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Internal Medicine (IM platinum) > Asthma > Flashcards

Asthma Flashcards

1
Q

Etiopathogenesis of Bronchial asthma

A

Heterogenous disease

Characterized by:

  • Chronic airflow inflammation that varies markedly both spontaneously and with treatment

Associated with airway hyperresponsiveness and airflow inflammation.

Cells:

  • Mast cells
  • Eosinophils
  • T-cells
  • Neutrophils
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2
Q

Measures how much air an individual can exhale during a forced breath during the first second

A

Forced Expiratory Volume in 1 second (FEV1)

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3
Q

Total amount of air exhaled during the FEV test

A

Forced vital capacity (FVC)

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4
Q

FEV1/FVC Ratio

(FEV1%)

A
  • Normal: 75-80%
  • Reduced: Obstructive diseases
    • Asthma
    • COPD
  • May be normal or increased in Restrictive diseases
    • Fibrosis
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5
Q

Individual’s maximum speed of expiration, measured by a peak flow meter

A

Peak Expiratory flow

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6
Q

Clinical Manifestations of Asthma

A

Typical symptoms: (worse at night or early morning and vary over time and intensity)

  • dyspnea
  • wheeze
  • cough
  • chest tightness

Symptoms usually demonstrates REVERSIBILITY AND VARIABILITY

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7
Q

Most frequent PE abnormality in Bronchial Asthma

A

Expiratory weheezing or rhonchi on ausculation

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8
Q

Asthma Phenotypes

A
  • Allergic Asthma
  • Non-Allergic Asthma
  • Late-onset Asthma
  • Asthma with fxed airflow limitation
  • Asthma with obesity
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9
Q

Allergic asthma

A
  • Most frequent
  • Atopy
  • Sputum examination
    • eosinophilic airway inflammation
  • Responds well to inhaled corticosteroids
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10
Q

Non-allergic asthma

A
  • Sputum examination
    • neutrophilic or paucigranulocytic airway inflammation
  • Less responsive to ICS
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11
Q

Late-onset Asthma

A
  • Common in women
  • Adulthood
  • Requires higher doses of ICS or are relatively refractory to ICS
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12
Q

Asthma with fixed airflow limitation

A
  • Seen in patients with long standing asthma who develop fixed airflow limitation due to airway wall remodeling
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13
Q

Asthma with obesity

A
  • Obesisty
  • little eosinophilic inflamamtion
  • prominent respiratory symptoms
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14
Q

Diagnostic Criteria for asthma

A

1. History of variable Respiratory symptoms

  • Cough, dyspnea, Wheezing, chest tightness
    • More than one respiratory symptom
    • Occurs variably
    • Worse at night or early morning
    • Triggered by exercise, allergies, viral infections, laughter

2. Confirmed Variable Expiratory Airflow Limitation

  • Documented excessive variability in lung function AND
  • Documented Airflow limitation
    • FEV1 low, FEV1/FVC reduced (0.75-0.80)
    • The greater the variation, the more likely the Dx of asthma
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15
Q

Tests to Document Variable Expiratory Limitation

A
  • Positive bronchodilator Reversibility test
    • ​Increase in FEV1 >12% and >200ml from baseline
    • 10-15 mins after albuterol 200-400 mcg or equivalent
    • Bronchodilator meds witheld
      • >4 hours for SABA
      • >12 hours for LABA
  • Excessive VAriability in PEF
    • ​Average diurnal variability : >10%
    • calculated from twice daily readings, average for over 2 weeks
      • Day’s Highest - Day’s lowest / (mean of day’shighest and lowest PEF)
  • Increase in lung function after 4 weeks of anti-inflammatory treatment
    • ​FEV1 >12% and >200ml from baseline after 4 weeks of treatment
  • Others
    • ​Positive Exercise test
      • fall in FEV1 <10% and >200 ml from baseline
    • (+) bronchial challenge test
      • fall in FEV1 >20% with methacholine or histamine or >15% with hyperventilation, saline, mannitol
    • Excessive variation in lung function between visits
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16
Q

Assesing Asthma Symptom Control

A
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18
Q

Risk Factors for Poor Asthma Outcomes

A

Measure FEV1 start of treatment, after 306 months of controller treatment, then periodically

Presence of 1 or more increases the risk of exacerbations

  • Potentially Modifieble independent risk factors for exacerbations
    • Uncontrolled asthma sx
    • High SABA use
    • Inadequate ICS
    • Low FEV1 (<60%)
    • Major psychological or socioeconomic problems
    • Exposure: smokinh, allergen
    • Comorbidities
    • Sputum or blood eosinophilia
    • elevated FENO
  • Others
    • History of intubation or ICU admission for asthma
    • >1 severe exacerbation per year
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19
Q

Goals of Asthma Therapy

A
  • Minimal (ideally no) chronic symptoms, including nocturna sx
  • Minimal exacerbations
  • No emergency visits
  • Minimally use of as required B2-agonist
  • No limitations on activities
  • PEF circadian variation <20%
  • Normal PEF
  • Minimal or no adverse effects from medications
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20
Q

Reliever Medications

A
  • SABA
  • SAMA
  • Methylxanthines
21
Q

SABA

A

Stimulate adenyly cyclase increasing cAMP levels -> bronchodilation

Rapid onset of bronchodilation and best use for symptom relief

  • Salbutamol
  • Procaterol
  • terbutaline
  • Albuterol

No effect on chronic inflammation

May cause tremors, palpitations, and mild hypokalemia

22
Q

SAMA

A

Muscarinic receptor antagonists

Inhibits only the cholinergic reflex components and therby less effective than SABA

