ASTHMA MANAGEMENT Flashcards
ASTHMA MANAGEMENT
Recommendations
2.1 Initial Clinical Assessment
Check for symptoms like wheezing, breathlessness, and triggers. Physical examination should assess wheezing and rule out other respiratory conditions.
2.2 Objective Tests for Diagnosing Asthma
Adults & Children (5-16 years old): Tests include blood eosinophil count, FeNO (fractional exhaled nitric oxide), bronchodilator reversibility (BDR) with spirometry, peak expiratory flow (PEF), and bronchial challenge tests.
Children Under 5: Diagnosis is challenging due to difficulty performing objective tests; treatment trials with inhaled corticosteroids are recommended.
2.3 Diagnosing Occupational Asthma
Occupational exposure should be considered in adult-onset asthma cases. Symptoms should be monitored concerning work environment and holidays.
2.4 Monitoring Asthma Control
Regular monitoring at every review, including symptoms, medication use, and exacerbation history.
Symptom questionnaires and FeNO tests may be used for assessment.
ASTHMA MANAGEMENT
2.5 Principles of Pharmacological Treatment
Assess factors affecting asthma control before adjusting medication. Ensure correct inhaler technique and address non-adherence. Short-acting beta-agonists (SABAs) should not be prescribed without inhaled corticosteroids.
2.6 Pharmacological Management
People Aged 12 and Over:
Initial treatment includes low-dose inhaled corticosteroid/formoterol (ICS/Formoterol) as needed.
Maintenance and reliever therapy (MART) recommended for uncontrolled asthma. Stepwise approach based on control, involving leukotriene receptor antagonists (LTRAs) or long-acting muscarinic receptor antagonists (LAMAs) if necessary.
Children Aged 5-11:
Initial treatment with low-dose ICS and SABA as needed.
MART may be considered for children capable of managing it. LTRA may be added if MART is unsuitable.
Children Under 5:
Trial of ICS recommended if symptoms indicate asthma.
Step-up approach with moderate ICS or LTRA if symptoms persist.
2.7 Decreasing Maintenance Therapy
Step-down approach when asthma is well controlled for at least a year. Reduction should be gradual and monitored closely.
2.8 Adherence
Regular adherence checks using prescription records and inhaler technique assessments.
ASTHMA MANAGEMENT
2.9 Asthma in Pregnancy & Breastfeeding. Emphasis on maintaining asthma control during pregnancy.
Safe use of ICS, SABAs, and theophyllines. Monitoring and adjustments should be made based on asthma control.
2.10 Asthma in Adolescents
Discuss future career choices and occupational risks.
Address smoking and vaping.
Consider psychological and social factors affecting adherence.
2.11 Self-Management
Offer personalized asthma action plans.
Provide education on symptom control, environmental triggers, and medication use.
2.12 Risk-Stratified Care
Identify high-risk patients (e.g., frequent SABA use, multiple hospital visits).
Tailor management plans accordingly.
2.13 Organisation and Delivery of Care
Annual asthma reviews for all patients.
Consider telehealth for self-management support.
Use digital tools and decision-support systems.
- Research Recommendations
Areas requiring further research include diagnostic test accuracy, medication sequencing, self-management programs, and risk-stratified care.
- Implementation Considerations
Healthcare professionals should consider environmental sustainability when implementing asthma care strategies.
This guideline aims to standardize asthma diagnosis and treatment across different age groups, emphasizing evidence-based approaches and individualized care plans.
ASTHMA MANAGEMENT
Recommendations
2.1 Initial Clinical Assessment
Key Points:
Diagnosis should start with a structured clinical history including:
Symptoms: Wheeze, breathlessness, chest tightness, and cough.
Patterns: Symptoms worsening at night, with triggers (allergens, exercise, infections).
Family history: Asthma, atopic conditions (eczema, allergic rhinitis).
Differential diagnosis: Ruling out conditions such as chronic obstructive pulmonary disease (COPD), heart failure, or vocal cord dysfunction.
Physical Examination:
Look for (prolong) expiratory wheeze and rule out other causes.
A normal exam does not exclude asthma.
Initial Treatment and Testing:
If symptoms are severe, initiate bronchodilator therapy and assess response.
Perform objective lung function tests where possible.
Clinical Impact:
Ensures asthma is not misdiagnosed, reducing unnecessary treatment or delays in appropriate care.
Prevents over-reliance on clinical symptoms alone by incorporating objective measures.
ASTHMA MANAGEMENT
Objective Tests for Diagnosing Asthma
Adults & Children (5-16 years old)
Fractional exhaled nitric oxide (FeNO):
Indicates eosinophilic inflammation.
≥50 ppb in adults or ≥35 ppb in children supports an asthma diagnosis.
Spirometry with Bronchodilator Reversibility (BDR):
Forced expiratory volume (FEV₁) increase of ≥12% and 200mL after bronchodilator suggests asthma.
Peak Expiratory Flow (PEF) Monitoring:
Variability ≥20% over 2 weeks supports asthma diagnosis.
Bronchial Challenge Tests (Methacholine, Mannitol, Exercise-Induced):
Used in uncertain cases to assess airway hyper-responsiveness.
Children Under 5
Objective testing is unreliable; diagnosis relies on clinical history and treatment response.
Trial of inhaled corticosteroids (ICS):
Improvement suggests likely asthma.
Clinical Impact:
Increases diagnostic accuracy by using multiple tests instead of symptoms alone.
Avoids misdiagnosing asthma in conditions like vocal cord dysfunction or COPD.
2.3 Diagnosing Occupational Asthma
Occupational history:
Symptoms worsening at work and improving on days off.
Common triggers: Isocyanates (paint, plastics), flour dust, wood dust, latex.
Peak Flow Monitoring at Work:
PEF measured several times daily over 2 weeks.
Greater variability during workdays suggests occupational asthma.
Clinical Impact:
Helps prevent work-related disability.
Guides employer and employee decisions regarding workplace exposure modifications.
Avoids misdiagnosing asthma in conditions like vocal cord dysfunction or COPD.
Avoiding Asthma Misdiagnosis: Accurate Diagnosis, Red Flags & Enhancing Diagnostic Accuracy
Asthma is frequently overdiagnosed and misdiagnosed, often confused with vocal cord dysfunction (VCD), COPD, heart failure, GERD, or anxiety-induced dyspnea. Accurate diagnosis is critical to ensure proper treatment and avoid unnecessary use of inhaled corticosteroids (ICS) or bronchodilators.
