Week 7 Resp: Asthma & COPD Flashcards
An adolescent who has exercise-induced asthma (EIA) is on the high school track team and has recently begun to practice daily during the school week. The adolescent uses two puffs of albuterol via a metered-dose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do?
A Counsel the adolescent to decrease the number of practices each week
B Increase the albuterol to four puffs, 20 minutes prior to exercise
C Order a daily, inhaled corticosteroid medication
D Prescribe cromolyn sodium in addition to the albuterol
C Order a daily, inhaled corticosteroid medication
Children with EIA should use 2 puffs of a B2-agonist and/or cromolyn MDI 15 to 30 minutes prior to exercise, but, since tolerance may develop if a B2-agonist is used more than a few times a week, it should not be used as a controller monotherapy. Those who exercise regularly should use an ICS as a controller medication. Patients with asthma should be encouraged to exercise to improve overall health. Increasing the albuterol dose will not overcome the tolerance. And ICS is a preferred controller medication.
The primary care pediatric nurse practitioner is examining a school-age child who has had several hospitalizations for bronchitis and wheezing. The parent reports that the child has several coughing episodes associated with chest tightness each week and gets relief with an albuterol metered-dose inhaler. What will the nurse practitioner order?
A Allergy testing
B Chest radiography
C Spirometry testing
D Sweat chloride test
C Spirometry testing
Spirometry testing is the gold standard for diagnosing asthma and is then used on a regular basis to monitor, evaluate, and manage asthma. Allergy testing should be considered but is not diagnostic of asthma. Chest radiography should not be routine. A sweat chloride test is used based on history.
A school-age child who uses a short-acting beta2-agonist (SABA) and an inhaled corticosteroid medication is seen in the clinic for an acute asthma exacerbation. After four puffs of an inhaled, short-acting B2-agonist (SABA) every 20 minutes for three treatments, spirometry testing shows an FEV1 of 60% of the child’s personal best. What will the primary care pediatric nurse practitioner do next?
A Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA
B Admit the child to the hospital for every two hour inhaled SABA and intravenous steroids
C Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department
D Order an oral corticosteroid, continue the SABA every three to four hours, and follow closely
D Order an oral corticosteroid, continue the SABA every three to four hours, and follow closely
Children with an incomplete response (FEV1 between 40% and 69% of personal best) should be given oral steroids and instructed to continue the SABA every 3 to 4 hours with close follow-up. Hospitalization is not necessary unless severe distress occurs. An FEV1 less than 40% after treatment indicates a need to be seen in the ED.
A child who has been diagnosed with asthma for several years has been using a short-acting B2-agonist (SABA) to control symptoms. The primary care pediatric nurse practitioner learns that the child has recently begun using the SABA two or three times each week to treat wheezing and shortness of breath. The child currently has clear breath sounds and an FEV1 of 75% of personal best. What will the nurse practitioner do next?
A Add a daily inhaled corticosteroid
B Administer three SABA treatments
C Continue the current treatment
D Order an oral corticosteroid
A Add a daily inhaled corticosteroid
The child is showing a need to step up treatment based on the frequency of symptoms, greater than twice each week. The PNP should order an inhaled corticosteroid maintenance medication to control symptoms and reduce the need for a SABA. The child is not having an acute exacerbation, so does not need 3 SABA treatments. Oral corticosteroids are given for moderate obstruction
An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a short-acting beta2-agonist (SABA) and a daily high-dose inhaled corticosteroid. What will the primary care pediatric nurse practitioner do next to manage this child’s asthma?
A Consider daily oral corticosteroid administration
B Order an anticholinergic medication in conjunction with the current regimen
C Prescribe a LABA/inhaled corticosteroid combination medication
D Refer to a pulmonologist for omalizumab therapy
D Refer to a pulmonologist for omalizumab therapy
Children older than 12 years who have moderate to severe allergy-related asthma and who react to perennial allergens may benefit from omalizumab as a second-line treatment when symptoms are not controlled by ICSs. The PNP should refer children to a pulmonologist for such treatment. Daily oral corticosteroid medications are not recommended because of the adverse effects caused by prolonged use of this route. Anticholinergic medications are generally used for acute exacerbations during in-patient stays or in the ED. A LABA/ICS combination will not produce different results.
