EXAM #1: ASTHMA

Question 1

What is asthma?

Answer 1

Chronic inflammatory lung disease characterized by REVERSIBLE airway bronchoconstriction

Question 2

What are the hallmark clinical features of asthma?

Answer 2

1) Non-productive cough
2) Dyspnea (episodic typically)
3) Wheezing

*Typically triggered by an environmental trigger

Question 3

What is the current emphasis in the treatment of asthma?

Answer 3

Control of the underlying INFLAMMATION

Question 4

What patient population has the worst prognosis with asthma?

Answer 4

Young African Americans

Question 5

What are the two major risk factors associated with future fatal or near-fatal asthma?

Answer 5

1) History of recent uncontrolled asthma
2) History of prior near-fatal asthma (ICU or intubation)

*Thus, for every patient with asthma, you should be asking them, “Have you ever been hospitalized for your asthma?” and “Have you ever been intubated because of your asthma?”

Question 6

What classes of medications classically exacerbate asthma?

Answer 6

1) Beta-blockers
2) Aspirin/ NSAIDs*

*7% of asthmatics have ASA/NSAID exacerbated asthma

Question 7

What is the primary pathophysiologic mechanism of asthma?

Answer 7

Airway obstruction

Question 8

What are the three identifiable components of the inflammation seen in asthma?

Answer 8

1) Normal cells are upregulated to a proinflammatory state
2) Airway infiltration with eosinophils and lymphocytes
3) Anatomical remodeling of the airway wall

Question 9

What inflammatory mediators that are implicated in asthma?

Answer 9

1) Histamine
2) Leukotriene (C4, D4, and E4)
3) Kallekrein
4) Platelet activation factor

Question 10

What are the components of airway obstruction seen in asthma i.e. what obstructs the airway?

Answer 10

1) Inflammation
2) Smooth m. contraction and hypertrophy
3) Mucus gland hypersecretion/ plugging
4) Airway remodeling

Question 11

What is “cough variant asthma?”

Answer 11

Asthma where cough is the only complaint

Question 12

What are the typical physical exam signs associated with asthma?

Answer 12

1) Wheezing
2) Tachypnea/ tachycardia
3) Decreased breath sounds (ominous)
4) Accessory muscle use

Question 13

What diagnostic tests are indicated for a patient with a history and physical consistent with asthma?

Answer 13

1) Methacholine-challenge i.e. bronchoprovocation
2) Pre/post bronchodilator spirometry
3) Serial peak flow measurements

Question 14

What are the pitfalls of bronchoprovocation testing?

Answer 14

1) Recent viral infection leading to false positive

2) False negative if tested on asthma meds

Question 15

What are the criteria for the NHLBI classification of asthma severity?

Answer 15

1) Days with sx.
2) Nocturnal sx.
3) Peak flow rates
4) Peak flow rate variability

Question 16

What are the two major categories of asthma classification?

Answer 16

Intermittent vs. persistent

Question 17

What classification of asthma can be treated with rescue inhalers only?

Answer 17

Intermittent asthmatics i.e. patients with:

1) Sx. less than 2 days per week (daytime)
2) 2x episodes or less of nocturnal asthma per MONTH**
3) Use of rescue inhaler less than 2x per week

• Patients with MORE sx. than this require anti-inflammatory medications
• *“Does your asthma wake you up at night?”**

Question 18

What are the categories of persistent asthma?

Answer 18

1) Mild
2) Moderate
3) Severe

Question 19

List the medication classes that are used to treat asthma.

Answer 19

• Beta agonists
• Anticholinergics
• Theophylline
• Leukotriene modifiers
• Inhaled/ systemic corticosteroids
• Omalizumab*

*IgE antagonist (v. expensive and restricted for refractory asthma)

Question 20

Is there any difference in the efficacy of a MDI vs. nebulizer for administration of beta-agonists for acute asthma exacerbation?

Answer 20

No

Question 21

What type of medication should never be used as a monotherapy for asthma?

Answer 21

Long-acting beta agonist

*Black-box warning b/c of associated with cardiac death

Question 22

What are the three leukotriene inhibitors used in the treatment of asthma?

Answer 22

1) Zileuton
2) Zafirlukast
3) Montelukast

Question 23

If that patient has persistent asthma (post- step 1), what medication do they need?

Answer 23

Inhaled corticosteroid

Question 24

What drugs should be used in the setting of an acute asthma exacerbation?

Answer 24

Systemic steroids

*Note that IV does NOT have any benefit vs. PO

Question 25

If a patient has not responded to aggressive therapy for an hour in the ED, in the setting acute asthma exacerbation, what drug should you add?

Answer 25

Mg++