Respiratory & Sleep Medicine\ Asthma

Question 1

What is the most common chronic lung disease in childre?

Answer 1

asthma

Question 2

what is asthma?

Answer 2

• chronic lung disease in which smooth muscle contraction, airway wall thickening (due to edema, vasodilation, inflammatory cell infiltrates and intraluminal debris, and mucous cause episodes of airway obstruction.

Question 3

Does asthma worsen over time?

Answer 3

• Asthma is not usually a progressive disease.
• However, patients may experience periods of exacerbations and remissions.

Question 4

In some patients with astma, what lung structure changes occur over time and progressively reduce airway obstruction and reversibility?

Answer 4

• thickening of sub-basement membrane
• subepithelial fibrosis
• airway smooth muscle hypertrophy
• angiogenesis
• Mucus gland hyperplasia.

Question 5

Clinical studies should include spirometry at the time of diagnosis (and subsequently for monitoring purposes) in all patients starting at what age?

Answer 5

• Most children are developmentally ready at five years.

Question 6

In most asthma patients how is airway obstruction evident when measuring FEV1 before bronchodilator therapy?

Answer 6

• Asthmama is a disease of airway obstruction and therefore FEV1 is usually reduced in the absence of a bronchodilator.

Question 7

In most asthma patients, how is airway obstruction reversibility evident when measuring FEV1 post bronchodilator therapy?

Answer 7

• Post bronchodilator FEV1 improvement indicates reversibility
• reversibility is more common in asthma than COPD
• reversibility is defined by FEV1 post bronchodilator improvement of 12% and 200 mL.
• larger changes become less likely to be COPD, more likely to be asthma.

Question 8

Occassionally patients with severe untreated asthma may not show obstruction reversibility with bronchodilator. What strategy is used in this scenario?

Answer 8

The patient may require 2-3 weeks of oral glucocorticoid therapy prior to the test, to demonstrate reversibility.

Question 9

If a patient with suspected asthma, has normal or near normal spirometry measurement, a Bronchial provocation can help establish the diagnosis. Describe the test.

Answer 9

• It is an inhalation challenge test used in the PFT laboratory.
• The patient is exposed to stages of progressively increasing concentration of methacholine. Although challenge can also be done with histamine,cold air or exercise.
• the patient performs spirometry at each stage.

Question 10

What constitutes a positive versus negative bronchial provocation?

Answer 10

• A 20% FEV1 reduction in response to the provocation is a positive test for airway hyper-responsiveness
• the test is negative, if FEV1 drops less than 20%, through the entire test.

Question 11

Positive bronchial provocation test establishes the diagnosis of asthma. True or False?

Answer 11

• False
  
  • it strongly suggested diagnosis of asthma, but they are other diseases that produce a positive result.
  • However, a negative test reliably excludes the diagnosis of asthma.

Question 12

During a diagnostic workup what value do a chest X ray and ECG provide?

Answer 12

• patients usually have a normal chest X ray and ECG.
• This test should not be done routinely but are useful in excluding pulmonary and cardiac conditions suspected of mimicking or compounding asthma symptoms.

Question 13

What is the Samter triad?

Answer 13

• asthma
• nasal polyps
• aspirin sensitivity.

Question 14

What is the atopic triad (chronic conditions associated with asthma)?

Answer 14

• asthma
• atopic dermatitis (eczema)
• Allergic rhinitis.

Question 15

What are some examples of common asthma triggers?

Answer 15

• Exercise
• upper respiratory infection
• allergens
• irritants
• cold or dry weather
• gastro esophageal reflux disease
• physical or emotional stress.

Question 16

When is allergy testing beneficial?

Answer 16

Manyasthma patients have a notable allergies and knowledge obtained from allergy testing may aid in avoiding this asthma triggers.

Question 17

What are the three main symptoms of asthma?

Answer 17

• end expiratory wheezing
• dyspnea/chest tightness
• cough.

Question 18

Besides asthma, what are other causes of wheezing in children?

Answer 18

• anything that restrics the airways:
  
  • infection e.g bronchiolitis, pneumonia
  • foreign body aspiration
  • congenital heart disease
  • tracheomalacia
  • CF

Question 19

In some patients, coughing may be the only symptom of asthma. True or False?

Answer 19

True.
This occurs more often in children than adults. Coughing usually occurs at night or is associated with exercise. A positive response to asthma medication confirms the diagnosis.

Question 20

Based on symptom frequency, what are the four classification of asthma?

Answer 20

• Mild intermittent < 2 symptoms per week.
• Mild to persistent > 2 symptoms per week
• moderate - persistent daily symptoms
• severe persistent - continuous symptoms.

