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Asthma: chronic, inflammatory, obstructive disease of the airways - Coggle…
Asthma: chronic, inflammatory, obstructive disease of the airways
Pathophysiology
3 principal triggers for exacerbations
allergens & environmental factors
inhaled; molds, pollens, dust, animal dander, cosmetics, tobacco smoke. Food additives w/sulfite preservatives, beta blockers, aspirin, or aspirin containing drugs
infections
URI-particularly viral infections
psychological factors
stressful events or crises at work or home
often overlooked or dismissed
reversible hyperreactivity of the bronchi & bronchioles to a variety of stimuli
Inflammation
bronchial hyperreactivity
bronchial obstruction
airflow limitations
bronchocontriction
airway edema
mucous plug formation
airay narrowing
major mechanism
Immunologically mediated inflammation
mast cells, eosinophils, lymphocytes, neutrophils, macrophages
stimulate bronchoconstriction, vasodilation, edema, increased mucus production,
allergy stimulate asthma
1) initiated-CD4+Th cells w/Th2 phenotype produce IL-3, IL-4, IL-5, granulocyte-macrophage colony-stimulating factor
2) eosinophils are a source of leukotrienes causing bronchial contraction and increase vascular permeability
3) activated B lymphocytes transform to plasma cells creating more IgE activating mast cells and eosinophils
4) mast cells and IgE cross-link by allergens then activate histamine, IL-4, IL-5 provoking bronchial smooth muscle contraction and vasodilation
acute exacerbation
structural remodeling
thickening of bronchial and bronchiolar mucosa, submucosa, smooth muscle
alveoli unaffected
increased collagen deposited below basement membrane
areolar connective tissue undergoes hypertrophy
Epidemiology
affects 100 million people worldwide
9.5% of children currently have asthma
African Americans have a 47% higher prevelance than Caucasians
responsible for 134 million days of restricted activity
greater than $56 billion annually is lost
14 million ambulatory care visits related to asthma
5,500 deaths/year
children 5-17 years have highest attack prevelance rates
35% higher prevalence in adult females
persons 65 years and older have lowest prevalence
younger than 18 years boys have 16% higher prevalence
Presentation of Disease
asthma attack
wheezing
breathlessness
unable to talk or able to only blurt out short sentences
chest tightness
at night or early morning
cough
Profuse sweating
air hunger
exercise intolerance
nocturnal awakening
acute exacerbation
hypoxia
altered ABGs
hyperventilation
respiratory alkolosis
hypocapnia
status asthmaticus
fatal
objective
nasal discharge
mucosal swelling
frontal facial tenderness
nasal polyps
dark discoloration under eyes
possibly eczema
inspiratory/expiratory wheeze
accessory muscles used w/breathing
Classification
Intermittent: symptoms <2 days/week, nighttime symptoms <2x/month, asymptomatic & normal PEF between exacerbations
Mild persistent: symptoms >2 days/week, may be several times at night, PEF or FEV1 >80% predicted, PFT variability 20-30%
Moderate persistent: symptoms daily not continual, nighttime symptoms >1x/week, exacerbations affect activity/sleep, PEF or FEV1 60-80% predicted, PFT variability >30%
Severe persistent: continuous daily symptoms, frequent nighttime symptoms, frequent exacerbations, physical activities limited, PEF or FEV1 <60% predicted, PFT variability >30%
Treatment Plan
pharmacotherapeutics
short-acting beta agonists
anticholinergics
leukotriene receptor antagonists
inhaled corticosteroids
combination therapy
inhaled corticosteroids/long acting beta agonist
systemic corticosteroids
methylxanthines
herbal medicine:soursop, leaves of graviola tree, eucalyptus, lycopene, vitamin B12, vitamin C, goldenseal, onions, garlic
lifestyle modifications
avoid allergens & triggers
smoking cessation
avoid second hand smoke
GOAL
prevent acute exacerbation to minimize remodeling
patient and family education
asthma facts
when and how to use SABA inhaler
recognize early symptoms
how to initiate a plan of action
