Asthma Disease and Management Quiz

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Questions and Answers

What characterizes asthma as a disease?

It affects only children and is not present in adults.

It is always associated with a viral infection.

It involves reversible airway obstruction and chronic inflammation. (correct)

It is primarily a genetic condition.

Which of the following symptoms is NOT commonly associated with asthma?

Persistent fever (correct)

Wheezing

Chest tightness

Shortness of breath

Which cells are primarily involved in the inflammatory response during an asthma attack?

Neutrophils and erythrocytes

Platelets and fibroblasts

Mast cells and lymphocytes (correct)

Neutrophils and endothelial cells

What mechanism does the autonomic nervous system use in asthma pathogenesis?

Promoting smooth muscle contraction through neuropeptides Signup and view all the answers

What is a common consequence of airway inflammation in asthma?

Airway hyperresponsiveness Signup and view all the answers

What condition is indicated by a decreased FEV1/FVC ratio in both adults and children?

Airflow limitation Signup and view all the answers

Which of the following is NOT a potential cause of congenital lobar emphysema?

Acquired respiratory distress Signup and view all the answers

What does a peak flow meter primarily measure?

Peak Expiratory Flow Rate Signup and view all the answers

What is the predicted normal PEFR formula for Filipino males?

(Height in cm - 100) x 5 + 175 Signup and view all the answers

How can spirometric tracings vary in patients with asthma after bronchodilator (BD) use?

FEV1 increases compared to pre-BD use Signup and view all the answers

What changes occur in the bronchioles of an asthmatic patient compared to normal bronchioles?

Contracted smooth muscles and increased mucus secretion Signup and view all the answers

Which of the following is a minor criterion in the Asthma Predictive Index?

Wheezing apart from colds Signup and view all the answers

Which of the following factors is NOT considered a risk factor for developing asthma?

Living in a high-altitude area Signup and view all the answers

What symptom pattern suggests a higher probability of asthma?

Symptoms worsening at night or in early morning Signup and view all the answers

Which of the following is a common trigger for asthma?

House dust mites Signup and view all the answers

What is a characteristic feature of asthma in children aged five years or younger?

Persistent non-productive cough, particularly at night Signup and view all the answers

Which statement would decrease the probability that symptoms are due to asthma?

Shortness of breath with light-headedness Signup and view all the answers

What is one of the characteristics that may be present in the diagnosis of asthma?

Variable airflow limitation evident through testing Signup and view all the answers

Which symptom is not typically associated with asthma in children?

Chest pain during physical activity Signup and view all the answers

Which factor is least likely to be considered when diagnosing asthma in children?

Exposure to high altitudes Signup and view all the answers

What is a key physical examination finding that suggests asthma?

Expiratory wheezing on forced expiration Signup and view all the answers

Which condition is a differential diagnosis for asthma in children under 5 years?

Tuberculosis Signup and view all the answers

Which diagnostic test is NOT typically used for asthma in children under 5 years?

Cardiac stress test Signup and view all the answers

Which symptom would most likely indicate a need for a therapeutic trial with ICS and SABA?

Improvement in symptoms after consistent treatment Signup and view all the answers

What does the Asthma Predictive Index (API) help to determine?

Risk of developing asthma Signup and view all the answers

What might indicate 'silent chest' in an asthma patient?

Complete absence of wheezing during an exacerbation Signup and view all the answers

Which condition is least likely to cause wheezing in children?

Lung cancer Signup and view all the answers

Which of these factors is NOT a characteristic symptom pattern in asthma?

Persistent fever Signup and view all the answers

What indicates that a child has excessive variability in lung function when measuring twice-daily PEF?

Average daily variability >12% Signup and view all the answers

Which medication category is focused on long-term management of asthma?

Controller medications Signup and view all the answers

During the positive bronchodilator reversibility test, what increase in FEV1 indicates a positive result in children?

<blockquote> 12% increase </blockquote> Signup and view all the answers

What does a fall in FEV1 of ≥20% with a bronchial challenge test indicate?

Severe asthma Signup and view all the answers

What is a common side effect of inhaled corticosteroids?

Skin thinning Signup and view all the answers

Which of the following medications is least effective in controlling asthma symptoms compared to low doses of inhaled corticosteroids?

Leukotriene receptor antagonists Signup and view all the answers

What is the recommended pulse rate indication for severe asthma exacerbations in children aged 0-3 years?

≤ 180 bpm Signup and view all the answers

Which condition may result from long-term severe asthma exacerbations?

