Asthma. Board Review Sam Sandlin August 13, 2008

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1 Asthma Board Review Sam Sandlin August 13, 2008

2 Content Specification Know that exercise induced asthma may be a sign of poorly controlled asthma. Many patients complain only of exercise related symptoms but further questioning frequently elicits additional nonexercise related symptoms.

3 Content Specification Plan the most appropriate treatment for a patient with acute asthma. Adding short acting bronchodilators to maintenance preventive therapy.

4 PREP 1 A mother contact you at 2030 because her 10yo daughter has been receiving nebulized beta agonist therapy every 3 hours for the last day. Although her wheezing resolves after each treatment, symptoms recur in a few hours. The girl currently has a mild cough and nasal congestion but is afebrile. She awoke once last night and took a nebulized beta agonist treatment. The mother has been following the recommendations of the asthma action plan prescribed by your practice for her child. Next step? A. add a long acting beta agonist to her therapy B. change beta agonist therapy to a metered dose inhaler C. change therapy to nebulized levalbuterol D. increase the nebulized beta agonist frequency to every 2 hours E. start a course of oral corticosteroids

5 Please make your selection Add a long acting beta agonist to her therapy 2. Change beta agonist therapy to a metered dose inhaler 3. Change therapy to nebulized levalbuterol 4. Increase the nebulized beta agonist frequency to every 2 hours 5. Start a course of oral corticosteroids Add a long acting bet... Change therapy to n... Change beta agonist... 0% 0% 0% 0% 0% Increase the nebulize... Start a course of oral...

6 Content Specification Plan the most appropriate treatment for a patient with an acute exacerbation of asthma that is severe and unresponsive to adrenergic agonist therapy. Adrenergic bronchodilators with inhaled anticholinergic agents and systemic corticosteroids.

7 Content Specification Know that corticosteroids in acute asthma can increase adrenergic response, improve FEV1 and improve oxygenation.

8 PREP 2 An 8yo girl is admitted to the ICU for a severe asthma excerbation. As part of her management, she is placed on continuous albuterol nebulizationat 15mg/h. Most likely electrolyte imbalance? A. hypercalcemia B. hypermagnesemia C. hypernatremia D. hypoglycemia E. hypokalemia

9 Please make your selection Hypercalcemia 2. Hypermagnesemia 3. Hypernatremia 4. Hypoglycemia 5. Hypokalemia 0% 0% 0% 0% 0% Hypercalcemia Hypermagnesemia Hypernatremia Hypoglycemia Hypokalemia

10 Content Specification Recognize the clinical manifestations of toxicity to adrenergic agonists. Tremor, tachycardia and hypokalemia.

11 PREP 3 An 8 year old boy presents with wheezing, coughing and difficulty breathing of 6 months duration. Findings on history and PFT are consistent with moderate persistent asthma. In preparation for asthma management, you have reviewed current asthma guidelines, educated the patient on peak flow monitoring, and discussed possible therapeutic options. You decide to start him on a daily inhaled corticosteroid. Most likely adverse effect? A. acne B. decreased adult height C. mood swings D. oral candidiasis E. weight gain

12 Please make your selection Acne 2. Decreased adult height 3. Mood swings 4. Oral candidiasis 5. Weight gain 0% 0% 0% 0% 0% Acne Decreased adult height Mood swings Oral candidiasis Weight gain

13 Content Specification Understand the risks and benefits of inhaled corticosteroids. Benefits are increased adrenergic response, improved FEV1 and improved oxygenation. Risks are mild growth suppression in the first year of usage, oral candidiasis and other oropharyngeal symptoms.

14 PREP 4 A 10yo boy presents to the ED with a severe asthma exacerbation that requires intubation and admission to the ICU. His parents state that this is his 3 rd hospital admission for asthma since his diagnosis at age 6. They are worried about the severity of their son s asthma flares and would like to know the underlying risk factors for fatal asthma. His current medications include an oral antihistamine, an inhaled corticosteroid and an as needed beta agonist. Risk factor most associated with fatality? A. coexisting allergic rhinitis B. female sex C. high socioeconomic status D. inhaled corticosteroid use E. poor perception of symptoms

15 Please make your selection Coexisting allergic rhinitis 2. Female sex 3. High socioeconomic status 4. Inhaled corticosteroid use 5. Poor perception of symptoms 0% 0% 0% 0% 0% Coexisting allergic rhi... Female sex High socioeconomic... Inhaled corticosteroi... Poor perception of...

16 Content Specification Recognize the characteristics of a child at increased risk of dying from asthma. One or more life threatening episodes, severe asthma requiring chronic corticosteroids, poor control of daily symptoms, abnormal FEV1, poor compliance, family dysfunction, depression and atopy.

