Rochelle M. Nolte, MD CDR USPHS Family

ASTHMAASTHMA

Rochelle M. Nolte, MDRochelle M. Nolte, MDCDR USPHSCDR USPHS

Family MedicineFamily Medicine

ObjectivesObjectives

At the conclusion of the presentation, At the conclusion of the presentation, participants should be able to:participants should be able to: ID signs and symptoms consistent with asthma and ID signs and symptoms consistent with asthma and

allergic rhinitisallergic rhinitis Differentiate the various severities of asthmaDifferentiate the various severities of asthma Summarize an appropriate treatment regimen for Summarize an appropriate treatment regimen for

asthma of various severitiesasthma of various severities

Allergic RhinitisAllergic Rhinitis

Symptoms: sneezing, itching, rhinorrhea, and Symptoms: sneezing, itching, rhinorrhea, and congestion congestion

Nasal smear with >10% eosinophils suggestiveNasal smear with >10% eosinophils suggestive Dx can be confirmed by allergen-specific Ig-EDx can be confirmed by allergen-specific Ig-E Classification Classification

Persistant or intermediate Persistant or intermediate Graded relative to severityGraded relative to severity


Affects 15%-50% of world-wide populationAffects 15%-50% of world-wide population Affects 40 million people in the USAffects 40 million people in the US Prevalence increasing (increasing airborne Prevalence increasing (increasing airborne

pollutants, rising dust mite populations, poor pollutants, rising dust mite populations, poor ventilation in buildings, increased time indoors ventilation in buildings, increased time indoors by people and pets, dietary factors, changes in by people and pets, dietary factors, changes in gut indigenous microflora, increased abx use, gut indigenous microflora, increased abx use, increasingly sedentary lifestyle????????)increasingly sedentary lifestyle????????)


Associated with asthmaAssociated with asthma 95% of people with allergic asthma have rhinitis95% of people with allergic asthma have rhinitis 30% of people with allergic rhinitis have asthma 30% of people with allergic rhinitis have asthma

(compared to 3-5% of general population)(compared to 3-5% of general population) Family history of atopy seems associated with Family history of atopy seems associated with

progression of either allergic rhinitis or asthma to progression of either allergic rhinitis or asthma to allergic rhinitis + asthmaallergic rhinitis + asthma

Treatment of allergic rhinitis reduces ER visits for Treatment of allergic rhinitis reduces ER visits for asthmaasthma

Management of Allergic RhinitisManagement of Allergic Rhinitis

Identification of allergensIdentification of allergens PollenPollen Molds/fungiMolds/fungi Dust mitesDust mites Animal danderAnimal dander CockroachesCockroaches

Avoid or minimize exposure to allergensAvoid or minimize exposure to allergens Patient educationPatient education


PharmacotherapyPharmacotherapy Intra-nasal corticosteroids Intra-nasal corticosteroids Antihistamines (non-sedating preferred)Antihistamines (non-sedating preferred)

Not recommended to use sedating qhs and non-sedating Not recommended to use sedating qhs and non-sedating qAMqAM

DecongestantsDecongestants Antihistamine/decongestant combinationsAntihistamine/decongestant combinations Mast cell stabilizersMast cell stabilizers Leukotriene antagonistsLeukotriene antagonists


Allergen ImmunotherapyAllergen Immunotherapy Repeated, controlled administration of specific Repeated, controlled administration of specific

allergens to patients with IgE-mediated conditionsallergens to patients with IgE-mediated conditions May impede progression of allergic rhinitis to May impede progression of allergic rhinitis to

asthmaasthma May prevent multiple sensitizations and the need May prevent multiple sensitizations and the need

for prolonged/excessive use of pharmacotherapiesfor prolonged/excessive use of pharmacotherapies Consider when sx not controlled on medicationsConsider when sx not controlled on medications

Definition of AsthmaDefinition of Asthma

Chronic inflammatory disorder of the airways Chronic inflammatory disorder of the airways in which many cells and cellular elements play in which many cells and cellular elements play a role. In susceptible individuals, this a role. In susceptible individuals, this inflammation causes recurrent episodes of inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early coughing, particularly at night or in the early morning. These episodes are associated with morning. These episodes are associated with widespread but variable airflow obstruction widespread but variable airflow obstruction that is reversible either spontaneously, or with that is reversible either spontaneously, or with treatment.treatment.

