Asthma

Question 1

Asthma Classifications

Answer 1

Intermittent (persistent cough may be only sign)

Persistent (Mild, Moderate, or Severe)

Question 2

Intermitten Asthma

Answer 2

Symptoms 2 or fewer days per week
Nighttime awakenings 2 or fewer per month
SABA needed 2 or fewer days per week
No Effect on Normal Activity
Normal FEV1 > 80%, and FEV1/FVC normal
Step 1

Question 3

Mild Persistent Asthma

Answer 3

Symptoms 2 or more days per week, but not daily
Nighttime awakenings 3-4 per month
SABA needed 2 or more days per week, but not daily or ever more than once per day
Minor Effect on Normal Activity
FEV1 > 80%, and FEV1/FVC normal
Step 2

Question 4

Moderate Persistent Asthma

Answer 4

Symptoms daily
Nighttime awakenings more than once a week, but not every night
SABA needed daily
Some Limits on Normal Activity
Normal FEV1 > 60% but < 80%, and FEV1/FVC reduced by 5%
Step 3

Question 5

Severe Asthma

Answer 5

Symptoms daily, multiple times
Nighttime awakenings often 7 times per week
SABA needed many times per day
Severe Effect on Normal Activity
Normal FEV1 < 60% and FEV1/FVC reduced by more than 5%
Step 4 or 5

Question 6

Asthma Diagnosis

Answer 6

1 - episodic symptoms of airflow obstruction (wheeze, cough, SOB, decreased PEF)
2 - Evidence that obstruction is partly reversible
3 - Exclusion of other differentials

An FEV1 of 80% of predicted or less with a reduced FEV1/FVC ratio that normalizes or significantly improves with bronchodilator therapy raises the suspicion of asthma.

Question 7

Asthma Differentials

Answer 7

Stridor from foreign body
Tracheomalacia
Airway masses
vocal cord dysfunction (consider this in athletes before asthma)
COPD (not reversible)
α1-Antitrypsin (AAT) deficiency

Question 8

Asthma Risk / Grading

Answer 8

Done at diagnosis and every 1-2 years

Measure personal best FEV1 at start of treatment, then after 3-6 months for new best.

Question 9

Asthma Step Approach

Answer 9

All steps have a SABA for PRN quick relief
Step 1 - no daily meds
Step 2 - low dose IGC (alt - either LTRA, cromolyn, or theophylline)
Step 3 - Low dose IGC + LABA or Medium dose IGC (alt - low dose IGC + either LTRA, zileuton, or theophylline)
Step 4 - Medium dose IGC + LABA (alt - medium dose IGC + either LTRA, zileuton, or theophylline)
Step 5 - High dose IGC + LABA
Step 6 - High dose IGC + LABA + oral glucocorticoid

Question 10

Seasonal Asthma

Answer 10

For purely seasonal allergic asthma, start ICS immediately upon onset of symptoms and discontinue using 4 weeks after exposure ends.

Question 11

Asthma Referral

Answer 11

Emergency evaluation/treatment is indicated for persons with signs and symptoms suggestive of respiratory compromise, including respiratory rate >30/min, pulse rate >120 beats per minute, O2 saturation (on room air) <90%, peak expiratory flow (PEF) <50% predicted or best, drowsiness, confusion, or silent chest.

Question 12

Aspirin exacerbated respiratory disease

Answer 12

moderate to severe airway obstruction
Rhinorrhea
sneezing, tearing
dermal changes
GI disturbances

All on exposure to aspirin or other prostaglandin inhibitors

Question 13

Asthma and GERD

Answer 13

Another exacerbating factor of asthma is esophageal reflux of gastric contents. The incidence of gastroesophageal reflux in adults with asthma ranges from 25% to 80%. Gastroesophageal reflux resulting in distal esophageal stimulation with acid may cause bronchoconstriction or may increase bronchial reactivity through vagal mechanisms.

Question 14

Classic Asthma Presentation

Answer 14

Episodic wheezing associated with dyspnea, cough, sputum production

Question 15

PEF Zones

Answer 15

Green >80%
Yellow 60% to 80%
Red <60%

Some scales use 60%, some use 50%. Yellow = step up, Green = step down, Red = urgent intervention and step up

Question 16

Asthma Action Plan

Answer 16

Asthma episode
Up to three/four doses of SABA, go to ER if no improvement in 20-60 min
If improved, may also try albuterol puffs every 20 min for 4 hours to improve PEF if it is low during episode

Question 17

When to refer to pulmonology

Answer 17

A. Life-threatening exacerbation in ED with hospitalization
B. Any patient ≤4 yr of age requiring ICS+LABA (Step 3)
C. Has been in hospital >2 times or had >2 bursts of OGC in the last year
D. Poor control or unresponsiveness to current treatment
E. There is a question as to diagnosis of asthma
F. Other physical anatomical restrictions causing poor control of asthma (e.g., nasal polyps, chronic URI, COPD, vocal cord dysfunction)
G. Unknown severe environmental/occupational allergy triggers (referral to allergist for testing and management of medications)

Question 18

Exercise induced asthma

Answer 18

Use inhaler 15 min before exercise

Episodes can occur during, or hours after exercise

Question 19

Risk factors for poor asthma outcomes

Answer 19

ICS not prescribed; poor ICS adherence; incorrect inhaler technique
High SABA use (with increased mortality if >1 × 200-dose canister/month)
Low FEV1 especially if <60% predicted
Higher bronchodilator reversibility
Major psychological or socioeconomic problems
Exposures: smoking; allergen exposure if sensitized
Comorbidities: obesity; chronic rhinosinusitis; confirmed food allergy
Sputum or blood eosinophilia; elevated FENO in allergic adults taking ICS
Pregnancy

Other major independent risk factors for exacerbations include:
• Ever being intubated or in intensive care for asthma
• Having one or more asthma exacerbations in the last 12 months

Question 20

Methacholine challenge

Answer 20

can be used in patients to diagnose Asthma, since it’s a Muscarinic Cholinergic Agonist, it will increase Bronchial Smooth Muscle Contraction and Mucus Production.