​Kembara Xtra - Medicine - Asthma

​Kembara Xtra - Medicine - Asthma 
A diverse illness marked by persistent airway inflammation is described in general terms.

Exercise, exposure to allergens and irritants, changes in the weather, laughter, or viral respiratory illnesses are typical triggers.
The patient may go through periods of no symptoms followed by periodic flare-ups (exacerbations).
The most typical asthma phenotypes are:
- Allergic asthma: typically present since childhood, with a significant family history of allergic conditions
asthma that isn't allergic
- Late-onset asthma is more prevalent in women.
- Obesity and asthma: Fixed airflow limitation caused by airway remodeling
The extent of asthma is determined after the fact based on the care needed to manage symptoms.
- Mild asthma: well managed with Step 1 or 2 therapy (low-intensity maintenance controller therapy or as-needed ICS-formoterol alone).
- Moderate asthma: adequately managed with Step 3 or 4 therapy (low- or medium-dose inhalers). ICS-LABA
- Severe asthma that is "uncontrolled" even after receiving optimal care and high-dose ICS-LABA, or that needs high-dose ICS-LABA to stay "controlled."


EPIDEMIOLOGY Incidence
13% of asthma cases worldwide may be attributed to air pollution from traffic.
Prevalence
There are 235 million asthma sufferers in the world.
In the United States, asthma affects 10% of children between the ages of 5 and 18; it is more common in boys than in girls, but it affects adults more often in women; and obesity is linked to both an increased prevalence and incidence of asthma.
Deaths from asthma are most common in people over 65.

PATHOPHYSIOLOGY AND ETIOLOGY
Inflammatory cell infiltration and degranulation, subbasement fibrosis, mucus hypersecretion, epithelial injury, significant smooth muscle hypertrophy and hyperreactivity, and angiogenesis are all symptoms of airway hyperreaction. These symptoms eventually result in intermittent airflow obstruction from reversible bronchospasm.
Genetics
Asthma is caused by a genetic connection between elevated levels of interleukin (IL) or IgE production and airway hyperresponsiveness.

RISK FACTORS Aspirin or NSAID hypersensitivity Individuals with food allergies and asthma are at increased risk for fatal anaphylaxis from those foods. Host factors include genetic predisposition, sex, race, obesity, preterm, or small for gestational age (SGA) Individuals with environmental risk factors include viral infections, animal and airborne allergens, tobacco smoke exposure, pollution, and stress.

CONDITIONS OFTEN Associated with
Atopy, which includes eczema, allergic rhinitis, and allergic conjunctivitis; obesity, which is linked to an increased risk of asthma; and gastroesophageal reflux disease (GERD).

OSA, or obstructive sleep apnea,

DISEASE HISTORY
past experience with various respiratory symptoms:
 Multiple symptoms, such as wheeze, SOB, cough, and tightness in the chest

 Symptoms vary in time and intensity and are worse with typical triggers at night.

Focus on the use of auxiliary muscles, rhinitis, nasal polyps, and enlarged nasal turbinates during the physical examination, which may be normal.
- Prolonged expiratory phase and wheezing upon inspiration. Due to the significantly decreased airflow, wheezing may not be present in severe exacerbations.
Eczema on the skin


DIFFERENTIAL DIAGNOSIS In children, foreign body aspiration, vocal cord dysfunction, vascular ring or laryngeal web, laryngotracheomalacia, enlarged lymph nodes, or tumor may cause a large airway obstruction.
Other reasons (recurrent cough, chronic upper airway cough syndrome, aspiration/GERD) include viral bronchiolitis, cystic fibrosis, bronchopulmonary dysplasia, heart disease, primary ciliary dyskinesia, and bronchiectasis.
Adults may also experience Churg-Strauss syndrome, medication-induced cough (ACE inhibitors), bronchiectasis, heart failure, pulmonary embolism, tumor, pulmonary infiltration with eosinophilia, heart failure, vocal cord dysfunction, and chronic obstructive pulmonary disease.

