1. MTB Step 3 - Asthma

Question 1

INTRODUCTION

What are (2) Clinical Manifestations of mild-to-moderate Asthma?

Answer 1

1. Shortness of Breath (SOB)
2. Expiratory Wheezing

Question 2

INTRODUCTION

What are (2) additional Clinical Manifestations of severe Asthma?

Answer 2

1. Use of Accessory Muscles
2. Unable to Speak in Complete Sentences

Question 3

INTRODUCTION

What are the (5) Most Important Features of Severe Asthma?

Answer 3

1. Hypoxia
2. Hyperventilation (increased respiratory rate)
3. Respiratory Acidosis
4. Decrease in Peak Flow
5. Possible Absence of Wheezing (beyond wheezing)

Question 4

UNCLEAR DIAGNOSIS

What (4) Tests should ALL patients with Shortness of Breath (SOB) receive?

Answer 4

1. C ontinuous Oximeter
2. O xygen
3. C hest X-Ray (CXR)
4. A rterial Blood Gas (ABG)

Question 5

UNCLEAR DIAGNOSIS

What should be Performed in a patient with Shortness of Breath (SOB) and an unclear diagnosis of Asthma?

Answer 5

Pulmonary Function Tests both BEFORE and AFTER Inhaled Bronchodilators:

PFT Methods:

• Spirometry
• Plethysmography

PFT Measures:

• Tidal Volume (TV)
• Minute Volume (MV)
• Vital Capacity (VC)
• Functional Residual Capacity (FRC)
• Forced Expiratory Volume (FEV)

Question 6

UNCLEAR DIAGNOSIS

What Pulmonary Function Test (PFT) Finding is Confirmatory for Asthma and Reactive Airway Disease in a patient currently Short of Breath (SOB)?

Answer 6

Increase in FEV1 of > 12% AFTER given Bronchodilators (compared to FEV1 from BEFORE given Bronchodilators)

Question 7

UNCLEAR DIAGNOSIS

What Test Finding is Confirmatory for Asthma and Reactive Airway Disease in a patient who is NOT currently Short of Breath (SOB)?

Answer 7

Methacholine Stimulation Test

Decrease in FEV1 of > 20% AFTER give Methacholine = Asthma

Methacholine** = synthetic **Acetylcholine

Question 8

TREATMENT

What are the (5) Best INITIAL Therapies for Asthma (which should be ordered with the first screen on CCS)?

Answer 8

1. Albuterol (inhaled bronchodilator)
   
   • there is NO max dose.
2. Methylprednisolone (steroid bolus)
   
   • need 4 - 6 hours to be effective.
3. Ipratropium (inhaled)
4. Oxygen
5. Magnesium

Question 9

TREATMENT

When should you place a patient with Asthma in the ICU?

Answer 9

Respiratory Acidosis with CO₂ Retention

Question 10

TREATMENT

What is Persistent Respiratory Acidosis in a patient with Asthma an indication for?

Answer 10

Intubation

and

Mechanical Ventilation

Question 11

ACUTE ASTHMA

What are (8) Therapies that have NO Mortality Benefit for Acute Asthma?

Answer 11

1. Theophylline
2. Cromolyn and Nedocromil
3. Montelukast
4. Inhaled Corticosteroids
5. Omalizumab (anti-IgE)
6. Salmeterol and other long-acting beta agonists (LABAs) such as Formoterol
   • however, if there is an indication for BBs that decreases mortality [MI, CHF] in an asthmatic, then use the BB)
7. Epinephrine
   • Subcutaneously administered epinephrine has no benefit in addition to inhaled bronchodilators.
8. Terbutaline
   • ​​​less efficacious than inhaled Albuterol (Terbutaline is always a wrong answer choice).

Question 12

NON-ACUTE ASTHMA

1. What is the Best INITIAL Therapy for Non-Acute Asthma?
2. What should you Add if the patient remains uncontrolled after the initial treatment?
3. What should you Add if the patient remains uncontrolled after the two initial treatments?

Answer 12

1. Inhaled Bronchodilator (e.g., Albuterol)
2. Inhaled Steroid (chronic controller medication)
   
   • Beclomethasone dipropionate(Qvar)
   • Budesonide (Pulmicort)
   • Fluticasone (Flovent)
3. Inhaled Long-Acting Beta-Agonist (e.g., Salmeterol, Formoterol, Olodaterol, Indacaterol).
   
   • LABAs are never to be used alone

**Oral steroids are used only as a last resort because of adverse effects.​**

Question 13

NON-ACUTE ASTHMA

1. What is “Bronchial Thermoplasty”?
2. When is Bronchial Thermoplasty used?

Answer 13

1. Bronchial Thermoplasty = treatment of airway walls with radiofrequency energy that heats the airway and ablates the smooth muscle.
2. Used when there is severe asthma despite the use of maximum medical therapy and the question describes a patient who is often or continuously on steroids.

Question 14

NON-ACUTE ASTHMA

When would you use Cromolyn or Nedocromil as an alternative Long-Term Controller Therapy in an Asthmatic?

Answer 14

Extrinsic Allergies (e.g., Hay Fever)

Question 15

NON-ACUTE ASTHMA

When would you use Montelukast as an alternative Long-Term Controller Therapy in an Asthmatic?

Answer 15

Atopic Disease

Question 16

NON-ACUTE ASTHMA

When would you use Tiotropium or Ipratropium as an alternative Long-Term Controller Therapy in an Asthmatic?

Answer 16

Chronic Obstructive Pulmonary Disease (COPD)

Question 17

NON-ACUTE ASTHMA

When would you use Omalizumab (Anti-IgE Antibody) as an alternative Long-Term Controller Therapy in an Asthmatic?

Answer 17

• High IgE Levels
• No Control with Cromolyn

Question 18

NON-ACUTE ASTHMA

When would you use Mepolizumab or Reslizumab (IL-5 Inhibitors)​ as an alternative Long-Term Controller Therapy in an Asthmatic?

Answer 18

High Eosinophils

Question 19

NON-ACUTE ASTHMA

What is the Mechanism of Action (MOA) of the Antimuscarinic medication Tiotropium & Ipratropium?

Answer 19

• Because they are inhaled, Ipratropium and Tiotropium inhibit muscarinic receptors predominantly on respiratory mucosae.
• Antimuscarinic activity dries the secretions of goblet cells, decreases bronchoconstriction, and inhibits excess fluid production in bronchi.
• These agents are especially effective in COPD.

Question 20

EXERCISE-INDUCED ASTHMA

What is the Best Treatment for Exercise-induced Asthma?

Answer 20

Inhaled Bronchodilator (e.g., Albuterol) PRIOR to exercise.