Chapter 15 Flashcards
A 23-year-old patient with mild intermittent asthma comes into clinic for asthma follow-up.
Which of the following would be concerning about the patient’s use of inhalers?
A. She uses budesonide/formoterol daily 15 minutes before exercising
B. She uses budesonide–formoterol as needed for shortness of breath
C. She uses a spacer with her MDI inhaler
D. She uses salmeterol twice daily as her maintenance inhaler
Option D: Correct. It would be concerning if the patient was using salmeterol as a
maintenance medication in the absence of daily ICS therapy. LABAs contain a boxed
warning for causing increase in asthma-related death when used as monotherapy without an
ICS.
A 68-year-old patient is having difficulty coordinating his breath with actuation of his MDI
inhaler. Which of the following will maximize delivery of the medication while minimizing
local adverse effects?
A. Using a spacer with a face mask
B. Switching to an inhalation solution for nebulization and using a face mask
C. Using a spacer with a mouthpiece
D. Rinsing and expectorating after use
Option C: Correct. Use of a spacer prevents the patient from having to coordinate breathing
with actuation of the inhaler. This improves the amount of medication able to reach the lungs
and also decreases local adverse effects because less medication deposits in the mouth/throat.
Which one of the following medications treats both asthma and allergic rhinitis?
A. Tiotropium
B. Montelukast
C. Albuterol
D. Salmeterol
Option B: Correct. Montelukast is indicated for both asthma and allergic rhinitis and is often
prescribed for asthma patients presenting with both diseases.
Which of the following is a common side effect of inhaled corticosteroids?
A. Dyspnea
B. Tremor
C. Oral candidiasis
D. Urinary retention
Option C: Correct. Oral candidiasis occurs when patients do not rinse and spit after use. The
corticosteroid changes the normal oral flora if the medication settles on the inside of the
mouth. Ciclesonide is an ICS that does not cause this side effect. Using a spacer for ICS in
the MDI formulation also helps.
A 10-year-old girl presents with an asthma exacerbation. She weighs 70 pounds and is able to swallow tablets well. Which of the following is the correct prednisone dose for this patient?
A. 10 mg orally daily
B. 10 mg orally twice daily
C. 70 mg orally once daily
D. 20 mg orally twice daily
Option D: Correct. Converting 70 lbs into kilograms by dividing 70 by 2.2 is 31.8 kg. The
dose is 1 to 2 mg/kg/day, so multiplying 31.8 kg × 2 gives a total daily dose range of 31.8 mg
to 63.6 mg/day. Option D is the only option that is within the recommended dose range.
An 87-year-old man has a history of asthma, COPD, heart failure, and osteoarthritis in his
hands and knees. His FEV 1 is 35% predicted (severe obstruction) and he has low inspiratory
flow. The patient requires an inhaler to help manage his shortness of breath. He has a
caregiver who can assist him with medication administration. In the past, the patient has
demonstrated very poor technique with an albuterol MDI inhaler because he was unable to
coordinate his breath with the actuation of the device. Which of the following inhaler devices
would be best for this patient?
A. A metered-dose inhaler with spacer
B. A slow-mist inhaler
C. A breath-activated inhaler
D. A dry-powder inhaler
Option A: Correct. MDIs can be difficult to use for patients with arthritis or other conditions
that affect their dexterity. Patients also have a difficult time coordinating inhalation with
actuation of the device. Since this patient has a caregiver who helps him with medication
administration, the caregiver can actuate the inhaler device into the spacer for the patient and
then he can breathe from the device when he is ready. If the patient is unable to hold his
breath after breathing from the spacer, a face mask may be considered.
A 4-year-old patient with asthma has parents who both smoke cigarettes. Which of the
following parental actions is appropriate to help improve the child’s asthma?
A. Smoking outside the home and car
B. Using an air purifier
C. Quitting smoking together by getting counseling and using medication
D. Switching to electronic cigarettes or cigars
Option C: Correct. Using medication and counseling doubles the tobacco abstinence rates at 1 year. If both parents quit together, it will help each of them be successful working as a team to help their child.
Which of the following patients is exhibiting poor asthma control?
A. A 23-year-old patient who uses her albuterol MDI 3 to 4 days per week prior to
exercise class
B. A 38-year-old patient who refills his albuterol MDI twice per month
C. An 8-year-old patient who used his albuterol MDI twice this month after visiting his
grandmother who smokes
D. A 62-year-old patient whose peak expiratory flow has consistently been 85% of her
personal best this week
Option B: Correct. An albuterol MDI contains 200 puffs of medication. If the patient needs
to refill his inhaler twice in 1 month, this means he is averaging at least 13 puffs/day.
Which patient should be considered for initiation of tiotropium therapy?
A. A 15-year-old who is on low-dose mometasone–formoterol as needed before playing volleyball daily.
B. A 5-year-old who is on medium-dose budesonide–formoterol and continues to
experience asthma symptoms every day
C. A 24-year-old who is on medium-dose budesonide–formoterol and had an asthma
exacerbation in the past month.
