Asthma/Allergy Flashcards
A 25-year-old female with asthma uses her albuterol (Proventil, Ventolin) inhaler only before
running, but reports waking up short of breath four times per month. She went to the emergency
department recently for increased dyspnea during peak ragweed season and remained overnight
until her symptoms improved.
Which one of the following is the best treatment option now?
(check one)
Oral prednisone as needed
Inhaled albuterol daily
Inhaled cromolyn sodium daily
Inhaled salmeterol (Serevent Diskus) daily
Inhaled fluticasone (Flovent) daily
Inhaled fluticasone (Flovent) daily
Patients with mild asthma are often undertreated. Constant inhaled corticosteroids improve both asthma
control and quality of life. Inhaled albuterol is useful as a quick treatment for acute symptoms in patients
with mild asthma. Oral prednisone causes many side effects and is best for chronic use in patients whose
symptoms are not controlled by other means. Cromolyn sodium has a good side-effect profile, but is not
as effective as inhaled corticosteroids. Inhaled salmeterol, when used chronically, increases the risk of
asthma-related death.
A 15-year-old male is brought to the office for a well child visit. His parents report that he has had a nighttime cough and wheezing for the past several months. He is otherwise healthy and up-to-date on all of his immunizations. You suspect that he has asthma. Which one of the following would be most appropriate at this point? (check one)
Treat empirically with a short-acting β-agonist
Perform spirometry
Order radiologic testing
Start an inhaled corticosteroid
Start a leukotriene inhibitor
Perform spirometry
The American Academy of Asthma, Allergy, and Immunology recommends that asthma not be diagnosed or treated without spirometry. Once the diagnosis is confirmed, treatment should commence with a short-acting β-agonist as needed, followed by stepwise treatment based on the severity of asthma.
A 17-year-old cross country runner sees you to discuss the results of pulmonary function tests to evaluate his episodic shortness of breath and chest tightness. He had previously been diagnosed with exercise-induced asthma and prescribed albuterol (Proventil, Ventolin), which provided minimal relief. You tell him that the pulmonary function tests revealed normal expiratory findings including normal FEV1 and FVC and a flattened inspiratory flow loop.
The test most likely to confirm a diagnosis for this patient’s shortness of breath is (check one)
a sleep study
chest radiography
chest CT
esophagogastroduodenoscopy
nasolaryngoscopy
nasolaryngoscopy
This patient has vocal cord dysfunction, sometimes called paradoxical vocal fold motion, a condition in which the vocal cords close during inspiration when they should be open. It is not entirely understood why this occurs but it is associated with other conditions including asthma, GERD, and anxiety disorders. It typically causes sudden, severe shortness of breath and often has a trigger such as exercise, gastroesophageal reflux, inhalation of an irritant, or stress. Symptoms may include chest or throat tightness, inspiratory stridor, and wheezing predominantly over the upper airway. In less severe situations the voice may be impacted, and patients sometimes also describe a chronic cough that occurs separately from more acute symptoms. Vocal cord dysfunction is confirmed by direct visualization of the vocal cords during inspiration via nasolaryngoscopy. Pulmonary function tests are often performed as part of the assessment for shortness of breath and, if performed while the patient is experiencing symptoms, will show a flattened inspiratory flow loop. Treatment is primarily focused on therapeutic breathing maneuvers and vocal cord relaxation techniques. A speech therapist may assist in instructing patients in these techniques. Associated conditions should also be treated to help prevent vocal cord dysfunction. A sleep study, chest radiography, chest CT, and esophagogastroduodenoscopy would not confirm a diagnosis of vocal cord dysfunction.
A 12-year-old female with asthma sees you for a follow-up visit. The girl’s mother states that she is currently coughing several days per week and uses her albuterol (Proventil, Ventolin) inhaler 3–4 times weekly. She has awakened with a cough during the night 3 times in the last month. The patient thinks her asthma only mildly affects her day-to-day activity. In-office spirometry reveals that her FEV1 is 83% of predicted, with a normal FEV1/FVC ratio.
Which one of the following asthma classifications best fits this patient’s presentation?
