2 Asthma, COPD, and Hiccups

Question 1

Mild asthma

Answer 1

s/s: dyspnea only with activity
initial PEF ≥70% predicted or personal best
cc: prompt relief with inhaled SABA

Question 2

Moderate asthma

Answer 2

s/s: dyspnea interferes with or limits usual activity
initial PEF 40-69 predicted or personal best
cc: relief from frequent inhaled SABA. Symptoms for 1-2 days after oral corticosteroids begun

Question 3

Severe asthma

Answer 3

s/s: dyspnea at rest; interferes with conversation
initial PEF **<40% predicted or personal best
cc: partial relief from frequent inhaled SABA. Symptoms for ≥3 days after oral corticosteroids begun

Question 4

Life-threatening asthma

Answer 4

ss: too dyspneic to speak; perspiring 😰
initial PEF ≤25% predicted or personal best
cc: minimal or no relief from frequent inhaled SABA;
IV steroids; adjunctive therapy; needs ED or ICU

Question 5

Rirsk factors for death from asthma

Answer 5

past history of severe exacerbation
≥2 hospitalizations for asthma in the past year
≥3 canisters per month of inhaled SABA
≥4 ED visits for asthma in the past year

difficulty perceiving airflow obstrution or its severity
low SE status or inner-city resident
illicit drug use
psychiatric disease or medical comorbidities

Question 6

Heart failure can largely be excluded in patients with acute dyspnea and NTproBNP of

Answer 6

NT-pro-BNP ≤300 pg/mL
| BNP <100 pg/mL

Question 7

only drug that’s US FDA approved for intractable hiccups

Answer 7

Chlorpromazine
initial dose in ED:
25-50 mg IV, repeat in 2-4 h if needed

maintenance dose on discharge
25-50 mg PO 3-4x/day

• benign and self-limited hiccups: <48 hours
• persistent: >48 hours
• intractable - last longer than a month

Question 8

Other drugs for hiccups

Answer 8

Metoclopramide 10 mg IV or IM
MD: 10-20 mg PO 3x/day for 10 days

Haloperidol 2-5 mg IM
MD: 2-4 mg PO 3x/day

Nifedipine 10-20 mg PO
MD: 10-20 mg PO 3-4x/day

Gabapentin 100 mg
MD: 100 mg PO 3x/day, titrated up to 120 mg/day (?)

Question 9

Physical maneuvers as management for hiccups

Answer 9

FIQS

Foreign body removal
Ice water, sip
Quickly drink water
Sugar, swallow a teaspoon

Question 10

Classification of COPD severity

Answer 10

mild: FEV1 ≥80% pred
mod: FEV1 50-79%
SEV: FEV1 30-49%
very sev: FEV1 <30%

Question 11

Target SpO2 for COPD patients

Answer 11

88-92%

Question 12

Doses of magnesium sulfate for status asthmaticus

Answer 12

1-2g IV over 30 minutes

Nebulization:
95 mg of nebulized MgSO4 in 4 divided doses 20mins apart
384 mg of nebulized MgSO4 in sterile water (?)

Question 13

Other drugs for status asthmaticus

Answer 13

KETAMINE
IV bolus dose of 0.15 mg/kg
then infusion of 0.25 mg/kg/hour

EPINEPHRINE
SC or IM, 0.5 mg (standard adult EpiPen dose) 📌

HeliOx
80% helium, 20% oxygen

Question 14

Inclusions for NIV

Answer 14

Acidosis <7.36
Hypercapnea, PaCO2 >50 mmHg
Oxygen deficit, PaO2 <60 mmHg or SaO2 <90%
Severe dyspnea with clinical signs such as respiratory muscle fatigue or increased work of breathing

Question 15

Exclusions for NIV

Answer 15

Respiratory arrest
High aspiration risk
Viscous or copious secretions

CV instability
Burns
Change in mental status; uncooperative patient

Recent facial or gastroesophageal surgery
Craniofacial trauma
Fixed nasopharyngeal abnoramalities
Extreme obesity

Question 16

Indications for intubation

Answer 16

Respiratory or cardiac arrest
Respiratory failure
Persistent hypoxemia despite optimal respiratory treatment
Unable to tolerate NIV or NIV failure

Massive aspiration
Persistent inability to remove respiratory secretions

Hemodynamic instability
Hypotension

Decreased consciousness
or increased agitation