7 Asthma Takahashi

Question 1

What is the diagnostic criteria for Asthma?

Answer 1

Episodic airflow obstruction. At least partial reversibility. Alternative diagnoses are excluded (obstructive sleep apnea, GERD). Wheezing, with a history of: cough (worse at night), recurrent wheeze, recurrent difficulty breathing, recurrent chest tightness. Symptoms worse with exercise, etc.

Question 2

What are the measures for assessment and monitoring?

Answer 2

Severity (baseline). Control (intensity of exacerbation). Responsiveness (reversibility)

Question 3

What symptoms describe impairment with asthma?

Answer 3

Nocturnal awakenings. Needs for SABA. Work/school days missed. Ability to perform normal/desired activities. QOL assessments

Question 4

How does HEDIS measure asthma severity?

Answer 4

(# canister controller medications) / (# canister controller medications + # canister relief medications)

Question 5

What are the characteristics of Intermittent Asthma?

Answer 5

Sx < 2x/week (asymptomatic between episodes, brief duration of episodes). Nighttime Sx < 2x/month. Lung function: 80-100% of predicted (< 20% variability)

Question 6

What are the characteristics of Mild Persistent Asthma?

Answer 6

Sx > 2x/week, < daily (may affect activity). Nighttime Sx > 2x/month. Lung function: 80-100% of predicted (20-30% variability)

Question 7

What are the characteristics of Moderate Persistent Asthma?

Answer 7

Daily Sx (daily use of rescue medication), activity affects, attacks > 2x/week. Nighttime Sx > 1x/week. Lung function: 60-80% of predicted (PEF variability > 30%)

Question 8

What are the characteristics of Severe Persistent Asthma?

Answer 8

Continual symptoms. Frequent nighttime symptoms. Lung function < 60% of predicted (variability > 30%)

Question 9

What is the primary therapy for intermittent asthma?

Answer 9

Beta-Agonist PRN

Question 10

What is the primary therapy for the lowest step of persistent asthma?

Answer 10

Low-Dose ICS + Beta-Agonist PRN

Question 11

Whats the 2nd step up in persistent asthma treatment?

Answer 11

ICS + LABA OR Medium-Dose ICS. PLUS. Beta-Agonist PRN

Question 12

What is the 3rd step up in persistent asthma treatment?

Answer 12

Medium-Dose ICS + LABA. PLUS. Beta-Agonist PRN

Question 13

What is the 4th step up in persistent asthma treatment?

Answer 13

High-Dose ICS + LABA. PLUS. Beta-Agonist PRN

Question 14

What is the 5th (last) step up in persistent asthma treatment?

Answer 14

High-Dose ICS + LABA + Oral CS. PLUS. Beta-Agonist PRN

Question 15

What are the safety guidelines for LABAs?

Answer 15

Not to be used as monotherapy. Long-term use for patients without control on other therapy. Shortest duration during step-up therapy. Use combination products to ensure adherence

Question 16

What are the characteristics of Pediatric Asthma?

Answer 16

50-80% of childhood asthma develops before age 5. Underdiagnosed (Chronic bronchitis, wheezy bronchitis, recurrent pneumonia, GERD, URI). Differential diagnosis (CF, primary immunodeficiency, foreign body, congenital heart disease, parasitic disease)

Question 17

When is a diagnosis of pediatric asthma strongly suspected?

Answer 17

3 or more episodes in the last 12 months (lasts for more than 1 day and interrupts sleep). Parental Hx of asthma. Atopic dermatitis. Allergic rhinitis. Eosinophilia. Wheeze apart from URI

Question 18

What are some higher intensity treatments when taken to hospital for episode?

Answer 18

Use of oxygen to drive nebulizer. Continuous albuterol nebulized. Beta-agonist infusion (terbutaline). Intubation

Question 19

When formulating a treatment plan, what should you think about with maintenance medications?

Answer 19

Inhaled route preferred. Leukotriene modifiers

Question 20

When formulating a treatment plan, what should you think about with Acute Episode Management?

Answer 20

SABA inhaler. SABA nebulizer. SABA oral solution/tablet

Question 21

When should patients have follow-ups for their asthma?

Answer 21

Within 1 week of flare. 3 days of hospitalization. Schedule before leaving the office

Question 22

How can you “sell” preventative therapy to parents?

Answer 22

Reduce frequency of PO steroid bursts. Improved exercise tolerance. Reduce days missed from school. Reduce days parents miss work. “Topical” steroid administration. Reduce hospital and urgent clinic appointments

Question 23

What is asthma’s impact on growth and development in pediatrics?

Answer 23

Inhaled corticosteroids improve health outcomes for children with mild or moderate persistent asthma and that the potential albeit SMALL risk of delayed growth from the use of inhaled corticosteroids is well balanced by their effectiveness. Most children treated with recommended doses of inhaled corticosteroids achieve their predicted adult heights

Question 24

When should a referral to an Allergist/Primary Care Physician be done for Asthma?

Answer 24

History of intubation. Anaphylactic reactions. History of rapidly escalating symptoms. Severe persistent Asthma

Question 25

What agents require Medguides to be given with them?

Answer 25

Advair. Xolair. Dulera. Symbicort. Serevent. Foradil

Question 26

What is Omalizumab (Xolair)?

Answer 26

IgE Blockade agent. Administered by SQ injection (stable for 6 hrs after reconstitution). Potential for anaphylactic reactions (Murine component to recombinant DNA process in manufacture)

Question 27

What is the dosing for Omalizumab (Xolair)?

Answer 27

Dosage based on algorithm based on weight and IgE levels. Approved for 12 yo and older. Persistent symptoms while taking controller therapy

Question 28

What are the ADRs with Omalizumab (Xolair)?

Answer 28

Higher incidence of cancer in patients with history of Ca. Anaphylaxis. HA. Injection site pain. URTI/sore throat. Sinusitis

Question 29

What are some recommendations and considerations for Omalizumab (Xolair)?

Answer 29

Cost. Administration in controlled clinic environment. Limited efficacy information. For moderate to severe persistent asthma. Return to baseline after discontinued

Question 30

What are some characteristics of Mometasone Inhaled?

Answer 30

Once to twice daily dosing (very good for compliance). Dry powder delivery system. Counter on device. Humidity dependent expiration

Question 31

What is the first nebulized corticosteroid?

Answer 31

Pulmicort Respules. Suspension, delivery device needed for safe administration

Question 32

What caution should be used with Leukotriene Inhibitors?

Answer 32

Reported neuropsychiatric events: Agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, etc.

Question 33

What is Hydrofluroalkane?

Answer 33

One of the new alternative propellants used. Lower vapor pressure, soluble for beclomethasone, smaller particle size, lower velocity, does not require spacer, can still use spacer

Question 34

What are the spacer device instructions?

Answer 34

Shake canister. Insert pressurized MDI mouthpiece into device. Exhale completely. Spray once. Inhale slowly, breath hold, then exhale. Brush teeth or rinse mouth after inhaled corticosteroids

Question 35

When should nebulized medications be used?

Answer 35

Patient not able to use other delivery systems. Patient adheres to scheduled appointments

Question 36

What are the Pro’s of Nebulizers?

Answer 36

Easy to inhale - not technique dependent. Higher dose can be administered

Question 37

What are the Con’s of Nebulizers?

Answer 37

Higher dose - more side effects. Bulky. Expensive. Time consuming