Asthma Flashcards
1
Q
How is asthma characterized?
A
paroxysmal or persistent symptoms
dyspnea, chest tightnesss, wheezing, sputum & cough
airway hyper-responsiveness to a variety of stimuli
variable and occurs at any age
chronic inflammatory disorder
2
Q
Provide a brief overview of the epidemiology of asthma.
A
> 3 million Canadians (Canada has one of the highest rates in the world)
childhood asthma is the #1 chronic condition in Canada
6/10 ppl do not have control
3
Q
Describe the effects of asthma on mortality
A
250 ppl die/year in Canada (preventable)
most dont die from long-term progression
lifespan is unaltered
can maintain all activities of daily living
QOL can be same as non-asthmatic
4
Q
What is the etiology of asthma?
A
genetic predisposition + environmental factors
5
Q
Describe genetic predisposition for asthma.
A
multiple genes involved
-genes predisposing to atopy
-genes predisposing to airway hyper-responsiveness
-genes associated with response to treatment
sex
-childhood: male>female
-age 20: male=female
->age 40: female>male
obesity
6
Q
What are the many environmental factors for ashtma?
A
tobacco smoke
allergen exposure (pollens, dander, dust mites)
infections in infancy (RSV, hygiene hypothesis)
environment (air, fog, smoke)
occupational sensitizers (chemicals)
exercise (mainly in cold, dry climate)
drugs/preservatives (NSAIDs, benzalkonium chloride, non-selective BB)
diet
7
Q
Differentiate between asthma that is atopic and non-atopic.
A
atopic:
-allergy to antigens
-1/2 children and young adults
non-atopic:
-secondary to chronic/recurrent infections
-hypersensitivity to bacteria/viruses causing infection
can be mixed
8
Q
Describe the impact of age on asthma.
A
can occur at any time but primarily a pediatric disease
-most diagnosed by 5, 50% of symptoms by 2
-most kids improve markedly or are symptom free by adulthood
9
Q
What are the predictors of persistent adult asthma?
A
atopy
onset during school age
presence of bronchiole hyper-reactivity
10
Q
What is the hallmark of asthma?
A
bronchial hyper-reactivity of airways to physical, chemical, and pharmacological stimuli
11
Q
What can occur if anti-inflammatory therapy is not prescribed for asthma?
A
airway remodeling
12
Q
Define the following:
bronchospasm
hyper-reactivity
airway remodeling
A
bronchospasm:
-constriction of the muscles in the walls of the bronchioles caused by inflammatory mediators
hyper-reactivity:
-an exaggerated response of the bronchial smooth muscle to triggers
-correlates with the course of the disease
airway remodeling:
-structural changes in the extracellular matrix in the airway wall leading to airflow obstruction
-may become only partially reversible
13
Q
Differentiate the early asthmatic response from the late asthmatic response.
A
early:
-occurs in minutes
-causes bronchospasm
-mast cells–>histamine
late:
-occurs in hours (6-9hrs)
-bronchospasm returns, edema, hyper-responsiveness
-inflammatory cells
14
Q
What is chronic asthma?
A
occurs in days
hyper-reactive airways, epithelial cell damage, mucous hypersecretion
leads to airway remodeling
15
Q
What are the elements of diagnosis for asthma?
A
- medical history
-symptoms and severity, history
-precipitating factors - physical exam
-poor indicator of the degree of airflow obstruction - pulmonary function tests
-necessary for diagnosis
-FEV1/FVC < 75-80% predicted - other laboratory tests
16
Q
What are three very important topics to ask about when collecting an asthma history?
A
amount of rescue med needed
symptoms at night
exercise induced
17
Q
What are the main things we want to be asking about when collecting an asthmatics history?
A
symptoms and severity:
-severe episodes of symptoms?
-worsening during a season?
-worsening in certain locations or exposures?
-awakening at night?
-after exercise?
history:
-family history of asthma/allergies
-positive patient history of allergies
precipitating triggers
-variable between patients
18
Q
What are some of the many triggers of asthma?
A
exercise
-drop in FEV1 of 15% or > from baseline (most asthmatics)
time of day
-nocturnal asthma (low cortisol and EP)
aero-allergens (smoke, fumes, pollen)
irritants (perfumes, air fresheners)
respiratory tract infections
-esp if <10yrs old or viral
weather (cold, dry or hot, humid)
psychological factors
hormonal fluctuations
GERD
medications
-ASA/NSAIDs, beta-blockers, benzalk chloride, contrast media
19
Q
True or false: a physical exam is a good indicator of the degree of airway obstruction
A
false
poor indicator
20
Q
What are some things that might be observed from a physical exam?
