Term
asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular: mast cells, eosinophils, Th2 cells, macrophages, neutrophils, epithelial cells
3 main components of asthma:
inflammation - causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning
obstruction - episodes are usually associated with wide spread but variable airflow obstruction; often reversible either spontaneously or with treatment
hyperresponsiveness - to various stimuli by the bronchioles
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Definition
| definition of asthma and the 3 main components |
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Term
EARLY ASTHMA RESPONSE = bronchoconstriction
inhaled antigen activates mast cells and Th2 cells in the airways
they in turn induce production of mediators of inflammation (such as histamine and LTs) and cytokines (IL-4, IL-5)
CHRONIC ASTHMA = mucus, hyperresponsiveness
IL-5 travels to the bone marrow and causes terminal differentiation of eosinophils
the eosinophils release inflammatory mediators such as LTs and granule proteins to injure airway tissues |
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Definition
| pathophysiology of the early asthma response and chronic asthma |
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Term
bronchoconstriction:
reversible
bronchial smooth muscle contraction
allergen induced: IgE-dependent release of mediators from mast cells that include histamine, tryptase, LTs, and prostaglandins that directly contract airway smooth muscle
non-IgE dependent: irritants, exercise, cold air, ASA/NSAIDs, stress
airway edema:
reversible
occurs along with mucus hypersecretion and mucus plugs
airway hyperresponsiveness:
reversible
exaggerated bronchoconstrictor response to a wide variety of stimuli
inflammation is a major factor in determining degree of hyperresonsiveness
airway remodeling:
irreversible
permanent structural changes associated with a progressive loss of lung function
thickening of sub-basement membrane
sub-epithelial fibrosis
airway smooth muscle hypertrophy and hyperplasia
blood vessel proliferation and dilation
mucus gland hyperplasia and hypersecretion |
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Definition
| airflow limitation in asthma caused by: |
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Term
host factors:
imbalance between Th1 (cell-mediated immunity) and Th2 (humoral immunity, allergic disease)
higher prevalence in boys until puberty, then girls
genetic predisposition for the development of IgE-mediated response to common aeroallergens is a strong identifiable predisposing factor for development of asthma
environmental factors:
viral respiratory infections - 40% of children with RSV will wheeze or develop asthma later in life
tobacco smoke
air pollution |
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Definition
| what initiates the inflammatory response? |
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Term
RECURRENT COUGH
NIGHTTIME COUGH
WHEEZING
SOB
CHEST TIGHTNESS
decreased exercise tolerance
sputum production |
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Definition
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Term
VS: tachypnea, tachycardia
skin: atopy (predisposition toward developing certain allergic hypersensitivity reactions), diaphoresis
lung: wheezes (usually on expiration), accessory muscle use
HEENT: erythematous or boggy turbinates or the presence of polyps from sinusitis, allergic rhinitis, or upper respiratory tract infection
chest x-ray: normal or hyperinflated |
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Definition
| physical exam findings of asthma |
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Term
exercise induced bronchospasms (EIB):
10-15% decreased in PEF or FEV1
no limit to participation or success in activities
cough variant asthma:
dry, non-productive cough is only manifestation of asthma
occurs especially in young children
seasonal asthma:
symptoms only in relationship to pollens/molds
persistent asthma during the season and has intermittent asthma the rest of the year
nocturnal asthma:
may be confused with GERD or OSA
vocal cord dysfunction:
episodic dyspnea and wheezing caused by intermittent paradoxical vocal cord adduction during inspiration
triggered by irritants
confused with EIB as athletes are prone to both
no treatment; can only do physical therapy |
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Definition
| differential diagnosis of asthma |
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Term
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Lung Function:
mild = FEV1 > 80% predicted
moderate = FEV1 > 60% but < 80% predicted
severe = FEV1 < 60%
level of severity based on MOST SEVERE CATEGORY in which any feature appears |
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Definition
| determine if a patient (>/= 12 yo) has intermittent, mild persistent, moderate persistent, or severe persistent asthma |
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Term
IMPAIRMENT
symptoms: nighttime awakenings, need for SABA for quick relief of symptoms, work/school days missed, ability to engage in normal daily activities or desired activities, QOL assessment
