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What are the key sx of asthma?
- Wheezing
- Breathlessness
- Chest tightness
- Cough (particularly at night)
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What are the chances that a young patient will "outgrow" their asthma?
- 30-70%
- chances seem to improve by well-controlled symptoms d/t decreased occurrence of airway remodeling
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What are the risk factors for developing asthma?
- genetics
- exposure to 2nd-hand smoke
- socioeconomic status
- family size
- exposure to allergens
- urbanization
- decreased exposure to common childhood infectious agents
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What agents and events can trigger asthma?
- house-dust mites
- danders
- cockroaches
- cold air
- ozone
- tobacco smoke
- anxiety/stress
- exercise
- aspirin
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What is the singe most significant precipitant of severe asthma in children?
viral respiratory tract infection
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What cells of the airways become involved in chronic inflammation of asthma?
- Eosinophils
- T cells
- Mast cells
- Macrophages
- Epithelial Cells
- Fibroblasts
- Bronchial smooth muscle cells
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What is released from mast cells once allergen binds to surface IgE?
- Histamine
- Eosinophil and Neutrophil chemotactic factors
- Leukotrienes C4, D4, and E4Prostaglandins
- Platelet-activating factor
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What is airway remodeling in asthma?
- Repair initiated by inflammation resulting in replacement of injured tissue by parenchymal cells of the same type and connective tissue which matures into scar tissue
- This can result in fibrosis and increased smooth muscle and mucus gland mass
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What is the cause of hypertrophy and hyperplasia in asthmatics?
chronic inflammation
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What is the effect of NO on asthmatic airways?
- Smooth muscle relaxation in the vasculature and bronchials
- Amplification of the inflammatory process (this makes it useless for tx)
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What would a high level of NO in exhaled air mean in an asthmatic?
poor control of the disease
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Besides PFTs, what other tests can be used to diagnose asthma?
- elevated eosinophil count
- elevated IgE concentration in blood
- elevated FeNO
- positive methacholine challenge
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What are the major risk factors for severe exacerbation of asthma?
- Underuse of anti-inflammatory drugs
- Over-reliance on SABAs
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What are the sx of a severe exacerbation of asthma?
- Only able to say a few words with each breath
- Sx unresponsive to usual measures
- Expiratory and inspiratory wheezing (may be no breath sounds if severely plugged)
- Tachypnea
- Pale or cyanotic skin
- Intercostal and supraclavicular retractions
- PEF or FEV1 < 50% predicted
- O2 < 90%
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What is exercise-induced bronchospasm?
- Decline in FEV1 of > 15% of baseline
- provoked more easily in cold, dry air
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What role does influenza vaccination have for preventing asthma exacerbations?
None, it doesn't work
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What is the treatment for allergic rhinitis/sinusitis in asthmatics?
- inhaled corticosteroids and cromolyn
- NOT antihistamines!!!
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What foods can trigger an asthma attack (d/t high concentrations of metabisulfites)?
- Beer
- Wine
- Dried fruit
- Open salad bars
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What is the aspirin triad (Samter's triad)?
- Aspirin
- Asthma
- Nasal polyposis
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How often should inhaler spacers be cleaned with detergent to decrease static?
monthly
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How does particle size affect medication deposition?
- > 10 microns - oropharynx
- 5-10 microns - trachea, large bronchi
- 1-5 microns - lower airways
- < 0.5 microns - exhaled as gas
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What is the difference b/w asthma and COPD when it comes to systemic CS for tx of severe exacerbations?
In asthma, you don't need to taper off of the corticosteroids
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What is the DOC for tx of mild persistent asthma in pregnancy/lactation?
Budesonide (low dose)
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What are the determining factors that mean a pt has mild persistent asthma rather than intermittent asthma?
- Sx occur > 2d/wk, but not daily
- Nighttime awakenings 1-2 times/mo
- Use SABA for sx control > 2d/wk
- (RULE OF 2s)
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What is the treatment for Intermittent asthma?
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What is the treatment for mild persistent asthma?
- Step 2:
- Low-dose ICS (or LTRA)
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What is the tx for moderate persistent asthma?
- Step 3:
- Medium-dose ICS (kids)
- Lo-dose ICS + LABA, LTRA, or Theophylline (Adults)
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What is the tx for severe persistent asthma?
- Step 4:
- Med-dose ICS + LTRA or LABA (kids)
- Med-dose ICS + LABA (Adults)
- Med-dose ICS + LTRA, Theophylline, or Zileuton (Adults alternate)
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What is the tx for Step 5 in severe asthma?
- High-dose ICS + LTRA or LABA (kids)
- High-dose ICS + LABA + consider Xolair (Adults)
- High-dose ICS + LTRA + consider Xolair (adults alternate)
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What is the tx for Step 6 in severe asthma?
- High-dose ICS + LTRA or LABA + oral CS (kids)
- High-dose ICS + LABA + oral CS + consider Xolair (Adults)
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What is the tx for severe acute exacerbations of asthma?
- Albuterol/ipratropium q 20min x 3 doses, followed by continuous albuterol
- Systemic CS
- Mg Sulfate, heliox, and/or ketamine
- Pt education and written action plan
- Consider initiation of ICS prior to discharge
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What FEV1 or PEF value determines a mild-moderate asthma exacerbation?
≥ 40%
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What FEV1 or PEF value determines a severe asthma exacerbation?
< 40%
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