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30 Cards in this Set
- Front
- Back
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What is asthma?
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its a CHRONIC inflammatory condition of the lung airways with heightened "responsiveness" of airways to provactive exposure
-- it is misunderstood among the public, expensive overall, and life changing (play, sports and physical exercise, playing musical instruments) MOST IMPORTANTLY -- ASTHMA KILLS |
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What is the etiology of asthma?
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there is no defined cause -- there are genetic and environmental factors that contribute
-- it has been linked to RSV -- strong association with perennial allergies -- environmental pollutants (smoke, ozone, sulfur dioxide, etc) aggrevate inflammation |
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epidemiology of asthma
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8.65 million children are diagnosed with astham in their lifetime -- there is particularly high morbidity and mortality among african american children
-there is an increase in prevalence and its more common in metropolitan areas (due to pollution) -- onset is usualy before the age of 6 -- minority of young children with recurrent wheezing will have persistent asthma |
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what are some early childhood risk factors for developing persistent asthma? (7)
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(1) Parental asthma
(2) allergies (3) severe lower respiratory tract infection (pneumonia or bronchiolitis that required hospitalization or was accompanied with wheezing) (4) wheezing apart from colds (5) male gender (6) low birth weight (7) environmental tobacco smoke exposure |
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what clinical manifestations are associated with asthma
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chronic symptoms are key!!
intermittent dry cough and expiratory wheeze are most common -- respiratory symptoms are typically worse at night, especially during prolonged exacerbations may other symptoms in children may be very subtle: (1) decreased physical activity (2) general fatigue (3) difficulty keeping up with peers in physical activity |
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what clinical manifestations are seen in younger children
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associated intermittent, non-focal chest "pain"
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what clinical manifestations are seen in older children
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associated shortness of breath and chest tightness
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what should you ask of a patient that you think might be asthmatic?
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ASK ABOUT PREVIOUS BRONCHODILATOR AND STEROID USE
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what symptoms typically provoke an attack in asthmatics?
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(1) physical exertion
(2) hyperventilation (laughing) (3) cold or dry air (sudden weather changes) (4) airway irritants (dist mites, cockroaches, mold, pollen, smoke, perfumes, hairsprays, cleaning supplies) |
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What are some things that can make symptoms worse in asthmatics?
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viral infections or inhaled allergens along with "occupational" exposures
** must obtain thorough history of triggers and environment for optimal management |
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how do you diagnose asthma?
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RELIES A LOT ON HISTORY!
-- physical exam may be normal when they are not having an exacerbation but during exacerbation: (1) expiratory wheezing (2) prolonged expiratory phase (3) decreased breath sounds (4) crackles and rhonchi (from excessive mucus production) (5) labored breathing (6) signs of respiratory distress |
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who would you suspect to have asthma?
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(1) those with recurrent wheezing episodes/ have been hospitalized for wheezing
(2) people that have "colds" that do not go away unless they receive albuterol (3) have limited physical activity because of coughing (4) repeated dry night time cough or repeated exaggerated response to common stimuli |
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what would be part of your differential diagnosis when dealing with asthma?
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**MUST REMEMBER THAT EVERYTHING THAT WHEEZES IS NOT ASTHMA**
could be allergic rhinitis, chronic sinusitis, GERD, congenital anatomic anomalies, tumors, foreign body aspiration, cystic fibrosis, vocal cord dysfunction (teens), pertussis or bronchiolitis |
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what are PFT's (spirometry) used for?
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its the basis of documenting the presence of asthma and severity of acute exacerbations
-- norms for FEV1 in children is based on height, gender, and ethnicity -- look for a response to albuterol --> improvement of >12% of FEV1 in response to albuterol is consistent with asthma |
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what are some problems faced with using spirometry
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(1) the patient must be compliant -- generally not reliable for patients until they are 6 years old
(2) results must be reproducible and that is a very difficult thing to do |
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what is the bronchoprovocation challenge?
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its used to measure responses to triggering stimuli -- rarely practical in a general practice setting
may perform an exercise challenge to diagnose exercise-induced bronchospasm (bronchospasm usually occurs within 15 minutes after vigorous exercise challenge) |
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what is Peak expiratory flow (PEF)
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its a device that can be used at home - must compare morning and evening PEF and correlate with symptoms [morning-to-evening variation of >20% is consistent with asthma]
** must know baseline** - may only decline during severe airflow obstruction in some patients |
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what would you see on X-ray for a patient with asthma?
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x-rays often appear normal or only have subtle changes like:
(1) flattened diaphragms (2) hyperinflation -- they are more helpful in identifying conditions that mimic asthma (because remember for asthma you must look for chronic symptoms) |
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what are your treatment goals for asthma?
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**maintain normal activity**
prevent sleep disturbance prevent chronic asthma symptoms keep exacerbations from becoming severe maintain normal lung function experience little to no adverse effects of treatment |
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how often do you monitor asthmatics?
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you want them to have regular clinic visits ever 2-4 weeks until good asthma control is achieved --> then you move to 2-4 check ups per year
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what criteria are needed in order to see what type of treatment a patient needs that has asthma?
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(1) MUST CLASSIFY SEVERITY OF PATIENTS ASTHMA
(2) NEED TO IDENTIFY PATIENTS REQUIRING CONTROLLER MEDICATIONS |
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what are the 4 classifications of asthma severity
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(1) MILD INTERMITTENT-- <3 days with symptoms/week and <3 nights with symptoms/month
(2) MILD PERSISTENT -- >2 days with daytime symptoms/week and 3/4 nights with symptoms/month (3) MODERATE PERSISTENT -- daily daytime symptoms and >5 nights of symptoms/month (4) SEVERE PERSISTENT -- continous daytime symtoms and frequent nighttime symptoms |
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3 strikes rule
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Patient needs controller therapy if child has:
(1) asthma symptoms or requires quick-relief medicine >3 times per week (2) awakens at night due to asthma >3 times per month (3) requires a refill for a quick relief inhaler >3 times per year |
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how can you help reduce the number of attacks an asthmatic has?
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(1) eliminate or reduce environmental triggers!
[pet dander, mattress and pillow covers, annual influenza immunization, dust/dust mites] (2) treat co-morbid conditions (allergic rhinitis, sinusitis, GER) |
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what is the "step up, step down" approach?
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initiate higher-level controller therapy in the beginning and then step down once good asthma control is achieved
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what are some examples of quick relief medications?
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(1) short acting beta agonists [albuterol] -- considered "rescue" medication, prevents exercised-induced bronchospasm
(2) anticholinergic agents (ipratropium bromide) -- less potent than beta agonists and its used in combination with SABA (3) systemic glucocorticoid therapy -- used in combinatino with the above two |
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what would be used for long term control
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(1) glucocortocids (preferably inhaled) are the most potent
(2) nonsteroidal anti-inflammatory agents (mast cell stabilizers like cromolyn and nedocromil) -- rarely used since they have to be administered multiple times a day (3) long acting beta agonists (4) leukotriene-modifying agents (montelukast) -- less potent than glucocorticoids and is often used with them (5) theophylline - rarely used because of potential toxicity |
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which have a quicker onset oral or IV steroids?
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they both have the same time of onset - the only reason they use IV steroids in hospitals is because you dont want them to aspirate with orals
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what is the stop light system
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its used for monitoring persistent asthma
green zone -- controlled yellow zone -- symptoms present red zone -- ER (severe exacerbation) |
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how do you manage exacerbations?
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-- make sure the parents understand --> educate the parents on signs and symptoms of an attack and make sure the parents are educated on when to bring their child to the office or Er
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