📌 How to Reach an Accurate Asthma Diagnosis
Asthma is a chronic airway disorder characterized by:
✅ Reversible airway obstruction
✅ Airway hyperresponsiveness
✅ Chronic inflammation
The key to an accurate diagnosis is correlating symptoms, pulmonary function tests (PFTs), and clinical response to therapy.
🔹 Step 1: Clinical History & Red Flags for Alternative Diagnoses
A thorough history differentiates asthma from conditions like COPD, heart failure, vocal cord dysfunction (VCD), or anxiety-related dyspnea.
Symptom:
A. WHEEZING
Asthma: Expiratory wheeze
VCD: Inspiratory wheeze
COPD: Expiratory wheezing
Herat Failure: No wheezing, Crackles
B. Dyspnea
Asthma: Episodic, worse at night.
VCD: Sudden onset, often during stress/exercise
COPD: Progressive, exertional
Heart failure: Exertional dyspnea, orthopnea
C. Triggers
Asthma: Allergens, exercise, cold air
VCD: stress, exercise, irritants
COPD: Smoking, pollutants
Heart Failure: Fluid overload, hypertension
D. Cough
Asthma: Dry or Productive, Nocturnal
VCD: Throat Triggers, no cough
COPD: Chronic, Productive
Heart Failure: Dry, worse when supine
E. Response to Bronchodilators
Asthma: Improves with Albuterol
VCD: No improvement
COPD: Partial response
Heart failure: No improvement
F. Spirometry:
Asthma: Obstructive, reversible
VCD: Normal PFTs, abnormal flow volume loop
CODP: Obstructive, not fully reversible
Herat Failure: Restrictive or normal.
📌 Red Flags Suggesting Alternative Diagnoses:
🚨 No response to bronchodilators (Suggests COPD, VCD, or cardiac causes)
🚨 Inspiratory stridor instead of expiratory wheezing (Suggests VCD or upper airway obstruction)
🚨 Crackles on lung exam (Suggests heart failure instead of asthma)
🚨 Chronic productive cough (Suggests COPD, bronchiectasis, or GERD-related cough)
🔹 Step 2: Objective Testing (Pulmonary Function Tests & Challenge Tests)
Pulmonary Function Tests (PFTs) with Spirometry are essential for confirming asthma.
1️⃣ Spirometry with Bronchodilator Reversibility Test
✅ FEV1/FVC < 70% (Obstructive Pattern)
✅ FEV1 improvement of >12% and >200 mL after bronchodilator → CONFIRMS asthma
❌ If FEV1 does NOT improve significantly → Consider COPD or VCD instead
2️⃣ Methacholine or Exercise Challenge Test
📌 For patients with normal spirometry but persistent asthma-like symptoms
✅ FEV1 drop >20% with methacholine → Confirms airway hyperresponsiveness (Asthma)
❌ Negative test → Rules out asthma in most cases
3️⃣ Peak Expiratory Flow (PEF) Variability Monitoring
* Asthma: ≥20% variability in PEF over 2 weeks
* COPD: Minimal daily variability
🔹 Step 3: Distinguishing Asthma from Common Mimickers
🚨 Misdiagnosis is common in the following conditions:
1️⃣ Vocal Cord Dysfunction (VCD)
* Key Feature: Paradoxical vocal cord movement causing inspiratory stridor instead of expiratory wheezing
* Diagnostic Test: Laryngoscopy during an episode → Shows adduction of vocal cords
* Treatment: Speech therapy, breathing exercises (not inhalers!)
2️⃣ Chronic Obstructive Pulmonary Disease (COPD)
* Key Feature: Persistent airflow limitation, not reversible with bronchodilators
* Diagnostic Test: Post-bronchodilator spirometry (FEV1/FVC < 70% and non-reversible airflow obstruction)
* Treatment: Long-acting bronchodilators, smoking cessation
3️⃣ Gastroesophageal Reflux Disease (GERD)
* Key Feature: Nocturnal cough & wheezing without triggers
* Diagnostic Test: pH monitoring or trial of PPI
* Treatment: Proton pump inhibitors (PPIs), lifestyle modifications
4️⃣ Heart Failure (Cardiac Asthma)
* Key Feature: Dyspnea, crackles, orthopnea, edema
* Diagnostic Test: BNP, echocardiogram
* Treatment: Diuretics, ACE inhibitors, beta-blockers
🔹 Step 4: Enhancing Diagnostic Criteria & Accuracy
To avoid misdiagnosis, consider the following approach:
✔ Use spirometry in ALL suspected cases before diagnosing asthma.
✔ Challenge tests (methacholine, exercise-induced challenge) if spirometry is normal.
✔ Peak flow variability monitoring to differentiate asthma from COPD.
✔ Consider alternative diagnoses when symptoms don’t improve with asthma therapy.
✔ Red flag symptoms (e.g., inspiratory stridor, chronic productive cough, cardiac symptoms).
🔹 Summary: Steps to an Accurate Asthma Diagnosis
🔹 Step 1: Detailed History & Symptom Analysis
✅ Episodic symptoms, wheezing, nocturnal cough
✅ Triggers (allergens, exercise, cold air)
❌ Red Flags for alternative diagnoses
🔹 Step 2: Objective Testing with Spirometry
✅ Obstructive pattern with bronchodilator reversibility
❌ If non-reversible, consider COPD, VCD, or heart failure
🔹 Step 3: Challenge Testing if Spirometry is Normal
✅ Methacholine challenge if symptoms persist but normal PFTs
❌ Negative test strongly suggests non-asthma cause
🔹 Step 4: Consider Common Mimickers
✅ VCD: Inspiratory stridor, confirmed with laryngoscopy
✅ COPD: Persistent obstruction, non-reversible with bronchodilators
✅ GERD: Nocturnal wheeze/cough, improved with PPIs
✅ Heart Failure: Dyspnea, crackles, positive BNP
🔹 Key Takeaways for ANCC/AANP Exam
✅ Asthma is reversible! If FEV1 does not improve after bronchodilators, reconsider the diagnosis.
✅ Methacholine challenge test helps rule in asthma if spirometry is normal.
✅ Inspiratory stridor = Think Vocal Cord Dysfunction (VCD), NOT Asthma!
✅ Red Flags: Crackles (Heart Failure), Chronic Cough (COPD), No Response to Albuterol (Consider VCD or Cardiac Cause).
