Bronchial Asthma

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ASTHMA:

ASTHMA

Allergic Rhinitis:

Allergic Rhinitis Symptoms: sneezing, itching, rhinorrhea, and congestion Nasal smear with >10% eosinophils suggestive Dx can be confirmed by allergen-specific Ig-E Classification Persistant or intermediate Graded relative to severity

Allergic Rhinitis:

Allergic Rhinitis Affects 15%-50% of world-wide population Affects 40 million people in the US Prevalence increasing (increasing airborne pollutants, rising dust mite populations, poor ventilation in buildings, increased time indoors by people and pets, dietary factors, changes in gut indigenous microflora, increased abx use, increasingly sedentary lifestyle????????)

Allergic Rhinitis:

Allergic Rhinitis Associated with asthma 95% of people with allergic asthma have rhinitis 30% of people with allergic rhinitis have asthma (compared to 3-5% of general population) Family history of atopy seems associated with progression of either allergic rhinitis or asthma to allergic rhinitis + asthma Treatment of allergic rhinitis reduces ER visits for asthma

Management of Allergic Rhinitis:

Management of Allergic Rhinitis Identification of allergens Pollen Molds/fungi Dust mites Animal dander Cockroaches Avoid or minimize exposure to allergens Patient education

Management of Allergic Rhinitis:

Management of Allergic Rhinitis Pharmacotherapy Intra-nasal corticosteroids Antihistamines (non-sedating preferred) Not recommended to use sedating qhs and non-sedating qAM Decongestants Antihistamine/decongestant combinations Mast cell stabilizers Leukotriene antagonists

Management of Allergic Rhinitis:

Management of Allergic Rhinitis Allergen Immunotherapy Repeated, controlled administration of specific allergens to patients with IgE-mediated conditions May impede progression of allergic rhinitis to asthma May prevent multiple sensitizations and the need for prolonged/excessive use of pharmacotherapies Consider when sx not controlled on medications

Definition of Asthma:

Definition of Asthma Chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are associated with widespread but variable airflow obstruction that is reversible either spontaneously, or with treatment.

Asthma-Epidemiology:

Asthma-Epidemiology According to epidemiological studies asthma affects 1-18% of population of different countries. Only in 2006 more than 300 million patients suffered from asthma all over the world, 250 thousand s of patients die of asthma. The incidence of asthma is higher in countries with increased air pollution.

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Most common chronic condition in children #1 cause of school absenteeism Death rate up 50% from 1980 to 2000 Death rate up 80% in people under 19 Morbidity and mortality highly correlated with Poverty, urban air quality, indoor allergens, lack of patient education, and inadequate medical care About 5000 deaths annually

Asthma:

Asthma Usually associated with airflow obstruction of variable severity. Airflow obstruction is usually reversible, either spontaneously, or with treatment The inflammation associated with asthma causes an increase in the baseline bronchial hyperresponsiveness to a variety of stimuli Clinical Diagnosis

Etiology:

Etiology As a sthma is a respiratory allergic disease, the influence of allergens permeated into the organism through airways is essential for the disease development. The allergens are divided into : communal, industrial, occupational, natural pharmacological

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Сommunal allergens are contained in the air of apartment houses. They are: house-dust mites which live in carpets, mattresses and upholstered furniture; spittle, excrements, desquamated epidermis, hair and fur of domestic animals; vital products of domestic insects (e.g., cockroach); mycelial yeast-like fungi ( molds); tobacco smoke during active or passive smoking; various communal aerosols and synthetic detergents.

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Among the industrial allergens nitric, carbonic, sulfuric oxides, formaldehyde, ozone and emissions of biotechnological industry - main components of industrial and photochemical smog - must be mentioned. The most important occupational allergens are dust of stock buildings, mills, weaving-mills, book depositories etc. Natural allergens are represented by plant pollen (especially ambrosia, wormwood and goose-foot pollen) and different respiratory, particularly viral, infections.