Which of the following exam findings can be seen in a patient with COPD?
A Increased tactile fremitus and a high-positioned diaphragm
B Decreased tactile fremitus and generalized hyperresonance to percussion
C Positive egophany and dullness to percussion
D Decreased AP to lateral diameter and adventitious sounds
B Decreased tactile fremitus and generalized hyperresonance to percussion
Patients with COPD may have low, flat diaphragm, decreased tactile fremitus and hyperresonance, increased AP to lateral diameter and adventitious sounds. Positive egophany and dullness are suggestive of consolidation or mass.
The nurse practitioner seeing a patient with dyspnea and cough considers asthma and COPD as differential diagnosis since symptoms often overlap. A diagnosis of COPD is favored if:
A Symptoms present earlier in life
B Airflow limitation is not reversible
C The patient has a productive cough
D The chest x-ray shows hyperinflation
B Airflow limitation is not reversible
Airflow limitation is largely reversible with asthma, and irreversible in COPD. COPD most often presents midlife with slowly progressive symptoms. Chest x-ray is not needed to diagnose asthma or COPD but may show hyperinflation with both conditions. Cough can occur with both asthma and COPD.
Which test is the most diagnostic for chronic obstructive pulmonary disease (COPD)?
A COPD Assessment Test
B Forced expiratory time maneuver
C Lung radiograph
D Spirometry for FVC and FEV1
D Spirometry for FVC and FEV1
Spirometry testing is the gold standard for diagnosis and assessment of COPD because it is reproducible and objective. The forced expiratory time maneuver is easy to perform in a clinic setting and is a good screening to indicate a need for confirmatory spirometry. Lung radiographs are non-specific but may indicate hyperexpansion of lungs. The COPD assessment test helps measure health status impairment in persons already diagnosed with COPD.
A patient diagnosed with chronic obstructive pulmonary disease reports daily symptoms of dyspnea and cough. Which of the following is an effective first line therapy?
A Anticholinergic or LAMA
B Inhaled corticosteroid
C Antibiotics
D Theophylline
A Anticholinergic or LAMA
Anticholinergic medication such as ipratropium is used as first-line therapy in patients with daily symptoms. Inhaled corticosteroids are used with LABA therapy in a step wise approach, especially in patients with stage 3 or 4 COPD. Antibiotics are used in an exacerbation. Theophylline is a third-line agent.
A patient with COPD has an FEV1 of 45%, a CAT score of 8, and 3 exacerbations in the past year. The patient’s COPD should be classified as:
A Stage 1, Group B
B Stage 2, Group B
C Stage 4, Group D
D Stage 3, Group C
D Stage 3, Group C
Stage 3 (severe COPD) the FEV1 is between 30-50% predicted with repeated exacerbations. Group C patient group are usually GOLD 3 or 4, more than 2 exacerbations in 1 yr or more than one with hospitalization and CAT score less than 10.
Grade: FEV1 % predicted GOLD 1: >/= 80 GOLD 2: 50-79 GOLD 3: 30-49 GOLD 4: < 30
Moderate/severe exacerbation hx/ Symptoms
Group A: 0 or 1 no hospitalization/ mMRC 0-1 or CAT < 10
Group B: 0 or 1 no hospitalization/mMRC >/=2 CAT >/=10
Group C:>2 or >1 w/ hospitalization/ mMRC 0-1 CAT < 10
Group D: >2 or >1 w/ hospitalization/ mMRC >/2 or CAT >/=10
Which is characteristic of obstructive bronchitis and not emphysema?
