Allergic Rhinitis, Asthma, and ARDS
What are leukotriene modifiers?
Montelukast, Zafirukast, Zileuton
Who commonly presents with food allergens?
Uncommon in adults; children have peanut and other food triggers
What patient education recommended for asthma?
More emphasis on patient education at ER discharge, pharmacy based education, clinics, community sites; Greater emphasis on two aspects of written asthma action plan = daily management and how to recognize/handle worsening asthma
What is the summary of triggers?
*Inhalant allergies*: pollens, molds, cats, dogs, birds, cockroaches, house dust mites; *Occupational Allergens*; *Irritants*: chemical exposures, cold air, smoke; *Respiratory infections*: viral, sinusitis, bronchitis, pharyngitis, pneumonia; *Food*: mostly in children peanuts, sulfites; *Drugs*: nonselective beta blockers, ASA, NSAIDs; *Strong emotions, hormonal fluctuations, exercise, changes in ambient temp and weather*; *Co-existent medical conditions* like GERD, obesity, chronic sinusitis, OSA
What is the mainstay of treatment for all asthmatics above intermittent disease?
*Inhaled corticosteroids*; these are patients with symptoms more than 2 times/week; Blocks many of the inflammatory pathways in asthma; Increase or decrease dose in stepwise manner--may take 3 months for plateau
What are the classification of duration of symptoms for allergic rhinitis?
*Intermittent* which is primarily seasonal with symptoms occurring <4 days/week or duration <4 weeks; *Persistent* which is primarily perennial with symptoms >4 days/week and >4 weeks
What are the 2 symptom severity categories of allergic rhinitis?
*Moderate-severe* with >1 of sleep disturbances, troublesome symptoms, impairment of daily activities, leisure, and/or sports, or impairment of school work; *Mild* with none of the above
What are the three leukotriene modifiers?
*Montelukast* 10 mg QHS, *Zafirlukast* 20 mg BID before meals, and *Zileuton* 1200 mg BID no food
How prevalent is allergic rhinitis?
*Most common allergic disease in the US* affecting 40 million people each year; 10-30% of adults and up to 40% of children; 50% of AR patient experience symptoms >4 months/year and 20% of AR patients are symptomatic >9 months/year. Responsible for >10 million physician visits/year and as many as 3.8 million missed days/year including work and school; Prevalence in industrial world is increasing
What are irritants?
*Non allergic* stimuli which provoke airway change in susceptible individuals, producing inflammation and disrupting normal function; Example: cold air, exercise, tobacco smoke, pollution
What are benefits and risks of mepolizumab?
*Risk of herpes zoster* so consider varicella vaccine before treatment; Indicated in severe allergic asthma; Expensive, but no anaphylaxis reported
What are triggers of ARDS?
*Sepsis*, pneumonia, severe trauma, massive blood transfusion, pancreatitis, aspiration, drugs, bone marrow transplant, UAO relief, near drowning, amniotic fluid embolism, gas inhalation, air/fat embolism
What is the pathophysiology of asthma?
*Smooth muscle dysfunction* and *airway inflammation* cause symptoms and exacerbations
What are signs and symptoms of an asthma exacerbation?
*Tachypnea*, initially respiratory alkalosis (7.46, 40, 75)--a normal pCO2 is *not* normal; *Wheezing*: silent chest is worrisome--sitting upright, accessory muscle use, unable to speak in full sentences; *Tachycardia*
How often does mortality result from ARDS?
Recent mortality estimates for ARDS range from 41 to 65%; there is substantial variability, but a trend toward improved ARDS outcomes appears evident; Improvement in survival is likely secondary to advances in the care of septic/infected patients and those with multiple organ failure
When should a patient with allergic rhinitis be referred?
Under 2 years of age since allergic sensitization has not yet developed so something else is happening; Severe or refractory symptoms; Intolerant or many side effects from therapy; Patients who want to minimize or avoid long term medications
What are key differences for environmental control in EPR 3?
Reduce exposure to inhalant indoor allergens through a multi-faceted approach; Formaldehyde and volatile organic compounds (VOCs) have been implicated as potential risk factors for asthma like new linoleum flooring, synthetic carpeting, particleboard, or recent painting
What can cause asthma exacerbations?
Allergens, respiratory viral infections, occupational agents, aspirin sulfites, irritants, exercise, and stress
What are potential causes of paradoxical vocal cord dysfunction?
Allergic rhinitis or reaction, conversion disorder, anxiety, respiratory-type or drug induced laryngeal dystonia, laryngo-pharyngeal reflux (LPR)-initial trigger then laryngospasm initiates VCD
What are asthma mimics?
