B4.032 - Big Case Asthma

Question 1

Answer 1

Type 1 HS - allergic asthma

Question 2

what is a T1 HS reaction

Answer 2

Immediate hypersensitivity reaction

Involve IgE mediated relaesae of histamine and other mediators from mast cells and basophils

Question 3

what are type 2 HS reactions

Answer 3

Cytotoxic hypersensitivity

Involve IgG or IgM antibodies bound to cell surface antigens, with subsequent complement fixation

Question 4

what is a T3 HS reaction

Answer 4

immune complexc reactions

involve circulating antigen-antibody immune complexes tha teposit in post ca;illary venules, with subsequent complement fixation

Question 5

what is a T4 HS reaction

Answer 5

delayed

cell mediated immunity

mediated by T cells rather than by antibodies

Question 6

what is an arthrus reaction

Answer 6

type 3 immune complex mediate dHS that occurs following the intrdermal injection of antigen in the presence of a high level of circulating antibody. Within 4-12 hours the area becomes red and oedematous

Question 7

which cell line is increased in patient with an acute asthma exacerbation, severe asthama or smokers with asthma?

Answer 7

in acute setting neutrophils are the major component

Question 8

what is the 2007 definiton of asthma

Answer 8

Chronic inflammatory disorder of airway in whihc many cells an cellular elements play a role : mast cells, eosinophils, neutorphils, T lymphocyetes, macrophages, epithelial celsls. In susceptible indiviiduals this inflammation causes recurrent episodes of coughing (particularly at night or early in the morning), wheezing, breathlessness and chest tightness.

Question 9

when do asthmatics wheeze

Answer 9

on expiration

Question 10

describe the cause of inflammation in asthma

Answer 10

1. inhaled antigen activates mast cells/Th2 cells in airway
2. inflammatory mediators/cytokines
3. bone marrow activation
4. eosinophils migrate ot area of allergic inflammation
5. eosinophils release inflammatory mediators

Question 11

In pt with acute episode of asthma

Answer 11

Airway remodeling

why? hes 31, hopefully hes recieved treatment and had controlled asthma so he wouldnt have remodeling

Question 12

what causes airway remodeling

Answer 12

chronic asthmatic episodes that are poorly controlled

the smooth muscle constricts during an asthmatic episode, if you have chronic constriction due to failure to control constant asthma then this smooth muscle hypertrophies

Question 13

asthma pathogenesis

Answer 13

1. airways infiltrated wiht eosinophils and mononuclear cells
2. vasodilation and mocrovascular leakage
3. airway smooth muscle hypertrophy
4. new vessel formation
5. increased numbrs of epithelial goblet cells
6. deposition of interstitial collagens beneath epithelium

Question 14

will giving bronchodilators help with airway remodeling

Answer 14

not if its already formed

Question 15

Answer 15

All can play a role

A. gender is key here

Question 16

describe gender and asthma prevalence

Answer 16

before puberty boys higher prevalence

after puberty girls higher

Question 17

what factors initiate inflammation/asthma?

Answer 17

Question 18

what factors favor Th1 phenotype

Answer 18

Presence of older siblings

Early exposure to daycare

TB, measles, hepA

Rural environment

Question 19

what factors favor Th2 phenotype

Answer 19

widespread use of antibiotics

western lifestyle

Urban evironment

diet

sensitization to house-dust mites and cockroaches

Question 20

What does the Th1 phenotype lead to

Answer 20

protective immunity

Question 21

what does the Th2 phenotype lead to

Answer 21

Allergic diseases including asthma

Question 22

Answer 22

A. currently available therapies (ICS) for asthma control symptoms, but do not modify disease severity

AKA if you give a beta agonist once they go off the medicine they will still have symptomes

Question 23

Answer 23

ENT consultation

Classic - woman with PTSD –> vocal chords spasm

once you bypass obstruction with probe the symptoms should dissapate

Question 24

Answer 24

Answer is A. Fibrotic stricture is going to result in flattening of both the inspiratory and expiratory flow-volume loop. The other three answers are extrathoracic issues that would result in flattening of the inspiratory limb like we see on the above loop. See next couple slides.

