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84 Cards in this Set
- Front
- Back
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This is a chronic inflammatory
disorder of the airways that manifests itself in reversible airway obstruction either spontaneously or with treatment. |
Asthma
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Characterized by hyperirritability and inflammation of the tracheo-bronchial
tree |
Asthma
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The tracheo-bronchial tree is considered the?
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Main stem bronchus
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What four things make asthma an episodic disease?
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Acute exacerbations
Symptom free periods Attacks lasting minutes to hours Patient recovering completely after attack |
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Some degree of airway obstruction daily
Without superimposed severity With superimposed severity Persists for days or weeks |
Status Asthmaticus
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When does asthma show Male predominance
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under 14yrs of age
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When does asthma show Female predominance
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after age 30
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What is the percentage of hereditability factor in asthma?
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60% hereditability factor
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What two things contribute to Asthma as a heterogenous disease?
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Genetic (Atopic) Predisposition
Environmental Factors |
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What environmental factors play a role in asthma as a heterogenous disease?
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Airborne allergens - dust mite, fungus called alternaria, viral-RSV, rhinovirus
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What are the two forms of asthma?
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Allergic (Atopic)
Intrinsic (Idiosyncratic/Nonatopic) |
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Asthma Associated with personal/family hx of
allergic diseases Responsible for most childhood asthma (IgE) mediated |
Allergic (Atopic) Asthma
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Asthma that Occurs in adults
Not necessarily immunologically mediated |
Intrinsic (Idioasyncratic/Nonatopic) Asthma
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What is the pathogenesis of asthma
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Persistent state of subacute inflammation
of the airways |
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What are the five things that contribute to the pathogenesis of asthma?
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1. Eosinophils, Neutrophils, Lymphocytes
With or without increase in collagen content of the epithelial basement membrane 2. Overall generalized increase in cellularity 3. Elevated capillary density 4. Glandular hypertrophy 5. Denudation of the epithelium |
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The hallmark of Asthma is
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a reduction in airway diameter
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The reduction of airway diameter in asthma is brought on by what four things?
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Contraction of smooth muscle
Vascular congestion Edema of the bronchial wall Mucous hypersecretion |
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Asthma involves an interaction between what three things?
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Resident and Infiltrating inflammatory cells
Inflammatory mediators Cytokines |
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What cells are involved in the pathophysiology of asthma?
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1. Mast cells
2. Eosinophils 3. T Lymphocytes Each Cell Line contributes Inflammatory Mediators and Th2 Cytokines 4. Neutrophils and Macrophages Role is less clearly defined |
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This becomes "sensitized" to an
allergen when the IgE specific for that allergen lands on the surface of the this. (e.g., a bronchial wall) |
Mast Cell
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Cross-linking of surface IgE by an allergen molecule triggers what?
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a rapid activation (<15 minutes) of the mast cell, which then releases numerous inflammatory mediators into the tissue surrounding the cell
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This is the inflammatory cell
most closely associated with asthma |
Eosinophil
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In asthma, these move from the
blood into the bronchi and onto the surface of the airway |
Eosinophil
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These play an essential role in
airway inflammation by orchestrating the entire inflammatory process |
T Lymphocytes
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These release a variety of cytokines that communicate with most other cells in the inflammatory process.
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T Lymphocytes
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What are the inflammatory mediators?
There are 8 of them. |
Acetylcholine
Histamine Leukotrienes Platelet - Activating Factor Bradykinin Nitric Oxide ECF-A NCF-A |
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Leukotrienes, an inflammatory mediator, are broken into four types, what are they?
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LTB4, LTC4, LTD4, LTE4
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Leukotrienes are produced by what three things?
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Mast cells
Eosinophils Alveolar macrophages |
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This is a potent contractile agonist on airway smooth muscle.
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Leukotrienes
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This causes constriction of the airway smooth muscle, and works at the muscarinic receptors (M3 subtype).
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Acetylcholine
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This inflammatory mediator is Produced by Mast cells and Eosinophils it Induces
Airway hyper-responsiveness and Inflammation |
Platelet-Activating Factor (PAF)
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This was identified in people
with higher levels of PAF corresponding to the severity of their asthma |
Dysfunctional Gene
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These are inflammatory mediator Released from activated Mast cells Potent bronchoconstrictor
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Bradykinin
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Produced by airway epithelial cells and inflammatory cells Thought to be Pro-inflammatory Asthmatics have higher levels in expired air during attacks decrease after tx
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Nitric Oxide
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This inflammatory mediator, that is an eosinophil chemotactic factor of anaphylaxis.
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ECF-A
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This inflammatory mediator, that is an neutrophil chemotactic factor of anaphylaxis.
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NCF-A
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What are the Th2 cytokines?
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IL-4, IL-5
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This regulates allergic inflammation by promiting Th2 cell differentiation and IgE synthesis.
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IL-4
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This is a Th2 cytokine that is highly specific for eosinophilic inflammation.
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IL-5
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Asthma exacerbation is caused by what six things?
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1. Intense, immediate inflammatory reaction
2. Constriction of smooth airway muscle - Bronchoconstriction 3. Thickening of basement membrane underlying the airway epithelium 4. Hypersecretion of mucous Impaired mucociliary transport 5. Edema Inflammatory cell infiltration of the airway mucosa 6. Vascular congestion |
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What are the six main stimuli/triggers for asthma?
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1. Allergens
2. Pharmacologic agents ASA/ NSAIDS/Beta-blockers 3. Environmental factors Temperature changes 4. Infections Bacterial Viral 5. Activity/Exercise 6. Emotions Stress, Anxiety |
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What are the four main clinical features associated with the History of a patient in asthma?