D. A 20-year-old who is on fluticasone–umeclidinium–vilanterol and is experiencing
frequent nighttime awakenings due to asthma symptoms
Option C: Correct. The patient is prescribed medium-dose ICS–formoterol and had an
asthma exacerbation. The next recommended step is the addition of tiotropium if adherence
and technique are adequate. Addition of tiotropium decreases exacerbations and improves
lung function..
According to current guidelines, which would be the preferred treatment for a 15-year-old
patient who experiences asthma symptoms once or twice per month when playing in her
grandmother’s basement?
A. Albuterol 2 puffs every 4–6 hours as needed
B. High-dose budesonide–formoterol 2 actuations as needed
C. Medium-dose budesonide daily plus albuterol as needed
D. Albuterol 2 puffs every 4–6 hour as needed plus low-dose fluticasone propionate
Option D: Correct. If the patient is unable to take or use ICS-formoterol as needed,
continuing albuterol prn along with administering low dose fluticasone with each albuterol use, decreases inflammation and exacerbations.
A 51-year-old woman with severe persistent asthma has been taking fluticasone–vilanterol
200/5 mcg, 1 inhalation daily; montelukast 10 mg orally daily; tiotropium 1.25 mcg, 2
inhalations daily; and prednisone 10 mg orally daily for the past 30 days. She has had
multiple exacerbations, especially when prednisone is tapered off. Which laboratory test may help determine if mepolizumab is a good treatment option to help this patient discontinue prednisone?
A. CBC with differential
B. IgE
C. RAST
D. Pulmonary function tests
Option A: Correct. Mepolizumab is an IL-5 antagonist useful in patients with eosinophilic
asthma. Checking a CBC with differential will assess if the absolute eosinophil count is
elevated.
According to current guidelines, which would be the preferred reliever regimen for a 5-year-
old patient with asthma symptoms occurring once a month or less?
A. Albuterol 1 to 2 puffs every 4 to 6 hours as needed
B. Low-dose budesonide–formoterol 1 puff as needed
C. Low-dose budesonide daily plus albuterol as needed
D. Montelukast 10 mg orally at bedtime
Option A: Correct. Since this is a 5-year-old patient with symptoms once a month or less, the
patient’s asthma is well controlled, and no controller therapy is necessary. Albuterol 1 to 2
puffs every 4 to 6 hours with a spacer and mouthpiece would be appropriate to use for a
reliever.
Which of the following would be an appropriate instruction to include in an asthma action
plan for an adult patient?
A. If experiencing asthma symptoms, use albuterol and ciclesonide 2 puffs each, every
20 minutes up to 1 hour if needed.
B. If having a difficult time speaking due to shortness of breath, call the nurse at the
doctor’s office for prednisone
C. If asthma symptoms persist despite more frequent use of albuterol and ciclesonide,
add prednisone 60 mg/day for 30 days
D. If asthma symptoms persist after initial use of albuterol and ciclesonide, continue
albuterol and add guaifenesin
Option A: Correct. Using albuterol along with an ICS 2 puffs every 20 minutes up to 1 hour
would be appropriate instructions to put on an asthma action plan for when the patient begins
experiencing asthma symptoms or has a drop in peak expiratory flow.
A 71-year-old woman with asthma is confused about all of her medications. Which of the
following issues needs to be addressed with the patient today?
A. Mometasone–formoterol 100/5 mcg, 2 inhalations twice daily (120 actuations). The
inhaler counter reads “10” and inhaler was last filled 4 months ago.
B. Albuterol 90 mcg, 2 inhalations every 6 hours as needed for shortness of breath. The
counter reads “170.” The inhaler was last filled 1 month ago.
C. Tiotropium Respimat 1.25 mcg, 2 inhalations daily. Dose counter “0.” Last filled 30
days ago.
D. Prednisone 20-mg tablets 40 mg orally for 3 days. Last filled one year ago. Four
tablets remaining.
Option A: Correct. Mometasone–formoterol is a controller medication containing both ICS
and LABA. If the patient were using it twice daily every day, her inhaler would be empty in
1 month. Adherence to ICS–LABA decreases the need for albuterol, decreases exacerbations,
and prevents hospitalizations. Counseling about the mechanism of action and perhaps
changing inhalers may help adherence.
Which of the following statements uses motivational interviewing to increase adherence to ICS?
A. It is important to take this medication every day as directed to prevent asthma
symptoms.
B. Inflammation is the key factor making the airways tight. This medication will keep
the inflammation away.
C. How did the doctor tell you to take this medication?
D. What is it that you dislike about this medication? What medications have helped your
asthma in the past?
Option D: Correct. Asking the patient what they dislike about their current regimen will help
identify misconceptions or alternative regimens that the patient may be willing to use.