AsthmaAsthma

Most common chronic condition in childrenMost common chronic condition in children #1 cause of school absenteeism#1 cause of school absenteeism Death rate up 50% from 1980 to 2000Death rate up 50% from 1980 to 2000 Death rate up 80% in people under 19Death rate up 80% in people under 19 Morbidity and mortality highly correlated withMorbidity and mortality highly correlated with

Poverty, urban air quality, indoor allergens, lack of Poverty, urban air quality, indoor allergens, lack of patient education, and inadequate medical carepatient education, and inadequate medical care

About 5000 deaths annuallyAbout 5000 deaths annually

AsthmaAsthma

Every day in the US, because of asthma:Every day in the US, because of asthma: 40,000 people miss school or work40,000 people miss school or work 30,000 people have an asthma attack30,000 people have an asthma attack 5,000 people visit the emergency room5,000 people visit the emergency room 1,000 people are admitted to the hospital1,000 people are admitted to the hospital 14 people die14 people die

(Asthma and Allergy Foundation of America)(Asthma and Allergy Foundation of America)

AsthmaAsthma

In 2000, 11 million reported having asthma In 2000, 11 million reported having asthma attacksattacks

>5% of kids <18 reported an asthma attack>5% of kids <18 reported an asthma attack In 1999, 2 million ER and 478,000 In 1999, 2 million ER and 478,000

hospitalizations with asthma as the primary dxhospitalizations with asthma as the primary dx Mortality in Black males 3X that of whiteMortality in Black males 3X that of white Mortality in Black females 2.5X that of whiteMortality in Black females 2.5X that of white

AsthmaAsthma

Usually associated with airflow obstruction of Usually associated with airflow obstruction of variable severity.variable severity.

Airflow obstruction is usually reversible, Airflow obstruction is usually reversible, either spontaneously, or with treatmenteither spontaneously, or with treatment

The inflammation associated with asthma The inflammation associated with asthma causes an increase in the baseline bronchial causes an increase in the baseline bronchial hyperresponsiveness to a variety of stimulihyperresponsiveness to a variety of stimuli

Clinical DiagnosisClinical Diagnosis

Asthma TriggersAsthma Triggers

AllergensAllergens Dust mites, mold spores, animal dander, Dust mites, mold spores, animal dander,

cockroaches, pollen, indoor and outdoor cockroaches, pollen, indoor and outdoor pollutants, irritants (smoke, perfumes, cleaning pollutants, irritants (smoke, perfumes, cleaning agents)agents)

Pharmacologic agents (ASA, beta-blockers)Pharmacologic agents (ASA, beta-blockers) Physical triggers (exercise, cold air)Physical triggers (exercise, cold air) Physiologic factorsPhysiologic factors

Stress, GERD, viral and bacterial URI, rhinitisStress, GERD, viral and bacterial URI, rhinitis

Diagnostic TestingDiagnostic Testing

Peak expiratory flow (PEF)Peak expiratory flow (PEF) InexpensiveInexpensive Patients can use at homePatients can use at home

May be helpful for patients with severe disease to May be helpful for patients with severe disease to monitor their change from baseline every daymonitor their change from baseline every day

Not recommended for all patients with mild or moderate Not recommended for all patients with mild or moderate disease to use every day at homedisease to use every day at home

Effort and technique dependentEffort and technique dependent Should not be used to make diagnosis of asthmaShould not be used to make diagnosis of asthma


SpirometrySpirometry Recommended to do spirometry pre- and post- use Recommended to do spirometry pre- and post- use

of an albuterol MDI to establish reversibility of of an albuterol MDI to establish reversibility of airflow obstructionairflow obstruction

>> 12% reversibility or an increase in FEV1 of 12% reversibility or an increase in FEV1 of 200cc is considered significant200cc is considered significant

Obstructive pattern: reduced FEV1/FVC ratioObstructive pattern: reduced FEV1/FVC ratio Restrictive pattern: reduced FVC with a normal Restrictive pattern: reduced FVC with a normal

FEV1/FVC ratioFEV1/FVC ratio


SpirometrySpirometry Can be used to identify reversible airway Can be used to identify reversible airway

obstruction due to triggersobstruction due to triggers Can diagnose Exercise-induced asthma (EIA) or Can diagnose Exercise-induced asthma (EIA) or

