Module 3: Respiratory Disorders Flashcards
1
Q
The asthma updates’ most highly pediatric-relevant recommendations involve three treatment options: (1) intermittent ICS dosing with -A- for quick-relief therapy, (2) -B- and reliever therapy, and (3) -C-
A
A. as-needed short-acting b2-agonist (SABA)
B. single maintenance (SMART)
C. add-on LAMA therapy
2
Q
In children 0 to 4 years with intermittent asthma, clinicians may now conditionally recommend a -1- course of -2- with as-needed SABA at the start of a -3- for children who have had -4- of similar wheezing or >1 episodes in the past year and who are -5-.
A
- short (7–10 days)
- daily ICS
- viral URI
- > 2 lifetime episodes
- asymptomatic between episodes
3
Q
In those >11 years with -1-, clinicians and families may jointly decide to use -2- -3- instead of daily ICS with as-needed SABA.
A
- mild persistent asthma
- intermittent as-needed concomitant
- ICS with SABA
4
Q
For patients >3 years with mild to moderate persistent asthma who are likely adherent with daily ICS alone, a short-term increase in the ICS dose (eg, doubling, tripling, or quadrupling the daily dose) -1-. It -2- for patients whose adherence is less certain.
A
- is not recommended
2. may be considered
5
Q
SMART is treatment with -1- and a specific LABA (-2-) for both -3- therapy
A
- ICS
- formoterol
- daily and rescue
6
Q
Formoterol is the LABA of choice for SMART because it has a -1- onset of action and can be used -2- daily.
A
- rapid
2. more than twice
7
Q
Individuals whose asthma is uncontrolled on daily ICS-LABA maintenance therapy should receive the preferred … before moving to a higher-step level of therapy
A
SMART
8
Q
-1- or -2- (in liquid or tablet form) reduces the -3- allergic response associated with asthma.
A
- Subcutaneous immunotherapy (SCIT)
- sublingual immunotherapy (SLIT)
- immunoglobulin E–mediated
9
Q
In children ages -1- with -2-, the Expert Panel recommends -3- to predict the future development of asthma.
A
- 0–4 years
- recurrent wheezing
- against FeNO measurement
10
Q
Asthma is characterized by variable and recurring symptoms of: -1-, -2-, and -3-
A
- Airflow obstruction
- Bronchial Hyperresponsiveness
- Underlying inflammation
11
Q
What is the most common trigger for an asthma exacerbation in a 4 year old child? A. Upper respiratory infection B. Exercise C. Cold air D. Cigarette smoke E. Allergic rhinitis
A
A
12
Q
Pathophysiology of asthma is a cycle of -1-, -2- in response to triggers, -3-, and -4-
A
- Airway remodeling
- Hyperresponsiveness and inflammation
- Obstruction
- Partial recovery (compared to full recovery in healthy lungs)
13
Q
Difficulty breathing/SOB, chronic cough, cough after exercise, chest pain, wheezing, and/or night cough
A
Symptoms of childhood asthma
14
Q
Early phase of asthmatic response is characterized by -1- and responsive to -2-. Begins in -3- in response to a trigger and abates in -4- to 2 hours. Common triggers include animal dander, pollen, mold, dust, -5-, exercise
A
- Inflammation and bronchoconstriction
- Albuterol
- 10-20 min
- 30 min
- cold air
15
Q
Late phase asthmatic response is characterised by -1-. Caused by an ongoing production of the -2-. Usually begins in -3- after initial attack, reaches a maximum in -4- and disappears within -5-
A
- obstruction of airflow
- mediators of inflammation and bronchoconstriction
- 4-12 hrs
- 6-12 hrs
- 12-24 hrs
16
Q
Late phase asthmatic response: May be more severe and occur -1-. -2- are not effective for this late phase, but -3- are.
A
- at night
- Bronchodilators
- anti-inflammatory medications, like steroids,
17
Q
A 3 year old child with multiple episodes of wheezing, which of the following is a major risk factor for the future development of asthma? • A. History of bronchiolitis • B. Atopic dermatitis • C. History of food allergy • D. 10% peripheral eosinophilia • E. Uncle with asthma
A
B
18
Q
Asthma Diagnosis (0-4): Major Criteria: -1- history of -2-; physician diagnosis of -3-; Minor Criteria: physician diagnosed -4-, wheezing unrelated to colds, -5- >3%
A
- parental
- asthma
- atopic dermatitis
- allergic rhinitis
- Eosinophils
19
Q
What is considered the “gold standard” for diagnosing asthma in children 6 years and up?
