Term
|
Definition
| Chronic inflammatory disease of bronchial tree |
|
|
Term
|
Definition
episodic, usually reversible: sense of breathlessness, chest tightness,
wheezing, dyspnea, cough, bronchospams, inflammation |
|
|
Term
|
Definition
| Immune mediated inflammation and thickening of airway, edema, remodeling |
|
|
Term
Patho of
Inflammatory process |
|
Definition
1. binding of allergen to IgE on mast cells
2. mast cells relases mediators (histamine, leukotrienes, prostaglandins, interleukins)
3. Mediators cause *bronchoconstriction & *promote activation of inflammatory cells (eosinophils, leukocytes, macrophages)
4. end result-*airway inflammation (edema, mucus plugging, smooth muscle hypertrophy), *bronchospasm, *airway obstruction which result in *bronchial hyperreactivity |
|
|
Term
| Cause of bronchoconstriction |
|
Definition
| mast cells release of mediators: histamine, leukotrienes, prostaglandins, interleukins |
|
|
Term
|
Definition
| Inflammatory cells: eosinophils, leukocytes, macrophages |
|
|
Term
|
Definition
| Infection, allergens, environmental, emotions, exercise, drugs, occupational |
|
|
Term
Gene by environment interactions
and asthma expression |
|
Definition
| allergic reactions & viral respiratory infections |
|
|
Term
| Atopy and asthma expression |
|
Definition
| genetic predisposition of developing IgE-mediated response to aeroallergens |
|
|
Term
| Groups with highest incidence of asthma |
|
Definition
non-hispanic blacks, Peurto Ricans
women, low income |
|
|
Term
|
Definition
Chronic
Acute severe
Allergic
Exercise-induced bronchospasm
Nocturnal |
|
|
Term
|
Definition
Inflammatory process
mucus production, airway smooth muscle, neural control |
|
|
Term
Symptom presentation to consider
asthma diagnosis |
|
Definition
Expiratory wheezing (especially kids)
Physical exam-focus on URT, chest, & skin |
|
|
Term
Medical history to consider
asthma diagnosis |
|
Definition
Cough (particularly at night)
recurrent-wheeze, dyspnea, chest tightness |
|
|
Term
Asthma diagnosis considerations
symptoms worsen under these conditions |
|
Definition
| exercise, viral exercise,night time, menstrual cycles, exposure to: animals w/fur,dust mites, mold, smoke,pollen, weather changes, strong emotions, airborne chemicals & dust |
|
|
Term
| Determinations to be made when diagnosing asthma |
|
Definition
| episodic symtoms, hyperresponsiveness, reversibility of airflow obstruction, exclude alternate diagnoses |
|
|
Term
| How to determine obstruction and assess reversibility |
|
Definition
spirometry (>/5y/o)
reversible FEV1 increase 12% baseline ot increase 10% of predeicted FEV1 after SABA |
|
|
Term
Asthma DX:Rule out other causes
KIDS |
|
Definition
upper airway-allergic rhinitis/sinusitis
Obstructions-foreign bodies, vocal cord dysfunction, vascular rings/laryngeal webs, laryngotracheomalacia, tracheal stenosis or bronchostenosis, enlarged lymph nodes, viral or obliterative bronchiolitis, cystic fibrosis, bronchopulmonary dysplasia, HD, coughother, GERD, dysphagia |
|
|
Term
Asthma DX:Rule out other causes
ADULTS |
|
Definition
| COPD, CHF, PE, mechanical obstructions, pulmonary infiltrates w/eosinophilia, cough side effect of drug, vocal cord dysfunction |
|
|
Term
|
Definition
| Reduce impairment (now) and risk (future) |
|
|
Term
| TX Goals in reducing impairment |
|
Definition
| maintain normal activities. meet pt & family expectations. prevent chronic troublesome symptoms, decrease use of SABA to less than 2x/week. maintain normal pulmonary function. |
|
|
Term
| TX Goals in reducing risk |
|
Definition
| prevent recurrent rxacerbations. minimize ER visits & hospitalizations. prevent progressive loss lung function. max benefit w/min side effects. Prevent morbidity & mortality. |
