Asthma

Question 1

Risk Factors

Answer 1

• Positive family history
• Concurrent atopy!*
   Predisposition for increased production of immunoglobulin E (IgE) after exposure to common allergens
   One of strongest predisposing factor in the development of asthma
• Smoking + secondhand smoke
• Higher BMI
• Severe viral respiratory infections during first 3 years of life

Question 2

Triggers

Answer 2

• Inflammatory: allergens, respiratory infections, work
• Irritants: temperature change, exercise, strong odors, stress/emotions, cold air
• Other: medication, tabacco, gastric reflux, pollutants, food additives

Question 3

Symptoms

Answer 3

• Intermittent episodes of wheezing, coughing, and dyspnea (esp. at night / early morning)
• Some patients experience chest tightness or chronic cough that is not associated with wheezing
• Vary in duration, severity, and frequency

Question 4

Self Treatment with OTC

Answer 4

1. Symptoms are mild, intermittent (<2/week), and of short duration (<24 hours)
2. A prior diagnosis of intermittent asthma has been made by a PCP
3. Pt knows the warning symptoms indicating the need for urgent medical care
4. Pt does not have any other serious concurrent diseases that might impair oxygenation or breathing (COPD, CAD)
5. The individual is >/= 4 yrs for nebulize treatment or >12 years old for oral, and not pregnant
6. The current asthma symptoms are consistent with previous symptoms
7. The nonprescription medications are for short-term (<24 hours) treatment of mild symptoms (until seen by PCP)

Question 5

Exclusions for Self Treatment

Answer 5

• No previous diagnosis of asthma
• Concurrent condition (sx similar to asthma)
• Hx of asthma episodes severe enough to require systemic corticosteroids or urgent medical care
• Use of (or non-adherence to) other Rx long-term control medications for asthma
• No asthma care provider (not seen in >1yr)
• Pregnancy or <4 years of age or <12 years of age for oral
• Rx medications are ineffective
• Sx moderate/severe or more frequent than 2/week
• Sx have lasted more than 24 hr
• Sx unresponsive OTC asthma meds within 24 hr
• Sx of different quality/severity than previous episodes
• Signs and sx of respiratory/sinus infection

Question 6

Non-pharmacologic Therapy

Answer 6

• Identify triggers
• Reduce exposure/eliminate triggers
• Reduce/eliminate tobacco smoke
• Ensure vaccinations are up to date (influenza, pneumococcal)
• Trigger screening tool

Question 7

Asthma Medications: 2 groups

Answer 7

Quick-relief medications (rescue/reliever inhaler)
• Short-acting Beta2-agonist (SABA), ex: albuterol
• Epinephrine inhaler (OTC)

Long-term control medications (controller)
• Inhaled Corticosteroids (ICS)
• Combination ICS + Long-acting Beta2-agonist (LABA)

Question 8

Non-prescription Products

Answer 8

• Racepinephrine nebulizer solution
• Ephedrine/guaifenesin
• Epinephrine metered-dose inhaler

Question 9

Epinephrine

Answer 9

• Epinephrine (AKA adrenaline) is one of a group of monoamines called the catecholamines
• Epinephrine can bind to β2 adrenergic receptors and stimulate bronchodilation

Question 10

Racepinephrine

Answer 10

• Adults / children 4years and older
• Pour 0.5mL (1 vial) into nebulizer reservoir
• Give 1 to 3 inhalations from nebulizer
• Not more than every 3 hours
• Do not exceed 12 inhalations per 24hr

Question 11

Racepinephrine: Seek Medical Advice

Answer 11

- Breathing does not improve within 20
minutes
- Breathing worsens
- Patient uses >9 inhalations in 24 hr
- Patient uses > 3 days/week
- Patient has >2 asthma attacks within 1 week

Question 12

Racepinephrine: Safety Considerations (AE/C)

Answer 12

• Adverse drug reactions: tachycardia, arrhythmias, nervousness
• Do not use with concomitant monoamine oxidase inhibitor (MAOi) therapy or for 2 weeks after stopping MAOi drug
• Contraindications: pregnancy, cardiac arrhythmias, coronary insufficiency, poorly controlled hypertension, seizures, hypokalemia, angina, hyperglycemia, and uncontrolled hyperthyroidism
• Do not use if brown in color or cloudy

Question 13

Safety Considerations: Ephedrine and Guaifenesin

Answer 13

Ephedrine side effects:
- Palpitations, tachycardia, arrhythmias, seizures, hypokalemia, angina, hyperglycemia, hypotension, and hypertension

Guaifenesin side effects:
- Nephrolithiasis (kidney stones) – case reports have linked to guaifenesin alone and in combination with ephedrine

Question 14

Epinephrine Inhaler

Answer 14

Brand name: Primatene Mist

• Dosage form: Metered-dose inhaler
• Only approved for mild, intermittent asthma
• Do not use if < 12 years old
• Not a replacement for Rx meds
• Inhale 1 puff by mouth, may repeat x1 after 1 minute
• Subsequent doses not given for 3 to 4hr

Question 15

Epinephrine Inhaler: PCP, AE

Answer 15

See a physician if:

• Have never been diagnosed with asthma
• Not better in 20 minutes
• Symptoms get worse
• Need > 8 inhalations in 24 hours
• Have > 2 asthma attacks in a week

Adverse Reactions:
- Hyperactivity, restlessness, excitability, palpitations, headache, upper respiratory irritation, pharyngeal dryness