STUDY Flashcards
An 18-year-old female presents to your office with a history of wheezing and year-round symptoms of rhinitis.
Initiation of inhaled formoterol (Foradil) and an inhaled corticosteroid
Albuterol, 1–2 puffs as needed
A discussion about removing the cat from her bedroom
True statements regarding the use of long-acting β2-agonists in asthma include which of the following? (Mark all that are true.)
They are beneficial when used in conjunction with inhaled corticosteroids
A 14-year-old female presents to you with a recent history of cough and shortness of breath with exercise. Baseline pulmonary function testing reveals an FEV1 of 3.1 L and a PEF of 600 L/min. Exercise testing is scheduled.
Which of the following measurements after exercise would support a diagnosis of exercise-induced bronchospasm? (Mark all that are true.)
FEV1 2.5 L (80%)
FEV1 2.2 L (70%)
Asthma treatments associated with a dose-dependent reduction in bone mineral density include which of the following? (Mark all that are true.)
Oral corticosteroids
Inhaled corticosteroids
Which one of the following is the most common acid/base abnormality in the EARLY stages of an asthma exacerbation?
Respiratory alkalosis
The mother of a 12-year-old male calls your office and tells you that over the past few days he has had a low-grade fever, runny nose, and cough with yellowish phlegm. He has a history of mild persistent asthma (personal best peak flow 410 L/min) managed with a low-dose inhaled corticosteroid.
Continue the inhaled β2-agonist every 3–4 hours for the next 1–2 days
Mediators linked to the pathophysiology of asthma include which of the following? (Mark all that are true.)
Histamine
Leukotrienes
Granulocyte-macrophage colony-stimulating factor (GM-CSF)
Interleukin-4 and interleukin-5
Tumor necrosis factor alpha
A 35-year-old male admitted to the intensive-care unit with a severe asthma exacerbation has failed to improve with aggressive bronchodilator therapy and systemic corticosteroid therapy. For the past 10 minutes he has appeared more fatigued, but less wheezing is heard and his pulsus paradoxus, which had been 30 mm Hg, is less than 10 mm Hg. His pO2 is 60 mm Hg on high-dose oxygen therapy and his pCO2 is 44 mm Hg.
Which one of the following interventions would be most appropriate?
Intubation and mechanical ventilation
True statements regarding written asthma action plans include which of the following? (Mark all that are true.)
They should be used in patients with moderate or severe persistent asthma
They should be used in patients with a history of severe exacerbations
They should be used in patients whose perception of airflow obstruction is poor
The lack of a written asthma action plan is a risk factor for death from asthma
Which one of the following is most effective for reducing the frequency of exacerbations in adults with asthma?
Inhaled corticosteroids
True statements regarding aspirin-induced asthma include which of the following? (Mark all that are true.)
It is often associated with perennial vasomotor rhinitis
It is associated with rhinosinusitis and nasal polyps
Salsalate is a safer alternative to aspirin
Leukotriene modifiers are particularly effective
A 22-year-old male with long-standing asthma develops a severe asthma exacerbation following an upper respiratory infection. He is seen in the emergency department with severe dyspnea and a fall in peak flow to 270 L/min (45% of personal best). His personal best peak flow is 600 L/min. He is hospitalized and aggressively treated with short-acting β2-agonists, plus oral prednisone, 40 mg/day. He responds to therapy and his peak flow rises to 340 L/min (57% of personal best).
According to National Asthma Education and Prevention Program guidelines, hospital discharge can be considered in this patient once the peak flow rate rises above a threshold of
420 L/min (70%)
A 25-year-old obese female with a history of moderate persistent asthma continues to have problems with frequent nighttime awakening and daytime wheezing despite treatment with a medium-dose inhaled corticosteroid and a leukotriene receptor antagonist.
Identification and treatment of which of the following chronic comorbid conditions can improve asthma management? (Mark all that are true.)
Allergic rhinitis
Allergic bronchopulmonary aspergillosis Obstructive sleep apnea Gastroesophageal reflux disease
Which one of the following allergens is most likely responsible for the disproportionately high morbidity from asthma among inner-city residents?
Cockroach allergen
A 24-year-old male with mild persistent asthma treated with a low-dose inhaled corticosteroid sees you for a follow-up visit. He reports that his cough and wheezing have improved, but that he continues to require the use of an albuterol HFA (Proventil, Ventolin) inhaler 3–4 times a week. He notes that he did not require the use of albuterol even once during a recent 1-week vacation in Maui. Office spirometry is normal. His serum IgE level is 130 IU/mL (N 6–97).