Some allergens which may cause asthma:

Some allergens which may cause asthma H ouse-dust mites which live in carpets, mattresses and upholstered furniture S pittle, excrements, hair and fur of domestic animals P lant pollen Pharmacological a gents ( enzymes, antibiotics, vaccines, serums ) F ood components ( stabilizers, genetically modified products ) D ust of book depo - sitories

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Genetic abnormalities which lead to excessive production of allergen-specific antibodies (Ig E) is called atopy - significant factor in asthma genesis in many patients. A lot of cases of atopy are inherited, and recent epidemiological studies showed steady increase in number of people with high serum level of Ig E. Trigger-factors , which provoke bronchospasm, are: a simultaneous penetration of a large quantity of allergen, viral respiratory infection, hyperventilation, physical exertion, emotional stress, becoming too cold, adverse weather conditions, administration of some medicines (aspirin, b -blockers).

Pathophysiology:

Pathophysiology Asthma pathophysiology is quite difficult and insufficiently studied. Undoubtedly, in most cases the disease is based on 1 type hypersensitivity reaction. The genesis of any allergic reaction may be divided into immune, pathochemical and pathophysio-logic phases.

Immune phase:

Immune phase After involving into the airways allergens activate immunocompetent cells. As a result B-lymphocytes produce antibodies of Ig E class. In case of asthma T-lymphocytes are inhibited, so the activation of B-lympocytes and Ig E production are excessive, exceeding normal needs. B-cell Allergens T-cell Allergen-specific IgE

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Further these antibodies bind to the surface of mast cells, basophils and eosinophils of bronchial mucous. When a new portion of allergen involves the respiratory system, it interacts with IgE-antibodies. This is a first, immune phase of allergic reaction.

Pathochemical phase:

Pathochemical phase As a result of antigen-antibody reaction the peculiar “explosion” occurs. The membranes of mast cells, basophils and eosinophils of bronchial mucous wreck with output of biologically active substances ( histamine, serotonin, chemotaxis factors, heparin, proteases, thromboxane, leukotrienes, prostaglandins) , which induce hyperergic inflammation, mucous edema, spasm of smooth myocytes, glands hypersecretion, viscous exudate formation in bronchial lumen. Airway fill with mucus Muscles contract Airways swell

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Asthma exacerbation, occurring as a result, is a clinical manifestation of the 3 rd , pathophysiolo-gical , phase of allergic reaction. The indicated mechanism is specific for atopic (exogenous) asthma genesis. I n addition to this, autosensibilization of damaged pulmonary tissue, neuropsychic disturbances, corticoid insufficiency, adrenergic imbalance, impairment of arachidonic acid metabolism, genetic and some other factors probably play a certain role in genesis of nonatopic (endogenous) asthma.

Pathologic anatomy:

Pathologic anatomy Macroscopic changes: viscous mucous/ mucopurulent phlegm airway dyskinesia with zones of spastic contraction and paralytic expansion of bronchi obstruction of airway lumen lung emphysema, pneumosclerosis RV and RA hypertrophy and dilation

Microscopic changes::

Microscopic changes : B ronchial wall infiltration with mast cells, eosinophils, basophils and T-lymphocytes E dema of mucous and submucous tunic s D estruction of bronchial epithelium Hypertrophy of bronchial smooth muscles, H yper plasy of submucous glands M icrovessels dilation

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Pathophysiology-schematic

Classification:

Classification Depending on etiology asthma is divided into exogenous (atopic) and endogenous (non-atopic). By clinical course asthma is divided into intermittent (beginning, early) and persistent (chronic, late). Depending on frequency of exacerbations, limitations of patient’s physical activity and lung function persistent asthma is divided into mild, moderate and severe (lung function is assessed by forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF) and daily variability of these parameters). There are also remission phase and exacerbations.

Asthma severity classification:

Asthma severity classification Clinical course, severity Daytime asthma symptoms Nighttime awakenings FEV1, PEF Intermittent < 1 /week 2 and < /month >80% predicted. Daily variability < 20% Mild persistent  1 /week but not daily > 2 /month >80% predicted. Daily variability – 20-30% Moderate persistent Daily > 1 /week > 60 but < 80% predicted. Variability>30%. Severe persistent Persistent, which limit normal activity Daily <60% predicted. Variability > 30%.

