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STEP 2 Pulmonary > Pulm. Asthma (09-27) (2) > Flashcards

Pulm. Asthma (09-27) (2) Flashcards

1
Q

asthma. Patohology?3

A

Bronchoconstriction and inflammation
Obstructive lung disease
IgE-mast cell mediated

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2
Q

Asthma. clinical presentation?

A

Wheezing from bronchoconstriction.

Shortness of breath.

Cough.

Worsens at night.

Atopy: eczema, seasonal allergies, and food. Response to triggers.

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3
Q

Asthma. diagnosis. ABG?

A

respiratory alkalosis

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4
Q

Asthma.diagnosis. spirometry used for diagnosing asthma in patients 5 years or more. findings?

A

o Decreased FEV1 to FVC ratio,
o Reversible by B agonist.
o Inducible with ach agonists.

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5
Q

Asthma. diagnosis. DLCO?

A

DLCO normal or increased. (vs decreased in COPD).

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6
Q

Asthma. algorithm. Do a PFT –> normal?

A

If normal –> methacholine challenge.
If positive –> asthma.

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7
Q

Asthma. algorithm. Do a PFT –> if OLD?

A

If OLD –> bronchodilator (albuterol) response.
If positive (>12% increase in FEV1) –> asthma.

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8
Q

Asthma. treatment. bronchodilators.

A

SABA (short acting)
LABA (long acting beta agonists)

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9
Q

Asthma. treatment. LABA adverse?

A

● Hypokalemia: muscle weakness, arrhythmias, and ECG changes.
● Tremor.
● Headache.
● Palpitations.

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10
Q

Asthma. treatment. anti-inflammatory. groups?

A

Inhaled corticosteroids.
Leukotriene antagonists - used interchangeably.
Oral corticosteroids.

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11
Q

Asthma. treatment. Inhaled corticosteroids. adverse?

A

● Oral thrush is the most common.
● Leukocytosis due to mobilization of marginated neutrophils, stimulation of release of immature neutrophils from the bone marrow, and inhibition of neutrophil apoptosis.
● Decreased lymphocytes and eosinophils.

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12
Q

Asthma. treatment. mast stabilizers? agents

A

Nedocromil.
Cromolyn.

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13
Q

Asthma severity. Intermitent. how often symtoms/use of SABA?

A

=<2 days a week

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14
Q

Asthma severity.Intermitent. nighttime awakenings?

A

=<2 times a month

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15
Q

Asthma severity. intermittent. what level treatment?

A

step 1

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16
Q

Asthma severity. mild persistent. Intermitent. how often symtoms/use of SABA?

A

> 2 days a week but not daily

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17
Q

Asthma severity. mild persistent. nighttime awakening.

A

3-4 times a month

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18
Q

Asthma severity. mild persistent. what level treatment?

A

Step 2

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19
Q

Asthma severity. moderate persistent. how often symtoms/use of SABA?

A

daily

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20
Q

Asthma severity. moderate persistent. nighttime awakening.

A

> 1 time a week but not nightly

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21
Q

Asthma severity. moderate persistent. what level treatment?

A

Step 3

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22
Q

Asthma severity. severe persistent. how often symtoms/use of SABA?

A

Throughout the day.

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23
Q

Asthma severity. severe persistent. nighttime awakenings.

A

4-7 times a week

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24
Q

Asthma severity. severe persistent. level treatment?

