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114 Cards in this Set
- Front
- Back
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What are the risk factors for asthma?
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Genetic predisposition, socioeconomic status, exposure to second hand smoke in infancy and utero, family size, allergen exposure, urbanization, decreased exposure to common childhood infectious agents
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What are the common triggers for asthma?
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Allergens, environment, emotions exercise, respiratory infection, medications
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What are the allergens associated with triggering asthma?
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Dust mites, cockroaches, airborne pollens (grass, weeds, tress), animal dander
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What are the environmental factors associated with triggering asthma?
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Cold air, tobacco smoke
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What are the medications associated with triggering asthma?
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Aspirin, NSAIDS, sulfites, nonselective beta blockers
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What are the emotions associated with triggering asthma?
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Anxiety, stress, laughter
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What are the two major goals of asthma therapy?
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Reduce impairment and reduce risk
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What are the subgoals in asthma associated with reducing impairment?
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Prevent chronic symptoms, decrease use of short acting B2 agonist, maintain normal lung function and activity level, meet patients and families expectations
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What are the subgoals in asthma associated with reducing risk?
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Prevent exacerbations, minimize ED visits and hospitalizations, prevent loss of lung function (in children reduced lung growth), minimize side effects
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For intermittent asthma, how often are symptoms?
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<= 2 days/wk
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For intermittent asthma, how often are night-time awakenings?
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<= 2x /month
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For intermittent asthma, how often are SABA use?
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<= 2 days/wk
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For intermittent asthma, what is the interference with normal activity?
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None
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For intermittent asthma, what is the FEV1?
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FEV1 > 80% predicted, normal FEV1 between exacerbations
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For intermittent asthma, what is the initial therapy?
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Step 1
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For mild persistent asthma, how often are symptoms?
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>2 days / wk but not daily
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For mild persistent asthma, how often are night time awakenings?
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3-4 x / month
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For mild persistent asthma, how often are SABA use?
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>2 days/wk but not daily
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For mild persistent asthma, what is the interference with normal activity?
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Minor limitation
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For mild persistent asthma, what is the FEV1?
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FEV1 > 80% predicted
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For mild persistent asthma, what is the FEV1/FVC?
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FEV1/FVC is normal
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For mild persistent asthma, what is the initial therapy?
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Step 2
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For intermittent asthma, what is the FEV1/FVC?
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Normal
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For moderate persistent asthma, how often are symptoms?
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Daily
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For moderate persistent asthma, how often are night time awakenings?
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>1 time/wk but not nightly
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For moderate persistent asthma, how often are SABA use?
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Daily
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For moderate persistent asthma, what is the interference with normal activity?
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Some limitation
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For moderate persistent asthma, what is the FEV1?
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FEV1 is 60-80% predicted
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For moderate persistent asthma, what is the FEV1/FVC?
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FEV1/FVC is decreased by up to 5%
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For moderate persistent asthma, what is the initial therapy?
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Step 3 or 4
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For severe persistent asthma, how often are symptoms?
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Throughout the day
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For severe persistent asthma, how often are nighttime awakenings?
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Often 7 times/wk
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For severe persistent asthma, how often are SABA use?
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Several times / day
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For severe persistent asthma, what is the interference with normal activity?
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Extremely limited
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For severe persistent asthma, what is the FEV1?
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FEV1 < 60% predicted
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For severe persistent asthma, what is the FEV1/FVC?
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FEV1/FVC is decreased by greater than 5%
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For severe persistent asthma, what is the therapy?
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Step 5 or 6
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In well controlled asthma, how often are symptoms?
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<= 2 days / wk
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In well controlled asthma, how often are nighttime awakenings?
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<= 2x / month
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In well controlled asthma, what is the interference with activity?
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none
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In well controlled asthma, what is the SABA use?
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<= 2 days/wk
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In well controlled asthma, what is the FEV1 or peak flow?
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> 80% predicted/personal best
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In well controlled asthma, how many exacerbations are likely per year?
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0-1 / yr
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In well controlled asthma, what is the recommended action for treatment?
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Maintain current step, consider step down if well controlled x 3 months
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In not well controlled asthma, how often are symptoms?
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> 2 days/wk
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In not well controlled asthma, how often are nighttime awakenings?
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1-3 days /wk
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In not well controlled asthma, what is the interference with activity?
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Some limitation
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In not well controlled asthma, what is the SABA use?
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> 2 days / wk
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In not well controlled asthma, what is the FEV1 or peak flow?