Avoids misdiagnosing COPD in conditions like Bronchiectasis and GarRD. Deep dive how to reach accurate diagnosis and avoid misdiagnosis, red flags to look for to enhance diagnostic criteria and accuracy
Avoiding COPD Misdiagnosis: Enhancing Diagnostic Accuracy & Identifying Red Flags
🔹 Why COPD is Misdiagnosed?
COPD is frequently misdiagnosed, either overdiagnosed in patients with asthma or underdiagnosed in patients with bronchiectasis, heart failure, or gastroesophageal reflux disease (GERD).
Accurate diagnosis is critical to ensure proper treatment, prevent inappropriate use of inhalers, corticosteroids, or antibiotics, and avoid delayed management of the true underlying condition.
📌 How to Reach an Accurate COPD Diagnosis?
COPD is a progressive, irreversible airway obstruction due to chronic bronchitis and/or emphysema. Key criteria for COPD diagnosis:
✅ Persistent respiratory symptoms (dyspnea, chronic cough, sputum production).
✅ Risk factors present (smoking, occupational exposure).
✅ Irreversible airflow obstruction on spirometry.
📌 Key to Accurate Diagnosis:
✔ Clinical symptoms + Risk Factors + Spirometry.
✔ Exclude mimicking conditions (Bronchiectasis, GERD, Heart Failure).
🔹 Step 1: Clinical History & Red Flags for Misdiagnosis
A thorough history differentiates COPD from other conditions like asthma, bronchiectasis, GERD, or heart failure.
COPD vs. Common Mimickers
See Asthma diagnosis and mangement on chatgpt.
Feature COPD Bronchiectasis Asthma GERD-Related Cough Heart Failure (Cardiac Asthma)
Cough Chronic, often productive Persistent, copious mucus, recurrent infections Episodic, dry or productive, nocturnal Nocturnal cough, triggered by reflux Dry, worse in supine position
Dyspnea Progressive, exertional Progressive, worse with infections Episodic, reversible with bronchodilators Postprandial, worse when lying down Orthopnea, PND
Sputum Production Scant, white sputum Large volumes, purulent Mild sputum Possible throat clearing Frothy, pink sputum
Trigger Factors Smoking, pollutants Recurrent infections Allergens, exercise, cold air Acid reflux, lying down Fluid overload, hypertension
Lung Exam Prolonged expiration, wheezing, distant breath sounds Crackles, wheezing, clubbing Wheezing, prolonged expiration Clear or mild wheezing Crackles, S3 heart sound
Response to Bronchodilators Partial response Partial or minimal response Marked improvement No effect No effect
Imaging Findings Hyperinflation, flattened diaphragm Bronchial wall thickening, mucus plugging Normal or mild changes Normal CXR Pulmonary edema, cardiomegaly
see in chatgpt and arrange it.
📌 Red Flags Suggesting Alternative Diagnoses:
🚨 Chronic large-volume mucus production + recurrent infections (Bronchiectasis).
🚨 Wheezing that resolves completely with bronchodilators (Asthma, not COPD).
🚨 Heart failure symptoms (edema, orthopnea, paroxysmal nocturnal dyspnea) with crackles.
🚨 No response to bronchodilators (Consider GERD, Bronchiectasis, or Heart Failure instead).
🔹 Step 2: Objective Testing (Pulmonary Function Tests & Imaging)
1️⃣ Spirometry – The Gold Standard for COPD Diagnosis
COPD = Persistent, irreversible obstruction on spirometry.
✅ FEV1/FVC < 70% (Obstructive Pattern)
✅ FEV1 does NOT fully improve after bronchodilator (IRREVERSIBLE airflow obstruction).
❌ If reversible, consider ASTHMA instead.
2️⃣ High-Resolution CT Scan (HRCT) – Differentiating COPD from Bronchiectasis
Indicated if:
✔ Frequent lung infections, chronic sputum, or clubbing → R/O Bronchiectasis.
✔ HRCT Findings in Bronchiectasis:
* Bronchial dilation
* Mucus plugging
* “Tram-track sign”
* “Signet ring sign”
3️⃣ Chest X-ray (CXR)
* COPD: Hyperinflation, flattened diaphragm, barrel-shaped chest.
* Heart Failure: Cardiomegaly, pulmonary edema.
* Bronchiectasis: Thickened bronchial walls, mucus plugging.
📌 Key Takeaway:
✅ COPD must be confirmed with SPIROMETRY.
✅ If large-volume mucus production → Order HRCT to R/O Bronchiectasis.
✅ If heart failure suspected → BNP, echocardiogram.
🔹 Step 3: Distinguishing COPD from Common Mimickers
🚨 Misdiagnosis is common in the following conditions:
1️⃣ Bronchiectasis (Frequently Misdiagnosed as COPD)
* Key Features: Chronic large-volume mucus production, recurrent lung infections, clubbing.
* HRCT Findings: Dilated bronchi, mucus plugging, bronchial wall thickening.
* Treatment: Airway clearance therapy (chest physiotherapy, mucolytics), antibiotics for exacerbations.
📌 Red Flags for Bronchiectasis:
✅ Recurrent lung infections
✅ Chronic purulent sputum > 3 months
✅ HRCT findings: bronchial dilation, mucus plugging
2️⃣ Asthma (Misdiagnosed in Overlapping Cases)
* Key Features: Episodic reversible airflow obstruction, no progressive lung damage.
* Spirometry: FEV1 improves >12% post-bronchodilator → ASTHMA, not COPD.
* Treatment: Inhaled corticosteroids (ICS), bronchodilators.
📌 Red Flags for Asthma Instead of COPD:
✅ Young age (<40), strong allergic history
✅ Reversible airflow obstruction on spirometry
✅ Wheezing that resolves completely with bronchodilators
3️⃣ GERD-Related Chronic Cough
* Key Features: Nocturnal cough, postprandial symptoms, worsens with lying down.
* Diagnostic Test: pH monitoring, trial of proton pump inhibitors (PPIs).
* Treatment: Lifestyle modifications, PPIs.
📌 Red Flags for GERD:
✅ Cough worse at night/post-meal
✅ No response to bronchodilators
✅ Heartburn, throat clearing symptoms
4️⃣ Heart Failure (“Cardiac Asthma”)
* Key Features: Dyspnea, orthopnea, PND, crackles.
* Diagnostic Tests: BNP, echocardiogram.
* Treatment: Diuretics, ACE inhibitors, beta-blockers.
