| 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. |
| What is a positive response to bronchodilator? | Increase in PEF of 12% > |
| 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) |