17 Content Specification Know the kinetics of inhaled beta adrenergic agonists. Peak effect in 15 minutes, duration 4 hours

18 Content Specification Know the benefits of home peak flow monitoring. Objective confirmation of symptoms, assessment of variations in daily obstruction, assessment of acute obstruction

19 Content Specification Plan appropriate outpatient treatment of moderate or severe chronic asthma to include daily anti-inflammatory drugs. Inhaled corticosteroids and long acting beta agonist

20 PREP 5 You see a 13yo AA boy every 3 weeks in the office because he has severe asthma symptoms. During this visit, he reports that his symptoms have been worsening over the last few months. He is taking his controller medication, as verified by his prescription refills, and the refill record also shows that he uses one beta agonist MDI every 3 weeks. Cause of his worsening symptoms? A. excessive use of the beta agonist inhaler B. ineffective controller medication C. poor metered dose inhaler technique D. recurrent viral infections E. underutilization of nebulized beta agonist therapy

21 Please make your selection... Excessive use of the... Ineffective controller... Poor metered dose in... Recurrent viral infect... Underutilization of ne Excessive use of the beta agonist inhaler 2. Ineffective controller medication 3. Poor metered dose inhaler technique 4. Recurrent viral infections 5. Underutilization of nebulized beta agonist therapy 0% 0% 0% 0% 0%

22 Content Specification Know that excessive daily use of beta adrenergic agonists has been associated with increased mortality and with diminished symptom control in asthma. Down regulates receptors

23 Content Specification Know that corticosteroids interfere with the late phase but not the immediate response to allergen exposure.

24 Content Specification Know that long term treatment with inhaled corticosteroids decreases bronchial inflammation together with bronchial hyperresponsiveness.

25 PREP 6 During a routine health maintenance visit for an 8yo child, you ask about his asthma. He states that he rarely uses his rescue beta agonist. His mother comments that he coughs 3 nights a week. He reports some chest tightness when he plays soccer on the weekend, but it goes away if he sits out the rest of the game. Most appropriate intervention? A. beta agonist before and during sports only B. exercise challenge to evaluate the degree of his asthma with sports C. long term controller therapy D. methacholine challenge to evaluate the severity of his asthma E. twice daily treatment with a long acting beta agonist

26 Please make your selection Beta agonist before and during sports only 2. Exercise challenge to evaluate the degree of his asthma with sports 3. Long term controller therapy 4. Methacholine challenge to evaluate the severity of his asthma 5. Twice daily treatment with a long acting beta agonist Beta agonist before a.. Long term controller... Exercise challenge to... 0% 0% 0% 0% 0% Methacholine challen.. Twice daily treatment...

27 Content Specification Know that maintenance medications are necessary in any patient with asthma whose symptoms occur more than twice a week.

28 PREP 7 The parents of a 6yo girl who has mild persistent asthma would like to discuss the therapeutic options for their daughter. Currently she is taking an inhaled corticosteroid and an as needed beta agonist. The parents are worried about the potential effect of steroids and have brought you an article from the internet on the dangers of steroids. The best long term alternative? A. albuterol B. ipratropium bromide C. montelukast D. prednisone E. salmeterol

29 Please make your selection Albuterol 2. Ipratropium bromide 3. Montelukast 4. Prednisone 5. Salmeterol 0% 0% 0% 0% 0% Albuterol Ipratropium bromide Montelukast Prednisone Salmeterol

30 Content Specification Know the role of leukotriene antagonists in the management of asthma. A leukotriene modifier can be used if inhaled therapy is not viable, but this is considered second line rather than primary treatment, even in very young children.

31 Content Specification Know the importance of medical and self assessment in a patient with asthma. The educational message should be reinforced and the intensity of therapy stepped down or up as appropriate.

32 Content Specification Know the importance of patient education in asthma medication. Too many patients end up in the ED because of lack of knowledge of appropriate intervention steps (action plans), under-recognition of the severity of symptoms and undertreatment with systemic steroids when increased bronchodilators and inhaled steroids are not effective.

33 Content Specification Know that chest physiotherapy, mucolytics, and anxiolytics are not recommended in the management of asthma. Atelectasis due to mucus plugging is not uncommon but usually resolves with antiinflammatory and bronchodilator therapy.

34 Prep 8 A 10yo boy who has moderate persistent asthma is in your office for a routine asthma follow up. He has been doing well for the past 4 months and the father wants to know the best test to measure his son s airflow. Your answer? A. exhaled nitric oxide B. methecholine challenge C. peak flow measurement D. pulse oximetry E. spirometry

35 Please make your selection Exhaled nitric oxide 2. Methecholine challenge 3. Peak flow measurement 4. Pulse oximetry Exhaled nitric oxide Methecholine challenge Peak flow measurement Pulse oximetry Spirometry 5. Spirometry 0% 0% 0% 0% 0%

36 Content Specification Know that routine pulmonary function testing is recommended for children with persistent asthma. Interval monitoring, including pulmonary function tests once or twice a year, is appropriate for all patients who have persistent asthma that requires daily anti-inflammatory treatment.

37 Quiz 1 Rules of two as pertains to asthma? Symptoms >2x/week or waking at night >2x/month = persistent asthma

38 Quiz 2 Asthma triggers Exercise Weather changes Cold air Allergens Tobacco smoke Irritants Acid reflux URI Emotional expression (anger, laughter, crying)

39 QUIZ 3 Asthma severity symptoms Intermittent- AM <2x/week, PM < 2x/month Mild- AM >2x/week, <1x/day, PM >2x/month Mod- AM daily, PM >1x/week Severe- AM continual, PM frequent

40 Quiz 4 How often should newly diagnosed asthmatics be seen in clinic? Quarterly for the first year, then every 6 to 12 months depending on their stability

41 Quiz 5 Stepwise approach Step 1 (intermittent)- no daily medication Step 2 (mild)- low dose inhaled corticosteroids Step 3 (mod)- low dose inhaled corticosteroid + long acting beta agonist (or medium dose inhaled corticosteroid +/- long acting beta agonist) Step 4 (severe)- high dose inhaled corticosteroid + long acting beta agonist

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