Cram The Pance - S1E32 Asthma

Episode Date: August 1, 2021

Asthma review for your Pance, Panre and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql  (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so let's go ahead and get started with asthma. I'm going to do a quick review. Thank you so much as always for the really nice comments you guys have been leaving. I really do appreciate everything. And if you haven't checked out the YouTube page, please do its cram the pants on YouTube. There's some really great visuals to go along with these presentations. So let's go ahead and get started with asthma. Asma, as I'm sure most of you know, is a reversible obstructive lung disease.

Now, it's important because it differentiates it from a lot of irreversible causes, other obstructive lung diseases like COPD and things like that. So this is generally a reversible obstructive lung disease. Now a little bit about the patho, it's an IGE mass cell mediated response in the body that leads to a few responses. You're going to see bronchal constriction, inflammation, and then something known as bronchial hyperresponsiveness. So all bronchial hyperresponsiveness is is bronchol constriction again, but it's in response to stimuli. So allergens, tobacco, smoke, perfume, things like that. These patients with asthma are going to have this exaggerated response, this bronchol constriction that a normal.

that a normal patient would have no response to. So that's the bronchial hyper-responsiveness you'll hear about. Asthma is generally diagnosed before the age of seven, about 75% of the cases. Some of the risk factors you need to be aware of, because these are the things that'll pointed out in the vignette for you. Male gender. So in childhood asthma is predominantly a male disease. After the age of 20, the prevalence is pretty much equal between males and females.

But younger individuals, it's going to be male gender predominant. Atopi, this is a big one. So remember, atopi is a genetic tendency to develop allergic diseases. So allergic rhinitis, eczema, it's very common in patients with asthma to have these other allergic conditions, which is atopi, this tendency to develop these other allergic diseases. So eczema, allergic rhinitis, remember to look out for those things. And then family history, there's components of the asthma phenotype that are strongly heritable. So the majority of children with asthma are going to have a positive family history of asthma. And then the last thing, any exposure to air pollution, secondhand smoke, there's some evidence that suggests early life exposure to air pollution can increase the risk of pediatric asthma.

Now clinical manifestations, there's really just three things that you need to look out for. It's going to be wheezing. Basically, most of the time it's going to be on exhalation. Cough, often described as worse at night. So you'll see that in the vignette. And then dyspnea, just the shortness of breath or trouble breathing. So that's the classic triad. Those are the three manifestations you'll likely see. But you need to be aware that these symptoms, they're not specific to asthma.

They can incur in a number of other respiratory diseases. So you need to be looking at the history more than just these three symptoms. But what you're looking for in a vignette is a pattern of respiratory symptoms listed above that occur following exposure to a trigger. So an allergy like cat or dog hair after intense exercise, after a viral infection, exposure to cold air, all of these things that you'll look for in the vignette. also the fact that they're normally going to be episodic. So symptoms will come on and then at a period of hours or days, they're back to normal. So those are your clinical manifestations that you should be aware of. Now on physical exam, you're going to be listening for that wheezing and you're going to be looking for that prolonged expiration, prolonged exhalation.

So this widespread, high-pitched musical wheezes, they're a characteristic feature of asthma. and then you'll also see that prolonged expiration described too on physical exam. They may have hyperresonance to percussion. So this is an obstructive airway disease. You have air trapping. It's going to lead to hyperinflated lungs. So when you percuss their lungs, the same way when you puff out your cheek, you blow air in your cheek and you tap on it, that's hyper resonant. So it's the same idea here.

You have air trapping. The lungs are hyperinflated. You tap on them, they're going to be hyper resonant to percussion. That's the same idea there with that air trapping. And then you may see use of accessory muscle. sternoclidomystoid, these accessory muscles, these patients are using, is helping them breathe. Now, be aware that all of these physical exam findings very well may be absent on clinical exam because you're really only going to see them in an acute exacerbation. But for the sake of

a vignette, they'll likely describe one of these. But in real life, they may have none of them because they may not be in a period of an acute exacerbation. They may feel normal at the time. Then also on physical exam, you should be aware of some extra pulmonary finding. So they may have pale or swollen membranes of the nasal cavities. You may see this cobblestone appearance of the posterior pharyngeal wall. These all suggest allergic rhinitis. It's a common condition, like I said before, to have allergic rhinitis with asthma. You may see nasal polyps.

