Barkley Asthma & Cough

-terol

1 Albuterol (Proventil)
2 Levalbuterol (Xopenex)
3 Pirbuterol (Maxair)

1 Salmeterol (Serevent)
2 Formoterol (Foradil)

-sone

1 Mometasone (Asmanex)
2 Fluticasone (Flovent)
3 Budesonide (Pulmicort)
4 Beclomethasone (QVAR)
5 Triamcinolone (Azmacort)

(LTM) Lukotriene Modifiers
(LTRA) Leukotriene Receptor Antagonists

TAKE ABOUT 1-2 WEEKS TO WORK

1 Montelukast (Singular)
2 Zafirlukast (Accolate)
Zileuton (Zyflo)

Cromolyn (Intal)

(stabilizes the mast cell so it doesn't release histamine)

</= 2 days/ week/ not at all

Prednisone 40-60 mg qd x 3-10 days (average 5-7 days)

for aggressive tx of inflammation during asthma flare; don't need to taper

-mab
nonoclonal antibody
>12 y/o moderate severe allergic asthma uncontrolled on optimized standard medication including high-dose ICS

rescue meds for bronchospasm
MUSCLE RELAXER it relaxes the muscle which stops the bronchospasm

rescue meds for bronchospasm
hang around a lot longer

1 Intermittent
2 Mild Persistent
3 Moderate Persistent
4 Severe Persistent

dx of air trapping
1hyperresonance
2 decreased tactile fremitus
3 wheeze (exp 1st, inspirat later)
4 low diaphragms
5 increased AP diameter

Intermittent Asthma
SABA

Mild Persistent
Preferred: Low dosed ICS

Alt: Mast cell stabilizer, LTRA, Theophylline

Moderate Persistent
Preferred: Medium dosed ICS

OR low dosed ICS+ LABA
Alt: Low dosed ICS + LTRA, Theophylline, Zileuton

Severe Persistent Asthma

Severe Persistent
Preferred:
Medium dosed ICS + LABA

Alt: Medium dosed ICS and either
LTRA, Theophylline/ Zileuton

Severe Persistent

Preferred:
High dosed ICS + LABA
and
Omalizumab use can be considered for pts who have allergies

Severe Persistent

Preferred:
High dosed ICS + LABA+ oral corticosteroid
and
Omalizumab use can be considered for pts who have allergies

200

10 puffs

1Lung function (FEV1 and FEV1/FVC ratio)
2 symptoms
3 nighttime awakening
4 use of SABA for control (not prvt)
5 interference with normal activities
6 Risk

85%

80%

75%

70%

1. intermittent
2. persistent:
a. mild persistent
b. moderate persistent
c. severe persistent

intermittent: 2 or fewer x/wk
mild pers: >2x/wk
mod pers: daily
severe pers: throughout the day

intermittent: 2 or fewer nights/mo
mild: 3-4 nights/ mo
moderate: more than weekly
severe: every night

intermittent: 2 or fewer x/week

mild: >2x/wk
moderate: daily
severe: through day

intermittent: none

mild: mild limitations
moderate: some limitation
severe: extreme limitations

intermittent and mild persistent: FEV1: >80% predicted

moderate persistent: FEV1 60-80% predicted; FEV1/FVC decreased by 5%

severe persistent: FEV1 <60%; FEV1/FVC decreased >5%

step 1
SABA prn

if using the SABA > 2 days per week for control of symptoms (not prevention)

Step 2
Low dose ICS

Step 3
Low dose ICS + LABA

Step4 or 5
Step 4: medium dose ICS + LABA
Step 5: high dose ICS + LABA + consider omalizumab for allergies

dosed according to severity of symptoms
given up to 3 treatments at 20 minute intervals

good control x3 mo

mimics intermittent asthma

Q1-6mo

Q2-6wks

2wks

Symptoms >2 days/wk
Nighttime awakenings 1-3x/wk
Some limitation
SABA use >2days/wk
FEV1 stays at 60-80%

Step up 1 step
Reeval in 2-6 wks

Night time awakenings throughout the day
Interference w/ normal activity ./= 4/wk
SABA use weveral times/day
FEV <60% predicted /personal best

consider short course oral corticosteroids
step up 1-2 steps
reeval in 2 wks.

spirometry

required for diagnosis
then every 1-2 years

the volume expired in the first second

OBSTRUCTIVE pattern - ski slope
decreased rate at any volume
longer forced expiration
the plateau is delayed
10-12 seconds!