COPD, CHF, pulmonary embolism, mechanical obstruction of the airways, pulmonary infiltration wtih eosinophilia, Allergic Bronchopulmonary Aspergillosis (ABPA), cough secondary to drugs, allergic rhinitis, non-asthmatic eosinophilic bronchitis, other respiratory conditions like bronchiectasis, post-infectious; Vocal cord dysfunction (VCD), obesity, GERD
How does allergic rhinitis affect children and adolescents?
Can cause ADHD, lower exam scores during peak pollen seasons, poor concentration, impaired athletic performance, and low self esteem
How does allergic rhinitis affect adults?
Can cause anxiety, depression, reduced academic performance and work productivity, impaired sexual performance, and lower quality of life scores
How does allergic rhinitis affect quality of life and cognitive function?
Can cause sleep disturbances, fatigue, and malaise
What are home environmental triggers?
Carpets, dust mite, aerosols, cockroaches, animals, coal, and other combustion in home
What are school environmental triggers?
Carpets, dust mites, pets, molds, fumes from science experiments, glues, paints, air fresheners, felt tip pens, chalk dust, dander
What does inflammation of the airway in asthma cause?
Causes bronchoconstriction, airway edema, airway hyper-responsiveness, and airway remodeling
What is the exudative stage of ARDS?
0-6 days; Characterized by accumulation of excessive fluid in the lungs due to *exudation* and acute injury; Hypoxemia, injury to endothelium and epithelium are most severe during this phase; Some individuals recover quickly, others progress to second stage
What are the three stages of ARDS?
1. Exudative stage; 2. Proliferative (or fibroproliferative) stage; 3. Fibrotic stage
What is the rule of thirds in asthma?
1/3 worse, 1/3 better, 1/3 unchanged
What are statistics about asthma in New Mexico?
150,000 or 13.9% have had asthma diagnosis; Current child prevalence 47K or 8.6%; Increased prevalence in Native Americans; Hispanics visit ER more than whites; 23.7% report limitations in daily life; Estimated cost of treating asthma in those under 18 is 3.2 billion per year; 30-40 deaths/year from asthma; >65 years at greatest risk
What are asthma statistics in the US?
25 million americans with asthma (8%), about 1 in 9 (11%) non-Hispanic blacks of all ages, 1 in 6 (17%) non Hispanic black children = highest rate among racial/ethnic groups; 50% increase in asthma rates from 2001-2009; 1 in 12 adults and 1 in 10 children; 5-6 million under 18 years; Increase of 61% from 1983 to 1994; 11 people die every day from asthma; 3,262 adults and 185 children died in 2007
What are patients with allergic rhinitis at increased risk of?
3-fold increase in asthma risk regardless of atopy; 80% asthma asthmatics have co-existing AR; 40% of allergic rhinitis patients have lower airway involvement; 50% of patients with sinus disease have asthma and 10% of asthmatics have polyposis
How is family history a risk factor for allergic rhinitis?
50% chance of developing allergies if 1 parent atopic; 66% chance if both parents atopic
What is the fibrotic stage of ARDS?
>10-14 days; Oxygenation improves and extubation becomes possible; Lung function may continue to improve for as long as 6-12 months after onset of respiratory failure, depending on precipitating condition and severity of initial injury; Varying levels of pulmonary fibrosis changes are possible
What is the rule of two's?
A rule to who needs controller therapy; Two beta agonists canisters/year; Two doses of beta agonist/week (other than with exercise); Two nocturnal awakenings/month; Two unscheduled visits/year; Two prednisone bursts/year
Describe the epidemiology of asthma.
About 300 million people worldwide are affected, 250,000 people die per year, low and middle income countries make up more than 80% of the mortality, it is more common in developed countries; Asthma is twice as common in boys as girls and asthma is more common in the young than the old
What are Dennie-Morgan lines?
Accentuated lines or folds below the lower eyelids
What is the economic burden of allergic rhinitis?
Accounts for 2.5% of all clinician visits, 2 million lost school days/year, 6 million lost work days, 28 million restricted work days/year; Average number annual *prescriptions for patients with AR is double* that for those that don't have AR; In 2000: 2.4 billion dollars spend on OTC meds and 1.1 billion in clinical billings for a total indirect and direct cost of several billion dollars/year; Medical spending doubled from 2000 to 2005
What are differentials of AR?
Acute infectious rhinitis (URI), chronic nonallergic rhinitis like vasomotor or gustatory rhinitis, chronic rhinosinusitis, rhinitis mendicamentosa, rhinitis due to systemic meds (OCP, ACE, NSAIDs, ED meds, Psych meds), atrophic rhinitis, rhinitis associated with hormonal changes, U/L rhinitis or nasal polyposis, rhinitis with immunologic disorders (Wegner's, Polychondritis)
How do beta 2 agonists work?
Acute relief of bronchoconstriction; Inhaled is preferred route; PRN, not scheduled dosing because tolerance can develop and schedule only pre-exercise or for 24-48 hours after exacerbation
When is anticholinergic therapy used in asthma exacerbations?
