Asthma

Question 1

Essentials of asthma diagnosis

Answer 1

Reversibility of airflow obstruction, either spontaneously or following bronchodilator therapy

Limitation of airflow on pulmonary function testing or positive broncho-provocation challenge [methacholine challenge]

Question 2

What changes occur with the walls of the airway with asthma?

Answer 2

Walls become inflamed and thickened + tightened smooth muscle

Question 3

How does exposure to allergens trigger asthma?

Answer 3

Mast cells release leukotrienes which contribute to smooth muscle constriction

Question 4

Characteristic findings in sputum or bronchoalveolar lavage in prolonged status asthmaticus

Answer 4

Curschmann spirals — extrusion of mucus plugs from subepithelial mucus gland ducts or bronchioles

Charcot-Leyden crystals — composed of protein called galectin 10

Question 5

What is the strongest predisposing factor to developing asthma?

Answer 5

Atopy

Triggers include exposure to inhaled allergens — dust mites, cockroaches, seasonal pollens

Atopic triangle = Asthma, allergies, eczema — if there is a history of one, there are likely others

Question 6

How is COPD differentiated from bronchial asthma based on FEV1 and FEV1/FVC ratio return to normal?

Answer 6

After drug therapy, these values should normalize in an asthmatic patient [asthma is considered reversible]

There is unlikely to be improvement in a pt with significant COPD

Question 7

In differentiating asthma from COPD, what are some key indicators that it is asthma?

Answer 7

Wheezing (especially in children — COPD is usually diagnosed later)

Hx of cough or recurrent wheezing, difficulty breathing, chest tightness

Symptoms occur/worsen in presence of exercise, viral infection, change in weather, strong emotional expression, menstrual cycles, or potential allergens

Symptoms occur/worsen at night (awakening patient)

Question 8

Asthma typically displays on flow-volume loop with ________-appearance

Answer 8

“Scooped out”

Question 9

If you have a patient who appears to have asthma, but they are not responding to asthma medications — and spirometry shows truncated inspiratory loop (and no “scooped out” appearance that would indicate asthma), what diagnosis should you be considering?

Answer 9

Vocal cord dysfunction

Question 10

The rescue medication for asthma always includes what class?

Answer 10

Short acting beta2 agonist — likely albuterol or levalbuterol

Question 11

What are the long term control medications for asthma?

Answer 11

Inhaled corticosteroids

Leukotriene modifiers

[other options include inhaled LABAs, cromolyn and nedocromil, tiotropium, methylxanthines, immunomodulators]

Question 12

Signs/symptoms that respiratory arrest is imminent

Answer 12

Breathlessness at rest

Not able to speak

Appear drowsy or confused

RR >30/min (or in infants >60/min)

Unable to recline

Paradoxical thoracoabdominal movement

Wheezing absent, bradycardia

FEV <25%, PaO2 <60, possible cyanosis, PCO2>42, O2 sat <90

Question 13

When an asthma patient goes from the _______ to the _____ category, it is an indication for long term preventative medicine like an ICS

Answer 13

Intermittent; persistent

Question 14

Symptoms, nighttime awakenings, SABA use, and interference with normal activity associated with asthma classified as intermittent

Answer 14

Symptoms <2 days/week

Nighttime awakenings <2x/month

SABA use <2 days/week

No interference with normal activity

Question 15

An asthma patient’s risk is based on exacerbations requiring oral systemic corticosteroids. What are the criteria for intermittent vs. persistent classification?

Answer 15

Intermittent risk = 0-1x/year

Persistent = 2+/year

Question 16

Key aspects of education in asthma patients/their parents

Answer 16

Treatment goals

Inhaler techniques

Elimination of triggers

Asthma action plan

Question 17

In a pt with acute asthma exacerbation, if breath sounds prior to treatment are diminished with very faint expiratory wheezes, and after treatment there is increased wheezing - it is a sign of ______

Answer 17

Improvement

Question 18

A previously healthy 2 y/o girl presents with the complaint of acute onset wheezing. Her mother denies previous wheezing episodes and denies a FH of asthma or atopy. The mother says that she left the child playing in her older brother’s room. Approx. 20 min later, she heard the child coughing and wheezing. Which of the following is the best next step in management?

A. Determining what the girl was playing with and order a CXR
B. Refer the child to a pulmonologist
C. Prescribe abx for PNA
D. Administer IM prednisone and send her home
E. Accuse mom of poor supervision

Answer 18

A. Determine what the girl was playing with and order a CXR

Question 19

A 14 y/o girl develops acute onset SOB with exercise. The SOB resolves fairly quickly after cessation of exercise. Her discomfort is associated with breathing in vs. breathing out. She is an accomplished athlete with a thin body habitus. She doesn’t have a previous hx of asthma or FH of asthma. Which of the following is the most likely dx?

A. Asthma
B. FB aspiration
C. GERD
D. Oropharyngeal dysphagia with aspiration
E. Vocal cord dysfunction

Answer 19

E. Vocal cord dysfunction

Question 20

A 10 y/o boy on the junior high track team develops difficulty breathing associated with documented wheezing when running. He never experiences these sxs other than when running. Which of the following meds is the first-line therapy for this child?

A. LABA before exercise
B. SABA before exercise
C. Inhaled corticosteroid before exercise
D. Leukotriene inhibitor
E. Mast cell stabilizing medication before exercise

Answer 20

B. SABA before exercise

Question 21

A 5 y/o girl is given a new dx of asthma. After a brief discussion with her parents, the doc prescribes several meds. Which of the following is MOST likely not to be filled by her parents?

A. LABA
B. SABA
C. ICS
D. Leukotriene inhibitor
E. Mast cell-stabilizing medication

Answer 21

C. ICS

[parents are often hesitant to give child steroids]

Question 22

A 4 y/o boy is newly dx as having mild persistent asthma. His parents are concerned about AEs of ICS medications. Which of the following is recommended to reduce these?

A. Distilled water in nebulizer
B. Rinse mouth before inhalation
C. Rinse mouth after inhalation
D. Oral nystatin daily
E. Spacer with MDI

Answer 22

C. Rince mouth after inhalation