Any Asthma patient needs influenza and pneumococcal shot True/False?

Patient should be treated for rhinitis, sinusitis and GERD if present T/F?

TRUE 

TRUE

1. Albuterol and other short acting Beta2 Agonist.

2- Short acting Acetylcholine Agonist. 

3-Systemtic Corticosteriod 

1. inhaled corticosteriod- cornerstone of long term asthma

2. Long acting BETA2 agonist

3. leukotriene receptor modifiers

4. theophylline

5. IgE Inhibitor

6. Mast Cell Modifier  

Managing ACUTE EXCERBATION of asthma has three goals:

1- Correction of significant HYPOXEMIA

2- Rapid reversal of airflow obstruction

3- Reduce recurrence of severe obstruction

4- reduce morbidity and mortality

Explain how to assess severity of acute excerbation of asthma at home-

1. Measure PEAK EXPIRATORY FLOW: if less than 80% then it suggests severe exacerbation. Note the signs and symptoms such as degree of cough, breathlessness, wheezing and cheat tightness.

Initial treatment of SABA; three treatments of 2-4 puffs by MDI at 20mins intervals or single nebulizer treatment. 

After the Intitial treatment patient usually does a PEF and finds percent of best. Explain the three possible findings and treatment (home).

>80%  50%-80%  <50%

1.   >80% is a mild exacerbation, usually no wheezing or SOB. Responses to Beta2 agonist sustained for 4 hrs. Continue using b2 agonist every 3-4hrs for 48hrs. 

-call MD for follow up

2-    50%-80% moderate exacerbation  usually with persistent wheeze or SOB. Add oral corticosteroids (short burst) and continue the use of b2 agonist. Call MD for more urgent follow up. 

3.  <50% is severe exacerbation, marked wheezing or SOB. Add oral corticosteroid (short burst) and repeat beta agonist immediately. CALL MD AND GO TO ER. 

1- what is the dose of Prednisone, Methylprednisolone and Prednisolone 

2- how is corticosteroid dosed?

1- 120- 180 mg/day divided doses for 48hrs, then 60-80 mg/day until PEF reachest 70%.

2. Dosed 1mg-2mg per Kg per day. 

remember this is dosages for drugs for acute asthma exacerbation in ER or hospital. 

intermittent- Symp less than 2d/week, Nightwake less than 2xmonth, SABA use Less than 2d/week, Lung function greater than 80%

Mild- symp more than 2 days a week but not daily, nightwake- 3-4x month, SABA use >2days/weeek/ not daily. greater than 80% PEF

Moderate- daily symptoms, 1x week night wake, Daily SABA use, PEF 60-80%. 

Severe- sympt throughout the day, 7x week nightwake, SABA use throughout the day, PEF less than 60%

step 1

Intermitten Asthma

Step 2

Persistent asthma

Preferred Low dose ICS

with SABA PRN for control of symptoms. 

Alternative- 

Cromolyn

Nedocromil

LTRA or Theophylline

Step 3 

Persistent Asthma

Preferred Medium dose ICS 

OR

Low dose ICS n LABA

with alternatives of

low dose ICS and either LTRA or Theophyline

Step 4

Persistent Asthma

Medium Dose ICS and LABA

alternative

Medium dose ICS and either LTRA or Theophylline

Step 5

Persistent Asthma

Preferred High dose ICS and LABA

and CONSIDER

Omalizumab for patients with allergies!

Step 6

Persistant Asthma

Preferred High dose ICS and LABA and ORAL corticosteroids

and Consider

omalizumab for patients with allergies! 

if a patient has less than 2 days a week of symptoms and 1-3x a week nighttime awakwenings, uses the SABA about 2/d/week, No interference with Normal activites... with a PEF greater than 80%

is this patient controlled? well or not..

Well control= <2day/week symptoms, <2x/month nightwake/ <2days/weekSABA/ No interference with physical activites PEF>80%

recommended maintain current step and follow regular checkups 1-6months. 

