Nur 731 Asthma

Front 1

With chronic throat clearing, think?

Back 1

sinusitis, rhinitis, PND

Front 2

Dry, tight cough think?.

Back 2

asthma, allergic rhinitis, foreign body.

Front 3

S/s gerd?

Back 3

heartburn, nausea, substernal chest pain or discomfort and sour taste in mouth

Front 4

s/s of CF?

Back 4

On PE, note any clubbing or signs of hyperinflation. In an infant, if also has recurrent URIs, 2 or more episodes of pneumonia in one year, FTT or parasinusitis, consider CF.

Front 5

Wheezing takes place in which part of the lungs?

Back 5

-large airway involvement

Front 6

Small airway involvement induces?

Back 6

dyspnea and cough more than wheezing.

Front 7

Gender incidence?

Back 7

male > female incidence in childhood, until puberty, then in adults, female > male.

Front 8

Intrinsic asthma is?

Back 8

Intrinsic asthma is most common in adults; symptoms are provoked by infection, exertion, nonspecific environmental factors; not related to allergen exposure.

Front 9

Non-allergenic triggers include ?

Back 9

Non-allergenic triggers include exercise induced (5-10 minutes after vigorous activity), workplace triggers such as fumes, dyes, chemicals; drug induced from drugs such as SAIDS, aspirin, indomethacin, beta-blockers.; smoke and pollutants.
Onset is often in early adulthood

Front 10

atopia?

Back 10

allergic reaction for whch there s a genetic predisposition

Front 11

Triggers of atopic allerges?

Back 11

These triggers are allergenic in nature, including pollen, pet dander, feathers, dust mite and cockroach excrement, and food additives such as sulfites.

Front 12

rhinitis?

Back 12

nflammation or irrtation of the nasal passages

Front 13

Rhinits results in?

Back 13

runny nose, nasal congestion and or PND

Front 14

rhinorrhea?

Back 14

thin watery discharge form the nose

Front 15

Gustatory rinorrhea?

Back 15

a flow of thn watery material from the nose whcle one is eating

Front 16

rhinorrhagia?

Back 16

epistaxis

Front 17

Pulsus paradoxus ?

Back 17

(= > 20 mmHg fall in BP during inspiration)
May occur during a acute exacerbation of asthma

Front 18

How do you evaluate bronchodilator response?

Back 18

FEV 1 = forced expiratory volume in one second: check before and after inhalation of bronchodilator

Front 19

Snyder’s syndrome?

Back 19

may experience fatal asthma if use ASA or any NSAID that inhibits cyclooxygenase)

Front 20

Sputum exam?

Back 20

checked for eosinophilia.

Front 21

With viral ifect, what happens?

With bact ifect, what happens?

Back 21

With viral infection, lymphs increase; with secondary bacterial infection, neutrophils increase.

Front 22

Sputum eosinophils may be depressed in which pts?

Back 22

If pt is on glucocorticoid therapy, eos may be depressed, as expected also in pt under stress or with regular epinephrine use.

Front 23

PEFR?

Back 23

PEFR = peak expiratory flow rate.

Front 24

PEFR = peak expiratory flow rate.
For an average adult, PEFR range is usually?

Back 24

For an average adult, range 400-500.

Front 25

Mild obstruction with PEFR=

Back 25

generally under 300 in an adult

Front 26

Moderate obstruction with PEFR =

Back 26

100-200 range

Front 27

Severe obstruction wth PEFR =

Back 27

under 100

Front 28

PEFR less than 100 should?

Back 28

usually admit after trial epi and nebulization treatments.

Front 29

PEFR of 300 should?

Back 29

may be treated as outpatient

Front 30

What do you do wth pts that have moderate obstruction

Back 30

hold in office after treatment until improved;

Front 31

Yellow Zone?

Back 31

Yellow = 60-80% baseline
Peak flow zones

Front 32

Red Zone?

Back 32

Red = below 50-60%
Peak flow zone

Front 33

Green zone?

Back 33

Peak flow zones:
Green = 80-100% baseline

Front 34

Peak flow is a good screening test for predicting?

Back 34

obstructive abnormalities of the large airways.

Front 35

Large airway obstruction is assessed via ?

Back 35

Large airway obstruction is assessed via expiratory flow

Front 36

Large airway obstruction is assessed via?

Back 36

expiratory flow rate and ratio FEV 1 to VC (vital capacity, which is the maximum volume of air that can be expired after a full inspiration).

Front 37

VC?

Back 37

which is the maximum volume of air that can be expired after a full inspiration

Front 38

VC=?

Back 38

VC = sum IC (inspiratory capacity) and ERV ( expiratory reserve volume)

Front 39

Pt is SOB at rest with what % reduction of FEV 1 ?

Back 39

If down to 25% of maximum, pt is SOB at rest.

Front 40

Pt is usually dyspneic and hypoxemic on exertion with what % reduction of FEV 1 ?

Back 40

50%

Front 41

How is spirometry done?

Back 41

Spirometry is performed with pt’s nose clipped; three easy breaths are taken, then deeply inhale, exhale forcibly and completely.