And any time you see nasal polyps, this should prompt questioning about concomitant aspirin sensitivity. So aspirin sensitivity, nasal polyps, along with rhinocinucitis, and asthma. So asthma, chronic rhinocytocitis with nasal polyps and aspirin or insin sensitivity is something known as Samtors triad. So you'll see these three things combined. The insed sensitivity or aspirin sensitivity is this nasal congestion and bronchol constriction that typically happens after about half hour to an hour or two after the administration of inset. So you see that triad, Samtras triad, asthma, nasal polyps along with that rhinocinocytis, and then aspirin or nshead sensitivity. And then finally, the last thing you may see in extra pulmonary finding is atopic dermatitis.

So just a type of eczema, another one of those coexisting allergic conditions, those itchy plaques on the flexural surfaces, the elbows, knees, etc. Now diagnosis, there's a lot of things you can do in the workup for a patient. You can do chest x-rays. You can do labs looking for those increased eocinophils, increase, you know, you know, kind of suggesting allergic condition. But really the only one you need to know of, especially for your vignette, is pulmonary function testing. This is by far the one you need to know for diagnosis. It's the most important test to diagnose asthma. So it's your PFTs using spirometry.

So what are you looking for on spirometry? You're looking for a decreased FV1 FEC. Remember, FV1 is your forced expiratory volume at one second. FEC is your force vital capacity. So this is positive indicating an obstructive disease of the airway when the FV1 FEC ratio is less than 0.70 or less than the normal, the lower limit of normal. So that's what you're looking for. That obstructive pattern, FV1, FEC decreased less than 0.70. So you do your PFTs, you do your pulmonary function testing, and you see they have an obstructive pattern. They have that decreased FV1, FEC ratio.

But that's not enough for diagnosis because I'm sure you know. there's other obstructive pulmonary conditions. So you can't just diagnose asthma from that alone. So when you get this diagnosis on PFTs of an obstructive pattern, what can you do next to ascertain a higher degree of confidence that this is indeed asthma, not some other obstructive cause, like COPD, things like that? Well, what you do next is something called a broncholidor challenge. So it's a test you use to confirm the diagnosis of asthma and a patient with positive PFTs with that obstructive pattern. So you give them albuterol, two to four puffs of a quick acting broncholidilator, then you repeat your PFTs, the spirometry, about 10 to 15 minutes later, and you assess for

improvement. So how much are you looking for to see that they improve? Well, generally, it's a 12% or a higher increase in FEV1. When you see this increase, this is considered a significant increase, and it's suggestive for a diagnosis of asthma. It's a good way to differentiate between a reversible obstructive cause like asthma and an irreversible cause like COPD because COPD, if you give them a broncholidator, they may improve, but it's going to be minimal. It's not going to be 12% or higher. It's going to be a fairly low increase in their FV1. So asthma is going to have this dramatic increase, 12% or higher. COPD is going to be very minimal. And that's how you can kind of differentiate between asthma and other irreversible causes like COPD. So that's what you do next. You do your

your broncholidator challenge, you look for a 12% or higher increase in the FEV1. Now, let's say this patient comes in, you really suspect asthma, they fit the criteria, you know, they tell you every time they exercise they wheeze, they're, you know, they have these, this coexisting allergic rhinitis, eczema, whatever. You suspect asthma, but their PFTs are normal. You don't see that decreased FV1 FEC ratio that indicates an obstructive pattern. Because remember, asthma symptoms are generally episodic, so they may come in and their PFTs may be completely normal because they're not in an acute exacerbation. So very well may be the case

that you have normal PFTs. So what do you do next? Do you just give up and say, well, we really don't know? No, there's another way you can test them. And this is something known as a bronco provocation test or also known as a methacoline challenge. So methacoline is the most common stimulant used. It's a colonergic drug that acts directly on the muscarinic receptors of smooth muscle, causes contraction and airway narrowing. So basically it causes bronchic constriction. It mimics an asthma attack. So you give them something that's going to mimic an asthma attack in a patient that's

susceptible to this. So a positive test would indicating bronchial hyperresponsiveness would be if you see a 20% or higher decrease in their FEV1. That's a positive test. You give them methacoline. You see a decrease in their FEV1, 20% or higher. So that would indicate that this is likely a patient with asthma because a, a, A patient that does not have asthma, you give them metacoline, you're going to see a very minimal, if any

response at all. But in a patient with asthma, you're going to see a big change in their FV1, 20% or higher decrease in FV1. So that's the way you can test the patient that's not an acute exacerbation and you want to, you know, really make sure that this is not asthma. You can give them a methacoline challenge. Let's run through that again. Just because it's a lot and let's just go through the process. You do your pulmonary function testing, comes back to normal.