DETECTION & INTERPRETATION OF DIAGNOSIS
Initial examinations (lab and imaging)
Blood tests aren't necessary, but they could reveal eosinophilia or high serum IgE levels (a sign of allergic asthma).
Variable expiratory airflow limitation that has been documented:
Spirometry with a methacholine challenge: A normal test does not exclude asthma; it measures the FVC and the FEV1; a reduced projected FEV1/FVC ratio with reversibility (an increase of 200 mL and 12% from baseline) after administering a short-acting bronchodilator (SABA) is seen.
- Overly variable peak expiratory flow (PEF) twice daily for two weeks (daily PEF variability > 10%).
- The bronchial challenge test, which is primarily used in adults, is positive when the FEV1 falls by more than 20% in response to methacholine or histamine, or by more than 15% in response to a mannitol or hypertonic saline challenge.
Exercise challenge test: 200 mL and a >10% drop in FEV1 from baseline
After four weeks of anti-inflammatory therapy, there has been a significant improvement in lung function. A chest x-ray is done to rule out other possible diseases.
Tests in the Future & Special Considerations
Patients keep track of their own symptoms and/or peak flow readings as part of their asthma action plan. Review your action plan every three to six months.
Evaluate the control of asthma symptoms using straightforward screening measures, such as the Primary Care Asthma Control Screening Tool (PACS), which is based on the Global Initiative for Asthma (GINA) symptom control tool.

Other/Diagnostic Procedures
Allergy skin testing may be used to determine atopic triggers but is not helpful for diagnosing asthma.

Eosinophilic airway inflammation is suggested by the fractional concentration of exhaled nitric oxide (FENO) measurement.

GENERAL TREATMENT MEASURES
Put an emphasis on symptom management and exacerbation avoidance.
The use of holding chambers (sometimes known as "spacers") with inhaled medications enhances therapeutic results.
A written action plan for managing one's asthma
Encourage people to exercise, lose weight, quit smoking, stay away from irritants, and reduce their mental stress.

 Reducing occupational exposure
Pneumococcal vaccine suggested for high-risk patients; annual influenza vaccination
Patients who are susceptible to anaphylaxis carry EpiPens.
Medication used as a controller is used to maintain the condition, lessen airway inflammation, control symptoms, and lower the chance of exacerbations:
Treatment of asthma with SABAs alone is no longer advised by the GINA guidelines for adults and adolescents. - Inhaled corticosteroids (ICS) - Long-acting -agonist (LABA) (formoterol, salmeterol) The ICS can be delivered by regular daily treatment or, in mild asthma, by as-needed low-dose ICS-formoterol.
- To lower the risk of death and severe exacerbations, ICS therapy is crucial.

 All patients are given Reliever (rescue drug) to treat breakthrough symptoms as needed.
SABA-albuterol/levalbuterol is an add-on therapy for people with severe asthma when their symptoms don't go away despite receiving the best possible care from high-dose controller drugs (ICS + LABA).

Child Safety Considerations
Tiotropium is contraindicated in children under the age of 12.
SABA is the reliever for all management actions in children aged 6 to 11 years.
Asthma self-management programs offered in schools cut down on hospital stays, ER visits, and days spent resting.

pregnant women's issues
Use of the bronchial provocation test and the discontinuation of controller therapy should wait until after delivery.
In about one-third of individuals, asthma symptoms become worse, one-third get better, and one-third don't change.

In the second trimester, exacerbations are frequent.
Poorly managed asthma increases the risk of prematurity, low birth weight, and perinatal mortality.
All short-acting drugs (SABA) and ICS are pregnancy category C drugs.
Montelukast and zafirlukast are Category B medications, however they have not been thoroughly researched in pregnant women. Cessation of ICS during pregnancy is a substantial risk factor for exacerbation.

