Asthma Flashcards
1
Q
What is the key prevention to asthma related deaths according to expert advocates
A
Patient education
2
Q
Asthma Risk Factor: household
A
- Asthma history in the family
3
Q
Asthma Risk Factor: birth and nursing
A
_ Caesarian Section
_ Formula feeding
4
Q
Asthma risk factor: farm living
A
_ Sheep farming
_ pressed or loose hay
5
Q
Asthma risk factor: Urban living
A
_ Altered dietary practices
_ Community associated infection
6
Q
Asthma risk factor: microbiological exposure
A
_ Dysbiotic microbiota
_ Respiratory viral infection
_ Bacterial pathogens
_ Lower burden helmith infection
7
Q
Asthma risk factor: lower socioeconomic status
A
_ Increased smoking rates
_ Higher stress
8
Q
Asthma Risk factors: other environmental factors
A
_ Smoking
_ Obesity
_ Use of antibiotics
9
Q
What are the major characteristics of asthma
A
- airflow obstruction: Bronchospasm, edema, mucous hypersecretion
- bronchial hyper-responsiveness
- airway inflammation
10
Q
Pathophysiology of Asthma
A
- Basement membrane is inflamed and have mucus plug
- Inflammatory cells induce submucosal edema or inflammation
11
Q
- Bronchoconstriction
- occurs in minutes
- mast cells
A
Immediate acute response
12
Q
_ Submicosal edema, hyper-responsiveness
_ occurs in hours
_ inflammatory cells activation
A
Late acute response
13
Q
- epithelial cell damage, mucus hypersecretion, hyper-responsiveness
- occurs within days
- eosinophils and lymphocytes
A
Chronic asthma
14
Q
Forced vital capacity
A
Volume of air that can be forcibly blown out after full inspiration
15
Q
Forced expiratory volume one
A
Forced expiratory volume in one second
16
Q
How is FEV1 represented
A
Percentage of the predicted
17
Q
Spirometry
A
Measures FVC and FEV1
18
Q
Peak expiatory flow
A
Measures maximum flow of an expelled in one forceful breath out in L/min
19
Q
Used in conjunction with asthma action plan
Measures highest of 3 readings
A
Peak expiatory flow
20
Q
What is the control-based asthma management cycle
A
Assess
Adjust
Review response
21
Q
How is asthma symptoms graded
A
Intermittent to chronic
22
Q
True/False: Asthma is always wheezing and wheezing is always asthma
A
False
23
Q
How is asthma diagnosed
A
Patient history
Airway obstruction reversibility following SABA
24
Q
What are the long-term management goals for asthma
A
Reduce impairment and risk:
Prevent chronic symptoms
Require infrequent SABA use
Maintain normal lung function and activity
Prevent exercebation
Minimize need for emergency care
Minimize ADR of therapy
25
Steps to asthmas diagnosis
Detailed history and examination for asthma
Perform spirometry and reversibility test
Confirm diagnosis
Treat for asthma
26
What is the normal FEV1/FVC ratio in healthy adults and children
Adults > 0.75-0.80
Children > 0.85
27
What is the bronchodilator reversibility and what is it used for
FEV1 increasing by > 200ml and > 12% of the baseline value after a bronchodilators
Used for asthma diagnosis
28
What FEV1/FVC ratio value used for asthma diagnosis
< 70%
29
What is another indication for asthma looking at the FEV1
FEV1 increasing by > 200ml and > 12% of the baseline value after 4 weeks anti inflammatory treatment
30
How is asthma symptom severity assessment classified?
Well controlled
Partly controlled
Uncontrolled
31
When is symptoms considered controlled?
Daytime Sx > 2x/week
Nighttime asthma waking
SABA needed > 2x/week
Any activity limitation due to asthma
No to any of the above
32
When is symptoms considered partly controlled?
Daytime Sx > 2x/week
Nighttime asthma waking
SABA needed > 2x/week
Any activity limitation due to asthma
Yes to 1 or 2 of the above
33
When is symptoms considered uncontrolled?
