R2

FEV1

how much air can be forcefully exhaled in one second

FEV1/FVC

percentage of total air capacity

What is intermittent asthma (STEP 1)?

daytime ≤2 days per week

nighttime ≤2x per month

SABA use is ≤2 days per week

no activity limitations

FEV1 > 80% predicted

FEV1/FVC normal

0-1 per year exacerbations

What is Mild persistent asthma (STEP 2)?

daytime >2 days per week/ not daily

nighttime 3-4x per month

SABA use is >2 days per week/ not daily; or >1x/day

minor limitations

FEV1 > 80%

FEV1/FVC normal

>2 per year exacerbations

What is Moderate Persistent asthma (STEP 3)?

daytime daily

nighttime >1x/week but not nightly

SABA use is daily

some limitations

FEV1 = 60-80% of predicted

FEV1/FVC reduced 5%

≥2 per year exacerbations

What is severe persistent asthma (STEP 4)?

sx’s throughout day

nighttime 7x/week

SABA use several times per day

extremely limitations

FEV1 = <60%

FEV1/FVC reduced >5%

>2 per year exacerbations

With each follow up visit, what should be done?

inhaler technique

priming and cleaning technique

step up maintain or step down

Vaccines for asthma?

flu

Pneumovax 23 (age 2-64)

How often would you have to use the SABA in order to indicate worsening asthma control?

>2 days per week

Asthma triggers

smoke, pollution, SO2, NO, high humidity, exercise (EIA), irritants, emotion, upper respiratory infection (URI), Cold air, GERD, aspirin (ASA), NSAIDs

Asthma cascade

Exposure to allergens or irritants triggers the inflammatory cascade involving a variety of inflammatory cells

Inflammation leads to bronchoconstriction, hyper responsiveness, edema of the airways

Leads to limited airflow

Asthma cascade image

Inflammatory mediator effects

Blood vessels vasodilate, increased capillary permeability (runny nose)

Nerve cells (itching)

Smooth muscle cells (bronchial spasms and narrowed airway)

Goblet cells (mucus production)

Inhaled Corticosteroids (ICS) clinical effect

Reduce inflammation in the lumen

Early phase response - Asthma

30 to 60 minutes after exposure to Allergen/irritant

Mast cells release inflammatory mediators

Leukotrienes, histamine, cytokines, prostaglandins, nitric oxide

Increase mucus prouction, vasodilation an vascular permeability begins

o Increased permeability can cause edema, thickening and narrowing airway wall

o Can also compromise epithelial integrity, reduce mucus clearance, promote formation of exudative plugs

Late phase response - Asthma

4 to 6 hours after initial attack

• Cytokine production (epithelial cells, Th2) d/t T cell activation

• Recruitment of eosinophils, CD4+ T cells, basophils, neutrophils, and macrophages;

• less intense bronchoconstriction while increase in airway hyperresponsiveness and airway inflammation and further edema

Airway remodeling

Structural changes in the broccchial walls from chronic inflammation

Changes include fibrosis, smooth muscle hypertrophy, mucus hyper secretion, Angiogenesis

Progressive loss of lung function not fully reversible, results in persistent asthma

Drug therapy

1) SABA - short acting beta adrenergic agonist - albuterol

2) LABA - Long acting beta to adrenergic agonist - corticosteroids - salmeterol

3) methylxanthines

4) anti-cholinergic (used more with COPD)

5) leukotriene modifiers - montelukast

6) Monoclonal antibodies - anti IgE

7) oral corticosteroid (OCS)

SABA - short acting beta adrenergic agonist

Simulate beta 2 receptors and bronchioles to produce Bronchodilation

Onset in minutes, duration 4 - 8 hours

Most effective for acute bronchospasm

Can be taken as a preventative for exercised induced asthma

LABA - Long acting beta adrenergic agonist

Inhaled

Effects in 30 minutes and last for over 12 hrs

Used daily to control asthma, not for acute attacks

Taken twice daily

Use for one to two weeks from maximum effect

THE MOST EFFECTIVE FOR LONG TERM CONTROL

LABA ARs

tremor, nervousness, h/a dry mouth, dry cough nausea, throat irritation

Symptoms can be reduced using a spacer and gargling after admin

Anticholinergics clinical effects

Promotes bronchodilation by preventing muscle around bronchi from tightening

Less effective than SABA

not used in regular management, use for severe acute attack

Leukotriene modifiers

Prophylactic use, produce both bronchodilator and anti-inflammatory effects

Not for acute attacks

Monoclonal antibodies

Prevents IgE from attaching to mast cells preventing release of chemical mediators.

