1
Q
Asthma is the ___________ in childhood
A
most common chronic disease
2
Q
Hospitalization rates highest in _____ and _______ population
A
children & black population
3
Q
Death rates highest in ______ y/o blacks
A
15-24
4
Q
What are the risk factors of asthma?
A
- ***Atopy (genetic tendency to develop allergies)
Atopic Triad:
- Eczema
- Asthma
- Atopic dermatitis
- Allergen exposure
- Fam hx
- Male child
- 20-40 M:F 1:1
- >40 F>M
- smoking
- viral illness
- obesity
5
Q
What are the 3 main factors of Asthma pathophys?
A
- Airway hyperresponsiveness
- Inflammation
- Airflow obstruction & narrowing
6
Q
What causes airway hyper-responsiveness?
A
- inhalants/allergens
- temp changes: humidity
- stress
- reflux: GERD
- exercise
7
Q
What causes inflammation in asthma?
A
- eosinophils
- lymphocytes: T cells
- Neutrophils
- mast cell act.
- hyperplasia of goblet (mucus) cells
8
Q
What causes airflow obstruction & narrowing?
A
- smooth muscle abnormality
- hypertrophy/hyperplasia
- decreased relaxation
- B-2 receptors
- Muscarinic receptors
9
Q
Classic symptoms of Asthma
A
- wheezing
- cough
- dyspnea
10
Q
Diagnosis of Asthma
A
- Hx of respiratory symptoms AND variable, reversible expiratory airflow obstruction
- AND H&P AND Spirometry
11
Q
What will you see on a PE for a non-exacerbation pt?
A
- pale, swollen nasal mucosa? -> allergic rhinitis
- nasal polyps?
- eczema
- Cardiac: possible tachycardia
12
Q
What is the GOLD STANDARD for dx asthma?
A
Spirometry/ Pulmonary Function Testing (PFT)
13
Q
What is spirometry/PFT?
A
max inhalation followed by rapid and forceful, complete exhalation
14
Q
“predicted values” are based on _____, _____ & ______
A
age, height, sex
15
Q
What is FEV1?
A
Forced expiratory volume in 1 sec
16
Q
FEV1 is _______ in obstructive dz
A
decreased
17
Q
_____ is the normal value of FEV1
A
greater than or equal to 80% of predicted value
18
Q
What is FVC?
A
forced vital capacity: amount of air forcefully exhaled after a maximal inhalation
19
Q
FVC predicted value varies with ______ & ______
A
height & age
20
Q
FVC normal value is…
A
greater than or equal to 80% of predicted
21
Q
What does the FEV1/FVC ratio determine?
A
whether obstruction is present
22
Q
What does an FEV1/FVC ratio <70% indicate?
A
obstructive disease
23
Q
How does a normal pulmonary function graph differ from a severe airflow obstruction graph?
A
Normal pulmonary function is curved and severe airflow obstruction has a decreased slope
24
Q
Predictive versus obstructive defect
A
Obstructive defect demonstrates scooping of the expiratory portion of the flow-volume curve compared with the predicted curve. The expiratory flow rate is reduced over most of the vital capacity.
25
**Pre and post bronchodilatory measurements** are done to determine \_\_\_\_\_\_\_
reversibility
26
Describe the **steps** of a pre and post bronchodilator measurement
1. 2-4 puffs of SABA (albuterol)
2. Wait 15 minutes
3. Perform spirometry again
27
**FEV1** increase of \_\_\_\_% or more = **positive response to reversibility**
12%
28
Asthma is _____ so PFT values may vary depending on patient status, therefore __________ are important in asthma.
episodic
serial measurements
29
What are some additional tests a pulmonologist would do?
* Bronchoprovication testing
* Total lung volume
* CBC: eosinophilia, anemia
* Serum IgE levels
* Allergy testing (IgE specific)
* ABG's for acute settings
* Pulse O2
* Imaging
30
What kind of patients would you use Bronchoprovocation testing for?
Pts who do not have any signs of FEV1/FVC being less than 70% but are still symptomatic
31
Describe Bronchoprovocation testing
Pt would inhale methacholine or mannitol, which challenges their airways
You would see how the patient reacts
32
How would you measure total lung volume?
Helium dilution
Plethysmography
33
Asthma therapy is based on severity of which 4 symptoms?
1. symptom frequency
2. Nighttime awakenings
3. need for SABA
4. inferference with normal activity
34
Categorize pts symptoms by the _______ symptom/parameter
**MOST SEVERE**
35
What is the **normal FEV1/FVC %** for **8-19** y/o?
