Pharm - Asthma

Question 1

Given a patient with asthma presenting symptoms, physical exam information, PEF or FEV1, and blood gases, classify severity as moderate.

Answer 1

• talking in phrases/sentences; alert/agitated; may or may not use accessory muscles
• PFR > 200 L/m or 50-75% best or predicted
• O2 > 92%
• HR < 120
• RR < 30

Question 2

Given a patient with asthma presenting symptoms, physical exam information, PEF or FEV1, and blood gases, classify severity as severe

Answer 2

• using words or unable to complete sentence; agitated; usu use accessory muscles
• PFR < 200 L/m or 33-50% best/predicted
• O2 < 92%
• HR > 120
• RR > 30

Question 3

Given a patient with asthma presenting symptoms, physical exam information, PEF or FEV1, and blood gases, classify severity as life threatening

Answer 3

• unable to talk; confused, drowsy or coma; usu use accessory muscles
• PFR < 200 L/m or < 33% best/predicted or unable to do it
• O2 < 90%; cyanosis; nl to high CO2, acidosis
• HR > 120 or bradycardia / silent chest
• RR > 30 unless resp. failure

Question 4

major risk factors for a fatal asthma attack

Answer 4

i. Recent history of poorly controlled asthma
ii. Prior history of near-fatal asthma
(~70% of patients report prior history of intubation or cardiopulmonary resuscitation)

Question 5

minor risk factors for a fatal asthma attack

Answer 5

i. Allergic asthma
ii. Food allergies
iii. Aspirin/NSAID-induced asthma
iv. Sports/exercise→MC in basketball and track
v. Illicit drugs→cocaine/heroin
vi. Smoking
vii. Respiratory viruses→picornavirus/adenovirus
viii. Menstruation
ix. Other: long duration asthma, non-adherence, comorbid illnesses, delay in getting care

Question 6

goals of treatment for an acute asthma exacerbation

Answer 6

a. Rapid reversal of airflow limitation: airflow limitation is most rapidly alleviated by combining repeated inhaled bronchodilators and early systemic glucocorticoids
b. Correct severe hypercapnia/hypoxemia

Question 7

what is the treatment of choice for an acute asthma exacerbation

Answer 7

SABAs are 1st line for acute asthma exacerbation

Question 8

nebulized albuterol dose

Answer 8

• 2.5 - 5 mg by jet nebulization q 20min. x 3 doses

- then 2.5-10 mg q 1-4hrs PRN

Question 9

MDI albuterol dose

Answer 9

4-8 puffs q 20 mins for 1st hour→used with spacer

Question 10

continuous nebulization abuterol dose

Answer 10

10-15mg over 1 hour

Question 11

place in therapy of ipratropium in an acute asthma exacerbation

Answer 11

In severe exacerbations:

• RR>30
• accessory muscles use
• HR>120
• O2<92%
• PFR<200 L/min

Question 12

dose of nebulized delivery of ipratropium for an acute asthma exacerbation

Answer 12

• 500mcg Q 20 mins x3 doses

- Then PRN

Question 13

dose of MDI delivery of ipratropium for an acute asthma exacerbation

Answer 13

-4-8 inhalations Q 20 mins PRN for up to 3 hours

Question 14

role in therapy of systemic glucocorticoids

Answer 14

Essential for exacerbations refractory to intensive bronchodilator therapy because persistent airflow obstruction is likely due to airway inflammation and intraluminal mucus plugging

Question 15

Identify the patients who are candidates for systemic glucocorticoids

Answer 15

a. Severe exacerbation with PEF ≤50% of baseline
b. Moderate exacerbation with PEF >50% but <70% of baseline
c. Exacerbation despite daily/alternate day oral glucocorticoid therapy→need additional glucocorticoids above baseline dose

Question 16

time to effect of systemic glucocorticoids

Answer 16

Onset of action usually not clinically apparent until about 6 hours after administration

Question 17

IV dose of methylprednisolone

Answer 17

a. 40-60mg q 12-24 hours if admitted but not in ICU

b. 60-80mg q 6-12 hours if admitted to ICU

Question 18

Identify the role of magnesium sulfate in the treatment of acute asthma

Answer 18

For patients who have life-threatening exacerbation or whose exacerbations remains severe (PEF <40%) after 1 hour of intensive conventional therapy

Question 19

dose of magnesium sulfate in treatment of acute asthma

Answer 19

2g infused over 20 minutes

Question 20

Identify the discharge medications a patient should have after treatment for an acute asthma attack

Answer 20

a. Oral glucocorticoids
b. Intramuscular glucocorticoids
c. Inhaled glucocorticoids

Question 21

State the asthma education areas that should be covered before discharge

Answer 21

Medications, PEF device, asthma action plan

Question 22

components of an asthma action plan

Answer 22

a. Agree on treatment goals
b. Teach patient how to use asthma action plan to take daily actions to control asthma, adjust medications in response to worsening asthma and seek medical care as needed
c. Encourage adherence to asthma action plan
i. Choose treatment that achieves outcomes and addresses preferences important to patient/family
ii. Review at each visit: any successes in achieving control, any concerns about treatment, any difficulties following the plan and any possible actions to improve adherence
iii. Provide encouragement/praise, which builds patient confidence. Encourage family involvement to provide support

Question 23

the recommended dosage regimen for oral systemic glucocorticoids

Answer 23

40-60mg daily in 1-2 doses x 5-10 days

Question 24

Given a patient with an asthma exacerbation select the most appropriate treatment on an outpatient basis

Answer 24

a. SABA should be self-administered when onset of exacerbation is recognized:
i. 2-8 puffs from MDI with spacer Q20 minutes for 1st hour
ii. Nebulized albuterol 2.5mg Q20 minutes for 1st hour if needed
iii. Then: if feels improvement, repeat peak flow measurement→subsequent SABA dose can be used if needed, or contact clinician

Question 25

Identify the risks associated with over the counter inhaled epinephrine products

Answer 25

a. Chest pain, N/V, HTN, tachycardia, hemoptysis, defective atomizer devices
b. Epi is NOT a β-2 adrenergic receptor selective so has greater risk of β-1 and αadrenergic type ADEs, especially when used in excessive doses