Bronchiolitis obliterans Signup and view all the answers

What defines a 'Severe or Life-Threatening' asthma exacerbation in older children and adolescents?

Sits hunched forward Signup and view all the answers

Regarding systemic corticosteroids, which is a known side effect when used long-term?

Hypertension Signup and view all the answers

What percentage predicts minimal PEFR variability in a well-controlled asthma patient?

<10% Signup and view all the answers

In the management of asthma, which medication is primarily used during acute exacerbations?

Short-acting beta agonists Signup and view all the answers

Study Notes

Pediatric Obstructive Airway Diseases

Presented by Josy Naty M. Venturina-Fano, MD, DPPS, DPAPP

Asthma

Airway obstruction is reversible in most, but not all, patients, either spontaneously or with treatment.
Airway inflammation occurs.
Airway responsiveness is increased to various stimuli.
Asthma is a heterogeneous chronic inflammatory disorder.
Respiratory symptoms such as wheezing, shortness of breath, chest tightness, and cough vary over time and intensity.
Variable expiratory airflow limitation occurs.

Pathogenesis of Asthma

Non-immunologic stimuli, such as viral infections, physical stimuli, or chemical stimuli, trigger cell activation.
Immunologic stimuli (antigens) also trigger cell activation.
Mast cells, epithelial cells, macrophages, eosinophils, and lymphocytes are activated.
Inflammatory mediators, smooth muscle contraction, and chemotaxis result.
Airway edema, cellular infiltration, subepithelial fibrosis, mucous secretion, and mucosal vascular permeability occur.
Airway hyperresponsiveness results, eventually leading to asthma.

Asthma Risk Factors

Parental asthma
Allergies (atopic dermatitis, allergic rhinitis, food allergy; inhalant/allergen sensitization)
Severe lower respiratory tract infections (pneumonia, bronchiolitis) requiring hospitalization
Wheezing apart from colds
Male gender
Low birth weight
Environmental tobacco smoke exposure
Possible use of acetaminophen
Exposure to chlorinated swimming pools
Reduced lung function at birth

Asthma Predictive Index

Major Criteria: Parents with asthma, eczema, inhalant allergen sensitization
Minor Criteria: Allergic rhinitis, wheezing apart from colds, eosinophils ≥ 4%, food allergen sensitization.

Asthma Triggering Factors

House dust mites
Pets
Rodents
Cockroaches
Molds
Pollen
Food additives
Polluted environment
Smoking
Exercise
Viral upper respiratory tract infections (URTI)

Diagnosis of Asthma

Based on a history of characteristic symptom patterns.
Evidence of variable airflow limitation from bronchodilator reversibility testing or other tests.
Increased probability that symptoms are due to asthma if: More than one symptom type (wheeze, shortness of breath, cough, chest tightness), symptoms often worse at night or in the early morning, symptoms vary over time and intensity, symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather, laughter, irritants such as car fumes, smoke, or strong smells.
Decreased probability that symptoms are due to asthma if: Isolated cough with no other respiratory symptoms; chronic production of sputum; shortness of breath associated with dizziness, light-headedness or peripheral tingling; chest pain; exercise-induced dyspnea with noisy inspiration (stridor).

Physical Examination in Asthma

Physical examination may be normal in people with asthma.
The most common finding is expiratory wheezing on auscultation, especially with forced expiration.
Wheezing may be absent during severe asthma exacerbations ("silent chest").

Differential Diagnoses of Asthma in Children

Children ≤5 Years: Recurrent viral respiratory infections, gastroesophageal reflux, foreign body aspiration, tracheomalacia or bronchomalacia, tuberculosis, congenital heart disease
Older Children: Chronic upper airway cough syndrome, inhaled foreign body, bronchiectasis, primary ciliary dyskinesia, bronchopulmonary dysplasia, vocal cord dysfunction, hyperventilation, dysfunctional breathing, congenital heart disease, cystic fibrosis.

Tests to Diagnose Asthma in Children ≤5

Lung function testing for children 4–5 years of age.
Exhaled nitric oxide (FENO) measurement.
Asthma Predictive Index.
Therapeutic trial (as-needed short-acting beta2-agonist and regular inhaled corticosteroids [ICS]).
Skin prick testing, or allergen-specific immunoglobulin E.
Chest X-ray.

