10 y/o with cough and difficulty breathing
Patient will present as → a 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes.
Asthma is a chronic, REVERSIBLE, inflammatory airway disease characterized by recurrent attacks of breathlessness and wheezing.
- lack of wheezing in an acute attack = emergency
- Peak flow is an inexpensive and easily available monitoring device once the diagnosis of asthma has been established.
- Diminished forced expiratory volume in 1 second (FEV1) you administer an inhaler and they will improve
- (FEV1) to Forced Vital Capacity (FVC) is < 80%
"Did you know that NSAIDs and aspirin can precipitate an acute asthma attack"
Making Sense of Forced Vital Capacity
- Forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath. The amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath. Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
- You would expect the amount of air exhaled during the first second to be the greatest amount. In asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio.
GOLD STANDARD = PEAK EXPIRATORY FLOW RATE
Spirometry with pre and post-therapy (albuterol inhalation) readings
- Decreased FEV1/FVC (75-80%)
- > 10% increase of FEV1 with bronchodilator therapy
Four major classifications of asthma severity used primarily to initiate therapy:
- Intermittent: symptoms ≤2 days/week, nighttime awakenings ≤2×/month. short-acting β-agonist use ≤2 days/week, no interference with normal activity
- Mild persistent: symptoms >2 days/week but not daily, nighttime awakenings 3–4×/month, short-acting β-agonist use >2 days/week but not daily, minor limitations in normal activity
- Moderate persistent: daily symptoms, nighttime awakenings ≥1×/week but not nightly, daily use of short-acting β-agonist, some limitation in normal activity
- Severe persistent: symptoms throughout the day, nighttime awakenings often 7×/week, short-acting β-agonist use several times a day, extremely limited normal activity
Treatment is stepwise:
Intermittent: Less than 2 times per week or ≤2 night symptoms per month
- Step 1: Short-acting beta2 agonist (SABA) PRN
Mild Persistent: More than 2 times per week or 3-4 night symptoms per month
- Step 2: Low-Dose inhaled corticosteroids (ICS) daily
Moderate Persistent: Daily symptoms or more than 1 nightly episode per week
- Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily
- Step 4: Medium-Dose ICS +LABA daily
Severe Persistent: Symptoms several times per day and nightly
- Step 5: High-Dose ICS +LABA daily
- Step 6: High-Dose ICS +LABA +oral steroids daily
Acute treatment:
Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
![]() |
|
![]() |
Picmonic | |
![]() |
Asthma is a common form of obstructive lung disease characterized by bronchial hyperresponsiveness in which the airways become inflamed, produce excess mucus, and constrict to triggers such as cold air, dust, pollen, exercise or smoke. Asthma is more common in those with other atopic disease like eczema or hay fever. Unlike other obstructive lung diseases, a key component of asthma is the reversibility of symptoms. Curschmann's spirals and Charcot Leyden crystals can be found in the sputum of asthmatics and chronic asthma can lead to smooth muscle hypertrophy of the airways. Signs and symptoms include cough, wheezing, initially decreased PaCO2 levels, and pulsus paradoxus. A methacholine challenge test can be used to assist in the diagnosis of asthma and common treatment modalities include beta 2 agonists and corticosteroids Play Video + Quiz |
![]() |
Wheezes are continuous musical tones which can be auscultated throughout the lung. These are often high-pitched and result from air moving through narrowed airways. Play Video + Quiz |
Stages of Asthma Treatments | |
![]() |
Stages of Asthma Treatments: Asthma stages of pharmacological treatment is a leveled system to reduce impairments and reduce risk of complications. A typical 1-6 level approach is used in children, who are older than 12. Asthma severity is classified by how often symptoms occur, and how much medication is needed to control symptoms. Additional treatments are added or indicated for any patient who does not currently have control of their symptoms. Patients who are asymptomatic or have well-controlled symptoms should be reevaluated after 3 months. Play Video + Quiz |
![]() |
Intermittent asthma is the mildest form of asthma. It describes asthma symptoms requiring rescue inhaler use no more than twice a week, with nocturnal symptoms less than twice per month. Symptoms do not interfere with the patient's daily life, and patients have normal pulmonary function tests when asymptomatic. Intermittent asthma is treated with inhaled short-acting beta-agonists. Play Video + Quiz |
![]() |
Persistent Mild Asthma: Patients with mild persistent asthma have symptoms most days of the week, nocturnal awakenings three to four times a month, and need to use their rescue inhaler more than twice a week. Pulmonary function tests are within normal ranges. It is treated with inhaled glucocorticoids or long-acting beta-agonists in addition to a short-acting beta-agonist. Play Video + Quiz |
![]() |
Persistent Moderate Asthma: Patients with moderate persistent asthma have symptoms requiring a rescue inhaler daily, with nocturnal awakenings at least once a week but not nightly. Pulmonary function tests show a decrease to 60-80% of predicted normal. Pharmacologic management in step 3 of the asthma management protocol calls for the addition of a long-acting beta agonist to the step 2 medications, or increase to medium-dose inhaled glucocorticoids. Play Video + Quiz |
![]() |