Subcutaneous admin every 2 to 4 weeks for moderate to severe asthma

AR - risk for anaphylaxis

Characteristics of asthma

Lower airway disorder negatively impacts oxygenation, ventilation, gas exchange

Chronic and progressive

Obstructive pulmonary disease, results in air trapping

Diagnosis

History, physical, spirometry, pulmonary function test, chest x-ray, pulse symmetry, arterial blood gases (ABGs)

symptoms alone can be used to diagnose

pulmonary function tests (PFTs)

battery of studies/maneuvers. Measuring the ventilation mechanics of the lungs: airway function, lung volume, and the capacity of the lungs to exchange oxygen and carbon dioxide efficiently

Asthma related to allergy symptoms

May include:

Signs of chronic rhinitis, nasal edema, nasal polyps, rhinorrhea, oropharyngeal erythema

Risk factors

Genetics

Atopy - genetic predisposition to develop IgE-mediated response to common allergens

Immune response - babies immune system must be conditioned to function properly, exposure to microbes

Asthma Impairment criteria

Frequency of symptoms

Night time awakenings

SABA use for symptoms

Interference with normal activity

Lung function

PEFR (peak expiratory flow rate)

Shows the amount and rate of air that can be forcefully breathed out of the lungs.

Treatment for mild to moderate asthma

Inhaled bronchodilators and oral corticosteroids

Monitor vital signs

Outpatient monitoring

Follow up with healthcare provider

Severe attack symptoms

Alert and oriented but focused on breathing

Tachycardia, tachypnea (breath greater than 30 a minute)

Accessory muscle use, sits forward, sniffing position

Wheezing

PEFR Less than 50% predicted or personal best

Recurring symptoms interfere with ADLs

Feeling of impending doom

Silent chest

Severe attack treatment

Emergency department, hospital admission

Supplemental O2 and oximetry

PaO2 greater than 60 mmHg or O2 sat below 93%

Monitor PEFR, ABGs, vital signs

Bronchodilators, oral corticosteroids

LAMA

Long acting muscarinic antagonist

Final step 5 in GINA treatment protocol of asthma

ICS-formoterol place in threapy

As needed: offers a therapeutic alternative to maintenance low-dose ICS plus SABA

Maintenance and reliever therapy (MART)

Budesonide/formoterol

Low dose ICS

Markedly reduces hospitalizations and deaths

Very effective in preventing severe exacerbations, reducing symptoms, improving lung function, and preventing exercise induced bronchospasm

Early treatment with ICS associated with better lung function if symptoms have been present for 2 to 4 years

Treatment follow up

Review response after 2 to 6 weeks then every 6 months if controlled.

Consider step down when asthma has been well-controlled for three months

In adolescence and adults ICS should not be stopped completely

Asthma action plan - green zone

Doing well: no symptoms, participate in usual activities,

peak flow results greater than 80% of personal best,

remain on medication

Action plan yellow zone

Cough, Wheeze, chest tightness or SOB; or

Waking at night d/t asthma; or

Can do Some but not all activitites

PEFR 60—79% of best

Action plan - red zone

Medical alert!

Symptomatic and medications not helping,

cannot do usual activities,

Sx’s are same or worsen after 24 h in yellow zone

PEFR < 50% of personal best.

Call the doctor now, ambulance, get to the hospital

Asthma and COVID-19

Not at a increased risk of acquiring COVID-19

Not at risk of severe COVID-19 if well-controlled mild to moderate asthma

If well-controlled not at increased risk of death

Death risk increased in people who recently needed oral corticosteroids (OCS)

