Asthma Exacerbation and Chronic Asthma Management

Question 1

duration and dosing of prednisone in mild to moderate asthma exacerbation

Answer 1

5-7 days of prednisone 40-60 mg daily appropriate for mild to moderate asthma exacerbation.

Question 2

Do we use antibiotics for asthma exacerbations

Answer 2

no.

Question 3

Do you use intranasal steroid therapy (budesonide) in exacerbation?

Answer 3

no.

Question 4

what is the most common cause for ineffective inhalers

Answer 4

poor inhaler technique (45%) Need to exhale before inhalation or inhalation through the nose

Question 5

Correct inhaler method

Answer 5

full exhalation followed by deep inhalation and then breath hold. Sometimes a metered dose inhaler should be slow 405 seconds for adults and inhalation with a dry poweder should be fast and start immediately.

Question 6

IN treatment of a acute asthma exacerbation, what should pts be discharged on:

Answer 6

oral steroids for 3-10 days inhaled corticosteroids personalized asthma action plan

Question 7

while hospitalized what is the ED protocol of management for acute asthma exacerbation?

Answer 7

inhaled beta agonist (repeated doses) corticosteroids IV or PO if able to tolerate maintain oxygen saturation for SaO2>92% ipratropium bromide if failure to improve with beta agonist.

Question 8

severe asthma exacerbation is defined as

Answer 8

peak flow <200 L/min or <40% of normal peak flow

Question 9

moderate asthma exacerbation is defined as:

Answer 9

<70% of normal peak flow

Question 10

moderate to severe asthma exacerbations are treated with

Answer 10

systemic steroids. IV and PO are equivalent but prefer IV if in respiratory distress

Question 11

indication for maintenance inhaled corticosteroids

Answer 11

one episode of asthma exacerbation severe enough to merit hospitalization

Question 12

duration of steroid therapy in severe asthma exacerbations

Answer 12

3 to 10 days for most patinets no need to taper since it will be <3 weeks.

Question 13

nocturnal asthma like symptoms could be the result of:

Answer 13

true nocturnal asthma, GERD, OSA, upper airway cough syndrome

Question 14

symptoms suggestive of nocturnal asthma like symptoms that are actually: GERD

Answer 14

frequent regurgitation symptoms (worse at night) awakenings with heart burn possible cough and wheezing responds to PPI

Question 15

symptoms suggestive of nocturnal asthma like symptoms that are actually: OSA

Answer 15

difficulty maintaining sleep and daytime sleepiness awakenings with cough responds to intranasal corticosteroids

Question 16

symptoms suggestive of nocturnal asthma like symptoms that are actually: upper airway cough syndrome

Answer 16

daytime rhinorrhea or allergic symptoms awakenings with cough responds to intranasal corticosteroids

Question 17

symptoms suggestive of nocturnal asthma like symptoms that are truly related to NOCTURNAL ASTHMA

Answer 17

symptoms usually are between 2-4am awakenings with cough and wheezing responds to albuterol or step up in asthma therapy

Question 18

retrognathia is

Answer 18

lower jaw is set further back than upper jaw making it look like someone has a severe overbite.

Question 19

step up therapy for asthma

Answer 19

Question 20

nocturnal asthma symptoms

Answer 20

Question 21

allergic rhinitis as a cause for nocturnal asthma would have findings of

Answer 21

inflamed nares, pharyngeal erythema and cobblestoning for signs of post nasal drip

tx with inhaled corticosterois (fluticasone)

Question 22

chart with asthma severity levels

Answer 22

Question 23

intermittent asthma is defined by:

Answer 23

<2 days/week or nighttime awakenings <2/month

Question 24

Mild persistent asthma is defined as:

Answer 24

>2 days/week but NOT daily

or night time symptoms 3-4x/month

Question 25

moderate persistent asthma definition of severity

Answer 25

daily symptoms

nighttime symptoms are >1 week/wk but not nightly

Question 26

severe persistant asthma definition

Answer 26

symptoms throughout the day

nighttime awakenings symptoms: often 7x/week.

Question 27

what do we see in allergic bronchopulmonary aspergillosis (ABPA) with persistent asthma

Answer 27

see episodes of bronchial obstruction, malaise, fever, expectoration of brownish mucous plugs, hemoptysis, peripheral blood eosinophilia and elvated serum IgE.

CXR in ABPA shows parenchymal infilitrates (often involving upper lobes) and/or bronchiectasis.

Question 28

asthma step up therapy

Answer 28

Question 29

what is the black warning about asthma treatment

Answer 29

it’s about the chronic use of LABA as it can cause severe exacerbations and asthma related deaths.

