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Asthma


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[Front]


What are the risk factors for asthma exacerbation?
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Allergens ( pets, seasonal), improper use of meds, recent ER visit, Black or Hispanic

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Asthma - Details

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34 questions
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What are the risk factors for asthma exacerbation?
Allergens ( pets, seasonal), improper use of meds, recent ER visit, Black or Hispanic
Risk factors for asthma death?
Comorbidities ( COPD, Emphysema, sensitivities to ASA, GERD, obesity, OSA, rhinitis, chronic stress, sensitive to sulfites, bronchopulmonary aspergillosis) Psych, low class, IVDU, difficulty perceiving obstruction, previous intubation, > 2 hospitalizations/ yr, > 3 ER visits / yr, > 2 inhalers/mo, sensitivity to alternaria
Asthma Goals
1. minimal need for SABA < 2x/wk, < 2 night/mo, normal activity and optimal lung function. , prevention of exacerbation
What is included in Asthma Plan?
Assessment of signs and sx each visit, PEF, exacerbation, adherence to treatment, side effects and pt satisfaction. Asthma Control Questionaire
Def. well controlled asthma
Day sx < 2x/wk, night < 2x/mo, SABA < 3x/wk, normal activity, PEF > 80, steroid and Urgent care < 1x/yr.
Def Intermittent
Day sx < 2x/wk, night < 2x/mo, SABA < 2x/wk, normal activity, PEF 80, steroids < 1x/yr. Exercise induced Rx SABA prn.
Def. mild persistent
Day sx > 2x/wk, night sx 3-4x/mo, SABA > 2x/wk, minor limitation of activity, PEF > 80, steroid > 2x/yr Rx: Step 2 addition of ICS
Def Moderate persistent
Daily sx, night > 1x/wk, SABA daily, limitation of activity, PEF 60-80%, steroid > 2x/yr. Rx Step 3 Low dose ICS + LABA or Med ICS
Def. Severe persistent
Dyspnea at rest, daily sx, nightly sx, SABA several x/day, PEF < 60% Rx Step 4-5 Med - High dose ICS, LABA + Leukotriene inhibitor.
What are the step of asthma treatment
Step 1 : SABA prn If exercise induced take 10 min before exercise. Step 2: Low dose ICS or leukotriene inhibitor or Cromonlyn Step 3: Low dose ICS + LABA +/- Leukotriene Inhibitor or Med dos e ICS Step 4 Med to High dose ICS + LABA + Leukotriene Inhibitor
What is anti IgE therapy
Omalizumab, monoclonal Ab against interleukin 5 for pt with eosinophilic asthma.
Who do you refer to pulmonology?
1. Life threatening asthma exacerbation, 2. Hospitalization 3. Step 4 or higher treatment 4. Comorbidities, 5. Need for additional testing ( skin test or complete PFT) 5. Candidate for immunotherapy or biologics.
Home treatment of asthma exacerbation
Def: Decrease of 20% PEF . If PEF < 50% to ER. SABA 4-6 inhalations Q 10-20 min x 3 . PEF 50-70% (incomplete response) Repeat SABA 20 min x 3 and reassess. If PEF > 80 good response and can lengthen SABA Q 3hours. If no improvement start oral steroids and continue with SABA Q3. Seek medical attention if not improved.
Office Management of Asthma Exacerbation
Assess sx and severity. To ED if unable to speak full sentence, breathless at rest or drowsy or agitated, PEF < 50%, HR > 120, RR > 30 , O2 < 90. Start Albuterol Neb Q 20 min x 3 (Consider co neb with ipratropium) , oral prednisone 40 mg. If improved with PEF 60-80% and O2 > 94 Ok to go home. Continue with SABA Q 3-4 hours, ICS, oral steroids, and avoid triggers. Instruction to go to ED if worse.
Asthma exacerbation due to anaphylaxis
Epinephrine auto-inj 0.3mg
When do you preform spirometry?
At initial evaluation, To determine severity, pre and post bronchodilat or. If obstruction due to Asthma or COPD( FEV1/ FVC ratio < 70%, see low FEV1, and low FEV1/FVC with a normal FVC.
How long can airway inflammation persist after exacerbation?
3 wks, Continue with SABA until PEF at baseline.
How do you dx Exercise induced asthma?
> 10 % decrease in PEF with exercise and recovery with SABA
Side Effects of ICS
No increase fracture or cataracts. Slow growth in children and easy bruising. Accelerated bone loss and thrush. Caution with active or latent TB, untreated fungal or viral infection and ocular herpes.
Side effects of SABA
Tremor, tachycardia, elevated glucose, low potassium, temp. lowers oxygen.
Leukotriene inhibitors
Bronchodilators 1/2 as potent as SABA. Equivalent to IC as first line controller Rx. Recommended for mild persistent asthma and asthma with allergies. ( Montelukast and Zafirlukast.)
Anticholinergics
Iprotropium bronchodilators. Helpful in GERD with asthma and for severe exacerbation.
COPD Def
No. nreversible airflow obstructio due to exposure to irritants < 70% FEV!/FVC on spirometry
What is the DDX of COPD
Chronic asthma, crhonic bronchitis, bronchiectasis, TB, heart failure, central airway obstruction
How do you classify COPD?
GOLD ABCD based on spirometry and symptoms.Mild > 80%, Mod 50-79%, Severe 30-49%, Very severe < 30 %
Mild GOLD A def. and treatment
0-1 exacerbation inpast year. SABA prn
Def and RX of GOLD B
0-1 exacerbation or hospitalization / yr, has to stop to catch breath when walking. . Rx Add LABA (tiotropium ) or LABA (salmeterol) or ICAS with LABA and with SABA prn.
Def and Rx of GOLD C
> 2 hospitalization or exacerbation / yr. Rx LAMA or ICS with LABA and SABA prn. Oral steroids and abx not indicated prophylactically.
Def and Rx GOLD D
Very severe with > 2 exacerbations and hospitalization. Rx LAMA or LABA with ICS and SABA prn
How do you monitor COPD
Yearly spirometry. If see low FVC then do full PFT to check for restrictive disease. Keep O2 sat > 90%
When do you start O2
Resting PaO2 < 55, O2 sat < 88%, PaO2 < 59 with evidence of cor pulmonale, erythrocytosis with Hct > 55. Must use continuously . Re evaluate at 2 mo.
Copd management
Smoking cessation at every visit, yearly flu and pneumococcal vaccine, pulmonary rehab for severe disease.
Treatment of COPD exacerbation
Increase albuterol dose, , Add atrovent, sort course steroids, and abx fore severe exacerbation ( azithromycin, augmenting, CFP)