NOT WELL CONTROLLED= >2DAYS/WEEK(NOT DAILY) OF SYMPTOMS, 1-3X WEEK NIGHTWAKE, >2D/WEEK OF SABA USE

SOME LIMITATION OF ACTIVITIES, PEF60-80%, CONSIDER SHORTBURST STRERIOD   {STEP UP ONE STEP AND REVALUATE}

VERY POORLY CONTROLLED

Symptoms throughout the day

nighttime awakingins- 4xweek

SABA use several times per day more than 2 days a week.

extremely limiting physical activities

less than 60% PEF

consider short burst oral corticosteroid 

STEP UP 2 STEPS AND REEVALUATE IN 2-6 WEEKS. 

ICE?

BEFORE CHANGING THERAPY, NEED TO ASSESS OTHER REASONS FOR POOR ASTHMA CONTROL. 

I-INHALED COMPLIANCE

C- COMPLIANCE

E- ENVIROMENTAL CHANGE

B2 SELECTIVE AGONIST

SHORT ACTING!!

I WANT ROUTE, ONSET and DOA

1-albuterol- PO-30mins onset, 4-8 DOA INH- 5mins onset, 3-6 DOA. 

2. Bitolterol- INH less than 5min Onset and 4-8 DOA 

3. Levabuterol- INH less than 5min onset with 3-6hr DOA

4. Pirbuterol INH less than 5min Onset with 4-8hr DOA

5. Terbutaline- PO<30mins Onset 4-8DOA

SC<15mins onset 2-4 DOA

INH<5mins Onset 3-6 DOA

Long acting Beta 2 selective agonist

Route- onset- DOA and Dosage

Formoterol (foradil) DPI 5min onset with 12hr DOA

Salmeterol- (Serevent) DPI <30mins onset and12hr DOA

What are some Adverse Effects of Beta agonist

increase HR

can cause tremmors, Shakiness, Can cause low potassium ( usually with PO or SUBQ)(this low K is probably due to a shift in the potassium from out to into the cell) monitor for hypokalemia. 

How would one monitor for 

1. Efficacy

2. Toxicity 

with Beta 2 Blockers!

1- Efficacy monitor Peak Flow , signs and symptoms and usage of SABA. 

2. Toxicity- Heart rate, tremors, and K if its PO  or SQ. 

Mast Cell stabilizers! 

name- indications, and AE

Cromolyn (intal)- MDI, DPI, nebulized solution

Nedocromil (Tilade)- MDI

indications- long term prevention of symptoms, prevention of allergen induced bronchospasm and exercse induced asthma, response seen in 2 weeks but 4-6 for maximal benefits. disadvantage- need to be dosed 3-4times a day. 

AE- 15-20% complain of unplesant taste from nedocromil,  preferred over corticosteroids for anti-inflammatory action in children. 

Corticosteroids

Used as anti-Inflammatory

Inhaled- long term prevention of symptoms

Systemic- short-course burst following an acute exacerbation or to gain quick control of poorly controlled asthma.  

systemic for long term prevention (step 6) 

inhaled- cough, dysphonia, oral thrust ( candidiasis) 

Systemic- increase glucouse and appetite, some fluid retention, weight gain, mood alteration and even hypertension and peptic ulcer , with long term use.. adrenal axis suppression, growth suppression, cushin syndrome, osteoporosis and muscle weakness. 

8 Corticosteriods, name them and long medium and high dose!

Beclomethasone (Qvar) HFA(40or 80mcg/puff) L-80-240mcg M-240-480mcg H- >480mcg

Budesonide (pulmocort)(DPI) 90-180-160mcg/inh L-180-600mcg M-600-1200mcg H->1200mcg

Ciclesonide (Alvesco) 80mcg, 160mcg L-80-160mcg M-160mcg-320mcg H>320mcg.

Flunisolide (Aerobid) 250mcg/puff L- 500-1000mcg M 1000mcg-2000mcg L- >2000mcg

Flunisolide HFA- 80mcg/puff L-320 mcg M 320-640mcg H- >640mcg

Fluticasone (flovent) HFA/MDI- 44, 110, L- 220mcg/puff 88-264 M