Practical Respiratory Clinical Therapeutics

Question 1

What is the preferred device for patients younger than 4 years old?

Answer 1

PMDI plus spacer with a face mask

Question 2

What is the preferred device for patients 4-6 years old?

Answer 2

PMDI plus spacer with a mouthpiece

Question 3

What is the preferred device for patients older than 6 years old?

Answer 3

DPI 
OR 
PMDI plus spacer with mouthpiece 
OR 
Autohaler

Question 4

By definition, what makes a week an uncontrolled week?

Answer 4

By definition, any exacerbation in any week makes that an uncontrolled week.
- any exacerbation should prompt a review of maintenance to ensure that it is adequate

Question 5

Characteristic: Daytime symptoms

What is considered controlled (green)?

Answer 5

<2/week

Question 6

Characteristic: Daytime symptoms

What is considered partly controlled (yellow)?

Answer 6

> 2/week

Question 7

Characteristic: Limitation on activity

What is considered controlled (green)?

Answer 7

None

Question 8

Characteristic: Limitation on activity

What is considered partly controlled (yellow)?

Answer 8

Any

Question 9

Characteristic: Nocturnal symptoms / awakenings

What is considered controlled (green)?

Answer 9

None

Question 10

Characteristic: Nocturnal symptoms / awakenings

What is considered partly controlled (yellow)?

Answer 10

Any

Question 11

Characteristic: Need for reliever / rescue treatment

What is considered controlled (green)?

Answer 11

<2/week

Question 12

Characteristic: Need for reliever / rescue treatment

What is considered partly controlled (yellow)?

Answer 12

> 2/week

Question 13

Characteristic: Lung function (PEF/FEV1)

What is considered controlled (green)?

Answer 13

Normal

Question 14

Characteristic: Lung function (PEF/FEV1)

What is considered partly controlled (yellow)?

Answer 14

<80% of predicted or personal best

Question 15

Characteristic: Exacerbations

What is considered controlled (green)?

Answer 15

None

Question 16

Characteristic: Exacerbations

What is considered partly controlled (yellow)?

Answer 16

1 or more per year

Question 17

What is considered uncontrolled (red)?

Answer 17

1. 3 or more features of partly controlled asthma in any 1 week
2. 1 exacerbation in any 1 week

Question 18

What are symptoms of acute severe asthma?

Answer 18

• anxiousness
• acute distress
• severe dyspnoea
• SOB
• chest tightness or burning
• the patient is only able to say a few words
• symptoms are unresponsive to usual measures

Question 19

What are signs of acute severe asthma?

Answer 19

• expiratory and inspiratory wheezing on auscultation
• dry hacking cough
• tachypnoea
• tachycardia
• pale or cyanotic skin, hyper-inflated chest
• PEF less than 40% of normal
• O2 sats by pule oximetry less than 90%

Question 20

What is the treatment for acute severe asthma?

Answer 20

1. O2 via face mask (40%)
   AND
2. Beta-2 agonist via nebulizer (must use an O2 driven nebulizer) - Salbutamol or Fenoterol
   OR
   IH beta-2 agonist (large-volume spacer)
   AND
3. Systemic corticosteroids are essential
   - oral prednisone or IV hydrocortisone or IV methylprednisolone
   - only give IV if not able to swallow

Question 21

When should additional therapy be given following standard therapy in acute severe asthma?

Answer 21

Additional therapy when symptoms do not improve & in severe and imminently life-threatening situations

Question 22

What additional therapy can be given following standard therapy in acute severe asthma?

Answer 22

• Ipratropium Bromide / beta-2 agonist
• Theophylline (aminophylline)
• IV beta-2 agonist

Question 23

What additional therapy can be given in acute severe asthma only if severe and life-threatening?

Answer 23

IV magnesium sulphate

Question 24

What additional therapy can be given in acute severe asthma only prior to respiratory arrest?

Answer 24

Intubation and ventilation

Question 25

What additional therapy can be given in acute severe asthma if moribund and ONLY if moribund?

Answer 25

Epinephrine

Question 26

For acute severe asthma, what should patients be discharged with once improved?

Answer 26

1. Short course of oral corticosteroids (prednisone for 7-14 days) 2. Improved asthma plan 3. Re-inforce inhaler technique 4. Letter to treating doctor / pulmonologist if present to ER

Question 27

How is exercise induced asthma treated?

Answer 27

SABA e.g. Salbutamol - 15 minutes prior to exercise (most preferred) OR LABA with ICS - Salmeterol + Fluticasone - 30 minutes prior to exercise OR Montelukast once daily at night

Question 28

How should geriatric asthma patients be treated?

Answer 28

Insensitive toward beta-2 agonists with age & adverse effects e.g. tachycardia and tremor are common = Use Ipratropium Bromide as first line "reliever" (remember it has an onset of action of 30 minutes)