Asthma Flashcards
1
Q
Define Asthma.
A
- Chronic inflammatory disorder of the airways characterized by variable and reversible airflow obstruction due to bronchial hyper-responsiveness
- Characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough
2
Q
What are the 2 key defining features of asthma? (GINA)
A
- A history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity AND
- Variable expiratory airflow limitation
3
Q
What % of the population has asthma?
A
- ~7%
- May develop at any age, although less common as get older
4
Q
What is a differential diagnosis (15) for a cough?
A
- Upper Airway Disorders
- Foreign-body aspiration
- Tracheomalacia
- Angioedema and anaphylaxis
- Vocal cord paralysis
- Laryngotracheal mass
- Lower Airway Disorders
- Asthma
- Bronchiolitis
- COPD
- Bronchiectasis
- Cystic fibrosis
- Pneumonia
- Other (often cough predominant)
- CHF
- GERD
- PE – consider CT if not improving on treatment
- Churg-Strauss syndrome
5
Q
What is the classic triad on history for asthma?
A
- Episodic dyspnea
- Cough
- Wheezing
6
Q
At what age can children reliably cough up sputum?
A
- +9 years old
7
Q
What are 5 important symptoms to ask about in a patient presenting with asthma?
A
- Wheezing – high-pitched whistle sound
- Cough variant asthma do not wheeze
- If poor air entry, then cannot wheeze (Status Asthmaticus)
- Cough worse at night
- May be only symptom
- Before age 9 cannot reliably cough up sputum
- Dyspnea – stops from participating in activities that peers can do
- Subjective SOB does not correlate with the FEV1 or severity of disease
- Chest tightness, heavy – rarely sharp
- Rhinosinusitis 80% associated
- Treating PND helps with asthma
8
Q
What are 7 potential asthma triggers? (GINA)
A
- Exercise
- Cold air
- Viral URIs – fever
- Domestic and Occupational Allergens
- House dust mite
- Pollens
- Cockroach
- Smoking and 2nd hand smoke
- Stress
- Drugs
- Beta-blockers
- ASA
- NSAIDs
9
Q
What is commonly seen in patients with aspirin-exacerbated respiratory disease? (GINA)
A
- Severe asthma
- Nasal polyposis
10
Q
What is important to ask on family history in a patient presenting with asthma?
A
- History of Atopy
- Eczema
- Asthma
11
Q
What is important to ask an asthma patient about regarding their asthma control?
A
- Prior ER visits
- Doses of prednisone per year
- ICU admission
12
Q
What are 9 criteria to measure asthma control? (CTS)
A
13
Q
Which age group has the highest rate of emergency department visits and hospital admissions for asthma symptoms? (CTS)
A
- Preschoolers (1-5 years)
14
Q
In which preschool (1-5 years) children should the diagnosis of asthma be considered? (CTS)
A
- Frequent (≥8 days/month) asthma-like symptoms OR
- Recurrent (≥2) exacerbations (episodes with asthma-like signs)
15
Q
What is required for the diagnosis of asthma in preschoolers? (CTS)
A
- Objective documentations of signs (or convincingly reported symptoms) of airflow obstruction
- Personal atopy (e.g. eczema, food allergy) or family history of asthma increase suspicion but are not necessary for diagnosis
- Reversibility of airflow obstruction
- Documented response to SABA (with or without OCS) by health care professionals during an acute exacerbation
- In children with NO objective signs of airflow obstruction (i.e. only symptoms) then can be determined by either:
- 3-month therapeutic trial of medium dose inhaled corticosteroids (200 ug to 250 ug) with SABA prn OR SABA prn
- Absence of an alternative diagnosis
- Recurrent URTIs with postnasal drip
- Croup
- Bronchiolitis (1st episode usually <1 year of age)
16
Q
What is the preferred diagnostic method for asthma in preschoolers? (CTS)
A
- Recurrent (≥2) episodes of asthma-like symptoms AND WHEEZING ON PRESENTATION