|
|
Term
| Asthma severity classifications |
|
Definition
Intermittent
Mild persistent
Moderate persistent
Severe persistant |
|
|
Term
Stepwise approach to drug therapy in
asthma |
|
Definition
All levels have PRN SABA
step 1-6
Starting step determined by classification
Step up when needed.Step down when possible. Step 2-6 have long term control med, when move up control med increased and/or second control med added |
|
|
Term
| Assess asthma control goals |
|
Definition
| Reduce impairment and risk. Periodic reassess & ongoing monitoring by pt and clinician. Spirometry testing. Biomarkers. WRITTEN asthma plan. Peak flow & symptom monitoring. |
|
|
Term
| Asthma control classifications |
|
Definition
| well controlled, not well controlled, very poor controlled |
|
|
Term
| Recommended action for well controlled asthma |
|
Definition
| maintain tx. f/u q 1-6mo. consider step down when well controlled over 3months |
|
|
Term
| Recommended action for not well controlled asthma |
|
Definition
| Increase step & reassess in 2-6 weeks. Decrease side effects by changing drugs. |
|
|
Term
| Recommended action for very poor controlled asthma |
|
Definition
| Short course PO glucocorticoids. Step up 1-2 steps and reassess in 2wks, decrease side effects by changing drugs. |
|
|
Term
|
Definition
FEV1-forced expiratory volume, how much air expelled in 1 sec, compare to normal
FVC-forced vital capacity (total vol exh after full inh)
FEV1/FVC normal is 85%(8-19 y/o) 75% (60-80 y/o), asthma may be norm or >/5% less
Peak expiratory flow-max rate airflow expiration |
|
|
Term
| Drugs for acute exacerbations |
|
Definition
Oxygen (hypoxemia)
systemic glucocorticoid (inflammation)
Nebulized high dose SABA (air obstruct)
Nebulized ipratropium (obstruction)
if severe-IV Mg sulfate, Inh heliox
when d/c'd 5-10 days of PO glococorticoid & a med dose inh gluc. |
|
|
Term
| Drugs for Exercise-induced Bronchospasm |
|
Definition
SABA immediately before
cromolyn 15min before |
|
|
Term
| How to reduce allergen triggers |
|
Definition
| weekly bathe pets & band from bedrooms. Encase pillows, box springs & mattresses in impermeable covers, weekly wash bedding and stuffed animals in hot water, take out carpet & rugs, do not sleep or lay on upholstered furniture. keep indoor humidity <50% |
|
|
Term
|
Definition
| albuterol, levabuterol, pirbuterol |
|
|
Term
|
Definition
| Relief of acute asthma symptoms, prevent EIB, prn in all asthma classes. more than one canister/month=poor control |
|
|
Term
|
Definition
| Causes smooth muscle relaxation (bronchodilation). increases ciliary beat, inhibits mast cell degranulation |
|
|
Term
| Comparing albuterol and levalbuterol |
|
Definition
| levobuterol cost more, same results, dose schedule. maybe beneficial to use levobuterol in tachycardia/a-fib |
|
|
Term
|
Definition
| formoterol, salmeterol, SR albuterol(oral), arformoterol, indacterol |
|
|
Term
|
Definition
In asthma prevent of long-term symptoms (symptom control, EIA< nighttime symptoms, need for SABA,
acute attacks)take 1-4hrs to work
Added to corticosteroids-not 1st line |
|
|
Term
|
Definition
| Increased risk of severe asthma exacerbations and related death. Use a 2nd drug, do not stop abruptly, do not use to tx wheeze. |
|
|
Term
|
Definition
| tachycardia, tremor, irritablity, HA, hypokalemia, hyperglycemia, paradoxical bronchospasm, arrythmias, throat irritation, tachyplaxis, asthma exacerbations, asthma related deaths |
|
|
Term
| Special SABA & LABA inhaler instructions |
|
Definition
SABA's-count & keep track of how many times used
Albuterol-/
Levalbuterol-clean mouthpiece weekly
Pirbuterol-raise lever until snap, inhale until click, lower level
Salmeterol-side lever-keep level
Formoterol-1 capsule into aerolizer.
