Asthma

Question 1

Asthma

What is asthma?

Answer 1

inflammatory
variable
reversible

Question 2

Asthma

age of dx

Answer 2

peak dx before age 5

Question 3

Asthma

asthma risk factors

Answer 3

age at onset
allergen exposure
urban residence
exposure to air pollution, tobacco smoke
recurrent RTI
GERD
obesity
poverty
COPD (COPD + asthma = bad)

Question 4

Asthma

Atopy triad

Answer 4

asthma
allergic rhinitis
atopic eczema

Question 5

Asthma

Asthma patho (immune cells) early, late & end-stage

Answer 5

Early asthma (immediate):

• Innate + adaptive immune response
• T-helper cells release cytokines to activate B cells
• B cells produce IgE to bind to mast cells
• Mast cells –> histamine and other inflammatory cytokines –> vasodilation, mucosal edema (mucous production & mucous plugs), bronchospasm
• eosinophils release toxic neuropeptides –> bronchospasm

Late asthma (4-8 hours):

• untreated inflammation –> airway remodelling & irreversible damage
• damaged epithelial cells –> impaired muco-ciliary action
• airway obstruction –> air trapping
• hyperventilation –> resp alkalosis

End-Stage
- alkalosis changes to acidosis as airway obstruction/resistance = air trapping = CO2 retention = death

Question 6

Asthma

4 Q to assess asthma symptom control

Answer 6

ANY nighttime waking
Daytime symptoms > 2/week
SABA > 2/week
Any activity limitation

1-2 = partly controlled 
3-4 = uncontrolled

Question 7

Asthma

Diagnosis in children 1-5

Answer 7

• Persistent symptoms:
• 8+ days/months with symptoms
• 8+ days/month with use of SABA
• 1+ night wakening due to symptoms/month
• Any exercise limitation “their legs should wear out before their lungs”

Question 8

Asthma

Diagnosis > 6 years of age

Answer 8

FEV1 change >12% after bronchodilator is evidence of reversibility

• negative test does not exclude asthma
• methacholine challenge?

Question 9

Asthma

Risk/harm of SABA-only therapy

Answer 9

• Regular SABA use reduces bronchodilator response to SABA when needed
• Overuse of SABA (>3 canisters/year) assoc with ­risk of exacerbation, >12 canisters/year assoc with ­risk of death

Question 10

Asthma

Follow-up schedule

Answer 10

• 1-3 months after starting treatment
• Every 3-12 months after (recommend minimum annual
• In pregnancy: q4-6 weeks
• After exacerbation: review within 1 week

Question 11

Asthma

Spirometry intervals

Answer 11

• At start of treatment
• After 3-6 months for personal best lung function
• Q1-2 years
• PFT most useful indicator of future risk

Question 12

Asthma

Indications for referral

Answer 12

If pts have been hospitalized for asthma, or have 1-2 exacerbations/year despite step 4/5 treatment (considered difficult to treat asthma)

Question 13

Asthma

PEAK flow meter monitoring

Answer 13

• BID with best of 3 each time, averaged over 1-2 weeks

- Do before inhalers (expected to be lowest in early morning, highest in afternoon)

Question 14

Asthma

2021 GINA guidelines Track 1 for Steps 1-2 and 3-5

Answer 14

Step 1-2 PRN ICS-formeterol

Step 3-5 ICS-Formeterol MART

Question 15

Asthma

2021 GINA guidelines Track 2 (not preferred) for Steps 1 and 2-5

Answer 15

Step 1 PRN ICS w/ SABA

Step 2-5 ICS regularly + SABA PRN

Question 16

Asthma

When can asthma be stepped down?

Answer 16

after 3 months of controlled symptoms

Question 17

Asthma

Exacerbations - when to seek emergency care

Answer 17

• Need to seek medical care if needing SABA again within 3 hours, or more than max dose of controller
• Increase controller: consider quadrupling ICS dose (max 72 mcg formeterol)
• Oral corticosteroids: adults prednisone 40-50 mg 5-7 days, do not need to taper if <2 weeks

Question 18

Asthma

Proper inhaler technique

Answer 18

• standing position
• look slightly up
• blow out gently first, bring up to mouth and then inhale (to reduce hyperinflation)
• use of spacer
• gargle and spit after using ICS