Asthma outpatient

Asthma out patient

Claudia Carranza, PGY-3

Multiple Choice

18-month-old boy has been hospitalized with “bronchitis” two times in the past 6 months, the first time he was positive for RSV, his viral panel was negative the second time. After each dismissal he needed a nebulizer with albuterol for several weeks for prolonged wheezing. Mom had asthma as a kid.

• He meets criteria for asthma and needs oral steroids

• Is too young to be asthmatic and can be symptomatically treated with albuterol

• Is more likely to be asthmatic if he develops eczema and presents in future episodes with cough or wheezing that respond to albuterol

• Needs blood testing for CF

Open Ended

ASTHMA PREDICTIVE INDEX:

≥3 wheezing episodes per 12 months

With one major criterion or two minor criteria:

-Major criteria:

Atopic dermatitis

Parental asthma

-Minor criteria:

Peripheral eosinophilia > 4%

Wheezing apart from cold

Allergic rhinitis*

Multiple Choice

He presented to clinic after 6 weeks with a runny nose, eczema on his face, and cough with post-tussive emesis. He was found to be hypoxic and required a third hospitalization.

Management in hospital was supportive for eczema, URI, supplemental oxygen, and albuterol that significantly reduced wheezing and helped wean off O2.

What is missing from the treatment and diagnosis of this patient?

• He needs to be tested for environmental allergies

• He is being exposed to passive smoking

• Albuterol is not properly administered

• He will likely develop asthma and should currently be treated as persistent asthma with inhaled corticosteroids with a spacer and a mask

Multiple Choice

13-year-old freshman started track and comes to see you with new onset cough and chest tightness that occur after running short distance, especially on cold fall days. Preciously healthy, no history of eczema, allergic rhinitis, no family history of asthma, normal spirometry and CBC. No symptoms active.

• Patient’s symptoms consistent with exercise-induced bronchospasm.

• Symptoms are due to a viral illness that will resolve in time

• Treatment for this condition is speech therapy

• Repeat spirometry is necessary

Multiple Choice

7 year old with moderate persistent asthma diagnosed 2 years ago and treated with moderate dose inhaled corticosteroids shows up to your clinic for a follow-up, family reports no need for rescue albuterol except less than twice a month with exercise, no hospitalizations, and good tolerance for activity. In addition to attempting to wean the inhaled steroids on this patient

• You obtain a CBC to assess his eosinophil count

• You don’t wean steroids because of good symptom control

• You obtain spirometry if it was not obtained on this patient since chronologically patient is old enough now to do it

• You ask patient to return for follow-up in the fall

Multiple Choice

14 year old presents to your office with wheezing and cough that occur during the “cold” months and when he is sick, otherwise he is asymptomatic. He needs clearance to participate in football and a doctor’s note to use his inhaler if needed.

To determine if this patient is asthmatic:

• You obtain spirometry since he is older than 5 and if his results show obstructive disease (FEV1, FEV1/FVC less than 80%) then he has asthma

• You get an IgE to check for atopy

• You get more history as well as spirometry to classify and treat accordingly

• He is asthmatic because he wheezes with exercise

Multiple Choice

This patient tells you he never uses albuterol more than two times a week, has less than two awakenings per month at night due to cough/wheezing, he has not been to emergency room in the past year, nor has he been hospitalized. His wheezing occurs with viral colds and resolves usually within a week, exercise makes him cough and wheeze during the cold months.

• Intermittent

• Mild persistent

• Moderate persistent

• Severe persistent

• He has no asthma

Multiple Choice

You treat him with

• Exercise avoidance during cold months

• Inhaled steroids

• No treatment

• Albuterol as needed

Multiple Choice

During the cold months when this patient needs to exercise, you:

• Recommend he avoids football since it makes him sick

• Pretreat him with albuterol

• Give him inhaled steroids during football season since he is symptomatic daily

• Repeat spirometry

Multiple Choice

12 year old with daily wheezing when she climbs stairs and during recess and gym. She is awakened by cough at least once a week and has been hospitalized once in the past year and visited the ER three times with asthma exacerbations requiring steroids. Her asthma is

• Intermittent

• Mild persistent

• Moderate persistent

• Severe persistent

Multiple Choice

You start this patient on which of the following and see her back in:

• Oral steroids, and follow her in a week.