Aformoterol-/
Indacterol-capsule, daily dose |
|
|
Term
Inhaled corticosteroid
examples |
|
Definition
| Qvar, Pulmicort, Aerobid, Flovent, Azmacort |
|
|
Term
|
Definition
| Bind to glucocorticoid receptors, reduce inflammation (inhibit release of genes, promote antiinflammatory genes)Reduces production of inflammatory mediators, increase # beta2 receptors,enhance beta receptor expression, decreases mucous production, prevent endothelial and vascular leakage |
|
|
Term
Inhaled corticosteroid
use |
|
Definition
| Asthma-improve symptoms, prevent exacerbations, increase lung function, reduce airway hyperresponsiveness, decrease need for oral rescue, fewer acute care visits. Use on fixed schedule.may take 4-6 wks for max benefit |
|
|
Term
Inhaled corticosteroid
side effects |
|
Definition
| adrenal suppression, cough, dysphonia, thrush, growth suppression, bone loss, cataract & glaucoma |
|
|
Term
Inhaled corticosteroids
cautions |
|
Definition
herpes, varicella, TB, HTN, peptic ulcer
Preps are not dose:dose interchange
rinse mouth to avoid thrush
BID dosing
can be combo w/beta agonist |
|
|
Term
Systemic corticosteroid
examples |
|
Definition
| Solu-Medrol, Medrol, prednisolone, Prednisone |
|
|
Term
PO/IV (systemic) corticosteroid
side effects |
|
Definition
| Hyperglycemia, increased appetite, fluid retention, weight gain, mood alteration, HTN, peptic ulcer, growth suppression, dermal thinning, DM, muscle weakness, impaired immune function, osteoporosis |
|
|
Term
Corticosteroid dosing
adult asthma |
|
Definition
use lowest dose
low, medium, high |
|
|
Term
| Special corticosteroid inhaler instructions |
|
Definition
Qvar-clean inhaler weekly w/dry cloth
Pulmicort-has dose indicator. twist R>L til click, horizontal, keep dry
Aerobid-clean inhaler daily
Flovent-clean daily,keep level,dose indicator on rotadisk
Azmacort-dose indicator, mouthpiece comes w/ |
|
|
Term
Combo corticosteroids & LABA inhalers
examples w/instructions |
|
Definition
Advairdose indicator, open/slide, keep level
Symbicort-dose indicator, turn one way then the other until clicks. wipe mouthpiece wkly w/dry cloth
Dulera-mouthpiece comes w/.Dose indicator |
|
|
Term
|
Definition
| Leukotriene receptor antagonists, inhibits leukotriene synthesis, reduce bronchoconstriction, decrease bronchial reactivity,edema & mucous hypersecretion |
|
|
Term
|
Definition
| Alternate to ICS in mild asthma, adjunct to ICS, allergic rhinitis, prophylaxis for EIB or ASA intolerance |
|
|
Term
|
Definition
| HA, dyspepsia, dizzy, churg-strauss syndrome, chewable tabs contain aspartame, neuropsych-hallucinations, mood changes, suicidal ideations (delayed effect) |
|
|
Term
|
Definition
| HA,dizzy, nausea, diarrhea,neuropsych-hallucinations, mood changes, suicidal ideations |
|
|
Term
Zafirlukast
drug interactions
other considerations |
|
Definition
ASA, Erythromycin,theophyline, warfarin,dofetilide
*caution in liver impair, 1 hr before or 2hr after food |
|
|
Term
|
Definition
| HA,abdominal pain, asthenia, nausea, dyspepsia,myalgia,Churg-Strauss syndrome, neuropsych-hallucinations, mood changes, suicidal ideations |
|
|
Term
Zileuton
Drug interactions
other considerations |
|
Definition
propranolol, theophyline, warfarin
*contraindicated in hepatic impair or excessive alcohol consumption, qid dosing. aminotransferase lab monthly x3months then q2-3 months for 1 yr, then periodic |
|
|
Term
|
Definition
|
|
Term
|
Definition
