Asthma Explained Clearly by | 2 of 2

By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , /

okay well welcome to another MedCram
lecture we were just talking about asthma in our first lecture about the
causes the pathophysiology where exactly this is happening this is happening in
the small Airways there’s many different causes for asthma some people just have
asthma because of the air they breathe and the other genetic makeup that they
have but there are things that can actually mimic asthma and set it off and
if you get rid of these things you can make it better so like things like GERD
gastroesophageal reflux disease post nasal drip some people even have a
condition associated with sampras triad where they take an aspirin or an end set
of some sort like ibuprofen or leave and this can cause the patients to actually
get set off an asthma exacerbation so things to look out for what we’re going
to talk about today though is that the diagnosis in this lecture so asthma is a
clinical diagnosis type of things that you might hear about in patients are
patients who say you know when they breathe cold air they they suddenly get
a tightness in their chest and it’s hard to breathe
they may wheeze maybe exercising because they’re exercising the air that’s moving
through their lungs is moving so quickly that it can’t be warmed and so the air
inside the bronchus is is cool enough so that it’s good actually cause
inflammation and constriction are the things that can cause asthma is just an
allergy to food that can cause them to get it so these these type of symptoms
of wheezing chest tightness episodic after they they do things or if they
smell different types of perfume or if they’re around someone with cigarette
smoke this should make you think of asthma but how do we make a numeric
diagnosis we can do something called pulmonary function tests and if there’s
any questions on that please refer to our pulmonary function test lectures the
thing about pulmonary function tests though that may be misleading is of
course that asthma is reversible so sometimes it’s bad sometimes it’s good
so if you schedule a patient for a pulmonary function test and they’re
asthmatic you just don’t know it yet and they go in and they’re having a good day
well the pulmonary function test may just come out as being normal so then
what do you do well it’s also possible that it might come
out to be abnormal and it may show obstruction and from our lectures you
know that obstruction is where you have an fev1
/ FEC of less than 0.7 that’s also the definition for COPD the nice thing about
COPD ironically in that case is that COPD doesn’t get better so it doesn’t
matter when you get there pulmonary function test that’s always
going to be less than 0.075 struction it’s possible that you could send the
patient in they’re having a good day and they’ve got a normal pulmonary function
test well if that’s the case you do a provocative test at that point that
provocative test you’re provoking the small Airways to see whether or not
they’re reactive in nature and the name of that test is called a methacholine
challenge test so that’s a methacholine challenge and that’s where we have
patients breathe in a concentration very small concentration of methacholine now
you should know kollene it’s a analog of a muscarinic agonist in you as you
recall from our first lecture if you stimulate the smooth muscle with choline
or acid steel choline or a muscarinic agonist you’re going to get constriction
usually if a normal person were to breathe in a methacholine concentration
nothing should happen but if they constrict and their Airways get smaller
that is suggestive that they have reactive Airways disease or in this case
asthma and let me kind of plot for you what this looks like so if you were to
graph this and we were to plot fev1 here on the y-axis and arbitrarily set this
to a hundred percent that’s what the patient can do and then what we do here
is we do different trials okay here we do a control and of course the patient
by definition is always going to breathe at one hundred percent of their first
try and then what we start to do is we start to use a very small concentration
like let’s say 1 to the 16th concentration of methacholine and we
keep going 1 to the eighth one to the fourth 1/2 one concentration and we see
what happens now in a normal patient you’re going to really not much have
much change at all ok so this is what they would look like this is a patient
without asthma without reactive Airways disease however in a patient with asthma
depending on if it’s very reactive or not so reactive let’s let’s pretend that
they in this case are very reactive you might see something like this ok and if
they weren’t very reactive let’s say they were mildly reactive you might see
something like this okay now the lie I didn’t draw for you
at the beginning was the 80% mark because that’s the key that’s what
determines when we stop this test so clearly here in the very reactive
patient going from 1 to 16 to 1 to 8 we cross the line at this point and so when
