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99 Cards in this Set
- Front
- Back
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Asthma
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a CHRONIC INFLAMMATORY DISORDER of the airways, involving many cells
1) recurrent episodes 2) airflow obstruction 3) bronchial hyperresponsiveness |
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2 categories of causes of Asthma
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1) Host Factors
2) Environmental Exposures |
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Host Factors for Asthma
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1) Innate immunity - imbalance between T-helper Type 1 and Type 2 cells
2) Genetics |
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Environmental Factors for Asthma
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1) Allergens (house-dust mites, animal dander)
2) Respiratory Infections (RSV, flu, rhinovirus) 3) Other (smoke, air pollution) |
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Issues with Airflow Limitation in Asthma
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1) Bronchoconstriction
2) Edema (increased microvascular permeability) 3) Mucus Secretion (increased) 4) Airway Remodeling (thickening) |
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Bronchial Hyperresponsiveness in Asthma
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exaggerated bronchoconstriction
influenced by inflammation, impaired neuroregulation |
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Airway Inflammation in Asthma
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1) Immediate Asthmatic reaction (IAR) - within minutes
2) Late asthmatic Response (LAR) - hours later |
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Key Indicators that lead to diagnosis of Asthma
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1) Wheezing - high pitched whistling sound when breathing out
2) history of cough (worse at night), difficulty breathing, chest tightness Symptoms worsen or occur at night |
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Pulmonary Function Tests for Asthma (SPIROMETRY)
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used in the diagnosis and monitoring of asthma to assess the presence, severity, and reversibility of airflow obstruction
Before and after use of short acting bronchodilator |
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Measurements used in Spirometry to assess asthma
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1) Forced Expiratory Volume in 1 second (FEV1) - volume of air forcibly exhaled in 1 second
2) Forced Vital Capacity (FVC) - max volume of air forcibly exhaled after max inhalation |
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Airflow Obstruction with Spirometry in Asthma
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reduction in FEV1/FVC below 5th percentile
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Reversibility measured with Spirometry in Asthma
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increase in FEV1 of >200ml and >/= 12% from baseline after inhalation of short acting bronchodilator
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Classification of Asthma is based on 2 domains
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1) Impairment (symptoms, nighttime awakenings, SABA use, interference with daily activities)
2) Risk (frequency of exacerbations) |
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Goals of Therapy in Asthma Treatment
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REDUCE IMPAIRMENT
1) prevent symptoms 2) require infrequent use of inhaled SABA 3) maintain near normal pulmonary function REDUCE RISK 1) prevent recurrent exacerbations 2) prevent loss of lung function |
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2 categories of agents used to treat asthma
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1) Quick Relief Meds (Rescue) - used to provide prompt relief of bronchoconstriction
2) Long Term Control Meds (Maintenance) - used to achieve and maintain control |
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Quick Relief Medications for Asthma
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1) Short Acting Beta Agonists (SABA)
2) Racepinephrine (Asthmanephrine) 3) Short Acting Anticholinergics |
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Indication and MOA for Short acting beta agonists for Asthma (SABA)
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IND: quick relief of acute symptoms, preventative treatment prior to exercise
MOA: stimulate beta receptors -- increase cAMP -- relaxation -- antagonism of bronchoconstriction |
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SABA for use in asthma
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1) Albuterol HFA (Proventil, Ventolin, ProAir)
2) Levalbuterol HFA (Xopenex) 3) Albuterol Soln for Nebulizer (Proventil, Accuneb) 4) Levalbuterol Soln for Nebulizer (Xopenex) |
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Dosing of Albuterol Inhaler and levalbuterol Inhaler
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Adults & Kids: 2 puffs every 4-6 hours prn
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ADRs of Albuterol and Levalbuterol
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Tachycardia
Skeletal Muscle Tremor Hypokalemia Hyperglycemia headache |
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Place in Therapy for Albuterol and Levalbuterol in asthma
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*Drugs of Choice for Acute Bronchospasm*
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Indication and place in therapy of Racepinephrine (Asthmanephrine)
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IND: temporary relief of SOB, chest tightness, and wheezing
Place: available OTC |
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Indication and Place in Therapy of Ipratropium (Atrovent) in Asthma
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IND: relief of acute bronchospasm, not FDA approved
PLACE: choice for bronchospasm due to beta-blocker therapy, added benefit to SABA, alternative for those intolerant to SABA |
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Long Term Medications used in Asthma