Exercise-induced bronchospasm (EIB) by Exercise-induced bronchospasm (EIB) by measuring FEV1/FVC before exercise and measuring FEV1/FVC before exercise and immediately following exercise, then for 5-10 immediately following exercise, then for 5-10 minute intervals over the next 20-30 minutes minute intervals over the next 20-30 minutes looking for post-exercise bronchoconstrictionlooking for post-exercise bronchoconstriction


SpirometrySpirometry National Asthma Education and Prevention National Asthma Education and Prevention

Program (NAEPP) recommends spirometry:Program (NAEPP) recommends spirometry: For initial assessmentFor initial assessment Evaluation of response to treatmentEvaluation of response to treatment Assessment of airway function at least every 1-2 yearsAssessment of airway function at least every 1-2 years


Methacholine challengeMethacholine challenge Most common bronchoprovocative test in USMost common bronchoprovocative test in US Patients breathe in increasing amounts of Patients breathe in increasing amounts of

methacholine and perform spirometry after each methacholine and perform spirometry after each dosedose

Increased airway hyperresponsiveness is Increased airway hyperresponsiveness is established with a 20% or more decrease in FEV1 established with a 20% or more decrease in FEV1 from baseline at a concentration < 8mg/dlfrom baseline at a concentration < 8mg/dl

May miss some cases of exercise-induced asthmaMay miss some cases of exercise-induced asthma

Diagnostic testingDiagnostic testing

Diagnostic trial of anti-inflammatory Diagnostic trial of anti-inflammatory medication (preferably corticosteroids) or an medication (preferably corticosteroids) or an inhaled bronchodilatorinhaled bronchodilator Especially helpful in very young children unable to Especially helpful in very young children unable to

cooperate with other diagnostic testingcooperate with other diagnostic testing There is no one single test or measure that can There is no one single test or measure that can

definitively be used to diagnose asthma in every definitively be used to diagnose asthma in every patientpatient

Goals of Asthma TreatmentGoals of Asthma Treatment

Control chronic and nocturnal symptomsControl chronic and nocturnal symptoms Maintain normal activity, including exerciseMaintain normal activity, including exercise Prevent acute episodes of asthmaPrevent acute episodes of asthma Minimize ER visits and hospitalizationsMinimize ER visits and hospitalizations Minimize need for reliever medicationsMinimize need for reliever medications Maintain near-normal pulmonary functionMaintain near-normal pulmonary function Avoid adverse effects of asthma medicationsAvoid adverse effects of asthma medications

Treatment of AsthmaTreatment of Asthma

Global Initiative for Asthma (GINA) 6-point planGlobal Initiative for Asthma (GINA) 6-point plan Educate patients to develop a partnership in asthma Educate patients to develop a partnership in asthma

managementmanagement Assess and monitor asthma severity with symptom Assess and monitor asthma severity with symptom

reports and measures of lung function as much as reports and measures of lung function as much as possiblepossible

Avoid exposure to risk factorsAvoid exposure to risk factors Establish medication plans for chronic management in Establish medication plans for chronic management in

children and adultschildren and adults Establish individual plans for managing exacerbationsEstablish individual plans for managing exacerbations Provide regular follow-up careProvide regular follow-up care

Written Action PlansWritten Action Plans

Written action plans for patients to follow Written action plans for patients to follow during exacerbations have been shown to:during exacerbations have been shown to: (Cochrane review of 25 studies)(Cochrane review of 25 studies) Decrease emergency department visitsDecrease emergency department visits Decrease hospitalizationsDecrease hospitalizations Improve lung functionImprove lung function Decrease mortality in patients presenting with an Decrease mortality in patients presenting with an

acute asthma exacerbationacute asthma exacerbation NAEPP recommends a written action plan*NAEPP recommends a written action plan*

PharmacotherapyPharmacotherapy

Long-acting beta2-agonists (LABA)Long-acting beta2-agonists (LABA) Beta2-receptors are the predominant receptors in Beta2-receptors are the predominant receptors in

bronchial smooth musclebronchial smooth muscle Stimulate ATP-cAMP which leads to relaxation of Stimulate ATP-cAMP which leads to relaxation of

bronchial smooth muscle and inhibition of release bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivityof mediators of immediate hypersensitivity

