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Respiratory Disorders
Module 3. Asthma and Pulmonary
Thromboembolism
Process
• Step 1. Complete Module #3 with voice
overlay
• Step 2. Answer the question following
Module #3
• Step 3. This completes all the modules in
the respiratory unit, you can either move
on to another unit or take a break.
Module #3 Learning Objectives
• Describe the definition and diagnostic
features for asthma and how this disorder
differs in later life.
• Explain how the stage of severity of
asthma directs treatment
• Outline the approach to evaluation of
suspected pulmonary emboli and
treatment of this process when that
diagnosis is confirmed
Asthma: Prevalence & Mortality
• Second peak in
prevalence after age
65
• 5-10% after 65 yrs
meet criteria for
obstruction &
bronchial
hyperactivity
• 45% of all asthma
deaths after 65 yrs
Asthma: Definition
• Chronic inflammatory disorder of airways
• Triggers:
– Air pollutants
– Allergies
– Chemicals
– Emotional distress
– Exercise
– Tobacco smoke
– viruses
Asthma: in later life
• Cough is a common presentation
• Air flow restriction is less variable and
episodic
• Presents more fixed obstruction
• More difficult to classify
• PEF less reliable
Asthma: Symptoms
• Classic Symptoms:
Image from :http://www.images.md
In older patients DDX
of this same set of
symptoms
includes:
• Heart Failure
• COPD
Asthma: Diagnosis & Staging
Stage
Intermittent
Mild
Persistent
Moderate
Persistent
Severe
Persistent
Daytime
Symptoms
<1/ wk,
asymptomatic
in between
≥ 2/wk, may
affect activity
Daily, attacks
affect activity
Continual,
limits activity
Nighttime PEF or
Symptoms FEV1
< 2/month ≥ 80%
> 2/month
≥ 80%
> 1/wk
60-80 %
frequent
≤ 60%
Asthma: Nonpharmacologic
Therapy
• Avoid triggers
• Educate on disease
management
• Use of MDIs/ peak
flow meters
Asthma: Geriatric Pharmacotherapy
Stage
Daily med
Other options Geri Notes
Intermittent
Mild
Persistent
None
ß-2 agonist MDI prn
Low dose steroid
by MDI
ß-2 agonist MDI or
LK** or SR-TH* or
cromolyn
Many drug
interactions with
theophylline
Moderate
Persistent
Low-med dose
MDI steroid + long
acting MDI ß-2
agonist
Med dose MDI
steroid +SR-Th or
med MDI steroid +
LK** or high dose
MDI steroid
Many patients
have fixed
obstruction and
ipratropium is
helpful & tolerated
Severe
Persistent
high dose MDI steroid + long acting MDI ß-2 agonist + one
or more of the following: ipratropium or tiotropium LK** , SRTH*, or oral steroid
* SR-TH= slow release theophylline ** LK=leukotriene modifiers/inhibitors
Pulmonary Thromboembolism (PE)
•
•
•
•
•
Incidence increases with age
3.5/1000 60-74 years
9/1000 after age 75
30% fatality untreated
Many conditions common in old age mimic
PE: Symptoms
Classic Triad
• Dyspnea
• Chest pain
• Hemoptysis
Occurs in < 20% of
cases
Any of these:
• Dyspnea
• Chest pain
• Hemoptysis
• Hypotension
• Hypoxia
• Syncope
• Tachycardia
PE: Evaluation
Suspect
PE
VQ
Scan
High
Intermediate
Low
Anticoagulate
Evaluate Further
No Treatment
Suspect
PE
PE: Evaluation
Angiography
Unstable
VQ Scan
Intermediate
Stable
Or
Ultrasound LEs
Or
D-dimer
> 500
< 500
No Treatment
Suspect
PE
VQ Scan
Intermediate
PE: Evaluation
Stable
Ultrasound LEs
Negative or Nondiagnostic
Comprehensive US of
LEs, serial US LEs, or
Helical CT
Positive
Anticoagulate
High-probability VP lung scan
Image from :http://www.images.md
Angiogram Showing Main Pulmonary
Artery Thromboemboli
Image from :http://www.images.md
PE: Therapy
• First line: low
molecular weight
heparins
• Unfractionated IV
heparin if renal failure
• If using IV heparin do
not bolus
• When warfarin started
do not load
• Acute Massive PE
(filling defects ≥ 2
lobar arteries)
– hypotension,
– severe hypoxia
– or high pulmonary
pressures on echo
• Treat with
thrombolytics
References
• Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TP, eds.
Geriatrics at Your Fingertips, 7th Edition, American Geriatrics Society, New
York, NY, 2005. Respiratory Diseases pp167-176
• Geriatric Review Syllabus: a core curriculum in geriatric medicine. Fifth
Edition 2002-2004. E. L. Cobbs, E.H. Duthie, J.B. Murphy (Eds).
• Value of the ventilation/perfusion scan in acute pulmonary embolism.
Results of the prospective investigation of pulmonary embolism diagnosis
(PIOPED). The PIOPED Investigators.
JAMA. 1990;263(20):2753-9.
• Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive
Lung Disease (GOLD) . NHLBI/WHO Workshop Report, Executive
Summary. National Institutes of Health, National Heart, Lung and Blood
Institute. March 2001. NIH Publication No. 2701A.
http://www.goldcopd.com.
• National Asthma Education and Prevention Program, NAEPP Working
Group Report: Considerations for Diagnosing and Managing Asthma in the
Elderly. Bethesda, MD: National Heart, Lung, and Blood Institute; Feb.
1996. NIH Publication No. 96-3662;
• Global Initiative for Asthma, Global Strategy for Asthma Prevention and
Management. Bethesda, MD: National Heart, Lung, and Blood Institute, April
2002. NIH Publication No. 02-3659. http://www.ginasthma.com.