Like I said, most of the time it won't have been yet. Provoke them with metacole. causes bronco constriction. If they have asthma, you're going to see that decrease in your FV1 over 20%. If not, very unlikely that it's asthma. Now, let's say their PFTs are positive for obstructive disease. They have that decreased FV1 FEC ratio. And you want to ensure that this obstructive disease is asthma.

Go ahead and give them a bronchol dilator. Albuterol, if it reverses 12% or higher, likely asthma, if not very low chance that it's going to be asthma. So that is your algorithm you can kind of run through. that way. Now let's move on to the the treatment plan. So medications, there's a few different classes of asthma medications, but in the spirit of my reviews, I don't want to focus on the ones I don't think you're going to be tested on. So let's focus on the ones I feel like you need to know. And the three classes that you need to know, they're the main ones used in asthma. You're going to see them on all of the treatment guidelines. They're your sabas, your labas, and your

inhaled corticostero-steroids. So let's start with sabas. That's your short acting beta two agonists. That's your albuterol, level buterol. Those are the main ones you'll hear about. Their first line for acute exacerbations, they're bronchodilator. So remember, beta 2 receptors are found in the lungs, well, some other places too. And when activated through the inhalation of a saba, they create smooth muscle relaxation, which is what causes the bronchol dilations. Remember, saba's first line for acute exacerbation, albuterol, level butylabutrol, main ones you'll hear about.

Next is your inhaled corticosteroids. You have triumcinolone, becholmethosome. There's a few different ones. their first line for chronic maintenance. So regular use of inhaled glucocorticoids reduces the frequency of symptoms, the need for Sabas for symptom relief, and it also decreases the risk of serious exacerbation. So it's a great med to be used as daily controller therapy to prevent those exacerbations. And as we know, steroids inhibit the inflammation and cytokine release.

So that's the way they work in these patients. And then finally, you have your lava. So long acting beta 2. agonis. Formotrol is the one, the main one you'll hear about. There's also selmeterol. They're normally combined with an inhaled corticosteroid like formodol with Budesinai, which is the brand name is Simbacord. I'm sure you've heard of that one. So these are long acting bronchodilators. They work just like the Sabas did, but they have a longer duration of action, sometimes up to about 12 hours. So they're good at prevention of symptoms, particularly nocturnal asthma.

And for real life practice, you need to know that you never use labas as monotherapy. They always have to be combined with an inhaled corticosteroid. You can't use them by themselves. The reason it comes down to this, there's this down regulation of beta 2 receptors when you use them by themselves. They make sabas rendered ineffective, which the inhale corticosteroids prevent. Don't worry so much about the reason. Just know really the only wrong answer in the treatment of asthma would be a lot. by itself never use it by itself so just remember that so those are the three classes I

would focus on those are the three preferred agents in all of the guidelines don't worry so much about your lucetrine modifiers like Montalukast which actually has a black box warning on it for behavior and mood related changes they're not very effective they're not used very often same with theophiline it's rarely used focus on your saba's your labas your inhale cortical steroids are the backbone of asthma treatment they're the ones you're likely going to get tested on now with the treatment guidelines There's multiple guidelines. They're broken up into multiple age groups.

If you tried to memorize them all, you'd go crazy. So I boiled it down to the bare minimum. Focused on one of them known as the NAEPP 2020 guidelines. Up to date has some preference for this one. It's the one you'll see in Pants Pearls. The other guideline you'll hear about is the Gina guidelines, the Global Initiative for Asthma. I'm not going to focus on this one, but I will briefly go over it. It's fairly simple, it's just a step up, step down approach,

and it really just involves two meds and inhale corticostero. steroid and a laba, which is from odorol. So the main difference with the Gina guidelines compared to most of the other guidelines out there is the fact that the Gina guidelines, their first line treatment for an exacerbation, the first time this has really ever been done in over 50 years is not Saba. Sabas have always been used for first line exacerbation, but with the GINA guidelines, and this is obviously controversial, it's off-label use here in the U.S., but instead of a Saba as your acute exacerbation, use,

they actually use a laba specifically for motorol. It can only be for motorol because it has this fast onset of action about three minutes. So you actually use for motorol combined with an inhale corticosterone. And that's what they use for their acute exacerbations with the genome protocol. And like I said, we've been using savas for over 50 years here in the United States. So this one, I don't think you'll get tested on, but it is the newer guideline. It's starting to come out and be used in some places. So you need to at least be somewhat familiar with it.