85%
36
What is the **normal FEV1/FVC %** for **20-39 y/o**?
80%
37
What is the **normal FEV1/FVC %** for **40-59** y/o?
75%
38
What is the normal **FEV1/FVC %** for **60-80** y/o?
70%
39
**Intermittent** symptoms
less than or equal to 2 days
40
Intermittent nighttime awakenings
1-2 times a month
41
Intermitten SABA use
1-2 days a week
42
Intermittent interference with normal activity
none
43
Intermitten lung function
* Normal FEV1 between exacerbations
* FEV1 \>80%
* FEV1/FVC normal
44
**Mild**
symtptoms
nighttime awakenings
SABA
Interference with normal activity
Lung Function
* **\>2 days/week** but NOT DAILY
* **3-4x/mo**
* **\>2 days/week** but not \>1x/day
* Minor limitation
* FEV1 greater than or equal to 80
* FEV1/FVC normal
45
Moderate-Persistent
Symptoms
nighttime awakenings
SABA
interference with normal activity
lung function
* daily
* \> 1x/week but not nightly
* daily
* some limitation
* FEV1: 60-80
* FEV1/FVC reduced 5 percent from normal
46
Severe Persistent
Symptoms
Nighttime awakenings
SABA
interference with normal activity
lung function
* throughout the day
* often 7x/week
* several times per day
* extremely limited
* FEV1 \<60
* FEV1/FVC reduced \>5 percent from normal
47
What are the 4 essential componenets of asthma management?
* Monitor symptoms and lung function routinely
* Educate patient
* Control environmental factors ike triggers and comorbid conditions that contribute to asthma severity
* pharmacologic therapy
48
What are the two main goals of asthma treatment?
- Reduction in **impairment**
- Reduction of **risk**
49
How do we reduce impairment?
* Minimal need: **1-2 days/week of inhaled SABA**
* **\<2 nighttime awakenings** due to asthma
* Optimize **lung function**
* **Maintain** normal daily activities like **work** or **school** attendance and **participation in athletics and exercise**
50
How do we reduce the risk of asthma?
* prevent recurrent exacerbations
* prevent need for emergency services/hospital care
* prevent reduced lung growth in children
* prevent lost lung function in adults
* optimize pharmacotherapy with minimal or no adverse effects
51
How do we **control the triggers** and **contributing conditions** of asthma?
* Treat **allergies**
* Avoid **respiratory irritants**
* work on **obesity, GERD, sleep apnea**
* Control med triggers: **NSAIDS, ASA**
* **Avoid dietary sulfides**: beer, wine, processed potatoes, dried fruit, sauerkraut, shrimp
52
B-2 Agonists (SABA) are _________ that relieve _______ by ________ bronchial smooth muscle.
* bronchodilators
* bronchospasm
* **RELAXING**
53
**SABA**
**describe its usage**
* works immediately: used **preventatively** or **emergently**
* **Albuterol:** HFA inhalers
* **Levalbuterol:** causes less tachycardia
54
LABA
Describe its usage
* Used only for prevention
* DO NOT USE AS RESCUE OR PRN INHALER
* Examples:
* **Formoterol**
* **Salmereol**
* **Arformoterol**
55
What does the Black Box warning on LABA say?
LABAs may **increase the risk of asthma death** **when used alone** w/o an inhaled steroid simultaneously.
