ABFM KSA - Asthma

Question 1

Question: 1 of 60

An 18-year-old female presents to your office with a history of wheezing and year-round symptoms of rhinitis. She reports wheezing and coughing several times a week but rarely more than once a day, except in the last year, when she has had to intermittently use albuterol (Proventil, Ventolin) every day for a week at a time. She wakes up with nighttime coughing weekly, without fever or other symptoms, and tells you this tends to scare her cat, who sleeps with her. Albuterol helps her symptoms temporarily. She has been treated with oral corticosteroids on three occasions this past year, most recently 6 weeks ago. Her Asthma Control Test score is 17. Pre- and post-bronchodilator spirometry results are shown below.

Initial testing

FVC…………2.0 L (80% of predicted)
FEV1…………1.4 L (70% of predicted)
FEF 25–75…………1.5 L/sec (89% of predicted)

15 minutes post bronchodilator administration

FVC…………2.3 L (105% of predicted)
FEV1…………2.0 L (100% of predicted)
FEF 25–75…………1.9 L/sec (100% of predicted)

Appropriate management at this time includes which of the following? (Mark all that are true.)

1. Initiation of inhaled formoterol (Foradil) and an inhaled corticosteroid
2. Albuterol, 1–2 puffs as needed
3. A discussion about removing the cat from her bedroom
4. Follow-up in 2 months

Answer 1

1. Initiation of inhaled formoterol (Foradil) and an inhaled corticosteroid
2. Albuterol, 1–2 puffs as needed
3. A discussion about removing the cat from her bedroom
4. Follow-up in 2 months

Critique:

This patient has moderate persistent asthma. She should begin an

• inhaled corticosteroid (choice A) and a
• long-acting β-adrenergic agent (choice A). She should also have a
• short-acting β-adrenergic inhaler (choice B) available for use on an as-needed basis. The patient should also be counseled about
• removing the cat from the room (choice C).
• Follow-up should occur 2–5 weeks (not D) after initiating therapy.

Question 2

Question: 2 of 60

True statements regarding the use of long-acting β2-agonists in asthma include which of the following? (Mark all that are true.)

1. They are useful for treating acute symptoms or exacerbations
2. They represent an alternative to inhaled corticosteroids in patients with persistent asthma
3. They provide a mild anti-inflammatory effect
4. They are beneficial when used in conjunction with inhaled corticosteroids
5. Salmeterol (Serevent) acts more rapidly than formoterol (Foradil)

Answer 2

1. They are useful for treating acute symptoms or exacerbations
2. They represent an alternative to inhaled corticosteroids in patients with persistent asthma
3. They provide a mild anti-inflammatory effect
4. They are beneficial when used in conjunction with inhaled corticosteroids
5. Salmeterol (Serevent) acts more rapidly than formoterol (Foradil)

Critique:

Long-acting β₂-agonists can be used in patients with persistent asthma to provide sustained symptom control, particularly for nocturnal or exercise-induced symptoms.

Because of their relatively slow onset of action and time to peak effect, they should NOT be used for acute symptom relief (not A).

Because they do NOT have a significant anti-inflammatory effect (not C), they should be used with another controller medication, such as an inhaled corticosteroid (not B), in patients with persistent asthma.

The onset of bronchodilation occurs in 2–3 minutes with formoterol, as opposed to 10–15 minutes with salmeterol (i.e. Formoterol is faster-acting than salmeterol)(not E).

Given the possibility of excess mortality noted in the Salmeterol Multi-center Asthma Research Trial (SMART), Long-acting β₂-agonists should be added only when inhaled corticosteroids or other controller medications have failed to control the asthma.

Question 3

Question: 3 of 60

A 14-year-old female presents to you with a recent history of cough and shortness of breath with exercise. Baseline pulmonary function testing reveals an FEV1 of 3.1 L and a PEF of 600 L/min. Exercise testing is scheduled.

Which of the following measurements after exercise would support a diagnosis of exercise-induced bronchospasm? (Mark all that are true.)

1. FEV₁ 2.8 L (90%)
2. FEV₁ 2.5 L (80%)
3. FEV₁ 2.2 L (70%)
4. PEF 540 L/min (90%)
5. PEF 525 L/min (87.5%)

Answer 3

1. FEV₁ 2.8 L (90%)
2. FEV₁ 2.5 L (80%)
3. FEV₁ 2.2 L (70%)
4. PEF 540 L/min (90%)
5. PEF 525 L/min (87.5%)

Critique:

An exercise challenge test is used to establish the diagnosis of exercise-induced bronchospasm (EIB). This can be performed in a formal laboratory setting or a free-run challenge, or by simply having the patient undertake the physical activity that previously caused the symptoms. A 15% decrease in PEF or FEV₁ after exercise is compatible with EIB.

Question 4

Question: 4 of 60

Asthma treatments associated with a dose-dependent reduction in bone mineral density include which of the following? (Mark all that are true.)

1. Oral corticosteroids
2. Inhaled corticosteroids
3. Long-acting inhaled β2-agonists
4. Leukotriene modifiers
5. Theophylline

Answer 4

1. Oral corticosteroids
2. Inhaled corticosteroids
3. Long-acting inhaled β2-agonists
4. Leukotriene modifiers
5. Theophylline

Critique:

Oral corticosteroid therapy has long been known to accelerate bone loss, with fractures occurring in up to 30%–50% of chronically treated patients. A statistically significant, but widely variable, dose-dependent reduction in bone mineral content of subjects with asthma has also been demonstrated in patients treated with inhaled corticosteroids.

No association between the loss of bone mineral content and the use of long-acting inhaled β₂-agonists, leukotriene modifiers, or theophylline has been reported.

Question 5

Question: 5 of 60

Which one of the following is the most common acid/base abnormality in the EARLY stages of an asthma exacerbation?

1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
5. Mixed respiratory alkalosis with metabolic acidosis

Answer 5

1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
5. Mixed respiratory alkalosis with metabolic acidosis

Critique:

Initial findings on arterial blood gas analysis in a patient with an asthma exacerbation typically include hypoxemia and hypocapnia. Primary hypocapnia, with its resulting cellular (acute) and renal (chronic) compensation, produces a respiratory alkalosis. The finding of respiratory acidosis, or a failure to reduce pCO₂, in a patient with an asthma exacerbation would indicate respiratory muscle fatigue and impending respiratory failure.

Question 6

Question: 6 of 60

The mother of a 12-year-old male calls your office and tells you that over the past few days he has had a low-grade fever, runny nose, and cough with yellowish phlegm. He has a history of mild persistent asthma (personal best peak flow 410 L/min) managed with a low-dose inhaled corticosteroid. She says that the previous evening he woke up in the middle of the night because of a coughing fit. She reports that his peak flow dropped to 270 L/min today (69% of personal best), but following two treatments 20 minutes apart with his short-acting β2-agonist his peak flow rose to 385 L/min (94% of personal best) and has been no lower than 330 L/min (80% of personal best) over the past 4 hours.

Which of the following should routinely be recommended in this situation? (Mark all that are true.)

1. Continue the inhaled β2-agonist every 3–4 hours for the next 1–2 days
2. Add an inhaled long-acting β2-agonist
3. Double the dosage of the inhaled corticosteroid for 7–10 days
4. Add an oral corticosteroid
5. Start a 7-day course of amoxicillin

Answer 6

1. Continue the inhaled β2-agonist every 3–4 hours for the next 1–2 days
2. Add an inhaled long-acting β2-agonist
3. Double the dosage of the inhaled corticosteroid for 7–10 days
4. Add an oral corticosteroid
5. Start a 7-day course of amoxicillin

Critique:

Home treatment of asthma exacerbations begins with measurement of peak expiratory flow and initial treatment with an inhaled short-acting β₂-agonist, up to two treatments at a 20-minute interval. This patient demonstrated a good response, as evidenced by the resolution of symptoms and improvement in PEF to at least 80% of personal best. In patients with a good response to initial therapy, continued use of the short-acting β₂-agonist on a time-contingent basis is recommended for 1–2 days.

Although there is evidence to suggest that quadrupling the dosage of inhaled corticosteroids may be of value in mild to moderate exacerbations, doubling the dosage (as recommended in the 1997 NIH guidelines) has been shown to be ineffective for reducing the severity of symptoms or preventing progression of exacerbations. For patients demonstrating a good response to home treatment, oral corticosteroids are not routinely required and should be prescribed only under certain circumstances. Antibiotics are not generally recommended for the treatment of acute asthma exacerbations except as needed for comorbid conditions.

Question 7

Question: 7 of 60

Mediators linked to the pathophysiology of asthma include which of the following? (Mark all that are true.)

1. Histamine
2. Leukotrienes
3. Granulocyte-macrophage colony-stimulating factor (GM-CSF)
4. Interleukin-4 and interleukin-5
5. Tumor necrosis factor alpha

Answer 7

1. Histamine
2. Leukotrienes
3. Granulocyte-macrophage colony-stimulating factor (GM-CSF)
4. Interleukin-4 and interleukin-5
5. Tumor necrosis factor alpha

Critique:

It is postulated that the allergic inflammation in asthma arises from an

1. imbalance between T helper 1 (Th1) cells and T helper 2 (Th2) cells. Th2 cells release specific cytokines, including interleukin-4, -5, -9, and -13 (choice D), which promote eosinophil growth and migration, as well as mast cell differentiation and IgE production. Inhaled antigens activate mast cells and Th2 cells in the airway, causing the release of histamine (choice A) and cysteinyl leukotrienes-C4 (choice B), leading to the rapid contraction of airway smooth muscle. Mast cells also can produce a variety of cytokines, including IL-1, -2, -3, -4, and -5, interferon-gamma, granulocyte-macrophage colony-stimulating factor (choice C), and tumor necrosis factor alpha (choice E) which, being pro-inflammatory proteins, can mediate both acute and chronic inflammation.

Th1 cells produce cytokine interferon-gamma, which inhibits the synthesis of IgE and the differentiation of precursor cells to Th2. It is theorized that a relative deficiency of interferon-gamma induces the Th2-type cytokine pathway and promotes the allergic inflammation responsible for asthma.

Question 8

Question: 8 of 60

A 35-year-old male admitted to the intensive-care unit with a severe asthma exacerbation has failed to improve with aggressive bronchodilator therapy and systemic corticosteroid therapy. For the past 10 minutes he has appeared more fatigued, but less wheezing is heard and his pulsus paradoxus, which had been 30 mm Hg, is less than 10 mm Hg. His pO2 is 60 mm Hg on high-dose oxygen therapy and his pCO2 is 44 mm Hg.