difference between LABA, SABA, antiinflammatory, steroid
skills for inhaler, spacer, daily peak flow meter, nebulizer use
environmental control
pneumococcal and flu vaccines
African Americans have negative reaction to LABA
follow treatment flowchart:
STEP 1 intermittent: no controller medication needed, reliever SABA PRN <2x/week
STEP 2 persistent-mild persistent: controller low-dose ICS daily, alternative LTRA/cromolyn, nedocromil, or theophylline. Reliever SABA PRN not >3-4x/day
STEP 3 moderate persistent: controller daily low-dose ICS + LABA or medium-dose ICS alternative low-dose ICS +/either LTRA, theophylline, zileuton. Reliever SABA not >3-4x/day
STEP 4 severe persistent: controller daily medium-dose ICS + LABA alternative medium-dose ICS +/either LTRA, theophylline, zileuton. Deliver SABA PRN not >3-4x/day, consider short course of oral systemic corticosteroids
STEP 5: controller daily high-dose ICS + LABA alternative omalizumab if allergies exist. Reliever SABA 20 minute interval 3x PRN, consider short course of oral systemic corticosteroids
STEP 6: controller daily high-dose ICS + LABA + oral corticosteroids alternative consider omalizumab if allergies exist, long-term systemic corticosteroids may be needed. Reliever SABA 20 minute intervals 3x if needed
Health Promotion & Education
Smoking Cessation
Avoid Second hand smoke exposure
Expectations for Patients with Asthma
be able to participate fully in any activity
sleep through the night
free of severe symptoms throughout the day and night
be satisfied with asthma care
have best pulmonary function
need fewer/no emergency visits/hospitalizations due to asthma
not miss work or school
use fewer medications with minimal adverse effects
Self-Care Management:
basic asthma facts
when & how to use a short-acting inhaler before exercising
how to recognize early symptoms of an exacerbation & how to initiate a predetermined plan of action
role of meds & critical role for anti-inflammatory controller medication regimen to reduce the rate of acute attacks
skills for proper inhaler use; including spacer use and daily peak flow meter monitoring
spacers recommended for metered dose inhalers for maximum benefit
use a nebulizer if needed
environmental control for allergen reduction
avoidance measures for asthma triggers
pneumococcal & annual flu vaccination
Risk Factors
Fatal Risk Factors
comorbidity
current use of, or recent withdrawal from systemic glucocorticoids
difficulty perceiving airflow obstruction or its severity
history of sudden severe exacerbation
hospitalization or emergency care for asthma within the past month
illicit drug use
low socioeconomic status & urban residence
prior intubation for asthma
sensitivity to the fungus Alternaria
serious psychiatric or psychosocial problems
3 or more emergency visits for asthma in past year
two or more hospitalizations for asthma in past year
use of 3 or more canisters of inhaled short-acting beta agonists per month
genetic predisposition
environmental factors
stress
infectious agents
Assessment and Diagnosis
history
cough, recurrent wheeze, recurrent dyspnea, recurrent chest tightness
symptoms worse w/specific factors
diagnostic Tests
pulmonary function test-spirometry
spirometry contraindication, use of bronchial provocation testing w/histamine, methacholine, or exercise as trigger
evaluation of FVC and FEV1
reversibility is 10% or greater increase in FEV1 after 2 puffs of SABA
prebronchilator and postbronchodilator PFTs
CBC, allergic status-nasal eosinophil, serum eosinophil, serum IgE, intradermal skin testing, chest x-ray, ABG
Referral
allergist
skin prick test
pulmonologists
PCP
ask about concerns and issues at each visit
continue teaching and reinforcing key educational points
ensure ongoing and open communication with patient and family
review short term goals at each visit
review the asthma action plan for worsening symptoms and exacerbations
review daily self-management plan and steps the patient needs to take
supply patient with appropriate educational material for self-management and prevention