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Pulmonary ClinMed Asthma & Sleep Apnea
Terms in this set (81)
What are the 3 components of Asthma
Intrinsic vs. Extrinsic
Intrinsic: non immune triggers
Extrinsic: Type 1 hypersensitivity to allergen (antigen)
during or w/in 3 minutes after it ends
• Peaks w/in 10-15 minutes
• Resolves by 60 minutes
• Contributing factors: exposure to cold or dry air, pollutants in air, duration and
intensity of exercise, allergen exposure in atopic patients, coexisting respiratory infection, level of bronchial hyper-reactivity and chronicity of asthma and symptomatic control
• Prevalence of Exercise induced asthma 3-10% (no hx of asthma or allergy)
Exposure to antigen/irritant results in immune response -> IgE (specific antigen) increase in #.
The more times you get exposed to that specific allergen - IgE attaches to the allergen. -> The IgE+allergen complex attaches to mast cells. The mast cells contain inflammatory
mediators: histamine, prostaglandins, leukotrienes -> which are then released into the blood stream.
Tissue injury stimulates eosinophils which release toxic neuropeptides -> hyper-responsiveness, fibroblast proliferation and airway scarring -> airway
remodeling over time
Neutrophils/PMNs are stimulated -> inflammation
Mucus glands in airway become activated, increase mucus production with decreased
Airflow obstruction / hyper-responsiveness
-Acute bronchoconstriction (seconds to minutes.) Bronchial smooth muscle spasm/contraction, increased mucus production which results in
SOB and wheezing.
-Airway edema (hours later): Vascular congestion, increased vascular permeability.
-Chronic mucus plug formation (late): impaired mucociliary function
-Airway remodeling (late): structural changes to long standing inflammation
Acute Asthma attack
Airway obstruction → airway resistance and decreased flow rates → air
trapping and hyperinflation distal to obstruction -> altered breathing mechanics and increased
work of breathing •
Continued air trapping→ increases gas pressures in alveoli and intra-pleural spaces →
decreased perfusion → uneven ventilation-perfusion relationship in different areas of lungs → hyperinflation → abnormal gas exchange and further hyperinflation -> pH increases resulting in
Obstruction worsens→ alveoli perfusion and ventilation decreases → obstruction of expiratory
flow → worsening air trapping → hyper-expansion of lungs (resp muscles decrease in function) → CO2 retention and respiratory acidosis
Becomes a vascular problem because of impaired gas exchange.
Asthma more common in males or females?
males until puberty then slightly more common in females after puberty.
When are most asthma diagnosis made?
before age 18.
symptoms can decrease/disappear by early adulthood.
Cannot diagnose until 2y/o or older
Asthma signs and symptoms
-Chest tightness -Cough
(may be only symptoms)
-Typically worse at night
What are some nonspecific symptoms of in infants
-recurrent resp. infections
What do you want to document in your HPI for asthma?
-hx of asthma
-prior treatments/hospitalizations/intubations, etc.
-FH of atopic disease,
tobacco in home, other risk factors, etc.
Asthma physical exam findings
varies based on time of presentation and severity of attack...
-Prolonged expiratory phase
-Reduced breath sounds
-Increased use of accessory muscles
-Pulsus paradoxus: abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration.
- or no signs if between attacks.
