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Pulm > Lecture 6: Asthma > Flashcards

Lecture 6: Asthma Flashcards

1
Q

Define asthma.

A

Reversible, obstructive lung disease caused by increased airway sensitivity.

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2
Q

What pathophysiologic characteristics are seen in asthma?

A
  • Inflammatory cell infiltration with eosinophils, neutrophils, and T-lymphocytes.
  • Goblet cell hyperplasia
  • Thick mucus plugging small airways
  • Hypertrophy of smooth muscle
  • Airway edema
  • Mast cell activation
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3
Q

What are the two physical factors that ultimately lead to asthma?

A
  • Airway obstruction
  • Bronchiole constriction
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4
Q

What is the strongest, identifiable, predisposing factor for development of asthma?

A

Atopy

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5
Q

What are the risk factors for asthma?

A
  • Obesity
  • Respiratory irritants
  • Pollutants
  • Weather (cold)
  • Environment
  • GERD
  • Viruses
  • URIs
  • Exercise
  • Stress
  • BBs
  • NSAIDs/ASA
  • FMHx
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6
Q

When does most asthma begin by?

A

< 5 years of age

77%

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7
Q

What asthma type is uncommon and typically idiopathic?

A

Intrinsic asthma.

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8
Q

What confirms a diagnosis of asthma?

A

Spirometry w/ reversibility test.

Usually not done until age 5

Can also do allergy testing.

Perform normal spirometry
Give BD and then perform spirometry again.

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9
Q

What are the primary S/S of asthma?

A
  • Cough
  • Chest tightness
  • SOB/Dyspnea
  • Difficulty breathing
  • Episodic wheezing
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10
Q

What do nasal polyps in the nose for a suspected asthmatic child suggest?

A

CF

In an adult, might just be benign.

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11
Q

What PE findings might suggest asthma?

A
  • Nasal secretions/mucosal swelling and/or nasal polyps
  • Atopy, ocular shiners, salute sign
  • Wheezing, prolonged expiratory, hyperexpansion of thorax
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12
Q

On a lung exam, what should be documented regarding the 4 parts of a lung exam?

A
  • Inspection: shape and movement
  • Palpation: reduced if hyperinflated, maybe reduced tactile fremitus
  • Percussion: normal to hyperresonant
  • Auscultation: Rhonchi to wheeze, prolonged expiratory, or even silent chest in severe.
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13
Q

For a child >= 5 years old, what is the spirometry criteria to diagnose asthma?

A
  • Reduced FEV1/FVC (< 85% for a child)
  • Increased FEV1 post BD
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14
Q

What substances does bronchoprovocation testing use to induce an asthma attack?

A
  • Histamine
  • Methacholine challenge test
  • Mannitol

Not indicated if FEV1 < 65%

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15
Q

What at home testing is good to monitor asthmatics with?

A

Peak flow meters

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16
Q

When are CXRs indicated for asthma?

A
  • Initial diagnosis of asthma
  • Uncertain diagnosis from PFT
  • Refractory acute asthma attack/status asthmaticus to r/o other causes and complications.

MC finding is nothing!

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17
Q

What might we see elevated in a CBC for asthma?

A
  • Eosinophils
  • IgE as well.
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18
Q

What might be seen in a sputum culture/sample of an asthma patient?

A
  • Charcot-Leyden crystals (Crystals of eosinophils)
  • Curschmann spiral (Shed epithelium)

Both are specific to asthma.

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19
Q

What is the methacholine challenge and what is a significant finding?

A
  • Inhalation of increasing methacholine dosages and PFTs.
  • Increased airway hyperresponsiveness with a >= 20% decrease in FEV1 per max dose.

Only inpatient and expensive.

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20
Q

What is the golden rule about asthma?

A

All wheezes are not asthma!

Could be a far more severe condition

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21
Q

What is tussive syncope?

