Other Pulmonary Disorders

Question 1

asthma mgmt/monitoring

Answer 1

• methacholine challenge if unsure if asthma (dec > 20%)
• peak flow qd at home (will change prior to sx onset)
• assess tx via night awakenings, SABA use, ER/UC visits
• step up med if nighttime 2+ q month
• office spirometry preferred to peak flow if avail

Question 2

asthma pcp tx for adult exacerbation

Answer 2

• peak > 70% predicted: SABA x 3, d/c home
• peak 40-69%: SABA x 3 + PO steroid if no improvement
• peak < 40%: ER

Question 3

asthma pcp tx for peds exacerbation

Answer 3

• use pulmonary index score (RR, wheeze, insp:exp)
• mild: SABA neb x 3 w/ PO steroids s/p 1st dose if no improvement
• mod: O2 prn, SABA + ipratropium neb x 3 w/ PO steroids s/p 1st dose

Question 4

step of asthma tx

Answer 4

• SABA prn
• low-dose ICS + SABA prn
• med-dose ICS OR (low-dose ICS + LABA) + SABA prn
• med-dose ICS + LABA
• high-dose ICS + LABA AND (allergy tx)
• high-dose ICS + LABA + PO steroid AND (allergy tx)

Question 5

Cannot give LABA w/o ____ in asthma

Answer 5

ICS (increased mort)

Question 6

SABA’s

Answer 6

• albuterol, levalbuterol

- if more than 1 cannister q month OR 2+ x/wk : step up tx

Question 7

anticholinergics

Answer 7

• ipratropium (short), tiotropium (long)

- alt to SABA or adjunct for severe exacerbation

Question 8

systemic corticosteroids

Answer 8

• prednisone

- x 3-10 days for exacerbation

Question 9

inhaled corticosteroids

Answer 9

• budesonide, beclomethasone, fluticasone, mometasone

- use a spacer

Question 10

LABA’s

Answer 10

• salmeterol, fomoterol, indacaterol
• use for short duration (control sx)
• use combo inhlrs (need ICS)

Question 11

leukotriene modifiers

Answer 11

• montelukast, zafirlukast, zileuton

- good for exercise-induced asthma

Question 12

mast cell stabilizers

Answer 12

• cromolyn
• good for seasonal asthma, exercise-indused bronchospasm
• takes 2 wks for therapeutic response

Question 13

theophylline

Answer 13

• bronchodilator
• adjunct to ICS for mgmt of nighttime sx
• req serum monitoring

Question 14

omalizumab

Answer 14

• anti-inflammatory

- for sev allergic asthma in pts w/ freq exacerbations & already on high steroid

Question 15

asthma exacerbation tx options

Answer 15

• duoneb (albuterol + ipratropium) q 20 min x 3 (MDI/inhlr just as effective as neb)
• PO/IV steroids if poor resp
• supp O2 prn
• NO ICS!
• MgS for refractory cases
• mechanical vent if peak stays < 25%
• admit if not responding in 4-6 hrs of tx
• nonstandard tx: montelukast, helium, furosemide, ketamine, macrolides

Question 16

asthma classifications

Answer 16

• intermittent: < 2x/wk, < 2/mos nights, < 2 SABA d/wk
• mild p: inbetween
• mod p: daily sx, > 1x/wk nights, SABA daily
• sev p: sx throughout day, q night, SABA muliple x/day

Question 17

CF

Answer 17

• autosomal recessive, white
• mucus obstruction, inflam, inf, fibrosis
• affects pancreas & vas deferens

Question 18

CF s/s

Answer 18

• recurrent pulm inf w/ atypical bact (s aureus in infancy, psudomonas in adult)
• FTT
• meconium ileus
• pancreatitis
• infertility
• delayed puberty

Question 19

CF acute exacerbations

Answer 19

• bronchial rather than PNA
• increased sputum/cough/color change
• decreased exercise tolerance
• poor appetite

Question 20

CF wu

Answer 20

• newborn screens (only detect sev dx)
• DNA (buccal)
• sweat chloride is confirmatory

Question 21

CF mgmt

Answer 21

• dietary support (higher BMI assoc w/ better lung fxn)
• promote mucus clearance (chest PT, veste, CPAP, albut)
• inf control (cyclic abx use, x 2-3 wk s/p exacerbation)
• freq office appts w/ PFTs, sputum cx, DEXA, PT/PTT, LFT, albumin, vaccines

Question 22

CF prog

Answer 22

• median age of survival is 38
• lung fx declines ~ 2% q yr (accelerates q exacerbation)
• pts unable to return to prev baseline s/p q exacerbation)