Front 42

PEFR varies per ?

Back 42

per indiv. Age, sex, height.

Front 43

VC depends on ?

Back 43

VC depends on age (< with time), > with > height and good physical fitness level, and lower in women than men with same age and height.

Front 44

asthmatics are more susceptible ?

Back 44

asthmatics are more susceptible to methacholine chloride than non-asthmatic pts

Front 45

Bronchial provocation testing ?

Back 45

Pt records baseline FEV 1, then via nebulizer, inhales increasing concentration of methacholine chloride; if FEV 1 decreases by 20% or more, the test is +. Inhaled brochodilator is given. Test is performed under hosp supervision usually, rather than out pt. Setting.

Front 46

How do you monitor COPD?

Back 46

Obstructive airway disease results in slow loss of ability to expel air from lung; therefore, measuring maximum expiratory flow rate helps monitor disease progress.

Front 47

When should baseline PFTs should be measured?

Back 47

6 or more hours after last dose of brochodilator

Front 48

Pt with asthma should improve -____% on PEFR or FEV 1 after bronchodilator administration?

Back 48

15-20%

Front 49

If no improvement of PEFR/ FEV 1 after bronchodialator occurs, consider diagnosis of ?

Back 49

chronic bronchitis or emphysema; or pt may have inflammatory disease that only responds to glucocorticoids.

Front 50

With aging, whch 2 F measuresments decrease?

Back 50

With aging, FEV 1 and FFV are lower. At age 55 for example, in men, 79% of normal and in women, 74%; by age 70, rate is usually 70%.

Front 51

What measurement is is an excellent indicator of small airway obstruction?

Back 51

Forced expiratory flow after 25-75% vital capacity is expelled (FEF 25-75) is an excellent indicator of small airway obstruction.

Front 52

PEF measures ?

Back 52

PEF measures only large airway changes; may be normal in cases of considerable peripheral obstruction; convenient and economical to measure.

Front 53

DD cough in elderly:?

Back 53

COPD, bronchiectasis, CHF, PE, bronchogenic carcinoma, cough secondary to ACE inhibitor use. About 3% of pts develop asthma after age 60. COPD more likely. Pulmonary lab can measure carbon monoxide diffusing capactiy: if low, suggests tobacco induced lung disease: do CXR to exclude tumor or signs cardiomegaly).

Front 54

DD for cough?

Back 54

DD all ages: foreign body aspiration, acute infections such as viral, pneumonia, bronchitis, TB, GERD, AIDS, psychogenic cough, neuromuscular weakness.

Front 55

How do you treat an asthma episode?

Back 55

measure peak flow, then administer nebulized albuterol 5 mg/5 cc: 0.5 cc in 2.5 cc NS, administered over 5 minutes. If not effective, repeat in 15 minutes.

Front 56

S/Q epi for asthma episode

Back 56

SQ epinephrine may be used, for an adult 0.2-0.3 cc 1:1000 aqueous solution; check vitals and may repeat x 2 with re-evaluation. If none of the above are effective toward the goal of improving the peak flow and airway sounds, consult.

Front 57

When admission is required, pts usually have ?

Back 57

CXR, ABGs, and evaluation of oxyen saturation. If O 2 sat is available in office setting, check it!

Front 58

ABG goal is to maintain the PaO2 ? What do you do if low?

Back 58

> 65. When under 60, admin oxygen at 2-4 l/min.
Start IV for hydration; methylprednisone often given, PO steroid started too.

Front 59

Status Asthmaticus may be triggered by?

Back 59

usual allergens, emotional crisis, URI, steroid withdrawal. Pt presents anxious, irritable, tachypneic, tachycardic, with labored breathing.

Front 60

NP may refer or consult re?

Back 60

newly diagnosed pts, those with underlying cardiac disease, pt over 60, pt with COPD, those in respiratory distress, PEFR < 100, those with extreme dyspnea, or pts with side effects from bronchodilator therapy (tremor, tachycardia).

Front 61

Treatment of step one disease is?

Back 61

SABA
Short term beta agonist bronchodilators.

Front 62

For step two treatment, add an?

Back 62

ICS
an anti-inflammatory agent. Inhaled corticosteroids

Front 63

Step three tx?

Back 63

LABA
Long acting beta agonist

Front 64

Step four tx?

Back 64

PO steroid use.

Front 65

Step four caution?

Back 65

adrenal suppression and death can occur with withdrawal from long term
AND evaluation/monitoring for osteoporosis: consider calcium supplementation prn.

Front 66

Management for asthma is?

Back 66

Management is primarily carried out by pt, with visits for follow up q 6 months,

Front 67

Ex of step one meds?

Back 67

albuterol (Ventolin, Proventil) 1-2 puffs QID prn
-metaproterenol (Allupent, Metapril), 2 puffs up to 12 per day;
-pirbuterol acetate (Maxair), 2 puffs up to 12 per day.

Front 68

What happens if pt over uses SABA ?

Back 68

These are “rescue” meds.
if recommended dosage is being exceeded, pt needs to be re-evaluated.