📌 Red Flags for Heart Failure:
✅ Orthopnea, PND, dependent edema
✅ Crackles (instead of wheezing) on lung exam
✅ Elevated BNP, echocardiogram abnormalities
🔹 Enhancing Diagnostic Criteria & Avoiding Misdiagnosis
✔ Use spirometry in ALL suspected COPD cases before diagnosing.
✔ If spirometry is normal, reconsider the diagnosis!
✔ Order HRCT if large mucus production suggests bronchiectasis.
✔ Check BNP and echocardiogram in heart failure-suspected cases.
✔ Consider GERD if cough persists despite COPD therapy.
🔹 Summary: Steps to an Accurate COPD Diagnosis
🔹 Step 1: Detailed History & Symptom Analysis
✅ Chronic symptoms, smoking history, progressive dyspnea.
❌ Red Flags for alternative diagnoses.
🔹 Step 2: Objective Testing
✅ Spirometry confirms COPD (FEV1/FVC <70%, irreversible).
✅ HRCT for bronchiectasis suspicion.
✅ BNP/Echo for heart failure suspicion.
🔹 Step 3: Consider Common Mimickers
✅ Bronchiectasis: Recurrent infections, purulent sputum.
✅ Asthma: Reversible airflow obstruction.
✅ GERD: Nocturnal cough, post-meal worsening.
✅ Heart Failure: Crackles, edema, orthopnea.
2.4 Monitoring Asthma Control
Should be assessed at every review.
Key indicators:
Asthma Control Test (ACT): Scores <20 indicate poor control.
Use of reliever inhalers: Frequent use (>3 doses per week) suggests poor control.
Exacerbations: Recent emergency visits or steroid courses indicate poor control.
FeNO monitoring can be used to detect inflammation and adjust corticosteroid dosing.
Clinical Impact:
Prevents unnecessary medication escalation by distinguishing poor adherence from therapy failure.
Reduces exacerbation risk through early intervention.
2.5 Principles of Pharmacological Treatment
Address potential causes of poor control before modifying medication:
Poor adherence (check prescription records).
Incorrect inhaler technique.
Smoking/vaping exposure.
Psychosocial factors affecting medication use.
Never prescribe short-acting beta agonists (SABA) without an ICS.
Over-reliance on SABAs without corticosteroids increases exacerbation risk.
Clinical Impact:
Emphasizes holistic asthma care by addressing non-medication factors.
Reduces SABA overuse and corticosteroid underuse, improving long-term outcomes.
ASTHMA CONTROL
2.6 Pharmacological Management
People Aged 12 and Over
First-line treatment: Low-dose ICS/formoterol as needed (AIR therapy).
Escalation if uncontrolled:
Low-dose Maintenance and Reliever Therapy (MART).
Moderate-dose MART or ICS/LABA with LTRA or LAMA.
Specialist referral for severe asthma.
Children Aged 5-11
Stepwise approach:
ICS + SABA as needed.
MART if capable, otherwise add LTRA.
ICS/LABA combination.
Specialist referral.
Children Under 5
ICS trial for 8-12 weeks.
Step-up therapy if symptoms persist.
Clinical Impact:
Introduces AIR therapy as a first-line approach, reducing steroid exposure.
Encourages personalized treatment escalation based on severity.
2.7 Decreasing Maintenance Therapy
Step-down therapy should be attempted after 12 months of good control.
ICS doses should be gradually reduced.
Patients must be monitored closely for symptom recurrence.
Clinical Impact:
Reduces unnecessary steroid exposure.
Prevents relapse through structured step-down planning.
ASTHMA CONTROL
2.8 Adherence
Check inhaler technique at every review.
Shared decision-making improves adherence.
Consider digital inhalers or reminders.
Clinical Impact:
Addresses major cause of poor asthma control.
Reduces steroid dose escalation due to poor adherence.
2.9 Asthma in Pregnancy & Breastfeeding
ICS, LABA, and theophyllines are safe.
Avoid stopping effective medication.
Oral corticosteroids should be used when necessary.
Clinical Impact:
Prevents exacerbations, which are harmful to fetal development.
Ensures asthma is controlled without unnecessary medication withdrawal.
2.10 Asthma in Adolescents
Discuss career choices and workplace risks.
Address psychosocial factors affecting adherence.
Encourage smoking/vaping cessation.
Clinical Impact:
Prevents occupational asthma in high-risk jobs.
Improves adherence in a group prone to poor medication use.
2.11 Self-Management
Asthma action plans should be documented for all patients.
Plans should include:
Triggers to avoid.
Medication adjustments during exacerbations.
Emergency escalation guidance.
Clinical Impact:
Empowers patients to self-manage effectively, reducing hospital visits.
2.12 Risk-Stratified Care
Identify high-risk patients (frequent reliever use, hospitalizations).
Targeted intervention programs reduce mortality.
2.13 Organization of Care
Annual asthma reviews are essential.
Digital tools and telehealth can improve access to care.
Clinical Impact:
Enhances chronic asthma management, preventing severe exacerbations.
Final Thoughts
This guideline emphasizes:
Objective diagnosis over symptom-based assessments.
Personalized, risk-stratified therapy.
Self-management and adherence strategies.
Safe medication use in pregnancy.
ASTHMA CONTROL
I. Disease Overview
Asthma is a chronic inflammatory airway disease characterized by variable airway obstruction, hyperresponsiveness, and inflammation. It presents with episodic wheezing, breathlessness, chest tightness, and cough that vary over time and in intensity.
Types of Asthma
Intermittent Asthma – Symptoms occur <2 times per week, normal lung function between episodes.
Mild Persistent Asthma – Symptoms >2 times per week but not daily; minor limitations in activities.
Moderate Persistent Asthma – Daily symptoms, frequent exacerbations, some activity limitations.
Severe Persistent Asthma – Symptoms throughout the day, frequent exacerbations, extreme limitations.
NOTE: WHEN YOU READ THE SYMPTOM, YOU CHECK AND MASTER THE PATTERN OF THE SYMPTOMS(>2 TIMES, < 2 TIMES, DAILY SYMPTOMS AND SYMPTOMS THROUGHOUT THE DAY). THEN CHECK FREQUENCY OF EXACERBATION AND ACTIVITY LEVELS. SO YOU HAVE SYMPTOMS AND PATTERNS TO LOOK AT, FREQUENCY AND ACTIVITY LEVELS IN ORDER TO DECODE THE QUESTION (IMMS FOR TYPES OF ASTHMA).
Triggers
Allergens: Dust mites, pollen, mold, pet dander.
Irritants: Smoke, pollution, strong odors.