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In recommendations of Global Initiative for Asthma (GINA) asthma is classified on the base of control assessment and is divided into well-controlled, partially controlled and uncontrolled. Asthma control is considered as: daytime symptoms  2 /week; ability to engage in normal daily activity; the absence of night time awakenings as a result of asthma symptoms; need in bronchodilators administration  2 /week; the absence of asthma exacerbations; normal or near normal lung function parameters.

Clinical manifestations:

Clinical manifestations Classic signs and symptoms of asthma are: attacks of expiratory dyspnea shortness of breath cough chest tightness wheezing (high-pitched whistling sounds when breathing out) sibilant rales

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In typical cases in development of asthma exacerbation there are 3 periods – prodromal period, the height period and the period of reverse changes . At the prodromal period: vasomotoric nasal reaction with profuse watery discharge, sneezing, dryness in nasopharynx, paroxysmal cough with viscous sputum, emotional lability, excessive sweating, skin itch and other symptoms may occur.

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At the peak of exacerbation there are: expiratory dyspnoea forced position with supporting on arms poorly productive cough cyanotic skin and mucous tunics Hyper expansion of thorax with use of all accessory muscles during breathing at lung percussion: tympanitis, shifted downward lung borders at auscultation: diminished breath sounds, rales, prolonged breathing-out, tachycardia. in severe exacerbations: the signs of right-sided heart failure, overload of right heart chambers on ECG.

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At the period of the reverse changes , which comes spontaneously or under pharmacologic therapy, dyspnea and breathlessness relieve or disappear, sputum becomes not so viscous, cough turns to be productive, patient breathes easi er .

Status Asthmaticus:

S tatus A sthmatic us The severe and prolonged asthma exacerbation with intensive progressive respiratory failure, hypoxemia, hypercapnia, respiratory acidosis, increased blood viscosity and the most important sign is blockade of bronchial b 2-receptors. Stages: 1 st - refractory response to b 2-agonists (may be paradoxical reaction with bronchospasm aggravation) 2 nd - “silent” lung because of severe bronchial obstruction and collapse of small and intermediate bronchi; 3 rd stage – the hypercapnic coma.

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In many cases asthma, particularly intermittent, manifests with few and atypical signs : episodic appearance of wheezing; cough, heavy breathing occurring at night; cough, hoarseness after physical activity; “seasonal” cough, wheezing, chest tightness (e.g., during pollen period of ambrosia); the same symptoms occurring during contact with allergens, irritants; lingering course of acute respiratory infections.

Asthma complications:

Asthma complications The complications of asthma exacerbations are: pneumothorax lung atelectasis pneumonia acute or subacute cor pulmonale status asthmatic us Persistent asthma causes : fibrosing bronchitis small bronchi deformation and obliteration emphysema pneumosclerosis, chronic respiratory failure chronic cor pulmonale. Asthma in childhood leads to growth inhibition and thoracic deformation.

Investigations:

Investigations Eosinophilia , moderate leukocytosis in blood count as well as increased serum level of Ig E can be found in patients with asthma, especially at asthma exacerbations. Inflammatory cells , Curschmann's spirals (viscous mucus which copies small bronchi) and Charcot-Leyden crystals (crystallized enzymes of eosinophils and mast cells) can be observed in sputum. Lab Data

Chest X-ray reveals::

Chest X-ray reveals: hyperlucency of lung fields low standing and limited mobility of diaphragm expanded intercostal spaces horizontal rib position.

ECG:

ECG especially in case of severe, persistent asthma, shows hypertrophy of right heart chambers .

Diagnosis:

Diagnosis Typical clinical manifestations and lung function assessment are sufficient for diagnosis of asthma.

Diagnostic Testing:

Diagnostic Testing Peak expiratory flow (PEF) Inexpensive Patients can use at home May be helpful for patients with severe disease to monitor their change from baseline every day Not recommended for all patients with mild or moderate disease to use every day at home Effort and technique dependent Should not be used to make diagnosis of asthma

Diagnostic Testing:

Diagnostic Testing Spirometry Recommended to do spirometry pre- and post- use of an albuterol MDI to establish reversibility of airflow obstruction > 12% reversibility or an increase in FEV1 of 200cc is considered significant Obstructive pattern: reduced FEV1/FVC ratio Restrictive pattern: reduced FVC with a normal FEV1/FVC ratio

Lung function assessment:

Lung function assessment The diagnosis and severity assessment of asthma is based mainly on parameters of lung function. The most important of them are: forced expiratory volume in 1 second ( FEV1 ) and peak expiratory flow ( PEF ), which are measured during spirometry at forced breathing-out.