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1) Inhaled Corticosteroids (ICS)
2) Systemic Corticosteroids 3) Long Acting Beta Agonists (LABA) 4) Methylxanthines 5) Mast cell Stabilizer 6) Leukotriene Modifiers 7) 5-lipoxygenase inhibitor 8) Omalizumab (Xolair) |
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Indication and MOA for Inhaled Corticosteroids in Asthma
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IND: long-term prevention of symptoms by suppression, control, and reversal of inflammation
MOA: anti-inflammatory; block late reaction and reduce airway hyperresponsiveness |
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Clinical Effects of Inhaled corticosteroids in Asthma
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1) reduce severity of symptoms
2) improve peak expiratory flow and spirometry 3) diminish airway hyperresponsiveness 4) prevent exacerbation 5) reduce use of systemic corticosteroids |
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Inhaled Corticosteroids used in Asthma
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1) Beclomethasone HFA (QVAR)
2) Budesonide (Pulmicort) 3) Ciclesonide (Alvesco) 4) Flunisolide HFA (Aerospan) 5) Fluticasone (Flovent) 6) Mometasone (Asmanex) |
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Dosing for Budesonide (Pulmicort)
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LOW: 200-600mcg
MEDIUM: >600-1200mcg HIGH: >1200mcg Twice daily dosing is usually sufficient for moderate disease |
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ADRs and Interactions of Inhaled Corticosteroids
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1) cough
2) Dysphonia (Hoarseness) 3) Oral Thrush 4) Growth Suppression Interactions: CYP3A4 inhibitors |
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Place in Therapy for Inhaled Corticosteroids for Asthma
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Most potent and consistently effective long term control medication for asthma
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Indication for Systemic Corticosteroids in Asthma
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IND: short term "burst" (3-10 days) to gain prompt control of inadequately controlled persistent asthma ; long-term prevention of symptoms in SEVERE persistent asthma
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Systemic Corticosteroids used in Asthma
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1) Methylprednisolone (Medrol)
2) Prednisolone (Millipred, Pediapred, Orapred) 3) Prednisone (Deltasone, Prednisone Intensol) 4) Methylprednisolone Acetate (Depo-Medrol) |
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Dosing for Prednisone in Asthma
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SHORT (burst): 40-60mg/day as single or in 2 divided doses for 3-10 days
LONG: 7.5-60mg daily in single dose int he morning or every other day |
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ADRs of Systemic Corticosteroids
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1) increase glucose and appetite
2) fluid retention and weight gain 3) facial flushing 4) adrenal suppression (>10 days) 5) Growth suppression 6) Cushingoid |
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Indication, MOA, and Place in therapy for Long Acting Beta Agonists
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IND: long term prevention of symptoms in addition to anti-inflammatory therapy
MOA: stimulate beta receptors -- increase cAMP -- smooth muscle relaxation -- antagonism of bronchoconstriction PLACE: preferred adjunct w/ ICS for long term control ; not recommended for monotherapy |
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LABAs for Asthma
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1) Formoterol (Foradil)
2) Salmeterol (Serevent) |
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Dosing of Formoterol (Foradil)
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1 capsule inhaled every 12 hours
cannot be used in children less than 5 years old |
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ADRs of LABA
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BBW: incrased risk of severe, life threatening exacerbation
1) tachycardia 2) skeletal muscle tremor 3) hypokalemia |
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IND, MOA, PLACE in therapy for Methylxanthines for asthma
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IND: long term control and prevention of symptoms in mild persistent asthma or as adjunct with ICS in mod-severe
MOA: nonselective inhibitor of PDE -- increase cAMP and cGMP -- relaxation of smooth muscle ; antiinflammatory PLACE: alternative treatment for mild; alternative adjunct with ICS |
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Methylxanthine for use in Asthma
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Theophylline (Theo-24, Elixophyllin, Theochron)
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ADRs of Theophylline in asthma
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Therapeutic doses: insomnia, GI upset, GERD
Toxicity: tachycardia, N/V, headache, seizures |
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Dosing for Theophylline in Asthma
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Start: 10mg/kg/day up to 300mg max (MAX 800mg/day)
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Indication, MOA, Place in Therapy of Mast Cell Stabilizers for asthma
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IND: long term prevention of symptoms
MOA: antiinflammatory (blocks early/late, inhibits activation and release of mediators) PLACE: alternative med for treatment of mild persistent asthma |
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Mast Cell Stabilizer used in Asthma
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Cromolyn (Intal)
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Dosing of Cromolyn (Intal) in Asthma
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1 ampule 4 times daily
used in children 2+ years old |
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ADRs of cromolyn (intal)
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1) cough
2) wheeze |
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2 classes of Leukotriene Modifiers