- Direct observation of improvement with inhaled bronchodilator (with or without OCS) by a physician or trained health care practitioner confirms the diagnosis
17
Q
Why is a minimum 3-month trial of moderate dose ICS suggested to diagnose asthma in preschoolers? (CTS)
A
- Onset of action within 1-4 weeks
- Efficacy within 3-6 months
18
Q
Which ICS is recommended for preschoolers with suspected asthma and why? (CTS)
A
-
Fluticasone
- Studied most effectively along with budesonide
- Budesonide only available for use by nebulization in Canada in children
- MDI preferred route
- Fluticasone shows less effect on growth than budesonide at equivalent dose
19
Q
What should be monitored in preschoolers to assess response to a 3-month trial of ICS in suspected asthma? (CTS)
A
- Asthma Diary
- Daytime and nighttime symptoms
- Rescue SABA use
- Effort limitation
- Absenteeism from usual activities
- Exacerbations requiring unscheduled medical visits
- Oral corticosteroids and/or hospital admission
20
Q
What should be done for preschoolers in whom there is an unclear response to a trial of ICS for suspected asthma? (CTS)
A
- Dechallenge – stopping therapy for a period of observation of 3-6 months or until recurrence of symptoms, whichever occurs first
21
Q
What are 5 reasons to refer to an asthma specialist for consultation or comanagement in preschoolers? (CTS)
A
- Diagnostic uncertainty or suspicion of comorbidity
- Repeat (≥2) exacerbations requiring rescue OCS or hospitalization or frequent symptoms (≥8 days/month) despite moderate (200 ug to 250 ug) daily doses of ICS
- Life-threatening event such as an admission to the ICU
- Need for allergy testing to assess the possible role of environmental allergens
- Other considerations (parental anxiety, need for reassurance, additional education)
22
Q
What % of children with asthma become asymptomatic by the age of 6? (CTS)
A
- 60%
23
Q
What is the normal FEV1/FVC ratio in adults and children? (GINA)
A
- Adults > 0.75-0.80
- Children > 0.90
24
Q
What is the gold standard for diagnosis of asthma?
A
- PFTs – Reversible Obstruction
- FEV1/FVC <0.8
- >12% (and 200 mL improvement in adults) with bronchodilators
25
**What are 3 methods to diagnose asthma? (CTS)**
\*\*\*GINA = average daily diurnal PEF variability is \>10% (in children, \>13%)
26
**Distinguish between bronchiolitis, croup and foreign body aspiration from asthma and how they would be managed?**
* Bronchiolitis
* First episode of wheezing in contact of respiratory infection (RSV)
* Treatment
* Reassure, hydration, monitor respiratory status
* SABA or Epinephrine if moderate symptoms
* No antibiotics
* Unless atopic child or recurrent, do NOT use prednisone
* Croup
* Upper respiratory wheezing – stridor
* Parainfluenza virus
* Febrile, non-toxic, barking cough
* Treatment
* Blow-by humidified oxygen, Dexamethasone
* Foreign body aspiration
* History of playing with small object
* No atopy
27
**In a patient with cough as the only respiratory symptom, what is the differential diagnosis? (GINA)**
* Cough variant asthma
* Chronic upper airway cough syndrome (‘post-nasal drip’)
* Chronic sinusitis
* GERD
* Vocal cord dysfunction
* Eosinophilic bronchitis
28
**What is the most frequent finding on physical examination in patients with asthma? (GINA)**
* Wheezing on auscultation (especially on forced expiration)
29
**What is the recommended maintenance therapy and matching step-up therapy for preschoolers, children and adults (12 and over)?**
* Can try intermittent high dose (750 mg Flovent) for children with recurrent viral associated wheezing (if persistent, trial daily therapy)
* Low-medium dose is not effective
30
**Name 11 potentially modifiable independent risk factors for asthma exacerbations? (GINA)**
* Uncontrolled asthma symptoms (e.g. daytime symptoms, night waking, reliever needed \>2x/week, activity limitation)