A
expiratory wheezing on auscultation
dry hacking cough
signs of atopy (allergic rhinitis and/or eczema)
21
Q
What is the adult criteria for ashtma?
A
FEV1/FVC < 75-80% predicted
12% improvement in FEV1 post B2-agonist challenge or after course of controller therapy
spirometry preferred
22
Q
What is a low FEV1 a predictor of?
A
exacerbation
23
Q
How should we monitor progress of lung function?
A
at diagnosis and 3-6mo after initiating treatment
every 1-2 years for most adults
24
Q
What is the diagnosis of asthma in kids?
A
FEV1/FVC <80-90% predicted
>12% increased in FEV1 post bronchodilator challenge or course of controller therapy
kids older than 6yrs
spirometry preferred
25
What are some laboratory tests that can be done for asthma?
eosinophil, CBC, IgE concentration
allergy skin tests
sputum eosinophils
26
Where do the asthma guidelines that we follow come from?
Canadian Thoracic Society
27
What is the definition of asthma control (chart)?
daytime symptoms: <2d/wk
nighttime symptoms: <1night/wk and mild
physical activity: normal
exacerbations: mild and infrequent
absence from school or work: none
need for reliever: <2 doses per week
FEV1 or PEF: >90% of PB
PEF diurnal variation: <10-15%
sputum eosinophils: <2-3%
28
Summarize good asthma control.
patient can:
-avoid symptoms during day and night
-need little or no reliever
-have productive, physically active lives
-normal or near-normal lung function
-avoid serious exacerbations
29
What are the goals of therapy for asthma?
prevent asthma-related mortality
maintain normal activity levels
prevent daytime and nocturnal symptoms
maintain normal (or near normal) spirometry
prevent exacerbations
provide optimal pharmacotherapy and avoid AE
30
What are the principles of asthma therapy?
1. environmental control
2. pharmacologic therapy
3. appropriate use of inhalation therapy
4. regular consultation with certified asthma educator
5. graduated approach to therapy
6. regular follow-up
31
Differentiate between endogenous stimuli and exogenous stimuli for asthma.
endogenous:
-stimuli generated inside the body
-GERD, stress, rhinitis
exogenous:
-stimuli generated outside the body
-irritants, allergens, exercise
32
How can an asthmatic with a pet try to perform environmental control?
remove the pet from home
HEPA filter
wash pets
33
Describe proper mold/fungus control to try help an asthmatic.
humidity in house <50%
clean moldy surfaces with a bleach cleanser
fix leaky faucets, pipes
refrain from walking in uncut fields, working with compost, & raking leaves
34
What kind of precautions can an asthmatic take if the outdoors are a trigger for them?
minimize outdoor activity when air quality is poor
keep windows closed; use an AC
consider increased anti-infl therapy prior to allergy season
35
How can house dust mites be minimized?
wash linen/blankets every week
vacuum weekly with a HEPA vacuum
humidity in house <50%
clean surfaces with damp cloth weekly
remove carpets, stuffed animals, etc
avoid bottom bunk
36
What is immunotherapy? What is its role in asthma?
administration of allergen in progressively higher doses to induce tolerance
limited role in adults
-must identify and use a single, well defined allergen
-inconvenient
37
Differentiate between a reliever and controller.
reliever:
-to have on hand and take only when needed (during an attack, dyspnea, or before exercising)
controller:
-prevents asthma attacks and inflammation
-take every day (even if no symptoms)
-acts slowly and works over the long-term
38
True or false: a controller will not help during an asthma attack
true
39
What is the MOA of SABAs?
selective B2 adrenergic agonist
-little effect on late (inflammatory) phase
40
What is the onset of SABAs?
