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23 Cards in this Set
- Front
- Back
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Asthma epidemiology
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7.8% overall prevalence (similar to diabetes)
More prevalent in children than adults (although there are more adults with asthma) More prevalent in females, men usually get asthma as children (but it goes away as adult) More prevalent in black and hispanic than white, and also more mortality |
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Asthma definition
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Airway obstruction that is episodic and reversible (at least to a significant degree)
Increased airway responsiveness to a variety of stimuli Airway inflammation Smooth muscle dysfunction Airway inflammation Airway remodeling |
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Pathobiology of allergic asthma
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Allergen comes in and meets APC
APC activates Th2 -IL-4, IL-13 smooth muscle effects -IL-4, B cells differentiate and produce IgE, Mast cell migration and degranulation (Histamine, Tryptase, Prostaglandins, Cysteinyl leukotrienes, IL-4, IL-5) -IL-5 Eosinophil migration and survival (Leukotrienes, ECP, MBP) Th2 Driven Pathobiology Eosinophils and Mast Cells are main effector cells |
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Pathobiology of nonallergic asthma
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Non-allergic environmental insults
Destruction and disarray of epithelium Viruses Subepithelial basement membrane thickening Th1/Th17 -Activate monocytes and macrophages which activate neutrophils -Activate mast cells -Affect smooth muscle ? Th1 or Th17 Driven Pathobiology Neutrophils are likely main effector cells Leads to airway remodeling |
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Airway remodeling in asthma
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Lumen filled with mucus,
cellular debris Denuded epithelial layer Subepithelial collagen Smooth muscle bundle |
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Pathophysiology of asthma
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Small Pipes = turbulent flow
Inspiration pulls pipes open (tethers) = favors smoother airflow Expiration collapses pipes = unable to exhale, hyperinflation "Wind in the sail" -Problems in expiration seen in flow volume plot |
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Classic spirometry in mild asthma
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Spirometry is Normal at Baseline
But Obstructed with Exacerbation of Asthma -FEV1/FVC decreased EPISODIC AND REVERSIBLE |
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Dynamic physiology in asthma
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Assess bronchial responsiveness to see if how the airways “respond” to stimuli using:
-Short-acting beta-agonist (reversibility) -Short-acting cholinergic (methacholine) to induce airflow obstruction (hyper-responsiveness) -Exercise challenge while breathing cold dry air -Allergen inhalation provocation REVERSIBLE and AIRWAY RESPONSIVENESS to a VARIETY of STIMULI |
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Classic asthma symptoms
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Cough:
-After exertion -Breathing cold air -At night -After colds -Paroxysmal Wheezing -Chest tightness -Noisy breathing Breathlessness -Intermittent -After exertion -At night EPISODIC |
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Asthma: Physical exam
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Exam can be completely normal
Forced expiration will usually induce wheezing, but not always In Acute Exacerbation: -Tachypnea (breathing fast) -Use of accessory muscles to breathe -Markedly prolonged expiration with wheezing -No air movement, “silent” chest |
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Asthma: Symptom relievers vs Disease controllers
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Symptom relievers (use as needed)
-Beta2 agonists -Anti-cholinergics Disease controllers (use daily) -Inhaled corticosteroids -Oral corticosteroids -Long acting beta2 agonists -Leukotriene modifiers -Cromolyn sodium -Nedocromil sodium -Theophylline |
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Mild intermittent: symptoms, PEF or FEV1, PEF variability, daily medications
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Symptoms/Day
- <=2 days/week Symptoms/Night -<=2 nights/month PEF ->=80% PEF variability -<20% Daily medications -No daily medication needed |
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Mild persistent: symptoms, PEF or FEV1, PEF variability, daily medications
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Symptoms/Day
- >2 days/week but <1x/day Symptoms/Night ->2 nights/month PEF or FEV1 ->=80% PEF variability -20-30% Daily medications -Low dose ICS -Alternative treatment: Cromolyn, LTM, nedocromil OR theophylline SR |
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Moderate persistent: symptoms, PEF or FEV1, PEF variability, daily medications
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Symptoms/Day
