Family Medicine - Asthma

Front 1

What is asthma?

Back 1

inflammatory disease of the airways
triggered by:
airborne allergens
irritants
cold air
exercise

Front 2

What is the most common chronic disease of childhood with the greatest prevalence and mortality among inner city kids?

Back 2

Asthma

Front 3

What population is affected most by asthma?

Back 3

african american youth bet ages 15-24

Front 4

What are some risk factors for mortality from asthma?

Back 4

previous history of intubation
admission to an ICU
2 or more hospitalizations
2 more more ER visits in a yr
2 canisters of short-acting Beta2 agonist in a single month
inability to perceive airway obstruction
use of chronic steroids

Front 5

Explain the inflammatory event which leads to an asthma attack

Back 5

initial inflammation causes degranulation of Mast cells
this releases mediators such as:
histamine
cytokines
leukotrienes
platlet activating factors
all of these mediators cause increased bronchiolar vascular permiability which increases grandular secretions and mucous production and leads to bronchospasms!!!

Front 6

What does it mean if you hear in the ER that a person is having an:
"early-phase asthmatic response"?

Back 6

these are the early symptoms of an asthma attack
wheezing, cough, and dyspnea

Front 7

What is the Late Phase Asthmatic Response?

Back 7

Migration of eosinophils and neutrophils occurs 6-12hrs after the mast cell degranulation phase - this is referred to as the late phase response

This phase can last up to 48 hrs
The release of mediators such as eosinophils causes epithelial damage, hypersecretion of mucous, and increased bronchial smooth muscle contractions

The recruited eosinophils AMPLIFY and sustain the inital inflammatory response without additional exposure to the triggering agent

Front 8

What is "airway remodeling"?

Back 8

occurs with chronic asthma and long standing airway inflammation

increased inflammation from the bronchioles causes increased # of mucous secreting cells (goblet cells), thickening of the basement membrane, edema, and thickening of the smooth muscle wall.

Front 9

A 25 yr old female presents to the office with wheezing, dyspnea, cough, and sputnum production. What she most likely have?

Back 9

classic presentation of asthma

Front 10

You need to be able to classify asthma for treatment purposes.....

Back 10

here we go woo woo

Front 11

What classification of asthma has:

<2 times/week
Brief exacerbations
Asymptomatic between attacks

Nighttime symptoms:
<2 times/month

Lung Function:
FEV1 or PEF >80% predicted
PEF variability <20%

Back 11

Intermittent

Front 12

What classification of asthma has:

>2 times/week
But < 1 time/day
Attacks may affect activity

Nighttime symptoms:
> 3-4/month

Lung Function:
FEV1 or PEF >80% predicted
PEF variability 20-30%

Back 12

Persistent-Mild

Front 13

What type of asthma has:

Daily symptoms
Daily use of Beta2 agonists
Attacks affect activity
Exacerbations may last for days

Nighttime symptoms:
>1 time a week but not nightly

Lung Function:
FEV1 or PEF 60-80%
Predicted
PEF variability >30%

Back 13

Persistent - Moderate

Front 14

What type of asthma has:

Continual symptoms with use of Beta2 agonist multiple times a day
Limited physical activity
Frequent attacks

Nighttime symptoms:
frequent, almost every night

Lung Function:
FEV1 or PEF <60% predicted
PEF variability >30%

Back 14

Persistent-Severe

Front 15

What are the PEF used for lung function?

Back 15

PEF = Peak expiratory flow
Part of a procedure called spirometry

Spirometry (meaning the measuring of breath) is the most common of the pulmonary function tests (PFTs), measuring lung function, specifically the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. Spirometry is an important tool used for generating pneumotachographs, which are helpful in assessing conditions such as asthma, pulmonary fibrosis, cystic fibrosis, and COPD.

Peak expiratory flow (PEF) is the maximal flow (or speed) achieved during the maximally forced expiration initiated at full inspiration, measured in liters per minute.

Front 16

What is FEV1?

Back 16

FEV1 is the volume of air that can forcibly be blown out in one second, after full inspiration. Average values for FEV1 in healthy people depend mainly on sex and age, according to the diagram at left. Values of between 80% and 120% of the average value are considered normal. Predicted normal values for FEV1 can be calculated online and depend on age, sex, height, weight and ethnicity as well as the research study that they are based on.

Front 17

What is the FEV1/FVC ratio?

Back 17

FEV1/FVC (FEV1%) is the ratio of FEV1 to FVC. In healthy adults this should be approximately 75–80%. In obstructive diseases (asthma, COPD, chronic bronchitis, emphysema) FEV1 is diminished because of increased airway resistance to expiratory flow; the FVC may be decreased as well, due to the premature closure of airway in expiration, just not in the same proportion as FEV1 (for instance, both FEV1 and FVC are reduced, but the former is more affected because of the increased airway resistance). This generates a reduced value (<80%, often ~45%).