  • Ipatropium

provide (+) benefits if with SABA

AE: dry mouth, urinary retention, glaucoma

23
Q

Methylxanthines

A

Inhibit phosphodiesterase activity causing increase in cAMP levels and bronchodilation

  • Theophylline
  • Aminophylline
  • Doxofylline

Nausea, vmiting, Headache(most common)

24
Q

Controller Medications

A

Used for regular maintenance treatment

  • ICS
  • Systemic Steroids
  • LABA
  • LAMA
  • Leukotriene modifying drugs
  • Cromones
  • Anti-IgE
25
Q

Inhaled Steroids (ICS)

A

Most effective anti-inflmmatory agents for asthma control

Best route

  • Beclomethasone
  • Budesonide
  • Fluticasone

AE: hoarseness/dysphonia and oral candidiasis. pneumonia

26
Q

Systemic Steroids for BA

A

useful for treatment of acute exacerbations

  • Prednisone
  • Methylprednisone
  • Hydrocortisone

AE: truncal obesity, bruisability, osteoporosis, DM, HPN, ulcers, proximal myopathy, depression, cataracts

27
Q

LABA for Bronchial Asthma

A

Improve asthma control and reduce inflmmation when added to ICS, allowing lower doses of ICS to be given

Should not be given in the absence of LABA

  • Formoterol
    • rapid onset
  • Salmeterol
  • Bambuterol
  • Vilanterol
  • Indacaterol
  • Olodaterol
28
Q

LAMA for bronchial asthma

A

blocks acetylcholine’s effect on muscarinic receptors

  • Tiotropium

For STEP 4

29
Q

Leukotriene modifying drugs

A

Block leukotriene receptors or inhibit lipoxygenase

  • Montelukast
  • Zafirlukast
  • Zileuton

Less effective than ICS

Add on therapy in those not controlled with low dose ICS

Indicated for aspirin or exercised induced asthma

30
Q

Cromones

A

Inibit mast cell and sensory nerve activation

  • Cromolyn sodium
  • nedocromil sodium

very short duration of action needing frequent dosing

favorable safety profile

31
Q

Daily Doses of ICS for Adults

A
32
Q

Anti-IgE

A

inhibits IgE-mediated Reactions

  • Omalizumab

Very expensive

Limited to patients with elevated serum IgE levels

34
Q

Initial Controller?

  • Symptoms or need for SABA <2x/month
  • No waking due to asthma in the last month; and
  • no risk factors for exacerbation; and
  • No exacerbations in the last year
A

NO controller

35
Q

Initial Controller?

  • Infrequent symproms, but with >1 risk factors for exacerbation
  • Sx or need for SABA 2x/month to 2x/week or wakes due to asthma >1x/month
  • Sx or need for SABA >2x/week
A

LOW DOSE ICS

(Start with step 2)

36
Q

Initial Controller?

  • Troublesome symptoms most days; or
  • Waking due to sx >1x/week
  • Especially f with any risk factors for exacerbations
A

Moderate-High dose ICS or Low dose ICS/LABA

(step 3)

37
Q

Initial Controller?

  • Initial presentation is with severely uncontrolled asthma or
  • Initial presenation with an acute exacerbation
A

Short-course oral corticosteroids and regular controller (high dose ICS or moderat dose ICS/LABA)

38
Q

Stepwise management for Asthma

A
39
Q

How many months after initial controller treatment befor reviewing response?

A

2-3 months or according ro urgency

40
Q

Consider Stepping down

A

symptoms controlled for 3 months, low risk for exacerbations

42
Q

Diagnostics of Asthma Exacerbations

A
43
Q

Assessment for Severity of exaccerbations

A
44
Q

Management of Acute Exacerbations Depending on setting

A
45
Q

Assessing Asthma Severity

A
  • Mild
    • Well controlled with step 1 or step 2
  • Moderate
    • Controlled with step 3
  • Severe ASthma
    • requires Step 4 or Step 5
46
Q

Disposition or Discharge Planning for Patients in asthma Exacerbations

A
  • Clinical status and oxygenation should be reassessed fequently (titrate treatment as needed)
  • Msaure lung function in all patients one hour after initial treatment
47
Q

Sample Doses

A
  • Salbutamol
    • metered dose inhaler 100 mcg/ actuation
    • Adult: 2 puffs then after 2 hours can add another 2 puffs
    • Pedia: 2 puff (inhaler with spacer)
  • Budesonide
    • 200 mcg MDI
    • Adult: 2 puffs OD
    • Pedia: 1 puff OD
  • Salmeterol
    • 50 mcg MDI
    • Adult: 1-2 times
    • Pedia: 1
  • Salmeterol + fluticasone
    • 25mg/125mg
    • Adult 2 puffs
48
Q

Etiopathogenesis in exacerbations in asthma

A
  • Represent an acute/subacute worsening o of symptoms and lung function from the usual status that may require a change in treatment (or “step-up”)
  • May be the initial presentation of asthma
52
Q

Examples of Systemic Steroids

A
  • Prednisolone 50 mg OD PO
  • Hydrocortisone 200 mg in divided doses (5-7 days)
54
Q

Asthama-COPD Overlap (ACO)

A
  • Describes aptients who have features of both asthma and COPD
  • Referral to specialists for confirmation of diagnosis and mangement is recommended
  • Outcomes for ACO are often worse than for asthma or COPD alone

Internal Medicine (IM platinum) (14 decks)

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