Inhibits release of mast cell mediators such as Inhibits release of mast cell mediators such as histamine, leukotrienes, and prostaglandin-D2histamine, leukotrienes, and prostaglandin-D2

Beta1-receptors are predominant receptors in heart, Beta1-receptors are predominant receptors in heart, but up to 10-50% can be beta2-receptorsbut up to 10-50% can be beta2-receptors


Long-acting beta2-agonists (LABA)Long-acting beta2-agonists (LABA) Salmeterol (Serevent)Salmeterol (Serevent) Salmeterol with fluticasone (Advair)Salmeterol with fluticasone (Advair) Should only be used as an additional treatment Should only be used as an additional treatment

when patients are not adequately controlled with when patients are not adequately controlled with inhaled corticosteroidsinhaled corticosteroids

Should not be used as rescue medicationShould not be used as rescue medication Can be used age 4 and above with a DPICan be used age 4 and above with a DPI Deaths associated with inappropriate use as only Deaths associated with inappropriate use as only

medication for asthmamedication for asthma


AlbuterolAlbuterol Short-acting beta2-agonistShort-acting beta2-agonist

ATP to cAMP leads to relaxation of bronchial smooth ATP to cAMP leads to relaxation of bronchial smooth muscle, inhibition of release of mediators of immediate muscle, inhibition of release of mediators of immediate hypersensitivity from cells, especially mast cellshypersensitivity from cells, especially mast cells

Should be used prn not on a regular scheduleShould be used prn not on a regular schedule Prior to exercise or known exposure to triggersPrior to exercise or known exposure to triggers Up to every 4 hours during acute exacerbation as part of Up to every 4 hours during acute exacerbation as part of

a written action plana written action plan


Inhaled CorticosteroidsInhaled Corticosteroids Anti-inflammatory (but precise MOA not known)Anti-inflammatory (but precise MOA not known) Act locally in lungs Act locally in lungs

Some systemic absorptionSome systemic absorption Risks of possible growth retardation thought to be Risks of possible growth retardation thought to be

outweighed by benefits of controlling asthmaoutweighed by benefits of controlling asthma Not intended to be used as rescue medicationNot intended to be used as rescue medication Benefits may not be fully realized for 1-2 weeksBenefits may not be fully realized for 1-2 weeks Preferred treatment in persistent asthmaPreferred treatment in persistent asthma


Mast cell stabilizers (cromolyn/nedocromil)Mast cell stabilizers (cromolyn/nedocromil) Inhibits release of mediators from mast cells Inhibits release of mediators from mast cells

(degranulation) after exposure to specific antigens(degranulation) after exposure to specific antigens Blocks Ca2+ ions from entering the mast cellBlocks Ca2+ ions from entering the mast cell Safe for pediatrics (including infants)Safe for pediatrics (including infants) Should be started 2-4 weeks before allergy season Should be started 2-4 weeks before allergy season

when symptoms are expected to be effectivewhen symptoms are expected to be effective Can be used before exercise (not as good as ICS)Can be used before exercise (not as good as ICS) Alternate med for persistent asthmaAlternate med for persistent asthma


Leukotriene receptor antagonistsLeukotriene receptor antagonists Leukotriene-mediated effects include:Leukotriene-mediated effects include:

Airway edemaAirway edema Smooth muscle contractionSmooth muscle contraction Altered cellular activity associated with the Altered cellular activity associated with the

inflammatory processinflammatory process Receptors have been found in airway smooth Receptors have been found in airway smooth

muscle cells and macrophages and on other pro-muscle cells and macrophages and on other pro-inflammatory cells (including eosinophils and inflammatory cells (including eosinophils and certain myeloid stem cells) and nasal mucosacertain myeloid stem cells) and nasal mucosa


Leukotriene receptor antagonistsLeukotriene receptor antagonists No good long-term studies in pediatricsNo good long-term studies in pediatrics Montelukast as young as 2; zarfirlukast age 7Montelukast as young as 2; zarfirlukast age 7 Alternate, but not preferred medication in Alternate, but not preferred medication in

persistent asthma and as addition to ICSpersistent asthma and as addition to ICS Showed a statistically significant, but modest Showed a statistically significant, but modest

improvement when used as primary medicationimprovement when used as primary medication