| stabilize mast cells inhibit degranulation, inhibit inflammatory & allergice response, inhibit EIB |
|
|
Term
|
Definition
| adjunct in prophylaxis of allergic asthma, prevent EIB on fixed schedule, allergic rhinitis(intranasal) |
|
|
Term
|
Definition
| unpleasant taste, HA, hoarseness, cough, postnasal drip, dizzy, fatigue |
|
|
Term
|
Definition
| QID dosing, takes 4-6wks to start working. count number of uses-no dose indicator |
|
|
Term
|
Definition
theophylline, aminophylline, dyphylline
caffeine in neonates |
|
|
Term
|
Definition
| Phosphodiesterase inhibition. increases mucociliary clearance, stimulate respiratory drive, enhances diaphragmatic contractility, improve ventricular ejection fraction, stimulate renal diuresis, modest bronchodilation by relaxing bronchial smooth muscle probably through blocking adenosine |
|
|
Term
|
Definition
| Asthma if SABA,corticosteroid, & LABA fail. Adjunct to corticosteroid in pts w/nocturnal/early morning symptoms. COPD if anticholinergics, SABA, LABA's fail |
|
|
Term
|
Definition
| narrow therapeutic index. monitor drug levels (5-15mcg/mL). IV is prodrug and 80% theophylline. Metabolism highly variable |
|
|
Term
|
Definition
DEC metabolism-age, cor pulmonale, decomp CHF, liver dysfunction, some drugs, fever or viral illness, fatty foods, high carb diet, caffeine
INC metabolism-age, tobacco/cannabis, certain drugs, food, high protein |
|
|
Term
|
Definition
| N/V/D, anorexia, palpitations, dizzy, restless, nervous, insomnia, reduced lower eosphageal sphincter tone. Toxicity:v-fib & convulsions, death from CV collapse |
|
|
Term
Theophylline
considerations |
|
Definition
Stop if it's not helping.
dose weight based-(ideal)lean body |
|
|
Term
| Other treatments to consider in asthma |
|
Definition
| mucolytics, expectorants, antioxidants, VACCINES |
|
|
Term
Anti-IgE monoclonal antibody
Xolair
MOA |
|
Definition
| inhibits Ige from binding to the surface of mast cells and basophils |
|
|
Term
|
Definition
| mod-severe asthma, response to perennial aeroallergen, inadequate control w/ICS |
|
|
Term
|
Definition
| SQ, peak-7days, 1/2 life 26days |
|
|
Term
|
Definition
| hypersensitivity, malignancy, anaphlaxis |
|
|
Term
|
Definition
| Only for allergens-skin test required proving allergen reaction.Keep in office after given to monitor for reactions-2hours after first 3 doses & 30minutes after all others. dose adjust for weight changes. given over 5-10sec-viscous. powder that is reconstituted-good 4hrs at room temp 8hr cold |
|
|
Term
|
Definition
| Injection site reaction, viral infection, URI, sinusitis, HA, pharyngitis, pain/fatigue, arthralgia, leg/arm pain, dizzy, pruritus, dermatitis, earache, thrombocytopenia, hair loss |
|
|
Term
Athma goals
minutes
hours
future |
|
Definition
relieve airway obstruction NOW
relieve hypoxemia NOW
restore lung function to normal ASAP
plan avoid of future exacerbations
develop written plan for tx future exacerbations |
|
|
Term
Assess severity of asthma exacerbation
s/s |
|
Definition
| breathlessness, talking, alertness,RR, use of accessory muscles, wheeze, pulse, pulsus paradoxus(dec SBP w/insp) |
|
|
Term
| Home TX asthma exacerbation |
|
Definition
Assess severity
SABA 2-4 puffs x3 20 minutes apart
good response-mild
incomplete response-moderate (see clinician today)
poor response-severe (go to ER) |
|
|
Term
|
Definition
-difference in asthma airways & normal airways