Adding Ipratropium to inhaled beta agonists has shown additional bronchodilation in those with severe bronchospasm; During exacerbations, increases FEV1, improves outcome and decreases hospitalizations; Not a major role in outpatient therapy or as inpatient after ED course
What is ARDS?
Adult Respiratory Distres Syndrome; Severe hypoxia, V/Q mismatching PaO2/FiO2 ratio <200 and at altitude <150; Bilateral diffuse infiltrations on CXR, No CHF with normal wedge pressures
What are combination ICS/LABAs in asthma?
Advir diskus (Flovent and Serevent); Advair HFA; Symbicort (Pulmicort and Foradil); Dulera (Asmanex and Foradil)
What are treatments for asthma during pregnancy?
Aggressive treatment of asthma during pregnancy is important; There are *no* category A medications
What are category C medications for asthma during pregnancy?
Albuterol, other inhaled CTS, theophylline, combination products
What can be seen on physical exam in allergic rhinitis?
Allergic shiners, Dennie-Morgan lines, "allergic salute," and "allergic facies"; When AR is active, nasal mucosa my have a pale bluish hue (boggy) with pallor and turbinate edema; Clear rhinorrhea anteriorly if nasal obstruction, clear drainage in posterior pharynx; Cobblestoning
How is allergic rhinitis managed?
Allergy avoidance measures, pharmacotherapy, complementary and alternative therapies, and allergen immunotherapy when appropriate
How can asthma (and other things) trigger GERD?
An asthma episode may be the trigger for GERD due to change in pleural pressure gradients, thoracic distention, and air trapping; Other triggers include abdominal obesity, OSA, asthma meds, or exercise Silent reflux especially in diabetes
How do leukotriene modifiers work?
Anti-inflammatory, affecting cysteinyl leukotriene pathway; Effective and allows decrease in ICS dosing; Decreases exercise induced bronchospasm by 30-50% and may be beneficial for true ASA allergic asthmatics; Side effects minimal, but check LFTs for Zileuton
What are pharmacologic therapies for allergic rhinitis?
Antihistamines, nasal corticosteroids, antihistamine-decongestant combinations, mast-cell stabilizers, anti-cholinergics, leukotriene-receptor antagonists, immunotherapy
What areas of quality of life should be periodically assessed for asthma management plan?
Any missed work or school due to asthma, any reduction in usual activity, any disturbances in sleep due to asthma, any change in caregiver activities due to a child's asthma (for caregivers)
What are the 5 As?
Ask, Advise, Assess, Assist, Arrange
What is Samter's Syndrome?
Aspirin and NSAID induced respiratory reactions, asthma and nasal polyps; These three things make up the asthma triad and occurs in 4.3-21% asthmatic
How can emotional factors trigger asthma?
Associated with increased exacerbation rates in patients with asthma and when present in parents, children will probably have more severe asthma; Chronic stress and depression; Prevention/management includes stress reduction, alternative therapies, counseling, and medications
How has low-dose ICS affected asthma deaths?
Asthma deaths decrease with use of low dosed inhaled corticosteroids
What will help patients take control of their asthma?
Asthma education, early intervention, and an individualized asthma plan of care, prepared in partnership with the patient, and repeated over time
What is work related asthma (WRA)?
Asthma exacerbated or induced by inhalation exposures in workplace; *Sensitizer induced OA* sensitization to a workplace substance; *Irritant induced OA*: exposure to inhaled irritant
How does obesity overlap with asthma?
Asthma mimic and risk factor; Pro-inflammatory state that may contribute to lung inflammation and asthma; Evaluate symptoms with complete PFT, bronchoprovocation studies, IgE levels; Obese patients with asthma require *more drugs, are more symptomatic, and have increased risk of ER visits*
What is aspirin induced asthma part of?
Asthma triad AKA Samter's Syndrome
How is AR diagnosed?
Based on clinical features and symptoms and if patient responds to treatment; No lab tests necessary
When should an asthma patient be referred to a specialist?
Being considered for immunotherapy; Requires step 4 or higher, possibly step 3; More than 2 bursts of oral steroids in 1 year or 1 hospitalization for exacerbations; Occupational or environmental inhalant or ingested substance provoking asthma; Significant psychiatric, psychologic, or family problems interfering with treatment; Life threatening exacerbation; Not meeting goals of treatment after 3-6 months of treatment; Atypical signs/symptoms; Other conditions complicating asthma or its diagnosis; Additional diagnostic testing is indicated; Requires additional education, problems with adherence
What are category B medications for asthma during pregnancy?
Budesonide, Montelukast, Cromolyn, Xolair
What does Roflumilast do?
Inhibits phosphodiesterase type 4 (PDE 4) with increased cAMP: bronchodilator and anti-inflammatory
What are the inflammatory mediators in asthma?