TheophyllineTheophylline Narrow therapeutic index/Maintain 5-20 mcg/mLNarrow therapeutic index/Maintain 5-20 mcg/mL Variability in clearance leads to a range of doses Variability in clearance leads to a range of doses

that vary 4-fold in order to reach a therapeutic dosethat vary 4-fold in order to reach a therapeutic dose Mechanism of actionMechanism of action

Smooth muscle relaxation (bronchodilation)Smooth muscle relaxation (bronchodilation) Suppression of the response of the airways to stimuliSuppression of the response of the airways to stimuli Increase force of contraction of diaphragmatic musclesIncrease force of contraction of diaphragmatic muscles

Interacts with many other drugsInteracts with many other drugs

Various severities of asthmaVarious severities of asthma

Step-wise pharmacotherapy treatment program Step-wise pharmacotherapy treatment program for varying severities of asthmafor varying severities of asthma Mild Intermittent (Step 1)Mild Intermittent (Step 1) Mild Persistent (Step 2)Mild Persistent (Step 2) Moderate Persistent (Step 3)Moderate Persistent (Step 3) Severe Persistent (Step 4)Severe Persistent (Step 4)

Patient fits into the highest category that they Patient fits into the highest category that they meet one of the criteria formeet one of the criteria for

Mild Intermittent AsthmaMild Intermittent Asthma

Day time symptoms Day time symptoms << 2 times q week 2 times q week Night time symptoms Night time symptoms << 2 times q month 2 times q month PEF or FEV1 PEF or FEV1 >> 80% of predicted 80% of predicted PEF variability < 20%PEF variability < 20%

PEF and FEV1 values are only for adults and for PEF and FEV1 values are only for adults and for children over the age of 5children over the age of 5

Mild Persistent AsthmaMild Persistent Asthma

Day time symptoms > 2/week, but < 1/dayDay time symptoms > 2/week, but < 1/day Night time symptoms < 1 night q weekNight time symptoms < 1 night q week PEF or FEV1 PEF or FEV1 >> 80% of predicted 80% of predicted PEF variability 20%-30%PEF variability 20%-30%

Moderate Persistent AsthmaModerate Persistent Asthma

Day time symptoms q dayDay time symptoms q day Night time symptoms > 1 night q weekNight time symptoms > 1 night q week PEF or FEV1 60%-80% of predictedPEF or FEV1 60%-80% of predicted PEF variability >30%PEF variability >30%

Severe Persistent AsthmaSevere Persistent Asthma

Day time symptoms: continualDay time symptoms: continual Night time symptoms: frequentNight time symptoms: frequent PEF or FEV1 PEF or FEV1 << 60% of predicted 60% of predicted PEF variability > 30%PEF variability > 30%

Pharmacotherapy for Adults and Pharmacotherapy for Adults and Children Over the Age of 5 Years Children Over the Age of 5 Years

Step 1 (Mild intermittent asthma)Step 1 (Mild intermittent asthma) No daily medication neededNo daily medication needed PRN short-acting bronchodilator (albuterol) MDIPRN short-acting bronchodilator (albuterol) MDI Severe exacerbations may require systemic Severe exacerbations may require systemic

corticosteroidscorticosteroids Although the overall diagnosis is “mild Although the overall diagnosis is “mild

intermittent” the exacerbations themselves can still intermittent” the exacerbations themselves can still be severebe severe

Pharmacotherapy for Adults and Pharmacotherapy for Adults and Children Over the Age of 5 YearsChildren Over the Age of 5 Years

Step 2 (Mild persistent)Step 2 (Mild persistent) Preferred TreatmentPreferred Treatment

Low-dose inhaled corticosteroid dailyLow-dose inhaled corticosteroid daily Alternative Treatment (no particular order)Alternative Treatment (no particular order)

CromolynCromolyn Leukotriene receptor antagonistLeukotriene receptor antagonist NedocromilNedocromil Sustained release theophylline to maintain a blood level Sustained release theophylline to maintain a blood level

of 5-15 mcg/mLof 5-15 mcg/mL


Step 3 (Moderate persistent)Step 3 (Moderate persistent) Preferred TreatmentPreferred Treatment

Low-to-medium dose inhaled corticosteroidsLow-to-medium dose inhaled corticosteroids WITH long-acting inhaled beta2-agonistWITH long-acting inhaled beta2-agonist