Which one of the following interventions would be most appropriate?

1. Intravenous β2-agonist therapy
2. Intravenous magnesium sulfate
3. Intravenous isoproterenol (Isuprel)
4. Intubation and mechanical ventilation
5. Heliox-driven albuterol nebulization

Answer 8

1. Intravenous β2-agonist therapy
2. Intravenous magnesium sulfate
3. Intravenous isoproterenol (Isuprel)
4. Intubation and mechanical ventilation
5. Heliox-driven albuterol nebulization

Critique:

Clinical findings indicating impending respiratory failure include inability to speak, altered mental status (such as a drowsy or confused state), intercostal retractions, worsening fatigue, a pCO₂ ≥42 mm Hg, absence of wheezing, bradycardia, and loss of pulsus paradoxus due to respiratory muscle fatigue. Because intubation can be difficult in asthma patients, it is best done semi-electively before the crisis of respiratory arrest. Intubation may be avoided with the use of adjunctive treatments such as intravenous magnesium sulfate therapy and heliox-driven albuterol nebulization, but should not be delayed once it is deemed necessary. Because of insufficient data, no recommendations can be made regarding the effectiveness of intravenous β₂-agonists, intravenous leukotriene receptor antagonists, or noninvasive ventilation. Intravenous isoproterenol is not recommended for the treatment of asthma because of the danger of myocardial toxicity.

Question 9

Question: 9 of 60

True statements regarding written asthma action plans include which of the following? (Mark all that are true.)

1. They should be used in patients with moderate or severe persistent asthma
2. They should be used in patients with a history of severe exacerbations
3. They should be used in patients whose perception of airflow obstruction is poor
4. The lack of a written asthma action plan is a risk factor for death from asthma
5. Peak-flow-based asthma action plans are more effective than symptom-based plans

Answer 9

1. They should be used in patients with moderate or severe persistent asthma
2. They should be used in patients with a history of severe exacerbations
3. They should be used in patients whose perception of airflow obstruction is poor
4. The lack of a written asthma action plan is a risk factor for death from asthma
5. Peak-flow-based asthma action plans are more effective than symptom-based plans

Critique:

A written asthma action plan that details the patient’s asthma management plans and how to recognize and manage worsening asthma is recommended for all patients (SOR C). They are particularly useful for patients who have moderate to severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (SOR B). Although evidence shows that symptom-based written asthma action plans have benefits similar to those of peak-flow based plans (SOR B), a peak-flow based plan may be particularly useful for patients who have difficulty perceiving signs of worsening asthma (SOR C). The National Asthma Education and Prevention Program considers the lack of a written asthma action plan to be a risk factor for death from asthma (SOR C).

Question 10

Question: 10 of 60

Which one of the following is most effective for reducing the frequency of exacerbations in adults with asthma?

1. Inhaled corticosteroids
2. Leukotriene modifiers
3. Long-acting β2-agonists
4. Monoclonal anti-IgE antibodies

Answer 10

1. Inhaled corticosteroids
2. Leukotriene modifiers
3. Long-acting β2-agonists
4. Monoclonal anti-IgE antibodies

Critique:

A meta-analysis found that inhaled corticosteroids were the most effective asthma agent for preventing exacerbations, reducing their occurrence by 55%. Leukotriene modifiers and long-acting β₂-agonists were less effective, reducing exacerbations by 41% and 25%, respectively. Use of monoclonal anti-IgE antibodies in combination with inhaled corticosteroids was associated with 45% fewer exacerbations.

Question 11

Question: 11 of 60

True statements regarding aspirin-induced asthma include which of the following? (Mark all that are true.)

1. It is often associated with perennial vasomotor rhinitis
2. It is associated with rhinosinusitis and nasal polyps
3. Salsalate is a safer alternative to aspirin
4. Ibuprofen is a safer alternative to aspirin
5. Leukotriene modifiers are particularly effective

Answer 11

1. It is often associated with perennial vasomotor rhinitis
2. It is associated with rhinosinusitis and nasal polyps
3. Salsalate is a safer alternative to aspirin
4. Ibuprofen is a safer alternative to aspirin
5. Leukotriene modifiers are particularly effective

Critique:

Aspirin-induced asthma is the syndrome of rhinorrhea, nasal polyps (choice B), sinusitis, conjunctival edema, and asthma following aspirin ingestion.

Aspirin-induced asthma usually begins with perennial vasomotor rhinitis (choice A), followed by hyperplastic rhinosinusitis with nasal polyps.

Cross-reactivity may be seen with other NSAIDs (not D), including indomethacin, naproxen, ibuprofen, fenoprofen, mefenamic acid, and phenylbutazone.

Safer alternatives to aspirin include salsalate (choice C) and acetaminophen.

Leukotriene modifiers are regarded as the treatment of choice for patients with aspirin-induced asthma.

Question 12

Question: 12 of 60

A 22-year-old male with long-standing asthma develops a severe asthma exacerbation following an upper respiratory infection. He is seen in the emergency department with severe dyspnea and a fall in peak flow to 270 L/min (45% of personal best). His personal best peak flow is 600 L/min. He is hospitalized and aggressively treated with short-acting β2-agonists, plus oral prednisone, 40 mg/day. He responds to therapy and his peak flow rises to 340 L/min (57% of personal best).

According to National Asthma Education and Prevention Program guidelines, hospital discharge can be considered in this patient once the peak flow rate rises above a threshold of

1. 360 L/min (60%)
2. 420 L/min (70%)
3. 480 L/min (80%)
4. 600 L/min (100)

Answer 12

1. 360 L/min (60%)
2. 420 L/min (70%)
3. 480 L/min (80%)
4. 600 L/min (100)

Critique:

Following an exacerbation, the National Asthma Education and Prevention Program recommends that short-term therapy with corticosteroids should be continued until the patient achieves at least 70% of his or her personal best peak flow rate or symptoms resolve. This usually requires 3–10 days, but may take longer.

Question 13

Question: 13 of 60

A 25-year-old obese female with a history of moderate persistent asthma continues to have problems with frequent nighttime awakening and daytime wheezing despite treatment with a medium-dose inhaled corticosteroid and a leukotriene receptor antagonist.

Identification and treatment of which of the following chronic comorbid conditions can improve asthma management? (Mark all that are true.)

1. Allergic rhinitis
2. Allergic bronchopulmonary aspergillosis
3. Obstructive sleep apnea
4. Gastroesophageal reflux disease

Answer 13

1. Allergic rhinitis
2. Allergic bronchopulmonary aspergillosis
3. Obstructive sleep apnea
4. Gastroesophageal reflux disease

Critique:

In patients with inadequately controlled asthma, it is recommended that clinicians evaluate the patient for the presence of specific chronic comorbid conditions if treatment of the condition may improve asthma management. These conditions include allergic bronchopulmonary aspergillosis (SOR A), gastroesophageal reflux disease (SOR B), obesity (SOR B), obstructive sleep apnea (SOR C), rhinitis/sinusitis (SOR B), and chronic stress/depression (SOR C).

Question 14

Question: 14 of 60

Which one of the following allergens is most likely responsible for the disproportionately high morbidity from asthma among inner-city residents?

1. House dust mite allergen
2. Cockroach allergen
3. Cat dander
4. Dog dander
5. Mold spores

Answer 14

1. House dust mite allergen
2. Cockroach allergen
3. Cat dander
4. Dog dander
5. Mold spores

Critique:

Morbidity from asthma is disproportionately high among inner-city residents. The National Cooperative Inner-City Asthma Study conducted a comprehensive analysis of factors that might be associated with the severity of asthma in inner-city children, and found that the highest levels of morbidity due to asthma were associated with both the presence of a positive skin-test response to cockroach allergen and current exposure to high levels of cockroach allergen in the bedroom.

Question 15

Question: 15 of 60

A 24-year-old male with mild persistent asthma treated with a low-dose inhaled corticosteroid sees you for a follow-up visit. He reports that his cough and wheezing have improved, but that he continues to require the use of an albuterol HFA (Proventil, Ventolin) inhaler 3–4 times a week. He notes that he did not require the use of albuterol even once during a recent 1-week vacation in Maui. Office spirometry is normal. His serum IgE level is 130 IU/mL (N 6–97).

Which of the following options would be most appropriate? (Mark all that are true.)

1. Discontinue the corticosteroid and begin omalizumab (Xolair)
2. Add ipratropium HFA (Atrovent)
3. Assess the patient for exposure to inhalant allergens
4. Ask the patient about exposure to tobacco smoke and other irritants
5. Review medication adherence

Answer 15

1. Discontinue the corticosteroid and begin omalizumab (Xolair)
2. Add ipratropium HFA (Atrovent)
3. Assess the patient for exposure to inhalant allergens
4. Ask the patient about exposure to tobacco smoke and other irritants
5. Review medication adherence

Critique:

Patients with persistent asthma should be seen at 2- to 6-week intervals initially, as well as when they require a step up in therapy to achieve or regain asthma control. After asthma control is achieved, follow-up visits can then be scheduled at 1- to 6-month intervals.

During the initial assessment, as well as whenever a step up in therapy is being considered, National Asthma Education and Prevention Program guidelines recommend reviewing adherence to controller medications and assessing for possible exposure to inhalant allergens, as well as tobacco smoke and other irritants, and identifying comorbid conditions that may impede asthma management (e.g., chronic rhinitis, GERD, obstructive sleep apnea, stress, obesity, or depression).

Ipratropium HFA is a quick-relief medication used to provide prompt relief of bronchoconstriction and its accompanying acute symptoms such as cough, chest tightness, and wheezing. It has no role as a long-term control medication. Omalizumab, a recombinant DNA-derived monoclonal antibody to the IgE antibody, is reserved for patients with allergies (and elevated IgE levels) with moderate to severe asthma inadequately controlled with high-dose inhaled corticosteroids and a long-acting β-agonist.

Question 16

Question: 16 of 60

A 22-year-old female with mild persistent asthma informs you that she and her husband have decided to have a baby. Which one of the following asthma agents would be preferred?

1. Inhaled corticosteroids
2. Inhaled cromolyn
3. Oral theophylline
4. An oral leukotriene receptor antagonist
5. A long-acting inhaled β2-agonist

Answer 16

1. Inhaled corticosteroids
2. Inhaled cromolyn
3. Oral theophylline
4. An oral leukotriene receptor antagonist
5. A long-acting inhaled β2-agonist

Critique:

The preferred agent for long-term control of mild persistent asthma during pregnancy is an inhaled corticosteroid. These agents have been shown to be both effective and safe during pregnancy. Budesonide is preferred during pregnancy because more data is available for this agent than for other corticosteroids, and the data is reassuring. Although cromolyn has a strong safety record, it is less effective than corticosteroids. There is only a minimal amount of published data on the use of leukotriene receptor antagonists, and data on the effectiveness of long-acting β₂-agonists is also limited.