A Damage to the alveolar wall
B Destruction of alveolar architecture
C Mild alteration in lung tissue compliance
D Mismatch of ventilation and perfusion
C Mild alteration in lung tissue compliance
Obstructive bronchitis causes much less parenchymal damage than emphysema does, so there is milder alteration in lung tissue compliance. The other symptoms are characteristic of emphysema.
A 35-year-old woman with a long history of well-controlled asthma presents with worsening of her symptoms over the last month. She has been using fluticasone MDI 110 mcg twice per day faithfully for the last 2 years. Over the last month, she has had to use her rescue inhaler in the mornings 2 to 3 times per week. She does not smoke. Her medications include an oral contraceptive pill (OCP), a multivitamin, ibuprofen as needed, and propranolol (recently added for migraine prophylaxis).
What would you advise?
Recognize that medications for arthritis (NSAIDS), hypertension (beta-blockers), or glaucoma may exacerbate asthma. It may be helpful to stop her propranolol. If that is ineffective, reevaluate for environmental factors such as new exposures at work or a smoking roommate. Consider comorbid conditions or other diagnoses, such as allergic rhinitis, obesity, GERD, or OSA. Pulmonary embolus may also be a consideration as she is taking an OCP.
potential side effects of long-term ICS as controller medication in adults
decreased bone density
sub-scapular cataracts
skin bruising
glaucoma
adrenal suppression used as a marker for systemic absoprtion - occurs at doses of 1.5 mg/day for aLL ICS except fluticasone, which occurs at 0.75 mg/day
bone mineral density should be followed in older adults on high dose ICS, esp w/ other RF for osteoporosis
Ca and Vit D supp recc for pts taking ICS w/ RF for osteoporosis
potential side effects of long-term use of LABAs
small but statistically significatn increase in ashtma-related and pulmonary death in pts using salmeterol vs placebo , focused in young African americans , unclear patho
unclear if ICS protect agaisnt this risk
black box warning: LABAs should not be used w/o ICS and should probably be given trial of ICS alone first
differences in classification of children vs adults with asthma
Classification of asthma severity is more difficult in younger children. Therefore, criteria for diagnosis and initiation of controller medications have been developed using the number of times steroids have been prescribed and factors which would predispose the child to asthma.
differences in comorbidities of children vs adults with asthma
Both the differential and the most common comorbidities seen with these patient populations require different thought processes. For example, cystic fibrosis and BPD usually come to mind at some point while working up a young child with asthma. GERD should probably be higher on our list when treating both children and adults. Allergic symptoms probably have an even greater role in children than in adults (hence the more frequent use of LTRAs)
differences in tx of children vs adults in asthma
Step 3 for children under 5 years is medium-dose ICS. However, there is an option to introduce a LABA for step 3 with a low-dose ICS for all patients 5 years and older. Concerns regarding the safety and efficacy of LABAs, particularly in the youngest children, have limited the use of LABAs in this population.
differences in referral of children vs adults in asthma
In children under 5 years old, the 2007 guidelines recommend specialist referral for treatment steps 3 and up (treatment above medium-dose ICS). Referral is recommended for treatment steps 4 and up (medium-dose ICS + LABA) for those over 5 years old.
A 10-month-old girl is brought to primary care clinic for hospital follow-up. She was admitted one week ago for three days with the diagnosis of WARI (wheezing-associated with respiratory infection). She has no additional medical history and was born at term. In addition to her well-child checks, she has been seen on two other occasions for wheezing associated with colds. She received oral steroids at one of those visits. She now appears well and is in no distress. Mom reports that she has not needed to use her albuterol for the last two days. She took her last dose of oral prednisone today.
What is her diagnosis?
persistent asthma
At what point would you consider using a controller medication in managing 10-month old with asthma?