Which of the following options would be most appropriate? (Mark all that are true.)
Assess the patient for exposure to inhalant allergens
Ask the patient about exposure to tobacco smoke and other irritants
Review medication adherence
A 22-year-old female with mild persistent asthma informs you that she and her husband have decided to have a baby. Which one of the following asthma agents would be preferred?
Inhaled corticosteroids
Which one of the following is LEAST likely to precipitate bronchospasm in a patient with exercise-induced asthma?
Swimming in a heated indoor pool
A 4-year-old female is diagnosed with mild persistent asthma. Which one of the following is preferred for long-term control?
Low-dose inhaled corticosteroids
Long-acting inhaled β-agonists are less likely to be effective in which one of the following ethnic groups?
African-Americans
The most common cause of recurrent wheezing in a child less than 5 years of age is
asthma
Inhaled corticosteroids have been shown to provide which of the following benefits in patients with asthma? (Mark all that are true.)
Reduced severity of symptoms
Improved pulmonary function
Reduced airway hyperresponsiveness
Fewer exacerbations
Nonpharmacologic measures that reduce the likelihood of exercise-induced bronchospasm include which of the following? (Mark all that are true.)
Warming up for at least 10 minutes before actual exercise begins
Covering the mouth and nose with a scarf or mask during cold weather
Gradually decreasing the intensity of the exercise before stopping
The 2007 National Asthma Education and Prevention Program guidelines recommend which of the following allergen avoidance measures for patients sensitive to house dust mite allergen? (Mark all that are true.)
Encasing pillows and mattresses in an allergen-impermeable cover
Washing sheets and blankets weekly in hot water (≥54°C, or 130°F)
Vacuuming carpets once or twice a week, using a vacuum cleaner fitted with a HEPA (High Efficiency Particulate Air) filter or double bag
The use of long-acting β-agonists (LABAs) has been associated with an increased risk for
severe asthma exacerbations
Useful agents for the management of acute severe asthma exacerbations in the emergency department setting include which of the following? (Mark all that are true.)
Albuterol (Proventil, Ventolin)
Levalbuterol (Xopenex)
Ipratropium (Atrovent)
Systemic corticosteroids
Which one of the following is LEAST effective for preventing exercise-induced bronchospasm?
Ipratropium (Atrovent)
Chronic low- to medium-dose inhaled corticosteroid use in children is associated with
no long-term adverse effects
A 26-year-old male with asthma is seen in the emergency department. He is short of breath and has diminished breath sounds with an occasional wheeze heard on examination. His FEV1 is 15% of predicted and his PCO2 is 40 mm Hg. He is given albuterol (Proventil, Ventolin) via nebulizer every 20 minutes, and after 1 hour his FEV1 has improved to 20% of predicted.
The development of which of the following would be consistent with imminent respiratory failure? (Mark all that are true.)
Bradycardia
The absence of wheezes
You see a 14-year-old female for a routine annual visit. She has a history of episodic wheezing in the past treated with inhaled albuterol (Proventil, Ventolin) as needed. She tells you that she uses her inhaler less than once a week and rarely develops nighttime wheezing. Her FEV1 is 90% of predicted. She reports that on four occasions during the past year she developed a persistent cough and wheezing, which required urgent care visits and a short course of oral corticosteroids.
Which one of the following would be the preferred treatment for her asthma?
Adding a low-dose inhaled corticosteroid
Risk factors for death from asthma include which of the following? (Mark all that are true.)
An emergency care visit for asthma during the past month
Lack of a written asthma action plan
Difficulty perceiving asthma symptoms
Illicit drug use
True statements regarding allergic bronchopulmonary aspergillosis include which of the following? (Mark all that are true.)
The associated bronchial asthma arises from colonization with Aspergillus fumigatus
It is associated with transient, recurrent infiltrates on chest radiographs It is associated with central bronchiectasis on high-resolution chest CT Diagnostic criteria include the presence of serum IgG to Aspergillus It should be considered in patients with severe asthma refractory to treatment
True statements regarding the use of systemic corticosteroids in the management of asthma exacerbations include which of the following? (Mark all that are true.)
They reduce the rate of relapse
Short-term therapy should be continued until the patient achieves at least 70% of his or her personal best peak expiratory flow, or until symptoms resolve
Extrinsic IgE-mediated allergy can serve as a trigger for asthma. Which one of the following can reduce corticosteroid requirements in asthmatics by reducing free circulating IgE?
Omalizumab (Xolair)
A 48-year-old male presents with a 3-week history of exertional chest pressure. He has moderate persistent asthma controlled with a moderate dose of an inhaled corticosteroid.