A

Fainting from coughing

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22
Q

What is the criteria for mild intermittent asthma?

A
  • daytime symtoms <=2 days/week
  • <=2 night awakenings/month
  • use of SABA <=2 days/weeks
  • No functional impairment between exacerbations.
  • FEV1 >= 80% between exacerbations.
  • FEV1/FVC normal between exacerbations.
  • 0-1 exacerbations requiring oral glucocorticoids per year.

Essentially, asthma attacks happens 2 or less times a week and it doesn’t affect you otherwise.

23
Q

What is the criteria for mild persistent asthma?

A
  • daytime symptoms more than twice a week (not daily)
  • 3-4 night awakenings per month
  • use of SABA > twice a week
  • Minor interference with normal activities
  • FEV1 normal and FEV1/FVC normal
  • 2+ exacerbations requiring oral glucorticoids annually.

Essentially, more frequent than mild intermittent, but not heavily impactful on your day-to-day

24
Q

What is the criteria for moderate persistent asthma?

A
  • Daily symptoms
  • Nighttime awakenings > once a week
  • Daily SABA use
  • Minor limitations in normal activities
  • FEV1 60-80% and FEV1/FVC lowered.

Not able to go on a run.

25
Q

What is the criteria for severe persistent asthma?

A
  • Daily symptoms
  • Nighttime awakenings nightly
  • Multidaily SABA use
  • Extremely limited
  • FEV1 <=60%, FEV1/FVC below normal.
26
Q

When is levalbuterol used over albuterol?

A

Presence of cardiac issues (It should have less cardiac SEs)

However, it is more expensive.

Main SEs of SABAs:
Tachycardia
Nervousness
Shakiness

I emailed Davis about it and she said its just a clinical pearl, won’t be tested on. Articles say it has no diff in SE.

27
Q

What are the inhaled corticosteroids used for asthma?

A
  • Budesonide/pulmicort (Neb/Inhaler, so it can be used in children/babies)
  • Beclometasone/Qvar (inhaler only)
  • Mometasone furoate/Asmanex (inhaler only)
  • Fluticasone propionate/Flovent (inhaler only)

Preferred long-term controller

28
Q

What are the most common SEs with inhaled corticosteroids?

A
  • Thrush
  • Hoarseness
  • Localized hypersensitivity
  • Cough and throat irritation

Rinse mouth out after use.

Also caution about systemic symptoms.

29
Q

What medical history is pertinent in prescribing an ICS?

A
  • H/o of glaucoma
  • Growth levels (BMI < 15)
  • Calcium and Vit D intake
30
Q

What ICS inhalers are recommended in pregnant women?

A
  • Budesonide

Can also use albuterol/proventil, but ICS is preferred.

31
Q

What are the systemic corticosteroids used for acute asthma attacks?

A
  • Prednisone (pill)
  • Prednisolone (liquid)
  • Solumedrol (IM/IV)

PO preferred if no IV access.

Oral and IV have the same onset for these meds.

32
Q

What are the SEs of systemic corticosteroids?

A
  • SSTI
  • Cushing/weight gain
  • Cataracts/glaucoma
  • CV disease
  • GI disease
  • Hyperinsulinemia w/ insulin resistance
33
Q

When are LABAs used?

A

Already on a SABA and ICS. Adjunct therapy

Salmeterol
Formoterol
Arformoterol

But usually combined with an ICS in a combo.

34
Q

What additional SEs can LABAs cause over SABAs?

A
  • Cramping of hands/legs/feet
  • Overuse can worsen symptoms
35
Q

For an acute asthma attack nonresponsive to a SABA, what is the usual next step?

A

Anticholinergics, such as:

  • Ipratropium bromide (atrovent)
  • Tiotropium bromide
  • Ipratropium and albuterol

Relax airway, prevent narrowing, and reducing mucus.

36
Q

What is theophylline?

