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What are the key sx of asthma?
- Chest tightness
- Cough (particularly at night)
What are the chances that a young patient will "outgrow" their asthma?
- chances seem to improve by well-controlled symptoms d/t decreased occurrence of airway remodeling
What are the risk factors for developing asthma?
- exposure to 2nd-hand smoke
- socioeconomic status
- family size
- exposure to allergens
- decreased exposure to common childhood infectious agents
What agents and events can trigger asthma?
- house-dust mites
- cold air
- tobacco smoke
What is the singe most significant precipitant of severe asthma in children?
viral respiratory tract infection
What cells of the airways become involved in chronic inflammation of asthma?
- T cells
- Mast cells
- Epithelial Cells
- Bronchial smooth muscle cells
What is released from mast cells once allergen binds to surface IgE?
- Eosinophil and Neutrophil chemotactic factors
- Leukotrienes C4, D4, and E4Prostaglandins
- Platelet-activating factor
What is airway remodeling in asthma?
- Repair initiated by inflammation resulting in replacement of injured tissue by parenchymal cells of the same type and connective tissue which matures into scar tissue
- This can result in fibrosis and increased smooth muscle and mucus gland mass
What is the cause of hypertrophy and hyperplasia in asthmatics?
What is the effect of NO on asthmatic airways?
- Smooth muscle relaxation in the vasculature and bronchials
- Amplification of the inflammatory process (this makes it useless for tx)
What would a high level of NO in exhaled air mean in an asthmatic?
poor control of the disease
Besides PFTs, what other tests can be used to diagnose asthma?
- elevated eosinophil count
- elevated IgE concentration in blood
- elevated FeNO
- positive methacholine challenge
What are the major risk factors for severe exacerbation of asthma?
- Underuse of anti-inflammatory drugs
- Over-reliance on SABAs
What are the sx of a severe exacerbation of asthma?
- Only able to say a few words with each breath
- Sx unresponsive to usual measures
- Expiratory and inspiratory wheezing (may be no breath sounds if severely plugged)
- Pale or cyanotic skin
- Intercostal and supraclavicular retractions
- PEF or FEV1 < 50% predicted
- O2 < 90%
What is exercise-induced bronchospasm?
- Decline in FEV1 of > 15% of baseline
- provoked more easily in cold, dry air
What role does influenza vaccination have for preventing asthma exacerbations?
None, it doesn't work
What is the treatment for allergic rhinitis/sinusitis in asthmatics?
- inhaled corticosteroids and cromolyn
- NOT antihistamines!!!
What foods can trigger an asthma attack (d/t high concentrations of metabisulfites)?
- Dried fruit
- Open salad bars
What is the aspirin triad (Samter's triad)?
- Nasal polyposis
How often should inhaler spacers be cleaned with detergent to decrease static?
How does particle size affect medication deposition?
- > 10 microns - oropharynx
- 5-10 microns - trachea, large bronchi
- 1-5 microns - lower airways
- < 0.5 microns - exhaled as gas
What is the difference b/w asthma and COPD when it comes to systemic CS for tx of severe exacerbations?
In asthma, you don't need to taper off of the corticosteroids
What is the DOC for tx of mild persistent asthma in pregnancy/lactation?
Budesonide (low dose)
What are the determining factors that mean a pt has mild persistent asthma rather than intermittent asthma?
- Sx occur > 2d/wk, but not daily
- Nighttime awakenings 1-2 times/mo
- Use SABA for sx control > 2d/wk
- (RULE OF 2s)
What is the treatment for Intermittent asthma?
What is the treatment for mild persistent asthma?
- Step 2:
- Low-dose ICS (or LTRA)
What is the tx for moderate persistent asthma?
- Step 3:
- Medium-dose ICS (kids)
- Lo-dose ICS + LABA, LTRA, or Theophylline (Adults)
What is the tx for severe persistent asthma?
- Step 4:
- Med-dose ICS + LTRA or LABA (kids)
- Med-dose ICS + LABA (Adults)
- Med-dose ICS + LTRA, Theophylline, or Zileuton (Adults alternate)
What is the tx for Step 5 in severe asthma?
- High-dose ICS + LTRA or LABA (kids)
- High-dose ICS + LABA + consider Xolair (Adults)
- High-dose ICS + LTRA + consider Xolair (adults alternate)
What is the tx for Step 6 in severe asthma?
- High-dose ICS + LTRA or LABA + oral CS (kids)
- High-dose ICS + LABA + oral CS + consider Xolair (Adults)
What is the tx for severe acute exacerbations of asthma?
- Albuterol/ipratropium q 20min x 3 doses, followed by continuous albuterol
- Systemic CS
- Mg Sulfate, heliox, and/or ketamine
- Pt education and written action plan
- Consider initiation of ICS prior to discharge
What FEV1 or PEF value determines a mild-moderate asthma exacerbation?
What FEV1 or PEF value determines a severe asthma exacerbation?