Respiratory infections: Viral infections (e.g., rhinovirus).
Exercise-induced asthma (EIA): Bronchoconstriction triggered by exertion.
Medications: Beta-blockers, NSAIDs (aspirin-induced asthma).
Cold air, stress, GERD.
ASTHMA PATHOPHYSIOLOGY
II. Advanced Pathophysiology
Asthma is a Type 1 hypersensitivity reaction mediated by T-helper 2 cells (Th2) leading to:
Airway Inflammation: Activation of eosinophils, mast cells, and IgE release → release of cytokines (IL-4, IL-5, IL-13).
Bronchial Hyperresponsiveness (BHR): Airway smooth muscle constriction leading to bronchospasm.
Mucus Overproduction: Goblet cell hyperplasia leads to airway plugging.
Airway Remodeling: Chronic inflammation leads to subepithelial fibrosis, thickening of the airway walls, and irreversible obstruction if untreated.
III. History of Present Illness (HPI)
Key Questions to Ask:
Symptom Frequency & Duration:
“How often do you have wheezing, breathlessness, or cough?”
“Do symptoms occur at night or early morning?”
Triggers & Aggravating Factors:
“Do symptoms worsen with exercise, cold air, allergens, or infections?”
Reliever Medication Use:
“How often do you use your rescue inhaler (albuterol)?”
Prior Exacerbations:
“Have you been hospitalized for asthma?”
“Have you needed oral steroids in the past year?”
Family & Atopy History:
“Do you or your family have allergies, eczema, or nasal congestion?”
Impact on Daily Life:
“Do symptoms limit work, school, or sleep?”
Medication Adherence:
“Do you take your inhalers as prescribed?”
Smoking & Environmental Exposure:
“Do you smoke or are you exposed to secondhand smoke?”
IV. Risk Factors
Genetic predisposition: Family history of asthma or atopic diseases.
Allergic conditions: Allergic rhinitis, eczema.
Environmental exposures: Pollution, occupational dust, fumes.
Obesity: Associated with chronic low-grade inflammation.
Prematurity and low birth weight: Linked to early lung dysfunction.
V. Systemic Review
Respiratory: Wheezing, dyspnea, cough, chest tightness.
ENT: Allergic rhinitis, postnasal drip.
Dermatologic: Eczema (atopic dermatitis).
GI: GERD (common asthma trigger).
VI. Diagnostics
1st Line Tests
Spirometry (Gold Standard for Diagnosis)
FEV₁/FVC ratio < 0.70 confirms airflow obstruction.
Reversibility test: ≥12% and 200mL improvement in FEV₁ after bronchodilator use supports asthma diagnosis.
Peak Expiratory Flow Rate (PEFR)
Used in monitoring, not diagnostic.
Variability >20% supports asthma diagnosis.
Advanced Tests
Fractional Exhaled Nitric Oxide (FeNO):
Marker of eosinophilic inflammation.
≥50 ppb in adults, ≥35 ppb in children suggests asthma.
Methacholine or Mannitol Challenge Test:
For cases where spirometry is inconclusive.
Positive if FEV₁ drops by ≥20%.
Allergy Testing:
Skin prick test or serum IgE for allergen identification.
Chest X-ray:
Usually normal but rules out alternative diagnoses like pneumonia.
ASTHMA TREATMENT
VII. Evidence-Based Guidelines
Stepwise Approach to Treatment (NHLBI/NICE Guidelines)
Step 1: Intermittent Asthma
SABA (Albuterol) PRN for symptom relief.
No daily medications required.
Step 2: Mild Persistent Asthma
Low-dose ICS (Fluticasone, Budesonide).
Alternative: Leukotriene receptor antagonist (LTRA) (Montelukast).
Step 3: Moderate Persistent Asthma
Low-dose ICS + LABA (Salmeterol, Formoterol) OR
Medium-dose ICS.
Step 4: Severe Persistent Asthma
Medium-High dose ICS + LABA.
Consider LAMA (Tiotropium) or Biologics (Omalizumab, Mepolizumab).
Step 5: Severe Uncontrolled Asthma
Add oral corticosteroids (Prednisone).
Refer to Pulmonology for biologic therapy (e.g., Dupilumab, Omalizumab).
ASTHMA DD
VIII. Differential Diagnosis
COPD (Persistent obstruction, history of smoking).
Heart Failure (PND, edema, BNP elevated).
Vocal Cord Dysfunction (Stridor instead of wheezing).
GERD-related Cough (No wheezing, post-meal symptoms).
IX. USPSTF Guidelines
Asthma screening: No routine screening for asymptomatic individuals.
Smoking cessation interventions: Strong recommendation.
Obesity management in asthma: Encouraged for better control.
X. Follow-Up & Referrals
Follow-Up
Mild-moderate asthma: Every 3-6 months.
Severe or uncontrolled asthma: Monthly.
Assess: Symptom control, inhaler technique, adherence, and spirometry.
Referrals
Pulmonologist: If step 4 or 5 treatment is needed.
Allergist: For allergy testing or immunotherapy.
ENT: If chronic sinusitis or vocal cord dysfunction is suspected.
ASTHMA QUESTIONS
A 34-year-old female presents to the clinic with complaints of intermittent wheezing, cough, and shortness of breath for the past 6 months. Symptoms worsen at night and with exercise. She has a history of allergic rhinitis but denies smoking. Physical exam reveals expiratory wheezing. Spirometry shows FEV₁ of 75% predicted, with a 15% improvement after bronchodilator administration.
What is the most appropriate initial treatment?
A. Short-acting beta agonist (SABA) as needed
B. Low-dose inhaled corticosteroid (ICS) daily
C. Low-dose ICS + long-acting beta agonist (LABA)
D. Oral corticosteroids for 7 days
Answer: B. Low-dose inhaled corticosteroid (ICS) daily
Rationale: The patient has mild persistent asthma (symptoms >2 days/week, nocturnal symptoms). First-line treatment per NHLBI & NICE guidelines is a low-dose ICS (e.g., fluticasone). SABA alone is for intermittent asthma. LABA is added for moderate-severe asthma.
Which of the following is a hallmark of asthma?
Variable expiratory airflow limitation
CHATGPT ON HALLMARK OF ASTHMA
Hallmark of Asthma: A Deep Dive
Asthma is a chronic inflammatory disorder of the airways characterized by reversible airflow obstruction, airway hyperresponsiveness (AHR), and airway inflammation. The hallmark features of asthma include:
1. Airway Hyperresponsiveness (AHR)
* A key feature of asthma, AHR refers to an exaggerated bronchoconstrictor response to various stimuli, such as allergens, irritants, cold air, and exercise.