Chemokines, cytokines, nitric oxide, IgE, cyst-leukotriene
How does passive tobacco smoking and asthma present?
Children exposed to passive smoke have increased risk of developing asthma between 21-37% and of having increased respiratory infections; Implicated in some cases of new onset adult asthma particularly women; Non-smoking asthmatics have increased risk for asthma symptoms and episodes
What are alternative therapies for asthma?
Chinese medicine/acupuncture, homeopathy, chiropractic, mind-body therapy; Nutrition: vitamins, minerals, anti-oxidants, selenium; Herbs: Gingko biloba, tylophoria indica, butterbur, boswellia serrata, Ma Huang, Licorice, saibuko-tu
What is allergic bronchopulmonary aspergillosis (ABPA)?
Complex hypersensitivity reaction to the fungus Aspergillus, in patient with asthma or cystic fibrosis; Bronchi are colonized with Aspergillus and become inflamed, obstructed, and lead to bronchiectasis and respiratory compromise
What are FDA recommendations for LABA?
Contraindicated without the use of an asthma controller med (ICS). *Never use as monotherapy in asthma*; Only use long-term in patients that cannot be controlled with ICS; Use for shortest duration of time and discontinue if possible
What is on going monitoring for asthma?
Correct inhaler technique, possible need for spacers or valve holding chamber (VHC-aerochamber), nebulized meds; Adherence to treatment regime; Side effects of medications; Co-morbidities
What is the classic presentation of EIB?
Cough, excessive sputum production, wheezing, dyspnea, and/or chest tightness immediately following at least 6-8 minutes of strenuous exercise; More subtle symptoms of stomach ache, fatigue, cramps, poorer performance, etc
What are early warning signs of an asthma exacerbation?
Cough, wheeze, chest tightness, SOB, runny/stuffy nose, sneeze, headache, funny feeling in chest, stomach ache, poor appetite, itchy throat/chin, glassy eyes, feeling tired, or coughing/waking at night
What is the proliferative phase of ARDS?
Days 7-10; Connective tissue and other structural elements in lung proliferate in response to initial injury with *development of fibroblasts*; *"Stiff lung" and "shock lung"* are used to characterize this stage; Abnormally enlarged air spaces and fibrotic tissue (scarring)
What is the obstructive pattern?
Decreased FEV1, Decreased FVC, Decreased FEV1/FVC <70% predicted; FEV1 used to follow severity in COPD, asthma, and diagnose obstruction
What are lung effects of obesity in asthma?
Decreased function residual capacity (FRC) and expiratory reserve volume (ERV), decreased airway caliber, increased airway resistance, possible increased airway hyper responsiveness, overall effect is *dyspnea*
What is a bronchodilator response?
Degree to which FEV1 improves with inhaled bronchodilator, documents *reversible* airflow obstruction; Significant response if FEV1 increases by 12-15% and >200 mL; Request if obstructive pattern on spirometry
What is atopy?
Derived from Greek word meaning strange or out of place, thus meaning a predisposition that favors occurrence of allergies
How does aspirin induced asthma present?
Develop persistent rhinitis in 3rd or 4th decade associated with viral URI; Usually asthma is severe and poorly responsive to corticosteroids; Women affected 2.5 times more than men
When is spirometry recommended?
Initial assessment; After treatment initiated and control achieved to document near normal airway function; During a period of progressive or prolonged loss of asthma control; At least every 1-2 years to assess maintenance of airway function; As needed depending on clinical severity
When are SABAs used?
Short acting bronchodilators used in COPD and asthma; Albuterol (short acting beta agonist)
How is EIB diagnosed?
Diagnosis usually straightforward, *spirometry FEV1 decrease by 10%*, exercise challenge, methacholine challenge, PEFR
What causes adult respiratory distress syndrome?
Direct injury to the lung resulting in alveolar-capillary membrane increased permeability--flooding of alveolar spaces with proteinaceous material
What did the SMART (Salmeterol Multicenter Asthma Research Trial) trial say about LABA use?
Do not use LABA without steroids due to this study; LABAs may *increase the risk* of severe asthma exacerbations or death in some patient; Always talk to patients when prescribing
How is work related asthma worked up?
Document obstruction/inflammation by PFTs, exhaled nitric oxide, serial PEFR 4x per day, specific and non-specific bronchoprovication challenge; Notify PCP, specialist, occupational health specialist
What allergens should be avoided to manage AR?
Dust mites, pets, cockroaches, indoor molds, outdoor allergens, rodents
How does vocal cord dysfunction (VCD) present?
Dyspnea, respiratory distress, with or without choking, throat tightening > chest symptoms; Abrupt onset and resolution, throat tightness, anxiety, wheezing, inspiratory stridor, dysphonia, voice loss; Mimics asthma, but does not respond to asthma meds which is a *red flag*
What do the ear and eye exams show in allergic rhinitis?