lung function: spirometry, peak flow
RISK
likelihood of asthma exacerbations, progressive decline in lung function, or risk of ADRs from medications
Assessment: frequency and severity of exacerbations, ORAL corticosteroid use, urgent-care visits, lung function, noninvasive biomarkers play an increased role in future |
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Definition
| severity and control of asthma are defined in terms of what 2 domains? |
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Term
allergens
viral infections |
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Definition
| major precipitates of severe asthma exacerbations |
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Term
air borne pollens (grass, tree, weeds)
management: allergy testing, stay indoors, keep windows closed (air conditioning)
mold
management: control dampness, keep bathrooms clean
dust mites, cockroaches
management: vacuum 1-2 times/week (wear face mask), wash bedding in hot water > weekly, use a dust-proof pillowcase and mattress cover
pet dander
management: keep pets outdoors and at a minimum out of the bedroom, bathe pets
rhinitis
management: intranasal steroid +/- antihistamine/decongestant
sinusitis
management: decongestant, antibiotics when indicated
air pollution
management: avoid exertion when levels are high
GERD
management: do not eat within 3 hours of bedtime, avoid foods that cause heartburn, elevate head of bed 6-8 inches, medication therapy (antacids, ranitidine)
sulfite sensitivity
management: avoid shrimp, beer, wine, dried fruit
drug interactions
management: beta-blockers (use B1 selective for heart conditions), NSAIDs (treat with acetaminophen)
occupational irritants
sawdust, dust, dry powders
viral infections
management: annual influenza vaccination |
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Definition
| asthma triggers and their management |
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Term
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IMPORTANT: have to be controlled for 3 months before you can step down therapy!
add on medications, never replace medications! |
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Definition
| step-wise approach to asthma pharmacotherapy |
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Term
achieve control
reduce impairment:
prevent chronic and troublesome symptoms
require infrequent use of inhaled SABA (maintain near "normal" pulmonary function
maintain normal activity levels
meet patients' expectations of, and satisfaction with, asthma care
reduce risk:
prevent recurrent exacerbations
minimize need for ER visits or hospitalizations
prevent progressive loss of lung function
provide optimal pharmacotherapy, with minimal or no ADRs |
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Definition
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Term
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level of control based on MOST SEVERE CATEGORY of impairment or risk |
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Definition
| Assessing Asthma Control and Adjusting Therapy in Youths ≥12 Years of Age and Adults |
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Term
recommended 1-6 months intervals
initially may assess at 2-6 week intervals |
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Definition
| how often should asthma control be assessed? |
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Term
long-term control: FOR INFLAMMATION
anti-inflammatory: may not prevent progression of asthma development
inhaled corticosteroids
mast cell stabilizers
leukotriene modifiers
immunomodulators
bronchodilators:
long-acting B2 agonists
theophylline
quick-relief: for acute symptoms/exacerbations; RESCUE FOR OBSTRUCTION
short acting B2 agonists
systemic corticosteroids
anticholinergic agents |
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Definition
| differences between "rescue" and "controller" asthma therapy |
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Term
V/Q mismatch: dilation of bronchioles that don't have sufficient circulation; V = volume, Q = perfusion
increase heart rate
tremor
hypokalemia: albuterol shifts K intracellularly
hyperglycemia: glyconeogenesis and glycogenlysis due to B2 receptors in the liver
potential drug interactions with MAOi |
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Definition
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Term
albuterol
levalbuterol
pirbuterol
terbutaline
first line therapy for acute relief, prevention of EIB
duration of action: 4 hours
systemically
the patient must have available AT ALL TIMES
AVOID OTC PRODUCTS
epinephrine/ephedrine - very non-selective, works in the lungs and systemically |
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Definition
| short acting beta agonists |
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Term
salmeterol
formoterol
arformoterol
preferred therapy for moderate-severe persistent asthma along with ICS
better control than increasing ICS dose alone?