A
Spirometry (PFT)
20
Q
Major differential for asthma in the newborn/early infant
A
bronchopulmonary dysplasia
21
Q
Top 3 differentials for asthma
A
Tracheo-bronchomalacia, GER, CF
22
Q
Four Components of Care: 1. Assessment and Monitoring
Four major factors used for classification of Asthma
A
Age
Phenotypes
Severity
Control
23
Q
Four Components of Care: 1. Assessment and Monitoring
Guiding Asthma Principle I: Reduce -1-
• -2- chronic and troublesome symptoms
• Minimize the need to use -3- of asthma symptoms to ≤two days/week, maintain (near) normal pulmonary function
• Maintain normal -4- levels
• Prevent -5-
A
- impairment
- Prevent
- SABA for relief
- activity
- reduced lung growth
24
Q
Four Components of Care: 1. Assessment and Monitoring
Guiding Asthma Principle II: Reduce -1-
• Prevent recurrent -2-
• Provide optimal -3- or -4-
• Step-down therapy: -5- to maintain control
A
- Risk
- exacerbations
- pharmacotherapy with minimal
- no adverse effects
- minimum medication necessary
25
Four Components of Care: 1. Assessment and Monitoring
Guiding Asthma Principle III: Optimize -1-
• Provide initial and ongoing -2- and family
• Educate patient and family to recognize -3-
• -4- and family to identify treatment goals and achieve well-controlled asthma that allows patient to fully and safely participate in activities (eg,
physical education, recess, sports, etc)
• Maintain patient’s and family’s -5- care
1. Health and Function
2. education to patient
3. and avoid triggers
4. Partner with patient
5. satisfaction with asthma
26
Four Components of Care: 1. Assessment and Monitoring
Asthma severity is the -1- of the disease process and dictates which step -2-
Level of severity is determined by both -3-.
1. intrinsic intensity
2. to initiate treatment
3. impairment and risk
27
Four Components of Care: 1. Assessment and Monitoring
| The stepwise approach is meant to -1- the clinical decision making required to meet -2-
1. assist, not replace,
| 2. individual patient needs
28
Four Components of Care: 1. Assessment and Monitoring
For treatment purposes, patients who had -1- oral systemic corticosteroids in the -2-, or -3- in the past year, and who have risk factors for -4- may be considered the same as patients who have -4-, even in the absence of -5- with -4-
1. ≥2 exacerbations requiring
2. past 6 months
3. ≥4 wheezing episodes
4. persistent asthma
5. impairment levels consistent
29
Four Components of Care: 1. Assessment and Monitoring
PFT Classificaiton of Asthma - FEV1 & FEV1/FVC:
1. >80% predicted & > 85% (80/85)
2. > 80/80
3. 60/75 - 80/80
4. <60/75
1. Intermittent
2. Mild Persistent
3. Moderate Persistent
4. Severe Persistent
30
Four Components of Care: 1. Assessment and Monitoring
-1- is the degree to which manifestations of asthma are minimized and the goals of therapy are met (e.g., prevent symptoms/exacerbations, maintain normal lung
function and activity levels).
A guide to either -2- therapy
1. Asthma control
| 2. maintain or adjust
31
Four Components of Care: 1. Assessment and Monitoring
| Asthma control classified into 3 categories:
well controlled, not well controlled, and poorly controlled
32
Four Components of Care: 1. Assessment and Monitoring
| The classification of severity or level of control is based on the -1- or -2- in which any feature occurs.
1. most severe impairment
| 2. risk category
33
Component of Care 2: Control -1- Factors and Comorbid Conditions
a. Identify -2- factors
b. Recommend measures to control
exposures to -3- that make asthma worse.
c. Identify -4- that may adversely affect asthma
management
d. -5-
1. Environmental
2. precipitating and exacerbating (ie, asthma triggers, including those in the home, school, and child care settings)
3. allergens and pollutants/irritants
4. comorbid medical conditions
5. Treat comorbid conditions
34
Component of Care 3: Education
Integrate education into all -1- where health professionals interact with patients.
Provide -2-
Knowledge: -3- asthma; Role of medications; Skills
-4- to control asthma
-5- in response to signs of worsening asthma
1. points of care
2. self-management education.
3. Basic facts about
4. Take daily actions
5. Adjust medication
35
Component of Care 3: Education
Develop a written -1- in partnership with the patient.
Take medications correctly, use appropriate type of -2- with proper technique
Identify and avoid asthma triggers
-3- of asthma control
Recognize early -4- of worsening asthma & seek medical care as appropriate
Communicate asthma information to -5- center, and other caregivers
1. asthma action plan
2. inhaler and spacer
3. Self-monitor level
4. signs and symptoms
5. school, child care
36
Component of Care 4: Medications
a. Select -1- devices to meet patient’s need and circumstances.
b. Periodically inspect -2- to verify appropriate type
1. medication and delivery
| 2. medications and inhaler/spacer
37
When to consult:
0-4 years and -1- or higher is required
5 years or older and -2- or higher is required
Difficulty in -3- asthma control
1. Step 3 care (may consider consultation at Step 2)
2. Step 4 care (may consider consultation at Step 3)
3. achieving or maintaining
38
* What are Beta adrenergic agonists?