Alternative TreatmentAlternative Treatment Increase inhaled corticosteroids within the medium dose Increase inhaled corticosteroids within the medium dose

rangerange Add leukotriene receptor antagonist or theophylline to Add leukotriene receptor antagonist or theophylline to

the inhaled corticosteroidthe inhaled corticosteroid


Step 4 (Severe persistent)Step 4 (Severe persistent) Preferred TreatmentPreferred Treatment

High-dose inhaled corticosteroidsHigh-dose inhaled corticosteroids AND long-acting inhaled beta2-agonistsAND long-acting inhaled beta2-agonists AND (if needed) oral corticosteroidsAND (if needed) oral corticosteroids

Pharmacotherapy for Infants and Pharmacotherapy for Infants and Young Children (<5 years)Young Children (<5 years)

Step 1(mild intermittent)Step 1(mild intermittent) No daily medication neededNo daily medication needed


Step 2 (mild persistent)Step 2 (mild persistent) Preferred treatmentPreferred treatment

Low-dose inhaled corticosteroidsLow-dose inhaled corticosteroids Alternative treatmentAlternative treatment

Cromolyn (nebulizer preferred)Cromolyn (nebulizer preferred) OR leukotriene receptor antagonistOR leukotriene receptor antagonist


Step 3 (moderate persistent)Step 3 (moderate persistent) Preferred treatmentPreferred treatment

Low-dose inhaled corticosteroids and long-acting beta2-Low-dose inhaled corticosteroids and long-acting beta2-agonistagonist

OR Medium-dose inhaled corticosteroidsOR Medium-dose inhaled corticosteroids Alternative treatmentAlternative treatment

Low-dose inhaled corticosteroids with either:Low-dose inhaled corticosteroids with either: Leukotriene receptor antagonistLeukotriene receptor antagonist OR theophyllineOR theophylline


Step 4 (severe persistent)Step 4 (severe persistent) Preferred treatmentPreferred treatment

High-dose inhaled corticosteroidsHigh-dose inhaled corticosteroids AND long-acting inhaled beta2-agonistAND long-acting inhaled beta2-agonist AND (if needed) Oral corticosteroidsAND (if needed) Oral corticosteroids

For young children, inhaled medications should be For young children, inhaled medications should be given by nebulizer, dry powder inhaler (DPI), or given by nebulizer, dry powder inhaler (DPI), or MDI with a chamber/spacerMDI with a chamber/spacer

Acute ExacerbationsAcute Exacerbations

Inhaled albuterol is the treatment of choice in Inhaled albuterol is the treatment of choice in absence of impending respiratory failureabsence of impending respiratory failure

MDI with spacer as effective as nebulizer with MDI with spacer as effective as nebulizer with equivalent dosesequivalent doses

Adding an antibiotic during an acute Adding an antibiotic during an acute exacerbation is not recommended in the exacerbation is not recommended in the absence of evidence of an acute bacterial absence of evidence of an acute bacterial infectioninfection

Acute ExacerbationsAcute Exacerbations

BeneficialBeneficial Inhaled atrovent added to beta2-agonistsInhaled atrovent added to beta2-agonists High-dose inhaled corticosteroidsHigh-dose inhaled corticosteroids MDI with spacer as effective as nebulizerMDI with spacer as effective as nebulizer OxygenOxygen Systemic steroidsSystemic steroids

Likely to be beneficialLikely to be beneficial IV theophyllineIV theophylline

Exercise-induced BronchospasmExercise-induced Bronchospasm

Evaluate for underlying asthma and treat Evaluate for underlying asthma and treat SABA are best pre-treatmentSABA are best pre-treatment Mast cell stabilizers less effective than SABAMast cell stabilizers less effective than SABA Anticholinergics less effective than mast cell Anticholinergics less effective than mast cell

stabilizersstabilizers SABA + mast cell stabilizer not better than SABA + mast cell stabilizer not better than

