Asthma

Question 1

What is asthma?

Answer 1

· Chronic respiratory disease
· Characterized by airway inflammation & hyperresponsiveness
· Causes reversible bronchoconstriction
· Symptoms: wheezing, dyspnea, cough, chest tightness

Question 2

What 4 processes define asthma pathophysiology?

Answer 2

1. Bronchoconstriction
2. Airway edema & inflammation
3. Airway hyperreactivity
4. Airway remodeling (long-term damage)

Question 3

What defines intermittent asthma severity?

Answer 3

· Symptoms: ≤2 days/week
· Night awakenings: ≤2x/month
· Normal FEV1 between flares
· Exacerbations: 0-1 per year

Question 4

What defines mild persistent asthma?

Answer 4

· Symptoms: >2 days/week but not daily
· Night awakenings: 3-4x/month
· FEV1: ≥80% predicted
· Exacerbations: ≥2 per year

Question 5

What defines moderate persistent asthma?

Answer 5

· Symptoms: Daily
· Night awakenings: >1x/week
· FEV1: 60-80% predicted
· Exacerbations: ≥2 per year (may be severe)

Question 6

What defines severe persistent asthma?

Answer 6

Symptoms: Throughout the day
· Night awakenings: Often nightly (7x/week)
· FEV1: <60% predicted
· Exacerbations: ≥2 per year

Question 7

What are the 3 asthma control levels?

Answer 7

1. Well-controlled: Minimal symptoms, normal activity, FEV1 >80%
2. Not well-controlled: Frequent symptoms, some limitation, FEV1 60-80%
3. Very poorly controlled: Daily symptoms, extreme limitation, FEV1 <60%

Question 8

What are the 2 main asthma endotypes?

Answer 8

1. T2-High: Eosinophilic inflammation, responds to steroids, has high FeNO/IgE/eosinophils
2. T2-Low: Non-eosinophilic (neutrophilic or pauci-granulocytic), steroid-resistant

Question 9

List 7 common asthma triggers.

Answer 9

1. Allergens (dust, pollen, pets)
2. Infections (viruses)
3. Irritants (smoke, pollution)
4. Exercise (especially cold/dry air)
5. Drugs (aspirin/NSAIDs, beta-blockers)
6. GERD
7. Strong emotions/stress

Question 10

What tests and methods are used to diagnose asthma?

Answer 10

1. Pulmonary Function Tests (PFTs):

· Spirometry: Shows obstruction (low FEV1/FVC). Bronchodilator reversibility (FEV1 increase >10%) confirms diagnosis.
· Bronchoprovocation: For normal spirometry. Methacholine challenge positive if FEV1 drops ≥20%.
· Peak Expiratory Flow (PEF) Monitoring: Home use to show variability.

2. Biomarkers & Blood Tests:

· FeNO (Fractional Exhaled Nitric Oxide): >50 ppb = T2-high/eosinophilic inflammation.
· Blood Eosinophils: >300-400 cells/µL suggests eosinophilic phenotype.
· Serum IgE: Elevated in allergic asthma.
· Allergy Testing: Skin prick or serum-specific IgE to identify triggers.

3. Imaging & Other Tests:

· Chest X-Ray: Rules out other causes (e.g., pneumonia, heart failure).
· DLCO (Diffusing Capacity): Normal or high in asthma; helps distinguish from COPD.
· Sputum Eosinophils: Supportive but not commonly done.

Question 11

What is the stepwise approach to treating chronic asthma?

Answer 11

Step 1 (Intermittent):

· Preferred: As-needed low-dose ICS-formoterol.
· Alternative: As-needed SABA + concomitant low-dose ICS.

Step 2 (Mild Persistent):

· Preferred: Daily low-dose ICS + as-needed SABA.
· Alternative: Daily LTRA (montelukast), mast cell stabilizer, or theophylline.

Step 3 (Moderate Persistent):

· Preferred: Daily & as-needed low-dose ICS-formoterol.
· Alternative: Daily low-dose ICS-LABA combo (e.g., fluticasone-salmeterol) + as-needed SABA.

Step 4 (Moderate-Severe):

· Preferred: Daily & as-needed medium-dose ICS-formoterol.
· Alternative: Daily medium-dose ICS-LABA + as-needed SABA. Consider add-on LAMA or LTRA.

Step 5 (Severe Persistent):

· Preferred: Daily high-dose ICS-LABA +/- LAMA.
· Add: T2-Biologic (Anti-IgE, Anti-IL5/5R, Anti-IL4/13R).

Step 6 (Severe Uncontrolled):

· Preferred: Daily high-dose ICS-LABA + Oral Corticosteroid + Biologic.
· Consider: Bronchial thermoplasty for selected patients.

Question 12

What are key non-drug strategies?(Non-pharmacological management)

Answer 12

· Trigger identification & avoidance
· Allergen-proof bedding
· HEPA filters & dehumidifiers
· Smoking cessation
· Written Asthma Action Plan
· Comorbidity management (rhinitis, GERD, obesity)

Question 13

List all asthma drug classes.

Answer 13

1. Relievers (Quick-Relief):

· Short-Acting Beta2-Agonists (SABA): Albuterol, Levalbuterol
· Short-Acting Muscarinic Antagonists (SAMA): Ipratropium

2. Controllers (Long-Term Control):

· Inhaled Corticosteroids (ICS): Fluticasone, Budesonide, Beclomethasone, Mometasone, Ciclesonide
· Long-Acting Beta2-Agonists (LABA): Salmeterol, Formoterol, Vilanterol
· Long-Acting Muscarinic Antagonists (LAMA): Tiotropium, Umeclidinium, Glycopyrrolate
· Leukotriene Receptor Antagonists (LTRA): Montelukast, Zafirlukast
· Mast Cell Stabilizers: Cromolyn, Nedocromil
· Methylxanthines: Theophylline
· Lipoxygenase Inhibitor: Zileuton (for ages ≥12)

3. Biologics (for Severe T2-High Asthma):

· Anti-IgE: Omalizumab
· Anti-IL5: Mepolizumab
· Anti-IL5 Receptor: Benralizumab
· Anti-IL4/IL13 Receptor: Dupilumab

4. Systemic Corticosteroids (for Acute Exacerbations/Severe Asthma):

· Oral: Prednisone, Prednisolone, Methylprednisolone
· IV: Methylprednisolone, Hydrocortisone

5. Combination Inhalers:

· ICS/LABA: Fluticasone-Salmeterol, Budesonide-Formoterol, Fluticasone-Vilanterol, Mometasone-Formoterol
· ICS/LABA/LAMA: Fluticasone-Umeclidinium-Vilanterol
· ICS/Formoterol (Maintenance & Reliever Therapy): Budesonide-Formoterol, Beclomethasone-Formoterol

Question 14

How treat acute asthma attack?

Answer 14

· High-dose SABA: Albuterol, repeat as needed
· Oral steroids: Prednisone 40-60mg daily x 5-7 days - START EARLY
· Add ipratropium in moderate-severe cases
· Oxygen to keep SpO2 >90%
· IV magnesium if severe/unresponsive