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1. [From 10$/Pg] Supplemental O2 Inhaled Saba
[From 10$/Pg] Supplemental O2 Inhaled SabaAmelia MangunePosted DateJun 23, 2022,
12:05 AMUnreadAsthma Asthma is a chronic respiratory disease associated with reversible
airflow obstruction, bronchial hyperresponsiveness (BHR), and airway inflammation
triggered by various stimuli, including viral upper respiratory infection, environmental
allergens, and occupational exposures. It can lead to recurrent episodes of wheezing, cough,
and dyspnea (Holguin, 2017). Presentation (Holguin, 2017) H&P reveals recurrent
respiratory symptoms characterized by wheezing, cough, and chest tightness. Trigger
exposures may exacerbate respiratory symptoms and include exposure to airway irritants
(smoke, strong fumes, air pollution, etc.), aeroallergens, respiratory infections, and cold
air. Psychological stress and physical exercise may also trigger respiratory symptoms
without any other concomitant exposures.Respiratory symptoms may have a nocturnal
predominance and are frequently more severe in the morning after waking up when
airflows are usually lower. Other presentation includes tachypnea, tachycardia, non-
productive cough, prolonged expiration, use of accessory muscles in severe attack, and
decreased exercise tolerance (Bray, 2018).Categories of Asthma Severity (Fanta & Barrett,
2022)Intermittent:Daytime asthma symptoms happen 2 or fewer days per week.Two or
fewer nocturnal awakenings per month.Use short-acting beta-agonists (SABAs) to relieve
symptoms two or fewer days per week.No interference with normal activities between
exacerbations.FEV1 measurements between exacerbations are consistently within the
normal range (i.e., ≥80% of predicted).FEV1/FVC ratio between exacerbations is
normal.One or no exacerbations require oral glucocorticoids per year.Mild
persistent:Symptoms > 2Xweekly (although < daily).About 3-4 nocturnal awakenings per
month due to asthma (but fewer than every week).Use SABAs to relieve symptoms > 2
days/week (but not daily).Minor interference with normal activitiesFEV1 measurements
within normal range (≥80% of predicted).Moderate persistent:Everyday manifestations of
asthma.Nocturnal awakenings as often as once per week.Daily requirement for SABAs for
symptom relief.Some limitations in normal activity.FEV1 ≥60 and <80% of predicted and
FEV1/FVC below normal.Severe persistent:Presence of asthma symptoms throughout the
day. Nocturnal awakening due to asthma every night. Reliever prescription needed for
symptoms several times/day. Severe activity limitation due to asthma. PathophysiologyThe
early phase of asthma (1st hour) is triggered by IgE antibodies that are sensitized and
released by plasma cells (Sinyor & Perez, 2022). Based on Sinyor & Perez (2022), these
antibodies respond to environmental triggers. IgE antibodies then bind to high-affinity mast

2. cells and basophils. When a pollutant or risk factor gets inhaled, the mast cells release
cytokines and eventually de-granulate. Released from mast cells are histamine,
prostaglandins, and leukotrienes. These cells, in turn, contract the smooth muscle and cause
airway tightening. In the late phase (4-6 hrs), eosinophils, basophils, neutrophils, and helper
and memory T-cells all localize to the lungs, which causes bronchoconstriction and
inflammation. As a result of inflammation and bronchoconstriction, there is an intermittent
airflow obstruction, resulting in increased work of breathing.Labs/Diagnostics (Holguin,
2017) Pulmonary Function TestReveals evidence of airway obstruction with a
bronchodilator response > or = 12% (or 200 mL) improvement of FEV1 after short-acting
bronchodilators.Bronchodilation should only be evaluated after withholding asthma
medications for at least 4 hrs for short-acting β2-receptor agonists (SABA) and 24 hrs for
long-acting β2-receptor agonists (LABA).Methacholine (a cholinergic agent utilized to
stimulate bronchial constriction excludes asthma). A positive test occurs when a reduction
in FEV1 > or = 20% from the baseline postmethacholine level. The methacholine test is very
sensitive but lacks specificity so that a positive test can be seen in other airway diseases or
allergies. Diligent assessment for the existence or lack of asthma through testing and
evaluation of treatment response will help eliminate the roughly 30% of patients who are
mistakenly diagnosed with this condition clinically (false positive) and are unnecessarily
treated with corticosteroids.Other studies (Bray, 2018)SpirometryAllergy testing
(consider)Peak flow monitoringDifferential Diagnosis (Holguin, 2017): Congestive heart
failure Wheezing and coughing can happen, which may be linked with airway vascular
congestion and peribronchial cuffing due to pulmonary edema, bibasilar inspiratory
crackles on auscultation, and an elevated serum BNP. Airway obstruction Foreign body
aspiration, tumor, laryngeal edema, anaphylaxis, and laryngospasm could lead to stridor,
which can be mistaken for wheezing.Other differential diagnoses (Bray, 2018)Respiratory
infectionGERDHabitual non-asthma-related coughTuberculosisTreatment (Holguin,
2017) Supplemental O2Inhaled SABA Anticholinergic agentsNebulizersOral systemic
corticosteroidsPatient Education and Prevention (Bray, 2018):Identify and minimize known
asthma triggers by avoiding allergens and irritants.Take prescribed asthma medications
daily.Learn how to identify early signs/symptoms of asthma exacerbation (frequency of
dyspnea, cough, chest tightness, and the need for quick-relief medication).Have an “asthma
action plan,” a preplanned medication plan for an exacerbation.Influenza and Pneumococcal
Pneumonia vaccinations.Monitor peak flow values.Learn the correct use of inhalers,
spacers, and other medications (about half of patients misuse inhalers, causing medications
ineffective).Routine follow-up visit ( 1 to 6 mons depending on the severity of
asthma).Referrals (Fanta & Barrett, 2022)Pulmonologist If there is uncertainty about
asthma diagnosis, poorly-controlled asthma, an episode of near-fatal asthma, treatment of
comorbid conditions, or the need for bronchoscopy.Allergist/Immunologist If considering
the need for specialized diagnostic studies (e.g., allergy skin testing) or potential treatment
with biologics.ReferencesBray, S.L. (2018). Asthma. In Hollier, A. (Ed). Clinical Guidelines In
Primary Care (2nd Ed, pp. 662-669). Advanced Practice Education Associates, Inc.La
Fayette, LA.Fanta, C.H. & Barrett, N.A. (June 06, 2022). An overview of asthma management.
UpToDate. https://www.uptodate.com/contents/an-overview-of-asthma-

3. management?source=history_widget#H31Holguin, F. (2017). Asthma. In McKean, S.C., Ross,
J.J. Dressler, D.D. & Scheurer, D.B. (Eds.). Principles and Practice of Hospital Medicine (2nd
ed., Chap. 231, pp. 4507-4509). McGraw-Hill Education. Sinyor, B. & Perez, L.C. (May 08,
2022) Pathophysiology of asthma. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK551579/