SABA aloneSABA alone

QuestionQuestion

Which one of the following is true concerning Which one of the following is true concerning control of mild persistent asthma in the control of mild persistent asthma in the pediatric population?pediatric population? Cromolyn should not be used under age 5Cromolyn should not be used under age 5 Atrovent should be added if beta-agonists do not Atrovent should be added if beta-agonists do not

maintain control of asthmamaintain control of asthma LABA should be added if SABA is ineffectiveLABA should be added if SABA is ineffective SABA may be used q2h to maintain controlSABA may be used q2h to maintain control Initial treatment should be an inhaled anti-Initial treatment should be an inhaled anti-

inflammatory such as ICS or cromolyninflammatory such as ICS or cromolyn

Answer EAnswer E

Initial medications for chronic asthma should Initial medications for chronic asthma should include an anti-inflammatory such as ICS or include an anti-inflammatory such as ICS or cromolyn. Cromolyn is safe for all pediatric cromolyn. Cromolyn is safe for all pediatric age groups. Atrovent is useful in COPD, but age groups. Atrovent is useful in COPD, but very limited use in asthma. Albuterol should very limited use in asthma. Albuterol should be used up to every 4 hours prn. Overuse of be used up to every 4 hours prn. Overuse of inhaled beta-agonists has been associated with inhaled beta-agonists has been associated with an increased mortality rate. an increased mortality rate.

QuestionQuestion

It is estimated allergic rhinitis affects how may It is estimated allergic rhinitis affects how may people in the US?people in the US? 20 million20 million 40 million40 million 50 million50 million 100 million100 million

Answer: B 40 millionAnswer: B 40 million

QuestionQuestion

Which one of the following statements concerning Which one of the following statements concerning the association between allergic rhinitis and asthma is the association between allergic rhinitis and asthma is false?false? Almost all patients with allergic asthma also have Almost all patients with allergic asthma also have

symptoms of rhinitissymptoms of rhinitis About 1/3 of patients with allergic rhinitis also have asthmaAbout 1/3 of patients with allergic rhinitis also have asthma Pharmacologic treatment for allergic rhinitis will not Pharmacologic treatment for allergic rhinitis will not

improve the symptoms of asthmaimprove the symptoms of asthma Patients with allergic rhinitis and patients with asthma Patients with allergic rhinitis and patients with asthma

exhibit peripheral eosinophilia and basophilia.exhibit peripheral eosinophilia and basophilia.

Answer: CAnswer: C

Patients with asthma should have their allergic Patients with asthma should have their allergic rhinitis treatedrhinitis treated

People with asthma and allergic rhinitis who People with asthma and allergic rhinitis who are treated for their allergic rhinitis have a are treated for their allergic rhinitis have a significantly lower risk of subsequent asthma-significantly lower risk of subsequent asthma-related events than those not treated for related events than those not treated for allergic rhinitis.allergic rhinitis.

QuestionQuestion

Which one of the following findings on a nasal Which one of the following findings on a nasal smear suggests a diagnosis of allergic rhinitis?smear suggests a diagnosis of allergic rhinitis? > 10% neutrophils> 10% neutrophils > 10% eosinophils> 10% eosinophils < 10% neutrophils< 10% neutrophils > 10% erythrocytes> 10% erythrocytes

Answer: B >10% eosinophilsAnswer: B >10% eosinophils

QuestionQuestion

Which of the following statements is true?Which of the following statements is true? An acceptable strategy for eliminating sedating An acceptable strategy for eliminating sedating

effects of 1effects of 1stst-generation antihistamines and -generation antihistamines and containing the cost of 2containing the cost of 2ndnd-generation is to use 2nd--generation is to use 2nd-generation in the AM and 1generation in the AM and 1stst-generation in the PM-generation in the PM

In most states, patients taking 1In most states, patients taking 1stst-generation are -generation are considered “under the influence of drugs.”considered “under the influence of drugs.”

Mast cell stabilizers are becoming an excellent Mast cell stabilizers are becoming an excellent choice for children because of their ability to treat choice for children because of their ability to treat symptoms after they have started and their safetysymptoms after they have started and their safety

Answer: BAnswer: B

Patients taking 1Patients taking 1stst-generation antihistamines -generation antihistamines are considered “under the influence of drugs.” are considered “under the influence of drugs.” The sedating effects have been shown to carry The sedating effects have been shown to carry over to the next day even when taken only at over to the next day even when taken only at night and this type of chronic use is not night and this type of chronic use is not recommended.recommended.

Mast cell stabilizers should be started before Mast cell stabilizers should be started before symptoms develop, not after.symptoms develop, not after.

Questions?Questions?

Date post:	17-Nov-2014
Category:	Documents
Upload:	theresiask
View:	130 times
Download:	0 times

Rochelle M. Nolte, MD CDR USPHS Family

Documents