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Asthma - Coggle Diagram
Asthma
Monitoring & Follow-Up
Nocturnal awakenings
Albuterol use
Daily symptoms
Exercise tolerance
Peak expiratory flow (in select pts)
Time frame
routine follow up for active asthma: 1-6 months
Follow up on inhaler technique, medication AE, patient satisfaction with care
Etiology/Pathophysiology
Before puberty, males are more likely to have severe asthmas. After puberty, females have more severe cases of asthma.
Environment
Socioeconomic status
Family size
Exposure to secondhand tobacco smoke in infancy or in utero
Allergen exposure
Ambient air pollution
Urbanization
Viral respiratory infections
Decreased exposure to common childhood infectious agents
Genetic predisposition
60-80% of susceptibility
Likely a result of polygenic inheritance or different combinations of genes
Link between atopy (genetically determined state of hypersensitivity to environmental allergens) and asthma
Linkages with genes on chromosome 17q21 (such as ZPBP2, GSDMB, and ORMDL3) and interleukin genes (IL33, IL1RL1/IL18R1, and IL2RB9) and HLA-DQ and SMAD3 that are associated with epithelial barrier function and innate and adaptive immune response abnormalities
Pathophysiology
Variable degree of airflow obstruction (related to smooth muscle bronchospasm, edema, and mucus hypersecretion)
BHR (bronchial hyperresponsiveness)
Airway inflammation
Treatment
Pharmacologic
Montelukast
Regimen
Monitoring: clinical improvement of asthmas symptoms, pulmonary function tests, change in mood/behavior (suicidal thoughts), blood chemistry or liver function tests
Adverse Events: headache, fatigue, abdominal pain, diarrhea, cough, hypersensitivity
MOA:
PK/PD/PGX: Rapid absorption, Vd: 8-11 L, > 99% protein binding, hepatic metabolism through CYP3A4, 2C8, 2C9, T1/2 2.7-5.5, excreted in feces and urine
albuterol
MOA: Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on heart rate.
Adverse Events: excitement, nervousness, tremor, upper respiratory tract infection, bronchospasm, pharyngitis, rhinitis, exacerbation of asthma
PK/PD/PGX for inhalation: half life: 3.8-5 hrs, excreted in the urine 80-100% and feces 20%, protein binding 10%
Regimen: PRN: MDI or DPI (90 mcg/actuation): 2 inhalations q4-6h PRN; Acute exacerbation MDI or DPI (90 mcg/actuation): 2-4 (or 4-8 if severe) inhalations every 20 minutes for 3 doses
Monitoring: SCr, glucose, K, pulmonary function tests, BP, HR
Duration: as needed, typically in conjunction w/ other meds
ICS: Formoterol
Adverse Events: Nausea, diarrhea, chest pains, headache, insomnia, dizziness, tremor,
cardiac dysrhythmia
Regimen: 12mcg Q12H PRN
MOA: relaxes smooth muscle by selection action on beta-2 receptors
Monitoring: reduction in asthma symptoms, pulmonary function tests, proper inhalation technique
PK/PD/PGX
Dry powder inhaler with 80% of peak effect within 15 min
t1/2: ~10-14 hours
Time to peak: max improvement I n FEV1 in 1-3 hours
Protein Binding: 61-64%
Duration: as needed low dose
Management steps
MIld persistent (Step 2)
Low-dose inhaled glucocorticd
Glucocorticoid-LABA
Addition of leukotriene modifiers
Intermittent (Step 1)
SABA
LABA
Moderate persistent (Step 3)
Medium doses of inhaled glucocorticoid
Inhaled glucocorticoid+LABA
Low dose glucocorticoid +leukotriene modifier
Severe persistent (Step 4)
Medium-High doses of inhaled glucocorticoids + LABA
Addition of leukotriene modifier, tiotropium, or biologic agent
Non-Pharmacologic
Pet removal
Carpet removal
Frequently wash mattress and pillow covers
Diagnostics & Testing
Determine that symptoms of recurrent airway obstruction are present, based on history and exam,
History of cough, recurrent wheezing, recurrent difficulty breathing, recurrent chest tightness
Symptoms occur or worsen at night or with exercise, viral infection, exposure to allergens and irritants, changes in weather, hard laughing or crying, stress, or other factors
In all patients ≥5 years of age, use spirometry to determine that airway obstruction is at least partially reversible.
Consider other causes of obstruction.
Goals of Therapy
Reduce risk
Minimize adverse effects of therapy
Prevent exacerbations
Prevent loss of lung function
Minimize ER visits/hospitalizations
Get yearly flu vaccination
Reduce impairment
Maintain near normal activity
Prevent chronic symptoms
Maintain near normal lung function
More infrequent use of SABAs