So let's just really quickly go over. it's a step up, step down approach. There's only five steps. And like I said, there's really only two meds used. So what do you do? Your preferred reliever, your preferred acute exacerbation, is going to be a low-dose inhale corticosteroid with a lava, but specifically it has to be for Motorola. It's the only one that has that fast onset that can be used as an acute reliever.

So across the board, low-dose inhale corticosteroid for Motorola. That's what you use for all of your acute exacerbations with the genocytes. Then you have your step one through step five for your controller to prevent exacerbations. Step one and step two, super easy. It's still just an as needed low dose inhale corticosteroid and femotrol. So step one and step two for Gina, all you need to know as needed, formalorol with an inhaled corticosteroid. Step three to step five, really easy. Step three, the only difference, that low dose inhale corticosteroid and the laba, the formoderole,

you're going to use daily instead of as needed. So step three starts daily. And then step four and step five, the only change is that you go from a low dose ICS to a medium dose inhale corticosteroid. Everything else stays the same. Really, really easy. Again, don't really focus on this one, but if you wanted to learn it, it's going to take you like three minutes. It's super straightforward. So that's pretty much it for the GNA guidelines.

So now let's move on to the NAEPP 2020 guidelines. I feel the two, like I said, you're probably going to be tested on this one. Unfortunately, it's a bit more complicated, but I do have a mnemon. free at the end to help. So let's start on this one. And the guidelines advise for this one initiating pharmacologic therapy based on the frequency severity of symptoms and then you adjust, you do therapy up or down. The same with the gena guidelines. It's a step-wise approach. If they're doing okay on step one or step two, say you can step down to step one or if they're on step two and their symptoms are not getting better, you can just bump it up to step three. Step up, step down.

That's it depending on their symptoms. So let's start with the NAEPP guidelines. with the first step one, which is intermittent symptoms, step one. So this is a patient with daytime symptoms, two or less days a week, nocturnal awakenings, two or less times a month, and then a normal FV1 of 80% or higher. So daytime symptoms, two or less days a week, nocturnal awakenings, two or less times a month, and a normal FV1 over 80%.

All you need to know for treatment for intermittent step one is Saba as needed. That's it. Saba as a week. needed nothing else for intermittent step one all right mild persistence step two daytime symptoms over two times a week but less than seven days a week nocturnal awakenings three to four nights a month and then still a normal FEV1 over 80% treatment inhale corticosteroids low dose plus your Saba PRN that's it for step two inhale corticosteroids it's the only thing you're adding a low dose and you could

still use your Saba as needed step three daily symptoms every single day they're having symptoms nocturnal awakenings now this is a little change i made here so nocturnal awakenings for step three they listed as over one day a week but if you remember step one and step two listed nocturnal awakenings by days in a month remember step one was less than or two or less days a month mild persistence step two was three or four nights a month and then step three they make it confusing they do it over one day a week i find it easier to stay the month guideline. So what's over one time a week, more than one time a week? That's a minimum of two. And then you figure four weeks in a month, that's eight. So the way that I remember

instead of over one day a week, I remember nocturnal awakenings, eight or more nights a month. That way you can be on the same page of step one and step two, you know, two or less a month and step one, three to four nights a month, step two, and then you get up to step three and then it's eight or more nights a month. It's much easy to remember and also helps with the mnemonic I'll tell you about later on. So that's how I remember moderate person. system, step three, nocturnal awakenings, eight or more nights a month. All right, FV1, this is the first one over the FVU1 is decreased. It's 60 to 80% predicted.

Treatment, the only change here, you're still using your low dose inhale corticosteroid, but you're adding on a lava for motorol, specifically for motorol. Because remember, they're kind of piggybacking on the GEDA guidelines here, and they're using that for motorol for your daily and you're as needed. So this one, treatment, step three, your laba specifically for plus your low dose ICS. Step four, symptoms are all day, nocturnal awakenings nightly, so they're having symptoms all the time, all day, all night.