-Allergic rhinitis signs +/- nasal polyps
Mild Asthma physical exam findings
-Breathless after physical activity
-Moderate wheezing (primarily end expiratory)
-No use of accessory muscles
-No pulsus paradoxus
Oxygen saturation >95%
PEF (peak expiratory flow) >= 70% predicted or personal best
Moderately Severe Asthma physical exam findings
-Use of accessory muscles
-HR b/w 100-120 bpm
-Expiratory wheezing -Pulsus paradoxus may be present (10-20 mmHg)
-Pulse oximetry 91-95%
-Usually assumes sitting position
-PEF 40-69 % predicted or personal best
Severe Asthma physical exam findings
-Breathless during rest
-Not interested in eating
-sitting upright (?tripod position)
-Talk in words, not complete sentences
-Accessory muscle use
-HR >120 bpm
-Expiratory and inspiratory wheezing
-Pulsus paradoxus (20-40 mmHg)
-Pulse Oximety <91%
-PEF <40% predicted
Asthma Imminent Respiratory Arrest
-Drowsy, confused, agitated
-patient willing to lie recumbent
-Wheezing may be absent
-Breath sounds may be nearly absent
-Pulsus paradoxus may be absent (respiratory muscle fatigue)
-PEF <25% predicted or personal best
What are some Asthma differentials to keep in mind?
-Upper airway disease -Lower airway disease -Systemic vasculitides: inflammation of blood vessel walls of any type, in any organ resulting in a broad spectrum of signs and symptoms.
What is a chronic complication of asthma
What are complications of acute asthma attacks?
-Respiratory failure (severe disease)
Asthma diagnosis is made by?
clinical signs/symptoms, activity limitations and QOL factors (quality of life factors)
Though labs/diagnostics not routinely performed to dx asthma what are some common tests?
CBC - inc. eosinophils
ABG (arterial blood gas): done in moderate to severe
ARDS Pulse oximetry: normal = 98-99%
What is the diagnostic test of choice for asthma?
What will the CXR look like in an asthma pt?
normal, may show some hyperinflation, usually done to r/o other causes.
Peak flow monitoring for asthma
Not as specific as spirometry. Pt has to do it properly .
A peak flow meter is an inexpensive, portable, handheld device for those used to measure how well air moves out of your lungs.
Metacholine challenge test
Bronchi provication test -> induces bronchoconstriction. If bronchoconstriction does not occurs than you can rule out asthma. Preform in controlled environment. Only for adults.
What does spirometry measure?
FEV1 and FVC
What is diagnostic of asthma on spirometry?
increase in FEV1 > 12%
200mL increase in FVC
15 minutes after SABA
Useful to assess severity at baseline and before/after SABA use prior to starting tx
What are diagnostic spirometry results of exercise induced asthma?
Check levels after 6-10 minutes of
15% decrease in FEV1 after exercise
Asthma Staging and Severity
Asthma tx goals
-Prevent recurrent exacerbations and chronic symptoms
-Minimize morbidity(disease state) from acute episodes
-Maintain normal activity levels
-Reduce/eliminate the need for ED visits or hospitalizations
-Maintain normal or near normal pulmonary function
-Optimal pharmacotherapy = minimal or no adverse side effects
Asthma tx approach
-monitor severity and control
-Impairment: symptoms, occurrences, etc.
-Risk: frequency of exacerbations and med use.
-Responsiveness to tx
-Patient education: triggers and reducing triggers, sx to better assess control and tx effectiveness, medications
-Create asthma self-management plan (i.e. school plan for school-aged children, when to contact
office or go to ER)
-Create asthma action plan for those w/ poor control and hx of severe exacerbations
-Recommend pneumococcal vaccine and annual flu shot (not Flumist - nasal, can trigger)
-Control environmental factors and comorbid conditions
-Pharmacotherapy reliever and maintenance tx
-Treat comorbid conditions appropriately (allergic rhinitis, URI, GERD, obesity, obstructive sleep apnea)
Asthma reliever meds for acute symptoms (acute relief of symptoms)
beta-adrenergic agonist (SABA)
Name 2 SABAs used to treat acute symptoms of asthma
Albuterol and levalbuterol
Relax smooth muscle increasing airflow and relieving symptoms
Repetitive administration produces incremental bronchodilation
Name an anticholinergic used to treat acute symptoms of asthma
Reverses vagally mediated bronchospasm
Less effective than SABA
When is an anticholinergic the drug of choice for acute asthma symptoms
pt does not tolerate SABA
bronchospasm d/t beta blocker meds
Name 2 systemic corticosteroids used to treat acute asthma symptoms
Prednisone & prednisolone
Used in moderate/severe exacerbations
improves airflow obstruction and reduces rate of relapse
Can be used for acute reaction in conjunction with SABA
What are controller meds/anti-inflammatory meds for Asthma?