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FEV1 and PEF directly depend on bronchial lumen size and elastic properties of surrounding lung tissue. Expiration Inspiration PEF Volume FEF FEF PIF Flow

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Increase in FEV1 and PEF after inhalation of bronchodilators ( b 2-agonists) of 15% and more is specific for asthma.

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PEF also can be measured with the help of individual devices – peak flow meters

Differential diagnosis:

Differential diagnosis Asthma is to be differentiated with a number of diseases manifesting with dyspnea – cardiac, uremic, hysteric asthma, systemic vasculitis, broncho-carcinoma, carcinoid and chronic obstructive lung diseases.

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In contrast to bronchial, in case of cardiac asthma the signs of severe heart disease and pulmonary congestion can be found.

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In case of uremic asthma severe renal pathology takes place as well as other manifestations of uremia. Dyspnea without bronchospasm is specific for hysteric asthma. In patients with systemic vasculitis fever, weight loss, impairment of other organs and nervous system, arterial hypertension, arthralgia, myalgia, specific changes in tissue sampling may be revealed.

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Carcinoid intestinal tumors manifest with watery excrements, rumbling, heat sensation in head, tricuspid valve damage. In differentiating of bronchospastic syndrome in bronchial tumors ray-path methods (X-ray, computer tomography, bronchography) and bronchoscopy are importantant

Diagnostic Testing:

Diagnostic Testing Spirometry National Asthma Education and Prevention Program (NAEPP) recommends spirometry: For initial assessment Evaluation of response to treatment Assessment of airway function at least every 1-2 years

Diagnostic Testing:

Diagnostic Testing Methacholine challenge Most common bronchoprovocative test in US Patients breathe in increasing amounts of methacholine and perform spirometry after each dose Increased airway hyperresponsiveness is established with a 20% or more decrease in FEV1 from baseline at a concentration < 8mg/dl May miss some cases of exercise-induced asthma

Diagnostic testing:

Diagnostic testing Diagnostic trial of anti-inflammatory medication (preferably corticosteroids) or an inhaled bronchodilator Especially helpful in very young children unable to cooperate with other diagnostic testing There is no one single test or measure that can definitively be used to diagnose asthma in every patient

Diagnostic Testing:

Diagnostic Testing Spirometry Can be used to identify reversible airway obstruction due to triggers Can diagnose Exercise-induced asthma (EIA) or Exercise-induced bronchospasm (EIB) by measuring FEV1/FVC before exercise and immediately following exercise, then for 5-10 minute intervals over the next 20-30 minutes looking for post-exercise bronchoconstriction

Management:

Management includes : 1. Avoiding the contact with allergen. If it is impossible, the specific hypo sensitization with standard allergens should be performed. It is rather effective in case of mono allergy, in intermittent and mild persistent asthma, in remission phase. 2. Elimination of trigger factors (rational job placement, changing the residence, psychological and physical adaptation, careful drug using) is the second condition for successful asthma treatment. 3. Optimally selected medical care is the base of asthma management.

Goals of Asthma Treatment:

Goals of Asthma Treatment Control chronic and nocturnal symptoms Maintain normal activity, including exercise Prevent acute episodes of asthma Minimize ER visits and hospitalizations Minimize need for reliever medications Maintain near-normal pulmonary function Avoid adverse effects of asthma medications

Treatment of Asthma:

Treatment of Asthma Global Initiative for Asthma (GINA) 6-point plan Educate patients to develop a partnership in asthma management Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible Avoid exposure to risk factors Establish medication plans for chronic management in children and adults Establish individual plans for managing exacerbations Provide regular follow-up care

Management:

Management includes : 1. Avoiding the contact with allergen. If it is impossible, the specific hyposensitization with standard allergens should be performed. It is rather effective in case of monoallergy, in intermittent and mild persistent asthma, in remission phase. 2. Elimination of trigger factors (rational job placement, changing the residence, psychological and physical adaptation, careful drug using) is the second condition for successful asthma treatment. 3. Optimally selected medical care is the base of asthma management.

