Pulmonology - Asthma

Question 1

What is asthma?

Answer 1

• A chronic recurring inflammatory disease of the airways.
• These symptoms are usually associated with widespread but variable airflow limitation that is at least partially reversible either spontaneously or with treatment.
• This inflammation also causes an associated increase in airway hyperresponsiveness to a variety of stimuli.

Question 2

What is the pathophysiology of asthma?

Answer 2

Inflammation and edema of the airways, smooth muscle constriction and hypertrophy, mucus secretion, and airway hyperreactivity

Question 3

What is the prevalence of asthma?

Answer 3

5%–6% of the general population

Question 4

What are the risk factors for asthma?

Answer 4

Genetic predisposition, history of atopy, and environmental or occupational exposure

Question 5

What are the symptoms of asthma?

Answer 5

Wheezing, shortness of breath, cough, and chest tightness

Question 6

What are the signs of asthma?

Answer 6

• Wheezing (from narrowed airways), rhonchi (from mucus in the airways), decreased breath sounds (from hyperinflation), and cough.
• Crackles are not characteristic and indicate the presence of another process.

Question 7

What else can cause wheezing?

Answer 7

• Any process that decreases the radius of the airways can cause wheezing.
• Other etiologies include upper airway obstruction (e.g., laryngospasm, tracheal stenosis and webbing, foreign body aspiration, vocal cord dysfunction, tracheal malacia), heart failure, COPD, bronchiectasis (e.g., CF), bronchiolitis, pulmonary embolism, pulmonary infiltrates with eosinophilia, aspiration, and carcinoid syndrome.

Question 8

What is the definition of a chronic cough?

Answer 8

Cough lasting >3 weeks

Question 9

What are the most common causes of chronic cough?

Answer 9

Asthma, upper airway cough syndrome (formerly postnasal drip syndrome), gastroesophageal reflux, smoking, ACE-Is, postviral syndrome, pertussis and smoking

Question 10

How is asthma diagnosed?

Answer 10

Demonstration of reversible airflow obstruction by spirometry

Question 11

What if the spirometry is negative?

Answer 11

• Other options include a bronchoprovocation test with methacholine, histamine, or exercise, or monitoring PEF over several weeks looking for variability ≥ 20%.
• Significant improvement in spirometry after asthma therapy can also establish the diagnosis.

Question 12

Is allergy testing useful in treating asthma?

Answer 12

• Asthma is an allergic disease in the majority of young adults, and allergen avoidance is the treatment with the fewest adverse effects.
• Testing should be considered in any patient who requires chronic controller therapy.

Question 13

What is the Asthma Control Test (ACT)?

Answer 13

• A way to clinically determine the patient’s level of control on his or her current medical regimen.
• The test is made up of 5 questions regarding symptoms over the past 4 weeks, scaled 1–5. Scores >21 indicate good asthma control.

Question 14

How is asthma characterized for treatment purposes?

Answer 14

Asthma is divided into:

• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

Question 15

What are the symptoms and PFT criteria for…….

Answer 15

page 603

Question 16

What is the treatment for mild intermittent asthma?

Answer 16

A short-acting β-adrenergic agonist bronchodilator on an as-needed basis is necessary.

Question 17

What is the treatment for mild and moderate persistent asthma?

Answer 17

Inhaled anti-inflammatory agents (e.g., steroids, cromolyn, or nedocromil),

• long-acting β2-adrenergic agonists (salmeterol [Serevent], formoterol [Foradil])
• leukotriene-modifying agents (montelukast [Singulair]
• zafirlukast [Accolate]
• zileuton [Zyflo]), and theophylline (third-line, serum peak levels 5–15 µg/mL)
• β-Adrenergic agonists are also used as needed.

Question 18

What is the treatment for severe asthma?

Answer 18

The same as for mild and moderate persistent asthma in addition to oral steroids at the lowest dose tolerated

Question 19

Is allergen immunotherapy useful?

Answer 19

In select patients with mild to moderate asthma; the risk of death is too high in patients with more severe disease.

Question 20

What is the role of aspirin as an allergen in asthma?

Answer 20

• In select patients with asthma, aspirin and NSAIDs can precipitate bronchoconstricion and cause severe and even fatal exacerbations.
• All patients with asthma should be questioned regarding the precipitation of asthma symptoms by these agents.

Question 21

What physical finding increases the likelihood of an aspirin allergy?

Answer 21

Nasal polyps

Question 22

What are the symptoms and signs of a severe asthma exacerbation?

Answer 22

Breathlessness at rest, sitting upright, talking in words (not sentences), agitation, drowsiness or confusion, pulse >120 bpm, pulsus paradoxus >25 mm Hg, respiratory rate >30 breaths/min, use of accessory muscles, and silent chest (no wheezing)

Question 23

What is an ominous sign of a severe exacerbation?

Answer 23

Normal CO2 despite tachypnea

Question 24

What is the treatment in the emergency room for severe asthma?

Answer 24

Nebulized bronchodilators every 20 minutes (albuterol and ipratropium bromide), IV or oral steroids (35–125 mg of methylprednisolone every 6 hours), and oxygen

Question 25

Which patients are at high risk for asthma-related death?

Answer 25

Patients who have a history of intubation, ICU admission, hypercarbia, or pneumothorax; recent use of or dependence on oral corticosteroids; history of prior sudden, precipitous attacks; history of 2 or more hospitalizations or 3 or more emergency room visits in the last year; recent attack of prolonged duration; history of serious psychiatric disorders; poor adherence or lack of knowledge

Question 26

What should a peak flow meter be used for?

Answer 26

To provide an objective measure of a patient’s condition at home (patient may have a decrement in airflow and be unaware of the change) and objective information about the response to the therapy in the emergency room

Question 27

What are the potential treatments for exercise-induced asthma?

Answer 27

• The first step is adequate asthma treatment.
• If exercise-induced asthma persists despite this treatment, long- and short-acting inhaled β-adrenergic agonists used 5–60 minutes before exercise, leukotriene-modifying agents, cromolyn, and nedocromil can be useful.

Question 28

What subgroups of the population are at high risk for asthma death?

Answer 28

Inner-city minorities and men

Question 29

What is the most important drug regimen to be given to patients who are discharged from the emergency room after an asthmatic episode?

Answer 29

Inhaled and oral corticosteroids with close follow-up

Question 30

Is Primatene mist useful?

Answer 30

No. It is essentially inhaled epinephrine and therefore associated with greater side effects than selective β2-adrenergic agonists such as albuterol.

Question 31

What are the 3 major types of occupational or work-related asthma?

Answer 31

Work-aggravated asthma, irritant-induced asthma, and immunologically mediated asthma