Asthma

Question 1

What are the symptoms of asthma?

Answer 1

• Shortness of Breath
• Chest tightness
• Cough
• Wheezing
• Chest pain
• Rhinorrhea

Question 2

What are common exacerbating factors for asthma?

Answer 2

• Viral infection
• Allergens (dust, pollen..)
• Irritants (smoke, fumes)
• Exercise
• Emotions
• Change in humidity

Question 3

How come wheezing might not be present in a child presenting with asthma?

Answer 3

• Airway obstruction may result in poor air movement

Question 4

On exam what findings might be present in a patient presenting with asthma exacerbation?

Answer 4

• Tachypnea
• Tachycardia
• Cough
• Wheeze
• Prolonged expiration
• Cyanosis
• Retractions and accessory muscle use
• Tripod position
• Pulsus paradoxus
• May see other evidence of atopic disease (eczema, allergic rhinitis)

Question 5

What is pulsus paradoxus?

Answer 5

• Decrease in blood pressure of >15mm Hg with inspiration

Question 6

What are the 3 criteria needed for a diagnosis of asthma?

Answer 6

1) Episodic symptoms of airflow obstruction
2) Airflow obstruction is at least partially reversible
3) Alternative diagnosis are excluded

Question 7

What is pulsus paradoxus associated with? List 5 things

Answer 7

1) Obstructive lung disease (Asthma and COPD)
2) PE
3) Tension pneumo
4) Cardiac tamponade
5) Pericarditis
6) Croup
7) Chronic sleep apnea

Question 8

When should a chest radiograph be performed in a child presenting with asthma?

Answer 8

• First episode of asthma (or with recurrent episodes of undiagnosed cough) to rule out anatomic abnormality
• If child presents with fever (rule our pneumonia)
• Otherwise a child with known asthma who is afebrile does not require CXR

Question 9

What is the preferred long term control therapy medication for those with asthma?

Answer 9

• Inhaled Corticosteroids

Question 10

Why do you counsel patients to rinse their mouths after using inhaled steroids?

Answer 10

• Decreases G.I. absorption
• Reduces risk of:
  
  • Dysphonia
  • Oral candidiasis

Question 11

What are the effects of inhaled steroids on growth?

Answer 11

• May decrease growth velocity (approx 1cm in first year)
• Generally not progressive and may be reversible
• Note that poorly controlled asthma will also reduce growth velocity

Question 12

What are leukotriene modifiers? How are they given?

Answer 12

• Leukotrienes are potent mediators of inflammation and smooth muscle bronchoconstriction
• All oral medications
• Most popular (montelukast or singulaire) is a leukotriene receptor antagonist

Question 13

When should a long acting beta-2 agonist be used?

Answer 13

• If inhaled steroid treatment alone is not sufficient, adding a long acting bronchodilator to inhaled steroid is more effective.
• Note combination inhalers of ICS and LABA improve compliance

Question 14

Fomoterol and salmeterol are in which class of medication?

Answer 14

• Long acting beta-2 agonist (LABA)

- Bronchdilator

Question 15

What is theophylline?

Answer 15

• Bronchodilator, not commonly used anymore

Question 16

What is typically the role of a short acting beta-2 agonist?

Answer 16

• Acute symptom relief
• Prophylaxis before exposure or exercise
• Note overuse of this suggests poor asthma control (over 8 puffs per day or using over 1 puffer per month)

Question 17

How do anticholinergic agents work?

Answer 17

• bind to acetylcholine at muscarinic receptors in the bronchial smooth muscle
  
  • decreases mucous hypersecretion
  • counteracts cough receptor irritability

Question 18

What is the role for long term use of anticholinergic medications in treating asthma?

Answer 18

• Long term use is currently not supported by the literature

Question 19

What is the role of oral corticosteroids in the treatment of asthma?

Answer 19

• Treatment of acute exacerbations

Question 20

What dose of oral dexamethosone would you use in an acute asthma exacerbation? For how long would you use it?

Answer 20

• 0.6mg/kg
• Max dose is 16mg/dose
• Single dose or may be repeated in 24 hours once
• Not recommended any longer due to risk of metabolic effects

Question 21

What dose of oral prednisone or prednisolone would you use for acute asthma exacerbation? For how long?

Answer 21

• 0.2mg/kg/day on day one, then 0.1-0.2mg/kg/days for the next 2-4 days (3-5 days total)

Question 22

What are the Rules of Two? What do they tell you?

Answer 22

• The rules of two is a tool to determine if a childs asthma is persistent or intermittent
• It is persistent if when there is either:
  
  • Daytime symptoms occurring 2 or more times per week
• Nighttime awakening two or more times per month
• If persistent requires a daily anti-inflammatory medication (ICS)

Question 23

What is status asthmaticus?

Answer 23

• An acute exacerbation of asthma that does not respond adequately to therapeutic measures and may require hospitalization.

Question 24

What is your initial management for a patient with asthma exacerbation?

Answer 24

• ABC’s
• Vitals/Monitor (O2 sats important)
• Supplemental oxygen
• Short acting bronchodilators (salbutamol +/- ipratropium)
• Early oral corticosteroids

Question 25

What tests will you order on a patient who presents with an acute asthma exacerbation if any?

Answer 25

- ABG: Consider if unwell and not responding to initial treatment - CXR: If first presentation for asthma or if fever, crackles or other abnormal findings on respiratory examination

Question 26

What is magnesium sulfate and how does it work? What is it's role in the treatment of acute asthma exacerbation?

Answer 26

- Inhibits smooth muscle contraction, decreases histamine release from smooth cells and inhibits acetylcholine release - Used if there is clinical deterioration despite bronchodilator and oral steroid treatment

Question 27

When would you consider using epinephrine in the treatment of an asthma exacerbation? What is the dose?

Answer 27

- In severe asthma - Child with poor inspiratory flow (cannot get inhaled meds in) or if child is unable to tolerate inhaled therapy - Dose is 0.01mg/kg Max of 0.4mg given IM or SC

Question 28

What criteria would put a patient into the "green zone" on an asthma action plan

Answer 28

- No cough, wheeze, chest tightness or SOB during day or night - Can do usual activity * Asymptomatic essentially*

Question 29

What criteria would put a patient into the "yellow zone" on an asthma action plan

Answer 29

Any of: - Cough, wheeze, chest tightness or shortness of breath - Waking at night due to asthma - Can do some but not all of their usual activities

Question 30

What criteria would put a patient into the red zone on an asthma action plan

Answer 30

Any of: - Very short of breath - Rescue meds have not helped - Cannot do usual activity - Symptoms are same or worse after 24 hours in the yellow zone