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60-80% predicted/ personal best
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In not well controlled asthma, what are the expected number of exacerbations per year?
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>=2
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In not well controlled asthma, what is the recommended action for treatment??
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Step up 1 step, reevaluate in 2 to 6 weeks
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In very poorly controlled asthma, how often are symptoms?
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throughout the day
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In very poorly controlled asthma, how often are nighttime awakenings?
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>= 4x / week
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In very poorly controlled asthma, what is the interference with normal activity?
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extremely limited activity
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In very poorly controlled asthma, what is the SABA use?
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several times / day
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In very poorly controlled asthma, what is the FEV1 or peak flow?
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<60% predicted / personel best
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In very poorly controlled asthma, how many exacerbations are possible per year?
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>=2
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In very poorly controlled asthma, what is the recommended action for treatment?
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Consider oral steroids, step up 1 to 2 steps and reevaluate in 2 weeks
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What is the MOA of short acting Beta 2 agonist?
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Activation of adenylate cyclase and increase in cyclic amp which results in smooth muscle relaxation and subsequent bronchodilation
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What is the MOA of short acting anticholinergics?
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Bronchodilation via inhibition of muscarinic cholinergic receptors, reduction of glandular mucus secretion
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What is the MOA of systemic corticosteroids?
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Anti-inflammatory action: decrease in synthesis and release of pro-inflammatory cytokines, decrease in inflammatory cell activation, recruitment and infiltration, decrease in vascular permeability;;;; Effect of Beta receptors: increase number of receptors, improve receptor responsiveness to adrenergic stimulation
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What is the onset of action for SABAs?
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5 min
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What is the onset of action for anticholinergics?
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30 sec to 3 min
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What is the onset of action for systemic oral corticosteroids?
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2 to 6 h
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What is the duration of action of SABAs?
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4 to 8 h
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What is the duration of action of anticholinergics?
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Ipatropium (atrovent) = 6h
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What are the side effects of SABAs?
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tremor, tachycardia, palpitations, hyperglycemia; hypokalemia and hypomagnesemia during initial treatment
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What are the side effects of anticholinergics?
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Relatively uncommon; dry mouth, blurred vision, confusion
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What are the side effects of long term systemic oral corticosteroids?
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Adrenal suppression / growth suppression, osteoporosis, skin thinning, easy bruising
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What are the side effects of short term systemic oral corticosteroids?
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increase in appetite, weight gain, fluid retention, mood changes, HTN, peptic ulceration, abnormalities in glucose metabolism
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What are the long-term controller medications in asthma?
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ICS, LABA, Mast cell stabilizers, Leukotriene inhibitors, methylxanthines, omalizumab, systemic corticosteroids
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What is the place in therapy of asthma for inhaled corticosteroids?
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preferred long term prevention of symptoms in mild, moderate, and sever persistent asthma in all age groups
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What is the place in therapy of asthma for systemic corticosteroids?
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long term prevention of symptoms in severe persistent asthma (step 6)
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What is the place in therapy of asthma for LABAs?
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long term prevention of symptoms (esp nocturnal sx) IN ADDITION to ANTI INFLAMMATORY AGENTS, prevention of EIB
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What were the outcomes of the SMART trial?
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Black box warning of life-threatening risk of LABA use, risk may be greater in african americans. Subgroup on ICS did not have increase in mortality
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What is the place in therapy of asthma for mast cell stabilizers?
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Alternative to INH CS in pts with mild persistent asthma (step 2), alternative for EIB or known allergen induced bronchospasm (not as effective as SABA for prevention of EIB)
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What is the place in therapy of methylxanthines for asthma?
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Alternative therapy for mild persistent asthma (step 2) or as adjunctive with ICS in pts >= 5 yoa (generally considered third line agent due to narrow therapeutic range)
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What is the place in therapy of asthma for leukotriene modifiers?
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Alternative therapy for patients wiht mild persistent asthma (step 2), adjunctive agent in addition to inh CS at any level of asthma (not preferred compared to addition of LABAs in pts >=12yoa), can attenuate EIB, may be useful in children or patients with poor inhaler technique
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What is the place in therapy of asthma for Omalizumab (Xolair)?
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Adjunctive therpay for pts >= 12 yoa who have sensitivity relevant to allergens, adjunctive therapy in pts with severe persistent asthma (step 5 or 6)
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What agents can be used to treat exercise induced or allergen induced asthma?
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Only SABAs can treat EIB or allergen induced asthma. However, Mast Cell stabilizers, SABAs, and Leukotriene modifiers may be used to prevent EIB.
