PULMO-Asthma Flashcards by JHope .

Asthma

narrowing (obstruction/reacive) of bronchial airways
bronchoconstricat, hyperreactive= dyspna
reversible

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Prevlaance

8-11% us population
1/2 chidren. Inc AA- leave in polluted city, mold, old buildings, fast food, stressful, close prox,
<10y male to female 2:1
>10y female to male 2:1

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Risk factors

Rarely truth behind growing out of ashtma
many adults have asthma excbaeration w/ illness
Smoking parents
Work place bacteria

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Extrinsic Atopic Asthma

Pt response to IgE antibody. inc IGE
Atopy= common triad of eczema, allergy, asthma
FH
age <30y
Seasonal sx
Males

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Intrinsic

No Atopy
No triggers
Asthma w/ URI
Older age onset
No FH
*Normal serum IgE
No repsponse to bronci changes
*less respons to therapy
persistent and progressive

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Pahtophysiology

Breathing throough a straw c/c
Narrowing of airway
Inflammotory-mast cells, baophil eosnphils, reacte and, vessels enlarge, mucus produce w/ WBC, narrow
Inc. resisetance
Aireway edema
Pt breath at high volume to keep airway open, hyperinflation

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Bronchoconstriction

Exercise
Allergens
Pollutants
URI
Aerosols
GERD
Food persever-sulfates
Aspirin, NSaids
Dry, cold air

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Pathophysiology

Inflammatory mediators:
cause bronchial smooth muscle contraction resulting in airway edema, inflammation and narrowing

increase mucus production- edema and mucus plugging leads to narrowing of peripheral airways causing increased resistance to inspiratory and expiratory air flow and trapping of air

patient must breathe at high volumes to keep the airway open, causing hyperinflation

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What is the Dx of a patient who has episodic bronchoconstriction that follows exercise?

Exercise Induced Bronchoconstriction (EIB)

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Intermittent paroxysms of cough

chest tightness

wheezing

dyspnea

Cough variant asthma

May or may not report associated provoking factors

slowly progressive over a period of hours or days

Describe a patient with Asthma: Clinical Characteristics

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Cough variant asthma

cough may be sole presenting sx of asthma, in pts with or without h/o asthma;

may progress to include wheezing, SOB;

must be considered in pts with subacute or chronic cough

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Describe Asthma Physical Exam

Tachypnea
Tachycardia

SOB

diffuse inspiratory and/or expiratory wheezes

Use of accessory muscles

Hyperinflation,

HYPER-resonance

Position helps indicate severity
mild – supine
moderate – sitting
severe – tripod

Between exacerbations PE should be normal

Look for evidence of triggers (allergic rhinitis, URI, sinusitis)

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WBCs maybe elevated d/t: prednisone, infection, received epinephrine, or stress

ASX-lab normal – may have elevated serum IgE with atopic disease

Eosinophilia: useful in diagnosing asthma in NEW onset wheezing reversible by β-2 agonists

Pulse oximetry: baseline & measure desaturation with exertion; acute exacerbations

Peak Expiratory Flow Rate (PEFR) -Baseline gives indication of severity, or control of asthma
document response to tx
Maximal flow rate achieved in the FVC

Describe Diagnostics of Asthma Pt

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diffusing capacity of the lungs for carbon monoxide; measures ability of lungs to transfer gas from inhaled air to RBC in pulmonary capillaries; helps narrow ddx of lung disease

Quantitation of diffusing capacity of CO (DLCO

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Forced Vital Capacity: FVC

Volume of gas that can be forcefully expelled from the lungs after maximal inspiration

Spirometry

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FEV1

Volume expelled in the first second of the FVC

Forced Expiratory Volume:

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TLC
Volume of gas in lungs after a maximal inspiration

:RV
Volume remaining after maximal expiration

Total Lung Capacity:

Residual Volume

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Spirometry Results

RAD- all low, except TLC normal and Vol N
Narrow curver

Obstrucive- wider curve

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Performed in PFT laboratory

Inhaled methacholine MC stimulus - histamine, mannitol

Indicated in patients with unusual presentation (cough variant asthma, EIB) of asthma or unclear diagnosis

What is used for a Bronchoprovocation Test?

Pts EIB without documented asthma, adult onset

Treadmill exercise to raise HR 85% of predicted max, look for fall in FEV1 of 10-15% = dx EIB

Measured at 2.5, 5, 10, 15, 30 mins after exercise, correlate with symptoms

Alternatively do bronchoprovocation test

Exercise Testing

Normal or hyperinflation-uncommon

Pt w/ asthma presentatino and feibril, R/O pneumonia

Pt w/ pleuritic chest pain or subcutaneous emphysema, r/o pneumothorax or pneumomediastinum

Sinus CT may be useful to r/o sinusitis

CXR

Classification of Asthma Severity

Step 1: Intermittent

Sx <2 days/wk

Night wakes <2x/mo

SABA use <2 days/wk

No interferece w/ acivity

PFT- Normal FEV1

FEV1 >80 predicted

FEV1/FVC normal

Step 2: Mild Persistent

Sx >2 days/wk

Night wakes 3-4x/mo

SABA use >2 days/wk

Minor interference w/ acivity

FEV1 >_80 percent predicted

FEV1/FVC normal

Step 3: Mod Persistent

Sx Daily

Night wakes >1x/wk

SABA use Daily

some limits interference w/ activity

FEV1 >60 but <80 percent predicted

FEV1/FVC reduced 5%

Step 4: Severe Persistent

Sx throughtout day Night wakes >7x/wk SABA use several times/day extremely limited interference w/ activity FEV1 >_60, <80 percent predicted FEV1/FVCr educed 5%