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1. Personal or family Hx of allergic disease
2. Nocturnal wakening 3. The Triad 4. Associated - chest tightness and anxiety. |
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The personal or family Hx of allergic disease includes what three things?
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Eczema, rhinitis, urticaria
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What are the two things associated with the history of nocturnal wakening?
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Dyspnea, Wheezing
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The triad that is associated with the history of the patient is comprised of what three things?
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Cough, Dyspnea, and Expiratory Wheezing
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What four vital sign features are associated with asthma?
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Tachypnea
Tachycardia Pulsus paradoxus Pulse oximetry |
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Tachypnea in asthma is registered at?
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25-40 breaths per minute
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This is a decrease in systolic pressure with inspiration. The magnitude is directly related to severity of the attack.
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Pulsus paradoxus
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The pulse oximetry measurement on room air, in asthma, is near?
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90%
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In spirometry measurements, asthma airflow obstruction is partially reversible after inhalation of what?
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Short acting beta agonist.
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The FEV1 increases over ? mL or over or equal to ? % from baseline after inhalation of a short acting beta agonist?
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1. 200 mL
2. 12% |
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When performing inspection in the physical examination, what are three things to look for in asthma?
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1. Accessory muscle use/intercostal retractions
2. Chest Hyperinflation 3. Prolonged expiratory phase |
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When you percuss the patient in physical examination of asthma what might be noticed?
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Hyperesonance
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What is noticed when auscultating a patient in physical exam with asthma?
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1. Wheezing (expiratory and inspiratory)
2. Rhonchi 3. Decreased breath sounds |
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This is a very ominous sign in asthma, and usually means the patient will have to be intubated.
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Absence of wheezing
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The PaCO2 is usually what at the onset of an asthma attack?
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Alkalemic
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PaCO2 normalizes in a prolonged attack because of what?
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metabolic compensation
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This is cause for major concern and is an indicator for intubation as respiratory failure is imminent.
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A normal PaCO2
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The sputum is what color in a sputum analysis of an asthmatic patient?
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Clear/Opaque to a yellow/green tinge
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What is present in the sputum analysis of an asthmatic patient?
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Eosinophils
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What three types of eosinophils are present in the sputum of an asthmatic patient?
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Charcot-Leyden crystals
Curschman's spirals Creola bodies |
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This eosinophil, is formed from teh breakdown of eosinohils?
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Charcot-Leyden crystals
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This eosinophil is a bronchiolar cast?
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Curschman's spirals
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This eosinophil is a cluster of airway epithelial cells w/o cilia
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Creola bodies
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In the hematologic studies of asthma what two things are present?
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Eosinophilia is common
Elevated levels of serum IgE |
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When performing spirometry as a diagnostic tool in asthma, what are the two rules?
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1. 3 consecutive exhalations
2. Performed before and then 10 minutes after short acting beta agonist bronchodilator treatment. |
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Pulmonary function test, such as FEV1 is used diagnostically in asthma to?
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Stage the severity of the disease
Tx is based on staging and symptomatology |
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FEV1 is the best method of pulmonary function testing when?
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The situation isn't acute or require intubation
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What are the main four classifications of asthma?
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Mild intermittent
Mild persistent Moderate persistent Severe persistent |
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This is when there are symptoms less than or equal to 2Xper week. There are brief exacerbations that may or may not be treated with SABA prn. The night time symptoms are less than 2Xper month, and it is asymptomatic with normal lung function between exacerbations.
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Mild intermittent
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Symptoms are over 2Xper week, but less than 1Xper day. Exacerbations may affect activity, night time symptoms occur >2Xper month.
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Mild persistent
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Daily symptoms, exacerbations > or equal to 2Xper week affecting activity, night time symptoms >1X per week, daily use of short acting beta agonist.
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Moderate persistent
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Continuous symptoms, frequent exacerbations, frequent night time symptoms.
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Severe persistent
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Staging occurs when patient is at?
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Baseline, not in an attack
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What is the Tx for mild intermittent asthma?
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SABA prn
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What is the Tx for mild persistent asthma?
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Low dose inhaled steroids
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What is the Tx for moderate persistant asthma?
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Low/Med dose inhaled steroids and long acting beta agonist
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What is the Tx for severe persistent asthma?
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High dose inhaled steroids and long acting beta agonist
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Quick relief for all asthma patients, the Tx is?
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SABA
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What is the Acute Tx for an Asthmat attack with FEV1 or PEF greater than or equal to 40%?
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O2 to achieve SaO2 over 90%
Inhaled SABA via nebulizer or MDI - up to three doses in first hour PO corticosteroids - 5 day scrip with no taper, or a 12 day scrip with taper Discharge Home |
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What is the acute Tx of asthma that has FEV1 or PEF <40%
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O2 to achieve SaO2 over 90%
Inhaled high dose SABA plus ipatropium via nebulizer or MDI - every 20 minutes or continuously for first hour PO corticosteroids - May require taper, most likely will taper Admit to hospital |
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Acute Tx of impending or acute respiratory arrest involves what?
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Intubation and mechanical ventilation with 100% oxygen
Nebulized SABA and ipatropium hourly or continuously Intravenous corticosteroids - Solumedrol Consider Adjunct Therapies Admit to ICU |
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Acute Tx for respiratory arrest is needed when?
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PaCO2 comes back normal, hardly any sound of wheezing, on full blown O2 with less than 92% PO2. Must intubate before airway closes.
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What may be given in respiratory arrest?
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IV epinephrine
IV terbutaline |