that were to happen we would have reached a reduction of by about 20% in
fev1 or more and the patient would then show reactivity so it’s a positive test
at that point the next thing we would do of course is instead of giving 1/4
concentration we would give them a beta agonist like albuterol and it would go
back up this V shape on a methacholine is suggestive and very indicative of
reactive Airways disease same thing for this patient we would do the same thing
now the purple versus the blue the purple reacted earlier in the test
meeting this patient is more reactive the blue reacted later in the test
meaning less reactive but still reactive the yellow is the one who never reacted
so the purple and the blue would both be diagnosed with reactive Airways disease
and again this is a methacholine challenge test ok let’s talk about the
treatment of asthma ok so since asthma is a reactive disease before we even
start talking about medications we got to start looking at what may be causing
it so I want to spend a little bit of time here because if you just skip to
the medication part you could be overlooking something that you might be
able to get rid of because medicines have side effects especially if you
could be putting this patient on a medication for a long period of time you
want to make sure that you’re not giving the medication that they don’t need so
you need to remove causes and I alluded to this earlier but some of the things
that I would definitely look at is down comforters down pillows
so these are down feathers you’re putting up right next to your nose right
next to your face you’re sleeping with it and you’re staying for it for six or
seven hours a night definitely want to consider that putting a mattress cover
on pets that sleep with you okay sometimes you’re allergic to the pets
getting them out of the bedroom looking for other things that might that you can
control you know you can’t control everything there’s there’s pollen in the
air you can’t control that but these things in your environment you can
control so looking for those sorts of things looking for post nasal drip
treating that the treatment for that is intranasal corticosteroids looking for
gastro esophageal reflux disease this is a big one don’t underestimate how much
gastroesophageal reflux disease driven asthma there is out there the treatment
for GERD is making sure the patient is elevated when they go to sleep at night
making sure they don’t eat anything three hours before they go to bed making
sure they’re avoiding spicy foods avoiding alcohol caffeine cigarettes
that sort of thing so I can’t stress enough looking for the underlying cause
because this is a reactive disease and we really need to make sure that we’re
eliminating that once you’ve done that let’s talk about pharmacotherapy okay so
everybody is going to get certain types of medications and the one that
everyone’s gonna get is a Samba s a B a that’s a short-acting beta agonist
specifically its albuterol comes in many different forms there is also this is an
enantiomer there’s a D and an L or R an S form the other one that you will see
is leave albuterol okay there’s many different brand names for albuterol
there’s pro air there is ventolin there is xopen X which is the brand name for
leave albuterol everybody needs to carry one of these around with them wherever
they go and they need to be educated on that because you never know when an
asthma exacerbation is going to hit and they need to make sure they’ve got a
rescue inhaler with them now there’s always the debate metered dose inhalers
versus nebulizers there’s really no difference between these two the MDI is
which are amita dose inhalers are actually easier
to carry around the nebulizers you’ve got to have power for some people can’t
activate the md eyes and so in those cases i don’t have a problem giving
nebulizers these are the things that people use on a as-needed basis so if
they have an exacerbation they can use it it’s usually prescribed up to every
four to six hours two puffs that type of thing so everybody gets one of these
things no matter how severe their asthma is if it’s very mild this may be enough
so if they’re only having an exacerbation once or twice a week or a
flare-up this may be all that they need now if they’re having difficulties with
exercise and they know exactly what it is that flares it up then they can take
this before they’re about to do that exercise and that would eliminate the
need for it later it’s always better to treat before the problem comes then
after there is a distinction made between intermittent and persistent
asthma intermittent is if it’s two or less times per week okay if that’s the
case then this is all you need if it’s persistent however if you’re having to
use this albuterol inhaler more than two times per week then it’s persistent at
that point we need to go to something higher and we’ll talk about that okay so
let’s talk about these steps that are reported in terms of treatment from one
being the least severe all the way up to six being the most severe and as we