ICS (inhaled corticosteroids)
Oral or parenteral corticosteroids (systemic)
What is the preferred 1st line tx for persistent asthma?
Side effects of ICS
-cataract w/ high dose
PEARLS for systemic corticosteroids and asthma tx
Most effective when initiating long term therapy in pts w/ severe symptoms.
May be needed for long term in severe cases w/ goal of reducing dose to minimum
needed to control symptoms
Same side effects as ICS but worse also
need to monitor osteoporosis, calcium/Vitamin D supplements
Never rapidly d/c, always a slow taper (adrenal insufficiency)
Now what really is a clinical pearl?
small bits of free standing, clinically relevant information based on experience or observation. Pearls are part of the vast domain of experience-based medicine, and can be helpful in dealing with clinical problems for which controlled data do not exist.
What are 4 controller type meds/long acting bronchodilators for asthma?
Mast cell stabilizers, beta agonists, anticholinergics, methylxanthine
What are 2 examples of mast cell stabilizers?
Cromolyn & Nedocromil
Work on mast cells- inhibits early and late responses to allergens
Effective if taken before exposure, not to relieve symptoms once present
Very safe, response is less predictable than inhaled corticosteroids
Name 2 long acting beta agonists (LABAs)
Salmeterol & formoterol
-last up to 12 hrs after single dose
-Not used as monotherapy
-Dry powder delivery
-Highly effective when used in combo w/ inhaled steroid
Name an anticholinergic used to asthma
-long acting bronchodilator
-Used as add-on therapy following ICS or steroid + LABA
What is Methylxanthine?
-mild bronchodilator, anti-inflammatory and immunomodulatory
-used as add on therapy in moderate to severe persistent asthma not controlled w/ inhaled steroids
-helps w/ nocturnal symptoms
-narrow toxic / therapeutic range)
-side effects: n/v, tachyarrhythmias, HA, seizures, hyperglycemia and hypokalemia
Monoclonal IgE antibody
Omalizumab, Xolair, Reslizumab, Cinqair
-Binds to IgE w/o activating mast cells
-Studies show it reduces need for steroids
-Only FDA approved in patients 18y and older w/ severe asthma
What is the step wise approach to asthma meds?
-SABA (short acting beta 2 agonist)
-LABA (long acting beta 2 agonist)
-ICS (inhaled corticosteroid)
-LTRA (Leukotriene antagonist)
(I'm a bit confused with slide 41... doesn't ICS come before LABAs?)
Mild Asthma exacerbation tx
-May require increased dosage
-If not on ICS consider adding one
If already on ICS - oral steroids x 7 days may be necessary
moderate asthma exacerbation tx
-SABA administration (continuous)
-early administration of systemic steroids
severe asthma exacerbation tx
-high dose inhaled SABA adding Ipratropium (Duoneb) reduced hospital admit.
-consider IV magnesium sulfate - improves airflow and reduces hospital admit
-avoid mucolytic agents, anxiolytic agents and hypnotic drugs
ASA sensitive asthma pos
Exacerbations w/ ASA (aspirin) and other Cox inhibitors
Associated w/ nasal polyps and perennial rhinitis
Symptoms: rhinorrhea, conjunctival inflammation, facial flushing, wheeze
elderly pts w/ asthma
increase side effects w/ meds
Pregnancy and asthma
what asthma meds are safe in pregnancy?
Can use prednisone (oral steroid) since fetal liver cannot convert to active
How often do you do asthma follow ups?
