes = asthma

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24
Q

What are some complications of asthma?

A

Exhaustion
Dehydration
Airway infection
Pneumothorax

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25
After a diagnostic of asthma, what do you do next?
Determine severity Development of treatment plan Educate on how to use dilator Close monitoring of patient
26
To stage asthma, what are important questions to ask?
1. How many days a week do you have symptoms? 2. How many times a month do you wake up from attacks? 3. How is your life effected between exacerbations? 4. Have you required oral steroids Should test for FEV1 measurements and FEV1/FVC ratio at every visit
27
What is mild intermittent asthma?
Daytime asthma symptoms occurring ≤ 2 or fewer days per week ≤ 2 night awakenings per month Use of SABA/rescue inhaler fewer than 2 times per week No interference with normal activities between exacerbations (not missing activities) FEV1 measurements between exacerbations are consistently within normal range (≥ 80% predicted value) FEV1/FVC ratio between exacerbations that is normal 0-1 exacerbations requiring oral glucocorticoids per year
28
What is mild persistent asthma?
Symptoms more than 2 weekly (although less than daily) Approximately 3-4 night-time awakenings per month due to asthma (but fewer than every week) Use of SABA to relieve symptoms more than 2 times a week (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
29
What is moderate persistent asthma?
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
30
What is severe persistent asthma?
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
31
What are the goals of asthma treatment?
1. Minimal or no chronic symptoms in the day, night, or after exertion 2. Minimal to no exacerbations 3. No limitations on activities 4. Maintain near normal pulmonary function 5. Minimal use of rescue inhaler (less than or equal to 2 times a week) 6. Minimal or no adverse effects of medications
32
What are the pharm treatments for asthma?
Short-Acting Beta-Agonist (SABA) Inhaled Corticosteroids Long-acting Beta Agonist (LABA) Combined Agents Inhaled Anticholinergics Theophylline Leukotrienes Miscellaneous (Cromolyn) Racemic Epinephrine Monoclonal Antibodies
33
What are SABAs vs LABAs used for?
SABAs = relievers LABAs = preventers
34
What pharm should every asthmatic have?
SABA Albuterol Levalbuterol known as rescue inhalers relaxes smooth muscles -everyone asthmatic needs this!!!
35
What is the difference between albuterol and levabuterol
levalbuterol = no cardiac problems, but they are more expensive
36
What are the SE of SABAs?
Tachycardia Nervousness Shakiness Less SE with levalbuterol though
37
What are the inhaled corticosteroids used for in asthma? How much should you percribe?
Preferred long-term controller Prescribe the lowest dose possible
38
What are the common inhaled corticosteroids for asthma? Which is also in a nebulize form?
Pulmicort (only one in nebulize solution, perferred in preggo) Qvar Asmanex Flovent
39
What is the MOA of inhaled corticosteroids for asthma
Reduces airway inflammation and reduces sensitivity to asthma triggers reduce symptoms and decreases risk of exacerbations
40
What are the common SE of inhaled corticosteroids for asthma and patient eduction to reduce this?
Thrush Hoarseness (dysphonia) Localized contact hypersensitivity Cough and throat irritation Should wash out mouth after use
41
What are the rare SE of inhaled corticosteroids for asthma? What do you need to monitor as a result?
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 Regular eye exams with h/o or family h/o glaucoma Monitor growth in children on ICS (BMI <15%); cortisol levels Watch calcium and Vit D intake in women and children on ICS ICS is the recommended inhaler in pregnant women. Budesonide (Pulmicort) is proven very safe in pregnancy. Proventil is also safe.
42
What is the preferred ICS for preggos?
Pulmicort Proventil Both Ps = preggo!
43
What systemic corticosteroids do you use for asthma? When do you give these?
Prednisone Prednisolone Methylpredinsolone 5 days for kiddos 7 days for adults Oral always, because it works just as quickly Always give to moderate/severe asthmatics
44
What are the SE of prednisone, prednisolone, and methylprednisolone?
Side Effects Contraindications Skin and soft tissue Cushingoid appearance / weight gain Cataracts / glaucoma CV disease GI disease - gastritis, ulcer formation, GI bleeding, pancreatitis Hyperinsulinemia with insulin resistance
45
What are the LABAs and when do you use it?
Only after starting SABA + systemic steroid salmeterol formoterol arformoterol
46
What is the MOA of LABAs and therefore associated SE?
Affects smooth muscle not limited to the airways and therefore can affect smooth muscle in the heart causing tachycardia and palpitations Shakiness Cramping of hands, legs and feet May cause worsening of symptoms if used too often
47
How are ICS and LABAs typically taken? Pros/cons?