5 minutes
-peak effect on FEV within 30 minutes
41
What is the indication of SABAs?
prevention of exercise induced or cold air induced bronchospasm
treatment of intermittent episodes of bronchospasm
42
True or false: equipotent doses of all adrenergic agents will produce the same degree of bronchodilation
true
43
What is the selectivity (a, B1, B2) and DOA of the following SABAs:
epinephrine
isoproterenol
metaproterenol
terbutaline
salbutamol
epinephrine:
-a=4, B1=4, B2=2
-DOA: 1-2hrs
isoproterenol:
-B1=4, B2=4
-DOA: 0.5-2hrs
metaproterenol:
-B1=3, B2=3
-3-4hrs
terbutaline:
-B1=1, B2=4
-DOA: 4-8hrs
salbutamol:
-B1=1, B2=4
-DOA: 4-8hrs
44
What are examples of SABAs?
salbutamol
terbutaline
45
What are the many adverse effects of SABAs?
tachycardia, palpitations
skeletal muscle tremor
nervousness, irritability, insomnia, headache
BP changes
cardiac arrythmias
increased blood glucose
hypokalemia at high doses
tachyphylaxis
children: excitement/hyperactivity
46
What are the drug interactions of SABAs?
beta-blockers: oppose effect of SABAs
loop/thiazide diuretics: increased risk of hypokalemia
TCAs: may increase AEs of SABAs
QT prolongation
*less risk with inhaled therapy*
47
What is the typical dosing of SABAs?
1-2 puffs q4-6hrs prn
-some patients use them 15min prior to exercise or triggers
-during an asthma attack, safe to take puffs every few mins
48
When should patients on SABAs be referred to their physician?
requiring their rescue med >2 times/week
49
How long do LABAs work? What are the adverse effects of LABAs?
slowly over a 12 hour period to keep airways open and muscles relaxed
-similar MOA to SABAs
AE are similar to SABAs
50
Are LABAs a controller or reliever?
controller
-formoterol also approved for rescue therapy
51
Are LABAs used alone?
never used alone in any age group
always added to inhaled steroid therapy
52
What are examples of LABAs?
formoterol (Oxeze)
-full agonist
salmeterol (Serevent)
-partial agonist
available in combination products only:
-vilanterol (+fluticasone=Breo)
-indacaterol (+mometasone=Atectura)
53
What is the selectivity (a, B1, B2) and DOA of the following LABAs:
salmeterol
formoterol
vilanterol
indacaterol
salmeterol
-B1=1, B2=4
-DOA= >12h
formoterol
-B1=1, B2=4
-DOA= >12h
vilanterol
-B1=1, B2=4
-DOA= >24h
indacaterol
-B1=1, B2=4
-DOA= >24h
54
What is the therapy that is most effective anti-inflammatory for the management of asthma?
inhaled corticosteroids
-most common and effective controller
55
Describe the use and onset of ICS.
require daily use
onset: days-weeks (maximal=months)
56
What are the benefits of ICS?
improve lung function
decrease frequency/severity of attacks
increases QOL
decreases asthma mortality
57
What is the MOA of ICS?
inhibit inflammatory response at all levels
inhibits the late asthmatic response & decreases bronchial hyper-responsiveness in asthma
58
What are some examples of ICS?
fluticasone propionate/furoate
budesonide
ciclesonide
beclomethasone
mometasone
59
Which ICS is preferred in pregnancy?
budesonide
60
True or false: ICS have an effect on acute symptom relief
false
61
Describe the dosing of beclomethasone for preschoolers (1-5yrs), children (6-11yrs), and adults/adolescents (>12yrs).
preschoolers
-low: 100
-medium: 200
children:
-low: <200
-medium: 201-400
-high: >400
adults:
-low: <200
-medium: 201-500
-high: >500 (max 800)
62
Describe the dosing of budesonide for preschoolers (1-5yrs), children (6-11yrs), and adults/adolescents (>12yrs).
preschoolers
-na
children
-low: <400
-medium: 401-800
-high: >800
adults:
-low: <400
-medium: 401-800
-high: >800 (max 2400)
63
Describe the dosing of ciclesonide for preschoolers (1-5yrs), children (6-11yrs), and adults/adolescents (>12yrs).
preschoolers
-low: <100
-medium: <200
children:
-low: <200
-medium: 201-400
-high: >400
adults:
-low: <200
-medium: 201-400
-high: >400 (max 800)
64
Describe the dosing of fluticasone propionate for preschoolers (1-5yrs), children (6-11yrs), and adults/adolescents (>12yrs).
preschoolers:
-low: <200
-medium: 200-250
children:
-low: <200
-medium: 201-400
-high: >400
adults:
-low: <250
-medium: 251-400
-high: >500 (max 2000)
65
Describe the dosing of mometasone for preschoolers (1-5yrs), children (6-11yrs), and adults/adolescents (>12yrs).
preschoolers:
-na
children:
-low: 100
-medium: 200-400
-high: >400
adults:
-low: 100-200
-medium: 200-400
-high: >400 (max 800)
66
What are the side effects of ICS?