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1) Leukotriene Receptor antagonists (LTRAs)
2) 5-lipoxygenase inhibitors |
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MOA and Place in therapy of LTRAs in Asthma
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MOA: competitive inhibitor of CysLT1 receptor -- block effects of leukotrines
PLACE: Alternative treatment option for mild persistent or adjunct therapy with ICS |
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LTRAs in asthma
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1) Montelukast (Singulair)
2) Zafirlukast (Accolate) |
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Dosing of Montelukast (Singulair) in asthma
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Adults: 10mg daily
1-5 years old: 4mg daily 6-14 years: 5mg daily >14 years: 10mg daily |
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ADRs of Montelukast (Singular)
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1) upper respiratory tract infection
2) headache 3) abdominal pain |
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MOA and Place in therapy of 5-lipoxygenase inhibitors
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MOA: inhibit 5-lipoxygenase -- decrease production of leukotrienes
PLACE: alternative treatment in adults but less desirable than LTRAs |
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5-Lipoxygenase inhibitor for asthma
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Zileuton (Zyflo)
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Indication and MOA of Omalizumab (Xolair)
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IND: long-term control/prevention of symptom in adults >12yrs with moderate-severe persistent asthma
MOA: recombinant anti-IgE antibody binds to Fc portion and prevents IgE binding to mast cells |
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Dosing of Omalizumab (Xolair) in asthma
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150-375mg subq every 2 or 4 weeks
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ADRs of Omalizumab (Xolair)
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BBW: anaphylactic reactions
1) injection site pain and bruising 2) malignancy |
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Place in therapy of Omalizumb
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adjunct therapy for those with allergies and severe persistent asthma that are inadequately controlled with ICS
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Combination products for Asthma
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1) Fluticasone/Salmeterol (Advair)
2) Budesonide/Formoterol (Symbicort) 3) Mometasone/Formoterol (Dulera) |
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Dosing of Fluticasone/Salmeterol (Advair) for asthma
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1 inhalation BID
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Other therapies for asthma
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1) Tiotropium (Spiriva) -- not FDA approved
2) Alair Bronchial Thermoplasty System |
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Preferred therapy for Step 2 in Managing Asthma for Children 0-4 years
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Preferred: Low-Dose ICS
Always: SABA |
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Therapy for Step 3 in Managing Asthma 0-4 years
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Preferred: Medium Dose ICS
Always: SABA |
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Therapy for Step 4 in Managing Asthma 0-4 yeras
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Preferred: Medium Dose ICS + LABA or Montelukast
Always: SABA |
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Therapy for Step 5 in managing Asthma 0-4 years
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PreferredHigh Dose ICS + LABA or Montelukast
Always: SABA |
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therapy for Step 6 in managing Asthma 0-4 years
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Preferred: High Dose ICS + LABA or Montelukast
Maybe: Oral Systemic Corticosteroid Always SABA |
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Step 2 in managing Asthma 5-11 years
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Preferred: Low dose ICS
Always: SABA |
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Step 3 in managing Asthma 5-11 years
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PReferred: Low dose ICS + LABA/LTRA/Theophilline OR Medium dose ICS
Always: SABA |
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Step 4 in managing asthma 5-11 years
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Preferred: Medium Dose ICS + LABA
Always: SABA |
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Step 5 in managing asthma 5-11 years
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Preferred: High Dose ICS + LABA
Always: SABA |
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Step 6 in managing asthma 5-11 years
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Preferred: High Dose ICS + LABA + oral systemic corticosteroid
Always: SABA |
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Step 2 in managing asthma in adults
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Preferred: Low dose ICS
Always: SABA |
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Step 3 in managing asthma in adults
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Preferred: low dose ICS + LABA OR medium dose ICS
Always: SABA |
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Step 4 in managing asthma in adults
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Preferred: Medium dose ICS + LABA
Always: SABA |
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Step 5 in managing asthma in adults
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Preferred: High dose ICS + LABA AND consider omalizumab if necessary
Always: SABA |
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Step 6 in managing asthma in Adults
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Preferred: high dose ICS + LABA + oral corticosteroids AND consider omalizumab if necessary
Always: SABA |
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Inhalent Allergens that can cause asthma
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1) Animal Allergens