Question 17

Question: 17 of 60

Which one of the following is LEAST likely to precipitate bronchospasm in a patient with exercise-induced asthma?

1. Swimming in a heated indoor pool
2. Ice skating
3. Cross-country skiing
4. Ice hockey
5. Running outdoors

Answer 17

1. Swimming in a heated indoor pool
2. Ice skating
3. Cross-country skiing
4. Ice hockey
5. Running outdoors

Critique:

Exercise-induced bronchospasm (EIB) is caused by a loss of heat, moisture, or both, from the bronchial tree during exercise.

Activities that require hyperventilation of air that is cooler and drier than the respiratory tree are most commonly associated with exercise-induced asthma. Such activities include

• ice skating,
• cross-country skiing, and
• ice hockey.

Running can also trigger EIB, particularly if the air is dry and/or cool.

Question 18

Question: 18 of 60

A 4-year-old female is diagnosed with mild persistent asthma. Which one of the following is preferred for long-term control?

1. Low-dose inhaled corticosteroids
2. Inhaled cromolyn
3. A leukotriene modifier
4. Sustained-release theophylline (Theo-24)

Answer 18

1. Low-dose inhaled corticosteroids
2. Inhaled cromolyn
3. A leukotriene modifier
4. Sustained-release theophylline (Theo-24)

Critique:

The 2007 National Asthma Education and Prevention Program guidelines recommend inhaled corticosteroids as the preferred treatment for initiating long-term control in children of all ages with persistent asthma. For children age 0–4 years, cromolyn and montelukast, a leukotriene receptor antagonist, are now recommended as alternative therapies.

Question 19

Question: 19 of 60

Long-acting inhaled β-agonists are less likely to be effective in which one of the following ethnic groups?

1. Hispanics
2. Non-Hispanic whites
3. African-Americans
4. Asians
5. Native Americans

Answer 19

1. Hispanics
2. Non-Hispanic whites
3. African-Americans
4. Asians
5. Native Americans

Critique:

There is evidence that asthmatic patients homozygous for the variant resulting in arginine at the 16th amino acid position of the β₂-adrenergic receptor (the so-called Arg/Arg genotype) may experience reduced airflow and worsening asthma control when using β₂-agonists to treat their asthma. This genotype occurs in 1/6 of the American population and appears to be disproportionately present in some ethnic groups, such as African-Americans. As a result, African-Americans may be particularly vulnerable to the potential long-term adverse effects associated with the use of long-acting inhaled β₂-agonists (choice C).

In the Salmeterol Multi-center Asthma Research Trial (SMART), a disproportionate increased risk for asthma-related deaths was seen in African-American subjects. Although this study was not designed to assess subgroups, a recently published subgroup analysis reported that African-Americans (who made up 18% of the study population) had a significantly increased risk for combined asthma-related deaths or life-threatening events.

Question 20

Question: 20 of 60

The most common cause of recurrent wheezing in a child less than 5 years of age is

1. bronchiolitis
2. gastroesophageal reflux disease
3. obstructive sleep apnea
4. asthma
5. vocal cord dysfunction

Answer 20

1. bronchiolitis
2. gastroesophageal reflux disease
3. obstructive sleep apnea
4. asthma
5. vocal cord dysfunction

Critique:

It is estimated that 60% of children have had an episode of wheezing during their lifetime. The most likely cause of recurrent wheezing in a child less than 5 years is asthma (SOR C). Other common causes include bronchiolitis, allergies, obstructive sleep apnea, and infections, including bronchiolitis. Less common causes include foreign body aspiration, laryngomalacia, vocal cord dysfunction, bronchopulmonary dysplasia, tracheobronchial anomalies, bronchopulmonary dysplasia, heart failure, immunodeficiency diseases, and cystic fibrosis.

Question 21

Question: 21 of 60

Inhaled corticosteroids have been shown to provide which of the following benefits in patients with asthma? (Mark all that are true.)

1. Reduced severity of symptoms
2. Improved pulmonary function
3. Reduced airway hyperresponsiveness
4. Fewer exacerbations
5. Prevention of airway wall remodeling

Answer 21

1. Reduced severity of symptoms
2. Improved pulmonary function
3. Reduced airway hyperresponsiveness
4. Fewer exacerbations
5. Prevention of airway wall remodeling

Critique:

Clinical effects of inhaled corticosteroids (ICs) include a reduction in the severity of symptoms, improvement in peak expiratory flow and spirometry results, diminished airway hyperresponsiveness, and prevention of exacerbations. Whether ICs prevent airway wall remodeling is still unknown, and remains an area of study. In fact, a recent study by Guilbert, et al, offers evidence against a disease-modifying effect. This study found that 2 years of IC therapy failed to affect the development of asthma symptoms or lung function in preschool children at high risk for asthma during a third, treatment-free year.

Question 22

Question: 22 of 60

Nonpharmacologic measures that reduce the likelihood of exercise-induced bronchospasm include which of the following? (Mark all that are true.)

1. Warming up for at least 10 minutes before actual exercise begins
2. Breathing through the mouth
3. Covering the mouth and nose with a scarf or mask during cold weather
4. Gradually decreasing the intensity of the exercise before stopping

Answer 22

1. Warming up for at least 10 minutes before actual exercise begins
2. Breathing through the mouth
3. Covering the mouth and nose with a scarf or mask during cold weather
4. Gradually decreasing the intensity of the exercise before stopping

Critique:

Exercise-induced bronchospasm is caused by a loss of heat, moisture, or both from the bronchial tree during exercise. Breathing through the nose (as opposed to the mouth) (not B) and covering the mouth and nose with a scarf or mask (choice C) during cold-weather activities warms the air and reduces the cooling and drying stimuli. A lengthy warm-up period before exercise can induce a refractory period (choice A), and may preclude the need for repeated medications. Other recommended measures include improving physical conditioning; exercising in a warm, humidified environment; avoiding aeroallergens and pollutants; cooling down before stopping the activity (choice D); and waiting at least 2 hours after a meal before exercising.

Question 23

Question: 23 of 60

The 2007 National Asthma Education and Prevention Program guidelines recommend which of the following allergen avoidance measures for patients sensitive to house dust mite allergen? (Mark all that are true.)

1. Encasing pillows and mattresses in an allergen-impermeable cover
2. Washing sheets and blankets weekly in hot water (≥54°C, or 130°F)
3. Regular use of a humidifier
4. Vacuuming carpets once or twice a week, using a vacuum cleaner fitted with a HEPA (High Efficiency Particulate Air) filter or double bag
5. Regular use of an indoor air-filtering device

Answer 23

1. Encasing pillows and mattresses in an allergen-impermeable cover
2. Washing sheets and blankets weekly in hot water (≥54°C, or 130°F)
3. Regular use of a humidifier
4. Vacuuming carpets once or twice a week, using a vacuum cleaner fitted with a HEPA (High Efficiency Particulate Air) filter or double bag
5. Regular use of an indoor air-filtering device

Critique:

Effective allergen avoidance in asthma patients with house dust mite allergies requires a multifaceted, comprehensive approach; individual steps alone are generally ineffective. For asthma patients found to be sensitive to house dust mite allergen, the 2007 National Asthma Education and Prevention Program (NAEPP) guidelines recommend that

• mattresses and pillows be encased in allergen-impermeable covers (choice A), and
• sheets and blankets be washed weekly in hot water (choice B). A minimum water temperature of 54°C (130°F) is needed to kill house dust mites.
• Although inefficient for removing live mites, vacuuming with a vacuum cleaner fitted with a HEPA filter (choice D) removes mite allergen from carpets and may also be helpful.
• REDUCING indoor humidity to 60% or less (ideally 30%–50%) (not C),
• removing carpets from the bedroom, removing carpets that are laid on concrete elsewhere in the home, minimizing the number of stuffed toys in children’s beds, and avoiding sleeping or lying on upholstered furniture may also be effective.

Indoor air-filtering devices are NOT recommended (not E) because house dust mite allergens are relatively heavy and do not remain airborne.

It should be noted that the efficacy of the interventions recommended by the NAEPP has not been clearly demonstrated. In fact, a Cochrane review found no evidence that any of the measures recommended for eliminating mite antigen in the home is effective.

Question 24

Question: 24 of 60

The use of long-acting β-agonists (LABAs) has been associated with an increased risk for

1. hyperkalemia
2. hypoglycemia
3. cataracts
4. severe asthma exacerbations
5. pulmonary fibrosis

Answer 24

1. hyperkalemia
2. hypoglycemia
3. cataracts
4. severe asthma exacerbations
5. pulmonary fibrosis

Critique:

The use of long-acting β₂-adrenergic agonists has been associated with an increased risk of serious asthma exacerbations and asthma-related death.

As a result, the FDA issued an alert in November 2005 advising that these agents be used only as additional therapy in patients who have not adequately responded to other asthma-controller medications, such as low- to medium-dose inhaled corticosteroids. 2007 National Asthma Education and Prevention Program guidelines recommend that the daily dose not exceed 100 µg for salmeterol or 24 µg for formoterol, and that these agents not be used as monotherapy for long-term control. Patients should be instructed not to stop inhaled corticosteroid therapy while taking a long-acting β-agonist, even though their symptoms may significantly improve.

Question 25

Question: 25 of 60

Useful agents for the management of acute severe asthma exacerbations in the emergency department setting include which of the following? (Mark all that are true.)

1. Albuterol (Proventil, Ventolin)
2. Levalbuterol (Xopenex)
3. Ipratropium (Atrovent)
4. Systemic corticosteroids
5. Methylxanthines

Answer 25

1. Albuterol (Proventil, Ventolin)
2. Levalbuterol (Xopenex)
3. Ipratropium (Atrovent)
4. Systemic corticosteroids
5. Methylxanthines

Critique:

National Asthma Education and Prevention Program guidelines include the following recommendations for treatment of asthma exacerbations in the emergency department:
* * Oxygen should be given to achieve an oxygen saturation ≥90%.
* All patients should be given inhaled short-acting β-agonists (choie A). These agents are the most effective means of reversing airflow obstruction.
* Ipratropium bromide (choice C) should be added to the aerosolized β₂-agonist solution to increase bronchodilation.
* Systemic corticosteroids (choice D) should be given.
* Methylxanthines are NOT recommended (not E) because they appear to provide no additional benefit and may increase the frequency of adverse events.
In addition, aggressive hydration, mucolytics, and sedation are not recommended. Antibiotics should not be prescribed except as needed for comorbid conditions.