Drug therapy:

Drug therapy Antiinflammatory drugs (basic) Bronchodilators 2 drug categories are used: Are divided into: hormone-containing (corticosteroids) nonhormone-containing (cromones, leukotriene receptor antagonists) 3 groups : anticholinergic drugs b 2-agonists methylxanthines

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Leukotriene receptor antagonists (montelukast, zafirlukast) Leukotriene -mediated effects include: Airway edema Smooth muscle contraction Altered cellular activity associated with the inflammatory process Receptors have been found in airway smooth muscle cells and macrophages and on other pro-inflammatory cells (including eosinophils and certain myeloid stem cells) and nasal mucosa have the moderate intiinflammatory activity used in case of aspirin-induced asthma and asthma of physical exertion

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Leukotriene receptor antagonists No good long-term studies in pediatrics Montelukast as young as 2; zarfirlukast age 7 Alternate, but not preferred medication in persistent asthma and as addition to ICS Showed a statistically significant, but modest improvement when used as primary medication

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Inhaled Corticosteroids- first line drugs ( beclametha s one, budesonide, flutica s one ) Anti-inflammatory- inhibition of inflammatory mediators cell membrane stabilization restoring the sensivity of b 2-receptors Act locally in lungs -some systemic absorption Risks of possible growth retardation thought to be outweighed by benefits of controlling asthma Not intended to be used as rescue medication Preferred treatment in persistent asthma. Systemic are used during short courses, mainly in case of severe persistent asthma or status asthmatic us .

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Mast cell stabilizers (cromolyn/nedocromil) Blocks Ca2+ ions from entering the mast cell Safe for pediatrics (including infants) Should be started 2-4 weeks before allergy season when symptoms are expected to be effective Can be used before exercise (not as good as ICS) Alternate med for persistent asthma used mainly in pediatric practice ( in childhood ) in case of intermittent or mild persistent asthma.

Bronchodilators:

Bronchodilators b 2-agonists Anticholinergic drugs Smooth muscle relaxation Stimulates b 2-adrenergic receptors of bronchi reduce tonus of vagus Methylxanthines inhibit phosphodiesterase

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Inhaled b 2-agonists are the basic drug group among bronchodilators. Short-acting (duration of action 5-6 h) b 2-agonists - salbutamol, fenoterol - are used for quick relief of asthma symptoms. Long-acting (> 12 h) b 2-agonists - salmoterol, farmoterol - for prevention of asthma symptoms occurring.

Mechanism:

Mechanism Long-acting beta2-agonists (LABA) Beta2-receptors are the predominant receptors in bronchial smooth muscle Stimulate ATP-cAMP which leads to relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity Inhibits release of mast cell mediators such as histamine, leukotrienes, and prostaglandin-D2 Beta1-receptors are predominant receptors in heart, but up to 10-50% can be beta2-receptors

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Long-acting beta2-agonists (LABA) Salmeterol (Serevent) Salmeterol with fluticasone (Advair) Should only be used as an additional treatment when patients are not adequately controlled with inhaled corticosteroids Should not be used as rescue medication Can be used age 4 and above with a DPI Deaths associated with inappropriate use as only medication for asthma

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Albuterol Short-acting beta2-agonist ATP to cAMP leads to relaxation of bronchial smooth muscle, inhibition of release of mediators of immediate hypersensitivity from cells, especially mast cells Should be used prn not on a regular schedule Prior to exercise or known exposure to triggers Up to every 4 hours during acute exacerbation as part of a written action plan

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Anticholinergic drugs ( ipratropium bromide, atrovent, troventol ) are used predominantly in nighttime asthma and in elderly patients because of the least cardiotoxic effect. Methylxanthines in compari son with other bronchodilators have the less bronchodilating potential. There are long-acting (>12 h) - ( theopec, theolong, theodur, euphilong) as well as short-acting ( aminophylline, theophylline ) drugs in this group.