There have not been increased asthmatic exacerbations during the pandemic

Fluticasone

Flovent HFA (MDI), Flovent Diskus (DPI)

ipatropium brand

atrovent HFA

salmeterol

Serevent Diskus

Tiotropium brand

spiriva

Umeclidinium/vilanterol

Anoro Ellipta

levalbuterol brand

xopenex HFA

albuterol brand

proventil HFA

ventolin HFA

Fluticasone/umeclidinium/vilanterol

Trelegy Ellipta

formoterol + budesonide brand

symbicort

Tiotropium/olodatero

Stiolto Respimat

beclomethasone brand

qvar redihaler

formoterol + mometasone brand

dulera

Glycopyrrolate/formoterol

Bevespi Aerosphere

Fluticasone/salmeterol

Advair Diskus, Advair HFA

B2 agonist MOA

increases cAMP which causes smooth muscle relaxation

anticholinergic MOA

decreases cGMP which causes smooth muscle relaxation

methylxanthine MOA

several MOA... thought to inhibit PDE III and PDE IV --> inc cAMP, inc CA++ influx, dec prostoglandins

corticosteroid MOA

inhibit inflammatory response

PDE 4 inhib MOA

inhibits PDE 4 --> inc cAMP which relaxes bronchial smooth muscle

ipratropium MOA

SA anticholinergic

albuterol MOA

SABA

Tiotropium MOA

LAMA anticholinergic

Umeclidinium MOA

LAMA anticholinergic

Glycopyrrolate MOA

LA anticholinergic

Levalbuterol MOA

SABA

Formoterol MOA

LABA

Salmeterol MOA

LABA

Theophylline MOA

methylxanthine

budesonide MOA

ICS

Fluticasone MOA

ICS

Methylprednisolone MOA

systemic CS

roflumilast MOA

PDE 4 inhib

Which LABAs have a 12hr DoA

salmeterol

arformoterol

formoterol

The inflammation and bronchoconstriction associated with asthma is reversible/irreversible

reversible

What 2 tests help diagnose asthma

spirometry

peak expiratory flow

Spirometry measures _____ and ____

Forced Vital Capacity

FEV1

What is Forced Vital Capacity

maximum volume of air exhaled after taking a deep breath

Bronchodilator reversibility is documented when FEV1 increases by more than ___% from baseline

12%

PEF is measured by what

Peak flow meter

With moderate and severe asthma severity, how much is FEV1/FVC reduced

at least 5% (greater than 5% in severe)

T/F

Exercise should be avoided as much as possible in pts with exercise induced bronchospasm

False

When a pt is using a SABA to control their asthma, when would you consider Stepping up therapy

if they need to use it >2day/wk

In addition to acute asthma symptoms, what else are SABAs used to control

exercise-induced bronchospasm (EIB)

Which drug class is the mainstay and taken on a daily basis to treat asthma

inhaled corticosteroids (ICS)

How should LABAs be used in treating asthma

in combo with ICS

NEVER used alone is asthma

Asthma Treatment Algorithm:

Step 1: Intermittent asthma

SABA prn

Asthma Treatment Algorithm:

Step 2: mild-persistent asthma

Daily low-dose ICS &PRN SABA

or

PRN concomitant ICS & SABA

Alt: Daily LTRA & PRN SABA OR cromolyn or theophylline & PRN SABA

Asthma Treatment Algorithm:

Step 3: moderate persistent asthma

Daily & PRN combo low-dose ICS formoterol

Asthma Treatment Algorithm:

Step 4: severe persistent asthma

Daily & PRN combo medium-dose ICS-formoterol

---

Alt: med dose ICS-LABA OR daily med dose ICS + LAMA, and PRN SABA, or daily med dose ICS + LTRA, theophylline, zileuton or same plus saba

Asthma Treatment Algorithm:

Step 5: severe persistent asthma

Daily med-high dose ICS-LABA + LAMA and PRN SABA

---

ALT: Daily medium-high dose ICS-LABA or dally high-dose ICS + LTRA. and PRN SABA

Asthma Treatment Algorithm:

Step 5

Daily high dose ICS-LABA + PO CS + PRN SABA

SABA MOA

B2 agonist--> bronchodilation

What are the SABAs

albuterol

levalbuterol

Side effects of SABA

nervousness

tremor

tachycardia/palpitation

dec K+

cough

rhinitis

nausea

SABA warnings

caution in:

CVD

glaucoma

DM

angina

Salmeterol BBW

inc risk of asthma related death; should only be used in pts who are on ICS

ICS common side effects

hoarseness, cough, sore throat, oral candidiasis (rinse mouth); pneumonia in COPD