talked about step one is the intermittent asthma and so the Saba or
the short-acting beta agonist is all that’s needed once you have more than
two exacerbations per week because of the fact that you’re having inflammation
that’s the cornerstone there you’re going to start the patient everybody
gets a Sabba of course but you’re going to add an inhaled corticosteroid and you
could start this out of the low dose and go from there so I’ll say a low dose when you get to step three if that’s
working and if your if the patient is still using this – 2 + times per week
then move on to the next step which would be of course keep using that Sabba
if you’d have to and use that low-dose inhaled corticosteroid so you can use
low dose or medium dose okay and these inhaled corticosteroids by the way are
medications like fluticasone mometasone budesonide these are all inhaled
corticosteroids that come as packaged into many different marketing tools
you’ll see advair you’ll see symbicort you’ll see dual era these are all
inhaled corticosteroids as combinations so you use the Saba which is the
albuterol that’s going to take care of your exacerbations and then you want to
add this inhaled corticosteroid to reduce the inflammation and so you can
either increase the dose to a medium dose or at step three what you can do is
you can add a lab la VA and that’s a long-acting beta agonist not a
short-acting but a long-acting now I want to make a point here that’s
important they’re long-acting beta agonists are medications like salmeterol
and for Adel okay for moderate and some either all these are the two long-acting
beta agonists I want you to notice an important point they may ask you about
this and test you on a test regarding this is that the lava is always added to
the inhaled corticosteroid never in asthma will we ever start a patient on a
mono therapy with Alaba a long-acting beta agonist first before
starting the inhaled corticosteroid they have noticed and there there’s some
literature out there that there are increased cardiac deaths when a patient
is placed on just a lawn acting beta agonist without an inhaled
corticosteroid so you can see as we step up the lab is always added to the
inhaled corticosteroid I think I made that point okay step four of course
we’re gonna go back and continue the Saba and we’re gonna probably be using
an inhaled corticosteroid slash lab ah okay the other thing you can add here as
an alternative is this Luco I mean receptor antagonist that would be
medications like montelukast or zephyr Lu caste
these are medications like singulair accolade those are the brand names for
them and remember what we talked about before this medicine is actually very
helpful if you know you’re dealing with something like santer’s triad where
you’ve got nasal polyps and aspirin or NSAIDs sensitivity these are medications
that that you could add at this point and these are basically inhibiting the
leukotrienes when we give it to step 5 then we’re going up to Sabbath of course
we always have the Sabha and the inhaled corticosteroid / lab but these are
high-dose inhaled corticosteroids so we’re using very high dose in
combination with your lab so you’ve got a low dose a medium dose and a high dose
now when you get up here to step five there’s another medication that I’ve
alluded to that you could use remember we talked about IgE in the first lecture
when these immunoglobulins are high they could be driving the reaction there’s a
medication called o mal is you mAb which is actually an antibody itself which
attacks the IgE antibody now this is a very expensive medication we don’t use
it very frequently and we usually use it if nothing else is going to work but
that’s another potential thing that we can use and then finally when you get up
to stage six you’re using everything that we use before but now you’re
putting the patients on oral prednisone which we don’t like to do now let’s talk
about side effects briefly Sabah these are the short-acting beta agonists
tachycardia you have to watch out for a fast heart rate inhaled corticosteroids
these are inhaled corticosteroids even though they’re being inhaled there are
some side effects that you have to be aware of osteoporosis pneumonia and make
sure your parents are aware of this also you need to rinse mouth out
after use because they can cause fungal infections on your tongue the OMA Lizzie
mAb this has got a side effect of cancer of lymphoma so you definitely want to be
having a conversation with your patients in terms of risks and benefits the risk
of cancer is pretty small and you’re gonna use Oh Melissa mab if you’ve got a
higher risk of death from asthma than you would from cancer okay so just be
aware that you’ve got to always weigh the risks and benefits of course oral
prednisone increases your risk of osteoporosis pneumonia and fungal
infections but this is higher than inhaled corticosteroids because this is
being given orally and it’s getting into your system systemically okay so that
was a overview of asthma the pathophysiology causes diagnosis and
treatment thanks for joining us you

