Asthma & COPD Flashcards
Asthma: Pathophysiology
- Chronic inflammatory disorder of airways
- Recurrent episodes of wheezing, breathlessness, and chest tightness
- Airflow obstruction is reversible
Asthma: Classifications
Classifications:
- Mild persistent, moderate persistent, and severe persistent
Slightly differing definitions for adults and children
Asthma: Goals of Therapy
Reduce impairment
- Prevent chronic symptoms
- Reduce use of inhaled short-acting beta agonists
- Maintain normal or near-normal pulmonary function
- Maintain normal activity levels
- Meet patient/family expectations of asthma care
Reduce risk
- Prevent recurrent exacerbations & minimize ER visits & hospitalizations
- Prevent loss of lung function
- Provide optimal therapy with minimal ADRs
Asthma Step Therapy
- First, determine severity of asthma symptoms
- Go to Step Therapy Chart, and start at recommended step
- The GINA Guidelines prefer an aggressive approach to gaining quick control
- Assess patient’s response ever 2-3 months
Asthma- Mild: Pharmacodynamics
- Use step 1 therapy
- Use short-acting beta2 agonists, as needed, for symptoms
- Patients have symptoms when exposed to triggers (upper respiratory infections, allergens, chemical inhalants)
- Exercise can be mild intermittent
- Patients need an annual flu shot
Asthma- Mild: Treatment
Treat with low dose inhaled corticosteroid medication daily
- Low dose inhaled corticosteroids are the mainstay for patients of all ages
Use beta agonists as needed; if using 2 days or more per week, then step up therapy
Asthma- Moderate: Treatment
Treat with medium-dose inhaled corticosteroids
- or low-dose inhaled steroids plus leukotriene receptor modifier
Short-acting beta agonists may be used
Exacerbations may require oral corticosteroids
Asthma- Severe Persistent Asthma: Treatment
Step 4 therapy
- Medium-dose inhaled corticosteroids plus long-acting beta agonist
- Or medium-dose inhaled corticosteroid and a leukotriene modifier or theophylline
Step 5 therapy
- High-dose inhaled corticosteroids plus long-acting beta agonists
Step 6 therapy
- High-dose inhaled corticosteroids plus long-acting beta agonists and oral corticosteroids
Requires consultation with asthma specialist
Asthma: Monitoring
Once control is achieved, the patient is seen every 2-3 months to determine if a step-up or -down in therapy is indicated
The GINA Guidelines recommend that the dose of inhaled corticosteroids be reduced about 25-50% every 2-3 months to the lowest possible dose to maintain control
Asthma: Managing Exacerbations
Treat with oral steroids to regain control
Use a short burst
- Adults: 40-60 mg/day for up to 5-10 days
- Children: 1-2 mg/kg/day (max 50 mg/day) for 3-10 days
If not effective, then step up therapy
Asthma: Home Management
Assessing severity
- Risk factors for fatal asthma attack include: previous severe exacerbations requiring intubation or ICU admission, 2 or more hospitalizations or 3 ED visits in the past year, use of more than 2 short acting beta agonist inhalers per month, worsening asthma, low socioeconomic status
In-home Treatment
- Increased use of inhaled beta agonist (2-6 puffs every 20 minutes)
- Oral corticosteroiuds
- Good response: stepped up therapy for several days
Asthma: Pregnant Patients
Monitor asthma symptoms at each prenatal visit
Inhaled beta agonists are the drug of choice
Inhaled corticosteroids are the long-term drug of choice
Asthma: Pediatric Patients
Three categories of wheezing in children younger than age 5 years
- Transient early wheezing
- Persistent early-onset wheezing
- Late-onset wheezing/asthma
The GINA Guidelines have treatment categories for 0-5 years & 5-11 years
Stepwise approach is similar in adults and children but not the same
- Some medications are not approved or should not be used in children
- Long-acting beta agonists should not be prescribed singly but need to be combined with an inhaled corticosteroid
Asthma: Challenges in Pediatrics
Delivering medication to children
- Use aerochamber with mask for infants and young children
- Use spacer for all children
- Home nebulizer is an option
School-age and adolescent children: need to use inhalers at school
- Need education & observation of self-administration
- Will need note to school about use of medication at school
- Asthma action plan provided to school nurse
Asthma: Older Adults
Determine if symptoms are reversible (asthma) or not (possibly COPD)
Medications
- Increased ADRs
- Interactions with medications taken for chronic medical conditions (beta blockers)
Asthma: Special Situations
Seasonal Allergies
- Start long-term control medications more than 1 month before allergy season starts
Cough variant asthma
- Trial of bronchodilator
- Same stepwise management
Exercise Induced Asthma (EIA)
- Most asthmatics have EIA
Asthma: Treatment for EIA
- Short acting beta agonist 15 minutes before exercise (2 to 3 hours)
- Salmeterol lasts 10-12 hours (cannot use if using as long-term care medication)
- Mask or scarf over mouth if EIA is cold-induced
- Leukotriene modifier may help
Asthma: Monitoring
The GINA Guidelines recommend ongoing monitoring of the following six areas:
- Signs and symptoms
- Pulmonary function
- Quality of life and functional status
- History of asthma exacerbations, pharmacotherapy
- Patient-provider communication
- Patient Satisfaction
Asthma: Outcome Evaluation
Optimal outcome is being able to do activities of daily living with minimal asthma symptoms
Refer to an asthma specialist:
- If there is difficulty achieving or maintaining control
- If immunosuppressive therapy is being considered
- Any adult who requires step 4 therapy or child who requires step 3 therapy
Asthma: Patient Education
Written asthma action plan include:
- Overall treatment plan
- Specific drug therapy
- Drugs as part of treatment regimen
- Adherence issues
Review asthma action plan routinely, at least every 6 months
COPD: Definition and Risk Factors
Definition:
- Condition of chronic airflow limitation
- Progressive and heterogeneous
- Involves airways and lung parenchyma
Risk Factors:
- Smoking
- Occupational exposure
COPD: Diagnosis and Classifications
Diagnosis
- Spirometry Tests: positive when forced expiratory volume in 1 second (FEV1) & forced vital capacity (FVC) is less than 70%
Classifications:
- Mild, moderate, severe, very severe
COPD vs. Emphysema
Patients with COPD
- Are obese
- Are diagnoses as chronic with copious sputum production
- Suffer from hypoxemia, cyanosis, & carbon dioxide retention
Patient with Emphysema
- Are older and thinner at diagnosis
- Are barrel chested and breathe through pursed lips
- Suffer from dyspnea
COPD: Pathophysiology
Acute and chronic inflammation
Cellular proliferation changes
Environmental triggers implicated in immune response