Short term vs long term management Rescue vs controller medications Supplemental O2 if pulse oximetry < 93% Cardiac monitoring in acutely ill patients

Management | Stepwise approach

Smooth muscle relaxant short term treatment Blocks muscular contraction Increases ciliary motion Decreases mediator release from basophils and mast cells ADR-tremor, tachycardia, headache ``` #1 SABA-Albuterol, levalbuterol exacerbations of asthma, EIB Oral inc. ADR ``` #LABA- Salmeterol, formoterol recommended only as add-on therapy to inhaled corticosteroids as controller medications

β-adrenergic (β2) Agonists | SABA

Components of Controls | Well

``` Sx- <2d/wk Night wakes <2x/mo Activity- none SABE use- <2d/wk FEV1 or PF> 80/personal best Questionnaires- 0, 20 ```

Components of Controls | NotWell

``` Sx- >2d/wk Night wakes 1-3x/mo Activity- some limits SABE use- >2d/wk FEV1 or PF 60- 80/personal best Questionnaires- 2, 19 ```

Components of Controls | Poor

``` Sx- thorughout day Night wakes >4x/mo Activity- extremely limit SABE use- several /day FEV1 or PF <60/personal best Questionnaires- 4, 15 ```

PS ActylCholinergic receptor blockade promotes bronchodilation by removing tonic vagal input to the smooth muscle of the airway ipratropium bromide (Atrovent): less side effects; added therapeutic effect when combined with LABA Atropine: effective anticholinergic but numerous side effects (HA, flushing, palpitations, delerium)

Anti-Cholinergic Agents | LAMA

Anti-inflammatory therapy Topical local effect while minimizing systemic Indicated Systemic steroids Frequent ER visits Hx of admissions for recurrent asthma exacerbations Hx of intubation for acute asthma Currently on inhaled steroids Experiencing symptoms > 3 days per week- continue

INhaled Corticosteroids

Long term controller oral Anti-inflammatory and bronchodilatory effects by blocking leukotrienes in bronchial smooth muscle cells, macrophages, and eosinophils allergic disease 70% + 30% - Montelukast and Zafirlukast

Leukotriene Receptor Antagonists

frightened and fatigued pattern deep and slow with progression to rapid shallow breathing; expiratory grunting heralds the onset of respiratory failure Coughing is ineffective Absent breath sounds in one hemithorax with wheezing in another suggests possible pneumothorax

Emergency Management

``` Step up if needed But considere resources enviroment, comorbid Adhereance Step down-only if well controlled 3mo. ``` SABA PRN

Stepwise RX Step 1 Intermintent Mild

Stepwise RX Step 2 Mild Mod

Low dose ICS Alt- LTRA, Nedocciman

Stepwise RX Step 3 Mod

Low dose ICS + LABA or Med dose ICS or Low dose ICS + LTRA, Zileuton

Stepwise RX Step 4 Mod- Severe

Med. dose ICS + LABA or Med dose ICS or Med dose ICS + LTRA Like Zileuton (less diserabel

Stepwise RX | Step 5

``` High dose ICS + LABA AND Ige Omalizumab (w/ Allergies need EPI ```

Stepwise RX | Step 6

``` 1stHigh dose ICS + LABA+ (Oral steroid, if needed) AND Ige Omalizumab (w/ Allergies ```

Arterial blood gas

O2 treatment for POx < 90% after tx (hypoxia) acute asthma-hypoxemia; arterial pO2 < 80 (ideal 95) dec CO2 hypocapneic as a result of reflex hyperventilation (breathing in bag bc inhale CO2 back in) ``` ABG in moderately ill pt: pO2=67 pCO2=32 pH =7.47 Severe asthma: hypoxemia worsens and pCO2 increases ```

Hypoxia and Hypoxemia | WHAT IS A NORMAL ABG?

HYPOXIA (O2 sat) VS HYPOXEMIA (ABG) pH 7.35-7.45, PaO2 80-100 PaCO2 35-45

Allergen Avoidance | Refer pts for allergy testing if indicated

H/o eczema, allergic rhinitis Asthma occurs seasonally, assoc with specific exposures Patient notes improvement in different locations Asthma not well controlled, especially children Pollens, molds, fungi, dust – common allergens, educate pts Cats/animals: avoid in the home, especially on bedding and clothing Smoke: discourage smoking and second-hand smoke exposure, wood burning stoves Serum eosinophils/IgE elevate

Annual influenza vaccine Tdap vaccine: 1st dose at 11-12 yrs Every pregnancy 27-36 one booster in adulthood Zoster vaccine (>60 yrs)

Prevention: Vaccines in Asthma

Adults who smoke or have chronic lung disease: 1 dose PPSV23 •Give 1 dose of PPSV23 to all adults 65 years or older at least 1 year after any prior PCV13 dose and at least 5 years after any prior PPSV23 dose. ◦Adults who received one or two doses of PPSV23 before age 65 should receive one final dose of the vaccine at age 65 or older.

Pneumococcal vaccines