56
Inhaled Corticosteroids
Describe usage
* Decreases inflammation
* Used as preventative therapy
* Examples:
* **Beclamethasone**
* **Fluticasone**
* **Triamcinolone**
**B**e a **T**rue **F**riend and give them an inhaler
57
LABA & ICS combination inhalers
* Long acting relief of bronchospasm PLUS decreased inflammation
* Preventative only, not for PRN use
* Examples
* **Salmeterol + fluticasone**
* **Formoterol + budesonide**
* **Formoterol + mometasone**
58
Leukotriene Receptor Antagonists **(LTRA)**
* Leukotrienes cause inflammation & mucosal edema
* Blocking the LT receptor mitigates this effect
* **Oral tablets**, preventative only
* treats allergic symptoms
* Examples:
* **Montelukast**
* **Zafirlukast**
59
Anticholinergics
Describe the usage
A for acute exacerbations only
* decrease mucus
* inhaler or solution for nebulization
* Examples
* **Ipratropium**
* **Trotropium**
60
**Mast-cell stabilizer**
* **Cromolyn sodium**
* **inhibits** the relase of **histamine, leukotrienes,** and other mediators **from sensitized mast cells**
61
Monoclonal Antibody
* **Omalizumab**
* Recombinant antibiody **that binfs IgE without activating mast cells**
* **Reslizumab & Mepolizumab**
* **Interleukin-5 antagonist monoclonal antibodies**
* **severe, recalcitrant** asthma with eosinophilia
62
Oral corticosteroids
* **systemic anti-inflammatory effect**
* used for **acute exacerbations or severe chronic symptoms**
* many adverse effects
63
Examples of oral corticosteroids
Predinisone, methylprednisone
64
Methyxanthines/Phosphodiesterase inhibitors
* old, inexpensive
* may cause toxicity & adverse CV effects
* potential for drug-drug interactions
* benefit may be related to improved diaphragmatic function
* **avoid use except in certain special cases**
65
Example of methylxanthines/Phosphodiesterase inhibitors
**Theophylline**
66
What drugs are used for Bronchospasm?
SABA & LABA
67
What drugs are used for Mucosal edema (inflammation) ?
- inhaled and corticosteroids
- Leukotriene Receptor antagonists (LRA)
- 5-lipoxygenase inhibitor, mast-cell stabilizers, monoclonal antibodies
68
What drugs are used for Mucus production?
Antibholinergics
69
Step Therapy:
Start with the ________ step based on the patient's \_\_\_\_\_\_\_, ________ & \_\_\_\_\_\_\_\_
- highest
- symptoms
- severity categorization
- spirometry
70
Step therapy:
Reassess control every \_\_\_\_\_\_\_
few weeks
71
Step _____ or ______ as needed
Up, down
72
All patients are on \_\_\_\_\_\_\_
SABA prn
73
Step 1
Preferred: SABA PRN
74
Step 2
* Preferred:* **low-dose inhaled glucocorticoids**
* Alternative:* **cromolyn, LTRA or Theophylline**
75
Step 3
*Preferred:* Low-dose inhaled GC + LABA
OR
Med-dose inhaled GC
Alternative: Low-dose inhaled GC + either [LRTA or theophylline or Zileuton]
76
Step 4
Preferred: med-dose inhaled GC + LABA
Alternative: med-dose inhaled GC + either [LRTA or theophylline or Zileuton]
77
Step 5
***Preferred:*** High-dose inhaled GC + LABA
AND
consider omalizumab for pts w/allergies
78
Step 6
**Preferred:** High-dose inhaled GC + LABA + oral systemic GC
AND
consider omalizumab for pts who have allergies
79
Peak Flow (Peak Expiratory Flow Rate/PEFR)
- **simple and inexpensive** monitoring
- **helps pts determine need for rescue inhaler**
- peak flow diary **helps clinican evaluate sx control** AND determines "personal best"
- Predicted **average PEFR based on AGE & HEIGHT**
80
When do you use the PEFR?
- **every morning before taking rx** as part of daily morning routine
- **during asthma symptoms** or an attack
- **after taking medicine for an attack**
81
What do the following mean on PEFR?
Green
Yellow:
Red:
Green: good to go
Yellow: caution, use SABA
Red: Go to ER
82
What would you use on top of a SABA for a severe exacerbation?
ipratropium
83
When should you start systemic steroids?
if there is not an immediate and marked response to the inhaled SABA
84
Which patients with acute exacerbations do you admit and after how long?
Those who do not respond well; after 4-6 hours
85
Signs/sx of severe exacerbations
- inability to speak full sentences
- accessory muscle use
- tri-pod positioning
- inability to lie supine
- **tachy**pnea
- **tachy**cardia
- O2 \<90%
- PCO2 elevated (hypercapnia)
- PEFR
86
Imminent respiratory arrest
- confusion
- cyanosis
- fatigue
- agitation
87
Rx treatment of Acute exacerbation (mild-moderate)
- SABA use
- Oral glucocorticoids
- Increase controller meds **(step up)**
- review adherence
- patient education
88
Adjunct therapies for severe exacerbations
- IV mag
- IV epinephrine
- Terbutaline
- Heliox
- Ketamine
- Neuromuscular blockers
89
Preventative care for Asthma
- **pneumococcal** vaccination
- **annual influenza** vaccination
these infections can complicate or exacerbate asthma
90
MJ- Foundations 2 Exam 3
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