* Beta-adrenergic agonists or Beta-agonists -1- muscle and may -2- from -3- and basophils
* They are a class of -4- which act upon the -5-.
1. relax airway smooth (bronchodilation)
2. modulate mediator release (i.e. histamine)
3. mast cells
4. sympathomimetic agents
5. beta adrenoceptors
39
What is the difference between Beta-1 (β1) receptors, beta (β2) receptors and beta (β3) receptors?
• Beta-1 (β1) receptors are found in the -1- and kidneys while beta (β2) receptors are found in the -2-, liver, -3-, and skeletal muscle.
• The third type, beta (β3) receptors are found in -4-
1. heart, eye,
2. lungs, gastrointestinal tract
3. uterus, blood vessels
4. fat cells.
40
Short acting beta (β2) agonist (SABAs) recommended in -1- asthma to be administered -2- to -3- for -4- or -5-
1. mild to moderate
2. before exposure
3. known allergens
4. symptom relief
5. rescue therapy
41
Inhaled beta 2 agonists delivered -1- are preferable to -2-; inhaled therapy causes fewer -3- has -4- with similar -5-, and achieves results at lower doses
1. directly to airways
2. oral agents
3. systemic adverse effects (CV stimulation, anxiety, skeletal muscle tremor)
4. faster action onset
5. duration of action
42
Treatment for patient under 5 with:
1. intermittent asthma
2. mild persistent asthma
3. moderate persistent asthma
1. SABA PRN
2. Low-dose ICS > Cromolyn or Montelukast; consider referral
3. Medium-dose ICS; refer
43
Inhaled Corticosteroids (ICS) MOA: suppression of -1-
• Decreased synthesis and release of -2-
• Decreased infiltration and activity of -3-
• Decreased -4-
• Block -5- to allergen
• Diminishes airway reactivity to histamine, methacholine, and cold air
• May take 1-3 months to decrease -3-, decrease shedding of epithelial cells and reduce hyperplasia of epithelial goblet cells.
1. inflammation, reduce hyperresponsiveness
2. inflammatory mediators (prostaglandins, leukotrienes)
3. inflammatory cells (eosinophils, leukocytes)
4. airway mucosal edema
5. late phase reaction
44
ICS Therapy:
True or False: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis
True
45
* Pediatric Patients Aged 4 - 11 Years: Dosage for FLOVENT HFA
* Recommended dosage: -1- daily, approximately -2-
1. 88 mcg twice
| 2. 12 hours apart
46
The starting dosage for QVAR Redihaler is based on -1- and -2-, including consideration of the patients’ current -3- and risk of -4-. -5- are not used with QVAR, as it may interfere with delivery.
1. previous asthma therapy
2. disease severity
3. asthma symptom control
4. future exacerbation
5. Spacers
47
Oral Corticosteroids
• Gain initial control of acute asthma or -1-
• May cause -2- suppression, -2- function returns rapidly
• Suppression may be prolonged with -3- short courses of oral corticosteroids per year
1. severe persistent exacerbations
2. adrenal
3. > 4
48
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Cromolyn sodium. Drug class: -1-
• Not useful for -2-
• Prevent asthma attacks with -3-
• Also used to prevent -4-
• MOA: suppresses inflammation (is not a bronchodilator). Stabilizes -5- membranes and prevents release of histamine and other mediators.
```
1. mast cell inhibitor
2. acute attack
3. bronchial asthma
4. bronchospasm (wheezing, chest tightness, trouble breathing)
5. mast cell cytoplasmic
49
[Leukotriene Receptor Antagonist (LTRA), e.g. singulair]
Effective for:
• Preventing asthmatic responses to -1---important esp. in children with unpredictable schedule of -1-
• -2- exposure and -2- rhinitis
• Additive effect with inhaled -3- and may be able to use lower -3- dose
MOA:
• Blocks/Inhibits -4- mediators
• Can decrease -5- mucous secretion, and recruitment of eosinophils and other inflammatory cells
1. exercise/physical activity
2. Allergic
3. corticosteroid
4. leukotrienes: inflammation synthesis
5. inflammation, bronchoconstriction, edema,
50
Anticholinergics prevent the increases in intracellular
| concentration of -1- that are caused by -2- with the -3- on -4-
1. cyclic guanosine monophosphate (cyclic GMP)
2. interaction of acetylcholine
3. muscarinic receptor
4. bronchial smooth muscle
51
Cystic Fibrosis Diagnostic studies
• -1- screening
• -2- test
• Genetic -3- mutation
1. Newborn
2. Sweat
3. analysis for CFTR
52
Newborn screening for CF
• Many newborns will have a -1- for the disease, fewer than 10 percent will -2-
•Infants diagnosed with CF through newborn screening and -3- begin are healthier
1. positive newborn screen
2. actually have it
3. treated before symptoms
53
The newborn screen for CF is a two-tier process
• The first tier is the analysis of -1- using the Guthrie card.