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Theophylline Narrow therapeutic index/Maintain 5-20 mcg/mL Variability in clearance leads to a range of doses that vary 4-fold in order to reach a therapeutic dose Mechanism of action Smooth muscle relaxation (bronchodilation) Suppression of the response of the airways to stimuli Increase force of contraction of diaphragmatic muscles Interacts with many other drugs

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Combined inhaled drugs (corticosteroids with b 2-agonists) – seretid, simbicort – with use of delivery devices (nebulasers, turbuhalers, spasers, spinhalers, sinchroners) enhance the effectiveness of asthma therapy.

Management of status asthmaticus:

Management of status asthmaticus Oxygen Systemic corticosteroids ( Hydrocortisone 200mg or Methylprednisolone 125mg every 6h IV or Prednisolone 50 mg/day per os) Inhalations of short-acting b 2-agonists - Salbutamol 5mg or Fenoterol 2mg through nebulaser – 3 times at 1 st hour, then once an hour till distinct improvement of patient’s condition is achieved; then 3-4 times a day. Inhaled anticholinergic drugs or Aminophylline IV. If ineffective - artificial lung ventilation .

Prognosis:

Prognosis In case of early detection and adequate treatment the prognosis for the disease is favo u rable. It becomes serious in severe persistent and poorly controlled (insensitive for corticosteroids) asthma.

The examination of working capacity:

The examination of working capacity The patients with unfavorable for the disease conditions of work need the job replacement . Physical labours with severe asthma are disable to work.

Prophylaxis:

Prophylaxis Preservation of the environment, healthy life-style (smoking cessation, physical training) – are the basis of primary asthma prophylaxis. These measures in combination with adequate drug therapy are effective for secondary prophylaxis.

Pharmacotherapy for Adults and Children Over the Age of 5 Years :

Pharmacotherapy for Adults and Children Over the Age of 5 Years Step 1 (Mild intermittent asthma) No daily medication needed PRN short-acting bronchodilator (albuterol) MDI Severe exacerbations may require systemic corticosteroids Although the overall diagnosis is “mild intermittent” the exacerbations themselves can still be severe

Pharmacotherapy for Adults and Children Over the Age of 5 Years:

Pharmacotherapy for Adults and Children Over the Age of 5 Years Step 2 (Mild persistent) Preferred Treatment Low-dose inhaled corticosteroid daily Alternative Treatment (no particular order) Cromolyn Leukotriene receptor antagonist Nedocromil Sustained release theophylline to maintain a blood level of 5-15 mcg/mL

Pharmacotherapy for Adults and Children Over the Age of 5 Years:

Pharmacotherapy for Adults and Children Over the Age of 5 Years Step 3 (Moderate persistent) Preferred Treatment Low-to-medium dose inhaled corticosteroids WITH long-acting inhaled beta2-agonist Alternative Treatment Increase inhaled corticosteroids within the medium dose range Add leukotriene receptor antagonist or theophylline to the inhaled corticosteroid

Pharmacotherapy for Adults and Children Over the Age of 5 Years:

Pharmacotherapy for Adults and Children Over the Age of 5 Years Step 4 (Severe persistent) Preferred Treatment High-dose inhaled corticosteroids AND long-acting inhaled beta2-agonists AND (if needed) oral corticosteroids

Pharmacotherapy for Infants and Young Children (<5 years):

Pharmacotherapy for Infants and Young Children (<5 years) Step 1(mild intermittent) No daily medication needed

Pharmacotherapy for Infants and Young Children (<5 years):

Pharmacotherapy for Infants and Young Children (<5 years) Step 2 (mild persistent) Preferred treatment Low-dose inhaled corticosteroids Alternative treatment Cromolyn (nebulizer preferred) OR leukotriene receptor antagonist

Pharmacotherapy for Infants and Young Children (<5 years):

Pharmacotherapy for Infants and Young Children (<5 years) Step 3 (moderate persistent) Preferred treatment Low-dose inhaled corticosteroids and long-acting beta2-agonist OR Medium-dose inhaled corticosteroids Alternative treatment Low-dose inhaled corticosteroids with either: Leukotriene receptor antagonist OR theophylline