As a combo drug when not controlled with high dose ICS Beneficial because you have the bronchodilator working to widen the airway + inhaled corticosteroid that reduces and prevents inflammation of the airway Limitations - COST - 2nd tier on most insurance plans
48
What are the anticholinergics for asthma?
Ipratropium bromide Tiotropium bromide Ipratropium and albertol Relax airways and reduces mucus in airways
49
What is theophylline?
Nonselective phosphodiesterase enzyme inhibitor Mild bronchodilation, anti inflammatory, enhances mucociliary clearance, and strengthens diaphragmatic contractility Add on medicine for moderate to severe asthma Monitor serum concentrations Not for acute exacerbations Not used often!
50
What is the benefit of leukotrienes? Suffix?
Reduce mucous like crazy Suffix = lukast Prof Davis would be a drug rep for Montelukstat (singulair)
51
What is the MOA of -lukast?
Blocks the actions of cysteinyl leukotrienes at the 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
52
What is the BB warning for -lukast?
Psych at night, behavior issues
53
What is cromolyn?
Mast-cell stabalizer For early/late asthma Only as nebulizer
54
What is Nebulized Epi?
Racemic Alpha and beta agonist Bronchiole dilation, decreased mucous membrane secretion, reduce edema
55
What are the SE of Nebulized epi?
Restlessness, anxiety, tachycardia, etc. Children should be monitored closely in the ER or hospital setting for at least 3 - 4 hours after a single dose due to “rebound phenomenon”
56
What Monoclonal antibodies used for asthma?
Omalizumab DNA-derived, igG antibody binds to igE Allergy related BBW of anaphylaxis (need epi in case)
57
How are patients now treated when dx first with asthma?
ICS and a SABA! ICS typically used only during exacerbation, but can be used daily
58
What are the six steps of asthma treatment?
1. SABA + low dose ICS when symptomatic or low dose ICS daily 2. SABA + low dose ICS 3. SABA + low dose ICS + LABA OR medium dose ICS alone 4. SABA + medium dose ICS + LABA 5. SABA + high dose ICS + LABA (or montelukast) 6. SABA + high dose ICS + oral steroids + LABA (or montelukast); consider monoclonal antibody
59
How do you use a inhaler with spacer?
Breathe in and hold breath
60
How do you desensitize asthmatics?
Allergy shots to expose them
61
How often do you monitor patients with asthma?
Routine follow-up visits for patient with active asthma are recommended every 1-6 months depending upon the severity of asthma. Recommended 2-6 week follow up after any new med is administered to reassess function
62
When should you step down treatment for asthma treatment?
If stable for 3+ months Wanna do lower potency for example
63
What do you base an asthma diary off of?
Peak flow meter How often they are in the red, yellow, and green
64
How do you determine asthma control?
Well controlled Symptoms ≤ 2 days of symptoms a week Not well controlled Symptoms > 2 days a week or multiple times a night Very poorly controlled Symptoms persist throughout the day A 20% change in value from AM to afternoon or day to day shows poor control Can also give an asthma test
65
What are the goals of asthma treatment?
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
66
What is the patient education for asthma?
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”
67
When do you refer to pulm or allergist?
Unclear asthma dx spirometry 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
68
What is exercise-induced asthma?
Coughing, SOB, wheezing, chest tightness stars in 3 min, peaks 10-15 min, resolves within 60 minutes without broncho
69
What is the PFT for exercise-induced asthma? What do you write for them? How do you diagnose?
Normal A trial of an inhaler reduces symptoms = diagnosed with exercise-induced asthma
70
What is cough-variant asthma?
Non-productive cough PFT normal Bronchodilator = recovers symptoms = diagnosed
71
What is an Acute Asthma Attack (AAA)?
All asthma attacks give a warning Warning signs and symptoms for adults may include: 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 Warning signs or symptoms for children may include: 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 Primary care vs hospital treatment
72
How do you treat AAA?
Albuterol inhaler Monitor O2 <94% on child <92% for adult then O2 supplementation -albuterol/aprovent solution -recheck -then third nebulizer treatment If 3 nebulizers, it is an emergency, then they will go to PICU Also give oral steroid
73
What is the most severe variant of asthma?
Status asthmaticus
74
What is the presentation of Status asthmaticus?
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 Build-up of carbon dioxide leads to acidosis Blood pressure may fall to low levels The airways are so narrowed that it is difficult to move air in and out of lungs (from so much mucous) Require intubation and ventilator support as well as maximum doses of several medications Support is also given to correct acidosis

Clin Med IIB Pulmonology (12 decks)

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