Chest X-Ray Findings for Children

Hyperinflation
Peribronchial thickening
Subsegmental/lobar atelectasis

Spirometry

Normal Values: Adults: >0.75 to 0.80; Children: >0.90.
Abnormal values suggest airflow limitation.
Spirometry should track FEV1 values before and after bronchodilator treatment.

Peak Flow Meter

Measures PEFR.
Predicted normal PEFR for Filipino children.
Separate values for males and females based on height.

Tests to Diagnose Asthma in Adolescents and Children (6-11 Years)

Documented excessive variability in lung function.
Documented airflow limitation.
Positive bronchodilator responsiveness (BD) test (more likely to be positive if BD medication is withheld before the test).
At least one measure of reduced lung function (FEV1).
Excessive variability in twice-daily PEF over 2 weeks
Increased values in FEV1 are a positive sign.
Positive exercise challenge test
Variation in FEV1, or PEF, between visits

Asthma Severity Classification (Before Treatment)

Classification based on various factors: Daytime symptoms, nighttime symptoms, PEFR, variability, and FEV1.
Severity categories (from least-to-most severe): Intermittent, Mild persistent, Moderate persistent, and Severe persistent.

Asthma Medications

Controllers: Regular medications are used for long-term treatment.
They reduce airway inflammation, control symptoms, and minimize future risks (exacerbations, lung function decline).
Relievers (or Rescues): Medications provide short-term relief of breakthrough symptoms and exacerbations.
They are useful for short-term relief from exercise-induced bronchoconstriction.
Add-on Therapies: Medication for severe asthma who continues to have symptoms despite optimized treatment.

Drug Therapy in Asthma

Short-acting beta2-agonist (SABA): MOA: Relaxes airway smooth muscles; Enhances mucociliary clearance; Decreases vascular permeability; Modulates mast cell/basophil mediator release. Onset: 5 minutes (peak: 60 minutes). Duration 4-6 hours.
Long-acting beta2-agonist (LABA): MOA: Same as SABA but longer duration (12 hours or more). Role: Chronic treatment to improve symptoms, decrease nocturnal asthma, prevent exercise-induced asthma, improve lung function, and decrease SABA use.
Ipratropium bromide: MOA: Blocks postganglionic efferent vagal pathways, reducing intrinsic vagal tone to the airways; blocks reflex bronchoconstriction by inhaled irritants. Role: Valuable in intolerant patients with inhaled beta2 agonists.
Systemic Corticosteroids: MOA: Inhibits inflammatory cytokines/lymphocytes/eosinophils/airway mucosal inflammation. Role: For patients requiring urgent treatment or those who did not improve with bronchodilators or experience worsening symptoms with maintenance therapy. Side effects: Short-term: mood changes, GI irritation, increased appetite; Long term: osteoporosis, hypertension, diabetes, HPA suppression, muscle weakness, cataracts, obesity, skin thinning.
Inhaled Corticosteroids (ICS): Role: Effective in improving asthma control and reducing/eliminating the need for systemic corticosteroids. Side Effects: Oropharyngeal candidiasis, dysphonia; coughing; significant decrease in BMD (bone mineral density); HPA suppression with high doses (>400 mcg/day) in children.
Leukotriene Receptor Antagonist (LTRA): MOA: Anantagonizes leukotriene action at specific receptor sites in the airways and reduces inflammation. Role: Controls asthma symptoms but less effective than ICS; Use for patients with asthma and allergic rhinitis or refuse ICS use. Side Effects: Headache, abdominal pain, rashes, liver enzyme elevation.
Methylxanthines (Theophylline, Aminophylline): MOA: Inhibits phosphodiesterase which relaxes smooth muscles; Inhibits adenosine receptor sites; Anti-inflammatory action. Role: Should not be used in asthma exacerbations due to side effects. Side effects: Nausea, vomiting, tachycardia, arrhythmias, seizures.
Magnesium Sulfate: MOA: Decreases calcium uptake in bronchial smooth muscles. Role: Not for routine asthma exacerbations, but may be considered in patients unresponsive to initial treatment with severe hypoxemia and FEV1 <60% predicted after 1 hour of care. Side effects: Cardiac arrhythmias, hypotension, flushing, sweating, decreased reflexes, CNS depression.

Asthma Flare-Ups (Exacerbations)

Acute or sub-acute progressive increases in shortness of breath, cough, wheezing, and chest tightness along with decreased lung function (PEF, FEV1)
May occur in patients with existing asthma or as the first presentation.