Question 26

Question: 26 of 60

Which one of the following is LEAST effective for preventing exercise-induced bronchospasm?

1. Inhaled albuterol (Proventil, Ventolin)
2. Formoterol (Foradil)
3. Zafirlukast (Accolate)
4. Ipratropium (Atrovent)

Answer 26

1. Inhaled albuterol (Proventil, Ventolin)
2. Formoterol (Foradil)
3. Zafirlukast (Accolate)
4. Ipratropium (Atrovent)

Critique:

Albuterol, cromolyn, and formoterol can be used prior to exercise in patients with exercise-induced asthma.

1. Albuterol, 1–2 puffs 5 minutes before exercise, may be helpful for 2–3 hours.
2. Cromolyn is an alternative to short-acting β₂-agonists, but is less effective.
3. Formoterol’s clinical effect is detected within 1–3 minutes and maximal bronchodilation occurs within 1–3 hours.

Leukotriene modifiers can attenuate exercise-induced bronchospasm in up to 50% of patients.

Salmeterol is not indicated prior to exercise because even though its clinical effect is detected within 10–20 minutes, maximal bronchodilation does not occur for 3–4 hours.

Ipratropium does not block exercise-induced bronchospasm.

Question 27

Question: 27 of 60

Chronic low- to medium-dose inhaled corticosteroid use in children is associated with

1. a permanent reduction in vertical growth
2. a significant reduction in bone mineral density
3. cataract formation
4. glaucoma
5. no long-term adverse effects

Answer 27

1. a permanent reduction in vertical growth
2. a significant reduction in bone mineral density
3. cataract formation
4. glaucoma
5. no long-term adverse effects

Critique:

Clinical trial data suggests that the use of inhaled corticosteroids does not have long-term, clinically significant adverse effects. Although a reduction in growth velocity in children or adolescents can potentially occur as a result of inadequate control of chronic diseases such as asthma or from the use of corticosteroids for its treatment, the available cumulative evidence suggests that while low- to medium-dose corticosteroids may have the potential for decreasing growth velocity, the effects are small, nonprogressive, and possibly reversible. Low to medium doses of inhaled corticosteroids do not appear to have a serious adverse effect on bone mineral density in children, nor do they have a significant effect on the incidence of glaucoma or cataracts. On average, the available evidence indicates that in children, low- to medium-dose inhaled corticosteroids do not exert a clinically significant effect on the hypothalamic-pituitary-adrenal axis.

Question 28

Question: 28 of 60

A 26-year-old male with asthma is seen in the emergency department. He is short of breath and has diminished breath sounds with an occasional wheeze heard on examination. His FEV1 is 15% of predicted and his PCO2 is 40 mm Hg. He is given albuterol (Proventil, Ventolin) via nebulizer every 20 minutes, and after 1 hour his FEV1 has improved to 20% of predicted.

The development of which of the following would be consistent with imminent respiratory failure? (Mark all that are true.)

1. A drop in pCO2 to 32 mm Hg
2. The use of accessory muscles with suprasternal retractions
3. Bradycardia
4. Pulsus paradoxus of 15 mm Hg
5. The absence of wheezes

Answer 28

1. A drop in pCO2 to 32 mm Hg
2. The use of accessory muscles with suprasternal retractions
3. Bradycardia
4. Pulsus paradoxus of 15 mm Hg
5. The absence of wheezes

Critique:

All clinicians treating asthma exacerbations should be familiar with the characteristics of patients at risk for life-threatening deterioration. Symptoms suggesting that respiratory arrest may be imminent in patients with a severe asthma exacerbation include the

1. development of drowsiness,
2. paradoxical thoracoabdominal movement, the
3. absence of wheezes (choice E),
4. bradycardia (choice C), and the
5. loss of pulsus paradoxus due to respiratory muscle fatigue.

Question 29

Question: 29 of 60

You see a 14-year-old female for a routine annual visit. She has a history of episodic wheezing in the past treated with inhaled albuterol (Proventil, Ventolin) as needed. She tells you that she uses her inhaler less than once a week and rarely develops nighttime wheezing. Her FEV1 is 90% of predicted. She reports that on four occasions during the past year she developed a persistent cough and wheezing, which required urgent care visits and a short course of oral corticosteroids.

Which one of the following would be the preferred treatment for her asthma?

1. Continuation of the current management
2. Continued use of albuterol as needed, plus an inhaled long-acting β2-agonist at bedtime
3. Continued use of albuterol as needed, plus oral sustained-release theophylline at bedtime
4. Adding a low-dose inhaled corticosteroid

Answer 29

1. Continuation of the current management
2. Continued use of albuterol as needed, plus an inhaled long-acting β2-agonist at bedtime
3. Continued use of albuterol as needed, plus oral sustained-release theophylline at bedtime
4. Adding a low-dose inhaled corticosteroid

Critique:

The 2007 National Asthma Education and Prevention Program (NAEPP) guidelines recommend that every patient with asthma be taught to recognize symptom patterns and/or peak expiratory flow levels that indicate inadequate asthma control, and that control be routinely monitored. Control of asthma is viewed in the context of two domains, impairment and risk. Impairment is assessed on the basis of several factors, including symptoms (e.g., coughing or breathlessness in the daytime, at night, or after exertion), frequency of use of a short-acting β-agonist for quick relief of symptoms, pulmonary function testing, capability of maintaining normal activity levels (including exercise and other physical activity and attendance at work or school), and fulfillment of the patient’s and family’s expectations of and satisfaction with asthma care. The risk domain refers to the risk of adverse events in the future, including future exacerbations, irreversible loss of pulmonary function, and development of side effects from treatment.

Intermittent asthma is characterized by asthma symptoms no more than 2 days a week, nighttime awakenings no more than twice a month, a need for an inhaled short-acting β₂-agonist no more than 2 days a week, an FEV₁ ≥80% of predicted, and no interference with normal activity. Although this patient’s level of impairment would place her in the intermittent asthma category, her risk profile (i.e., a history of two asthma exacerbations requiring oral systemic corticosteroids) places her in the mild persistent asthma category. The 2007 NAEPP guidelines recommend step 2 therapy for patients with mild persistent asthma, with a low-dose inhaled corticosteroid being the preferred treatment.

Question 30

Question: 30 of 60

Risk factors for death from asthma include which of the following? (Mark all that are true.)

1. An emergency care visit for asthma during the past month
2. Use of 1 canister per month of an inhaled short-acting β2-agonist
3. Lack of a written asthma action plan
4. Difficulty perceiving asthma symptoms
5. Illicit drug use

Answer 30

1. An emergency care visit for asthma during the past month
2. Use of 1 canister per month of an inhaled short-acting β2-agonist
3. Lack of a written asthma action plan
4. Difficulty perceiving asthma symptoms
5. Illicit drug use

Critique:

Risk factors for death from asthma include the following:
* * a past history of sudden severe asthma exacerbation
* prior intubation for asthma
* prior admission to an intensive-care unit for an exacerbation
* two or more hospitalizations for asthma during the past year
* three or more emergency-care visits for asthma during the past year
* hospitalization or an emergency-care visit for asthma during the past month (choice A)
* use of more than 2 canisters (not B) per month of an inhaled short-acting β₂-agonist
* difficulty perceiving airflow obstruction or severity of exacerbations (choice D)
* lack of a written asthma action plan (choice C)
* comorbidity (as from cardiovascular disease or COPD)
* serious psychiatric disease or psychosocial problems
* low socioeconomic status and inner-city residence
* illicit drug use (choice E)
* sensitivity to Alternaria
A written asthma action plan is recommended for all patients, and should provide details about individual daily management (medications and environmental control strategies) and how to recognize and handle worsening asthma. 2007 National Asthma Education and Prevention Program guidelines state that a plan is particularly recommended for patients who have moderate or severe persistent asthma, a history of severe asthma exacerbations, or poorly controlled asthma.

Question 31

Question: 31 of 60

True statements regarding allergic bronchopulmonary aspergillosis include which of the following? (Mark all that are true.)

1. The associated bronchial asthma arises from colonization with Aspergillus fumigatus
2. It is associated with transient, recurrent infiltrates on chest radiographs
3. It is associated with central bronchiectasis on high-resolution chest CT
4. Diagnostic criteria include the presence of serum IgG to Aspergillus
5. It should be considered in patients with severe asthma refractory to treatment

Answer 31

1. The associated bronchial asthma arises from colonization with Aspergillus fumigatus
2. It is associated with transient, recurrent infiltrates on chest radiographs
3. It is associated with central bronchiectasis on high-resolution chest CT
4. Diagnostic criteria include the presence of serum IgG to Aspergillus
5. It should be considered in patients with severe asthma refractory to treatment

Critique:

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disease of the lungs related to colonization of Aspergillus (most commonly fumigatus) (choice A) in the airways, and its proliferation in airway mucus.

The bronchial asthma of ABPA likely involves an IgE-mediated hypersensitivity, whereas the central bronchiectasis (choice B) associated with this disorder is thought to result from a deposition of immune complexes in proximal airways.

Minimum criteria for ABPA complicating asthma include a

• positive immediate skin test to Aspergillus,
• total serum IgE >417 IU (choice D),
• elevated serum IgE and/or immunoglobulin G (IgG) to Aspergillus, and
• central bronchiectasis (inner two-thirds of the chest CT fields).

Additional supporting findings include a history of fleeting pulmonary infiltrates, peripheral blood eosinophilia, serum precipitins to Aspergillus, and production of mucus plugs containing Aspergillus.

Adequate treatment usually requires long-term use of systemic corticosteroids.

Question 32

Question: 32 of 60

True statements regarding the use of systemic corticosteroids in the management of asthma exacerbations include which of the following? (Mark all that are true.)