Daytime Sx > 2x/week
Nighttime asthma waking
SABA needed > 2x/week
Any activity limitation due to asthma
Yes to 3 or 4 of the above
34
GINA guideline for asthma control therapy:
symptoms less than twice a month
Preferred controller and reliever:
| ICS-Formoterol prn
35
GINA guideline for asthma control therapy:
symptoms twice a month or more but less than daily
Preferred controller:
Low dose ICS daily
Or
Low dose ICS-formoterol prn
Preferred reliever:
Low dose ICS-formoterol prn
36
GINA guideline for asthma control therapy:
Symptoms most days
Waking with asthma once a week or more
Preferred controller:
Low dose ICS-LABA
Preferred reliever:
Low dose ICS-Formoterol
37
GINA guideline for asthma control therapy:
Symptoms most days
Waking with asthma once a week or more
Low lung function ( PEF < 80%)
Preferred controller:
Medium dose ICS-LABA
Preferred reliever:
Low dose ICS-Formoterol prn
38
When can oral corticosteroids be added to asthma therapy
When patient has severe uncontrolled asthma
PEF < 60%
39
What is the characteristics of metered dose
Contain medication + propellant
Delivers 5-50% of actuated dose
Must be shaken
Slow, deep inspiratory flow
40
What is the characteristics of dry powder inhalers?
Its breath actuated
Does not require hand-breath coordination to operate
Inspiratory flow is deep and forceful
41
Which group of patients should use spacers
Patient using metered dosing inhalers
42
What is the benefit of spacers
Decreases oropharyngeal deposition
Can help decrease side effect: hoarseness and thrush
43
How should spacers be cared for
Wash weekly with dilute detergent
Single rinse
Drip dry
44
Albuterol and Levalbuterol
SABA reliever
45
Symbicort ( budesonide + formoterol )
ICS + formoterol reliever
46
Dulera (mometasone + formoterol)
ICS + formoterol reliever
47
Prednisone or prednisolone
Oral corticosteroids reliever
48
Commonly used controller
ICS
ICS + LABA
Leukotriene modifiers
49
Symbicort
Dulera
Advair ( fluticasone + salmeterol)
Commonly used ICS+LABA controllers
50
Montelukast, zileuton, zafirlukast
Commonly used leukotriene modifiers controllers
51
Cromolyn and nedcromil
Infrequently used mast stabilizers controller
52
Theophylline, aminophylline
Infrequently used methylxanthines controllers
53
Anti-IgE, Anti-IL5, Anti-IL4R
Infrequently used biologics controller
54
First line of therapy for acute exacerbation
SABA
55
How is SABA dosed
As needed
56
ADR of SABA and LABA
Tachycardia
Tremor
Headache
Hypokalemia
Hyperglycemia
57
R isomer of Albuterol with less side effect
Levalbuterol
58
Bronchodilators
SABA
59
SABA advantage
Most effective for reversal of acute exacerbation
Inhaled less systemic ADR
Tolerance to side effect can develop
60
SABA disadvantage
No anti-inflammatory effect
Ineffective against nocturnal Asthma
Continuous use can lead to hyper-responsiveness in patients with severe cases
Tolerance can develop
Continuous overuse can confuse with preventative
61
Traditional therapy for patients with newly diagnosed or mild Asthma
Albuterol
62
Oral should not be used for Asthma
Albuterol
63
How is Albuterol dosed
2.5 mg = 1 nebulizer dose = 4 puffs MDI
64
How long should one Albuterol MID last?
One month
65
First line for maintenance therapy
ICS
66
What is the emerging place in therapy:
prevention of exercise induced Bronchospasm
relief of acute exacerbation
Low dose ICS+ formoterol
67
How is ICS+ formoterol dosed
Twice daily
68
ICS ADR
Oral candidiasis
Dysphonia
Cough
Osteoporosis
Skin thinning
Increased bruising
Hypothalamic pituitary axis suppression
69
LABA
Salmetorol or formoterol
70
Maintenance therapy in combo with ICS
LABA
71
Emerging therapy for:
Preventing exercise induced Bronchospasm
Relief of acute exacerbation
Formoterol
72
How are LABA dose
Twice daily
73
What is the black box warning for using LABA alone
Slight increased death risk
74
What are recommendations for using salmeterol
Do not use as only long term medication
Maximize ICS prior to addition of salmeterol
Moderate and severe persistent Asthma
75
80mcg/4.5mcg two puffs twice daily
Low dose Symbicort
76
100mcg/50mcg one puff twice daily
Low dose Advair diskus
77
45mcg/21mcg two puffs twice daily
Low dose Advair HFA
78
55mcg/14mcg
Or
113mcg/14mcg
One puff twice daily
Low dose Airduo Respiclick
79
100mcg/5mcg two puffs twice daily
Low dose Dulera
80
160 mcg/4.5 mcg 2 puffs BID
Medium dose Symbicort
81
250 mcg/50 mcg 1 puff BID
Medium dose Advair Diskus
82
115 mcg/21 mcg 2 puffs BID
Medium dose Advair HFA
83
113mcg/14mcg one puff twice daily
Medium dose AirDuo RespiClick
84
200mcg/5mcg two puffs twice daily
Medium dose Dulera
85
What are the as needed low close ICS+formoterol?