(check one)
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Status asthmaticus
Mild persistent
Education of asthmatic patients is critically important in their follow-up care. This includes informing patients about the severity of their asthma in addition to instruction about appropriate treatment modalities. The National Heart, Lung, and Blood Institute’s National Asthma Education and Prevention Program uses the following definitions for asthma severity:
Intermittent: Symptoms less than or equal to twice weekly, nighttime awakenings ≤2 times/month, short-acting β-agonist usage ≤2 days/week, no interference with daily activities, and normal FEV1 and FEV1/FVC ratio at baseline
Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3–4 times/month, short-acting β-agonist usage >2 days/week but not more than once daily, minor limitation to daily activities, FEV1 ≥80% predicted, and normal FEV1/FVC ratio
Moderate Persistent: Daily symptoms, nighttime awakenings greater than once weekly but not nightly, daily use of a short-acting β-agonist, some limitation to daily activity, FEV1 >60% but <80% of predicted, and FEV1/FVC ratio reduced by 5%
Severe Persistent: Symptoms throughout the day, nighttime awakenings nightly, short-acting β-agonist usage several times daily, extremely limited daily activities, FEV1 <60% of predicted, and FEV1/FVC ratio reduced by >5%
Status asthmaticus is a medical emergency and requires emergent treatment in a hospital setting.
According to national and international guidelines, which one of the following is the next step for adults with asthma who require therapy with inhaled β-agonists more than three times a week?
(check one)
Inhaled glucocorticoids
Inhaled salmeterol (Serevent)
Sustained-release oral β-agonists
Sustained-release oral theophylline
Inhaled glucocorticoids
Patients who require inhalation therapy with β2-adrenergic-receptor agonists more than twice weekly but not daily have mild persistent asthma. Long-term control with inhaled corticosteroids is recommended for adults with persistent asthma.
A 13-year-old female with a peanut allergy is brought to the urgent care clinic 15 minutes after she was inadvertently exposed to a peanut butter sandwich while at a friend’s house. She develops swelling of the tongue, wheezing, and difficulty breathing.
Which one of the following should be administered at this time? (check one)
Low-dose chest CT 12 weeks after treatment and again in 1 year
Intramuscular epinephrine
Intravenous epinephrine
Intravenous dexamethasone
Intravenous diphenhydramine
Intramuscular epinephrine
This patient is having an anaphylactic reaction to peanuts. Intramuscular epinephrine administered in the outer mid-thigh, preferably via an autoinjector, is the appropriate treatment. The absorption of epinephrine via the subcutaneous route is erratic and results in slow increases in plasma and tissue concentrations compared to the intramuscular route. Intravenous epinephrine needs trained personnel to administer it. Its administration is restricted to refractory cases of anaphylaxis as it is associated with higher cardiovascular complications. Corticosteroids and antihistamines are not first-line treatments.
Which one of the following is most consistent with a diagnosis of asthma?
(check one)
Reduced FEV1 and a decreased FEV1/FVC ratio
Reduced FEV1 and a normal FEV1/FVC ratio
Reduced FEV1 and an increased FEV1/FVC ratio
Reduced FVC and a normal FEV1/FVC ratio
Reduced FVC and an increased FEV1/FVC ratio
Reduced FEV1 and a decreased FEV1/FVC ratio
Asthma is typically associated with an obstructive impairment that is reversible with short-acting bronchodilators. A reduced FEV1 and a decreased FEV1/FVC ratio indicates airflow obstruction. A reduced FVC with a normal or increased FEV1/FVC ratio is consistent with a restrictive pattern of lung function.
A 14-year-old male is brought to your office by his mother to establish care. The patient has been diagnosed with asthma, but has not been on any medications for the past year. When questioned, he reports that his asthmatic symptoms occur daily and more than one night per week. On examination, he is found to have a peak expiratory flow of 75%. Based on these findings, the most accurate classification of this patient’s asthma is: (check one)
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Moderate persistent
The National Asthma Education and Prevention Program (NAEPP) classifies asthma into four categories. Mild intermittent asthma is characterized by daytime symptoms occurring no more than 2 days per week and nighttime symptoms no more than 2 nights per month. The peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) is 80% or more of predicted. Mild persistent asthma is characterized by daytime symptoms more than 2 days per week, but less than once a day, and nighttime symptoms more than 2 nights per month. PEF or FEV1 is 80% or more of predicted. Moderate persistent asthma is characterized by daytime symptoms daily and nighttime symptoms more than 1 night per week. PEF or FEV1 is 60%–80% of predicted. Severe persistent asthma is characterized by continuous daytime symptoms and frequent nighttime symptoms. PEF or FEV1 is 60% or less of predicted.
An 8-year-old female is brought to the emergency department by her parents because of an asthma exacerbation that started earlier today in the context of a new upper respiratory infection. This morning she doubled her usual fluticasone (Flovent) inhaler and took 44 μg, four puffs. She has also been taking albuterol (Proventil, Ventolin), 90 μg, two puffs every hour for the past 3 hours, with minimal relief of shortness of breath and wheezing.