1. They reduce the rate of relapse
2. A “burst” dose of 20–30 mg/day (0.5 mg/kg/day in children) for 3–10 days is recommended to rapidly gain control of inadequately controlled persistent asthma
3. Short-term therapy should be continued until the patient achieves at least 70% of his or her personal best peak expiratory flow, or until symptoms resolve
4. Tapering the dose following asthma improvement is routinely recommended to prevent a relapse in asthma exacerbations
5. Intravenous corticosteroids are more effective than oral corticosteroids

Answer 32

1. They reduce the rate of relapse
2. A “burst” dose of 20–30 mg/day (0.5 mg/kg/day in children) for 3–10 days is recommended to rapidly gain control of inadequately controlled persistent asthma
3. Short-term therapy should be continued until the patient achieves at least 70% of his or her personal best peak expiratory flow, or until symptoms resolve
4. Tapering the dose following asthma improvement is routinely recommended to prevent a relapse in asthma exacerbations
5. Intravenous corticosteroids are more effective than oral corticosteroids

Critique:

Oral systemic corticosteroids suppress, control, and reverse airway inflammation. These agents speed the resolution of airflow obstruction, reduce the rate of relapse (choice A), and may reduce hospitalizations.

Systemic corticosteroids should be administered to reduce airway inflammation in patients with moderate-to-severe exacerbations and to patients who fail to respond promptly and completely to initial inhaled β₂-agonist therapy.

Their use as long-term control medication should be limited to patients with the most severe, recalcitrant asthma; well-documented side effects include adrenal suppression, growth suppression, hypertension, Cushing’s syndrome, cataracts, osteoporosis, and muscle weakness.

Systemic corticosteroids are commonly used as short-term (3–10 days) “burst” therapy to gain prompt control of inadequately controlled asthma, at a dosage of 40–80 mg/day in 1 or 2 divided doses (1 mg/kg/day in 2 divided doses in children) (not B).

Short-term therapy in patients with asthma exacerbations should be continued until the patient achieves 70% of his or her personal best peak expiratory flow (choice C), or until symptoms resolve; this usually requires 3–10 days, but may take longer.

There is NO evidence that tapering the dosage once improvement occurs is useful (not D) in preventing relapses of asthma exacerbations.

Intravenous corticosteroids have NO proven advantage over oral corticosteroids (not E) in patients with normal gastrointestinal function.

Question 33

Question: 33 of 60

Extrinsic IgE-mediated allergy can serve as a trigger for asthma. Which one of the following can reduce corticosteroid requirements in asthmatics by reducing free circulating IgE?

1. Omalizumab (Xolair)
2. Dapsone
3. Formoterol (Foradil)
4. Ondansetron (Zofran)
5. Zafirlukast (Accolate)

Answer 33

1. Omalizumab (Xolair)
2. Dapsone
3. Formoterol (Foradil)
4. Ondansetron (Zofran)
5. Zafirlukast (Accolate)

Critique:

Omalizumab is a murine monoclonal antibody directed against circulating IgE. In patients with moderate to severe asthma, the use of omalizumab can improve symptoms and reduce exacerbations, and may reduce corticosteroid requirements. Omalizumab is administered subcutaneously and is generally well-tolerated.

Question 34

Question: 34 of 60

A 48-year-old male presents with a 3-week history of exertional chest pressure. He has moderate persistent asthma controlled with a moderate dose of an inhaled corticosteroid.

Which of the following cardiac stress tests should be avoided? (Mark all that are true.)

1. Dobutamine echocardiography
2. Adenosine myocardial perfusion imaging
3. Dipyridamole myocardial perfusion imaging
4. Exercise myocardial perfusion imaging
5. Exercise echocardiography

Answer 34

1. Dobutamine echocardiography
2. Adenosine myocardial perfusion imaging
3. Dipyridamole myocardial perfusion imaging
4. Exercise myocardial perfusion imaging
5. Exercise echocardiography

Critique:

Both dipyridamole and adenosine can cause severe bronchospasm in patients with asthma or chronic obstructive lung disease. Therefore, it is recommended that these agents be used with extreme caution, if at all, in patients with asthma or COPD.

Question 35

Question: 35 of 60

Adjunctive therapies generally considered to be of value in the management of severe asthma exacerbations in the adult patient include which of the following? (Mark all that are true.)

1. Intravenous aminophylline
2. Chest physical therapy
3. Mucolytic therapy
4. Aggressive hydration
5. Intravenous magnesium sulfate

Answer 35

1. Intravenous aminophylline
2. Chest physical therapy
3. Mucolytic therapy
4. Aggressive hydration
5. Intravenous magnesium sulfate

Critique:

For patients with life-threatening asthma exacerbations, or those who remain in the severe asthma exacerbation category after 1 hour of intensive conventional therapy, adjunctive therapy with intravenous magnesium sulfate (choice E) should be considered.

Chest physical therapy is NOT generally recommended (not B) because it has not been shown to be beneficial and may be unnecessarily stressful for the dyspneic asthma patient.

Mucolytic agents such as acetylcysteine and potassium iodide are NOT recommended (not C) because they may worsen cough or airflow obstruction.

Aggressive hydration is NOT recommended for older children and adults (not D), but may be indicated in infants and young children because they tend to become dehydrated as a result of their increased respiratory rate and reduced oral intake.

Intravenous aminophylline has NOT been shown to add to optimal short-acting β-agonist therapy (not A) and it increases the risk for adverse effects.

Question 36

Question: 36 of 60

Adverse effects associated with the use of β2-agonists include which of the following? (Mark all that are true.)

1. Tremor
2. Tachycardia
3. Hypoglycemia
4. Hyperkalemia
5. A temporary reduction in arterial oxygen tension

Answer 36

1. Tremor
2. Tachycardia
3. Hypoglycemia
4. Hyperkalemia
5. A temporary reduction in arterial oxygen tension

Critique:

The most common side effect of β₂-agonists is tremor (choice A). Common cardiac side effects are tachycardia and palpitations (choice B).

Acute metabolic effects include INCREASED plasma glucose (not C), lactate, pyruvate, and free fatty acids.

By stimulating a cell-membrane-associated potassium-sodium pump, β₂-agonists increase the transport of potassium into the cells and are associated with hypokalemia (not D).

Because they produce a transient increased ventilation-perfusion mismatch, β₂-agonists can cause a temporary reduction in arterial oxygen tension (choice E) in patients with severe acute asthma. This reduction generally lasts less than 10 minutes and can be managed with the administration of oxygen.

Question 37

Question: 37 of 60

While some facets of asthma are reversible, changes seen in chronic, uncontrolled asthma may be irreversible. Histologic features of the irreversible airway remodeling seen in patients with chronic asthma include which of the following? (Mark all that are true.)

1. Goblet cell hyperplasia
2. Subepithelial collagen deposition
3. Smooth muscle hypertrophy
4. Microvascular proliferation

Answer 37

1. Goblet cell hyperplasia
2. Subepithelial collagen deposition
3. Smooth muscle hypertrophy
4. Microvascular proliferation

Critique:

Mast cell activation triggered by antigen-IgE crosslinking releases asthma mediators (e.g., histamine, leukotrienes, thromboxanes), causing smooth-muscle contraction, edema, and enhanced mucus secretion, and leading to airflow obstruction and the manifestations of acute asthma symptoms. Features of airway remodeling seen in patients with asthma include goblet cell hyperplasia, subepithelial fibrosis with collagen deposition, smooth-muscle hypertrophy and hyperplasia, submucosal gland enlargement, and bronchial microvascular enlargement and proliferation. The link between these structural changes (and resultant persistent airway limitation) and long-standing airway inflammation seen in asthma is still being studied; however, this is the basis for strategies calling for early intervention with anti-inflammatory therapy.

Question 38

Question: 38 of 60

True statements regarding exercise-induced bronchospasm include which of the following? (Mark all that are true.)

1. It is not commonly seen in patients with persistent asthma
2. It occurs during or in the minutes following vigorous physical activity
3. It usually peaks 5–10 minutes into the activity
4. It typically does not resolve until several hours after the activity
5. The differential diagnosis includes vocal cord dysfunction

Answer 38

1. It is not commonly seen in patients with persistent asthma
2. It occurs during or in the minutes following vigorous physical activity
3. It usually peaks 5–10 minutes into the activity
4. It typically does not resolve until several hours after the activity
5. The differential diagnosis includes vocal cord dysfunction

Critique:

Exercise-induced bronchospasm should be anticipated in all asthma patients. Exercise as a stimulus differs from other asthma provocations (e.g., allergens, viral infections, air pollutants) in that it does not evoke any long-term sequelae, nor does it increase airway reactivity.

It usually occurs during or after exercise (choice B), reaches its peak 5–10 minutes AFTER stopping the activity (not C), and remits spontaneously within the next 20–30 minutes (not D).

Other conditions associated with breathing difficulties during exercise, particularly vocal cord dysfunction (choice E), can be confused with exercise-induced asthma.

Question 39

Question: 39 of 60

True statements regarding leukotriene modifiers include which of the following? (Mark all that are true.)

1. They can be used as quick-relief asthma agents
2. They are effective for managing exercise-induced asthma
3. They are contraindicated in patients with aspirin-sensitive asthma
4. They are less effective than inhaled corticosteroids
5. They can be substituted for an inhaled corticosteroid in patients taking long-acting β2-agonists

Answer 39

1. They can be used as quick-relief asthma agents
2. They are effective for managing exercise-induced asthma
3. They are contraindicated in patients with aspirin-sensitive asthma
4. They are less effective than inhaled corticosteroids
5. They can be substituted for an inhaled corticosteroid in patients taking long-acting β2-agonists

Critique:

Leukotriene modifiers have no intrinsic smooth-muscle–relaxing ability, and therefore should not be used as quick-relief medications. They are less potent than inhaled corticosteroids, but they can be used as alternative long-term controller agents in patients with mild persistent asthma, and as an adjunct to low- to medium-dose inhaled corticosteroids in patients with moderate persistent asthma. The 2007 National Asthma Education and Prevention Program specifically recommends against using a leukotriene modifier as a substitute for an inhaled corticosteroid in patients taking long-acting β-agonists. Although monitoring of liver enzymes is required in patients treated with zileuton, a 5-lipoxygenase inhibitor, it is not required in patients treated with leukotriene receptor antagonists such as montelukast or zafirlukast. Leukotriene modifiers may be particularly effective in patients with exercise-induced asthma and aspirin-sensitive asthma.

Question 40

Question: 40 of 60

True statements regarding inhaled corticosteroids include which of the following? (Mark all that are true.)

