Asthma

Question 1

What 3 treatments should immediately be started in a patient suffering a severe acute asthma exacerbation?

Answer 1

Oxygen therapy, high doses of an inhaled beta-2 agonist, and systemic corticosteroids.

Question 2

Asthma symptoms may occur spontaneously or precipitated or exacerbated by many different triggers including:

Answer 2

Allergens, exercise, URIs, rhino sinusitis, postnatal drip, aspiration, occupational exposure, cigarette smoke, GERD, changes in weather, and stress.

Question 3

What are the two strongest identifiable predisposing factors for the development of asthma?

Answer 3

Atopy and obesity

Question 4

Asthma is characterized by what patient complaints?

Answer 4

Episodic wheezing, difficulty in breathing, chest tightness and cough.

Question 5

True/false: asthma symptoms are usually worse in the day and better at night.

Answer 5

False. Worse at night between 3-4am when bronchial reactivity peaks

Question 6

What Physical exam findings increase the probability of asthma?

Answer 6

Nasal muscosal swelling, secretion increases, and polyps are often seen in patients with allergic asthma

Question 7

True/false. Wheezing during forced expiration is a sign of airflow obstruction.

Answer 7

False. Wheezing during normal expiration is

Question 8

What diagnostic tool helps clinicians determine the presence and extent of airflow obstruction and whether it is immediately reversible?

Answer 8

Spirometry. Before and after the administration is a short-acting bronchodilator.

Question 9

What is a tool that can be used to help confirm the asthma diagnosis and identify environmental and occupational causes of symptoms?

Answer 9

Peak exploratory flow (PEF). Handheld devices designed as personal monitoring tools

Question 10

What time of day are PEF values the most useful?

Answer 10

PEF should be measured in the morning before administration of a bronchodilator and in the afternoon after taking a bronchodilator. A 20% change suggests inadequate asthma control.
They show diurnal variation and is generally lowest when waking and highest several hours before midpoint of the day.

Question 11

When is a CXR indicated for asthma?

Answer 11

When pneumonia or pneumothorax is suspected.

Question 12

What are the major complications from asthma?

Answer 12

Exhaustion, dehydration, airway infection, and tussock syncope.

Rarely: pneumothorax

Question 13

What is a common finding on a spirometry with a patient with asthma?

Answer 13

concave-shaped flow-volume curve

Question 14

On an arterial blood gas, a CO2 level is rising, what could this be an indication of?

Answer 14

A need for mechanical ventilation

Question 15

What is pulsus paradoxus?

Answer 15

A >10mmHg fall in systolic pressure on inspiration

Question 16

What severity of asthma attack is a patient having if pulsus paradoxus is present and is >25mmHg?

Answer 16

Severe!

Question 17

Asthma is most common in which demographic?

Answer 17

Male children and female adults. Hospitalization and death rates highest in blacks and children.

Question 18

True/false. Selected individuals may experience asthma symptoms after exposure to aspirin or NSAIDs.

Answer 18

True!

Question 19

True/False. Asthma can be predicted by certain times in the menstrual cycle.

Answer 19

True!

Question 20

What is cardiac asthma?

Answer 20

Wheezing precipitated by decompensated heart failure

Question 21

If patient responds to therapy, is a CXR indicated?

Answer 21

No, probably not due to other cause beside asthma

Question 22

What type of asthma attack is a patient having if they are able to talk in sentences, not using accessory muscles, and are only breathless while walking?

Answer 22

mild

Question 23

What type of asthma attack is a patient having if they are having difficulty with conversation at rest, RR >30, and wheezes are heard both on inspiration and expiration?

Answer 23

SEVERE

Question 24

What type of asthma attack is a patient having if their PEF is 42% and they have trouble breathing when supine?

Answer 24

Moderate

Question 25

What are signs of a patient’s asthma attack showing respiratory arrest is imminent?

Answer 25

They aren’t talking, they appear drowsy or confused, wheezes are absent, bradycardia, PEF 42

Question 26

What are the 2 components taken into consideration when assessing asthma control?

Answer 26

Impairment - frequency and intensity of symptoms and functional limitations Risk - likelihood of acute exacerbations or chronic decline in lung function

Question 27

T/F. Some patients may have minimal impairment yet remain at risk for severe exacerbations.

Answer 27

True, like if have a upper respiratory infection

Question 28

Which asthma patients should have a written asthma action plan?

Answer 28

ALL asthma patients! Especially those with poorly controlled symptoms or history of severe exacerbations

Question 29

What are the 3 drug classes that are used for long-term asthma control?

Answer 29

Corticosteroids, long-acting bronchodilators, and leukotriene modifiers.

Question 30

What does NAEPP 3 emphasize as the cornerstone of treatment of persistent asthma?

Answer 30

daily anti-inflammatory therapy with inhaled corticosteroids.

Question 31

What vaccinations are indicated in asthma patients?

Answer 31

seasonal flu shot and pneumococcal vaccinations

Question 32

T/F: Infections with viruses (rhino) and bacterial (mycoplasma, chlamydia) predispose acute exacerbations of asthma and may underlie chronic, severe asthma

Answer 32

true. use of empiric abx is not recommended in routine exacerbations. But abx should be considered when there is fever or purulent sputum and evidence of pneumonia or bacterial sinusitis.

Question 33

If a patient is having a mild-moderate acute attack what is the stepwise approach?

Answer 33

1. measure PEF - values of 50-79% indicate need for quick relief medication. If below 50, need immediate medical care. 2. initiate treatment of SABA - up to 2 treatments 20 minutes apart of 2-6 puffs

Question 34

If patient has a good response to inhaled SABA (no more wheezing or dyspnea and PEF >80%) what do you do next?

Answer 34

contact clinician for follow-up instructions and further management. May continue inhaled SABA every 3-4 hours for 24-48 hours. Consider short course of oral systemic corticosteroids.

Question 35

If patient has incomplete response to inhaled SABA (persistent wheezing and dyspnea) and PEF is still 50-79%, what do you do next?

Answer 35

Add oral systemic corticosteroid, continue inhaled SABA, contact clinician urgently for further instruction.

Question 36

If patient has poor response to inhaled SABA (marked wheezing and dyspnea, PEF <50), what do you do next?

Answer 36

Add oral systemic corticosteroid, repeat inhaled SABA immediately, Call doctor AND PROCEED TO ED! (consider calling 911!!)

Question 37

In the emergency room setting, what is the best predictor of the need for hospitalization?

Answer 37

Response to initial treatment. Better than severity of exacerbation

Question 38

Asthma hospitalization rates are highest amongst:

Answer 38

blacks and children