* ICS not prescribed; poor ICS adherence; incorrect inhaler technique
* High SABA use (with increased mortality if \>1x200-dose canister/month)
* Low FEV1, especially \<60% predicted
* Major psychological or socioeconomic problems
* Exposures: smoking, allergen exposure if sensitized
* Comorbidities: obesity; rhinosinusitis; confirmed food allergy
* Sputum or blood eosinophilia
* Pregnancy
* Ever being intubated or in ICU for asthma
* Having 1 or more severe exacerbations in the last 12 months
31
**Define an asthma flare-up or exacerbation and what terminology is preferred. (GINA)**
* An acute or sub-acute worsening in symptoms and lung function from the patient’s usual status
* ‘Flare-up’ is preferred
32
**How would acute management in the ER differ for mild, moderate, severe and near death asthma attacks and how would they present?**
**Assessment**
**Clinical**
**Treatment**
**Mild**
- Exertional SOB/cough
- Nocturnal symptoms
- Increased SABA use with good response
- Speaks in *sentences*
* FEV1 \>60% predicted
* PEF \>300L/min
* Oxygen
* SABA
* Consider steroids
**Moderate**
- SOB *at rest*
- Cough
- Partial relief from SABA
- SABA use \>8x/day
- Chest tightness
- Speaks in *phrases*
* FEV1 40-60% predicted
* PEF 200-300L/min
* Oxygen
* SABA
* Anticholinergics
* Steroids
**Severe**
- Laboured breathing
- Difficulty speaking
- Agitated
- Diaphoretic, Tachycardic
- No relief from SABA
- Speaks in *words*
* O2 sat \<90%
* FEV1 \<40% predicted
* PEF \<200L/min
* 100% O2
* Continuous SABA
* Anticholinergics
* IV Steroids
* IV 2g Magnesium sulfate as a last ditch
* IV SABA
* Telemetry, O2 sat, ABG, CXR
* Consider BI-PAP, must be awake, monitor for barotrauma and hypotension
* Consider Inubation
* Consider IM Epi
**Near Death**
- Exhausted
- Confused
- Diaphoretic, cyanotic
- Failing heart rate
- Near death
- *Can't speak*
* O2 sat \<90%
* FEV1 and PEFR not appropriate
* **Ventolin** 4-8 puff or 2.5-5mg (0.15mg/kg/dose, min 2.5mg) in 3cc neb q20min x3
* **Atrovent** 4-8 puffs or 250-500mcg (\<2 years 125mcg/dose) in same neb q20min x3
* Delayed effect. No benefit to greater than 3 treatments.
* **Prednisone** 50mg or 1mg/kg x 3-10 days. First dose within the hour at the ER. No taper needed with doses less than 10 days
33
**What steroid is best for the treatment of pediatric asthma exacerbations and why? (TFP)**
* 1-2 doses (2 days) dexamethasone 0.6 mg/kg (safe and effective, no difference in relapse rates as 5-day course of prednisone)
* NNT = 20 for reduced vomiting compared to prednisone
34
**What finding on examination would be most concerning for an asthma exacerbation and how should it be treated? (GINA)**
* Silent chest
* Inhaled SABA
* Inhaled Iptratropium bromide
* Oxygen
* Systemic corticosteroids
35
**What criteria would allow a patient with asthma to be discharged home from the ER after an asthma attack?**
* Ventolin longer than q4h
* Never had a prior ICU admission
* Must be admitted regardless
* No recurrent ER visits or admissions
* PEF \> 300, or \>70%, never if less than 200 or 40%
* Improvement on steroids
* If not improvement by 6h, unlikely to occur
* Nothing trumps clinical judgement
* Use Ventolin q4h for 48h with aerochamber and steroids
36
**What investigations would you consider performing in a patient with an asthma attack in the ER?**
* CXR if not improving, moderate to severe symptoms or comorbidities
* Potassium – can get low with repeated dosing of Ventolin
* PEF pre and post treatment
37
**Why should regular daily controller treatment be initiated as soon as possible after the diagnosis of asthma is made? (GINA)**
* Early treatment with low dose ICS leads to better lung function than if symptoms have been present for more than 2-4 years