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What is the order in using an ICS, LABA, and SABA?
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1st SABA, then LABA, then ICS. Then rinse and spit.
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What are the steps to using an MDI albuterol inhaler?
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1) Shake well prior to use, activate if not used for awhile 2) hold inhaler 1 to 2 inches away from mouth or use a space 3) exhale completely, start inhale slowly. Press inhaler right after starting inhalation. Inhale 3 to 5 sec 4) Hold for 10 secs to allow penetration 5) Wait 30sec to 1 minute between puffs if doing multiple
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What are the steps to using a DPI (dry powder inhaler) diskus?
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1) No need to shake. Do not use spacer 2)Hold like a sandwich 3) slide lever with thumb until click 4) breath out all the way 5) put lips to mouth piece and breath in strongly 6) hold 10 sec 7) rinse mouth and spit
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What are the steps to using a Peak flow meter?
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1) take at the same time each day (usually morning) 2)blow as hard and fast as you can into the peak flow meter 3) repeat three times 4) record highest number (not avg) 5) record daily for 2 weeks when well. the highest number during that time is your personal best
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What is Step 1 of NIH Asthma Guidelines?
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SABA prn
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What is Step 2 of NIH Asthma Guidelines?
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Preferred: Low dose ICS
Alternative: mast cell, LTRA, theopylline |
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What is Step 3 of NIH Asthma Guidelines?
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Preferred: Low-dose ICS + LABA (>=5yoa) OR Medium dose ICS
Alt: Medium dose ICS + LTRA or theophylline |
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What is Step 4 of NIH Asthma Guidelines?
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Preferred: Med dose ICS + LABA (or montelukast if <=11yoa)
Alt: Med dose ICS + LTRA or theophylline |
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What is Step 5 of NIH Asthma Guidelines?
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Preferred: High dose ICS + LABA (or montelukast if <= 4 yoa) and consider omalizumab for pts (> 12yo) w// allergies
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What is Step 6 of NIH Asthma Guidelines?
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High dose ICS + LABA (or montelukast if <= 11yoa) + oral CS and consider omalizumab for pts (>12 yoa) with allergies
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What are the treatments for an asthma exacerbation?
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oxygen (to maintain 02 saturation >= 90%), repetitive or continous SABA, ipratropium (only in ER setting), oral corticosteroids x 3 - 10 days, IV magnesium sulfate or heliox for severe exacerbations
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What is the trade name of albuterol?
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Ventolin, Proair, Proventil
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What is the trade name of levalbuterol?
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Xopenex
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What is the trade name of montelukast?
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Singulair
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What is the trade name theophylline?
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Theo-24, uniphyl, Theo-dur, respbid
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What is the trade name of salmeterol?
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Serevent
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What is the trade name of formoterol?
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Foradil
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What is the trade name of fluticasone inhaler?
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Flovent
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What is the trade name of budesonide?
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Pulmicort
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What is the trade name of fluticasone/salmeterol?
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Advair
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What is the trade name of formoterol / budesonide?
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Symbicort
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What is the trade name of mometasone / formoterol?
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Dulera
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What is the trade name of zafirkulast?
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Accolate
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What is the trade name of Zileuton?
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Zyflo
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What is the trade name of Omalizumab?
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Xolair
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What is the trade name of Cromolyn sodium?
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Intal
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What is the trade name of Nedocromil?
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Tilade
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What is the MOA of Mast cell stabilizers?
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Stabilize mast cell membranes, inhibit activation and release of inflammatory mediators from eosinophils, block early and late reaction to allergen, inhibit acute response to exercise, cold, air, sulfur dioxide
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What is the MOA of Methylxanthines?
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smooth muscle relaxation/bronchodilation via inhibition of phosphodiesterases
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What are the side effects associated with therapeutic doses of methylxanthines?
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insomnia, gi upset (potential for GERD), hyperactivity in children
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What are the possible side effects associated with toxic doses of methylxanthines?
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tachycardia, tachyarrhythmias, nausea, vomiting, CNS stimulation, headache, seizures, hypokalemia
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What are the side effects associated with montelukast?
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No liver issues like zileuton or zafirlukast. Can cause Churg-Strauss syndrome. Also neuropsychiatric effects like mood changes or suicidal thoughts
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What are the side effects associated with zafirlukast?
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Liver injury (elevated ALT), HA, GI upset, Churg-strauss syndrome
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What are the side effects associated with zilueton?
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elevated ALT leading to liver injury, dyspepsia
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