asthma Flashcards
1
Q
How can asthma be successfully managed?
A
- routine monitoring of lung function (PFTs and peak flow)
- pt education
- environment factors (avoid triggers)
- pharm: either start high or low dose
2
Q
What type of disorder is asthma?
A
- chronic inflammatory disorder of the airways
- reversible and obstructive disease
3
Q
Who is predominately effected by asthma?
A
- occurs in persons of all races
- ## occurs predominately in boys in childhood (2:1 ratio until puberty) then male to female ratio becomes 1:1
4
Q
Before what age are 2/3rd of all asthma cases dx?
A
- before age 18
- approx 1/2 of all children dx with asthma have a decrease or disappearance of sxs by early adulthood
5
Q
What is asthma?
A
- complex disorder characterized by variable and recurring sxs, airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation
6
Q
What are the airflow limitations in asthma?
A
- bronchoconstriction: bronchial smooth muscle contraction in response to exposure to a variety of stimuli
- airway hyperresponsiveness: exaggerated bronchoconstrictor response to stimuli
- airway edema: edema, mucus hypersecretion, formation of thickened mucus plugs
7
Q
What occurs chronically with asthma?
A
- 1: breakdown of epithelial cells
- 2: collagen deposition
- 3: massive airway edema, mast cells are activated and release histamine
- overtime this causes hypertrophy of airway: thick mucus is produced and more likely to develop pneumonia
8
Q
What is asthma characterized by?
A
- episodic, reversible bronchospasm resulting from an exaggerated bronchoconstrictor response to various stimuli
9
Q
How can asthma sxs vary?
A
- perennial versus seasonal
- continual versus episodic
- duration, severity, and frequency
- duirnal variations (nocturnal and early morning)
10
Q
What players are involved in the inflammatory response?
A
- the trigger or stimulus may be exposure to intrinsic or extrinsic host factors
- eosinophils: release granular protein that damages bronchial epithelium and promotes airway hyper-responsiveness
- lymphocytes: produce cytokines, leukotriene B-4, C-4, and prostaglandin and histamine
- Mast cells: initiate arousal condition in IgE receptors
11
Q
What are leukotrienes and what do they do?
A
- potent inflammatory mediators
- increased vascular perm/edema
- increased mucus production
- decreased mucociliary transport
- inflammatory cell recruitment (eosinophils - release inflammatory mediators)
- LTD 4: profound bronchoconstriction, about 1000x more potent than histamine
12
Q
Describe the early phase of asthma?
A
- IgE is secreted by plasma cells, binds to receptors on mast cells and basophils
- mast cells release mediators that contract airway smooth muscle directly
13
Q
Late phase of asthma?
A
- recruitment of inflammatory and immune cells, including eosinophils, basophils, neutrophils, and helper, memory T cells to site of allergen exposure
- dendritic cells are also recruited and plan an impt role
- the late phase rxn is more complex than just causing smooth muscle contraction
14
Q
What is intrinsic asthma?
A
- considered non-immune
- usually no personal or family hx
- *** serum IgE levels are normal
- usually develop in later life
- stimuli that have little or no effect in normal subjects can trigger bronchospasm: ASA, pulm infections (viral), cold, psychological stress, exercise, inhaled irritants, GERD, post nasal drip
15
Q
What is extrinsic asthma?
A
- initiated by type-1 hypersensitivity reaction
- atopic is most common
onset is usually the first 2 decades of life - associated with other allergic manifestations, family hx
- ** serum IgE and eosinophil count are usually elevated
- also is occupational asthma
- allergic bronchopulmonary aspergillosis
16
Q
What is exercise induced asthma?
A
- an asthma variant
- exercise or vigorous physical activity triggers acute bronchospasms in persons with heightened airway reactivity
- can be found in asthmatics, pts with atopy, allergic rhinitis or even healthy individuals
17
Q
What is tx for EIA?
A
- beta agonist 10-15 minutes before activity
- avoid activity in cold air if possible
18
Q
What are the classic triad of sxs for asthma?
A
- persistent wheeze, end expiratory wheeze
- chronic episodic dyspnea
- chronic cough
19
Q
What are the other associated sxs of asthma?
A
- tachypnea, tachycardia, and systolic HTN
- audible harsh respirations, prolonged expiration and wheezing
- sputum production
- chest pain or tightness
- hemoptysis
- diminished breath sounds during acute exacerbations
- pulses paradoxus
- sxs may be worse or only present at night (b/c of circadian rhythms)
20
Q
What is the DDx for asthma?
A
- COPD
- anaphylaxis
- FB ingestion
- CHF
- PE
- panic disorder, hyperventilation (heart attack sxs)
- pneumonia, bronchitis
- alpha1 -antitrypsin deficiency
- GERD
- sarcoidosis
- vocal cord dysfunction
- cough secondary to drugs (ACEI)
21
Q
What should you consider when pt presents with hemoptysis?
A
- allergic bronchopulmonary aspergillosis
- bronchiectasis
- lung carcinoma
- TB
22
Q
When should you consider a Dx of asthma?
A
- wheezing
- any hx of cough that is worse at night
- recurrent wheeze
- recurrent difficulty in breathing, recurrent chest tightness
-sxs occur or worsen in presence of:
exercise
viral infection
inhalant allergens and irritants
changes in weather, strong emotional expression, stress, menstrual cycles - sxs occur or worsen at night, awakening the pt
23
Q
What are the dx studies for asthma?