Which of the following cardiac stress tests should be avoided? (Mark all that are true.)
Adenosine myocardial perfusion imaging
Dipyridamole myocardial perfusion imaging
Adjunctive therapies generally considered to be of value in the management of severe asthma exacerbations in the adult patient include which of the following? (Mark all that are true.)
Intravenous magnesium sulfate
Adverse effects associated with the use of β2-agonists include which of the following? (Mark all that are true.)
Tremor
Tachycardia
A temporary reduction in arterial oxygen tension
While some facets of asthma are reversible, changes seen in chronic, uncontrolled asthma may be irreversible. Histologic features of the irreversible airway remodeling seen in patients with chronic asthma include which of the following? (Mark all that are true.)
Goblet cell hyperplasia
Subepithelial collagen deposition
Smooth muscle hypertrophy
Microvascular proliferation
True statements regarding exercise-induced bronchospasm include which of the following? (Mark all that are true.)
It occurs during or in the minutes following vigorous physical activity
The differential diagnosis includes vocal cord dysfunction
True statements regarding leukotriene modifiers include which of the following? (Mark all that are true.)
They are effective for managing exercise-induced asthmaThey are less effective than inhaled corticosteroids
True statements regarding inhaled corticosteroids include which of the following? (Mark all that are true.)
A spacer/holding chamber should routinely be used with aerosol preparations to reduce the risk for local adverse effects
A 28-year-old male with a history of moderate persistent asthma presents to the emergency department with a 2-day history of worsening dyspnea despite frequent use of an inhaled β2-agonist. An examination reveals a restless patient with a respiratory rate of 35/min, obvious suprasternal retractions, and loud inspiratory and expiratory wheezes. His FEV1 is 1.6 L (48% of predicted) and his peak flow is 250 L/min (49% of personal best). His oxygen saturation is 89%.
Which of the following management options would be appropriate? (Mark all that are true.)
Oxygen therapy
High-dose inhaled β2-agonist therapy
An inhaled anticholinergic agent
Systemic corticosteroid therapy
Validated tools for ongoing clinical assessment of asthma control include which of the following? (Mark all that are true.)
The Asthma Therapy Assessment Questionnaire (ATAQ)
The Asthma Control Test (ACT)
The Asthma Control Questionnaire (ACQ)
The Asthma Control Score (ACS)
A 20-year-old female is diagnosed with mild persistent asthma. Her past medical history is notable for a history of recurrent ocular herpes simplex and perennial allergic rhinitis.
Which one of the following would be the most appropriate treatment?
A leukotriene modifier
A 19-year-old male has severe persistent asthma treated with high-dose inhaled corticosteroids and a long-acting inhaled β2-agonist. For the past few months he has experienced daily wheezing and is using his albuterol (Proventil, Ventolin) inhaler several times per day. His past medical history is notable for a history of perennial allergic rhinitis related to cockroach allergy.
According to National Asthma Education and Prevention Program guidelines, which one of the following adjunctive therapies would most likely be of benefit?
Omalizumab (Xolair)
Following bronchodilator inhalation, the minimum improvement in FEV1 or FVC consistent with reversibility is
12% (absolute increase 200 mL)
A 15-year-old male has mild persistent asthma managed with zafirlukast (Accolate). At a routine visit he reports that over the past 2 months he has been wheezing 3–4 days of the week and has been awakened at night by his asthma twice a week. His peak flow is found to be 400 L/min (75% of his personal best).
Which of the following interventions would be appropriate at this visit? (Mark all that are true.)
Review his adherence to his medication regimen
Assess his environment for new or increased exposure to allergens or irritants Identify psychosocial issues that might adversely affect his asthma Identify comorbid conditions that can diminish asthma control Discontinue zafirlukast and switch to a low-dose inhaled corticosteroid
A 22-year-old female presents to the emergency department with a severe asthma attack. Examination reveals a severely dyspneic female with diffuse inspiratory and expiratory wheezing, use of accessory muscles, pulsus paradoxus of 30 mm Hg, and a pulse rate of 110 beats/min. Her peak expiratory flow is found to be 150 L/min, her pO2 is 60 mm Hg, and her pCO2 is 30 mm Hg.
Aggressive asthma treatment with inhaled β2-agonists and systemic corticosteroids is instituted, and she is reevaluated 1 hour later. Which one of the following would provide the most reassurance that she is responding to therapy?
A PEF of 300 L/min
A 6-year-old male with a past history of reactive airways disease has a 2-month history of cough and wheezing 3–4 times per week requiring treatment with his albuterol (Proventil, Ventolin) inhaler. He also has had nighttime awakening with coughing and wheezing slightly less than once a week. Office spirometry reveals an FEV1 that is 85% of predicted.