NOT indicated for acute relief or for monotherapy
onset of action is variable for products
duration of action: 12 hours |
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Definition
| long acting beta agonists |
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Term
receptor selectivity: non-selective B1/B2
duration of bronchodilation: 0.5-2 hours
duration of protection: 0.5-1 hour
oral activity: NO |
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Definition
isoproterenol:
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
receptor selectivity: non-selective B1/B2
duration of bronchodilation: 3-4 hours
duration of protection: 1-2 hours
oral activity: YES |
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Definition
metaproterenol
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
receptor selectivity: B2 selective
duration of bronchodilation: 4-8 hours
duration of protection: 2-4 hours
oral activity: YES |
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Definition
albuterol
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
receptor selectivity: B2 selective
duration of bronchodilation: 4-8 hours
duration of protection: 2-4 hours
oral activity: YES |
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Definition
pirbuterol
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
levalbuterol is the R isomer of albuterol so a lower dose is needed, marketed for less ADRs
receptor selectivity: B2 selective
duration of bronchodilation: 6-8 hours
duration of protection: 3-4 hours
oral activity: unknown |
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Definition
levalbuterol
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
receptor selectivity: B2 selective
duration of bronchodilation: 4-8 hours
duration of protection: 2-4 hours
oral activity: YES |
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Definition
terbutaline
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
onset of action of formoterol is 5 minutes due to lower lipophilicity than salmeterol; full agonist
receptor selectivity: B2 selective
duration of bronchodilation: > 12 hours = LONG ACTING
duration of protection > 12 hours
oral activity: YES |
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Definition
formoterol
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
onset of action of salmeterol is 30 minutes; partial agonist
receptor selectivity: B2 selective
duration of bronchodilation: > 12 hours = LONG ACTING
duration of protection: > 12 hours
oral activity: unknown |
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Definition
salmeterol
receptor selectivity, duration of bronchodilation, duration of protection, oral activity |
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Term
MOA:
anti-inflammatory agent
inhibits mast cell degranulation, release of inflammatory mediators
dosing: QID, only available as a nebulizer solution
therapeutic uses:
alternative therapy for mild persistent asthma
beneficial for allergic rhinitis
EIB (not as effective compared to SABA)
NOT indicated for acute relief |
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Definition
| MOA and therapeutic uses of mast cell stabilizers |
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Term
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Definition
| ADRs of mast cell stabilizers |
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Term
anti-inflammatory agent
decrease production of inflammatory mediators
decrease production of pro-inflammatory cytokines
anti-inflammatory potency varies between agents |
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Definition
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Term
time to clinical benefit varies: alleviates symptoms within 2 weeks, full benefit by 2 months
systemic effects at HIGH DOSES
oropharyngeal candidiasis: decrease by rinsing mouth, use of spacer
dysphonia
in children, decreases the rate, not extent, of growth |
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Definition
| ADRs of inhaled corticosteroids |
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Term
adrenal insufficiency
fluid retention
hypertension
hyperglycemia
osteoporosis |
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Definition
| ADRs of systemic corticosteroids |
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Term
SYNERGISTIC with beta-agonist therapy
restoration of beta-receptor density after chronic beta-agonist use
preferred therapy for mild-severe persistent asthma
improves lung function
reduce severe exacerbations
ONLY THERAPY SHOWN TO REDUCE RISK OF ASTHMA DEATH
ciclesonide and mometasone are dosed daily
budesonide is the only ICS available in a nebulizer form |
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Definition
| therapeutic uses of inhaled corticosteroids |
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Term
SYNERGISTIC with beta-agonist therapy
restoration of beta-receptor density after chronic beta-agonist use
oral option for severe persistent asthma
indicated for short-term "burst" for inadequately controlled persistent asthma
increase B2 receptor expression
response to B2 agonist within 2 hours, full benefit by 12 hours
