1
Q
What is SABA?
A
Short Acting Beta Agonist
2
Q
Example of SABA?
A
Albuterol
3
Q
What is LABA?
A
Long Acting Beta Agonist
4
Q
Examples of LABA?
A
Salmeterol
Formoterol
5
Q
What is LTRA?
A
Leukotriene Receptor Antagonist
6
Q
Example of LTRA?
A
Singulair
Montelukast
7
Q
About how much of the US is affected by Asthma?
A
8%
~22 million people (Men and Women
8
Q
Annual treatment costs of asthma in adults?
A
18 billion dollars
Total costs – Doubled (missing school/work)
9
Q
What is the hygiene hypothesis?
A
Factors that have been implicated include urbanization, air pollution, passive smoking, and change in exposure to environmental allergens.
Children aren’t exposed to anything to build their immune system anymore
10
Q
What are some components of the pathophysiology of asthma?
A
- Airway inflammation
- Intermittent airflow obstruction
- Bronchial Hyperresponsiveness
11
Q
Recent research shows that asthma is…
A
NOT a single disease! Different phenotypes
12
Q
Asthmatic Bronchioles are more ______ than normal bronchioles
A
Constricted
13
Q
Some of the principal cells identified in airway inflammation include:
A
Mast cells Eosinophils Epithelial cells Macrophages Activated T lymphocytes
14
Q
What can cause airway obstruction?
A
- Acute Bronchoconstriction
- Airway edema
- Chronic Mucous Plug Formation
- Aiways Remodeling
15
Q
Exercise-Induced Asthma
A
Controversial pathogenesis.
The disease may be mediated by water loss from the airway, heat loss from the airway, or a combination of both.
16
Q
How do you establish the dx of asthma?
A
- Episodic symptoms of airflow obstruction (wheezing, cough, chest tightness)
- Obstruction is at least partially reversible
- Alternative dx are excluded
- PFTs
- Simple spirometry with post-bronchodilator testing is adequate if COPD is not considered in the differential
17
Q
How does the typical patient present?
A
- Periodic cough/SOB/Chest Tightness (often assc with triggers)
- Nocturnal symptoms are common
- Recurrent episodes of SOB assc with a nighttime cough that awakens the pt is a classic presentation.
- “Wheezing” non-specific term with pts
- Childhood/family hx of asthma
18
Q
What is Bronchoprovocation Testing?
A
Methacholine-Mannitol Testing
- Methacholine is administered in incremental doses up to a max dose of 16 mg/mL
- Mannitol is also used
- 20% Decreased in FEV1 is considered a positive test result for the presence of bronchial hyperresponsiveness
19
Q
What is the standard method for evaluating patients with Exercised Induced Asthma?
A
Exercise Spirometry!
- 6-10 minutes of strenuous exertion at 85-90% of predicted maximal HR and measurement of post-exercise spirometry for 15-30 minutes
- Defined cut off for a positive test = 15% decrease in FEV1 after exercise
20
Q
When doing PFTs are they definitive?
A
No, it could be within normal limits if they are having a good day.
Asthma is reversible (controversially speaking)
21
Q
What might be a better measure than PFTs for asthma
A
Methacholine
22
Q
If the test goes up 10% more after albuterol treatment, then we can assume
A
Asthma, regardless of absolute values
23
Q
When do you suspect it’s not asthma?
A
- Long-time smoker (COPD)
- Older than 50 with no prior history
- Symptoms such as palpitations or syncope
- Poor response to asthma treatment
24
Q
When doing a physical exam on a patient with asthma or suspected asthma, what are you looking for?
A
- Nasal Polyps
- Chronic Sinusitis/Post-Nasal Drip
- Atopic Dermatitis
- Eczema
- End-expiratory wheezing with prolonged expiration
25
Are all wheezes indicative of asthma?
No
26
What can mimic asthma?
1. Vocal Cord Dysfunction
| 2. Cardiac Wheeze
27
What is Vocal Cord Dysfunction?