Question 25

what is vocal cord dysfunction, what does it mimic, epidemiology

Answer 25

an abnormal adduction of vocal cords durign respiratory cycle Often mimics persistent asthma more common in young females with psychiatric illnesses localization of airflow obstruction to laryngela pharynx is an important clinical discriminatory feature wiht VCD

Question 26

what type of lesion causes this

Answer 26

Fixed lesion \* neoplams of central airway \* vocal cord paralysis with fixed stenosis \* fibrotic stricture

Question 27

what type of lesion causes this

Answer 27

variable extrathoracic lesions \* vocal chord paralysis \* subglottic stenosis \* neoplasm \* goiter

Question 28

what type of lesion can cause this

Answer 28

variable intrathoracic lesion \* Tumor of lower trachea \* thracheomalacia \* strictures \* wegners granulomatosis or relapsing plychondrosis

Question 29

Answer 29

Everything essentially

Question 30

key indicators for considering diagnosis of asthma

Answer 30

Question 31

what is spirometry looking for

Answer 31

airflow obstruction reversibility

Question 32

is there one single test to diagnose asthma?

Answer 32

no

Question 33

what is reversibility

Answer 33

when the patient blows the FEV1 is low, but when you give a bronchodilator in the clinic the FEV1 should open up

Question 34

whats methocholine challenge testing

Answer 34

Given to bronchocontrict and if it doesnt work think something else

Question 35

Answer 35

C - allay the spasm during the paroxysm

Question 36

Answer 36

B

Question 37

why does avoidance improve asthma symptoms?

Answer 37

decreased exposure means decreased reaction

Question 38

what is the best appraoch to asthma treatment

Answer 38

mutlifaceted. single steps are generally ineffective

Question 39

Answer 39

A. yes

Question 40

Answer 40

D. medium dose ICS

Question 41

what is mild intermittent asthma

Answer 41

\* symptoms = 2 days / week \* Breif exacerbations \* SABA use \<2x/month \* nighttime symptoms \<2x / week \* asymptomatic with normal lung function between exacerbations \* FEV1 and PEF \>/= 80% predicted \*PEF variablility

Question 42

what mediaction do you give someone with mild intermittent asthma

Answer 42

albuterol

Question 43

what is mild persistent asthma and how do you treat

Answer 43

inhaled cortico steroid (ICS) is the gold standard \*symptoms \>2 d / wk but not daily \* minor limitations \* SABA \>2d/week but not daily, not more than 1x /day \*nighttime asthma symptoms 3-4x/month \* FEV1 and PEF \>/= 80% predicted \* PEF variability 20-30%

Question 44

how do you treat mild persistent asthma

Answer 44

ICS

Question 45

what is moderate persistent asthma

Answer 45

\* daily symptoms \* exacerbations \>2x/week \* affects activity \* nighttime symptoms \>1x / week but not nightly \* daily use of short activng beta agonist \* FEV1 adn PEF \> 60% and \<80% predicted \* FEV1/FVC reduced 5% \*PEF variability

Question 46

what is severe persistent asthma

Answer 46

\* continuous symptoms \* frequent exacerbations \* frequent nighttime symptoms \* limited activity \*FEV1 and PEF \<60 \* PEF variability \>30%

Question 47

Answer 47

Answer is E. IV steroids are important but will not help in the acute exacerbation phase. They take 12 to 24 hours to work.

Question 48

what is the expert panel conclusion on sever asthma exacerbations in the ED

Answer 48

Ipratropium bromide (atrovent) , administered in multiple doses along with SABA provides additive benfit

Question 49

Answer 49

D. his LABA use you need to have ICS with LABA always!!! Never just LABA

Question 50

why do patients start taking LABAs instead of ICS

Answer 50

because ICS dont make you feel good but dont bronchodilate, LABA makes you feel better sooner so patients tend to just use those

Question 51

what is bronchothermoplasty

Answer 51

burn airways/scar muscle layer so the muscle cant constrict

Question 52

You are taking care of Mr. Smith, a 35 yo veteran, who reports intermittent compliance issues with is asthma meds. You should be most concerned about what? A. his dose of ICS B. allergen avoidacen strategies C. his occupational exposure risk D. his LABA use E. his inhaler technique

Answer 52

Answer is D. We don’t want asthmatics to use LABA's alone. Need to be on inhaled steroid as well.

Question 53

Mrs. P. is a 35 yo female with moderate compliance with her asthma. Which of the following statements is correct in regards to her management of acute asthma exacerbations? ## Footnote žA. A peak-flow-based plan may be particularly useful for patients who have difficulty perceiving airflow obstruction and worsening asthma (Evidence D). žB. Appropriate intensification of therapy by increasing inhaled short-acting beta2-agonist (SABA) and, in some cases, adding a short course of oral systemic corticosteroids (Evidence C). žC. Recognition of early signs of worsening asthma and taking prompt action (Evidence B). žD. Patient education, including a written asthma action plan to guide patient self-management of exacerbations at home, especially for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations (Evidence D).