HAVE TO KNOW DOSE: 1-2 mg/kg/day in 1-2 divided doses (DNE 60 mg/day)
duration of therapy: 3-10 days - NO adrenal insufficiency; do not need to taper |
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Definition
| therapeutic uses of systemic corticosteroids |
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Term
MOA of zafirlukast: leukotriene receptor antagonist
MOA of montelukast: leukotriene receptor antagonist; only one approved in patient >/= 6 months
MOA of zileuton: leukotriene receptor inhibtor
therapeutic uses:
alternative therapy for mild persistent asthma, adjunct for moderate-severe persistent asthma
beneficial for non-comopliance, seasonal allergic rhinitis, EIB |
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Definition
| MOA of leukotriene modifying agents (zafirlukast, monetlukast, zileuton) and therapeutic uses |
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Term
1) remove cap, hold inhaler upright, shake inhaler 3-4 times
2) (attach inhaler to spacer)
3) slowly breath out completely
4) place mouthpiece between teeth and tongu, close lips around mouthpiece
5) BREATH IN SLOWLY and press down on inhaler while continuing to breath in deeply OVER 3-5 SECONDS
6) hold breath for 10 seconds
7) wait 1 minute before next puff
8) rinse mouth to minimize side effects after using ICS
important spacer points:
whistle indicates breathing too quickly
technique with mask:
place mask on face covering nose and mouth
keep mask in place for 6 breaths/30 seconds |
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Definition
| MDI technique, closed mouth |
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Term
1) open by using thumb to push cover sideways until a click is heard
2) slide the lever until it clicks
3) slowly breathe out completely, away from inhaler
4) place mouthpiece between lips, keeping teeth apart
5) BREATHE IN QUICKLY and deeply OVER 1-2 SECONDS
6) remove inhaler from mouth and hold breath for 10 seconds
7) rinse mouth to minimize side effects after using ICS |
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Definition
| DPI technique (NOT AN OPTION FOR CHILDREN < 4) |
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Term
1) set pointer to zero
2) take a deep breath
3) place mouthpiece between teeth and tongue, close lips around mouthpiece
4) blow as hard and fast as possible into the meter
5) read number next to pointer
6) return pointer to zero
7) repeat 2 more times
8) record higher of the 3 readings |
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Definition
| Peak flow meter technique (used in patients >/= 5 years |
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Term
personal best:
asthma under good control, take PEF for 2-3 weeks
highest reliable reading during the 2-3 weeks is the personal best
recording:
record readings AM and early PM
PM readings are generally higher
prior to medication
document best of 3 attempts in diary |
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Definition
when should personal best peak flow be determined?
when should peak flow readings be taken? |
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Term
moderate to severe persistent asthma
history of asthma exacerbations |
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Definition
| patients that should be using a peak flow meter and an action plan |
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Term
GREEN ZONE:
no asthma symptoms
PEF 80-100% personal best
action: take controller medication as usual
YELLOW ZONE:
potential exacerbation, sub-optimal control
PEF 50-80% personal best
action:
use short-acting B2 agonist immediately, up to 3 treatments at 20 minute intervals in 1 hours
schedule short acting B2 agonist for 1-2 days
RED ZONE:
medical alert
PEF < 50% personal best
action:
use short-acting B2 agonist immediately, up to 3 treatments at 20 minute intervals in 1 hour
schedule short acting B2 agonist for 1-2 days
initiate corticosteroid "burst" |
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Definition
| elements of an asthma action plan |
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Term
budesonide (nebulization)
fluticasone (MDI) |
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Definition
| ICS approved for 0-4 years |
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Term
budesonide/formoterol: ALWAYS 2 PUFFS BID
fluticasone/salmeterol HFA: ALWAYS 2 PUFFS BID
fluticasone/salmeterol DPI: ALWAYS 1 PUFF BID |
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Definition
dosing schedule of combination therapy inhalers:
budesonide/formoterol
fluticasone/salmeterol HFA
fluticasone/salmeterol DPI |
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Term
disease education
environmental control (trigger avoidance/management)
peak flow monitoring
action plan
medication role: controller/reliever
medication use: inhaler technique, spacer use
ADRs:
SABA - counsel on increased HR
LABA - counsel on increased HR
ICS - counsel on thrush
LTRA - headache
adherence |
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Definition
| components to asthma education |
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