* Patients not taking ICS who experience a severe exacerbation have lower long-term lung function than those who have started ICS
38
**For which patients (3) is regular low dose ICS recommended? (GINA)**
* Asthma symptoms more than 2x per month
* Waking due to asthma more than 1x per month
* Any asthma symptoms plus any risk factor(s) for exacerbations (e.g. needing OCS for asthma within the last 12 months; low FEV1; ever in ICU for asthma)
39
**What are 5 lifestyle management suggestions for the chronic management of asthma?**
* Reduce allergen exposure – animal dander, dust, pollen, mold, pollution
* No smoking
* ASA induced, nasal polyps and rhinosinusitis triad
* Avoid NSAIDs – blocking PG synthesis shifts the pathway towards bronchoconstrictors
* Immunizations – Flu and Pneumococcal
* Inhaler technique
40
**When would you consider stepping down asthma treatment and what is NOT advised? (GINA)**
* Symptoms controlled for 3 months + low risk for exacerbation
* Ceasing ICS is NOT advised
41
**How should ICS dose be stepped down when asthma is well controlled? (GINA)**
* Reduce ICS dose by 25-50% at 2-3 month intervals
42
**Should LABAs be used as monotherapy for asthma in any age group? (CTS)**
* NO
43
**If low-dose ICS is not adequate to maintain asthma control, what is the next step in children 6-11 years old and adults 12+ years? (CTS)**
* 6-11 – Increase to Medium-dose ICS
* 12+ - Add a LABA to low-dose ICS
44
**If medium-dose ICS is not adequate to maintain asthma control, what is the next step in children 6-11 years old? (CTS)**
* Addition of either a LABA or LTRA
45
**If LABA+ICS is not adequate to maintain asthma control, what is the next step in adults 12+ years? (CTS)**
* Consider addition of LTRA
* Consider referral to specialist
46
**What is the recommended controller therapy by age? (CTS/DFCM)**
6-11 years old
\>12 years old
First-line
Low dose ICS
Low dose ICS
Second-line
Medium dose ICS
Low dose ICS + LABA
Third-line
Medium dose ICS + LABA
OR
Medium dose ICS + LTRA
Medium dose ICS + LABA
OR
Medium dose ICS + LABA + LTRA
47
**What would management options be for asthma in patients \< 6 years old?**
* Can only suspect diagnosis and confirm based on response to treatment
* Same management as ages 6-11, but consider referral 1 step before
* Use lowest effective dose
48
**What would management options be for asthma in patients 6-11 years old?**
* Lifestyle management – decrease allergens, no humidifier, action plans
* Intermittent asthma
* SABA prn
* QID standing with viral respiratory illness for 24h
* Persistent daily asthma
* Low dose ICS
* Second line LTRA if allergic component
* Medium dose ICS – consult if not controlled
* Add LABA or LTRA
* Prednisone
49
**What would management options be for asthma in patients \>12 years old?**
* Lifestyle management – decrease allergens, no humidifier, action plans
* Intermittent asthma
* SABA prn
* QID standing with viral respiratory illness for 24h
* Persistent daily asthma
* Low dose ICS
* Second line LTRA if allergic component
* Add LABA – consult if not controlled
* Add LTRA if not done already
* Anti IgE (Omalizumab) or Prednisone
50
**For purely seasonal allergic asthma, how should ICS be prescribed? (GINA)**
* Start ICS immediately and cease 4 weeks after end of exposure
51
**What is the 5-step approach for adjusting asthma treatment? (GINA)**
* Step 1 – as-needed SABA with no controller
* Symptoms are rare, no night waking due to asthma, no exacerbations in the last year
* Normal FEV1
* Step 2 – regular low dose ICS plus as-needed SABA
* Step 3 – low doses ICS/LABA either as maintenance treatment plus as-needed SABA, or as ICS/formoterol maintenance and reliever therapy