1. B-2 Adrenergic Receptor Agonist
- albuterol
- levalbuterol
- epinephrine

2. Anticholinergics
- atropine
- ipatromium bromide

(1) antiinflammatory
- Steroids - FLUTICASONE
- Mast Cell Stabilizers - CROMLYN
- IgE therapy
- Leukotriene Modifiers - MONTELUKAST

(2) Long acting B-2 Adrenergic recpt agonists
- SALMETEROL
- FORMOTEROL
** ALWAYS USE LABA WITH AN ANTI INFLAMMATORY

Step 1 - SABA - Albuterol PRN
Step 2 - Low ICS - Fluticasone (Flovent)
Step 3 - either...
(a) Med ICS - increase Fluticasone
(b) Low ICS + LABA (ie ADVAIR: Fluticasone and Salmeterol)
(c) Low ICS + Leukotriene Mod (ie Fluticasone and Singular)
Step 4 - Med Dose ICS and LABA (increase the Advair dose)

Low Dose - 2 puffs of 44mcg each (88mcg) given BID
Med Dose - 2 puffs of 110mcg each (220mcg) given BID
High Dose - 2 puffs of 220 mcg each (440mcg) given BID)

Low: 100/50 Fluticasone/Salmeterol BID

Med: 250/50 Flut/Salmet BID

High: 500/50 Flut/Salmet BID

CHILD 4-11 - 100/50 DAILY

SABA use 2x/wk --> go up a step.

- avoidance of triggers
- patient and parent ed on how to use meds properly
- recognizing s/s

inflammation with superimposed bronchospasms

Productive or nonproductive cough for greater than 3 weeks

1st generation antihistamine OR
Decongestant

Brompheniramine
and sustained release Pseudoephedrine

Bromfed

cough present for 3-8 weeks after an acute resp infection?

Atrovent (Ipratropium bromide)

Inhaled Corticosteroids

1 week for symptom relief

Prednisone 30-40 mg po/day for a short period of time (ex 4 days)
AFTER rhinosinusitis, asthma and GERD are ruled out.

central antitussive agents such as codeine and dectromethrophan

Increased tactile fremitus occurs with increased tissue density

A peak flow meter helps monitor respiratory conditions such as asthma, by measuring maximum airflow out of your lungs.

1Slide the red piston to the bottom of the scale, next to the mouthpiece
2 Inhale deeply
3 then place your mouth over the mouthpiece and blow forcefully. Make sure your lips act as a seal over the mouthpiece so that no air escapes.

The red piston will slide up the scale. This is the reading.

Take 3 readings, record the date time and the highest of the 3 readings

to MONITOR asthma, not to diagnose it. Spirometry's used to diagnose asthma.

1 Put on a nose piece.
2 Inhale as much as can
3 Exhale into mouthpiece as fast as you can in the 1st second and make sure you exhale completely
x 3 times (for reproducibility)

The best FEV1 and FVC results should be selected from three reproducible blows (these need not be from the same manoeuvre as long as results are within 100ml and five per cent of each other). The FEV1/FVC ratio should be calculated from the best VC reading, whether this is a relaxed or a forced manuver. Reference values and ranges should be reported. 3-8 tries. 30 sec b/t each.

helpful in assessing conditions such as asthma, pulmonary fibrosis, cystic fibrosis, and COPD.

Sometimes, to assess the reversibility of a particular condition, a bronchodilator is administered before performing another round of tests for comparison.
Important part in diagnosing asthma versus COPD.

A restrictive pattern affects lung expansion and is characterised by a LOW FEV1, a LOW FVC and a HIFH FEV1/FVC ratio..

An obstructive pattern is one which affects the rate at which air can be expelled from the lungs and is characterised by a REDUCED FEV1, NORMAL FVC and a LOW FEV1/FVC ratio.

represents the total amount of air exhaled at force from a maximum inhalation (total lung capacity) to maximum exhalation (residual volume), measured against time.

is the volume of air inspired or expired in a single breath at rest

is the maximum volume of air present in the lungs.