A

Step 4 or 5

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25
Asthma. Step 1?
SABA pagal reikala
26
Asthma. Step 2?
Low dose inhaled corticosteroids (ICS)
27
Asthma. Step 3?
Low dose ICS + LABA OR medium dose ICS
28
Asthma. Step 4?
Medium dose ICS + LABA
29
Asthma. Step 5?
High dose ICS + LABA AND Consider omalizumab for patients with allergies
30
Asthma. Step 6?
High dose ICS + LABA + oral corticosteroid AND Consider omalizumab for patients with allergies
31
Asthma. New recommendations: ICS for all steps including step 1 (taken as needed).
.
32
Asthma. Intermitent FEV1?
80 proc.
33
Asthma. mild FEV1?
80 proc.
34
Asthma. moderate FEV1?
60-80 proc.
35
Asthma. severe FEV1?
60 proc.
36
Asthma. Theophylline: PDE inhibitor that causes bronchodilation. Use as an alternative to step 3. what adverse? toxicity
Theophylline toxicity: ● CNS: headache, insomnia, and seizures. ● GI: nausea and vomiting. ● CVS: arrhythmia.
37
Asthma. Refractory asthma treatment?
chronic oral steroids.
38
Asthma. if patient is asks for more medications?
If someone comes in with need of more medications: ▪ Observe how they use inhaler. ▪ Use of spacer. ▪ Medication adherence.
39
Asthma. Exercise-induced bronchoconstriction, prevention?
short-acting beta-adrenergic agonists such as albuterol, used 10-20 minutes prior to exercise.
40
Asthma. high performance athletes?
albuterol plus antileukotriene agent.
41
Asthma. Exercise-induced bronchoconstriction. Inhaled steroids can be used for those who exercise daily and require pre-treatment with albuterol.
.
42
Asthma. Exercise-induced bronchoconstriction. Montelukast can be used as an alternative to the daily steroids.
.
43
Asthma. Exercise-induced bronchoconstriction Asthma exacerbation --> limit daily activity.
.
44
Severe life-threatening asthma. table. risk factors?
Recent poor control (frequency of symptoms, albuterol use) Frequent hospitalizations, emergency department visits or use of systemic glucocorticoids prior intubation for asthma
45
Severe life-threatening asthma. symptoms?
RR >30 k/d Pulse > 120 k/min SpO2 < 90 proc. incr. PaCO2 > 45 Peak expiratory flow =< 50 proc. predicted
46
Severe life-threatening asthma. examination findings?
Severe shortness of breath (eg inability to finish sentence or lie supine) Marked accessory muscle use Abscent wheezing (due to poor aeration) Pulsus paradoxus Mental status changes
47
Severe life-threatening asthma. 5 steps?
1. Give oxygen 2. nebulizers 3. IV steroids 4. you can try epinephrine and MAGNESIUM 5. Assess PEF rate
48
Severe life-threatening asthma. Give oxygen --> maintain SpO2 > 90 proc.
.
49
Severe life-threatening asthma. what nebulizers?
ipratropium and albuterol
50
Severe life-threatening asthma. assess PEF rate. 3 scenarios?
Get better --> go home (no need O2, no wheeze, PEF > 70 proc.) Needs more time --> ward (nebulizers and they'll transition to MDI; IV steroids and they'll transition to oral prednisone) Gets worse --> ICU, intubate (PEF < 50 proc.)
51
Respiratory failure in asthma. table. clinical?
extreme fatigue, altered mental status, absent/minimal wheezing (poor air entry), cyanosis, chest wall retractions
52
Respiratory failure in asthma. table. lab findings?
decr. PaO2 and pH (respiratory acidosis) incr. CO2
53
Normally in an asthma exacerbation: respiratory alkalosis. Normal pH and normal or high PaCO2 indicates respiratory muscle fatigue and impending respiratory failure.
.
54
Pharma for ACUTE asthma exacerbations SABA = inhaled albuterol. use?
Bronchodilator Continuous (if severe) or repeated dosing
55
Pharma for ACUTE asthma exacerbations anticholinergic = inhaled iptratropium bromide use?
bronchodilator repeated dosing only in acute setting and in conjuction with albuterol
56
Pharma for ACUTE asthma exacerbations glucocorticoid = prednisone, methylprednisolone, dexamethasone (oral/iv) use?
anti-inflammatory delayed effect (6h) Multiday dosing for control of late-phase inflammation Mehlman: ONLY IV, in acute po hospitalizacijos - oral corticosteroids ICS does not have a role in acute management
57
Occupational asthma. pathogenesis?
Antigens --> Inflammation (lgE dependent or Independent) --> reversible bronchoconstriction Animal proteins (eg, veterinary/laboratory animal workers, seafood processors), grain antigens (eg, bakers, food processors), isocyanates (eg. painters)
58
Occupational asthma. clinical. Onset?
asthmatic symptoms (cough, wheezing, dyspnea) closely linked lo workplace
59
Occupational asthma. clinical. chronic?
symptoms persist throughout workweek, abating after sustained absence
60