dysphoria, hoarseness, throat irritation, cough
thrush (rinse mouth)
URTI increase? (benefit>risk)
growth retardation in kids
-can occur in low-mod doses; does not seem to affect adult heigh
*dose, drug, inhalation technique dependent*
67
What are some education points to provide about ICS?
regular use; delayed onset
spacer/rinse mouth & spit
wash face after each dose (if use spacer with mask)
efficacy reduced in patients who smoke
68
What are drug interactions of ICS?
desmopressin: increased risk of hyponatremia
69
What are contraindications of ICS?
initiation during untreated respiratory tract infection
precautions:
-HPA axis suppression upon dc
-long term steroid effects at high doses
-increase URTIs?
70
What is the use of oral/IV corticosteroids in asthma?
short periods of time in acute, severe asthma
71
What is the MOA of LTRAs?
antagonize effect of leukotrienes
-reduce airway inflammation, small variable bronchodilation
72
What are the side effects of LTRAs?
headache
dizziness
heartburn
nausea
drowsiness
*minimal & non-specific*
73
What is the only LTRA on the market?
Montelukast (Singulair)
74
How efficacious are LTRAs?
variable patient response
NOT for reversal of acute bronchospasm
-must be taken regularly (hs dosing)
75
True or false: you should not abruptly change someone from an ICS to an LTRA
true
76
What are the age guidelines for LTRAs?
>2 years
77
What is the use of LTRAs?
alternative to increasing dose of ICS in patients who remain symptomatic
very mild asthmatics who cannot/will not use an ICS
78
What are the advantages of LABA/ICS combo products?
*as effective as separate medications*
more convenient
enhanced adherence
ensures patient receives dose of ICS
avoids SABA dependence
79
Which combo product can be used as a reliever?
Symbicort (formoterol + budesonide)
-up to 8 pfs/day
80
True or false: methylxanthines are more effective bronchodilators than B-adrenergic agonists
false
81
What is theophylline structurally related to?
caffeine
82
What is the MOA of methylxanthines?
non-specific inhibition of phosphodiesterase, which causes mild bronchodilation
increases diaphragmatic contractility and enhances conciliary clearance
83
What are the therapeutic uses of methylxanthines?
add on in patients that require high dose corticosteroid
used only in severe asthma cases
-no role in rescue therapy (delayed onset)
-safer, more effective agents has minimized use
84
What are the side effects of methylxanthines?
diarrhea
nausea
heartburn
anorexia
headaches
nervousness
tachycardia
upset stomach
85
What are the drug interactions of methylxanthines?
significant potential
-3A4 and 1A2 substrate
86
Describe omalizumab as asthma treatment.
anti-IgE antibody
sc injection (150-375mg sc q2-4wks)
use (>6yrs): atopic asthma poorly controlled despite high-dose inhaled steroids and appropriate add-on therapy, w or w/o prednisone
AE: pain at injection site, rash, headache, fatigue
expensive
87
When might tiotropium be considered for asthma?
add-on therapy for individuals >12yrs with severe asthma despite combination of ICS/LABA therapy
88
Which antibiotics may decrease asthma exacerbations in >18yrs with severe asthma independent of their inflammatory profile?
macrolides
89
What is the biggest change to the approach of asthma treatment in the past couple of years?
use of ICS with SABA early on
-alt: Symbicort PRN
90
What is the role of IL-5 inhibitors (reslizumab, benralizumab, mepolizumab) and IL-4 and 13 inhibitors (duplimumab) in asthma?
severe eosinophilic asthma who experience recurrent asthma exacerbations despite high doses of ICS in addition to one other controller
91
What is the biggest change made to the treatment approach in asthma during the past few years?
use of ICS with SABA early on
-alt: Symbicort PRN
92
What is the rationale against SABA monotherapy?
even mild, intermittent asthma symptoms still have severe or fatal exacerbations
2/3 reduction in exacerbations when ICS added
93
What are the two things we take into consideration when deciding on optimal treatment for asthma?
asthma control
risk of exacerbation
94
What is the definition of "higher risk for exacerbation"?
one of the following:
1. history of prev severe exacerbation
2. poorly-controlled asthma as per CTS
3. overuse of SABA (>2 inhalers/year)
4. current smoker
95
Differentiate between severe asthma exacerbation and mild exacerbation.
severe:
-any of: needs systemic steroids, ED visit, hospitalization
mild:
-increase in sx from baseline that does not require the above
96
Describe the continuum of adjusting asthma therapy.