Ear exam may reveal serous fluid behind TM in patients with significant nasal swelling and eustachian tube dysfunction; Eyes may be injected or reddened, possibly allergic conjunctivitis
What therapy is used for asthma exacerbation?
Early administration decreases hospital admissions and relapses; Intravenous for ICU patients, intubated or those not tolerating PO; 125 mg Solumedrol IV versus 60 mg Prednisone PO; IM may have role in fatality-prone, mentally impaired, or non-compliant patients
What triggers cause symptoms to occur or worsen?
Exercise, *viral infection*, animals with fur/hair, house-dust mites, mold, smoke, aspirin/NSAIDs, work environment, pollen, weather change, strong emotional expression (laughing/crying hard), airborne chemicals/dust, menstrual cycles, night, GERD
Who is most likely to respond to Omalizumab?
FEV1 <65%, recent exacerbation, high dose ICS requirement; Anaphylaxis reported, requires epipen and observation (2 hours s/p first 3 shots in clinic)
What does spirometry with bronchodilation show in asthma?
FEV1 >200 mL or >12-15%; Decreased FEV1/FVC ratio; Not all patients show reversibility, need for follow up spirometry after treatment; Peak flow (PEFR) monitoring tool; Bronchoprovication studies with methacoline
What are risk factors of allergic rhinitis?
Family history of atopy, Serum IgE >100 before age 6, presence of IgE (allergen-specific immunoglobulin), exposure to indoor allergens (dust mites, animals), males > females, birth during pollen season, maternal smoking exposure in first year of life, early use of antibiotics, firstborn
What happens with allergen exposure?
First time the allergy-prone person runs across an allergen, they make large amounts of ragweed IgE antibody. These IgE molecules attach to mast cells. The second time that person has a brush with ragweed, the IgE-primed mast cell will release its powerful chemicals and the person will suffer the wheezing, and/or sneezing, runny nose, watery eyes, and itching of allergy.
What should you assess in management of asthma?
For patients *not* on a controlled, assess asthma *severity*; For patient *on* therapy (including controller), assess asthma *control*
What is the assessment of impairment in asthma?
Frequency and intensity of symptoms and functional limitations the patient is experiencing or has recently experienced = how the patient is feeling now; Measured by direct medical history, lung function measurement, standardized questionnaires like asthma control test and ACQ
What are questions to ask asthma patients on every visit-assessment of impairment/risk?
Frequency of symptoms in past week, activity limitations, nocturnal symptoms, frequency of use of SABA in past week, frequency of oral steroids in past 3-6 months, ER/urgent clinic visits for asthma in past year, Asthma Control Test (ACT), medication adherence/side effects
What can frequent exposure to tobacco cause?
Frequent exposure to passive smoke can increase risk of development of COPD and other smoking related diseases: lung cancer and cardiovascular disease; Teach patients about this relationship
How do you prevent/treat respiratory infection triggers?
Frequent hand washing, avoidance, adequate sleep, flu and pneumonia vaccines, initiation of early treatment
When would further testing be needed in asthma?
Further testing may be needed if restrictive defect, COPD, vocal cord dysfunction, or central airway obstruction is questioned
What are host risk factors that lead to asthma development?
Genetic predisposition, atopy, airway hyper-responsiveness, gender, race, ethnicity
What are SAMAs?
Short acting muscarinic antagonists used primarily in COPD; Ipratropium aka Atrovent
How does COPD present in adults?
Greater than 40, smoker, progressive loss of lung function that never normalizes, exacerbations more in winter, co-morbidities, incomplete reversibility, frequent sputum
What are risk factors for ARDS mortality?
Help estimate prognosis; Advanced age is an important risk factor; Pre-existing organ dysfunction from chronic medical illness is an important additional risk factor for increased mortality; Several factors related to the presenting clinical disorders also increase risk for ARDS mortality
How do HEPA filters work?
High-efficiency particulate air (HEPA) filter is a type of mechanical air filter that works by forcing air through a fine mesh that traps harmful particles like pollen, pet dander, dust mites, and tobacco smoke
What special attention is required for patients at risk for asthma-related death?
Intensive education, monitoring, and care; such patients should be counseled to seek medical care early during an exacerbation and instructed about the availability of ambulance services; The level of asthma severity *does not* correlated to the likelihood of sudden-death asthma
What is cobblestoning?
Hyperplastic lymphoid tissue lining posterior pharynx which resembles cobblestones
What is the mechanism of exercise induced bronchospasm (EIB)?
Hyperventilation leads to water loss in airway surface epithelium, causing dehydration of airway cells and increased osmolality; The latter releases mediator from mast cels with airway epithelia damage, inflammation and bronchospasm occur
What are controller medications for asthma?