* AHR is due to chronic inflammation leading to structural changes (airway remodeling) and increased smooth muscle reactivity.
2. Reversible Airflow Obstruction
* Unlike COPD, where obstruction is largely irreversible, asthma is characterized by episodes of reversible bronchoconstriction.
* The reversibility is demonstrated by an improvement in FEV1 (Forced Expiratory Volume in 1 second) of ≥12% and an increase of ≥200 mL after administration of a bronchodilator.
3. Chronic Airway Inflammation
* Persistent inflammation leads to edema, goblet cell hyperplasia, and increased mucus production.
* Inflammatory cells such as eosinophils, mast cells, and T-helper 2 (Th2) lymphocytes play a role.
* This inflammation contributes to airway remodeling, which can become partially irreversible over time.
Key Clinical Features
* Episodic Symptoms: Asthma symptoms tend to be intermittent rather than constant and often worsen at night or early morning (circadian rhythm effect).
* Classic Triad:
1. Wheezing (high-pitched, musical sound due to narrowed airways)
2. Cough (often worse at night, may be the only symptom in some patients—“cough-variant asthma”)
3. Dyspnea and Chest Tightness (due to bronchoconstriction and mucus plugging)
* Triggers: Exercise, allergens (dust mites, pollen, pet dander), viral infections, cold air, irritants (smoke, pollution), and strong odors.
Diagnosis & Hallmark Tests
1. Pulmonary Function Test (PFT)
* Spirometry with Bronchodilator Response: The hallmark finding is reversible airflow obstruction.
* Methacholine Challenge Test: Used when spirometry is inconclusive; a ≥20% decrease in FEV1 after inhaling methacholine suggests AHR.
2. Peak Expiratory Flow Rate (PEFR)
* Can help track variability in airflow limitation, especially for patients monitoring asthma at home.
3. Fractional Exhaled Nitric Oxide (FeNO)
* Elevated FeNO suggests eosinophilic airway inflammation, a hallmark of asthma.
Pathophysiology Overview
* Early-Phase Reaction (Minutes to Hours): Trigger exposure → Mast cell degranulation → Histamine, prostaglandins, and leukotrienes → Acute bronchoconstriction.
* Late-Phase Reaction (Hours to Days): Inflammatory cell recruitment (eosinophils, Th2 cells, neutrophils) → Persistent inflammation → Airway remodeling (thickened basement membrane, goblet cell hyperplasia, subepithelial fibrosis).
Differentiating Asthma from Other Diseases
Feature Asthma COPD Heart Failure Vocal Cord Dysfunction
Onset Childhood or early adulthood Middle age (≥40 years) Any age Any age
Symptoms Episodic, worse at night/early morning Progressive, persistent Dyspnea, orthopnea, edema Stridor, throat tightness
Reversibility Yes (Bronchodilator improves FEV1) No or partial No No
Airway Hyperresponsiveness Yes No No No
Inflammation Eosinophilic (Th2-mediated) Neutrophilic Cardiogenic Non-inflammatory
Takeaway: What is the True Hallmark of Asthma?
The hallmark of asthma is airway hyperresponsiveness (AHR), which results in episodic, reversible bronchoconstriction due to chronic inflammation.
Would you like a flowchart or case scenario to reinforce this concept for your FNP board prep?
CHATGPT
Which of the following is a hallmark of asthma?
A. Fixed airflow obstruction
B. Irreversible airway remodeling
C. Variable expiratory airflow limitation
D. Chronic bacterial infection
Deep dive
Correct Answer: C. Variable Expiratory Airflow Limitation
Deep Dive: Why “Variable Expiratory Airflow Limitation” is the Hallmark of Asthma
Asthma is characterized by variable and reversible airflow limitation due to airway inflammation and hyperresponsiveness. This means that patients experience fluctuations in airflow obstruction, often triggered by allergens, exercise, infections, or environmental irritants.
* “Variable”: Symptoms and airflow limitation change over time and in response to triggers.
* “Expiratory Airflow Limitation”: Airflow obstruction predominantly affects expiration due to bronchoconstriction, mucus production, and airway wall edema.
Supporting Evidence for “Variable Expiratory Airflow Limitation” as the Hallmark of Asthma
1. Spirometry Findings:
* Reversible airflow obstruction: FEV1 increases by ≥12% and ≥200 mL after bronchodilator administration (albuterol).
* Diurnal variability in Peak Expiratory Flow Rate (PEFR): More than 10-13% variation throughout the day is suggestive of asthma.
* Methacholine Challenge Test: Demonstrates airway hyperresponsiveness if there is a ≥20% decrease in FEV1 after inhalation.
2. Clinical Symptoms Reflect Variability:
* Symptoms fluctuate over time and worsen with triggers.
* Classic Triad: Wheezing, cough (often nocturnal), and dyspnea.
* Symptoms improve with bronchodilators and corticosteroids.
Why the Other Options Are Incorrect
A. Fixed Airflow Obstruction – Incorrect
* Fixed airflow obstruction is a hallmark of COPD, not asthma.
* While chronic asthma can lead to airway remodeling (which may cause some fixed obstruction over time), early and well-managed asthma remains reversible.
* COPD patients do not show significant improvement in FEV1 after bronchodilator use.
B. Irreversible Airway Remodeling – Incorrect
* Airway remodeling can occur in severe, chronic asthma, but it is not the hallmark feature.
* Hallmark Feature = Reversible Airflow Limitation (early in the disease).
* Remodeling includes thickened basement membrane, fibrosis, and goblet cell hyperplasia, which may make some cases more resistant to therapy, but this is a late-stage complication, not a defining characteristic.
D. Chronic Bacterial Infection – Incorrect
* Unlike conditions such as bronchiectasis or cystic fibrosis, asthma is not associated with chronic bacterial infections.
* Asthma involves chronic eosinophilic inflammation, not persistent bacterial colonization.
* However, viral respiratory infections (e.g., rhinovirus) are common triggers for asthma exacerbations.
Key Takeaways
✅ Hallmark of Asthma: Variable Expiratory Airflow Limitation
✅ Asthma symptoms wax and wane, often triggered by allergens, infections, or irritants.
✅ Reversibility with bronchodilators is a distinguishing feature.
✅ Fixed obstruction and airway remodeling are late-stage effects, not defining characteristics.