confirm diagnosis
environmental control, education and written action plan
SABA or Symbicort prn
ICS (LTRA as 2nd line)
1-11yrs: increase ICS, >12yrs: add LABA
6-11yrs: add LABA or LTRA, >12yrs: add LTRA and/or tiotropium
97
Describe the treatment approach for patients on PRN SABA or no medication.
see slide 80
98
What is the criteria for when to start an ICS if 12 and older?
if on prn SABA with well-controlled asthma at lower risk of exacerbation:
-continue prn SABA or switch to daily ICS+prn SABA or Symbicort prn
if on prn SABA with well-controlled asthma at higher risk of exacerbation:
-switch to either daily ICS+prn SABA or Symbicort prn
99
What is the criteria for when to start an ICS if <12 years old.
if on prn SABA well-controlled asthma and lower risk for exacerbation:
-continue prn SABA or switch to daily ICS+prn SABA
if on prn SABA well-controlled asthma and higher risk for exacerbation:
-switch to daily ICS+prn SABA
100
Differentiate the classifications of asthma severity.
very mild: prn SABA only
mild:
-low dose ICS (or LTRA) + prn SABA
-PRN Symbicort
moderate:
-low dose ICS + 2nd controller + prn SABA
-mod dose ICS +/- 2nd controller + prn SABA
-low-mod dose Symbicort + prn Symbicort
severe:
-high dose ICS + 2nd controller or systemic steroids
101
Differentiate uncontrolled asthma vs severe asthma.
uncontrolled:
-previously asymptomatic pt intermittently develops symptoms
-can be addressed with self-management education and action plan
severe:
-remains poorly controlled despite best practices
-requires treatment with high-dose ICS and a 2nd controller for the previous year or systemic steroids for 50% of previous year
102
How can we investigate uncontrolled asthma?
watch patient use their inhaler
assess adherence
remove risk factors and assess/manage comorbidities
confirm diagnosis of asthma
consider step-up therapy
103
How often should asthma be reviewed?
1-3 months after treatment started, then q3-12 months
pregnancy: q4-6 weeks
after an exacerbation: within 1 week
104
Differentiate between sustained step-up treatment, short-term step-up treatment, and day-to-day adjustment.
sustained step-up:
-at least 2-3 months if asthma poorly controlled
short-term step-up:
-for 1-2 weeks (ex: viral infection or allergen)
day-to-day adjustment:
-for pts prescribed low dose ICS/formoterol maintenance and reliever regimen
105
In which patients should we consider stepping down asthma therapy?
stable patients without history of severe asthma, exacerbations, or risk factors for exacerbations:
-only consider if >3 months of control
-ensure patient is on board for a "therapeutic experiment"
-have a plan in place if step down fails
*goal is to find lowest effective dose*
106
What are the general principles for stepping down controller treatment?
prepare for step-down:
-record level of symptom control and consider risk factors
-make sure the pt has a written action plan
-book a follow-up in 1-3 months
step down through available formulations
discontinuing ICS or LABA is not recommended in adults with asthma because of risk of exacerbations
107
True or false: only select asthma patients should have a written action plan
false
all patients should work with a HCP to develop an action plan
108
What should be included on an asthma action plan?
how to monitor and measure their symptoms
daily preventive management strategies
when and how to adjust meds
when to seek urgent care
109
What is the use of the peak expiratory flow meter?
moderate-severe asthmatics or asthmatics who are poor perceivers or airway obstruction
used by patients at home to:
-monitor treatment course/response
-determine when emergency care is necessary
-identify allergens
-detect asymptomatic deterioration in lungs
*allows patient to assume more responsibility & control in disease management*
110
What is the traffic light system of self-management?
green: good control, no changed required
yellow: worsening asthma, consult action plan
red: danger zone, seek emergency medical care
111
What are the three components of asthma self-management?
self monitoring
written asthma action plan
regular medical review
112
Describe the importance of adherence in asthma therapy.
poor adherence:
-contributes to uncontrolled sx, risk of exacerbations and asthma-related death
contributory factors:
-unintentional (forgetfulness, confusion)
-intentional (no perceived need, side effects, costs)
113
What are the first signs of asthma exacerbation?
worsening pattern of symptoms
exercise intolerance
unusual fatigue
nocturnal awakening
PEF decline of ~20% from patients PB is likely exacerbation
114
What are the risk factors for exacerbations?
poor adherence
suboptimal ICS use
high SABA use
obesity
chronic rhinosinusitis
GERD
pregnancy
allergen/pollution/smoking exposure
low FEV
exacerbation in last 12 months
115
What is a severe asthma exacerbation?
prolonged, severe episode of asthma unresponsive to usual treatment
develops over hours to days
116
Which medications should be avoided during a severe asthma exacerbation?
sedatives/hypnotics
117
What are the goals of treatment for acute severe asthma?
correction of significant hypoxemia
rapid reversal of airway obstruction
reduction of the likelihood of relapse
development of a written asthma action plan in case of further exacerbation
118
What is the treatment of acute severe asthma?