* Step 4 – low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as maintenance plus as-needed SABA
* Step 5 – refer for expert investigation and add-on treatment
52
**What would management options be for asthma in patients \>18 years old?**
* In moderate to severe asthma, can monitor sputum eosinophilia as a measure of asthma control
53
**What should patients with asthma be educated about?**
* Consider allergy testing if appear to be predominant feature
* Make a trigger log and avoid triggers
* Progressive decline in lung function if not controlled and can be minimized if start effective treatment
* YouTube videos for inhaler technique
* No beta-blockers
54
**How often should PFTs be performed to monitor patients with asthma? (GINA)**
* FEV1 at start of treatment
* FEV1 after 3-6 months of controller treatment to record personal best lung function
* Periodically for ongoing risk assessment
55
**What should be included in a written asthma action plan? (GINA)**
* The patient’s usual asthma medications
* When and how to increase medications and start OCS
* How to access medical care if symptoms fail to respond
56
**How should patients be told to increase their controller in written asthma action plans? (GINA)**
* Rapid increase in ICS component up to max 2000 mcg BDP equivalent
* **Type of ICS Controller**
**Dose Increase**
ICS
At least double dose
Maintenance ICS/formoterol
Quadruple maintenance ICS/formoterol dose (max formoterol dose 72 mcg/day)
Maintenance ICS/salmeterol
Step up at least to higher dose formulation; consider adding separate ICS inhaler to achieve high ICS dose
Maintenance and reliever ICS/formoterol
Continue maintenance dose; increase as-needed ICS/formoterol (maximum formoterol 72 mcg/day)
57
**How should patients be told to increase OCS in the written asthma action plans? (GINA)**
* Adults – prednisolone 1 mg/kg/day up to 50 mg, usually for 5-7 days
* Children – 1-2 mg/kg/day up to 40 mg, usually for 3-5 days
* Tapering not needed if treatment has been given for less than 2 weeks
58
**For children being given OSA, what should practitioners ensure the child is immunized against? (CTS)**
* Chickenpox
59
**How would you educate patients with asthma on using a MDI, Diskus, Turbuhaler and Handihaler?**
* **MDI** (require SPACER)
* Shake and then attach aerochamber – take at least 6 breaths if can’t hold their breath or are children
* Breathe out all the way, press MDI, then breathe in and breathe several breaths through aerochamber – repeat in 5 min
* Must wait 1 min between puffs
* Must prime dose with 1 puff (if not used in the last few days)
* Must reshake MDI after 2 puffs
* **Diskus** and **Turbuhaler**
* Do NOT require spacer
* \<6 years CANNOT generate required inspiratory force necessary to use
* When breathing out, do so away from the inhaler
* **Handihaler** (Spiriva)
* Must inhale 2x for each dose
60
**What should be included in an action plan for patients with asthma?**
* When symptoms increase:
* Allow patients to self-titrate medications with worsening symptoms
* Give patients clear indications of when to seek help
61
**When would you consider a referral for a patient with asthma?**
* \< 6 years – not controlled on low dose ICS
* \< 12 years – not controlled on moderate ICS
* ≥12 years – not controlled on ICS/LABA
* Frequent oral steroids
62
**At what age are children unlikely to have the required inspiratory force to use inhalers other than an MDI?**
* \< 6 years
63
**What forms does salbutamol come in and at what dose?**
* Ventolin HFA (MDI) – 100 mcg
* Ventolin Diskus – 20 mcg
64
**What are potential adverse effects of salbutamol use?**
* Tachycardia
* Nervousness
* Headache
* Dizziness
* Tremor
* Palpitations
* Increased QT
* Decreased K
* Tachyphylaxis