She has a temperature of 36.9°C (98.4°F), a respiratory rate of 28/min, a pulse rate of 128 beats/min, and an oxygen saturation of 96% on room air. On examination you note diffuse expiratory wheezing throughout both lungs. She received nebulized ipratropium/albuterol and oral prednisolone just prior to your assessment and reports feeling slightly better.
When administered intravenously, which one of the following has the best evidence of preventing the need for hospital admission for this patient’s acute asthma exacerbation? (check one)
Diphenhydramine
Epinephrine
Magnesium
Terbutaline
Theophylline
Magnesium
This child’s persistent asthma symptoms despite frequent use of an inhaled short-acting β-agonist (SABA) indicate an acute asthma exacerbation. Her vital signs show significant tachypnea and tachycardia consistent with this clinical picture and inhaled ipratropium is a good next step. Given this patient’s persistent symptoms and abnormal vital signs, intravenous magnesium is an appropriate next-line intervention. Its bronchodilator effects are thought to be related to improvements in airway excitability and smooth muscle relaxation. Its use has been associated with reduced hospitalization in children and adults without a subsequent increase in return for emergency care. It has a low incidence of side effects and toxicity. Diphenhydramine would be indicated if there were concern for an allergic process, but that is not the case in this patient. Parenteral epinephrine is indicated in asthma only if it is associated with anaphylaxis. Terbutaline is a SABA that can be administered parenterally and does not improve symptoms in patients who are already receiving an inhaled SABA. Theophylline is no longer recommended due to concerns about side effects and toxicity.
A 22-year-old male presents for follow-up of moderate persistent asthma. After discussing his treatment options, you decide to use a single maintenance and reliever therapy (SMART) approach.
Which one of the following daily inhaled therapies is appropriate to prescribe in this setting? (check one)
Budesonide (Pulmicort)
Budesonide/formoterol (Symbicort)
Fluticasone/salmeterol (Advair Diskus)
Fluticasone/vilanterol (Breo Ellipta)
Tiotropium/olodaterol (Stiolto Respimat)
Budesonide/formoterol (Symbicort)
In the single maintenance and reliever therapy (SMART) approach for asthma control, combination therapy with an inhaled corticosteroid and a long-acting bronchodilator is used as both controller and rescue medication. SMART is recommended as the preferred therapeutic approach in steps 3 and 4 in the 2020 National Asthma Education and Prevention Program guidelines. Formoterol is the only medication available in the United States recommended for use in SMART therapy due to its rapid onset of action. Budesonide monotherapy, fluticasone/salmeterol, fluticasone/vilanterol, and tiotropium/olodaterol are not appropriate options for SMART in asthma control.
A 24-year-old female seeks your advice regarding the recent onset of a cough when running. She moved to the United States from Mexico last year and her symptoms first became apparent during her first winter in the Midwest. The cough starts after she has been running approximately 1 mile but no sputum is produced and no other symptoms occur. She has no other health concerns.
A physical examination and office spirometry are consistent with a healthy young adult. You ask her to run around the outside of the clinic several times and then you reexamine her. The only change noted is an increase in her pulse rate and a 10% drop in her FEV1.
Which one of the following would be the most appropriate initial treatment for this patient? (check one)
An endurance conditioning program
An over-the-counter antihistamine as needed
An inhaled corticosteroid 2 hours before running
An inhaled short-acting β2-agonist 15 minutes before running
Daily use of an inhaled long-acting β2-agonist
An inhaled short-acting β2-agonist 15 minutes before running
This patient’s history and examination findings are typical for exercise-induced asthma. The most appropriate initial treatment for this condition is an inhaled short-acting β2-agonist (SABA) 15 minutes before exercise (SOR A). Daily use of an inhaled long-acting β2-agonist as a single agent is not recommended even for those who continue to experience symptoms when using an inhaled SABA (SOR B). The addition of a daily inhaled corticosteroid is an appropriate consideration for patients who require more than a SABA to control symptoms but these should not be used on an as-needed basis before exercise (SOR B). Use of an antihistamine in an individual with exercise-induced asthma but no known allergies is not recommended (SOR B). Other treatment considerations with weak recommendations include a low-sodium diet, air humidification, and supplemental dietary fish oils.
While sitting in the waiting room a patient develops the acute onset of diffuse hives, itching, and flushing; swelling of the lips, tongue, and uvula; and bilateral wheezing. He becomes weak and almost passes out.
