A 14-year-old male is brought to your office by his mother to establish care. The patient has been diagnosed with asthma, but has not been on any medications for the past year. When questioned, he reports that his asthmatic symptoms occur daily and more than one night per week. On examinations, he is found to have a peak expiratory flow rate of 75%.
Based on these findings, the most accurate classification of this patient’s asthma is:
Correct Answer C:
The National Asthma Education and Prevention Program (NAEPP) classifies asthma into four categories. Mild intermittent asthma is characterized by daytime symptoms occurring no more than 2 days per week, and nighttime symptoms no more than 2 nights per month. The peak expiratory flow (PEF), or forced expiratory volume in 1 second (FEV1) is 80% or more of predicted. Mild persistent asthma is characterized by daytime symptoms more than 2 days per week, but less than once a day, and nighttime symptoms more than 2 nights per month. PEF or FEV1 is 80% or more of predicted. Moderate persistent asthma is characterized by daytime symptoms daily and nighttime symptoms more than one night per week. PEF or FEV1 is 60%-80% of predicted. Severe persistent asthma is characterized by continuous daytime symptoms and frequent nighttime symptoms. PEF or FEV1 is 60% or less of predicted.
Metered-dose inhaler (MDI) and/or nebulizers can be used to administer short-acting beta-2-agonists for treating acute asthma exacerbations in children.
Which one of the following is true regarding these delivery methods?
The treatment of acute asthma exacerbations in children using β2 agonists delivered by metered-dose inhalers (MDIs) with spacers has been shown to be as effective as nebulized administration. The use of MDIs with spacers in this clinical setting has the advantage of lower costs, lower increases in pulse rate, and shorter emergency department stays. MDIs with spacers have been used successfully in children as young as 10 months of age and at doses as high as 10 puffs at once.
A 12-year-old African-Canadian female with asthma presents with a 2-day history of increasing cough and wheezing, preceded by symptoms of an upper respiratory infection. On examination she has a temperature of 37.2°C (99.0°F), 2+ expiratory wheezes throughout, and a peak flow of 50% of expected. Her oxygen saturation is 96%.
Which one of the following is true regarding treatment of this patient?
Correct Answer D: The addition of ipratropium to inhaled beta-2-agonists has been found to be more effective in acute asthmatic attacks than beta-2-agonists alone. Sudden exacerbations of asthma are common in children. Numerous treatments have been used in the past.
Beta-2-agonists have been shown to be equally effective whether administered via an inhaler and spacer device or by nebulization. As long as the gastrointestinal tract is working, intravenous corticosteroids have no benefit over oral corticosteroids.
Intravenous theophylline, which once was the mainstay of treatment, now is used only in a hospital setting to treat severe asthma not responding to other treatments. The marginal improvement is not great enough to outweigh the potential risk of cardiovascular, gastrointestinal, or central nervous system toxicity.
A 5-year-old male has moderate persistent asthma and allergic rhinitis.
Which one of the following is true regarding leukotriene inhibitors in this situation?
Correct Answer A:
In general, asthma is most effectively treated with inhaled corticosteroids (choice B). Adding a leukotriene inhibitor may be effective, but is less effective than adding a long acting beta-2-agonist (choice C). Leukotriene inhibitors are also less effective than intranasal corticosteroids for allergic rhinitis (choice A). Leukotriene inhibitors are considered inappropriate monotherapy for moderate persistent asthma (choice D), as they are less effective than inhaled corticosteroids. However, combined together these two medications allow significantly greater reduction in the dose of inhaled corticosteroids required to maintain clinical stability in chronic asthmatics.
An 8-year-old female with a history of reactive airway disease presents to your office for evaluation. She states that she uses her inhaled beta2agonist 4-5 times a week. She takes no other medications. She was hospitalized once last winter for an asthma exacerbation, but has been well since. She has some limitations in her exercise tolerance secondary to shortness of breath. She denies any pets at home and there is no tobacco exposure.
Which of the following medications should be added to her current regimen?
Correct Answer D: This patient has mild persistent asthma and is requiring use of her rescue beta2-agonist more than twice a week. An inhaled low dose steroid is the first line of therapy in controlling her symptoms.
A. There is nothing in the history provided that describes allergic symptoms that would be better controlled with an antihistamine.
B. Cromolyn sodium is sometimes used in addition to beta2-agonists, but inhaled steroids are first line therapy.
C. Theophylline is no longer preferred therapy because of side effects and drug levels that need to be followed.
E. Daily prednisone is used only in severe persistent asthmatics that are on maximum therapy and still having symptoms.
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