Persistent Severe Asthma: Patients with severe persistent asthma have symptoms requiring a rescue inhaler multiple times per day, with nocturnal awakenings every night. Pulmonary function tests show a decrease to less than 60% of predicted normal. Severe persistent asthma requires advancement to step four on the asthma management protocol. This includes escalation to medium-high dose inhaled steroids with a long-acting bronchodilator, or the addition of systemic corticosteroids. The anti-IgE monoclonal antibody, omalizumab, may also be added for patients with allergic asthma. Play Video + Quiz |
Question 1 |
chest x-ray Hint: A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above. | |
sputum gram stain Hint: A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia. | |
peak flow | |
ventilation - perfusion scan Hint: A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patient above does not have any risk factors that would lead you to suspect such a diagnosis. |
Question 2 |
Albuterol inhaler (Proventil) | |
Inhaled corticosteroids Hint: Inhaled corticosteroids are effective in exercise-induced asthma but are not acute acting and due to the side effect profile, they are not first line agents. | |
Aminophylline (Theo-Dur) Hint: Aminophylline is not used as a first-line agent as a bronchodilator for patients with exercise-induced asthma. | |
Ipratropium (Atrovent) Hint: Ipratropium main use is with suppression of mucous secretions and this is not a component of the exercise-induced asthma patient. |
Question 3 |
Oral prednisone Hint: Oral corticosteroids, such as prednisone, are added to therapy in severe persistent asthma. While a course of oral corticosteroids may be needed for mild exacerbations of asthma, they are not added until inhaled corticosteroids have failed to control the symptoms. | |
Oral theophylline Hint: Due to its safety profile, oral theophylline is now considered a third or fourth line treatment option for asthma. | |
Salmeterol inhaler Hint: Long acting inhaled beta2-agonists, such as salmeterol, are not added to the treatment regimen until the symptoms indicate a moderate persistent asthma. Long acting inhaled beta2 - agonists should also not be used in place of inhaled steroids. | |
Beclomethasone inhaler |
Question 4 |
Asthma | |
Tinea pedis Hint: Patients with atopic dermatitis are more likely to get superimposed viral or bacterial infections such as herpes simplex or staphylococcal, but they are not more at risk for fungal infections. | |
Squamous carcinoma Hint: Patients with atopic dermatitis are at no greater risk for any skin cancer. | |
Systemic lupus erythematosus (SLE) Hint: Lupus is a connective tissue disorder of the immune system, but unrelated to atopic dermatitis. |
Question 5 |
methylxanthine oxidase inhibitor Hint: Methylxanthine oxidase inhibitor preparations may have beneficial effects in some patients, but their value is limited due to a narrow therapeutic window and modest efficacy. | |
long acting beta agonist inhaler Hint: Long acting beta agonist inhalers should not be used in place of anti-inflammatory therapy. | |
leukotriene inhibitor Hint: Leukotriene inhibitors are less desirable alternatives to inhaled corticosteroids. | |
inhaled corticosteroid |
Question 6 |
call the health care provider regularly Hint: Calling the health care provider regularly or asking a family member to monitor symptoms is not effective in patients understanding how to manage their asthma symptoms. | |
keep a diary of symptoms Hint: Keeping a diary may be effective for patients to understand their cause of symptoms, but would not be effective in helping to manage their symptoms. | |
monitor peak flow | |
ask a family member to monitor symptoms Hint: See A for explanation. |
Question 7 |
Airway inflammation
| |
Increased pulmonary secretions Hint: Increased pulmonary secretions are the mechanism in chronic bronchitis. | |
Presence of Ghon complexes Hint: The presence of Ghon complexes is noted in pulmonary tuberculosis. | |
Irreversible fibrosis Hint: Irreversible fibrosis of the lung parenchyma is associated with interstitial lung diseases. |
Question 8 |
Albuterol (Proventil) inhaler | |
Montelukast (Singulair) Hint: Leukotriene modifiers, such as montelukast, may be added to the treatment of uncontrolled asthma as a long- term controller after the initiation of inhaled corticosteroids. | |
Salmeterol (Serevent) inhaler Hint: Long-acting beta 2-agonists, such as salmeterol, are indicated for long-term control of asthma that is categorized as moderate persistent to severe persistent. | |
Sustained release theophylline Hint: Sustained release theophylline is an alternative treatment for asthma that is at least categorized as mild persistent; however its narrow therapeutic window and side effects limit its use. |
Question 9 |
Decrease In FEV1 Hint: See B for explanation. | |
Increase in FEV1 | |
Decrease in FVC Hint: The forced vital capacity (FVC) is not a function of obstruction and is generally normal in early mild asthma or lower than expected in severe or long-standing asthma. Either way, it is not expected to change with administration of a short-acting bronchodilator. | |
Increase in FVC Hint: See C for explanation. |
Question 10 |
pH = 7.27 pCO2 = 46 pO2 = 56 | |
pH = 7.60, pCO2 = 18 pO2 = 80 Hint: See A for explanation. | |
pH = 7.44, pCO2 = 38 pO2 = 90 Hint: See A for explanation. | |
pH = 7.52, pCO2 = 28, pO2 = 80 Hint: See A for explanation. |
Question 11 |
Mast cell stabilizer Hint: A mast cell stabilizer is an alternative treatment but not the preferred treatment. | |
Long acting beta agonist Hint: Long acting beta agonist can be used as adjunctive therapy with an anti-inflammatory. | |
Leukotriene receptor antagonist Hint: Leukotriene receptor antagonists are an alternative treatment but not the preferred treatment. | |
Low dose inhaled corticosteroid |
Question 12 |
Anti-inflammatory Hint: See C for explanation. | |
Immunotherapy for specific allergens Hint: See C for explanation. | |
Relaxing of bronchial smooth muscle | |
Reduction of leukotriene production Hint: See C for explanation. |
List |