Follow up q6 weeks while gaining control
Follow up q 1-6 months to monitor control
Follow up q3 months if step down in therapy is indicated
order PFT's every 1-2 years
Obstructie Sleep Apnea (OSA)
Most common type of sleep disordered breathing
Recurrent episodes of upper airway collapse during sleep that are associated w/ recurrent
deoxygenation and disrupted sleep
Passive loss of normal pharyngeal muscle tone leading to collapse of the pharynx during inspiration
increases with age
Central sleep apnea
not trying to breath
Obstructive sleep apnea
trying to breath - more common
structural - males, obese, large tongue
OSA risk factors
-ETOH or sedative before sleep
Associated disorders of OSA
-CHF (increased mortality in presence of CHF)
-Myocardial ischemia and infarction
-Stroke (more likely to have a stroke and die than those w/o disease)
-Metabolic syndrome (may contribute to development of this)
OSA signs and symptoms
-Excessive daytime somnolence
-Cognitive impairment/memory changes
-Impotence/ decreased libido
-Dry or sore throat
-Recent weight gain/obesity
-Bed partners report loud snoring, breath cessation, witnessed apneic episodes, restlessness,
aggressive limb movements during sleep
Physical exam findings of OSA
-May be normal
-Enlarged neck circumference (men >47cm and female >37cm)
-Sleep in exam room
-Oropharynx narrowed soft tissue folds
-Nasopharynx nasal obstruction, deviated septum
OSA differential diagnosis
-Periodic limb movement disorder
Labs typically not necessary though thyroid function tests useful to r/o thyroid
OSA work up
-Polysomnography (sleep study) required to accurately diagnose OSA and assess tx
Polysomnography abnormal findings
-Apneic episodes in presence of respiratory effort
-Apneic episodes last 10 sec or longer
-Apneic episodes are most prevalent during REM sleep
-May have combo or apneic and/or hypopneic episodes
-Sleep disturbance due to arousals
-Oxygen saturation falls
OSA diagnostic Classification
Mild- 5-10 episodes per hour
Moderate- 15-30 episodes per hour
Severe- 30 episodes or more per hour
OSA conservative/preventative tx
-Weight reduction of 10%
-Sleeping on side
-Avoid smoking/smoking cessation
-Avoid ETOH or other sedatives
-Avoid sleep deprivation
OSA medical measures
OSA oral appliance
Hold jaw/tongue forward to prevent pharyngeal collapse
Fitted by dentist
More successful in pts with lower BMI, smaller neck circumference, younger age
Cost ranges $300-$2,500
Moderately successful for short term, but no long term studies
Benefits: easy, quiet, portable, convenient for travel, easy to care for
Adverse effects: excessive salivation, tooth movement +/- bite changes, TMJ pain, tooth
pain, gagging, gum irritation
continuous positive airway pressure
maintains airway patency during sleep
Complications: claustrophobia, sinus discomfort, difficulty exhaling, mask related
problems, rhinorrhea, nasal congestion, epistaxis, etc
To be effective, patient needs to use it >4hr/night on 5-7 nights/week
Compliance an issue
cheaper -approved by insurance
Similar to CPAP but the machine allows for independent adjustment of
pressures during inspiration and expiration (results in lower pressures)
Used in patients who cannot tolerate the high CPAP pressures
More expensive Better compliance than w/ CPAP
often not covered by insurance
Uvulopalatopharyngoplasty (UPPP)-effective in 40% of patients
Tracheostomy (last resort)- 100% effective b/c it bypasses the obstruction
Indicated for pts if noninvasive therapy was unsuccessful or rejected by patient
OSA Follow up
every 2 months after initiating CPAP then every 6-12 months if compliant and effective.
If not effective, then at 2-3 month intervals till adjusted and effective
Short term is good w/ regular use of CPAP/BiPAP, long term is unknown due toandlack of studies
Severe, untreated OSA increases risk of CV mortality (fatal MI or stroke) as well
as unfatal MI and MVA (motor vehicle accident) -2-7 times increased risk
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