Occupational asthma. diagnosis?
workplace-specific change in airway physiology (eg, serial PEFR (peak expiratory flow rate) at home & work, serial sputum eosinophil counts)
61
Occupational asthma. management?
* Antigen avoidance (removal from the workplace preferred) or reduction (eg. management respirator use, rotation scheduling) * Bronchodilators & inhaled corticosteroids, desensitization & immunotherapy
62
Occupational asthma. PEF measurement frequency?
Serial PEF measurement: 4 times a day for 2 or more weeks.
63
Occupational asthma. Other diagnostic tactics: in-workplace spirometry, serial methacholine bronchoprovocation testing, and serial sputum eosinophil count.
.
64
Asthma treatment is based on the severity of asthma in the patient
.
65
Once a patient begins asthma controller therapy (eg, Inhaled corticosteroids) they are evaluated based on symptomatic assessment of asthma control.
66
Patients whose condition remains well controlled on the same therapy for 3 months should be considered for a step down in medication management, pvz Step 3 --> step 2
67
In patients with poorly controlled symptoms, medication therapy should be increased by 1 or 2 steps, and a short course of oral prednisone should be considered, pvz step 4 -> step 5
.
68
Exercise-induced bronchoconstriction (EIB) pathophysiology?
Passage of high volumes of dry, cold air --> triggering of mast cell degranulation --> Bronchoconstriction
69
EIB can occur in asthmatic patients but may also cause bronchospasm in those without a preexisting diagnosis of asthma
.
70
EIB. Treatment a. SABA (eg, albuterol) 10-20 minutes prior to exercise b. Antileukotriene agent 15-20 minutes prior to exercise - It is used in patients who can’t tolerate beta agonists c. Inhaled corticosteroids d. Combination of SABA and antileukotriene agents is used in high-performance athletes
.
71
EIB. SABA is first-line treatment if it is required only a few times a week (ie, less than daily). If the patient exercises daily, use inhaled corticosteroids or antileukotriene agents
.
72
Algorithm. Suspected asthma: intermitent resp symptoms (cough, dyspnea, wheezing, chest tightness) --> DO SPIROMETRY --> NORMAL?
NORMAL --> do metacholine bronchoprovocation test
73
Algorithm. Suspected asthma. metacholine bronchoprovocation test --> positive?
Asthma possible
74
Algorithm. Suspected asthma. metacholine bronchoprovocation test --> negative?
asthma unlikely (seek alternative diagnosis - eg CHF, PH, vocal cord dysfunction)
75
Algorithm. Suspected asthma: intermitent resp symptoms (cough, dyspnea, wheezing, chest tightness) --> DO SPIROMETRY --> OBSTRUCTION (FEV1/FVC < 70 proc) --> ?
Inhale bronchodilator (SABA)
76
Algorithm. Suspected asthma. Inhale bronchodilator (SABA) --> nonreversible?
COPD
77
Algorithm. Suspected asthma. Inhale bronchodilator (SABA) --> reversible?
Asthma confirmed
78
Algorithm. Suspected asthma. Inhale bronchodilator (SABA) --> reversible. what is ,,reversible"?
at least 12 proc. and 200 ml increase FEV1 or FVC, with postbronchodilator FEV1/FVC rise to >=70 proc.
79
Ventilatory response in asthma exacerbation.
During asthma exacerbation, the initial physiologic response is an increase in respiratory drive and resultant hyperventilation
80
Ventilatory response in asthma exacerbation. what metabolic change?
respiratory alkalosis
81
Ventilatory response in asthma exacerbation. what metabolic shows impending respiratory failure?
However, a normal or elevated PaCO2 is an alarming and extremely important finding that suggests impending respiratory failure
82
Ventilatory response in asthma exacerbation. symptoms (jau dahuja kartoti)
i. Markedly decreased breath sounds ii. Absent wheezing iii. Decreased mental status iv. Marked hypoxia with cyanosis
83
Ventilatory response in asthma exacerbation. management. mild to moderate asthma exacerbation?
i. Oxygen ii. SABA iii. Systemic corticosteroids (for those who don’t respond to the above-mentioned therapy)
84
Ventilatory response in asthma exacerbation. management. severe asthma exacerbation?
i. SABA ii. Ipratropium nebulizer iii. Systemic corticosteroids iv. One-time IV MgSO4 infusion (indicated for additional bronchodilation if the asthma exacerbation shows no improvement after an hour of therapy)
85
Ventilatory response in asthma exacerbation. management. Impending or actual respiratory arrest?
i. Endotracheal intubation
86
Asthma. Unlike COPD exacerbation, abs are not recommended for asthma exacerbations as viral infections are the most common trigger
.

STEP 2 Pulmonary (30 decks)

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