Would you like a case scenario or visual aid to reinforce this?
What FeNO value suggests eosinophilic asthma?
A. >35 ppb (children) or >50 ppb (adults)
Which is an example of step-down therapy in asthma?
Switching from high-dose ICS to low-dose ICS
ASTHMA TREATMENT FLOW CHART
Stepwise Asthma Management
plaintext
CopyEdit
Step 1: SABA PRN → Intermittent Asthma
Step 2: Low-dose ICS → Mild Persistent
Step 3: Low-dose ICS + LABA OR medium-dose ICS → Moderate Persistent
Step 4: Medium/High-dose ICS + LABA → Severe Persistent
Step 5: Add LAMA/Biologic Therapy (Omalizumab, Mepolizumab) → Uncontrolled Asthma
FINAL TAKE AWAYS
VI. Final Takeaways for ANCC Exam Prep
Know Stepwise Approach (ICS is first-line for persistent asthma).
Spirometry (FEV₁ increase >12% = reversible airway obstruction).
FeNO levels (≥50 ppb suggests eosinophilic asthma).
Silent chest = impending respiratory failure → emergency management.
Asthma in pregnancy → ICS preferred, avoid LABA unless necessary.
Case 1: Elderly Patient with Polymicrobial Respiratory Tract Infection
Chief Complaint: Productive cough, fever, and shortness of breath for 5 days.
* History: COPD, history of pneumonia 2 years ago, chronic tobacco use (40 pack-year history).
* Medications: Albuterol, Tiotropium, Lisinopril.
* Exam Findings:
* Vitals: T 101.2°F, RR 24, HR 98, SpO2 90% on room air.
* Lung Exam: Coarse crackles in the lower lobes, mild wheezing.
* Labs: WBC 15,000/mm3, CRP elevated.
* Chest X-ray: Bilateral infiltrates with consolidation.
* Sputum Culture: Klebsiella pneumoniae and Staphylococcus aureus.
Answer: B) Levofloxacin and Vancomycin
Rationale:
* Levofloxacin: Broad-spectrum fluoroquinolone covers both typical and atypical bacterial pneumonia pathogens.
* Vancomycin: Covers methicillin-resistant
Staphylococcus aureus (MRSA).
* Not A) Amoxicillin-clavulanate lacks adequate
MRSA and multidrug-resistant coverage.
* Not C) Azithromycin is insufficient for a severe polymicrobial infection.
* Not D) Oseltamivir is used for influenza, not bacterial pneumonia.
Case 2: Immunocompromised Patient with a Polymicrobial Infection
Patient Profile:
* Name: Mrs. Linda Carter
* Age: 62
* Chief Complaint: Worsening cough, dyspnea, and fatigue for 2 weeks.
* History: Type 2 Diabetes, Stage 3 Chronic Kidney Disease (CKD).
* Medications: Metformin, Lisinopril.
* Exam Findings:
* Vitals: T 100.8°F, RR 20, HR 110, BP 105/70.
* Lung Exam: Decreased breath sounds, dullness to percussion.
* Labs: WBC 13,000/mm, A1C 9.0%.
* Chest CT: Right upper lobe cavitary lesion.
* Sputum Culture: Mycobacterium tuberculosis, Pseudomonas aeruginosa.
What is the most appropriate next step?
V Answer: B) Isolate the patient and initiate anti-tuberculosis therapy
Rationale:
* Pulmonary TB (cavitary lesions + immunosuppression + chronic cough) requires immediate isolation.
* Multidrug therapy for TB (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) should be started.
* Pseudomonas requires targeted antibiotic therapy (e.g., piperacillin-tazobactam).
* Not A) Steroids could worsen TB.
* Not C) Inhaled steroids are inappropriate for infectious lung disease.
* Not D) Delayed intervention could result in worsening infection and spread.
ASTHMA CASE SCENERIO
Case 2: Exercise-Induced Bronchospasm
Question:
A 16-year-old female with asthma complains of shortness of breath and wheezing during soccer practice. She is symptom-free at rest. She currently uses albuterol PRN. No history of nighttime symptoms or ER visits.
What is the best long-term management strategy?
A. Add a daily inhaled corticosteroid (ICS)
B. Pre-treat with albuterol 15 minutes before exercise
C. Start a leukotriene receptor antagonist (LTRA)
D. Use an ICS/LABA combination before exercise
Answer: B. Pre-treat with albuterol 15 minutes before exercise
Rationale: This is classic exercise-induced bronchospasm (EIB). First-line treatment is pre-exercise albuterol. Daily ICS is not needed unless symptoms occur outside of exercise.
ASTHMA CASE SCENERIO
Case 3: Poorly Controlled Asthma
Question:
A 38-year-old male with moderate persistent asthma presents with daily symptoms, nighttime awakenings 3-4 times per week, and frequent albuterol use. He is currently on low-dose ICS/LABA (Advair 100/50 mcg).
What is the most appropriate next step?
A. Add a long-acting muscarinic antagonist (LAMA)
B. Increase ICS dose to medium-dose ICS/LABA
C. Prescribe montelukast (LTRA) as add-on therapy
D. Switch to a biologic therapy (Omalizumab)
Answer: B. Increase ICS dose to medium-dose ICS/LABA
Rationale: The patient has uncontrolled asthma on a low-dose ICS/LABA. Per stepwise approach, the next step is increasing to medium-dose ICS/LABA. LAMA or biologic therapy is reserved for severe asthma.
ASTHMA CASE EXAMPLE
Case 4: Acute Severe Asthma Exacerbation
Question:
A 26-year-old female with asthma presents to the ER with severe dyspnea, accessory muscle use, and audible wheezing. She has used her albuterol inhaler every 2 hours with minimal relief. SpO₂ is 88% on room air.
What is the next best step?
A. Administer IV magnesium sulfate
B. Start high-dose ICS and observe
C. Give nebulized albuterol/ipratropium, steroids, and oxygen
D. Intubate immediately
Answer: C. Give nebulized albuterol/ipratropium, steroids, and oxygen
Rationale: This patient has severe asthma exacerbation. First-line treatment:
Nebulized albuterol + ipratropium (duoneb)
Systemic corticosteroids (prednisone 40-60 mg or IV methylprednisolone)
Oxygen to maintain SpO₂ >92%
IV magnesium sulfate is second-line if no improvement.
Viral respiratory infections
Which of the following is the most common cause of asthma exacerbations?