Question 21

Regardless of classification, an adequate prophylactic medication regimen should reduce the frequency of breakthrough asthma symptoms to how many times per week?

Answer 21

< 2

Question 22

(asthma)What is the preferred class of medication for treatment of breakthrough symptoms that occur despite prophylactic measures?

Answer 22

• Inhaled short acting beta 2 agonist (SABA) known as “rescue inhalers” such asalbuterol.

Question 23

What is more efficacious is SABA administered by inhaler or nebulizer?

Answer 23

• if used correctly they are equally efficacious
• people using inhalers may find spacers helpful.
• Young children usually need a nebulizer for proper delivery of medication.

Question 24

Inhaled corticosteroids are the mainstay of pharmacologic Asthma therapy and should be prescribed as first line prophylaxis for most patients experiencing symptoms more than twice weekly.

True or False?

Answer 24

True. Inflammation is a central feature of asthma.

Question 25

What are the alternatives to first line mdedication medications, that is inhaled glucocorticoids in asthma?

Answer 25

The alternatives

• cromolyn
• leukotriene receptor antagonist
• nedocromil or
• theophylline.

Question 26

Theophylline is rarely used because of ___

Answer 26

• has a narrow therapeutic index
• toxicty

Question 27

Which asthma drugs are mast cell stabilisers - inhibit histamine release?

Answer 27

• Cromolyn
• nedocromil

Question 28

Montelukast and zafirlukast belong to what class of drugs?

Answer 28

• Leukotriene receptor antagonists

Question 29

When a low dose inhaled steroid or alternative first line medication fails to manage asthma symptoms adequately what are the options for treatment management?

Answer 29

• increased dose of inhaled steroid
• use inhaled steroid plus one or the following:
  
  • inhaled a long acting beta two agonist (LABA)
  • Leukocyte receptor antagonist
  • theophylline
  • zileuton
• add an oral steroid
• In severe cases referred to pulmonologist or immunologist as needed.

Question 30

Risks of LABA as a single agent therapy in asthma

Answer 30

• LABAs taken alone can decrease the frequency of asthma attacks, but increase the severity of those attacks when they do okay.
• They may also disguise uncontrolled asthma
• lLABA should be taken in conjunction with steroids, and only when the steroid is not adequately controlling symptoms.
• Some inhalers combine a LABA and a steroid for easy administration.

Question 31

What is zileuton, and what precautions should be taken with its use?

Answer 31

• It is an oral medication that inhibits leukotriene formation.
• There are limited studies on this medication compared to alternative therapies
• it may cause liver toxicity and first requires closed loop monitoring.

Question 32

What is the treatment for exercise induced asthma?

Answer 32

• The treatment of choice is a SABA 15 to 30 minutes prior to exercise
• cromolyn is an alternative
• LABA are helpful in some situations, eg a schoolchild can take it in the morning and effects last through an afternoon sports activity, but safe only if the patient is also an asteroid.

Question 33

What device can patients use to quantitatively self assess their lung function in an acute exacerbation or to gauge prophylactic medication effectiveness?

Answer 33

• peak expiratory flow rate monitor

Question 34

What is an asthma action plan?

Answer 34

• a written plan established by the patient and doctor,

It describes a patient’s asthma triggers

• normal and abnormal peak flow ranges
• asthma symptoms, mild to moderate or severe.
• Medication protocols and emergency instructions.

Question 35

What is status asthmaticus?

Answer 35

A life-threatening asthma attack that is unresponsive to standard inhaled medication - bronchodilators and steroid, and requires emergency care.

Question 36

Can anybody with asthma have a severe asthma attack?

Answer 36

Yes.

Although patients with undertreated disease or severe underlying disease are generally more likely to have severe attacks, even patients with mild asthma have the potential for a life threatening event.

Question 37

What physical signs may indicate a severe asthma exacerbation?

Answer 37

• peak flow rate less than 50% of predicted normal
• severe wheezing or
• cessation of audible wheezing (airflow is so diminished that wheezing can no longer be appreciated).
• Tachyapnea
• severe retraction, nasal flaring
• breathlessness not relieved by rescue inhaler.
• Tachycardia
• cyanosis
• diaphoresis.

Question 38

What is the treatment of severe asthma exacerbation?

Answer 38

• Frequent or continuous inhaled beta-2 agonist
• oral or intravenous corticosteroids
• subcutaneous or intramuscular adrenaline
• +/- Oxygen supplementation, or mechanical ventilation.

Question 39

Why is an elevated PaCO2 of particular concern during a severe asthma attack?

Answer 39

• patients typically hyperventilate during an attack and thus have a low PaCO2 may indicate patient fatigue and impending respiratory failure