Effect of LABA is dminished or prevented by concomitant use of ICS. DO not use LABA agent alone as a single agent.

Question 30

What is aspirin exacerbated respiratory disease (AERD)?

what is the natural disease history for this syndrome?

Answer 30

this is seen in 20% of asthmatics and presents with classic triad of chronic rhinosinusitis with polyposis, asthma, and aspirin (or NSAID) sensitivity

They develop refractory rhinitis in their 30’s followed by chronic rhinosinusitis with anosmia and nasal polyposis. Then rhinosinusitis progresses to lower airway inflammation causing asthma. Aspirin and NSAID sensitivity develops during this progression. Then NSAIDs can cause lifethreatening asthma, nasal or ocular symptoms and facial flushing or erythema.

Question 31

what are the metabolic pathways of NSAIDS that cause proinflammatory pathways

Arachidonic acid metabolic pathways chart

Answer 31

Question 32

chart for aspirin exacerbated respiratory disease

Answer 32

Question 33

what causes the aspirin exacerbated respiratory disease

Answer 33

likely a shift in the arachidonic acid metabolic pathway which leads to excesive leukotriene production and this is not a IgE mediated allergy response.

Question 34

Diagnosis of Aspirin exacerbated respiratory disease

How to treat this?

Answer 34

diagnosis: made with clinical history of aspirin or NSAID reaction

Treatment: optimal asthma therapy and surgery for chronic rhinosinusitis, and advoidance of NSAIDS or aspirin.

Can also use montelukast (leukotriene receptor antagonist) per guidelines to improve pulmonary and sinus symtpoms.

Aspirin desensitization is considered in pts refractory to therapy or who require aspirin/NSAIDS for other condition (CAD or chronic headaches).

Question 35

What is reactive airway disease syndrome?

Answer 35

form of occupational asthma that occurs in context of workplaces and subcategory of irritant induced asthma. Not a immunological asthma

this happens following a single high dosed exposure with inhaled irritant is termed reactive airway dx.

can be seen after chlorine, ammonia, paint, diesal fumes, bleach and other cleaning agents

need at least 3 months of asthmatic symptoms following exposure and confirmed with obstruction or bronchial hypersensitivity.

Question 36

how to diagnose reactive airway disease?

Answer 36

methacholine challenge test is positive

spirometry may show obstruction but need the methacholine challenge test.

Question 37

Prognosis with reactive airway disease?

Answer 37

variable. some may improve with steroids but others respond poorly to typical asthma therapy.

some will suffer from persistent asthma like symptoms (requiring inhaled glucocorticoids and bronchodilators) and others will have complete resolution in 2 years.

Question 38

exercise induced bronchoconstriction:

Answer 38

transient form of upper airway hyperresponsiveness that occurs with strenous activity.

EIB can occur in pts who DON’T have history of asthma. due to increased minute ventilation during exercise and leads to increased exposure to environmental sitmuli (cool dry air, chlorine, outdoor allergens

Exertion is a common trigger for bronchoconstriction in pts with asthma,

Question 39

how to treat exercise induced bronchoconstriction?

Answer 39

short acting beta 2 agonists like SABA (albuterol)

are useful in both treatment and prevention of EIB and should be given 5-15 minutes prior to exercise for prophylaxis

Frequent SABA use may lead to tolerance and paradoxical increased airway hyperresponsiveness

if this happens, need a second agent:

1. inhaled corticosteroids: can take 4 weeks to reach peak effect but can be beneficial in pts with uncontrolled underlying asthma
2. leukotriene receptor antagonists (LTRAs) - montelukast - rapid effect and avoid use of daily inhaler.

Need to get PFTs when not having an exacerbation.

Question 40

what is allergic asthma?

Answer 40

it’s a subtype of asthma or phenotype seen with atopy

diagnosed with allergy skin prick tests and measurement of allergen specific IgE. Never measure total IgE levels because normal doesn’t mean that they don’t have allergic asthma

can see elevated serum or sputum eosinophils

important to diagnse becasue can benefit with omalizumab (monoclonal antibody for targeting IgE in severe atopic asthma) Can also need systemic steroids and antiinterluekin therapies like mepolizumab

Question 41

what mimics exercise induced bronchospasm?

Answer 41

cardiac disorders and vocal cord dysfunction

need to make sure that there’s bronchial hyperreactivity to make accurate diagnosis

Question 42

non pharmacological tx of exercise induced bronchospasm

Answer 42

wear a mask or scarf to warm up cold air before inhalation

Question 43

what is cough variant asthma?

Answer 43

asthma whos primary symptom manifestation is chronic cough without other symptoms.