-what happens in an attack
-how meds work (quick,prophylaxis)
-Chronic disease
-how to use inhaler
-trigger control
-symptom monitor
-response to severity
-WRITTEN plan |
|
|
Term
| Signs of potentially fatal asthma |
|
Definition
| hx of severe exacerbations, poor self-perception or symptoms & severity, hx of intubation or ICU admit, 2+hospitalizations 3+ER visits for asthma in 1 yr, hospitalization or ER in last month, frequent beta-agonist use, concurrent conditions |
|
|
Term
|
Definition
| airway obstruction following exercise |
|
|
Term
|
Definition
| wheezing, SOB, chest tightness or pain, cough, dyspnea, cramps, stomach pain, sore throat, HA (mistaken for being out of shape sometimes) |
|
|
Term
|
Definition
bronchospasm secondary to loss of heat and or water loss from lung
postexercise rewarming
can occur during or immediate following exercise |
|
|
Term
| How to reduce allergen triggers in the home |
|
Definition
| consider getting rid of pets. If keeping them give weekly baths and keep them out of bedroom. Encase pillow, mattress & boxsprings in impermeable covers. Weekly wash bedding and stuffed animals in hot (130) water. Remove carpet & rugs. Do not sleep or lay on upholstered furniture. Maintain humidity <50% |
|
|
Term
| Advantages of inhaled drugs in asthma |
|
Definition
-Therapeutic effect enhanced by direct site administer.
-Minimize systemic effects
-Rapid relief of acute attacks |
|
|
Term
|
Definition
| small hand held pressure device that deliver measured dose with activation. Begin inhalation then 1-2 puffs one minute apart |
|
|
Term
|
Definition
| increase drug delivery to lung. most have one way valves that are activated with inhalation |
|
|
Term
|
Definition
| Drugs in a dry powder directly to lung without propellant. Breath activated=increase to lungs decrease to oropharynx |
|
|
Term
|
Definition
| small machines that convert drug solution to mist. Take several minutes to administer same amount of drug in one puff of inhaler |
|
|
Term
| First line therapy for moderate-severe asthma |
|
Definition
|
|
Term
|
Definition
| atropine derivative, anticholinergic=bronchodilation |
|
|
Term
|
Definition
| COPD, allergen and EIB asthma-relieve bronchospasm, QID dosing |
|
|
Term
|
Definition
| dry mouth, pharynx irritation, minimal systemic:increase IOP, MI, CVA, death |
|
|
Term
Combivent
contraindication |
|
Definition
| Peanut allergy-soya same plant |
|
|
Term
|
Definition
|
|
Term
|
Definition
| anticholinergic, plateua reached in 8 days, once daily, more effective than Ipratropium |
|
|
Term
Tiotropium/Spiriva
side effects |
|
Definition
dry mouth
minimal systemic:constipation, blurred vision, urinary retention, tachycardia |
|
|
Term
| When to consider asthma step down therapy |
|
Definition
| FEV1 or PEF remain >80% personal best x 3mths |
|
|
Term
| Before stepping up asthma therapy assess |
|
Definition
| appropriate inhaler use technique (every visit) |
|
|
Term
| Evaluating effectiveness of asthma tx |
|
Definition
monitor symptoms(daytime <2x/week, nighttime <2xmonth, lung function)
monitor activity levels, monitor asthma impairment (questionaires), exacerbation frequency, long-term control med use, SABA use, adverse events, immunization status |
|
|
Term
|
Definition
| <80% monitor PEF 2x/day, PEF <50% uses SABA & consult asthma action plan |
|
|
Term
| Acute severe asthma outcome eval |
|
Definition
| monitor PEF, hypoxemia, PCO2, serum potassium |