FV1, less than 60% predicted. And then here you're using your lob again, you're formalorol, but you're increasing your inhale corticosteroid to a medium dose. That's the only difference between step three and step four. Your inhal corticosteroid is going up to a medium dose. Refractory, which would be steps five through six, don't even worry about these, but all you do is increase the strength of the end up. inhale corticosteroid. You add potentially a llama like teotropium, your biologics. At this point,

step five and six, you pretty much throw anything at them that you have that, because nothing else is working. So just throw anything and see if it sticks, if it works. That's steps five through six. I wouldn't worry about those. Okay. So the way that I remember this, it's harder without a visual here on the YouTube page. It's a lot easier because I have a little picture and a guide and a graph, but I'm going to try to explain it to you. So the mnemonic, have is the sentence because I do feel like it's silly to memorize this because you might get a question. I don't know if it's worth your time, but the sentence that I remember is it's silly to memorize it, but if you do, remember 248 and then an 8 on its side. It's silly to memorize it,

but if you do remember 248 and an 8 on its side, so silly is spelled S-I-L-I, and then the 24-8, the 8 that's on its side is actually the infinity symbol. So I'm sure you've seen the infinity symbol before, it's an eight on its side. So it's silly to memorize it, but if you do remember, 248, 8 on its side. So silly is the four steps. S stands for Saba, I stands for inhale corticosteroid, L stands for Laba. Remember, that's your third step. And then I stands for increased inhale corticosterone because remember at step four, the only change was you increased the strength of the inhale corticosteroid. It was a medium dose. And then silly corresponds to the 248 and 8. All of those relate to the amount of nighttime awakenings. So don't remember your FV. Don't remember the daytime.

They're going to give you your nighttime awakenings and they're all different. So you might as well just remember one part of it. There's no point in remembering every single different part of each step because they're going to give you all of them. You might as well just remember your nighttime awakenings since they're all different. And then that's all you have to remember. So two, four, eight and eight on its side. That stands for two. That's going to be two or less nighttime awakenings a month. that's at step one. Remember, that corresponds to the S in Silly, which is a Saba, because that's what you give it step one.

So Saba, two, two or less nighttime awakenings a month, that's step one. I in Silly stands for inhaled corticosteroid. That's going to correspond to four, which would be three or four nighttime awakenings a month. So you just remember the four and three or four nighttime awakenings. That's your mild persistence step two. L in Sili, that stands for lava, because remember at step three, you add your formal all, your laba, that corresponds to the eight and 248 because remember eight or more nighttime

awakenings in a month, that's your moderate persistence, step three. And then the eye and silly is going to stand for increased inhale corticosteroid. Remember, the only change from step three to step four was an increase in the inhale corticosteroid plus your laba. And then an eight on its side, which is the infinity symbol, because remember, these nighttime awakenings, these, they never end. There's no stop to them. They never end. It's every single day, every single night, infinity. It goes on forever and ever. So you just turn the eight on its side, the infinity symbol.

That's your severe persistence step four. So again, remember, I can only remember that you want to take a look at the little graph I made. You can check out the YouTube page and it just makes it a little bit easier. So really, that's it for asthma. That's all I feel like you really need to know. Let's do five quick questions and then we will wrap it up. So question one. A combination of asthma, chronic rhinocinocytis, combined with,

nasal polyps and sensitivity to aspirin is known as that is known as the Sampters triad. Question two. What diagnostic test is the gold standard for diagnosing asthma? That is going to be your pulmonary function test, your spirometry. Question three, what asthma medication should never be used as monotherapy? That is going to be your laba, like your formalderol, your cell motorol, must always be used in combination with an inhaled corticosteroid. Question four. A patient with history of asthma that performs a broncholidator challenge would be expected to have an increase of FV1 of what percent or higher. So they did a bronchodilator challenge. What increase you see in the FV1? That's going to be 12% or higher. And then question five, what is a classic triad of symptoms seen in patients with asthma? That's going to be wheezing, cough, and dyspnea. All right. So that is asthma. Hopefully that was helpful. Please let me know if it was. And thank you so much, as always, for everything. You guys are really supportive. And I really do.

do appreciate that so good luck on your pants your panery or eORs and good luck in pa school