- Will commonly have dysphonia and inspiratory wheeze
- Responds poorly to standard asthma therapy
- Dx with Laryngoscopy
28
What is "Cardiac wheeze"
Thought to be secondary to airways edema and extrinsic compression
29
When asthma has been confirmed, what do you do?
Identify precipitating factors!!!
30
What are common allergens that trigger asthma?
1. Molds
2. Pets
3. Insects
31
Occupation and Environment can lead to trigger factors for asthma because of:
- Pollutant/Dusts may be present
| - Secondhand smoke
32
What are some of the comorbidities that aggravate asthma?
1. GERD
2. Sinusitis
3. OSA
4. ABPA
33
When trying to treat asthma, what do we need to know about the social hx of the pt?
1. Home characteristics
2. Smoking
3. Workplace/school characteristics
4. Educational Level/Socioeconomics
5. Socia Support
34
At the initial dx of asthma, you need to pay attention to two factors that determine/assc with severity?
1. Current Impairment (based off symptoms and PFTs)
| 2. Future risks/exacerbation
35
Categorization of asthma is only valid for someone NOT on any treatment!
Fun Fact
36
A patient with newly diagnosed asthma comes to you for treatment. She has daily symptoms and uses her albuterol at least once a day. It has interfered with school, quit her part time job. She is awoken with cough 3-5x/week.
Severe Persistent Asthma
37
What do you start the patient on is they have severe persistent asthma?
Moderate dose of ICS and LABA
38
SABA + Montelukast
Not a severe asthma
39
After starting treatment after confirmatory dx, how frequent should you follow up?
1-3 months to establish pts control
40
If the patient follows up and they are not in control on their symptoms, what should you do?
Move up one step (if very poor control, steroids or 1-2 steps more)
41
What are the goals of therapy?
1. Achieve and maintain control of symptoms
2. Prevent asthma exacerbations
3. Maintain pulmonary function and activity levels as close to “normal” as possible
4. Avoid adverse effects from asthma medications
5. Prevent the development of irreversible airflow limitation
6. Prevent asthma mortality
42
If a patient has been exhibiting good control for over 3 months, what should you consider?
Stepping Down Therapy
43
Why do you try stepping down therapy?
Because you want the pt to be on the lowest amount of medication to maintain control
44
Cycle Seasonal Tx is good for people with?
Known allergic asthma (every Feb)
45
If a pt is discharging from hospitals, what do you give them?
LABA, because:
1. Use lowest effective dose of medication
2. Controversy over increased risk of death with LABA
46
Asthma Management Components (F/U)
1. Periodic peak flow measurements or symptom diaries
2. Patient education
3. Action plan (written)
4. Vaccines (influenza and pneumococcal) except for kids
47
Simple test that is used to quantitate and is a reproducible measure based on airflow obstruction.
Peak-Flow Monitoring
48
When can peak flow monitoring be used?
Short term Monitoring
Exacerbation Management
Long term monitoring
49
Using a peak flow monitor, you can check the __________ of an exacerbation.
Severity
50
Therapy for Asthma
1. LTRA
2. Omalizumab
3. Anticholinergics
4. Bronchial Thermoplasty
5. Miscellaneous
51
This type of therapy for asthma has been suggested to improve adherence when compared to inhaler, though it may be inferior to LABA.
LTRA
52
This drug is a monocolonal antibody against IgE, so it prevents the interaction with basophils and mast cells. However it does not interact with BOUND IgE and therefore not helpful in acute asthma.
Omalizumab
53
This drug is defined by the FDA as:
“Moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and who’s symptoms are inadequately controlled with inhaled steroids.”
Omalizumab
54
What is AERD?
Aspirin Exacerbated Respiratory Disease
55
A patient comes into clinic presenting with Asthma, Nasal Polyps, and persistent rhinosinusitis. When tested, the pt is actually allergic to ASA. What would this reaction be?
AERD
56
AERD is common in _____ to _____ % of asthmatics
10 to 20%
57
AERD is common in _____ to _____ % of asthmatics with nasal polyps.