Asthma (Reversible airway obstruction)
A patient’s FEV₁ improves by 15% after bronchodilator use. What does this indicate?
Which medication is first-line for persistent asthma?
ICS (Inhaled corticosteroids)
Patient Scenarios
Patient Scenarios
Scenario 1: Pediatric Asthma
A 7-year-old boy has daytime symptoms twice a week and nighttime cough once per month. No ER visits.
Diagnosis: Mild Persistent Asthma
Treatment: Low-dose ICS (Fluticasone) + SABA PRN
Flowchart: Stepwise Asthma Treatment
Flowchart: Stepwise Asthma Treatment
Step 1: SABA PRN → Intermittent Asthma
Step 2: Low-dose ICS → Mild Persistent
Step 3: Low-dose ICS + LABA OR Medium-dose ICS → Moderate Persistent
Step 4: Medium/High-dose ICS + LABA → Severe Persistent
Step 5: Add LAMA/Biologic Therapy (Omalizumab, Mepolizumab) → Uncontrolled Asthma
(IMMSU). NOTE: FOR MODERATE PERSISTENT AND SEVERE PERSISTENT ASTHMA, IF LOW DOSE DO NOT IMPROVE PATIENT CONDITION, YOU SCALE TO MEDIUM DOSE. WATCH OUT FOR SUCH TRICK QUESTIONS.
case
Scenario 2: Uncontrolled Asthma
A 50-year-old woman on ICS/LABA reports daily symptoms and ER visits.
Next Step: Increase to high-dose ICS/LABA and consider LAMA.
Final Takeaways for ANCC Exam Prep
Final Takeaways for ANCC Exam Prep
Know Stepwise Approach (ICS is first-line for persistent asthma).
Spirometry (FEV₁ increase >12% = reversible airway obstruction).
FeNO levels (≥50 ppb suggests eosinophilic asthma).
Silent chest = impending respiratory failure → emergency management.
Asthma in pregnancy → ICS preferred, avoid LABA unless necessary.
Mastering Stepwise Treatment: A Shortcut
Flowchart: Stepwise Asthma Management
Step 1: SABA PRN → Intermittent Asthma
Step 2: Low-dose ICS + SABA PRN → Mild Persistent
Step 3: Low-dose ICS + LABA OR Medium-dose ICS → Moderate Persistent
Step 4: Medium/High-dose ICS + LABA → Severe Persistent
Step 5: High-dose ICS + LABA + LAMA/Biologic → Uncontrolled Asthma
SYMPTOM TABLE
SYMPTOM TABLE
Symptoms ≤2x/week? → Intermittent asthma (Step 1)
Symptoms >2x/week but not daily? → Mild persistent (Step 2)
Daily symptoms? → Moderate persistent (Step 3)
Symptoms all day, every day? → Severe persistent (Step 4/5)
Mastering Stepwise Treatment: A Shortcut
Flowchart: Stepwise Asthma Management
Step 1: SABA PRN → Intermittent Asthma. Symptoms ≤2x/week? → Intermittent asthma (Step 1). (I am fine most days).
Step 2: Low-dose ICS + SABA PRN → Mild Persistent. Symptoms >2x/week but not daily? → Mild persistent (Step 2). (My asthma flares up sometimes/Somedays)
Step 3: Low-dose ICS + LABA OR Medium-dose ICS → Moderate Persistent. Daily symptoms? → Moderate persistent (Step 3). (Most days I have symptoms)
Step 4: Medium/High-dose ICS + LABA → Severe Persistent. Symptoms all day, every day? → Severe persistent (Step 4/5). (Severe daily symptoms)
Step 5: High-dose ICS + LABA + LAMA/Biologic → Uncontrolled Asthma. Symptoms all day, every day? → Severe persistent (Step 4/5). (All day symptoms)
V. Recognizing Asthma in Question Stems (How to Think)
✅ Step 1: Identify Triggers (Exercise, cold air, allergens, stress, infections)
✅ Step 2: Look for Pattern (I am fine most days, Night symptoms? Most days symptoms, Daily symptoms, severe daily symptoms? All day symptoms?)
✅ Step 3: Match Symptom Frequency with Stepwise Treatment
How often do symptoms occur? (Key to stepwise treatment)
Symptoms ≤2x/week? → Intermittent asthma (Step 1)
Symptoms >2x/week but not daily? → Mild persistent (Step 2)
Daily symptoms? → Moderate persistent (Step 3)
Symptoms all day, every day? → Severe persistent (Step 4/5)
Practice: Board-Style Question Walkthrough
Case 1: Mild Persistent Asthma
A 10-year-old boy has wheezing and coughing >2 days per week but not daily. No ER visits. His spirometry shows reversible obstruction.
What is the best next step?
SYMPTOM TABLE
Symptoms ≤2x/week? → Intermittent asthma (Step 1)
Symptoms >2x/week but not daily? → Mild persistent (Step 2)
Daily symptoms? → Moderate persistent (Step 3)
Symptoms all day, every day? → Severe persistent (Step 4/5)
A. Albuterol PRN
B. Low-dose ICS (Fluticasone) daily
C. Montelukast (LTRA)
D. Medium-dose ICS
✅ Correct Answer: B (Low-dose ICS daily)
Why? Symptoms >2 days/week but not daily = Mild Persistent Asthma (Step 2).
Case 2: Moderate Persistent Asthma
A 40-year-old female with daily wheezing and night awakenings 3x/week is currently using low-dose ICS but still symptomatic.
What is the next best step?
A. Add Montelukast
B. Increase ICS dose to medium-dose ICS
C. Add LABA (Salmeterol) to ICS
D. Oral corticosteroids
✅ Correct Answer: C (Add LABA to ICS)
Why? Daily symptoms = Moderate Persistent Asthma (Step 3) → Add LABA.
Case 3: Severe Persistent Asthma
A 60-year-old man with asthma has symptoms throughout the day despite high-dose ICS/LABA. He has 2 hospital visits in 3 months.
What is the next best step?
A. Add LAMA (Tiotropium)
B. Start a biologic therapy (Omalizumab)
C. Start daily oral corticosteroids
D. Increase LABA dose
✅ Correct Answer: A (Add LAMA - Tiotropium)
Why? Severe asthma requires triple therapy: ICS + LABA + LAMA (Step 5).
If eosinophilic asthma → Add biologics (Omalizumab, Dupilumab).
Serum Electrolytes
Serum Electrolytes
Hyperkalemia → ACEi/ARBs can worsen.
Hypocalcemia → Common in CKD.