A
- PFTs:
decreased FEV1 less than 80%
FEV1/FVC less than 65%, hyperventilation - establish reversibility: FEV1 increase of 12% and 200 ml after SABA
- or provocation testing with methacholine or histamine: detects bronchial hyperactivity, supports dx, sometimes done when asthma suspected but PFTs are near normal
- CXR: will help rule out pneumonia, CHF, pneumothorax, airway lesions or FBO
- GE reflux assessment
- skin tests: atopy
- blood tests: eosinophils and IgE elevations (absence doesn’t exclude asthma)
24
Q
What is the global strategy for asthma and prevention?
A
- achieve and maintain control of sxs
- prevent asthma exacerbations
- maintain pulmonary fxn as close to norm as possible
- maintain normal activity levels including exercise
- avoid adverse effect from asthma meds
- prevent development of irreversible airflow limitation
- prevent asthma mortality
25
What does effective asthma management require?
- a proactive, preventative approach
- routine FU visits for pts with asthma, 1 to 6 months depending on severity
- FU should assess multiple aspects of pts asthma:
signs and sxs
pulmonary function
quality of life
exacerbations, adherence with tx and SEs and pt satisfcation with care
26
What should be included in the sxs assessment?
- sxs over past 2-4 weeks should be assessed
- daytime sxs and nightime sxs
- use of SABA to relieve sxs (how often?)
- difficulty in performing normal activities and exercise
27
What is the asthma action plan?
- pts normal peak flow value is used to construct a personalized asthma action plan which provides specific directions for daily managemnt and for adjusting meds in response to increasing sxs or decreasing PEFR
- PEF:
monitors airway obstruction, alter long term therapy for optimal control of sxs, keep diary, have clear plan in place for using peak flow info to intervene early in exacerbations
28
What are the 4 classifications of asthma for the stepwise management approach?
- step 1: intermittent
- step 2: mild persistent
- step 3: moderate persistent
- step 4: severe persistent
29
What qualifies a pt for step 1 intermittent?
- daytime sxs occurring 2 or fewer days/week
- 2 or fewer nocturnal awakening per month
- use of SABA agonists to relieve sxs fewer than 2x a week
- no interference with normal activities b/t exacerbations
- FEV1 b/t exacerbations are within normal range
- FEV1/FVC b/t exacerbations within normal limits
- one or no exacerbations requairing oral glucocorticoids per year
30
Using what more than 2x a week may indicate the need to start long term control therapy?
- using SABA for resuce more than 2x a week
31
What is mild persistent asthma?
- sxs more than 2x weekly (less than daily)
- 3-4 nocturnal awakenings a month
- use of SABA more than 2x a week
- minor interference with normal activities
- FEV1 measurements within normal range (80% of pred)
- FEV1/FVC normal
- 2 or more exacerbations requiring oral glucocorticoids/ year
- using SABA more than 2x a week may indicate start to long term therapy
- low dose inhaled steroids or cromolyn, or leukotriene inhibitors should be used
32
What is step 3 moderate persistent sxs?
- daily sxs
- nocturnal awakening more than 1/week
- daily need for SABA for sx relief
- some limitation in normal activity
- FEV1 b/t 60-80%
- FEV1/FVC is 95-99% of normal
- 2 or more exacerbations requiring oral glucorticoids
- either inhaled steroid (medium dose) or low dose and either LABA or sustained release theophyline (no)
- if needed give inhaled steroids in a medium to high dose
- consider referral to specialist
33
What sxs qualify for step 4 severe persistent asthma?
- sxs of asthma throughout the day
- nocturnal awakenings nightly
- need for SABA for sx relief several times a day
- extreme limitation in normal activity
- FEV1 less than 60%
- FEV1/FVC less than 95% of normal
- 2 or more exacerbations requiring oral steroids a year
- High dose inhaled steroid and either a long acting oral B2 agonist and oral steroids
- make repeated attempts to reduce systemic steroids and maintain control with high dose inhaled steroid
- refer to specialist!!
34
How can we control asthma severity?
- ID and control contributing factors:
- inhaled allergens
- tobacco smoke
- rhinitis/sinusitis
- GERD
- occupational exposures
- viral respiratory infections
35
How should asthma be monitored by both pt and clinician?
- pt self monitoring:
peak flow measurements, and self awareness of sxs
- clinician:
frequent visits to achieve clinical control
assess achievement of therapy goals
prevention of chronic sxs/episodes
- maintain normal activity levels
36
What is status asthmaticus?
- severe bronchospasm that is unresponsive to routine therapy
- can be sudden and rapidly fatal
- most pts have hx of progressive dyspnea, over hours to days, with increasing bronchodilator use
37
What is the presentation of status asthmaticus?
- difficulty talking
- using accessory muscles of inspiration
- orthopnea
- diaphoresis
- mental status changes
38
What is the tx for status asthmaticus?
```
Want to get a CXR
- oxygen
- oximetry
- ABGs
- peak flows with txs:
inhaled B2 agonists
inhaled anticholinergics (reverse vago-mediated hyperresponse)
oral or IV corticosteroids
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39
What should be done if there is an inadequate response to tx? a good response?
- inadequate respone:
hospital admission
- if good response:
d/c with inhaled B2 agonist, inhaled anticholinergic, oral corticosteroids x 5 days (steroid burst), and a FU within 5 days