2) House Dust mite 3) Cockroach 4) Indoor fungi (molds) 5) Outdoor (tree, grass, weed pollen) 6) tobacco smoke 7) Pollutants and irritants |
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Comorbid conditions with asthma
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1) Allergic bronchopulmonary aspergillosis (ABPA)
2) GERD 3) Obesity 4) Sleep apnea 5) Rhinitis/sinusitis 6) Stress, depression, psychosocial factors |
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Other factors for asthma
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1) Meds (ASA, NSAIDS, beta blockers)
2) Sulfites (preservatives) 3) Infections (recommend flu and PPSV vaccine) |
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Key educational messages about asthma
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1) Basic facts
2) Roles of medications 3) Patient skills 4) Asthma action plan |
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Asthma Exacerbation
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acute state of extreme airway narrowing that is POORLY RESPONSIVE to usual bronchodilator therapy
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Hyperacute Attack of Asthma
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rapid onset of symptoms which usually RESOLVE RAPIDLY with bronchodilator therapy
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Symptoms and Signs of an Asthma Exacerbation
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1) acute distress
2) severe dyspnea 3) chest tightness or burning 4) wheezing 5) dry hacking cough 6) tachypnea/tachycardia 7) pale or cyanotic skin |
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Lab information point to an asthma exacerbation
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1) PEF and/or FEV1 < 40% of personal best
2) Decreased arterial Oxygen (normal 80-100) 3) Decreased Oxygen saturation (normal 93-100%) |
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Mild Asthma Exacerbation
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Symptoms: Dyspnea only with activity
PEF >/= 70% Treatment: cared for at home; SABA |
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Moderate Asthma Exacerbation
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Symptoms: dyspnea interferes w/ usual activities
PEF 40-69% Treatment: office or ED visit, SABA, oral systemic corticosteroids |
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Severe Asthma Exacerbation
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Symptoms: Dyspnea at rest
PEF < 40% Treatment: requires ED visit and likely hospitalization; frequent SABA use, oral systemic corticosteroid |
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Subset: Life Threatening Asthma Exacerbation
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Symptoms: too dyspeneic to talk; perspiring
PEF < 25% Treatment: ED/hospitalization/possible ICU; no relief from SABA, IV corticosteroids |
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Risk factors for Fatal Asthma Exacerbations
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1) Asthma History
2) Social History 3) Comorbidities |
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Asthma history as risk factor for fatal exacerbation
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1) previous severe one
2) 2+ hospitalizations for asthma in last year 3) 3+ ED visits for asthma in last year 4) hospitalization or ED visit for asthma in last month 5) 2+ SABAs per month |
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Social History as risk factors for fatal exacerbation
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1) low socioeconomic status
2) illicit drug use |
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Co-morbidities as risk factors for fatal exacerbation
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1) CV disease
2) chronic lung disease 3) psychatric disease |
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Things to avoid when doing home management of asthma exacerbations
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1) do not double ICS dose
2) do not drink large amounts of water or breath in warm, moist air 3) Do not take OTC antihistamines |
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General Guideline for home management of asthma exacerbation
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1) Assess Severity
2) Initial Treatment (Inhaled SABA - 2-6 puffs twice 20 minutes apart) 3) watch response |
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Good Response to Inhaled SABA for at home management of exacerbation
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1) No wheezing or Dyspnea
2) PEF > 80% 3) contact clinician for followup 4) continue SABA q3-4h for 24-48 hours |
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Incomplete Response to Inhaled SABA for at home managemnet of Exacerbation
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1) persistent wheezing and dyspnea
2) PEF 50-79% 3) add oral systemic corticosteroid 4) continue SABA |
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Poor Response to Inhaled SABA for at home management of Exacerbation
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1) marked wheezing and dyspnea
2) PEF < 50% 3) add oral systemic corticosteroid 4) repeat SABA immediately 5) distress is severe call doctor and go to ED |
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ED and Hospital Management of Asthma Exacerbation
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1) Oxygen - maintain SaO2 >90%
2) SABA - all patients 3) Ipratropium - in ED; not hospital 4) Systemic Corticosteroids - do not respond completely to SABA 5) Antibiotics - for infection 6) Fluids - can be dehydrated; oral preferred |
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Medications used for severe exacerbations unresponsive to initial treatments
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1) Subq epinephrine
2) Magnesium sulfate IV 3) Heliox 4) Ketamine |
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General Guidelines for Exacerbations in the ED/hospital
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1) Initial Assessment (mild-mod, severe, actual respiratory arrest)
2) Repeat assessment after initial treatment |