1. The full benefit is generally seen within 2–3 weeks
2. A spacer/holding chamber should routinely be used with aerosol preparations to reduce the risk for local adverse effects
3. Increasing the dosage of low-dose inhaled corticosteroids produces a greater benefit in persistent asthma than adding a long-acting β2-agonist
4. They have a linear dose-response

Answer 40

1. The full benefit is generally seen within 2–3 weeks
2. A spacer/holding chamber should routinely be used with aerosol preparations to reduce the risk for local adverse effects
3. Increasing the dosage of low-dose inhaled corticosteroids produces a greater benefit in persistent asthma than adding a long-acting β2-agonist
4. They have a linear dose-response

Critique:

Inhaled corticosteroids (ICs) are the most effective available controller therapy and should be regarded as first-line treatment for patients with persistent asthma. The dose-response curve for ICs is relatively flat (not D), with most of the benefit obtained from low-dose therapy.

Long-acting β₂-agonists and ICs are complementary when used in patients with persistent asthma, with the addition of the long-acting β₂-agonist producing more benefit (not C) than simply increasing the dosage of ICs.

Local side effects can be minimized by using the lowest dose possible, rinsing the mouth out after use to prevent systemic absorption, and using spacers with metered-dose inhalers (choice B).

Although some benefit can be seen within weeks after starting inhaled ICs, the full benefit typically occurs within 1–2 months (not A).

Question 41

Question: 41 of 60

A 28-year-old male with a history of moderate persistent asthma presents to the emergency department with a 2-day history of worsening dyspnea despite frequent use of an inhaled β2-agonist. An examination reveals a restless patient with a respiratory rate of 35/min, obvious suprasternal retractions, and loud inspiratory and expiratory wheezes. His FEV1 is 1.6 L (48% of predicted) and his peak flow is 250 L/min (49% of personal best). His oxygen saturation is 89%.

Which of the following management options would be appropriate? (Mark all that are true.)

1. Oxygen therapy
2. High-dose inhaled β2-agonist therapy
3. An inhaled anticholinergic agent
4. Systemic corticosteroid therapy
5. Intravenous isoproterenol (Isuprel)

Answer 41

1. Oxygen therapy
2. High-dose inhaled β2-agonist therapy
3. An inhaled anticholinergic agent
4. Systemic corticosteroid therapy
5. Intravenous isoproterenol (Isuprel)

Critique:

This clinical presentation is consistent with a severe asthma exacerbation. Features of a severe exacerbation include agitation, a respiratory rate >30/min, a pulse rate >120 beats/min, pulsus paradoxus exceeding 25 mm Hg, loud expiratory and inspiratory wheezing, use of accessory muscles of respiration with suprasternal retractions, a peak expiratory flow <40% of personal best or predicted, a pO₂ <60 mm Hg, and an oxygen saturation <90%.

Appropriate management would include a

1. high-dose inhaled β₂-agonist (choice B) plus
2. ipratropium (bronchodilator) (choice C) by nebulizer or MDI with a valved holding chamber, every 20 minutes or continuously for 1 hour;
3. oxygen therapy (choice A) to achieve an oxygen saturation ≥90%; and
4. oral systemic corticosteroid therapy (choice D).

Intravenous isoproterenol is NOT recommended (not E) for the treatment of asthma because of the danger of myocardial toxicity.

Question 42

Question: 42 of 60

Validated tools for ongoing clinical assessment of asthma control include which of the following? (Mark all that are true.)

1. The Asthma Therapy Assessment Questionnaire (ATAQ)
2. The Asthma Control Test (ACT)
3. The Asthma Control Questionnaire (ACQ)
4. The Asthma Control Score (ACS)
5. The SF-10 for asthma

Answer 42

1. The Asthma Therapy Assessment Questionnaire (ATAQ)
2. The Asthma Control Test (ACT)
3. The Asthma Control Questionnaire (ACQ)
4. The Asthma Control Score (ACS)
5. The SF-10 for asthma

Critique:

The impairment domain for determining the severity of disease in patients who have not started long-term-control treatment, or the level of control after treatment is initiated, can usually be determined from a careful, directed history and lung function measurement. Standardized questionnaires have been developed to facilitate and standardize the assessment of the impairment domain of asthma control. These include the

1. Asthma Control Test (ACT) (choice B), the
2. Childhood Asthma Control Test, the
3. Asthma Control Questionnaire (ACQ) (choice C), the
4. Asthma Control Score (ACS) (choice D), and the
5. Asthma Therapy Assessment Questionnaire (ATAQ) (choice A) control index.

These questionnaires can be used to categorize asthma into three categories: well controlled, not well controlled, and very poorly controlled. The ACQ is lengthy and takes up to 20 minutes to complete. For family physicians, the ACT and ATAQ are easy to administer and have been specifically validated in managed-care settings. English and Spanish examples of the ACT and ATAQ can be viewed at http://www.asthmacontrol.com/hcp.html.

Some patients appear to perceive the severity of airflow obstruction poorly, and this should be considered. These patients may have unconsciously accommodated to their symptoms, or they may mistakenly attribute symptoms to other causes such as aging, obesity, or lack of fitness, and thus do not report them readily. For these patients, other objective measures such as spirometry may show that the degree of airflow obstruction is poorly recognized or perceived by the patient. A trial of therapy may lead to unexpected improvement in quality of life.

Question 43

Question: 43 of 60

A 20-year-old female is diagnosed with mild persistent asthma. Her past medical history is notable for a history of recurrent ocular herpes simplex and perennial allergic rhinitis.

Which one of the following would be the most appropriate treatment?

1. Inhaled corticosteroids
2. A leukotriene modifier
3. A long-acting β-agonist
4. Methylxanthine

Answer 43

1. Inhaled corticosteroids
2. A leukotriene modifier
3. A long-acting β-agonist
4. Methylxanthine

Critique:

Although recommended as preferred therapy for patients with persistent asthma by the 2007 guidelines from the National Asthma Education and Prevention Program (NAEPP), inhaled corticosteroids should be USED WITH CAUTION, if at all, in patients with active or quiescent tuberculosis infection of the respiratory tract; untreated systemic fungal, bacterial, parasitic, or viral infections; or ocular herpes simplex.

Alternative agents listed by the NAEPP include cromolyn, leukotriene modifiers (choice B), and theophyllines.

Of these alternatives, leukotriene modifiers offer several advantages, including efficacy against allergic rhinitis, ease of use, high rates of compliance, and a good safety profile. Furthermore, a recent pragmatic trial found leukotriene modifiers to be equivalent to inhaled corticosteroids as a first-line controller therapy.

While it has a strong safety profile, cromolyn has less consistent and limited effectiveness in asthma. Theophylline provides minimal to no effect on airway reactivity, and monitoring serum levels of theophylline is essential to ensure toxic drug levels are avoided. In February 2010, the FDA required manufacturers of long-acting β-agonists (LABAs) to revise their drug labels because of an increased risk of serious asthma exacerbations and asthma-related death. Recommendations on the updated labels specifically contraindicate the use of a LABA alone for the treatment of asthma. A long-term asthma control medication, such as an inhaled corticosteroid, should be used with a LABA.

Question 44

Question: 44 of 60

A 19-year-old male has severe persistent asthma treated with high-dose inhaled corticosteroids and a long-acting inhaled β2-agonist. For the past few months he has experienced daily wheezing and is using his albuterol (Proventil, Ventolin) inhaler several times per day. His past medical history is notable for a history of perennial allergic rhinitis related to cockroach allergy.

According to National Asthma Education and Prevention Program guidelines, which one of the following adjunctive therapies would most likely be of benefit?

1. Theophylline
2. A leukotriene receptor antagonist
3. Omalizumab (Xolair)
4. Zileuton (Zyflo)
5. Subcutaneous allergen immunotherapy

Answer 44

1. Theophylline
2. A leukotriene receptor antagonist
3. Omalizumab (Xolair)
4. Zileuton (Zyflo)
5. Subcutaneous allergen immunotherapy

Critique:

This patient has a history of severe persistent asthma treated with high-dose inhaled corticosteroids plus a long-acting β-agonist (LABA), which constitutes step 5 therapy.

He would be classified as having “not well controlled” asthma based on the 2007 National Asthma Education and Prevention Program guidelines. This is defined as

1. having symptoms more than 2 days per week,
2. nighttime awakening 1–3 times per week,
3. some limitation of normal activity,
4. using a short-acting inhaled β₂-agonist more than 2 days per week,
5. having a peak flow or FEV₁ that is 60%–80% of predicted/personal best, or
6. having two or more asthma exacerbations requiring oral systemic corticosteroids two or more times a year.

A short course of oral systemic corticosteroids should be strongly considered in these patients. In addition, adjunctive therapy with omalizumabshould be strongly considered if the patient has allergies, since it is theonly adjunctive therapy shown to add to the efficacy of high-dose inhaled corticosteroids plus LABA in patients who have severe persistent allergic asthma.

• Omalizumab is approved for patients 12 years of age or older who have proven sensitivity to aeroallergens, such as those produced by dust mites, cockroaches, cats, or dogs. Immunotherapy is used primarily as adjunctive therapy in steps 2–4 asthma therapy; although it has been found to be of value for house-dust mites, animal danders, and pollens, evidence is weak or lacking for molds and cockroaches.

Question 45

Question: 45 of 60

Following bronchodilator inhalation, the minimum improvement in FEV1 or FVC consistent with reversibility is

1. 10% (absolute increase 100 mL)
2. 12% (absolute increase 200 mL)
3. 20% (absolute increase 250 mL)
4. 24% (absolute increase 300 mL)
5. 30% (absolute increase 275 mL)

Answer 45

1. 10% (absolute increase 100 mL)
2. 12% (absolute increase 200 mL)
3. 20% (absolute increase 250 mL)
4. 24% (absolute increase 300 mL)
5. 30% (absolute increase 275 mL)

Critique:

Airflow obstruction is defined as an FEV₁/FVC ratio ≤70%. Airway reversibility is defined as an increase in FEV₁ or FVC by 12% or more in conjunction with an absolute increase of 200 mL after inhalation of a bronchodilator.

Question 46

Question: 46 of 60

A 15-year-old male has mild persistent asthma managed with zafirlukast (Accolate). At a routine visit he reports that over the past 2 months he has been wheezing 3–4 days of the week and has been awakened at night by his asthma twice a week. His peak flow is found to be 400 L/min (75% of his personal best).

Which of the following interventions would be appropriate at this visit? (Mark all that are true.)