• Moderate dose ICS with spacer after teaching technique and follow her up in 2 weeks

• Immunotherapy in addition to ICS, follow her up in 5 days.

• Albuterol and montelukast (Singulair), follow-up in a month

Multiple Choice

After the initial 2 week visit the family tells you she is “a different kid,” able to run during family picnic and help with chores, she sleeps through the night. When do you bring this patient back for a follow-up and possible change in ICS?

• In 6 months but keep her for 1 year on current ICS dose.

• In 2–3 months but plan to increase her dose then.

• In 2–3 months and plan to half her ICS dose if it’s a favorable time of the year, and her spirometry is normal.

• As needed if she develops symptoms

Multiple Choice

23-year-old woman previously diagnosed and treated for mild persistent asthma. Presents in February after having stopped her inhaled steroids for over 3 weeks. Her spirometry is the following: FVC 103% FEV1 103% FEV1/FVC 89% FEF 25%–75% 108%. She neither denies any symptoms of cough nor wheezing, has not required any albuterol. She does best during winter, and her asthma flares back up again when the trees bloom. Best course of action with this patient is to:

• Keep her off ICS that she discontinued since her spirometry is normal

• Restart her on ICS, she has persistent asthma and that is treatment modality

• Keep her off ICS and look closely at her “flare-up” season to restart ICS inhaler early in the season.

• Keep her off ICS inhaler and ask her to return when her symptoms change

Multiple Choice

A 12 year old with asthma since fifth year of life presents with worsening shortness of breath over past month. She had been on low dose ICS and albuterol inhalations. Her symptoms of cough and shortness of breath occur daily, worsen during recess, and wake her up four to five nights per week. What is the best intervention at this time?

• Start omalizumab therapy (immunotherapy Xolair).

• Increase albuterol to every 4 hours

• Continue current regimen but pretreat exercise with albuterol.

• Increase inhaled corticosteroid to medium dose.

Multiple Choice

You get a message in your inbox to refill the albuterol inhaler of your 43-year-old patient with Intellectual Developmental Disability (IDD) from the assisted living facility, you deny the refill and ask to have her brought in to see you ASAP because of all but the following reason:

• This is the third refill this month.

• She has a history of severe disease requiring hospitalization.

• You gave her an action plan for the yellow zone.

• You had to start her on oral steroids twice in past 9 months

Multiple Choice

A 28-year-old woman presents with increased need for albuterol over the past 2 months, she is on daily-inhaled beclomethasone at a moderate dose. She has been waking up more than two nights a week with shortness of breath and wheezing, has not been able to tolerate going up stairs. She has a known allergy to mold and dust mites. She had stopped taking her nasal steroid due to recurrent nosebleeds.

The acute change is because:

• She is pregnant.

• She has moved and is now living in a basement with humidity

• Her rhinitis symptoms are exacerbating her asthma

• She stopped taking her H2 blocker.

Multiple Choice

12-year-old boy with asthma diagnosis has become progressively unresponsive to bronchodilators and corticosteroids in the past 2 years. Spirometry shows a flow-volume loop with flattening of the inspiratory loop. Flexible fiber optic laryngoscopy shows adduction of vocal cords and narrowing of the subglottic area during inspiration. Which of the following is the diagnosis?

• Vocal cord dysfunction

• Subglottic stenosis

• Laryngomalacia

• Worsening asthma

Multiple Choice

54-year-old welder comes to see you with chest tightness and cough. He recently was reassigned to a new location on the ship that has better “air” according to the patient so he doesn’t wear his mask as much. He has been taking his combination ICS/LABA as prescribed. The recent exacerbation/yellow zone can be attributed to:

• Poor compliance with maintenance steroids

• Chronic lung changes

• Increased exposure to fumes at workplace

• Viral illness