Young children may have little to no impairment on a daily basis but still be at high risk for severe exacerbations. Inhaled corticosteroids are recommended for long-term control therapy if:
• 4 wheezing episodes in a year affecting sleep and lasting more than 1 day and who have a positive asthma risk profile**
• 2 or more exacerbations requiring oral corticosteroids in the last 6 months
• the child requires more than 2 doses of short-acting bronchodilator per week for more than 4 weeks
**Positive asthma profile:
• One or more of the following: atopic dermatitis, sensitization to aeroallergen, parental history of asthma;
or
• Two or more of the following: wheezing apart from colds, more than 4% blood eosinophilia, food sensitization.
You decide to prescribe a controller medication in the 10 month old girl with asthma. Her mother is concerned about giving long-term medications to a child this young.
What would you prescribe?
What are the risks and benefits of controller medications in young children?
Budesonide is the only inhaled glucocorticoid that is FDA approved for children under 4 years old, but others such as fluticasone and beclomethasone are also frequently used. Although budesonide is approved for children over 1 year old, efficacy has been proven even in infancy in preventing recurrent wheezing. Budesonide tends to be the most expensive; beclomethasone is the least expensive.
Both asthma itself and repeated doses of oral corticosteroids are associated with growth suppression and delayed puberty. In general, ICSs are safe in adults and children of all ages. Primary concerns include linear growth and bone density. Dose related, short-term decreases in growth velocity have been observed with ICSs in the first 2 years of therapy.
Would you use a nebulizer or a metered dose inhaler (MDI) in the 10 month old with asthma?
Certainly, it is difficult for most children under the age of 5 to coordinate their breathing with a metered-dose inhaler (MDI). Traditionally, nebulizers have been used for young children, but recent data have shown a spacer (one-way valve) with a mask to be equally effective in delivering SABAs in mild to moderate asthma exacerbations. The most important point to make is proper technique with any delivery system. Masks should fit tightly. If a spacer is used, 3 to 4 breaths with each MDI activation should be attempted. If a nebulizer is used, a mouthpiece is preferred. If using a mouthpiece is not possible (as in young children), the mask should fit snugly over the mouth and nose. Holding it 1 cm away reduces the dose by 50%, 2 cm reduces it by 80%.
What can be done to minimize medication side effects in the 10 month old girl with asthma?
If the child does not have a measurable response in 4 to 5 weeks, discontinue the medication and consider other diagnoses.
If a child does have a measurable response sustained for 3 months, consider stepping down treatment to a lower dose.
Children have a high rate of remission. More efficient delivery of medication to the lungs (as opposed to the mouth or the room) minimizes the dose needed. Therefore, the use of spacers and masks and instructions to keep nebulizer masks on the patient’s face are helpful.
Instruct patients who are old enough to coordinate their breathing with the MDI.
Have patients rinse their mouths out after use to minimize the risk of thrush and systemic absorption.
Wash the face off after nebulizer treatments to minimize effects on skin.
Dry-powder inhalers may minimize cough, throat irritation, and dysphonia if these are present.
An 8-year-old boy presents to primary care clinic with nighttime cough. On further questioning, his mother did notice this at times when he was younger, but it seemed to go away within a day or two. It now wakes him from sleep at least once a week. He sometimes has difficulty breathing when he runs, but this has been attributed to his being a little overweight in the past. On physical exam, his lungs are clear, and he is in no distress. His BMI is 21 kg/m2. Nasal mucosa is hyperemic and bluish. Chest x-ray reveals slightly hyperinflated lungs.
Does this patient have asthma?
To confirm the diagnosis of asthma, you ideally need information from spirometry. The hallmark of asthma is episodic symptoms of airway obstruction with or without hyper-responsiveness (cough, wheezing, chest tightness). This obstruction is as least partially reversible on spirometry (10%-12%). Often, these symptoms are worse at night. In fact, they may be present only at night or with exercise, particularly in children. In general, triggers can be identified such as respiratory infections, dust, smoke, air pollution, stress, menstrual cycles, changes in weather, or exercise.