- Daily Symptoms/Night ->1 night/week PEF or FEV1 -60-80% PEF variability ->30% Daily medications -Low to medium dose ICS + LABA -Alternative treatment: increase ICS dose with medium dose range OR low-to-medium dose ICS +LTM or theophylline |
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Severe persistent: symptoms, PEF or FEV1, PEF variability, daily medications
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Symptoms/Day
- continual Symptoms/Night -frequent PEF or FEV1 -<=60% PEF variability ->30% Daily medications -High dose ICS + LABA and if needed corticosteroid tablets long term |
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Asthma severity vs control
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Asthma Severity
-Chronic Assessment -Ideally before patient was started on medications -“How bad is this person’s asthma overall” -Also includes exacerbations (intermittent is 0-2/ year, mild, moderate, and severe persistent is >2/year) Asthma Control -Real time Assessment -“How is this patient doing in the past month” |
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Asthma goals of care
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Reducing Discomfort/Impairment:
-Prevent chronic, troublesome symptoms -Maintain (near) normal pulmonary function -Maintain normal physical activity (including exercise) -Enable quality of life unimpaired by asthma Reducing Risk: -Preventing recurrent exacerbations of asthma and minimizing the need for ED visits/hospitalizations -Preventing disease progression --Progression of irreversible airflow obstruction --Development of more severe asthma -Minimal risk of toxicity from pharmacotherapy |
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Asthma control: assessing impairment
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Chest tightness, wheezing, shortness of breath, cough, sputum production, nocturnal awakenings, inability to exercise, inability to tolerate certain exposures or activities
-Final assessment of severity is reported by patient to provider but may require “prompts” -Spirometry and the Asthma Control Test™ are objective tools that serve as “prompts” |
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Asthma control test
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In the past 4 weeks
Level of Control Based on Composite Score 20-25 = Controlled 16-19 = Suboptimal <15 = Poorly Controlled Regardless of patients’ self assessment of control in Question 5 |
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Asthma control: assessing risk
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Risk of exacerbations, progressive, irreversible loss of pulmonary function, progression to severity causing greater discomfort and risk
Final assessment of severity may be estimates by clinical assessment, “biomarker” of activity of underlying pathophysiological processes, or assessment of exposure to aggravating risk factors: -History of prior exacerbations -Current pulmonary function -Current markers of inflammation (sputum eosinophils, FeNO, serum ECP, urinary leukotrienes) -Current marker of responsiveness to environmental agents (skin or RAST testing, bronchial reactivity) |
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Classification of asthma control
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Well controlled
-Symptoms <= 2 days/week -Nightime awakenings <=/month -Interference with normal activity: none -FEV or peak flow: >80% predicted/personal best -ACT: >=20 -Exacerbations: 0-1/year -Recommended action: maintain current step or consider step down if controlled for at least 3 months Not well controlled -Symptoms > 2 days/week -Nightime awakenings: 1-3/week -Interference with normal activity: some limitation -FEV or peak flow: 60-80% predicted/personal best -ACT: 16-19 -Exacerbations: 2-3/year -Recommended action: step up 1 step, reevaluate in 2-6 weeks Very poorly controlled -Symptoms throughout day -Nightime awakenings >4/week -Interference with normal activity: extremely limited -FEV or peak flow: <60% predicted/personal best -ACT: <=15 -Exacerbations: >3/year -Recommended action: Consider short course of systemic oral corticosteroids, step up 1-2 steps, reevaluate in 2 weeks |
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Asthma medications
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Step 1
-SABA PRN Step 2 -Add low doese ICS -Alternative: cromolyn, nedocromil, LTRA, or theophylline Step 3 -Add Medium dose ICS OR low dose ICS + LABA -Alternative: Low dose ICS+either LTRA, Theophylline, Zileuton Step 4 -Add Medium dose ICS+LABA -Alternative: Medium dose ICS+either LTRA, theophylline, or Zileuton Step 5 -Add High dose ICS+LABA and -Consider Omalizumab for patients who have allergies Step 6 -Add High dose ICS + LABA + oral corticosteroid and -Consider omalizumab for patients who have allergies |
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Monitoring and reevaluation to achieve control
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Present with asthma
Assess asthma control Symptoms Activity Patient assessment PFTs Exacerbations Periodic assessment of asthma Adherence Action plan Comorbidities ? Correct diagnosis If asthma well controlled -maintain or step down therapy If asthma not well controlled -assessment -optimize therapy |
