Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children (JACI, 2011). Prevalence of asthma is 8%, prevalence of AR is 3 times higher (24%). 40% of patients with AR have asthma, 80% of patients with asthma have AR.
Classification of asthma - mnemonic
I'M MS ("I'm a Master of Science")
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Number of controllers used in each stage of the classification of asthma - mnemonic:
I'M MS
0 1 2 3
0 - SABA PRN (albuterol) only
1 - ICS or LTRA
2 - ICS/LABA or ICS plus LTRA
3 - ICS/LABA and LTRA, consider omalizumab (anti-IgE mAb)
Allergic Rhinitis and its Impact on Asthma (ARIA): Achievements in 10 years and future needs. ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. http://buff.ly/QL1eYI
Pathogenesis of Asthma
Lymphocytes
CD4, Th2
Central effector cells
Cytokine release
Overview of adhesion molecules, 3 groups remembered by the mnemonic SIS:
Selectins
Integrins
Superfamily Ig
Mast cells are subdivided into 2 types based on proteinase content:
TC mast cells -- Tryptase and Chymase in granules
T mast cells -- Tryptase only granules
Mast cells
Mediator release
Mucosal inflammation
Mediators from eosinophils are remembered by the mnemonic CML EEE:
Cytokines
MBP
Lipid Mediators
EDN
ECP
EPO
Eosinophils
Emit
Eight mediators (at least 8, the first C in the mnemonic covers cytokines, chemokines and growth factors)
Overview of adhesion molecules, 3 groups remembered by the mnemonic SIS:
Selectins
Integrins
Superfamily Ig
There are 4 families of eicosanoids (PP-LT): prostaglandins (PG), prostacyclins (PGI), leukotrienes (LT) and thromboxanes (TX).
Diagnosis of Asthma
A mnemonic to remember the different PFTs is SPIROMEtry:
Spirometry
PEFR
Inhalation tests:
Reversibilty of
Obstruction with beta-agonist
Metacholine challenge
Exhaled NO
The phases of spirometry can be remembered by the mnemonic BEIF:
Breath normally x 6 times
Exhale fully
Inhalation (deep)
Forceful exhalation for 6 seconds
FEV1/FVC
FEF 25-75
R
Regular (normal) or
Raised in
Restriction
FEV1
1ow in both obstructive and restrictive disease
Bronchodilation test: BB RR
Baseline spirometry
Beta-agonist
Repeat spirometry
Reversibilty of obstruction
Methacholine challenge test, remember the numbers: 5-25-20-5:
5 breaths
25 mg/mL metacholine
20% FEV1 reduction
5% of patients with asthma have a negative test, 95% react to the challenge
Test for Respiratory and Asthma Control in Kids (TRACK)
5
5 questions
5 year-old or younger (2-5 years)
Test for respiratory and asthma control in kids (TRACK) - mnemonic: 3S
Symptoms (3 questions)
SABA use
Steroid use
Test for respiratory and asthma control in kids (TRACK) - complete mnemonic: 3S
Symptoms - SPA: Symptoms - how often, Play, At night, past 4 weeks
SABA use, past 12 weeks (3 months)
Steroid use, past 12 months (1 year)
Time frame of TRACK:
Symptoms - 4 weeks (1 month)
SABA use - 12 weeks (3 months), quarter
Steroid use - 12 months (1 year)
References:
Test for Respiratory and Asthma Control in Kids (TRACK): A caregiver-completed questionnaire for preschool-aged children. Kevin R. Murphy et al. JACI. Volume 123, Issue 4, Pages 833-839.e9 (April 2009).
Differential Diagnosis of Asthma
C
Children
Congenital conditions
CF
A
Adults
Acquired conditions
Asthma Classification: M MMS
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Treatment
One can remember the stages by the number of controller medications a patient would need at each stage:
I'M MS
0 1 2 3
"Rule of 2s” is used to determine level of control. If any of these are positive, consider a daily controller medication:
- daytime symptoms more than 2 days/wk
- rescue β2 -agonist use more than 2 times per week
- nighttime symptoms more than 2 nights/mo
- more than 2 asthma exacerbations per year
- more than 2 rescue β2-agonist canisters/yr
Reference for rule of 2's: Audio: Asthma, noon conference. Muthiah Pugazhenthi. Podcasting Project for the UT Internal Medicine Residency Program, 12/2006.
If asthma treatment is not working, check DAT:
Diagnosis - not asthma at all (VCD, CF, FBA), asthma plus AR, GERD
Adherence - compliance with medication
Technique - NEB, HFA with spacer, DPI, etc.
3 C's of care - communication, continuity, concordance (finding common ground) are critical for asthma management (http://goo.gl/8gJM6).
Medications
S
Singulair
Single daily dose
Suicude risk (potential)
LABA
M
Monotherapy
Masks inflammation
Mortality increase
Corticosteroids
C category during pregnancy
Budesonide
B category during pregnancy
Exercise-induced asthma treatment: CLIMB
Cromolyn
Leukotriene receptor antagonist
Inhaled steroids
Mast cell stabilizers other than cromolyn
Beta agonists
Leukotriene receptors
Leukotriene
B4
BLT 1, 2 receptors
Leukotriene
C4, D4, E4
CysLT 1, 2 receptors
Ciclesonide mnemonic
C
Ciclesonide
Converted to active form (des-CIC)
Carboxyl-esterases in bronchial epithelial cells
Clearance by liver
Published: 01/24/2008
Updated: 11/27/2012
3 comments:
Talk about stumbling upon a treasure trove! Thanks for this page... from a grateful med student
Very useful. What do you mean by A, b,c categories of drugs
United States FDA Pharmaceutical Pregnancy Categories
Pregnancy Category A Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
Pregnancy Category B Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.
Pregnancy Category C Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Pregnancy Category D There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Pregnancy Category X Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
http://en.wikipedia.org/wiki/Pregnancy_category
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