In restrictive diseases (such as pulmonary fibrosis) the FEV1 and FVC are both reduced proportionally and the value may be normal or even increased as a result of decreased lung compliance.

A derived value of FEV1% is FEV1% predicted, which is defined as FEV1% of the patient divided by the average FEV1% in the population for any person of similar age, sex and body composition.

Front 18

What is a important part of the Hx to ask about?

Back 18

Hx of intubation for the Tx of asthma
Good predictor for the severity and the need for aggressive therapy

Front 19

A 14 yr old presents with acute shortness of breath, cough, wheezing, increased respirations, and sputum production. What is this?

Back 19

Bronchiolitis - acute

asthma is more chronic

Front 20

A 12 yr old male presents with shortness of breath, cough, wheezing, sputum production. He also complains of recurrent sinus infections, GI symptoms, smelly stools, and has a hx of pneumonia.

Back 20

cystic fibrosis

Front 21

What are the 2 diseases in adults that are commonly confused with asthma?

Back 21

COPD and CHF

Front 22

What are a set of tests that can help you differentiate between CHF and pulmonary disease?

Back 22

Chest x-ray
ECG
Spirometry

Front 23

What might you see on xray for asthma?

Back 23

may be normal or may show hyper-inflation due to air trapping

Front 24

What is a good test if you suspect cystic fibrosis?

Back 24

sweat test

Front 25

There are 6 steps in managing asthma treatment

what is the 1st?

Back 25

only: quick relief medication of short-acting inhaled beta2 agonist

short acting Beta 2 agonists are given to all steps in asthma tx to manage short attacks

Front 26

What are the other steps?

Back 26

Step 2:
Long term: low-dose inhaled corticosteroid

Step 3:
low dose inhaled corticosteroid plus a Long acting beta2 agonist ot a medium dose inhaled corticosteroid

Step 4:
Medium dose inhaled corticosteroid plus a long acting inhaled beta2 agonist

Step 5:
High dose inhaled corticosteroid plus a long acting beta2 agonist AND consider omalizumab for patients with allergies

Step 6:
high dose corticosteroid, plus long acting beta2 agonist, plus oral corticosteroid, AND consider omalizumab for pts with allergies

Front 27

In what pts should you monitor asthma with PEF?

Back 27

moderate to severe asthma

Front 28

What PEF level indicates good control of asthma?

Back 28

>80%

Front 29

If a persons PEF was between 50 and 80% what should you administer?

Back 29

prompt inhaled short acting beta2 agonist and consult a specialist for adjustments in medications

Front 30

What does a PEF less then 50% mean?

Back 30

immediate use of inhaled beta2 agonist and emergency assessement by a doc

Front 31

What types of meds are give to a person with persistant asthma?

Back 31

Both long term control mediators (anti-inflammatory) and quick-relief meditors

Front 32

What is the only tx needed for intermittant disease?

Back 32

short acting beta 2 agonist
most commonly Albuterol
2 puffs 4-6hrs as needed to control symptoms
Adverse reactions: flushing, tremors, and tachycardia

Front 33

What are inhaled corticosteroids?

Back 33

most potent and effective anti-inflammatory agents used for the long-term tx of persistant asthma

most pts can be contained on twice daily dosing

Front 34

What should you advise your pt to do if you give them a inhaled corticosteroid?

Back 34

advise to gargle with water after use to prevent oral candidiasis

Front 35

What do you need to worry about in children on high dose oral inhaled corticosteroids?

Back 35

may interfere with normal vertical growth
give oral leukotriene instead

Front 36

How do Cromyln Sodium and Nedocromil work?

Back 36

Mast cell stabilzers

prevent mast cell degranulation in addition to inhibiting bronchoconstriciton

safe to use in children, pregnant women with mild-persistant asthma

also effective against exercise induced asthma if taken 15-30 minutes before activity

Front 37

What is Salmeterol

Back 37

long-acting beta2 agonist
used to tx nocturnal symptoms and exercise induced asthma
more effective then nedocromil in the tx of exercise induced asthma (lasts 9 hrs)

Front 38

Should you double someone's dose of inhaled steroid or give them salmeterol and a low dose steroid?

Back 38

salmeterol and a low dose steroid is more effective in improving symptoms and reducing the use of rescue medications than simply doubling the dose of inhaled corticosteroid

Front 39

What is Burst Therapy?

Back 39

oral systemic corticosteroids are used as burst therapy to gain control of asthma during an acute attack

Give prednisone:
adults - 40-60 mg/d
kids - 1-2 mg/kg/d
for 3-10 days or PEF >80%

Front 40

How do anticholinergics work?

Back 40

asthma inhaled Ipratropium = Atrovent

inhibits vagally mediated bronchoconstriction and mucous production

Effective for use in conjunction with Albuterol for the Tx of severe asthma exacerbations

Front 41

What is the cornerstone for asthma tx?

Back 41

pt education!!!!!!!!!!!!!