Diagnosis requires documentation of bronchial hyperreactivity as baseline spirometery will be normal. Need to have same therapy as other asthma.

Need to rule out other causes of chronic cough like GERD, upper airway cough syndrome from rhinitis

Question 44

Occupational asthma is seen with

Answer 44

direct exposure by sensitizing or irritant substances in the work place and preexisting asthma that is exacerbated the same factors.

seen with animal, plant allergens, latex, grains and diisocyanates.

Question 45

people at risk for occupational asthma

Answer 45

farmers, animal workers, healthcare workers, latex glove users, bakers, manufacturerers of polyurethane products

Question 46

treatment of occupational asthma

and how to diagnose?

Answer 46

diagnosis: spirometry before and after workplace eposure is cost effective way to confirm
- can see bronchial hyperrreactivity through bronchial challenge testing

Tx: reduce exposure to offending agent through workplace modifications or removing pts from the workplace entirely

Question 47

classic triad of

chronic rhinosinusitis with polyposis (nasal polyps),

airway and peripheral eosinophilia

persistent severe asthma,

Seen in a young adult and develops severe life threatening bronchospasm after NSAID or aspirin

Answer 47

Aspirin exacerbated respiratory dx

Chronic management is no NSAIDs, and no leukotriene receptor antagonists

May need aspirin desensitization.

Question 48

Chronic eosinophilic pneumonia is

Answer 48

rare idiopathic disorder with abnormal accumulation of eosinophils in lung. See asthma preceding diagnosis in 50% of cases. Peripheral eosinophilia and elevated IgE are present.

See bilateral upper lobe opacities or peripheral or pleural based opacities often called a “photographic negative” of pulmonary edema.

Chronic Eosinophilic Pneumonia presentation: insidious onset of fever, cough, progressive dyspnea, wheezing, weight loss. NO respiratory failure unlike AEP.

see peripheral eosinophilia>6% and elevated ESR and CRP, thrombocytosis.

BAL>25% eosinophils suggests this

lung biopsy will show interstitial and alveolar eosinophils with multinucleated giant cells and associated bronchiolitis obliterans with organizing pneumonia.

Respond to steroids within 48 hrs. lack of improvement point to different etiology.

Tx of steroids continues for 3 months until tapered over following 3 months.

Question 49

some is complaining of wheezing that is intermittent and varying intensity and sometimes happening at night. What is the differential for wheezing and how to evaluate for this?

Answer 49

interimittent wheezing - a course whistling sound caused by airflow in a narrow airway

differential diagnosis: asthma, bronchospasm, CHF (cardiac asthma), vocal cord dysfunction, post nasal drip and both intra and extrathoracic obstruction

Initial evaluation of stable pts for wheezing: PFTs (spirometry)

CXR can be obtained for focal or persistent wheezing

CT chest is based on those initial findings.

Question 50

Chronic Eosinophilic Pneumonia presentation

labs:

BAL findings?

Answer 50

Chronic Eosinophilic Pneumonia presentation: insidious onset of fever, cough, progressive dyspnea, wheezing, weight loss. NO respiratory failure unlike AEP.

see peripheral eosinophilia>6% and elevated ESR and CRP, thrombocytosis.

BAL>25% eosinophils suggests this

lung biopsy will show interstitial and alveolar eosinophils with multinucleated giant cells and associated bronchiolitis obliterans with organizing pneumonia.

Question 51

Treatment of Chronic Eosinophilic Pneumonia

Answer 51

Both acute and chronic eosinophilic pneumonia respond to steroids within 48 hrs

continue for 3 months with steroids and t_hen taper gradually over following 3 months_ (6 months of steroids)

Question 52

how to treat pregnant women with asthma?

Answer 52

same way you treat non pregnant woman

easier to treat than to deal with asthma symptoms or exacerbations because of increased perinatal complications and maternal morbidity

management while pregnant:

objective monitoring of lung function,

avoiding controlling asthma triggers,

educating pts on minimal amount of drug necessary to control symptoms.

Question 53

If you have asthma pt who presents with an asthma exacerbatio nand appears to be in moderate respiratory distress

breathing shallow and no wheezing or rales or rhonchi. Stat CXR is clear. What do you do next?

Answer 53

intubate. If in asthma exacerbation and he is not wheezing and normal lung exam means he is not moving much air and needs to be intubated or has impending respiratory failure.

Question 54

most typical acid base disturbnce in asthma exacerbation?

Answer 54

respiratory alkalosis is typical

respiratory acidosis and high CO2 is sign of respiratory failure and needing intubation.

can see normal pH which is an omnious sign of fatigue.