Severity of Asthma Exacerbations (in Children and Adolescents)

Mild/Moderate: Breathless, agitated, pulse rate within acceptable range (dependent on age), oxygen saturation ≥ 92%.
Severe/life-threatening: Unable to speak or drink, central cyanosis, confusion, marked retractions, oxygen saturation < 92%, silent chest on auscultation.

Start/Monitoring Treatment

Treatment depends on severity (mild/moderate vs severe/life threatening).
Mild-moderate: Medications are repeated as needed.
Severe: Require ICU transfer, aggressive management (IV fluids, high dose or high frequency of medications)

Continued Treatment (if needed)

Symptoms return within 3–4 hours, extra doses of salbutamol administered, Prednisone administered to the patient (2 mg/kg, maximum 20 mg for <2 years; 30 mg for 2-5 years) orally.

Discharge Management

Provide oral corticosteroids and relievers as needed.
Start inhaled corticosteroids prior to discharge if not previously prescribed.
Monitor patients and provide instructions on daily adherence.

Levels of Asthma Control

Categories (well-controlled, partially controlled, uncontrolled) based on daytime/nighttime symptoms, reliever needed, and activity limitation.

Stepwise Approach to Control Symptoms/Reduce Risk

Stepwise approach to address asthma management over time.

Choosing an Inhaler Device for Children ≤5

Choice of device is age contingent, with preferred and alternate options given.

Complications of Untreated Asthma

Pulmonary edema
Pneumonia
Lobar atelectasis
Pneumothorax
Pneumomediastinum
Subcutaneous emphysema

Bronchiolitis

Lower airway obstruction.
Swelling and mucus buildup in the smallest air passages in the lungs (bronchioles).
Viral infection cause.
Airway obstruction caused by bronchiolar wall edema, spasm and mucus build-up.

Bronchiolitis Risk Factors

Age <2 years, especially 3-6 months (most common).
Living in crowded conditions
Not breastfed
Prematurity

Conditions Associated with Severe Bronchiolitis

Prematurity
Chronic lung disease
Cardiac disease
Immunodeficiency
Neuromuscular disorders

Etiology of Bronchiolitis

RSV (most common)
Adenovirus
Influenza
Parainfluenza
Metapneumovirus
Coronavirus
Rhinovirus

Pathogenesis of Bronchiolitis

Viral infection instigates inflammation, epithelial cell necrosis/damage
Mucus and cellular infiltration block airways.

Signs and Symptoms of Bronchiolitis

Cyanosis
Cough
Rhinitis
Fatigue
Fever
Retractions
Nasal flaring
Tachypnea
Crackles and wheezing
Poor feeding

Diagnosis of Bronchiolitis

Based on clinical presentation, age, and if viruses are circulating.
Chest X-ray: hyperinflation and peribronchial infiltrates
White blood cell count
Nasal fluid culture (determine virus)
ABG (arterial blood gas)
BUN, creatinine, electrolytes

Differential Diagnoses of Bronchiolitis

Upper airway obstruction
Laryngeal obstruction
Asthma
Pneumonia
Metabolic disorders
Congestive heart failure
Parenchymal lung disease

Bronchiolitis Treatment

Fluid & Hydration Therapy: IV fluids, breast milk.
Supplemental Oxygen: Used if oxygen saturation is <90%
Nasal Suctioning: Often needed.
Chest Physiotherapy: Not routinely recommended.
Bronchodilators: Nebulized epinephrine
Corticosteroids: Orally, intramuscularly, or intravenously
Mucolytics: Inhaled hypertonic saline and deoxyribonuclease (DNase)
Antivirals (Ribavirin): For severe cases
Mechanical Ventilation: For severe cases with respiratory distress
Leukotriene Modifiers

Bronchiolitis Prevention

Hand hygiene (antimicrobial soap, alcohol-based rub)
No vaccine available
RSV Immune Globulin (RSV-IG)
Palivizumab

Bronchiolitis Disease Course

Initial illness often involves mild upper respiratory tract symptoms (URTI).
Symptoms typically worsen after a few days, involving lower airways and varying degrees of respiratory distress, with crackles and wheezing.
Mean duration of illness = 15 days.
Resolution occurs within 3–4 weeks.

Long-Term Sequelae of Bronchiolitis

Bronchiolitis obliterans
Allergic sensitization
Asthma

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Test your knowledge on the characteristics, symptoms, and mechanisms involved in asthma as a disease. This quiz covers various aspects including inflammation, peak flow measurement, and risk factors. Perfect for students and professionals in healthcare and respiratory fields.