Front 69

Two puffs of one of these administered 30 minutes prior to exercise should maintain adequate airway function for 4 hours, eliminating irritable airway response to exercise?

Back 69

SABA

Front 70

Ex of step 2 meds?

Back 70

(Flovent) Beclomethasone dipropionate (Vanceril, Beclovent),
Triamcinolone acetate (Azmacort) same as beclomethasone

Front 71

Fluticasone propionate (Flovent) dose?

Back 71

44, 110, or 220 mcg/inhalation doses. Start pt on bronchodilator for first time on 44 mcg/puff, 2 puffs BID to max 440mcg BID.

Front 72

Beclomethasone dipropionate (Vanceril, Beclovent dose?

Back 72

Beclomethasone dipropionate (Vanceril, Beclovent), 2 puffs, TID or QID, or 4 puffs BID

Front 73

Triamcinolone acetate (Azmacort) same as beclomethasone dose?

Back 73

2 puffs, TID or QID, or 4 puffs BID

Front 74

Example of LABA?
What step is this?

Back 74

Salmeterol (Serevent), 2 puffs BID

Step 3

Front 75

Examples of Leukotriene inhibitors are?

Back 75

Zafirlukast (Accolate) and zileutron (Zyflo)

Front 76

What do the Leukotrene inhibitors do?

Back 76

improve lung function, improve symptoms, decrease need for rescue meds
induce bronchodilation within 2 hours of use.

Front 77

Leukotrene inhibitors are most helpful in what type of pts?

Back 77

more helpful in pts sensitive to ASA,

Front 78

Zafirlukast is a?

Back 78

leukotriene receoptor antagonist

Front 79

Caution with ICS?

Back 79

**pt must rinse mouth with water after use; rinse canisters and/or spacer devices as well; use bronchodilator first, then steroid inhaler one minute between each puff; remember that measurable blood levels occur when recommended doses are exceeded.

Front 80

leukotriene is a ?

Back 80

leukotriene is a substance released by mast cells in response to various asthma triggers, which is in part responsible for the increased mucus production, bronchoconstriction and eosinophil infiltration that results

Front 81

Zileutron ?

Back 81

Zileutron inhibits the synthesis of all leukotrienes through enzyme inhibition. LFTs must be monitored for baseline and periodically with Zyflo.

Front 82

Montelukast (Singulair) may be used in children as young as?

Back 82

2 years of age.

Front 83

Side effects of PO corticosteroids also can include?

Back 83

hyperglycemia development, cataract formation, easy bruising, unwanted hair growth, thinning skin, GI bleed, mood disturbance, and osteoporosis.

Front 84

Side effects of long term po corticosteroids also can include?

Back 84

Short term courses are associated with insomnia, depression, anxiety, insulin resistance in diabetics, worsening glaucoma, hypokalemia and sodium retention in hypertensives, which may induce CHF from fluid retention

Front 85

How do diuretics affect prednnisone?

Back 85

Diuretics, non potassium sparing, have additive hypokalemic effects with prednisone.
Beta adrenergic blocking agents with theophylline can induce cardiac arrhythmias and myocardial damage.

Front 86

How do Beta adrenergic blockers asthma?

Back 86

Beta adrenergic blockers also worsen asthma and block the therapeutic action of beta adrenergic bronchodilators.

Front 87

Which eye drops may aggravate asthma sympts?

Back 87

Even beta adrenergic blocking eye drops may be absorbed from conjunctiva to aggravate asthma (e.g. Timoptic). Pilocarpine has same effect. If no alternative treatment is available, check peak flow before and after treatment.

Front 88

How may ACE inhibitors asthma?

Back 88

ACE inhibitors may induce cough, aggravating asthma.

Front 89

For pts with MDI coordination difficulty?

Back 89

a) MDI coordination difficulty: use tube spacer Inspirease (collapsible chamber), or Maxair for rescue med.

Front 90

In elderly pts with asthma, look for and treat underlying disease, especially

Back 90

GERD, rhinitis, chronic sinusitis, COPD, bronchiectasis, CHF. GERD for example may provoke asthma, by microaspiration or reflex bronchoconstriction or asthma may provoke reflux

Front 91

Imminuzatons for asthmatics?

Back 91

Annual flu shot is a must.
Pneumococcal vaccine also recommended q 5 years.

Front 92

Monitor pts with long term asthma for?

Back 92

allergic bronchopulmonary aspergillosis (ABPA), especially those on long term corticosteroids . Monitor via CXR: bronchiecstasis centrally, IgE skin test.

Front 93

Preg Cat B meds?

Back 93

Category B: ipratropium, cromolyn, leukotrienes, inhaled terbutaline.

Front 94

Preg Cat C meds?

Back 94

Category C: beta-adrenergic agonists, theophylline, inhaled and systemic corticosteroids.

Front 95

Follow-up clients with severe exacerbation in?

Back 95

Follow-up clients with severe exacerbation in 24 hours; then after 3-5 days, weekly until symptoms are controlled, and PEFR is consistently 80% of predicted. Then q 6 months.