Questions and Answers
What is the confirmed variable expiratory airflow limitation in asthma?
FEV1/FVC is reduced, usually >0.75-0.80 in adults
For asthma, the initial controller treatment involves referring to the ______.
sheet
Which of the following are common issues to assess before considering a step-up in asthma treatment? (Select all that apply)
Corticosteroids are recommended for outpatient use with pneumonia.
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What is RSV prevention administered to infants under 8 months entering their first RSV season?
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Which antiviral is recommended for children 2 weeks and older?
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Group A COPD patients with mMRC 0-1, CAT <=2 should receive a ______.
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What should the asthma action plan include?
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ICS increases the risk for pneumonia in COPD patients.
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What is the minimum duration for antibiotic treatment recommended for pneumonia?
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What are the components to assess in personalized asthma management?
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Using ICS-formoterol as a reliever reduces the risk of exacerbations compared to using a SABA reliever.
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What should be done before considering a regimen with SABA reliever?
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The preferred reliever for Track 1 is __________.
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Match the asthma treatment steps with their descriptions:
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Consider high dose __________ when adding treatments.
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Which of the following are alternative reliever options mentioned?
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What is the first step in controller treatment for patients with asthma who have symptoms less than twice a month?
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Which treatment step corresponds to patients experiencing symptoms most days or waking with asthma once a week or more?
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A patient with asthma symptoms occurring twice a month should start at Step 2.
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What should be assessed in patients before starting controller treatment for asthma?
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What is a preferred reliever for patients prescribed maintenance and reliever therapy?
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Low-dose ICS-form is the reliever only for patients prescribed __________.
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Which of the following is NOT listed as a component of the preferred controller options for asthma?
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What additional therapy may be added for patients with low lung function?
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What is a preferred controller to prevent exacerbations in children with asthma?
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Daily low dose inhaled corticosteroid (ICS) is recommended for all children with asthma.
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What should be assessed during the management of a child's asthma?
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The short-acting medication used as a reliever for asthma is called a __________.
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Which of the following are modifiable risk factors in asthma management? (Select all that apply)
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What is a non-pharmacological strategy for managing asthma?
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Match the following steps with their description in asthma medication management:
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What should be confirmed first in the assessment of a child with asthma?
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If a child has symptoms most days and low lung function, a medium dose ICS-LABA should be started.
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What should be initiated if a child has symptoms most days or wakes at night at least once a week?
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What is the treatment step for children with asthma who have symptoms twice a month or more?
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A child with asthma who has symptoms less than twice a month does not need any daily medication.
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A short course of ______ may also be needed for patients presenting with severely uncontrolled asthma.