Pharmacotherapy for Infants and Young Children (<5 years):

Pharmacotherapy for Infants and Young Children (<5 years) Step 4 (severe persistent) Preferred treatment High-dose inhaled corticosteroids AND long-acting inhaled beta2-agonist AND (if needed) Oral corticosteroids For young children, inhaled medications should be given by nebulizer, dry powder inhaler (DPI), or MDI with a chamber/spacer

Acute Exacerbations:

Acute Exacerbations Inhaled albuterol is the treatment of choice in absence of impending respiratory failure MDI with spacer as effective as nebulizer with equivalent doses Adding an antibiotic during an acute exacerbation is not recommended in the absence of evidence of an acute bacterial infection

Acute Exacerbations:

Acute Exacerbations Beneficial Inhaled atrovent added to beta2-agonists High-dose inhaled corticosteroids MDI with spacer as effective as nebulizer Oxygen Systemic steroids Likely to be beneficial IV theophylline

Exercise-induced Bronchospasm:

Exercise-induced Bronchospasm Evaluate for underlying asthma and treat SABA are best pre-treatment Mast cell stabilizers less effective than SABA Anticholinergics less effective than mast cell stabilizers SABA + mast cell stabilizer not better than SABA alone

Question:

Question Which one of the following is true concerning control of mild persistent asthma in the pediatric population? Cromolyn should not be used under age 5 Atrovent should be added if beta-agonists do not maintain control of asthma LABA should be added if SABA is ineffective SABA may be used q2h to maintain control Initial treatment should be an inhaled anti-inflammatory such as ICS or cromolyn

Answer E:

Answer E Initial medications for chronic asthma should include an anti-inflammatory such as ICS or cromolyn. Cromolyn is safe for all pediatric age groups. Atrovent is useful in COPD, but very limited use in asthma. Albuterol should be used up to every 4 hours prn. Overuse of inhaled beta-agonists has been associated with an increased mortality rate.

Question:

Question It is estimated allergic rhinitis affects how may people in the US? 20 million 40 million 50 million 100 million Answer: B 40 million

Question:

Question Which one of the following statements concerning the association between allergic rhinitis and asthma is false? Almost all patients with allergic asthma also have symptoms of rhinitis About 1/3 of patients with allergic rhinitis also have asthma Pharmacologic treatment for allergic rhinitis will not improve the symptoms of asthma Patients with allergic rhinitis and patients with asthma exhibit peripheral eosinophilia and basophilia.

Answer: C:

Answer: C Patients with asthma should have their allergic rhinitis treated People with asthma and allergic rhinitis who are treated for their allergic rhinitis have a significantly lower risk of subsequent asthma-related events than those not treated for allergic rhinitis.

Question:

Question Which one of the following findings on a nasal smear suggests a diagnosis of allergic rhinitis? > 10% neutrophils > 10% eosinophils < 10% neutrophils > 10% erythrocytes Answer: B >10% eosinophils

Question:

Question Which of the following statements is true? An acceptable strategy for eliminating sedating effects of 1 st -generation antihistamines and containing the cost of 2 nd -generation is to use 2nd-generation in the AM and 1 st -generation in the PM In most states, patients taking 1 st -generation are considered “under the influence of drugs.” Mast cell stabilizers are becoming an excellent choice for children because of their ability to treat symptoms after they have started and their safety

Answer: B:

Answer: B Patients taking 1 st -generation antihistamines are considered “under the influence of drugs.” The sedating effects have been shown to carry over to the next day even when taken only at night and this type of chronic use is not recommended. Mast cell stabilizers should be started before symptoms develop, not after.

Medications to Treat Asthma: How to Use a Spray Inhaler:

Medications to Treat Asthma: How to Use a Spray Inhaler The health-care provider should evaluate inhaler technique at each visit. Source: “What You and Your Family Can Do About Asthma” by the Global Initiative for Asthma Created and funded by NIH/NHLBI

Medications to Treat Asthma: Inhalers and Spacers:

Medications to Treat Asthma: Inhalers and Spacers Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication.

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