99 thoughts on “Asthma Explained Clearly by | 2 of 2

  1. Great explanation but just to clarify on some errors I noticed.

    1) For SABA, I would recommend albuterol and not levalbuterol that is the R-enantiomer of albuterol. There has been no benefit of using this medication (brand xopenex) and is more costly to the patient. They found in animal studies that the S-enantiomer caused side effects but when they did human trials they did not find any significant side effects.

    2) MDI vs. nebulizer and stating that there is no difference between the two is a HUGE misconception. You should ALWAYS prefer to give your patients MDIs as quite a few studies have shown that MDIs were able to give more of the drug into the airways of patients especially children. Using nebulizers on children causes tachycardia so especially in this patient population you would always want to use MDIs. They are more effective, don't require electricity, and are more efficient (nebulizers take at least 15-20 minutes to administer).

    Source: I'm a pharmacy student

  2. Thank you very much for the explanation. 聽Salman Khan was spot on about the improved learning from short videos with concise explanations and VISUALS that can be replayed. 聽You explained your criteria for going from step 1 to 2 and 2 to 3, but what about after that? 聽Is 2+ SABA uses/week still the defining factor for going up further steps? 聽Thank you very much.

  3. Thank you for this information. I am now warned about the many side effects which after 5 years of taking this medication i have only just been made aware. Thank you for the work you have put into the making of this COPD and ASTMA video's I for one am very grateful.

  4. Exam tomoro and for some reason this has just shone a bright light in thy mind. Thank you thank you thank you a million times. You are a Legend!!!!

  5. Hy your videos are amazing, if you had time could you please do one on skin integrity, such as the skin anatomy, pressure sores and skin injuries, thank you

  6. Thank you for this lecture series. I found these lectures to be concise, highlighting on key areas in a short amount of time. 聽This is exactly what I needed to know in reviewing material. Thank you for helping out this PA student.聽

  7. I only have one inhaler, even though I can use my inhaler up to 5 times a week. Well I exercise up to 5 times a week. I know, I'm lazy.

    Thank you for this (and the other) video! My understanding of asthma is better now!

  8. Really nice videos. Just on Respiratory rotation now and finding all of these videos incredible for our homework on specific conditions! Thanks 馃榾

  9. These were great videos, but they didn't go into what happens with people who have severe, persistent asthma, and how much "reversibility" is reduced.

  10. I am preparing usmle step 1 and I find these videos amazing. please do some more because they are so helpful. love the way you explain all this stuff. you make it look easier 馃槉

  11. I am preparing usmle step 1 and I find these videos amazing. please do some more because they are so helpful. love the way you explain all this stuff. you make it look easier 馃槉

  12. This is so clear and precise! I have a learning disability, so just listening to my professor lecture doesn't help! Your calm voice and diagrams really help! Thank you!!!

  13. I'm at 4 or 5 normally, been to 6 many times. Never was told any of this. Told COPD but wonder at that. How can I encourage my doctor to educate himself?

  14. I think you're confusing exacerbation/flare-up with symtoms. Exacerbation is caracterized by increased symptoms or air flow limitation or use of SABA which require use of systemic corticosteroid for a short duration.
    Symptoms are shortness of breath, cough, limitation of activity etc which resolve after use of SABA in the intermittent asthma. Intermittent asthma have a risk of less than two exacrebation per year. Correct me if i'm wrong.

  15. I have asthma, and this helped me a lot. One issue I have is thrush with the inhaled corticosteroids, despite rinsing my mouth. It really puzzles the PCMs I've had.

  16. excellent lecture as always. Please do consider not using dark blue colour when writing on the videos as it really affects visibility of the crucial information being shared

  17. Hello Medcram, you alluded that anti-muscarinic medication may also have a role in Asthma Tx but you haven't mentioned it in your treatment stages. Curious to know why. Thanks for the video, its very helpful.


  19. When I was about 3 or 4, we moved into a house that had roaches (my mom was a single mom and couldn't afford much). A few months after living there, I started having some pretty bad asthma attacks. Once we moved out, the attacks stopped. In fact, by high school, I was able to out run everyone. I was fast, but not the fastest, but I could run for much, much longer than the other kids. About a year ago, a friend of mine moved into an apartment that had roaches. The first couple times I went there, I was fine. Then, things started to progressively get worse each time I stopped by. First a mild cough with sputum, then slight wheezing, and finally a full on asthma attack. Needless to say, I haven't been back since, and he's not allowed in my house (lol).

  20. I am so glad and thankful I came across this channel! Im in nursing school and these helps me understand everything so much better!! I have a test on respiratory tomorrow!!!

  21. You are the best!! I call you the lecture Artiest.. seriously the way you explained these information is talent not everyone can do it !!

  22. I鈥檓 an RN wanting to understand how medicine works so that I鈥檓 able to better care for my patients. You lectures are easy to understand! You have helped me so much.

  23. You are so blessed with amazing gifts: To treat and to teach! You have helped me immensely in my Nurse Practitioner program. Buying your courses now!

  24. I wish my doctor knew all this stuff. I go to him every now and then telling him my breathing is getting worse and worse due to my asthma, and he just keeps prescribing me different brands of inhalers. I'm tired of paying for inhalers. I just want to be able to breath properly again.,,!!!

  25. Symptoms and Treatment part could have been updated to the present days of medication with newer drugs .
    In step 5 we can use oral glucocorticoids.
    Nice video to learn tho 馃憣馃挓

  26. This helps a lot. My kid has been diagnosed with asthma and I don鈥檛 even know what asthma is. Thanks!

  27. Question: how do you actually confirm asthma? How do you confirm your patient is having asthma. Triad of symptoms? Do you need to do a PFT?

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