SABA+SAMA
-nebulized or MDI+spacer
corticosteroids
-oral or IV (IV if: too breathless, intubated, or unable to tolerate oral medication, severe asthma, unresponsive to treatment)
-improves symptoms within 2h, 6h maximal
-7 to 10 days course is common
oxygen:
-correct hypoxemia (O2S>90%)
magnesium IV (bronchodilator)
mechanical ventilation/intubation
119
What is the home management criteria for an asthma exacerbation?
can follow their action plan
mild-moderate exacerbation (PEF>60% PB)
symptoms are bothersome but not debilitating
no comorbidities that place them at higher risk
*should see MD if partial response to tx after 1-2 days*
120
When should a patient with an asthma exacerbation be admitted to the hospital?
PEF <60% of PB
breathless at rest, severe drowsiness, cannot speak full sentences
comorbidities
symptoms worsen despite increased SABA/controller use
121
What is the magnitude of exercised-induced bronchospasm correlated with?
degree of BHR
*body attempts to warm/humidify increased volume of air, results in release of mediators*
122
What is the treatment for exercise-induced bronchospasm?
scarf/mask
enhance level of physical fitness
optimize treatment to reduce BHR
prophylactic therapy (SABA 5mins prior)
LTRA
warm-up for about 10 minutes
123
What are the phases of the development of ASA/NSAID induced asthma?
1. chronic rhinitis
2. chronic nasal congestion, anosemia, nasal polyps, mucosal thickening
3. inflammation in lower airways
4. acute sensitization to NSAIDs
124
What are the symptoms of the acute phase of ASA/NSAID induced asthma?
nasal symptoms
worsening asthma symptoms
allergic symptoms (hives, angioedema)
125
What is the management of ASA/NSAID induced asthma?
LTRAs first line
avoid NSAIDs
low doses of acetaminophen may be tolerated
aspirin desensitization (must regularly use aspirin after this)
126
What is the risk of beta-blockers with asthma?
decreased response to B agonists
increased airway hyper-responsiveness
*non-cardio selective poses the greatest risk (even ocular), cardio-selective present limited risk in low-mod doses*
127
What is occupational asthma? What are the symptoms?
asthma secondary to workplace exposures
symptoms:
-worse at work or after work hours
-go away when away from work/vacation
-may keep patient up at night
-may start after working with new substance
-co-workers have similar symptoms
128
What are the complications of uncontrolled asthma during pregnancy?
premature birth
low birth weight
maternal blood pressure changes
129
True or false: the benefits of medications for asthma during pregnancy outweigh the risks
true
130
Describe the pregnancy safety profiles of asthma medications.
salbutamol, LABAs seem safe
ICS: all safe, budesonide most studied
LTRA: no known issues
theophylline: keep low end of TR
biologics: unknown
131
Describe the breastfeeding safety profiles of asthma medications.
inhaled meds are ok
po corticosteroids are ok
theophylline: keep low end of TR
montelukast: transferred into breastmilk, but indicated for kids as young as 6 months
132
What are the symptoms of asthma?
heterogenous disease
-intermittent episodes of wheezing, cough and dyspnea
-chest tightness and chronic cough in some
133
Why are physical exams poor indicators of airway obstruction?
asthma is a disease of exacerbation and remission, so the patient may not have any signs or symptoms at the time of the exam
134
What is the dosing of montelukast?
2-5yrs: 4mg hs
6-14yrs: 5mg hs
>15yrs: 10mg hs
135
What are some situations that may have a possible role for montelukast?
suboptimal adherence to ICS
dose of inhaled steroid required to maintain control is very low (ex: EIB)
ASA/NSAID induced asthma
136
What are the drug interactions of LABAs?
same as SABAs
*beta blockers, diuretics, TCAs, QT*
137
Which ICS is dosed OD?
ciclesonide
*the rest are dosed BID*