* Hyperglycemia in DM
65
**How would you prescribe salbutamol for acute and chronic asthma in adults and children \<12?**
* Adults
* Acute
* 4-8 puffs q20min MDI for up to 4 hours, then q1-4h
* 2.5-5 mg neb q20min for 3 doses, then 2.5-10mg q1-4h
* Chronic
* 1-2 puffs QID prn MDI or 1 puff QID prn Diskus
* Children (\< 12)
* Acute
* 4-8 puffs q20min MDI x3 doses, then q1-4h
* 0.15 mg/kg (2.5mg minimum) neb q20min x3 doses, then 0.15-0.30 mg/kg (10 mg maximum) q1-4h
66
**What is another type of SABA that can be prescribed for asthma and what is the advantage of it?**
* Terbutaline (Bricanyl **Turbuhaler**)
* 1 inhalation, if not effective after 5 minutes may repeat dose
* Max is 6 inhalations in a 24-hour period
67
**What is the difference between salbutamol and terbutaline in regards to age of starting treatment? (DFCM)**
* Salbutamol ≥4-years
* Terbutaline ≥6-years
68
**What is considered regular use of a SABA necessitating adjunct therapy for asthma? (CTS)**
* \>3 doses per week
69
**Should LABA be used as monotherapy for asthma? Why or why not? (TFP)**
* LABA should NOT be used without ICS
* Increased risk of serious adverse events
* FDA meta-analysis of 110 trials found 2.8 extra events (asthma-related death, intubation and hospitalization) per 1000 asthmatic patients treated with LABA inhalers (NNH = 358)
* No clear increased risk of adverse events with ICS+LABA
* Not statistically significant (NNH = 3,334)
70
**What is a FABA and is it recommended as a reliever for asthma? (CTS)**
* Fast-acting beta2-agonist (FABA) – SABA or fast-acting LABA (e.g. Formoterol)
* Use of formoterol alone (without an ICS) as a reliever in asthma is NOT recommended and it is not approved for this indication in Canada
71
**What is recommended as reliever therapy for asthma in all patients with mild asthma? (CTS)**
* SABA
* Including individuals not on controller therapy and those on ICS monotherapy)
72
**When would BUD/FORM (budesonide/formoterol) be considered as a reliever therapy for asthma? (CTS)**
* Adults (12+ years) with poor controlled on maintenance ICS/LABA
73
**What forms does fluticasone come in and at what dose?**
* Flovent HFA (MDI) – 50, 125 and 250 mcg
* Flovent Diskus – 50, 100, 250 and 500 mcg
74
**What are potential adverse effects of fluticasone use?**
* Thrush (Oropharyngeal Candidiasis) – rinse after each use
* Short-term growth deceleration – achieve adult height but takes longer
* Dysphonia, cough at time of inhalation, sore throat
* With high dose – osteoporosis, adrenal suppression, cataracts, glaucoma
* Flovent Diskus has lactose in it – caution with lactose allergy but not intolerance
75
**What can be done to reduce the local adverse effects of ICS? (GINA)**
* Rinse mouth with water and spit out after inhalation
76
**What are 3 important points to tell patients when prescribing fluticasone?**
* Need to give 2 puffs BID to achieve required dose
* Takes 4 weeks to achieve maximal effect
* If stable, can decrease by 25% q3months if desired
77
**What dose should you prescribe fluticasone for asthma based on age?**
**\<12 years old**
**\>12 years old**
Low
Medium
Low
Medium
\<200
200-400
\<250
250-500
78
**What is the combination of fluticasone (ICS) and salmeterol (LABA) called?**
* Advair (Purple)
79
**What doses does Advair come in and how should it be prescribed?**
* Advair HFA (MDI) – 125/25 and 250/25 mcg
* Max 2 puffs BID for maintenance
* Advair Diskus – 100/50, 250/50 and 500/50 mcg
* Max 1 puff BID for maintenance
80
**Is Advair suitable as an on demand reliever for asthma?**
* No
81
**What is the max dose that children 4-11 years can use Advair for asthma?**
* 200/100 per day
82
**What are side effects of LABAs to warn patients taking Advair for asthma?**
* Elevated BP
* Tachycardia