ICS are mainstay; Leukotriene modifers like montelukast; LABAs are not used alone (salmeterol and formoterol); Combined meds (LABA/ICS); Systemic glucocorticoids; Theophylline; Long-acting oral beta 2 agonists; Anti-IgE Omalizumab or Mepolizumab used by specialists
What are immunotherapy considerations for allergic rhinitis?
Immeediate hypersensitivity skin testing (prick skin tests) or RAST (radioallergosorbent blood test) to identify specific antigens; Subcutaneous injection immunotherapy; Sublingual and oral immunotherapy; Anti-IgE therapy: Omalizumab (Xolair)
What is allergic rhinitis?
Immunologic disorder with production of allergen specific immunoglobulin (IgE) that stimulates histamine release and paroxysms of sneezing, rhinorrhea, nasal obstruction, itchy eyes, nose, and palate, post nasal drip cough, throat clearing, irritability, and fatigue
When should VCD be considered?
In patients with difficult-to-treat, atypical asthma and in elite athletes who have exercise related breathlessness *unresponsive to asthma medication*
What are environmental risk factors that lead to asthma development?
Indoor or outdoor allergens, occupational sensitizers, tobacco smoke, air pollution, respiratory infections, parasitic infections, socioeconomic factors, family size, diet and drugs, obesity
What are allergic shiners?
Infraorbital edema secondary to subcutaneous venodilation
What are pulmonary anti-inflammatory drugs?
Inhaled corticosteroids (ICS) like fluticasone, mometasone, ciclesonide, budesonide, beclomethasone; Oral corticosteroids like prednisone and methylprednisolone
What does omalizumab do?
Inhibits IgE binding to mast cells
What does mepolizumab do?
Inhibits cytokines, reducing eosinophils
How is severe hypoxia treated in ARDS?
Invasive mechanical ventilation, low tidal volume ventilation, positive end expiratory pressure (PEEP), High FiO2/prone position
How does asthma present in adults?
Less than 40, smoking not usually casual, allergies, intermittent, variable symptoms, lung function normalizes, attacks begin insidiously and last longer, infrequent sputum
What is omalizumab?
Monoclonal antibody indicated for moderate to severe asthma and documented in vitro or skin tested allergy sensitivity and symptoms not well controlled on maximum treatment; Block IgE; Causes decrease in exacerbations and based on weight and IgE level; SQ injection 2-4/week
What is mepolizumab?
Monoclonal antibody that binds to and interferes with interleukin-5 cytokine, reducing eosinophilic production and survival; Administration depends on eosinophilic level; Dose 100 mg SC Q 4 weeks
What are examples of short acting beta 2 agonists?
Levalbuterol (Xopenex), Albuterol (Ventolin, proair, proventil)
When are LABAs used?
Long acting bronchodilator used in COPD/asthma, usually in combination with ICS; Salmeterol and Formoterol
What are LAMAs?
Long acting muscarinic antagonists used primarily in COPD; Ipratropium and Aclidinium
How are beta 2 agonists nebulized?
MDI with spacer which is just as effective as nebulizer (4-6 puffs per neb); Continuous nebulization may be more effective in children, but *lactic acidosis* has been observed
Why is periodic assessment of asthma control essential?
Maintain control, by reducing impairment and risk; Establish lowest step/dose treatment to maintain control; Frequency of visits; Should be monitored by the health care professional and the patient
What is functional recovery in ARDS survivors?
Majority of patients recover nearly normal lung function with max lung function within 6 months; One year after endotracheal extubation, over a third of ARDS survivors have normal spirometry values and diffusion capacity; Most of the remaining patients have only mild abnormalities in pulmonary function
What is premenstrual asthma?
May occur in some women with asthma, can occur in pre-ovulatory phase (days 5-11) and peri-menstrual phase (days 26-4); Pathophys unclear, but could be due to increased estrogen/progesterone levels changing atopy, prostaglandin increase
What occurs with active tobacco smoking and asthma?
More frequent exacerbations, hospitalizations, ER visits; Therapeutic response to corticosteroids impaired; Increased theophylline clearance; Higher risk of developing worsening fixed airway obstruction, COPD, asthmatics smoking 15 or > cigarettes/day have an 18% decline in FEV1 over 10 years compared with a 10% decline in non-smokers with asthma; Increased risk of cancer, heart disease, GERD, chronic sinusitis
What are other names for vocal cord dysfunction?
Munchausen's Stridor, Emotional laryngeal wheezing, Pseudo-asthma, Fictitious asthma, Episodic Laryngeal Dyskinesia
What do inflammatory cells cause in asthma?
Neutrophils (more COPD), *eosinophils*, lymphocytes, TH2, mast cell activation, epithelial cell injury
Is theophylline beneficial?
No benefit to intensive inhaled beta-agonists for acute exacerbation; Side effect profile significant and many drug interactions; Not a strong role in outpatient asthma management and worsens GERD; Not recommended, but cheap
What medications are contraindicated in asthma?
