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Asthma (Treatment goals (symptoms (no distress, response sustained 60…
Asthma
Treatment goals
primary
prevention of life-threatening asthma
hospitalization
requiring intubation/mechanical ventilation
better control for acute exacerbation
symptoms
no distress
response sustained 60 minutes after last tx
PE
normal
FEV/PEF
FEV or PEF > 70%
Diagnosis
Diagnosis is primarily based on recurrent episodes coughing, wheezing, chest tightness, SOB
FEV1 <40% normal predicted values
Best predictor is response 30 min after inhaled Beta2- agonists
FEV1/FVC <80%
PaO2 & SaO2 <90% on room air
CBC may be appropriate for patients with fever or purulent sputum
Monitoring
Symptoms: nocturnal awakening, use of rescue inhaler, exercise tolerance,
Peak expiratory flow in certain patient
Check FEV1
O2 saturation
Pathophysiology
Airflow Obstruction
Bronchospasm
Edema
Mucosal Hypersecretion
High viscosity
Mucus plugs attached to goblet cells
BHR (bronchial hyper responsiveness)
Increased smooth muscle percentage
Vagal efferent activity regulation
Airway Inflammation
IgE mediation
rapid activation of mast cells and macrophages --> release pro-inflammatory mediators --> airway muscle contraction, mucus secretion, and vasodilation
Epithelial shedding
Other Key Players: T Cell recruitment, eosinophils, neutrophils, mast cells, alveolar macrophages, dendritic cells, epithelial cells, fibroblasts, bronchial smooth muscle cells
NANC nervous system activity (NO release)
Clinical presentation
acute severe asthma
Dry hacking cough, tachypnea, tachycardia, pale or cyanotic skin, hyper-inflated chest with intercostal and supraclavicular retractions, hypoxic seizures
Severe dyspnea, shortness of breath, chest tightness, or burning
Peak expiratory flow and/or FEV1 less than 40% of normal predicted values.
chronic ambulatory asthma
SOB, chest tightness, night coughing, wheezing, whistling sound when breathing
frequency is widely variable - may be days, weeks, months, or years interval between symptoms
Treatment
Step 1
Saba
Step 2
Low Dose ICS
Step 3
Low Dose ICS + LABA or Medium dose ICS
Step 4
Medium Dose ICS + LABA
Step 5
High Dose ICS and LABA
Step 6
High Dose ICS + LABA +Corticosteroid