Which one of the following would be the most appropriate immediate treatment? (check one)
Corticosteroids
Diphenhydramine (Benadryl)
Epinephrine
Glucagon
Normal saline
Epinephrine
This patient has symptoms of anaphylaxis. Symptoms include an acute onset (minutes to several hours); involvement of the skin, mucosal tissue, or both; plus one of the following: respiratory compromise (dyspnea, wheezing, bronchospasm, stridor, reduced peak expiratory flow, hypoxemia), reduced blood pressure, or associated symptoms of end-organ dysfunction (hypotonia, collapse, syncope, incontinence).
The first and most important treatment in anaphylaxis is intramuscular epinephrine, 1:1000 dilution dosed at 0.01 mg/kg (maximal dose of 0.3 mg in children and 0.5 mg in adults) (SOR B). Management of the airway, breathing, and circulation is also essential (SOR B).
Other essential treatments include volume replacement with normal saline for the treatment of hypotension that does not respond to epinephrine (SOR B). Histamine H1-receptor antagonists such as diphenhydramine and corticosteroids may be considered as second-line treatments in patients with anaphylaxis (SOR C). Glucagon can be considered for patients who are taking β-blockers.
A 45-year-old female has a history of intermittent asthma and her only medication is an albuterol (Proventil, Ventolin) inhaler. Over the past 2 months her asthma has limited her activities. She is using her inhaler daily and waking up at night once or twice a week with a cough.
Which one of the following would be the preferred medication to control her asthma? (check one)
Fluticasone (Flovent)
Salmeterol (Serevent Diskus)
Fluticasone/salmeterol (Advair)
Montelukast (Singulair)
Fluticasone/salmeterol (Advair)
This patient has intermittent asthma that has become at least moderate persistent as defined by the frequency of her symptoms. The National Asthma Education and Prevention guidelines recommend a moderate-dose inhaled corticosteroid (ICS) with a long-acting bronchodilator as the preferred treatment in moderate persistent asthma. Fluticasone/salmeterol at a dosage of 250/50 μg is the only option that fits this category. Montelukast alone is an alternative treatment for mild persistent asthma (SOR A).
You are playing in a community league soccer tournament and are asked to evaluate a 30-year-old female. She was in her usual state of health when she suddenly began having difficulty breathing while playing soccer. She tells you that she has had similar episodes in the past. Treatment with an albuterol (Proventil, Ventolin) inhaler does not improve her symptoms.
On examination you note dyspnea with audible inspiratory wheezing but no increased work of breathing, and she has an oxygen saturation of 98%.
Which one of the following is the most likely diagnosis? (check one)
Anaphylaxis
Exercise-induced asthma
Foreign body aspiration
Laryngeal edema
Vocal cord dysfunction
Vocal cord dysfunction
Vocal cord dysfunction occurs when the vocal cords close when they should be open, particularly during inspiration. It should be suspected in patients who develop sudden, severe dyspnea that presents with inspiratory stridor or wheezing and is not associated with hypoxia, tachypnea, or increased work of breathing. It is most common in women ages 30–40. Anaphylaxis and foreign body aspiration would be unlikely without an antecedent trigger. Exercise-induced asthma usually presents with expiratory wheezing and responds to the use of an albuterol inhaler. Laryngeal edema is usually preceded by signs of illness.
A 24-year-old female seeks your advice regarding the recent onset of a cough when running. She moved to the United States from Mexico last year and her symptoms first became apparent during her first winter in the Midwest. The cough starts after she has been running approximately 1 mile but no sputum is produced and no other symptoms occur. She has no other health concerns.
A physical examination and office spirometry are consistent with a healthy young adult. You ask her to run around the outside of the clinic several times and then you reexamine her. The only change noted is an increase in her pulse rate and a 10% drop in her FEV1.
Which one of the following would be the most appropriate initial treatment for this patient? (check one)
An endurance conditioning program
An over-the-counter antihistamine as needed
An inhaled corticosteroid 2 hours before running
An inhaled short-acting β2-agonist 15 minutes before running
Daily use of an inhaled long-acting β2-agonist
An inhaled short-acting β2-agonist 15 minutes before running
This patient’s history and examination findings are typical for exercise-induced asthma. The most appropriate initial treatment for this condition is an inhaled short-acting β2-agonist (SABA) 15 minutes before exercise (SOR A). Daily use of an inhaled long-acting β2-agonist as a single agent is not recommended even for those who continue to experience symptoms when using an inhaled SABA (SOR B). The addition of a daily inhaled corticosteroid is an appropriate consideration for patients who require more than a SABA to control symptoms but these should not be used on an as-needed basis before exercise (SOR B). Use of an antihistamine in an individual with exercise-induced asthma but no known allergies is not recommended (SOR B). Other treatment considerations with weak recommendations include a low-sodium diet, air humidification, and supplemental dietary fish oils.