Which one of the following is NOT appropriate for this patient?
A long-acting inhaled β2-agonist
A 25-year-old female with a history of mild persistent asthma presents to the emergency department with a 5-day history of increasing cough, wheezing, and shortness of breath. On examination, she is noted to be slightly agitated with a pulse rate of 110 beats/min. Examination of the lungs reveals loud expiratory wheezing on auscultation, and obvious suprasternal retractions. Her FEV1 is 1.71 L (63% of predicted) and her oxygen saturation is 92%.
Which of the following treatment interventions would you initially prescribe? (Mark all that are true.)
An inhaled short-acting β2-agonist, up to 3 treatments in the first hour
Oral corticosteroid therapy
A 2-year-old male is brought to your office because of a cough and wheezing. His mother states that on at least four other occasions during the past year he has experienced episodes of wheezing precipitated by “colds.”
Risk factors for developing persistent asthma include which of the following? (Mark all that are true.)
A parental history of asthma
A previous history of atopic dermatitis
Evidence of sensitization to aeroantigens
True statements regarding bronchoprovocative testing include which of the following? (Mark all that are true.)
A negative test is helpful in excluding the diagnosis of asthma
Testing is not recommended in patients with a baseline FEV1 <65% of predicted
A 15-year-old asthmatic male presents with an episodic cough and wheezing. He reports wheezing episodes 3–5 days per week and nighttime awakenings no more than 3 times a month. He states that 6 months ago he had to go to an urgent care center for an upper respiratory infection with a severe cough, which was treated with an asthma inhaler and some “oral medication for a few days.” His FEV1 is 70% of predicted.
This patient has
moderate persistent asthma
A 32-year-old patient has a history of moderate persistent asthma treated with a medium-dose inhaled corticosteroid. Over the past 3 months he has awakened with a cough once or twice a month and has required the use of his albuterol (Proventil, Ventolin) inhaler once a week. Once in the past year he had an exacerbation that required the use of an oral corticosteroid. His peak flow periodically drops as low as 540 L/min, down from a personal best of 600 L/min.
Which one of the following would be most appropriate?
No change in drug therapy
True statements regarding occupational asthma include which of the following? (Mark all that are true.)
The likelihood of complete resolution decreases with time of exposure to the sensitizer
The onset of symptoms may occur after a high-level exposure (e.g., a spill)
Symptoms can occur 2–8 hours after exposure
Serial measurement of peak expiratory flow rates at work and away from work is helpful in the diagnostic evaluation
Physical findings consistent with airway obstruction in a patient with uncomplicated asthma include which of the following? (Mark all that are true.)
Expiratory wheezing
Distant breath sounds
Hyperresonance of the thorax on percussion
True statements about written asthma action plans include which of the following? (Mark all that are true.)
They are recommended for all patients with asthma, regardless of severity
They have been shown to reduce hospitalizations and emergency department visits when used in the context of an asthma self-management program
They are of particular value for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma
A 17-year-old male reports that his asthma is usually worse in the early spring. Which one of the following is most likely triggering his symptoms at that time of year?
Tree pollen
The mother of a 15-year-old female with a history of moderate persistent asthma calls your office and tells you that over the past few days the girl has experienced rhinorrhea and cough with growing dyspnea. Her asthma is treated with medium-dose inhaled corticosteroids and a long-acting β2-agonist, and the problem has developed even though she has used her β2-agonist metered-dose inhaler four times a day. The mother reports that the daughter’s peak flow rate this morning was 310 L/min (61% of personal best) and that her personal best prior to the illness was 510 L/min. Following two treatments with her albuterol (Proventil, Ventolin) inhaler at 20-minute intervals, her wheezing improved and her peak flow rose from 310 L/min (61% of personal best) to 360 L/min (71% of personal best).
Which of the following would you recommend? (Mark all that are true.)
Continue use of the albuterol inhaler every 3–4 hours for 24–48 hours
Start oral prednisone at a dosage of 1–2 mg/kg/day
A 29-year-old female at 32 weeks gestation presents with a 3-day history of increasing wheezing and dyspnea. She has a history of asthma since childhood.
Which one of the following pCO2 levels is the threshold for respiratory failure in this patient?
35 mm Hg
Foods that should be avoided by patients with persistent asthma who have a known sulfite sensitivity include which of the following? (Mark all that are true.)
Processed potatoes
Wine
Dried fruit
Beer
Shrimp
