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
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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 |
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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. |
| 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. | |
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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. |
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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. |
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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. |
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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 addition of systemic corticosteroids. The anti-IgE monoclonal antibody, omalizumab, may also be added for patients with allergic asthma. |
Question 1 |
A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment?
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 1 Explanation:
A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.
Question 2 |
A 17 year-old male who is trying out for the track team notes excessive coughing with chest tightness when running. Which of the following is the most appropriate preventive agent for this patient?
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 2 Explanation:
Albuterol is a beta-2 agonist that results in bronchodilation that makes this a useful agent in a patient with exercise-induced asthma when used just prior to exercise.
Question 3 |
A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time?
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 3 Explanation:
This patient has progressed to mild persistent asthma. In addition to her inhaled beta2- agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control. Other options may include cromolyn or nedocromil.
Question 4 |
A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future?
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 4 Explanation:
Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future.
Question 5 |
A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen?
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 5 Explanation:
According to the stepwise approach for managing asthma by the National Asthma Education and Prevention Program, inhaled corticosteroids are indicated for mild to moderate persistent asthma.
Question 6 |
Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms?
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 6 Explanation:
Monitoring peak flow is the most effective way for the patients and healthcare providers to manage symptoms and guide treatment.
Question 7 |
Which of the following is the major pathogenetic mechanism that causes asthma?
Airway inflammation
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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 7 Explanation:
Airway inflammation is the major pathogenetic mechanism that leads to the development of asthma.
Question 8 |
A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment?
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 8 Explanation:
This patient has mild intermittent asthma which is initially treated with inhaled beta 2-agonists as needed. No long-term control medications are indicated.
Question 9 |
You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility?
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 9 Explanation:
In asthma, the airway obstruction should be at least partially relieved be a short-acting bronchodilator. This would be reflected in an increased forced expiratory volume in 1 second (FEV1).
Question 10 |
A 14 year-old male presents to the ED experiencing a severe asthma attack. His respiratory effort is shallow and he is using accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95. Which of the following ABG findings suggests the poorest prognosis?
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 10 Explanation:
pH = 7.27 pCO2 = 46 pO2 = 56 is associated with the poorest prognosis in this patient. The clinical presentation of asthma is a respiratory alkalosis with high RR, low pCO2, and decreased pO2. The fact that the pCO2 is elevated despite the high respiratory rate suggests profound air trapping and respiratory failure.
Question 11 |
A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient?
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 11 Explanation:
Low dose inhaled corticosteroids are the preferred treatment for mild persistent asthma.
Question 12 |
What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma?
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. |
Question 12 Explanation:
The mechanism of action for salmeterol is the relaxation of bronchial smooth muscle.
There are 12 questions to complete.
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