Symbicort ( 80 mcg / 4.5 mcg 2 puffs PRN)
Symbicort ( 160 mcg / 4.5 mcg 1 puff PRN)
Dulera ( 100 mcg / 5 mcg 1 puff PRN)
86
Oral alternative for mild and moderate persistent Asthma
Used for prevention of exercised induced bronchoconstriction
Allergen induced asthma / allergic rhinitis
Used as add on therapy
Leukotriene modifiers
87
Monitor liver enzymes
Zileuton
88
Take in the morning and doesn’t affect sleep at night.
mood, sleep or behavioral changes
Leukotrienes modifiers
89
Short term use as "burst" therapy for exacerbation
Not routinely used as long term therapy
OCS
90
What is OCS dosing
1-2 mg / kg / day with a max of 60 mg / day
Use lowest dose possible
91
OCS ADR
Osteoporosis
Thin skin
Infection
Hyperglycemia
Fluid retention
Mood
92
With each patient visit what should be reviewed
Medication
Technique
Adherence
93
What are the 4 c's to remember at every Patient visit
Choose
Check
Correct
Confirm
94
What is considered severe or late symptoms
PEF or FEV1 <60% of best
Or
No improvement in symptoms after 48hours
95
How should late or severe symptoms be managed?
Continue reliever
Continue controller
Add prednisolone 40-50mg/day
Contact doctor
96
How long till follow up appointment for acute exacerbation
1-2weeks
97
How long till follow up appointment while gaining control
2-6weeks
98
How long till follow up appointment to monitor control
1–6months
99
If anticipating step down how long till follow up with patient
Every 3 months
100
What is a sustained step up in asthma therapy
Assessing asthma therapy for adjustment if symptoms or exacerbation persist despite 2-3 months controller treatment
101
What is duration of short term step up
1-2 weeks usually during a viral infection or allergen exposures
102
Which patient group require day to day adjustment
Patients using as needed low dose ICS+formoterol
for mild asthma (Step 1)
Or
As maintenance and reliever therapy (Step 2)
103
When is step down therapy considered
Patient achieves good control for 3 months
104
How should ICS based formulation be stepped down
Reduce ICS dose by 25-50% at 2-3months interval
105
What are add on treatment in severe asthma cases for patient with good adherence and inhaler technique but still uncontrolled
Leukotriene receptor antagonist
Tiotropium
Low dose macrolides
Biologics agents
106
What should you consider then considering using OCS for severe asthma cases
Avoid maintenance OCS if other options are available because of serious side effects
107
What is the only adjunctive therapy in mild asthma
Mast cells stabilizers
3-4 times daily
108
What group of people are more likely to have inflammatory phenotype
Those with persistent symptoms or exacerbation despite high dose ICS, good adherence and inhaler technique
109
How do you step down for patient on high or moderate dose ICS-LABA as maintenance
Reduce ICS dose by 50%
110
How do you step down patient on medium dose ICS-formoterol as maintenance and reliever
Switch to low dose for maintenance and continue as needed low dose reliever
111
How do you step down patient on low dose ICS-LABA or ICS-formoterol as maintenance
Reduce to once daily instead of twice daily
112
How do you step down patient on low dose ICS alone
Consider once daily dose ICS
Or
Switch as needed low dose ICS-Formoterol
Consider adding LTRA
113
How do you step down low dose ICS OR LTRA
Switch to as needed low dose ICS-formoterol