Non selective beta blocker: propanolol, carvedilol because it blocks both Beta 1 (heart) and Beta 2 (lungs) receptors, producing *bronchconstriction* and used to treat migraines, heart disease; Some eye drops for glaucoma that contain these: timoptic, betimol, istalol
How common is exercise induced bronchospasm (EIB)?
Occurs in up to 90% of chronic asthmatics
What is the mechanism of aspirin induced asthma?
Shunting of arachidonic acid metabolism away from prostanoid production, leading to *increased leukotriene* production and resultant broncho-constriction
What are common co-morbidities seen with allergic rhinitis?
Otitis media with effusion, nasal polyposis, sinusitis, asthma, URI, obstructive sleep disorders, allergic conjunctivitis, otitis media with effusion
What are common inhalant allergens?
Outdoor allergens: tree, grass, weed pollen, mold spores; Animal allergens: warm-blooded pets like cats, dogs, rodents, birds; Dust mites: present in all but arid regions of the country; Cockroaches and indoor fungi (mold/mildew)
How is severity and control assessed in asthma?
PE with HEENT, chest/lungs, skin, and epigastrium; *Pulmonary function testing: spirometry with bronchodilator is the gold standard*
What is vocal cord dysfunction?
Paradoxical adduction (closing) of vocal cords during inspiration resulting in airflow obstruction and dyspnea; Causes including irritant (GERD), exercise, post nasal drip, strong odors, perfumes; Occurs in up to 40% of patients evaluated for asthma, more in females, can occur with asthma
What is cough variant asthma?
People with asthma that only cough and have no other symptoms; diagnosis of exclusion
What are out of doors environmental triggers?
Pollens, pollution, cold air, thunderstorms
What are aggravating co-morbidities in asthma?
Sinusitis, Rhinitis, Allergic rhinitis, GERD, OSA, nasal polyposis-ASA sensitivity, triad asthma, obesity, depression, anxiety, other psychiatric illness
What can uncontrolled asthma during pregnancy cause?
Preeclampsia, C-section delivery, placenta previa, preterm labor, vaginal hemorrhage, fetus increased risk of low birth weight, intrauterine growth retardation and death; Other pregnancy issues include obesity, GERD, rhinitis
How does allergic bronchopulmonary aspergillosis (ABPA) present?
Present with asthma 2-32% and CF 1-15%; Asthma with recurrent episodes of fever, *brown mucous plugs*, malaise, obstruction, peripheral blood eosinophilia, fleeting infiltrates or bronchiectasis (upper lobes or central location)
How does GERD overlap with asthma?
Presents in 50-70% of chronic asthma patients; Predisposed trigger mechanisms: micro aspiration and vagally mediated bronchospasm; Symptoms of GERD include cough, wheezing, chest tightness, SOB, water brash, and heart burn
What are the asthma goals of risk reduction?
Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations, prevent progressive loss of lung function, and provide optimal pharmacotherapy with minimal or no adverse effects
What are the goals of reducing impairment?
Prevent symptoms, require infrequent use of short-acting beta agonists (<2 days/week); Maintain "normal" pulmonary function; Maintain normal activity levels; Meet patients and families expectation of and satisfaction with asthma care
What are respiratory infection triggers?
Primarily URIs, flu, RSV, bronchitis, ear infections, sinusitis, pneumonia; Exacerbations more severe than with other triggers
What are risk factors for fatal asthma?
Prior intubation or ICU admission; Sudden severe exacerbations; >2 hospital visits or ED admits for asthma in the last year or within last month; Current oral steroid usage or recent taper; Use of >2 canisters of SABAs/month, Co-morbid illness, illicit drug use, urban area; Difficulty perceiving airflow obstruction or severity; Psych illness, non-adherence
What is an allergen?
Produces immune mediated IgE response (pollens) with release of mediators which produce immediate responses like sneezing, itching, watery eyes, rhinorrhea, and nasal congestion and late response including bronchoconstriction and inflammation
What are means of avoidance measures for animal dander?
Remove the animal from the house by keeping them outside or in the garage; Reduce reservoirs by removing carpet, reducing upholstered furniture/drapes, and have a vacuum with good filtration; HEPA or electrostatic air filter; Washing dogs twice a weeks, but washing cats does not reduce allergen levels significantly
What are primary therapies for asthma exacerbations?
Repetitive administration of rapid-acting inhaled beta-agonist; Early introduction of systemic steroids; Oxygen supplementation if needed; Inhaled steroid with education to use this regularly until seen in follow-up by PCP; Closely monitor response to treatment with serial measures of lung function
What are reliever medications for asthma?
SABA: nebulized forms of albuterol and levalbuterol; Systemic glucocorticoid: prednisone, medrol; SAMA: Ipratropium
What is the acronym to determine asthma severity and control?