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Study Notes
Asthma
- Diagnosing asthma involves:
- History of respiratory symptoms that vary in time and intensity, occurring or worsening at night, when walking, or triggered by exercise, laughter, allergens, or cold air
- Confirmed variable expiratory airflow limitation, with FEV1 reduction and FEV1/FVC ratio usually >0.75-0.80 in adults
- Documented excessive variability in lung function
- Shared decision making involves:
- Inhaler skills and adherence
- Written asthma action plan
- Self-monitoring of symptoms and/or peak flow
- Regular medical review
- Non-pharmacological interventions include:
- Smoking cessation
- Physical activity
- Investigation for occupational asthma
- Identification of aspirin-exacerbated respiratory disease
- Initial controller therapy:
- Sustained step-up for at least 2-3 months
- Short-term step-up for 1-2 weeks
- Day-to-day adjustment by the patient
- Stepping down asthma therapy:
- Considered once good asthma control has been achieved and maintained for 3 months
- Aim to find the lowest therapy that controls symptoms and exacerbations while minimizing side effects
- Treating exacerbations:
- Acute or sub-acute worsening of symptoms and lung function from the patient's usual status
- Oral corticosteroids (preferably morning dose) for 5-7 days
- Tapering not needed if OCS has been given for less than 2 weeks
- Stepwise approach for children under 5:
- Step 1: As-needed inhaled SABA
- Step 2: Low-dose ICS daily plus SABA as needed or daily LTRA + SABA as needed
- Step 3: Double low-dose ICS + SABA as needed or low-dose ICS + LTRA
- Step 4: Continue controller and refer to specialist for assessment
COPD
- Group E (exacerbation): those with ≥2 moderate exacerbations or ≥1 leading to hospitalization
- LABA + LAMA (consider LABA+LAMA+ICS if blood eosinophil ≥300)
- ICS increases risk of pneumonia in these patients
- For those with 0 or 1 moderate exacerbations (not leading to hospital admission):
- Group A: Bronchodilator (LABA) with mMRC 0-1, CAT ≤2, CAT ≥10
Community-Acquired Pneumonia
- Adults:
- Viral causes including influenza
- Bacterial causes including streptococcus, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma, Chlamydia, and Legionella
- Outpatient treatment:
- For healthy adults without comorbidities or risk factors for antibiotic-resistant pathogens:
- Amoxicillin 1g three times daily or
- Doxycycline 100mg twice daily
- For healthy adults without comorbidities or risk factors for antibiotic-resistant pathogens:
- High-risk individuals:
- Combination therapy:
- Amoxicillin/clavulanate or Cephalosporin
- AND Macrolide (azithromycin or clarithromycin) or Doxycycline
- Or monotherapy: respiratory fluoroquinolone (floxacin)
- Combination therapy:
- How to choose an agent:
- Consider recent antibiotic use and choose a different class
- Duration of treatment:
- Minimum of 5 days
- Patients should be afebrile and clinically stable for 48-72 hours before stopping
RSV
- Nirsevimab:
- A monoclonal antibody for infants under 8 months entering their first RSV season (October-March) not vaccinated
- Children up to 24 months who remain at risk of severe RSV disease through their second season
- Vaccinating pregnant people (32-36 weeks) generally means the baby will not need Nirsevimab
- Palivizumab:
- A monoclonal antibody produced by recombinant DNA
- Used for RSV prevention in infants/children at high risk for severe RSV disease
- Noted reduced RSV disease hospitalization rate by up to 55%
- Provides passive immunity, plays no role in treating acute RSV, and is FDA-approved for adults at high risk for severe RSV
- RSV Vaccination:
- Provides protection against RSV
- Models:
- Direct immunization of at-risk adults
- Immunize during pregnancy (especially in adults ≥60 years)
Flu
- Antiviral therapy:
- Does not treat the virus but helps prevent mortality and hospitalizations
- Recommend for anyone exposed to flu or has flu
- Management:
- Antivirals:
- Oseltamivir (children 2 weeks and older)
- Zanamivir (children 7 and older)
- Peramivir (children 2 and older, IV only)
- Baloxavir (children 5-12, not for pregnant or lactating women)
- Antivirals:
- Empiric treatment most effective within 24 hours
- For outpatients with suspected or confirmed uncomplicated influenza:
- Oral oseltamivir or inhaled zanamivir or oral baloxavir
COVID-19
- Preferred therapies:
- With + SARS test, eligible adults, and pediatrics patients at risk for severe COVID-19:
- Ritonavir-boosted nirmatrelvir PO (start within 5 days of symptom onset for 5 days)
- Remdesivir IV (start within 7 days of symptom onset for 3 days)
- Alternative therapies: bebtelovimab and molnupriravir
- With + SARS test, eligible adults, and pediatrics patients at risk for severe COVID-19:
Allergic Rhinitis
- Three classes of drugs are utilized:
- Glucocorticoids (intranasal):
- Best for both seasonal and perennial rhinitis