-This report is then sent to the -2-
•If the IRT is -3-, the second tier is diagnostic for
CF with either -4- by the State Lab or -5- at a CF center
• Positive screening with either an -3- IRT or CF
-4- needs follow up at a CF center facilitated by the -2-
1. immunoreactive trypsinogen (IRT)
2. PCP
3. elevated
4. gene analysis
5. sweat chloride testing
54
PCP actions given:
1. Elevated IRT w/o mutation
2. Elevated IRT w/ 1 mutation
3. Elevated IRT w/ 2+ mutations
1. monitor for signs of CF: persistent diarrhea, poor weight gain, chronic cough or other respiratory problems - any of these are call for CF specialist referral
2. Sweat chlorine test at a CF center (under 30, negative; 30-59, refer for further assessment; >60 positive Dx)
3. Positive diagnosis, refer for CF care
55
-Cystic Fibrosis Clinical findings-
Pulmonary
• Chronic lung disease, -1-, dysfunctional mucociliary transport, obstruction, chronic infections
• Chronic -2-, respiratory failure
• Progressive disease – -3-
GI/nutrition
• -4- insufficiency, rectal prolapse
• Thick, fat-laden stools, failure to thrive
• -6-, GER, A, K, E, D deficiencies
• Distal intestinal obstructive syndrome (DIOS) -blockage or bowel obstruction, seen only in people with CF
1. inflammation, viscous mucus
2. cough, sputum production
3. respiratory failure, death
4. Meconium ileus, pancreatic
6. Volvulus, duodenal inflammation
56
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Cystic Fibrosis Clinical findings
Hepatobiliary tract
• -1-, ascites, hematemesis
Endocrine
• Recurrent -2-
Musculoskeletal
• Vitamin -3-
Reproductive
• -4-
• -5-
```
1. Biliary cirrhosis, jaundice
2. pancreatitis, diabetes mellitus
3. D deficiency – osteoporosis
4. Delayed sexual development
5. Male sterility
57
CF inheritance pattern
autosomal recessive
58
Cystic Fibrosis
The defective gene and its protein product cause the body to produce -1- mucus that:
• -2- and leads to life-threatening bronchiectasis
• Affects the pancreas and stops enzymes from -3-
• Impacts other organ systems affecting -4-
1. unusually thick, sticky
2. Obstructs the airway
3. facilitating food absorption
4. quality of life
59
CF Mgmt:
• PCP manages -1- and -2- care, including immunizations
• -3- managed at a CF-accredited center with multidisciplinary team
1. Anticipatory guidance
2. routine well-child
3. Complicated treatment regimens
60
Cystic Fibrosis Management
Pulmonary
• -1- – for airway clearance
• Ivacaftor – transmembrane conductance regulator
• High-dose -3- inflammation
• -4-
GI
• Replacement of -5-
• -6- replacement
• Management of cystic fibrosis liver disease
• Distal intestinal obstruction syndrome (DIOS) management – osmotic laxatives
Endocrine
• Diabetes mellitus – management/diagnosis
1. Inhaled dornase alfa
3. ibuprofen reducing chronic
4. Manage chronic pneumothoraces
5. pancreatic enzymes
6. Fat-soluble vitamin
61
1. PROTEINURIA,
2. HYPOALBUMINEMIA, HYPERLIPIDEMIA
3. +/- EDEMA
NEPHROTIC SYNDROME
1. UA results
2. CMP/Lipid Panel results
3. Phy'l Exam
62
* Excessive excretion of protein in urine from increased -1-
* Selective (albumin only) or non-selective (most serum proteins) proteinuria
* Massive proteinuria (3-4+) or protein-creatinine ratio greater than 2-3:1
* Edema formation from decreased -2-
* Liver -3- – hyperlipidemia and lipiduria
* Reduced -4- – increased reabsorption of water
.Nephrotic Syndrome
1. glomerular filtration permeability
2. plasma oncotic pressure
3. increases protein synthesis
4. volume stimulates ADH