|
|
Term
| Anti-inflammatory drug classes for asthma |
|
Definition
| Inhaled or PO glucocorticoids, leukotrienes, cromolyn, IgE antagonist |
|
|
Term
| Bronchodilator drug classes for asthma |
|
Definition
| Short and Long acting inhaled Beta2 adrenergic agonists (SABA, LABA), oral beta2 agonists, methylxanthines, anticholinergics |
|
|
Term
| All asthmatics with moderate to severe asthma should be on... |
|
Definition
| Daily inhaled glucocorticoid |
|
|
Term
| Minimizing thrush and hoarseness with inhaled glucocorticoids |
|
Definition
| gargle after each administration, use spacer when able |
|
|
Term
| Lab monitoring in Zileuton |
|
Definition
| alanine aminotransferase (ALT) once a month x3 months, then q2-3mths x1yr, then periodic |
|
|
Term
| Lab monitoring in Zafirlast |
|
Definition
|
|
Term
| Monotherapy with SABA only appropriate in... |
|
Definition
| very mild asthma with infrequent attacks, EIB prevention |
|
|
Term
| Asthma Severity based on domains... |
|
Definition
| Risk(possible adverse events in future) & impairment(QOL & functional capacity now) |
|
|
Term
Classifying Asthma severity
Current impairment factors |
|
Definition
| Frequency of symptoms(<2/wk, >2/wk not dly, dly, throughout day). Night-time awakenings (<2/month, 3-4/month, >1/week, 7/week). SABA use (<2/wk, >2day wk, daily, several x a day). Impact on normal activitiy (none, minor, some, severe). Lung function tests (normal FEV1, 6080, FEV<60) |
|
|
Term
Classifying Asthma severity
Future risk factors |
|
Definition
| exacerbations requiring oral glucocorticoids (0-1/yr, >2yr) |
|
|
Term
Recommended initial treatment
intermittent asthma |
|
Definition
|
|
Term
Recommended initial treatment
mild asthma |
|
Definition
Step 2: SABA prn, Low dose IGS
Alternate-cromolyn, LTRA or theophylline |
|
|
Term
Recommended initial treatment
moderate asthma |
|
Definition
Step 3: SABA prn, Med dose IGS or Low dose IGS + LABA
Alternate-low-dose IGC + either LTRA or theophylline |
|
|
Term
Recommended initial treatment
severe asthma |
|
Definition
| Step 4 or 5: (4)SABA prn, med dose IGS+ LABA ALternate: med-dose IGC + either LRTA or theophylline(5) SABA prn, high-dose IGC + LABA (6) High-dose IGC + LABA + oral glucocorticoid |
|
|
Term
| Long term control of asthma drug classes |
|
Definition
| Glucocorticoids, leukotriene modifiers, cromolyn, omalizumab, LABA, theophylline |
|
|
Term
| Quick relief asthma medications |
|
Definition
| SABA, anticholinergics, systemic glucocorticoids(not to stop an ongoing attack) |
|
|
Term
Classifying Asthma control
components of impairment |
|
Definition
| symptoms, nighttime awakening, SABA use, impact on normal activity, Lung function tests, questionaires |
|
|
Term
Classifying asthma control
components of risk |
|
Definition
| exacerbations w/oral glucocorticoid, progressive loss lung function, tx related adverse effects |
|
|
Term
|
Definition
| Secondary heat and/or water loss from lung |
|
|
Term
Inhaled glucocorticoid
contraindications |
|
Definition
| pts persistently positive sputum culture Candida albicans |
|
|
Term
| Systemic beta2 agonists contrindications/cautions |
|
Definition
| tachydysrhythmias or tachycardia r/t dig. caution in DM, hyperthyroid, organic HD, HTN, angina |
|
|
Term
| Theophylline contraindications/caution |
|
Definition
| untreated seizures or peptic ulcer disease. Caution: HD, liver or keidney dysfunction, severe HTN |
|
|