Salsa; Symptoms, activity, lung function, SABA use, awakenings
What is supportive care for ARDS?
Sedatives, neuromuscular blockade, nutritional support, manage glucose, hemodynamic support to correct anemia/hypovolemia, pharmacologic intervention including dopamine, diuretics, and possibly steroids, and prophylaxis DVT and GI bleed
What medications are not contraindicated, but can trigger asthma?
Selective beta blockers: metropolol, atenolol, labetalol because it primarily affects beta 1 receptors; ACE-I can induce cough; Exogenous hormones use may affect asthma
What are the three parts of asthma assessment and monitoring?
Severity, control, and responsiveness
What happens after stopping exercise in EIB?
Small bronchiolar vessels around the trancheo-bronchial tree warm up, reactive hyperemia ensues with exudation of serum into the interstitial fluid and release of mediators causing bronchospasm
How are sulfites asthma triggers?
Sulfur dioxide is a gas that can irritate airways and provoke asthma symptoms; Some preservatives widely used in wine, beer, and cider, may contain additives in fresh sausages, previously used in salad bars; Most died fruits (died apricots) are treated with sulfur dioxide; If sensitive, read labels
What are signs and symptoms of ARDS?
Tachypnea, dyspnea, retractions, hypoxia, tachycardia, decreased pulmonary compliance; ABGs: decreased PO2 and increased dyspnea that does not improve with oxygen
What drugs should never be used for asthma during pregnancy?
Tetracycline, sulfa, and cipro
Why is it difficult to control allergen with an animal in the house?
The animal contains up to 50 mg of major allergen, but the quantities of airborne allergen are only up to 20; Using an air filter can only reduce airborne allergies
What is control?
The degree to which manifestations of asthma including symptoms, functional *impairments* and *risks* of untoward events are minimized and the goals of treatment are met
What is responsiveness?
The ease with which asthma control is achieved by therapy
What is severity?
The intrinsic intensity of the disease process; measure most easily in patients not on long-term control treatment usually on initial visit
What are concerns regarding work related asthma/occupational asthma?
Thorough occupation history, temporal relationship between symptoms and work, unusual work exposure, change in work process; Symptoms of allergic rhinitis/conjunctivitis worse at work; Removal of patient from exposure which is not an easy task
What are alternative medicine options for AR?
Traditional Chinese medicine: Chinese Herbal treatment and acupuncture show modest benefit; Homeopathy: Allergena Zone 6; Herbs/Vitamins: Vitamin C, Quercitin, Bromelain, Butterbar, Stringing Neetles, Gingo Biloba, Tinofend (Ayurvedic Herb), Grape seed extract; Acupressure; Nasal rinses: neti pot, squeeze bottle
What is the "allergic salute?"
Transverse nasal crease caused by repeated rubbing and pushing the tip of the nose up with the hand
What are the three general treatments for ARDS?
Treat underlying problem/cause, supportive care, and treatment of severe hypoxia
What are "allergic facies?"
Typically seen in children with early onset AR and include highly arched palate, open mouth due to mouth breathing, and dental malocclusion
Are beta agonists helpful?
Use was predictive of subsequent ER visits, hospitalizations, and oral corticosteroid use
How is premenstrual asthma managed?
Usually occurs in women with more severe asthma; Determine if NSAIDs sensitivity exist and increase use of SABAs, increase ICS
How is vocal cord dysfunction related to asthma?
VCD can mimic asthma, but it is a *distinct* disorder, it may coexist with asthma, but asthma meds do little, if anything, to relieve symptoms
How is VCD diagnosed and managed?
Variable flattening of the inspiratory flow volume loop on spirometry; Diagnosis is from indirect or direct vocal cord visualization during an episode, during which abnormal adduction can be documented; Treatment is to refer to speech pathologist or ENT that specializes in VCD
What are mimics of EIB?
Vocal cord dysfunction, laryngeal prolapse, laryngomalacia, GERD, cardiac conditions
Where is asthma most prevalent?
Wales, New Zealand, Ireland, Costa Rica, and US, in that order
Why are we treating asthma?
We only see the symptoms, but there is airflow obstruction, bronchial hyper-responsiveness, and airway inflammation that is occurring under the "iceberg"
What are common asthma symptoms?
Wheezing (whistling), dyspnea, coughing, SOB, chest tightness
How is allergic rhinitis an asthma trigger?
When are asthma symptoms worse? Early spring (trees), late spring (grasses), late summer to autum (weeds), summer and fall (Alternaria, Cladosporium); Severity of asthma/allergy symptoms
When is step down treatment done in asthma?
When controlled on medium to high dose ICS: 50% dose reduction at 3 month intervals; When controlled on low-dose ICS, switch to once daily dosing
What happens with work exacerbated asthma?
Workers with pre-existing or concurrent asthma triggered by work related factors is not considered to be occupational asthma