Pulm-Asthma

Question 1

Pathophys of allergic asthma

Answer 1

Mast cell degranulation and initiation of the inflammatory cascade with the Th-2 response, release of histamine and interleukins

Question 2

Pathophys of nonallergic asthma

Answer 2

Epithelial stimulation and initiation of inflammation can occur with viral or bacterial infections or exposure to noxious chemicals

Question 3

Symptoms of asthma

Answer 3

Episodes of coughing, chest tightness, SOB, and wheezing. Cough may be spastic and dry or productive of mucus.

Question 4

How is COPD on differential for asthma? How tell difference?

Answer 4

Airway obstruction is less reversible, typically seen in older patients with a smoking history

Question 5

How is vocal cord dysfunction on differential for asthma? How to tell the difference?

Answer 5

Abrupt onset and end of symptoms; monophonic wheeze; most common in younger patients; confirm with laryngoscopy or flow-volume loop

Question 6

How is allergic bronchopulmonary aspergillosis like asthma? How tell difference?

Answer 6

Recurrent infiltrates on chest radiograph; eosinophilia; positive skin testing to Aspergillus antigens, high IgE levels, positive to Aspergillus; frequent need for glucocorticoid treatments

Question 7

How is mechanical obstruction like asthma? How tell difference?

Answer 7

More localized wheezing; if central in location, flow volume loop may provide a clue

Question 8

How is Churg-Strauss like asthma? How tell difference

Answer 8

Churg strauss is eosinophilic granulomatosis with polyangiitis. It is an autoimmune small-vessel vasculitis that presents with a PERIPHERAL eosinophilia, lung symptoms similar to asthma; skin changes such as purpura and sensory or motor neuropathy, +ANCA, usually p-ANCA

Question 9

How is asthma diagnosed with testing? What is the first step?

Answer 9

The first step is spirometry to assess for obstruction as indicated by a REDUCED FEV1/FVC ratio and its reversibility (with a 12% or greater improvement in FEV1 after administration of a bronchodilator)

Question 10

What are the different types of asthma? How to treat each?

Answer 10

Allergic asthma: avoid trigger, step up/down, treat allergy

Cough-variant asthma-same as guideline based therapy for asthma

Exercise-induced bronchospasm-beta2 agonist 5-20 min before exercise

Occupational asthma-guidelines and avoid allergy triggers if able

ASA sensitive asthma-avoid ASA or NSAIDS with guidelines asthma management

Reactive airways dysfunction syndrome-guidelines, avoid irritan

Virus-induced bronchospasm-step-up, guidelines

Question 11

Treatment of ABPA

Answer 11

systemic glucocorticoids, inhaled glucocorticoids; may try anti fungal therapy such as fluconazole and anti-IgE therapy (omalizumab)

Question 12

What is the anti-IgE monoclonal Ab

Answer 12

omalizumab

Question 13

What are non-asthma mimics of asthma?

Answer 13

GERD, vocal cord dysfunction, post-nasal drip, OSA, vocal cord dysfunction, obesity

Question 14

Describe the symptoms of vocal cord dysfunction

**HY

Answer 14

(1) mid chest tightness when exposed to triggers
(2) difficulty with breathing in
(3) partial response to asthma medications

*Often misdiagnosed as severe asthma and ppl get intubated

Question 15

Gold standard for the diagnosis of vocal cord dysfunction?

Answer 15

Adduction of vocal cords on laryngoscope

Question 16

What does the flow-volume loop of vocal cord dysfunction look like when symptomatic?

Answer 16

Look up. There is a flat inspiration curve.

Question 17

What are some SABAs?

Answer 17

albuterol, salbutamol

Question 18

What are some anticholinergics?

Answer 18

ipratropium –less effective than beta-agonists, short acting agent can be used as adjunctive quick-relief

Question 19

When is asthma considered persistent?

Answer 19

When symptoms happen more than twice per week or more than one night per week

Question 20

What is the mainstay treatment for persistent asthma?

Answer 20

Inhaled glucocorticoids

Question 21

When is a LABA used in persistent asthma?

Answer 21

If inhaled glucorticoids aren’t working, then add a LABA as this has been proven to be effective for step-up therapy

Question 22

Name some LABAs

Answer 22

Salmeterol, formoterol

Question 23

What if inhaled glucocorticoids and LABA not enough?

Answer 23

Add leukotriene receptor antagonists: LTRAs like tiotropium

Question 24

What do you do following inhaled glucocorticoid, LABA, LRTA?

Answer 24

oral glucocorticoids

Question 25

Why not use theophylline any more?

Answer 25

Toxicity!

Question 26

What happens if patients are refractory to short courses of oral glucocorticoids and are on inhaled glucocorticoid, LABA, LRTA?

Answer 26

Chronic oral steroids, then Omalizumab

Question 27

What is the monoclonal antibody used for severe refractory asthma?

Answer 27

Omalizumab

Question 28

What can be used for the treatment of refractory ABPA?

Answer 28

Omalizumab!

Question 29

What has omalizumab been shown to do?

***HY

Answer 29

Reduce ED visits and is cost effective in:
(1) symptoms inadequately controlled with inhaled glucocorticoids; (2) allergies to perennial aeroallergens; (2) serum IgE levels high

Question 30

Intermittent asthma:

• symptoms
• nighttime awakenings
• SABA use
• interference with normal activity
• lung function

Answer 30

-symptoms: < or equal to 2 days/week
-nighttime awakenings: <2x per month
-SABA use: <2 days per week
-interference with normal activity: None
-lung function: Normal FEV 1 between exacerbations, FEV1 > 80% predicted
FEV1/FVC normal

Question 31

Mild asthma:

• symptoms
• nighttime awakenings
• SABA use
• interference with normal activity
• lung function

Answer 31

• symptoms: >2 days per week
• nighttime awakenings: <2x per month
• SABA use: <2 days per week
• interference with normal activity: minor limitation
• lung function: FEV1 >80% of predicted, FEV2/FVC normal

Question 32

Moderate asthma:

• symptoms
• nighttime awakenings
• SABA use
• interference with normal activity
• lung function

Answer 32

• symptoms: Daily
• nighttime awakenings: >1x per week but not nightly
• SABA use: daily
• interference with normal activity: some limitation
• lung function: FEV1 > 60% but <80% of predicted, FEV1/FVC reduced <5%

Question 33

Severe asthma:

• symptoms
• nighttime awakenings
• SABA use
• interference with normal activity
• lung function

Answer 33

• symptoms: throughout the day
• nighttime awakenings: often 7x per week
• SABA use: several times a day
• interference with normal activity: extremely limited
• lung function: FEV1<60% of predicted, FEV1/FVC reduced >5%

Question 34

Step Treatment for Intermittent Asthma

Answer 34

Step 1: SABA PRN

Question 35

Step Treatment for Mild Asthma

Answer 35

Step 2: Low dose inhaled GC

Question 36

Step Treatment for Moderate Asthma

Answer 36

Step 3: Low dose inhaled GC + LABA; OR medium-dose inhaled GC…. may need a short course of systemic GC

Question 37

Step Treatment for Severe Asthma

Answer 37

Step 4 or 5: Medium dose inhaled GC+LABA; OR high -dose inhaled GC + LABA; consider short courses of GCs

Question 38

When can you step down on therapy?

Answer 38

asthma is well controlled at least 3 months

Question 39

What increases the risk for a poor outcome in asthma exacerbation?

Answer 39

frequency of ED visits, need for intubation in the past, high work of breathing

Question 40

How do you treat pregnant women with asthma?

Answer 40

inhaled glucocorticoids! Budesonide is also okay .Most LTRAs are also ok.