1. Review his adherence to his medication regimen
2. Assess his environment for new or increased exposure to allergens or irritants
3. Identify psychosocial issues that might adversely affect his asthma
4. Identify comorbid conditions that can diminish asthma control
5. Discontinue zafirlukast and switch to a low-dose inhaled corticosteroid

Answer 46

1. Review his adherence to his medication regimen
2. Assess his environment for new or increased exposure to allergens or irritants
3. Identify psychosocial issues that might adversely affect his asthma
4. Identify comorbid conditions that can diminish asthma control
5. Discontinue zafirlukast and switch to a low-dose inhaled corticosteroid

Critique:

Based on the 2007 National Asthma Education and Prevention Program guidelines, this patient with mild persistent asthma would be classified as having asthma that is “not well controlled.” This category of asthma control is characterized by

• • symptoms more than 2 days per week
    
    • nighttime awakenings 1–3 times per week
    • some limitation of normal activity
    • use of a short-acting inhaled β₂-agonist more than 2 days per week
    • a peak flow or FEV₁ that is 60%–80% of predicted/personal best
    • 2 or more asthma exacerbations per year that require systemic corticosteroid therapy

Before increasing the patient’s therapy to the next step, it is important to review adherence to medication(s), inhaler technique, environmental control, and comorbid conditions. Other factors that can diminish control should be identified and addressed, including psychosocial issues and patient and family barriers to adequate self-management behaviors. If an alternative treatment option such as a leukotriene receptor antagonist is being used, that agent should be discontinued and the preferred treatment used prior to moving up a treatment step.

Question 47

Question: 47 of 60

A 22-year-old female presents to the emergency department with a severe asthma attack. Examination reveals a severely dyspneic female with diffuse inspiratory and expiratory wheezing, use of accessory muscles, pulsus paradoxus of 30 mm Hg, and a pulse rate of 110 beats/min. Her peak expiratory flow is found to be 150 L/min, her pO2 is 60 mm Hg, and her pCO2 is 30 mm Hg.

Aggressive asthma treatment with inhaled β2-agonists and systemic corticosteroids is instituted, and she is reevaluated 1 hour later. Which one of the following would provide the most reassurance that she is responding to therapy?

1. The absence of wheezing
2. A reduction in pulsus paradoxus
3. A pCO2 of 40 mm Hg
4. A PEF of 300 L/min
5. Inward movement of the abdomen with inspiration

Answer 47

1. The absence of wheezing
2. A reduction in pulsus paradoxus
3. A pCO2 of 40 mm Hg
4. A PEF of 300 L/min
5. Inward movement of the abdomen with inspiration

Critique:

In patients with an asthma attack, an improvement in PEF is indicative of an improvement in airway obstruction and a response to therapy. A rise in pCO₂ in a patient with severe asthma can be a sign of impending respiratory failure. Inspiratory descent of the abdomen is abnormal and results from transmission of markedly negative intrapleural pressures across a flaccid, fatigued diaphragm into the abdomen. The combination of wheezing and a high pulsus paradoxus requires the generation of markedly negative intrapleural pressures, and both of these findings can disappear in a patient with respiratory muscle fatigue and impending respiratory failure.

Question 48

Question: 48 of 60

A 6-year-old male with a past history of reactive airways disease has a 2-month history of cough and wheezing 3–4 times per week requiring treatment with his albuterol (Proventil, Ventolin) inhaler. He also has had nighttime awakening with coughing and wheezing slightly less than once a week. Office spirometry reveals an FEV1 that is 85% of predicted.

Which one of the following is NOT appropriate for this patient?

1. A low-dose inhaled corticosteroid
2. A long-acting inhaled β2-agonist
3. A leukotriene receptor antagonist
4. Theophylline

Answer 48

1. A low-dose inhaled corticosteroid
2. A long-acting inhaled β2-agonist
3. A leukotriene receptor antagonist
4. Theophylline

Critique:

The patient’s clinical picture places him in the category of mild persistent asthma, which is characterized by symptoms 3–6 days a week, nighttime awakenings 3–4 times per month, use of a short-acting inhaled β₂-agonist 3–6 days per week, minor limitation of activity, an FEV₁ >80% of predicted, and 2 or more exacerbations per year that require the use of oral corticosteroids. Although the 2007 National Asthma Education and Prevention Program guidelines list low-dose inhaled corticosteroids (ICs) as preferred therapy for children 5–11 years of age, alternatives include cromolyn, leukotriene receptor antagonists, and theophylline. The use of long-acting β-agonists (LABAs) is not recommended as monotherapy for asthma.

Question 49

Question: 49 of 60

A 25-year-old female with a history of mild persistent asthma presents to the emergency department with a 5-day history of increasing cough, wheezing, and shortness of breath. On examination, she is noted to be slightly agitated with a pulse rate of 110 beats/min. Examination of the lungs reveals loud expiratory wheezing on auscultation, and obvious suprasternal retractions. Her FEV1 is 1.71 L (63% of predicted) and her oxygen saturation is 92%.

Which of the following treatment interventions would you initially prescribe? (Mark all that are true.)

1. Intubation
2. An inhaled short-acting β2-agonist, up to 3 treatments in the first hour
3. Intravenous theophylline
4. Oxygen by mask
5. Oral corticosteroid therapy

Answer 49

1. Intubation
2. An inhaled short-acting β2-agonist, up to 3 treatments in the first hour
3. Intravenous theophylline
4. Oxygen by mask
5. Oral corticosteroid therapy

Critique:

The patient’s clinical presentation is consistent with a moderate asthma exacerbation. Features of a moderate exacerbation include

• • breathlessness at rest
    
    • loud expiratory wheezes on examination
    • agitation
    • use of accessory muscles of respiration with suprasternal retractions
    • a pulse rate of 100–120 beats/min
    • pulsus paradoxus of 10–25 mm Hg
    • a PEF or FEV₁ of 40%–69% of predicted
    • a PaO₂ ≥60 mm Hg
    • a pCO₂ <42 mm Hg
    • an oxygen saturation of 90%–95%

Initial treatment in the emergency department should include a

1. β₂-agonist by metered-dose inhaler or nebulizer (choice B) (up to 3 doses in the first hour at 20-minute intervals) and an
2. oral systemic corticosteroid (choice E), particularly if there is no immediate response or the patient recently took an oral corticosteroid.
3. Inhaled anticholinergic agents are generally used as an adjunct to β₂-agonist therapy and systemic corticosteroids in patients with a severe exacerbation (FEV₁ or PEF ≤40% of predicted/personal best).
4. Oxygen is recommended when required (not D) to maintain an oxygen saturation of more than 90%, or more than 95% in pregnant women and patients with coexistent heart disease.
5. Hospitalization should be considered if the patient fails to respond to the initial measures and the FEV₁ or PEF remains below 70% of predicted.
6. Intubation is recommended for patients with impending or actual respiratory arrest; findings in such patients include drowsiness or confusion, paradoxical thoracoabdominal movement, the absence of wheezes, bradycardia, and a PEF <25% of predicted (or personal best).
7. Theophylline is NOT generally recommended (not C) for treatment in the emergency department because there is no evidence it provides added benefit to treatment with inhaled β₂-agonists, and it is associated with significant adverse effects.

Question 50

Question: 50 of 60

A 2-year-old male is brought to your office because of a cough and wheezing. His mother states that on at least four other occasions during the past year he has experienced episodes of wheezing precipitated by “colds.”

Risk factors for developing persistent asthma include which of the following? (Mark all that are true.)

1. A parental history of asthma
2. A previous history of atopic dermatitis
3. Evidence of sensitization to aeroantigens
4. Elevated IgE levels
5. Improvement of wheezing with use of a β2-agonist

Answer 50

1. A parental history of asthma
2. A previous history of atopic dermatitis
3. Evidence of sensitization to aeroantigens
4. Elevated IgE levels
5. Improvement of wheezing with use of a β2-agonist

Critique:

For children younger than 3 years of age who have had four or more episodes of wheezing during the previous year, long-term longitudinal studies have identified the following risk factors for developing persistent asthma: a parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens. Risk factors also include the presence of any two of the following: evidence of sensitization to foods, peripheral blood eosinophilia ≥4%, or wheezing apart from colds.

Question 51

Question: 51 of 60

True statements regarding bronchoprovocative testing include which of the following? (Mark all that are true.)

1. Histamine is the most commonly used bronchoprovocative agent
2. A positive test is defined as a 12% decline in FEV1 following a challenge
3. A positive test is diagnostic of asthma
4. A negative test is helpful in excluding the diagnosis of asthma
5. Testing is not recommended in patients with a baseline FEV1 <65% of predicted

Answer 51

1. Histamine is the most commonly used bronchoprovocative agent
2. A positive test is defined as a 12% decline in FEV1 following a challenge
3. A positive test is diagnostic of asthma
4. A negative test is helpful in excluding the diagnosis of asthma
5. Testing is not recommended in patients with a baseline FEV1 <65% of predicted

Critique:

Asthma is characterized by nonspecific airway hyperreactivity. Bronchoprovocation tests can provide evidence of this hyperreactivity, which would support the diagnosis of asthma. Methacholine is the most commonly (not A) used bronchoprovocative agent, with histamine and hypertonic (or hypotonic) saline used less commonly.

A positive test is defined as a 20% decline in FEV_{<span><strong>1</strong><strong> </strong></span>}(not B).

Although a negative test is helpful for excluding the diagnosis of asthma (choice D), a positive test is not diagnostic of asthma (not C).

A positive test may also occur in patients with emphysema, bronchiectasis, or cystic fibrosis, as well as in up to 8% of normal subjects. For safety reasons, bronchoprovocative testing is not recommended if a patient’s baseline FEV₁ is <65% of predicted (choice E).

Question 52

Question: 52 of 60

A 15-year-old asthmatic male presents with an episodic cough and wheezing. He reports wheezing episodes 3–5 days per week and nighttime awakenings no more than 3 times a month. He states that 6 months ago he had to go to an urgent care center for an upper respiratory infection with a severe cough, which was treated with an asthma inhaler and some “oral medication for a few days.” His FEV1 is 70% of predicted.

This patient has

1. mild intermittent asthma
2. moderate intermittent asthma
3. mild persistent asthma
4. moderate persistent asthma
5. severe persistent asthma

Answer 52

1. mild intermittent asthma
2. moderate intermittent asthma
3. mild persistent asthma
4. moderate persistent asthma
5. severe persistent asthma

Critique:

Although the patient’s clinical symptoms and risk profile are both consistent with mild persistent asthma, his pulmonary function (FEV₁ 70% of predicted) is consistent with moderate persistent asthma. According to National Asthma Education and Prevention Program guidelines, patients should be assigned to the most severe category in which any feature occurs.