Answer 53

Answer D: This slide speaks to the importance of pt education and providing an asthma action plan so pt's can initiate a therapy plan from home if and when they start to develop an exacerbation. These plans often direct them to contact their physician if they are not improving with specified therapy.

Question 54

Mrs. P. does not recognize her asthma has worsened and ends up being admitted to unit 66 for an acute asthma exacerbation. She reports dyspnea, cough, and wheeze and believes her trigger is the humidity. Which therapy below has not been shown to have significant benefit for the hospitalized asthma patient? ## Footnote žA. Oxygen to keep sats\>92% žB. Prednisone 60mg po žC. Levaquin 500mg qd žD. SABA žE. Atrovent

Answer 54

E. Atrovent Remember, this has been shown to be beneficial on arrival to the ER during an exacerbation. If the pt does not improve and is admitted then albuterol is the drug of choice for bronchodilation but not both.

Question 55

You return to check on Mrs. P after admitting 2 other patients from the ER. She appears less tachypnic than before, but is still using her accessory muscles to breath. She appears mildly confused and is having a difficult time speaking. Her oxygen levels are stable on 2 liters. The most important next step in her care is? ## Footnote žA. Check an ABG žB. Intubate the patient žC. Start heliox stat žD. Add magnesium infusion to her management žE. Call a rapid response ž

Answer 55

A. check ABG ## Footnote Answer is A. This pt is showing signs of respiratory fatigue. Don’t be fooled by less tachypnea. As an asthmatic pt. fatigues they start to become more hypercapnic (retain CO2). This is likely contributing to her confusion. You need and ABG to assess her acid-base status and to see if she is developing a respiratory acidosis. If she is then you would call a rapid response, move her to the ICU and provide her with NIV or intubation. Additional magnesium is used for bronchodilation. Heliox is used for worsening hypercapnia when you are trying to clear CO2. Changes gas flow dynamics in the airway.

Question 56

Mrs. P. just can’t catch a break and gets intubated. You are asked by the respiratory therapist for ventilator settings. Your recommended ventilator strategy will be which of the following? ## Footnote žA. Active hyperventilation to remove C02. žB. Shortened expiratory phase to improve ventilation žC. Moderate tidal volume ventilation to maintain plateau pressures below 40. žD. Controlled hypoventilation žE. Permissive hypocapnia

Answer 56

Answer is D. We ventilate pt's with asthma at low lung volumes, slow rates (hypoventilation) and prolonged expiratory times. Remember, when they are obstructed with severe bronchial constriction during status asthmaticus they struggle to get the air out of their lungs. They are at increased risk of stacking breaths and air-trapping which will make the pressure in their thorax go up. This can result in hemodynamic compromise and shock. You don’t want them to hyperventilate, we always want to maintain plateau pressures below 30 to protect against ventilator-induced lung injury. We allow for permissive hypercapnia. Allow their PCO2 to run a little on the high side (pH of 7.20 to 7.25) until their bronchoconstriction improves with therapy.

Question 57

what is step one of treatment for asthma patients

Answer 57

SABA PRN

Question 58

what is step 2 for persistent asthma

Answer 58

**Low dose ICS** alternative: Cromoly, LTRA, Nedocromil, theophyline

Question 59

what is step 3 in treatment for persistent asthma patients

Answer 59

**ICS + LABA** **OR** **Medium dose ICS** Alternative: Low dose ICS and LTRA, theophylline or zileutron

Question 60

what is step 4 in treatment for persistent asthma

Answer 60

**medium dose ICS + LABA** alternative: medium dose ICS, adn LTEA, theophylline or zileuton

Question 61

what is step 5 in treatment for persistent asthma

Answer 61

**High dose ICS + LABA** AND consider **omalizumab** for patients with allergies

Question 62

what is step 6 for treatment of persistent asthma

Answer 62

High dose ICS + LABA + oral corticosteroid AND consider Omalizumab for patients who have allergies

Question 63

what should you check before stepping up asthma treatments

Answer 63

adherance, environmental control, comorbid conditions

Question 64

when can you step down mediactions

Answer 64

when asthma is well controlled at least 3 months