Underdiagnosed due to comorbidities; difficult to manage due to comorbidities (such as arthritis); and polypharmacy are some geriatric considerations

First Line: MEDICATION
Stepwise strategy for treating asthma in adults and adolescents (>12 years): Initial recommended controllers based on the patient's presenting symptoms
– First step: symptom-driven care
First, symptom-driven low-dose ICS formoterol when needed; low-dose ICS whenever SABA is given; ICS as preferred relief.formoterol
Low-dose controller plus as-needed relief in step two:
First, low-dose ICS plus SABA; alternate controllers include LTRA or low-dose ICS anytime SABA is administered (individually or in combination).
 Step 3: A controller or two plus a reliever as required
First (for adults/adolescents): low-dose ICS-LABA; alternate controllers include medium- or low-dose ICS. For those on maintenance medication, low-dose ICS/formoterol is preferred as a controller and relief when needed. For younger children (6 to 11 years old), medium-dose ICS plus SABA is a second possibility. For adults and adolescents, low-dose ICS plus LTRA is a third option.
Fourth step: two or more controllers plus a reliever as required
First (adults/adolescents): high-dose ICS, add-on tiotropium, or LTRA as controller; alternate controllers include medium-dose ICS-LABA. If a patient has allergic rhinitis and is sensitive, consider using home dust mite SLIT. If bud-form/BDP-form maintenance and reliever therapy is indicated, low-dose ICSformoterol is preferred as a reliever; otherwise, use SABA reliever when taking other ICS-LABA.
Step 5: Add low-dose OCS or high-dose ICS-LABA while weighing the risks and advantages of various add-on therapies, such as LAMA, anti-IgE, anti-IL5/5R, anti-IL4, and tiotropium.
LABA + ICS combination therapy reduced the number of asthma flare-ups compared to ICS alone therapy.
Special considerations for COVID-19
- Asthma sufferers should keep taking their prescribed medications, especially those that contain ICS and oral corticosteroids, if they have been prescribed them. Nebulizer use should be avoided wherever possible to reduce the risk of infection to other patients and medical personnel. Patients with suspected or confirmed asthma should also not undergo spirometry. COVID-19.
- The COVID-19 immunization is advised for those who have asthma.

QUESTIONS FOR REFERENCE
Specialized examinations, such as bronchoprovocation; Specialized therapies, such as immunotherapy; Poorly controlled asthma, frequent exacerbations, or repeated trips to the emergency room
Workplace asthma due to potential legal repercussions

ADVANCED THERAPIES
Exercise-induced bronchoconstriction (EIB): SABA before exercise, LTRA/chromones, or medication shown to decrease symptoms

 Allergen immunotherapy when symptoms and exposure are clearly related
Asthma acute exacerbation management
- Non-patient:
SABA with ICS or formoterol/ICS and prednisolone should be started; if symptoms subside within an hour, the patient should be allowed home with close monitoring. Mild: speak in complete sentences, HR 120 beats/minute, oxygen saturation 90-95%, and peak flow >50% of anticipated can be handled as an outpatient in the clinic.
 Severe symptoms include inability to talk in full sentences, heart rate greater than 120 beats per minute, oxygen saturation below 90%, peak flow below 50% of projected value, and drowsiness, confusion, or a silent chest; transfer to an inpatient hospital.
- Serious cases' treatment
 Oxygen: to sustain 93–95% saturation
SABA: within an hour of arrival, initially 24/7, then on demand
Systemic steroids: Oral is just as efficient as IV. 200 mg of hydrocortisone, divided into two doses, or 50 mg of prednisolone (morning dose). It should last for five to seven days.
Avoid sedatives; only use epinephrine when asthma is accompanied by angioedema or anaphylaxis.
Vital signs, pulse oximetry, the amount of time it takes for the body to respond to SABA, and a lung function like PEF or FEV1
asthma education - criterion for discharge
 Minimal or nonexistent symptoms of asthma
The hypoxia has disappeared.
 PEF or FEV1 projected at 70% or personal best
 60 minutes or more of sustained bronchodilator reaction

CONTINUAL CARE
quitting smoking if necessary

SUCCESSIVE RECOMMENDATIONS

Determine triggers and limit exposures.
Once symptoms have been under control for three months, think about stopping treatment.

PROGNOSIS

Male patients, nonsmokers, and youngsters with modest illness have favourable prognoses.

ATELETASIS, Pneumonia, and MEDICATION-SPECIFIC SIDE EFFECTS/ADVERSE EFFECTS/INTERACTIONS ARE COMPLICATIONS
The elderly (age >65) account for 50% of asthma deaths due to respiratory failure.