Question 53

Question: 53 of 60

A 32-year-old patient has a history of moderate persistent asthma treated with a medium-dose inhaled corticosteroid. Over the past 3 months he has awakened with a cough once or twice a month and has required the use of his albuterol (Proventil, Ventolin) inhaler once a week. Once in the past year he had an exacerbation that required the use of an oral corticosteroid. His peak flow periodically drops as low as 540 L/min, down from a personal best of 600 L/min.

Which one of the following would be most appropriate?

1. No change in drug therapy
2. Adding a long-acting inhaled β2-agonist to his regimen
3. Adding a leukotriene-receptor antagonist to his regimen
4. Adding theophylline to his regimen
5. A short course of an oral corticosteroid

Answer 53

1. No change in drug therapy
2. Adding a long-acting inhaled β2-agonist to his regimen
3. Adding a leukotriene-receptor antagonist to his regimen
4. Adding theophylline to his regimen
5. A short course of an oral corticosteroid

Critique:

The patient has well-controlled asthma and no intervention needs to be made. Well-controlled asthma is defined as symptoms that occur 2 days or less per week, nighttime awakening 2 nights or less per month, use of a short-acting inhaled β₂-agonist 2 days or fewer per week, a peak flow (or FEV₁) >80% of predicted/personal best, and no more than one asthma exacerbation requiring oral corticosteroids per year, with no interference with normal activity (SOR C).

Question 54

Question: 54 of 60

True statements regarding occupational asthma include which of the following? (Mark all that are true.)

1. The likelihood of complete resolution decreases with time of exposure to the sensitizer
2. Continued symptoms during weekends away from work excludes the diagnosis
3. The onset of symptoms may occur after a high-level exposure (e.g., a spill)
4. Symptoms can occur 2–8 hours after exposure
5. Serial measurement of peak expiratory flow rates at work and away from work is helpful in the diagnostic evaluation

Answer 54

1. The likelihood of complete resolution decreases with time of exposure to the sensitizer
2. Continued symptoms during weekends away from work excludes the diagnosis
3. The onset of symptoms may occur after a high-level exposure (e.g., a spill)
4. Symptoms can occur 2–8 hours after exposure
5. Serial measurement of peak expiratory flow rates at work and away from work is helpful in the diagnostic evaluation

Critique:

Early recognition and control of occupational asthma is important, since the likelihood of complete resolution decreases with time. Although improvement in symptoms is typically seen during vacations or days off, a week or more away from the sensitizer may be required. Symptoms may be immediate (within an hour) or delayed (commonly 2–8 hours) after exposure or may be nocturnal. Initial symptoms may be traced to a high-level exposure. Serial charting of peak expiratory flow rates at work and away from work to identify or exclude work-related changes in flow rates is helpful in the diagnostic evaluation.

Question 55

Question: 55 of 60

Physical findings consistent with airway obstruction in a patient with uncomplicated asthma include which of the following? (Mark all that are true.)

1. Clubbing
2. Expiratory wheezing
3. A shortened expiratory phase
4. Distant breath sounds
5. Hyperresonance of the thorax on percussion

Answer 55

1. Clubbing
2. Expiratory wheezing
3. A shortened expiratory phase
4. Distant breath sounds
5. Hyperresonance of the thorax on percussion

Critique:

If asthma is mild and airflow obstruction minimal, the chest examination is usually normal. Findings that suggest airflow obstruction include

• diffuse scattered expiratory wheezing (choice B), a
• prolonged expiratory time (not C), and
• hyperresonance of the thorax to percussion (choice E).
• Breath sounds can be distant (choice D) and difficult to auscultate in the presence of thoracic hyperinflation.

In more severe or active asthma, inspiratory and expiratory wheezing can be heard and patients may require the use of accessory muscles to breathe.

Clubbing is not found in uncomplicated asthma (not A).

Question 56

Question: 56 of 60

True statements about written asthma action plans include which of the following? (Mark all that are true.)

1. They are recommended for all patients with asthma, regardless of severity
2. They have been shown to reduce hospitalizations and emergency department visits when used in the context of an asthma self-management program
3. Medication adjustments by patients using a written asthma action plan are likely to be less effective than changes by a physician during an office visit
4. They are of particular value for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma

Answer 56

1. They are recommended for all patients with asthma, regardless of severity
2. They have been shown to reduce hospitalizations and emergency department visits when used in the context of an asthma self-management program
3. Medication adjustments by patients using a written asthma action plan are likely to be less effective than changes by a physician during an office visit
4. They are of particular value for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma

Critique:

The 2007 National Asthma Education and Prevention Program (NAEPP) guidelines recommend that all patients who have asthma be provided with a written asthma action plan. They are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (SOR B). Optimal asthma self-management, including self-monitoring of symptoms and/or peak control and a written asthma action plan, has been shown to significantly reduce hospitalizations and emergency department visits. Adjustment of medications for asthma control using a written asthma action plan appears to be as effective as changes by a physician during an office visit (SOR C).

Written asthma action plans provide a way to involve the patient directly in self-management by writing down the treatment plan the clinician and patient agree on together and by giving clear instructions that the patient can use at home. The asthma action plan should be reviewed and refined at the patient’s follow-up visits. Clinicians should choose an action plan that suits their practice, patients, and style. Examples of asthma action plans are provided in the NAEPP guidelines.

Written asthma action plans include two important elements: daily management and recognizing and handling worsening asthma. Daily management includes what medicine to take daily, including the specific names of the medications, and actions to control environmental factors that may worsen the patient’s asthma. Recognizing and handling worsening asthma includes an explanation of the signs, symptoms, and PEF measurements that indicate worsening asthma, what medications to take in response to these signals, how to know when urgent medical attention is required, and emergency telephone numbers for the physician, emergency department, and person or service to transport the patient rapidly for medical care.

Question 57

Question: 57 of 60

A 17-year-old male reports that his asthma is usually worse in the early spring. Which one of the following is most likely triggering his symptoms at that time of year?

1. Tree pollen
2. Grass pollen
3. Weed pollen
4. Alternaria
5. Mites

Answer 57

1. Tree pollen
2. Grass pollen
3. Weed pollen
4. Alternaria
5. Mites

Critique:

Patients with seasonal allergies become symptomatic only after exposure to certain pollens or molds. Symptoms occurring in the early spring are usually due to tree pollen. Grass pollen typically causes problems in the late spring, weed pollen in late summer to autumn, and Alternaria, Cladosporium, and mites in the summer and fall.

Question 58

Question: 58 of 60

The mother of a 15-year-old female with a history of moderate persistent asthma calls your office and tells you that over the past few days the girl has experienced rhinorrhea and cough with growing dyspnea. Her asthma is treated with medium-dose inhaled corticosteroids and a long-acting β2-agonist, and the problem has developed even though she has used her β2-agonist metered-dose inhaler four times a day. The mother reports that the daughter’s peak flow rate this morning was 310 L/min (61% of personal best) and that her personal best prior to the illness was 510 L/min. Following two treatments with her albuterol (Proventil, Ventolin) inhaler at 20-minute intervals, her wheezing improved and her peak flow rose from 310 L/min (61% of personal best) to 360 L/min (71% of personal best).

Which of the following would you recommend? (Mark all that are true.)

1. Continue current management
2. Continue use of the albuterol inhaler every 3–4 hours for 24–48 hours
3. Double the dosage of the inhaled corticosteroid
4. Start oral prednisone at a dosage of 1–2 mg/kg/day
5. Initiate mucolytic therapy

Answer 58

1. Continue current management
2. Continue use of the albuterol inhaler every 3–4 hours for 24–48 hours
3. Double the dosage of the inhaled corticosteroid
4. Start oral prednisone at a dosage of 1–2 mg/kg/day
5. Initiate mucolytic therapy

Critique:

Home treatment of asthma exacerbations begins with measurement of peak expiratory flow (PEF) and initial treatment with an inhaled short-acting β₂-agonist, up to two treatments at 20-minute intervals. A PEF of 50%–79% of predicted (or personal best) following a course of an inhaled β₂-agonist represents an incomplete response to therapy. In this situation, the 2007 National Asthma Education and Prevention Program (NAEPP) guidelines recommend that the β₂-agonist be continued every 3–4 hours for several days (choice B), and that the patient be given a course of an oral corticosteroid (choice D).

Although patients should be advised to continue intensive short-acting inhaled β₂-agonist therapy until symptoms and PEF are stable, NAEPP also recommends that patients be advised to seek medical care rather than rely on bronchodilator therapy in excessive doses or for prolonged periods (e.g., more than 12 puffs/day for more than 24 hours).

Doubling the dose of the inhaled corticosteroid was recommended in the 1997 NAEPP guidelines, but the 2007 guidelines indicate that subsequent studies have shown that this is NOT effective (not C) for reducing the severity or progression of exacerbations.

Mucolytic agents are NOT recommended (not E) because they may worsen cough or airflow obstruction. Antibiotics are not generally recommended for the treatment of acute asthma exacerbations, and are generally reserved for patients with fever and purulent sputum, or with suspected pneumonia or sinusitis.

Question 59

Question: 59 of 60

A 29-year-old female at 32 weeks gestation presents with a 3-day history of increasing wheezing and dyspnea. She has a history of asthma since childhood.

Which one of the following pCO2 levels is the threshold for respiratory failure in this patient?

1. 25 mm Hg
2. 35 mm Hg
3. 45 mm Hg
4. 55 mm Hg
5. 65 mm Hg

Answer 59

1. 25 mm Hg
2. 35 mm Hg
3. 45 mm Hg
4. 55 mm Hg
5. 65 mm Hg

Critique:

Asthma affects 1%–4% of pregnant women. Acute asthma attacks are rare during the last four weeks of pregnancy; attacks are most common between the 24th and 36th weeks of gestation. Since minute ventilation rises 30%–40% by late pregnancy, normal pCO₂ levels fall to 27–32 mm Hg, compared with 37–40 mm Hg in the nonpregnant state. If the pCO₂ is 35 mm Hg or greater in a pregnant patient with an asthma exacerbation, it signals respiratory failure.

Question 60

Question: 60 of 60

Foods that should be avoided by patients with persistent asthma who have a known sulfite sensitivity include which of the following? (Mark all that are true.)

1. Processed potatoes
2. Wine
3. Dried fruit
4. Beer
5. Shrimp

Answer 60

1. Processed potatoes
2. Wine
3. Dried fruit
4. Beer
5. Shrimp

Critique:

Sulfites are used to preserve foods and beverages. Use of these agents has been restricted, so heavy exposures now occur only with a limited number of foods, such as beer, wine, dried fruit, shrimp, and processed potatoes (all of them).