A
  • A non-selective phosphodiesterase enzyme inhibitor.
  • Enhances mucociliary clearance and anti-inflammatory.

Mainly only in mod-severe asthma. Need to monitor serum concentrations.

37
Q

What are the leukotrienes and their MOA?

A
  • Montelukast/singulair
  • Zafirlukast/accolate

MOA: Leukotriene receptor antagonist

Overall, improves symptoms, reduces exacerbations, and limits markers of inflammations such as eosinophil counts.

38
Q

When is cromolyn used and what is it?

A
  • Used when intolerant of ICS for asthma.
  • Mast cell stabilizer
  • Reduces airway reactivity.

Neb only.

39
Q

What is racemic (nebulized) epi mainly used for?

A
  • Severe Croup
  • Last resort for severe asthma

Slightly more beta-2 agonist.

Racemic = quick peak, quick onset, 1-3 hours and then it is gone.
Need to monitor after administration for 4 hours!!!!!!

40
Q

What MAB is used for asthma?

A

Omalizumab/Xolair.

Injectable that targets IgE mast cells.

Must be an allergy-related asthma.

Also used in chronic, idiopathic urticaria.

Can cause anaphylaxis as BBW.

41
Q

In general, what would you first prescribe to a newly diagnosed patient with asthma over 12 yo?

A
  • SABA PRN
  • Low dose ICS daily or PRN w/ SABA.
42
Q

What are the 6 steps of asthma treatment?

A
  1. SABA + low dose ICS when symptomatic or low dose daily.
  2. SABA + low dose ICS
  3. SABA + low dose ICS + LABA OR medium dose ICS only.
  4. SABA + medium dose ICS + LABA
  5. SABA + high dose ICS + LABA/montelukast
  6. SABA + high dose ICS + LABA/montelukast + oral steroids + (consider MAB)

AKA start with a SABA and low dose ICS and slowly go up.

43
Q

How often is asthma followed up on?

A
  • Routine: 1-6 months
  • Adjusting meds: 2-6 weeks

Once stable for 3+ months, consider stepping down treatment.

44
Q

What ethnicities have lower predicted values on peak flow meters?

A
  • Black
  • Hispanic

10% lower predicted

45
Q

How do we determine asthma control?

A

How often they have symptoms weekly.

46
Q

At what asthma step do you refer out to pulm or an allergist?

A
  • > 5 yo = step 4 or higher (SABA + med dose ICS + LABA)
  • < 5 yo = step 3 or higher (SABA + low dose ICS + LABA or med dose ICS
47
Q

What is Exercise Induced Asthma? (EIA)

A
  • Airway narrowing during vigorous exercise
  • usually at onset of exercise or within a few mins.
48
Q

How do we treat EIA?

A

Trial SABA

49
Q

What is cough variant asthma and how we do treat it?

A
  • Chronic non-productive and nocturnal cough > 3 weeks.
  • Treated same as asthma

Generally a r/o cause.

Usually normal PFTs.

50
Q

What are the warning S/S for an acute asthma attack in an adult?

A
  • Increased SOB or wheezing
  • Disturbed sleep
  • Angina/tightness
  • Increased SABA use
  • Fall in peak flow rate
51
Q

What are the warning S/S for an acute asthma attack in a child?

A
  • Audible wheezing/whistling
  • Coughing frequently or in spasms
  • Waking at night
  • SOB
  • Chest tightness
52
Q

What is status asthmaticus?

A
  • Most severe form of asthma.
  • Lungs are inadequate to provide adequate perfusion
  • Leads to organ dysfunction and ARDS
  • Requires intubation and ventilator support.
53
Q

How is an acute asthma attack treated in office?

A
  1. Nebulized albuterol + O2 check
  2. 2nd neb (duoneb) + O2 check
  3. 3rd neb + O2 check

If not > 94% or in severe distress still, refer to ER.

3 neb treatments is only for mild-mod.

Pulm (12 decks)

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