- Examples: budesonide, fluticasone propionate (flonase), and triamcinolone
- Adverse effects: nasal mucosa drying, burning/itching, sore throat, epistaxis
- Antihistamines (oral and intranasal):
- First line for mild-moderate allergic rhinitis
- Most effective when taken prophylactically
- Examples:
- Ethanolamines (diphenhydramine) and phenothiazines (promethazine)
- Alkylamines (chlorpheniramine) only modest reduction in alertness
- Fexofenadine (reduce dose for renal impairment)
- Intranasal: azelastine and olopatadine
- Sympathomimetics (oral and intranasal):
- Only relieve congestion
- Adverse effects: rebound congestion when used > a few days
- Examples:
- Phenylephrine (oral and nasal)
- Pseudoephedrine (oral)
- Glucocorticoids (intranasal):
Personalized Asthma Management
- Assess and adjust treatment based on individual patient needs, considering:
- Symptoms
- Exacerbations
- Side-effects
- Lung function
- Patient satisfaction
Confirmation of Diagnosis
- Verify diagnosis by considering:
- Symptom control and modifiable risk factors
- Lung function
- Comorbidities
- Inhaler technique and adherence
- Patient preferences and goals
Treatment of Modifiable Risk Factors and Comorbidities
- Implement non-pharmacological strategies
- Adjust asthma medications (up, down, or between tracks)
- Provide education and skills training
Controller and Preferred Reliever (Track 1)
- Using ICS-formoterol as reliever reduces exacerbation risk compared to SABA reliever
- Treatment steps:
- As-needed low-dose ICS-formoterol (Steps 1-2)
- Low-dose maintenance ICS-formoterol (Step 3)
- Medium-dose maintenance ICS-formoterol (Step 4)
- Add-on LAMA, refer for phenotypic assessment ± anti-IgE, anti-IL5/5R, anti-IL4R, consider high-dose ICS-formoterol (Step 5)
Controller and Alternative Reliever (Track 2)
- Before considering SABA reliever, ensure patient is likely to adhere to daily controller
- Alternative controller options for either track
- Reliever options:
- As-needed short-acting β2-agonist (Steps 1-5)
- Take ICS whenever SABA taken (Step 1)
- Low-dose maintenance ICS (Step 2)
- Low-dose maintenance ICS-LABA (Step 3)
- Medium/high-dose maintenance ICS-LABA (Step 4)
- Add-on LAMA, refer for phenotypic assessment ± anti-IgE, anti-IL5/5R, anti-IL4R, consider high-dose ICS-LABA (Step 5)
Assessing Asthma Patients
- Diagnosis confirmation is necessary
- Assess symptom control, modifiable risk factors, and lung function
- Identify comorbidities and evaluate inhaler technique and adherence
- Consider patient preferences and goals
Initial Treatment Steps
- Mild Symptoms (<2 times a month): As-needed low dose ICS-formoterol (Step 1)
- Moderate Symptoms (≥2 times a month, but < daily): Daily low dose inhaled corticosteroid (ICS) or as-needed low dose ICS-formoterol (Step 2)
- Daily Symptoms, or Waking with Asthma ≥1 time a week: Low dose ICS-LABA (Step 3)
- Daily Symptoms, Waking with Asthma ≥1 time a week, and Low Lung Function: Medium dose ICS-LABA (Step 4)
- Severe Symptoms: High dose ICS-LABA and consider referring for phenotypic assessment and add-on therapy (Step 5)
Preferred Controllers
- As-needed low dose ICS-formoterol to prevent exacerbations and control symptoms
- Low dose ICS taken whenever SABA is taken
- Daily leukotriene receptor antagonist (LTRA) as an alternative controller option
Preferred Relievers
- As-needed low dose ICS-formoterol for patients prescribed maintenance and reliever therapy
- As-needed short-acting β²-agonist (SABA) as an alternative reliever option
Personalized Asthma Management in Children 6-11 Years
Asthma Medication Options
- Adjust treatment up and down for individual child's needs based on symptoms, side-effects, lung function, and child and parent satisfaction
- Medication options include:
- Step 1: PREFERRED CONTROLLER to prevent exacerbations and control symptoms
- Step 2: Daily low dose inhaled corticosteroid (ICS) with dose ranges varying for children
- Step 3: Low dose ICS-LABA or medium dose ICS
- Step 4: Medium dose ICS-LABA, with referral for expert advice
- Step 5: Referral for phenotypic assessment and add-on therapy, such as anti-IgE
-
Other Controller Options:
- Low dose ICS taken whenever SABA taken or daily low dose ICS
- Daily leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken
- RELIEVER: As-needed short-acting β2β_2β2-agonist (SABA) using separate ICS and SABA inhalers
Assess
- Confirmation of diagnosis if necessary
- Symptom control and modifiable risk factors, including:
- Lung function
- Comorbidities
- Inhaler technique
- Adherence
- Child and parent preferences and goals
Adjust
- Treatment of modifiable risk factors and comorbidities
- Non-pharmacological strategies
- Asthma medications (adjust down or up)
- Education and skills training
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Description
This quiz covers the diagnosis and management of asthma, including signs and symptoms, trigger factors, and lung function tests.