* Hypokalemia
* Caution if epilepsy due to CNS stimulation
83
**What forms does budesonide come in and at what dose?**
* Pulmicort Turbuhaler – 100, 200, 400 mcg
84
**What dose should you prescribe fluticasone for asthma based on age?**
**\<12 years old**
**\>12 years old**
Low
Medium
Low
Medium
\<400
400-800
\<400
400-800
85
**What is the combination of budesonide (ICS) and formoterol (LABA) called?**
* Symbicort
86
**What doses does Symbicort come in and how should it be prescribed?**
* Symbicort Turbuhaler – 100/6 and 200/6
* Maintenance 1-2 puffs BID
* Maximum 8 puffs daily
87
**What is the max dose that children 5-11 years can use Symbicort for asthma?**
* Max 4 inhalations per day (Symbicort 80/4.5)
88
**What is SMART for asthma?**
* Symbicort Maintenance and Reliever Therapy
* Can be used for maintenance and reliever therapy
* Maintenance: 1-2 puffs BID or 2 puffs once daily
* Reliever: 1 additional inhalation as needed, may repeat if not relief for up to 6 inhalations total (maximum: 8 inhalations/day)
89
**What is recommended for reliever therapy in exacerbation-prone individuals 12 years of age and over with moderate asthma and poor control on a fixed-dose maintenance ICS/LABA combination? (CTS)**
* Budesonide/Formoterol
90
**What leukotriene receptor antagonist (LTRA) can be prescribed for asthma or for allergic rhinitis?**
* Montelukast (Singulair)
* 10 mg tablet once daily
91
**At what age can patients with asthma use LTRAs as an acceptable, second-line, daily monotherapy? (CTS)**
* Children 6+
92
**When would montelukast be used first line for asthma?**
* Allergy-related – if always allergic trigger
93
**What dose of montelukast would you prescribe for asthma based on age?**
* 2-5 years – 4 mg
* 6-14 years – 5 mg
* \>15 years – 10 mg
94
**What should you monitor on patients started on montelukast (Singulair)?**
* Monitor baseline and periodic LFTs
95
**When should the maximum effect be seen with montelukast (Singulair)?**
* Maximum effect within 6 weeks
* Starts within 2 days
96
**How do LTRAs compare to ICS and ICS+LABAs for treating pediatric asthma? (TFP)**
* Inferior to ICS monotherapy
* NNH = 21 for extra exacerbation
* Inferior as add-on to ICS compared to ICS+LABAs
97
**What subgroups of asthma has LTRAs demonstrated some benefit? (TFP)**
* Allergic rhinitis
* Exercise induced bronchospasm
* Specific genotypes
98
**What is the benefit of adding Tiotropium as add-on therapy for patients with moderate-severe asthma already on an ICS or ICS+LABA? (TFP)**
* Addition of Tiotropium prevents exacerbations for 1 in 18-36 patients over 4-52 weeks
99
**What delivery system is recommended for Tiotropium in asthma and what is the potential concern with this? (TFP)**
* Respimat (aqueous solution soft mist inhaler)
* Possibility of increased mortality with tiotropium delivered via the Respimat inhaler in COPD (particularly those with cardiovascular disease and arrhythmias)
100
**How would you prescribe prednisone for asthma exacerbations?**
* 50 mg OR 1-2 mg/kg x3-10 days
* Watch for acute bone necrosis and glaucoma, osteoporosis, immunosuppression
101
**How would you manage pregnant patients with asthma?**
* Treat as needed
* SABA and ICS safe
* Less data on LABA and LTRAs – use only if needed
* Systemic steroids are safe but…
* Increased risk of pre-eclampsia, hemorrhage, low birth weight, preterm birth and hyperbilirubinemia
102
**How often should pregnant patients with asthma be reviewed? (GINA)**
* Every 4-6 weeks
103
**What type of preschool children are more likely to have their asthma resolve in childhood?**
* Non-atopic child with minimal symptoms
104
**What are 3 symptoms that would make you consider a diagnosis of asthma in the elderly?**
* Dyspnea
* Wheezing
* Nocturnal cough