30 to 40%
58
Risk Factors associated with Asthma
1. Exacerbated by exercise
2. upper respiratory tract infections
3. rhiniits
4. sinusitis
5. postnasal drip
6. aspiration
7. GERD
8. changes in weather
9. stress
10. tobacco
11. occupational exposure
12. aspirin
13. NSAIDS
14. tartrazine dyes
59
How do you diagnose asthma?
1. Physical exam
2. CXR
3. PFTs: including spirometry, bronchoprovocation testing with either methacholine or histaminexercise spirometry, and peak-flow monitoring
60
It is important to do ________ before and after administration of SABA in "suspected asthma. Why?
Spirometry
It will show us if the SABA worked and if the condition was reversible -- aka Asthma
**20% change is diagnostic**
61
When is a bronchoprovocation test not indicated for a patient?
When their FEV1 is less than 65% of the predicted value.
62
Asthmatic Symptoms of less than 2x per week with short exacerbations and typically asymptomatic between them.
FEV1 >80% predicted
Mild Intermittent Asthma
63
What is the treatment for Mild Intermittent Asthma?
- No medication required.
| - SABA for quick relief.
64
Asthmatic Symptoms of more than 2x per week, but less that once per day. Exacerbations may affect activity.
FEV1 >80% predicted
Mild Persistent Asthma
65
What is the treatment for Mild Persistent Asthma?
Either an inhaled corticosteroid or cromolyn or nedocromil.
| PLUS use of short acting inhaled B2 bronchodilator
66
Asthmatic Symptoms at least once per day. Exacerbations less than 2 times per week and it may affect activity.
FEV1 60 to 80% predicted
Moderate Persistent Asthma
67
Treatment of Moderate Persistent Asthma:
Either inhaled corticosteroid OR inhaled corticosteriod AND long acting bronchodilator inhaled B2 agonist, theolphylline (Daily)
If needed: anti-inflammatory inhaled corticosteroid AND long acting bronchodilator PLUS short acting inahled B2 agonists
68
Asthmatic Symptoms are continuous. Limited physical activity with frequent exacerbations.
FEV1 <60% predicted
Severe Persistent
69
Treatment for Severe Persistent Asthma
Daily: anti-inflammatory inahled corticosteroid (high dose) AND long acting bronchodhilater inhaled B2, theolphylline inhaled B2 agonist tablets AND corticosteroid tablets or syrup PLUS short-acting inhaled B2 agonist as needed
70
Preventative measures and environmental control factors for patients with Asthma
1. Patients should be taught to recognize symptoms.
2. Written action plan should direct patient to adjust medications in response to particular signs, symptoms, and peak flow measurements and should state when to seek medical help.
71
Breathlessness at rest, difficultly completing words. Unable to recline. Respiratory rate >30 per minute; usually use accessory muscles. Loud inspiratory and expiratory wheezes. HR >120, pulsus paradoxus; agitated mental status.
Severe Exacerbation
72
What would you not use in regards to treating or vaccinating influenza or pneumococcal stuff?
NO INHALED VACCINATIONS they can cause exacerbations.
73
How would you treat a severe exacerbation?
1. Immediately receive O2
2. High doses of inhaled short acting B2 agonist
3. Systemic corticosteroids
***Frequent high dose delivery of an inhaled short acting B2 agonist is indicated and is usually well tolerated in the setting of severe airway obstruction.
74
What are the goals of Treatment for Asthma?
1. To minimize chronic symptoms that impair normal activity
2. To prevent recurrent exacerbations
3. To minimize the need for emergency department visits or hospitalizations
4. To maintain near normal pulmonary function.
75
Acute Asthma Treatment
Quick relief promote prompt reversal of acute airflow obstruction and relieve accompanying symptoms.
76
Long Term Asthma Treatment
Taken independent of symptoms to achieve and maintain control of persistent asthma for maintenance.
See cards about severe persistent and moderate persistent asthma
Pulmonary Medicine
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