Asthma Comorbidities (Mod 10)

Question 1

What is the Asthma Paradox?

Answer 1

Over reliance on SABA; rather than ICS/LABA use (preferred controller method)

• asthmatics typically treated the symptoms (bronchoconstriction) but not the underlying causes of inflammation

Question 2

What is the preferred method to prevent asthma exacerbations?

Answer 2

ICS/LABA (initial starting settings)

Question 3

Insert GINA 2023 (slide 5) and know the step ups…and drugs associated with each step

Question 4

What is Severe asthma on the GINA guidelines?

Answer 4

Steps 4-5 w/key being high dose ICS therapy for a year or OCS to maintain control for at least half of the year

Question 5

When assessing asthma severity, what should be taken into consideration before stepping up on the GINA guidelines?

Answer 5

Checking patient education, compliance, technique, , , incorrect diagnoses,and triggers.

• sometimes the asthma is not controlled as well, so it may not truly be within a step category within GINA
• Asthma severity is not static***

Question 6

add slide 7

Question 7

What is asthma often mistaken with?

Answer 7

VCD

Question 8

What do comorbities and complicating conditions have to do with asthma?

Answer 8

May incorrectly associate symptoms witho other conditions with asthma

Question 9

Add slide 8 later

Question 10

Slide 9

Question 11

How of ten is asthma response assessed in controlled asthma

Answer 11

every 3-6 months

Question 12

What are the 2 phenotypes of airway inflammation

Answer 12

Type 2 inflammation and non type 2 inflammation

Question 13

What is Type 2 Inflammation charactized by?

Answer 13

Cytokines (IL-4, IL-5, and IL-3) aka immune response to allergens. The following values would be expected:

• Sputum eosinophils > 2%
• blood eosinophils > 150/ul
• FeNO (fraction of examples nitric oxide) > 20 ppe

Question 14

What is Type 2 Inflammation accompied by?

Answer 14

Autopsy, often refractory to high dose ICS

Question 15

How is Type 2 Inflammation treated?

Answer 15

Treat type 2 comorbidites (nasal polyps, atopic dermatitis) etc. etc.

Question 16

Why are oral corticosteroids (OCS) the end game treatment for asthma?

Answer 16

OCS has quite a bit of side effects

Question 17

What is non type 2 inflammation characterized by?

Answer 17

Neutrophils

Question 18

What are non type 2 inflammation treatments?

Answer 18

Add on treatments (LAMA, LTRA, Low dose macro life, low dose OCS as last resort)

• Biologics are not a first line treatment option, but particular biological may be trialed

Question 19

What is Bronchial thermoplasty?

Answer 19

Thermal heat applied to selective ablate airway smooth muscles

Question 20

What does Bronchial Thermoplasty have to do with non type 2 inflammation?

Answer 20

Bronchial thermoplasty is a procedure used to treat severe asthma by delivering controlled thermal energy to the airy walls, reducing the amount of smooth muscle in the airways.

• only effective for type 2 airway inflammation, not non

Question 21

What is Biological Therapy?

Answer 21

An expensive IV/SC route to manage severe asthma (anti-i’ve for example)

Question 22

What are side effects of Biological therapies for asthma?

Answer 22

INjection site reactions, anaphylaxis, immunosuppressive

Question 23

What is the step wise approach?

Answer 23

A asthma treatment guideline for paediatrics

Question 24

Assuming no side effects, how long do Biological Trials run for?

Answer 24

Trial for at least 4 months, don’t d/c for 1 year.

• shots are done weekly

Question 25

How do Biological therapies work? - need to confirm******this slide doesn’t make sense

Answer 25

Uses thermal energy to reduce muscle associated with airway constriction in asthma patients - via Bronchial thermoplasty

Question 26

Common side affects of bronchodilators?

Answer 26

Increased HR

Question 27

Understand the asthma severity assessment card (slide 21)

Answer 27

Super similar to pram score stuff

Question 28

Goals of management for acute asthma exacerbations?

Answer 28

Early treatment with special attention to patient who are at high risk of asthma related events (aka visit the hospital early if relievers dont’ work) - Ventilatory support (NIPPV/Invasive) - Correctino of severe hypoxemia - Rapid reversal of air flow obstruction and inflammation via early treatment w/bronchodilators, corticosteroids, and adjunctive therapies - appropriate disposition decision making

Question 29

when should Bronchodilators be given via nebulizers vs mdi?

Answer 29

If sats drop below 85%

Question 30

Make a card for each med type in slide 23

Question 31

Add slide for other diagnotistic considerations (slide 24)

Question 32

Risk factors for Fatal Exacerbations

Answer 32

- Previous ventilation/ICU admissions/Hypercapnea - Previous asthma admission/ER visits - Requiring multiple classes of medications - Increased reliance on SABA - Poor medication adherence (not using ICS) - Older age - Poor perception of breathlessness (delays treatment) - Recent use of systemic corticosteroids - No asthma action plan - Psychosocial Factors

Question 33

Indications for intubation?

Answer 33

Deteriorating LOC - Exhaustion, fatigue, respiratory efforts, silent chest - Onset/progression of hypercarbia (ABG/etCO2) - Persistent hypoxemia despite oxygen therapy/NIV - Persistent instability (consider intubation pharmacology)

Question 34

What is dynamic hyperinflation? - need to confirm

Answer 34

Air just can’t get out???? can lead to hemodynamics instability

Question 35

Intubation is generally avoided for asthma, what strategies should you try first?

Answer 35

Maximize med therapies and NIV - ideal niv candidates would demonstrate persistent airflow limitations/respiratory fatigue, but normal vital signs

Question 36

What strategy can be used to help vent an asthmatic patient who is intubated?

Answer 36

Manually vent the patient by pushing their abdomen in

Question 37

General Asthma ventilation strategies?

Answer 37

lung protective strategies (low Vts, permissive hypercapnia) - High inspiratory flow rate - Long Term - Observe for dynamic hyperinflation - Use PEEP w/caution (5 or lower!) - may need to disconnect circuit to allow for exhalation if hemodynamics are suffering - Anesthetic agents (bronchodilation effects)

Question 38

Discharge planning for Severe Asthma?

Answer 38

Adequate oxygenation and responsive to treatment (significant improvement in PEF) - Able to manage symptom burden as outpatient - Medication; continue oral corticosteroids for 5-7 day, intimate ICS if not already taking. - Outpatient follow up (consult) within 2 weeks

Question 39

What is dynamic hyperinflation?

Answer 39

When there is insufficient time for exasbaration during breathing, leading to an increase in end expiratory lung volume during tidal breathing. - Air gets trapped (causing auto peep as well) - reducing subsequent breaths - COPDers usually expierence this, but asthmatics can do, the difference is asthmatics have trouble getting air in as well