Snapshot A 5-year-old is brought to his pediatrician’s office by his parents because he cannot keep up with his friends while playing outside because he is short of breath. His parents report that they notice him occasionally coughing at night but he is otherwise healthy. On physical exam, respiratory rate is within normal limits and slight end expiratory wheezing is appreciated diffusely. Introduction Clinical definition a reversible, intermittent obstructive disease of the small airways characterized by inflammation and hyperresponsiveness Epidemiology can present at any age most common chronic pediatric disease risk factors atopy strongest identifiable factor atopic dermatitis food allergies allergic rhinitis family history smoking obesity air pollution Pathogenesis acute, subacute, or chronic inflammation an elevated level of IgE binds mast cells and triggered by an antigen to release histamine and initiate an inflammatory cascade common triggers allergies (house dust mites) upper respiratory infection cold air exercise obstruction secondary to airway hyperresponsiveness, edema, mucus plugging, and smooth muscle hypertrophy Classification based on daytime and nighttime symptoms Asthma Classification Severity Symptom Frequency Pulmonary Function Test Intermittent ≤2 days/week ≤2 nights/month FEV1 > 80% of predicted Mild persistent > 2/week but < 1/day > 2 nights/month FEV1 ≥ 80% of predicted Moderate persistent Daily daytime > 1 night/week FEV1 60-80% of predicted Severe persistent Continual daytime Frequent nighttime FEV1 < 60% of predicted Presentation Symptoms often worse in the early morning and at night wheezing productive cough shortness of breath chest tightness Physical exam chronic asthma possibly normal wheezing acute exacerbation wheezing accessory muscle usage paradoxical breathing decreased breath sounds prolonged expiratory phase tachypnea pulsus paradoxus hyperresonance Special presentations Samter triad aspirin and nonsteroidal anti-inflammatory drug sensitivity, asthma, and nasal polyps exercise induced bronchoconstriction only associated with exercise cough variant only cough symptoms Studies Diagnostic testing diagnostic approach in acute exacerbation of asthma provide supportive care and lifesaving treatments first use peak expiratory flow rate to monitor pulmonary function test as an outpatient later imaging chest radiograph may be normal hyperinflammation if severe studies pulmonary function tests gold standard peak expiratory flow rate can be used at home to monitor obstruction < 50% of personal best indicates a severe obstruction arterial blood gas mild hypoxia with early respiratory alkalosis due to tachypnea normalization of PCO2 could indicate fatigue and impending respiratory failure interpret in the context of the overall clinical picture if severe, respiratory acidosis due to CO2 retention Diagnostic criteria pulmonary function tests an obstructive pattern of FEV1/FVC < 70% is consistent with diagnosis if consistent with obstructive lung disease, reverse with a beta-agonist increase of ≥ 12% from baseline and ≥ 200 mL if normal in a well patient but high clinical suspicion, induce with a methacholine challenge decrease of ≥ 20% from baseline increased residual volume and TLC normal DLCO Differential Anaphylaxis distinguishing factors swollen mouth, hypotension, and gastrointestinal symptoms Foreign object lodged in the respiratory tract distinguishing factors foreign object visualized on chest radiograph Post nasal drip distinguishing factors sore throat and excessive mucus Congestive heart failure distinguishing factors volume overload visualized on chest radiograph and physical exam Gastroesophageal reflux disease distinguishing factors sour taste, regurgitation, and burning sensation Treatment of Acute Exacerbations Management approach administer lifesaving treatments and monitor serially with for signs of respiratory failure physical examinations peak expiratory flow rate ABG Medical first-line humidified O2 β2-agonists via metered dose inhaler or nebulizer second-line intravenous methylprednisone indication if poor response to first-line treatment Interventional non-invasive positive pressure indication if poor response to medical management above only appropriate for alert patients with intact airway intubation indications if continued threat of airway obstruction despite first-line and second-line treatment if unable to protect airway due to reduced consciousness if PCO2 normalizes or is elevated (patient should be hyperventilating leading to low PCO2, if the patient becomes fatigued, PCO2 will begin to increase) Treatment of Chronic Asthma Management approach based on a step-wise approach building upon existing therapy all patients should have a short-acting β2-agonists as needed Therapy based on the classification intermittent treat with short-acting β2-agonists as needed no daily long-term treatment needed mild persistent add low-dose inhaled corticosteroid predisposes to oral candidiasis ("thrush") moderate persistent add long-acting β2-agonist to inhaled low-dose corticosteroid alternative: add leukotriene modifier or theophylline alternative: inhaled medium-dose corticosteroid only severe persistent inhaled medium- or high-dose corticosteroid with long-acting inhaled β2-agonist if continued poor control, consider oral corticosteroids or omalizumab (anti-IgE) Other medical management strategies cromolyn indication exercise prophylaxis montelukast indication exercise prophylaxis or aspirin-induced asthma inhaled β2-agonists indication prior to exposure to triggers such as exercise Lifestyle modifications including allergy avoidance Complications Acute respiratory failure Status asthmaticus Atelectasis Pneumothorax Use of non-specific β-blockers (i.e., blocking β2) can close airways leading to death
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M3.PL.43) A 27-year-old man with an unknown past medical history is brought to the emergency department acutely intoxicated. The patient was found passed out in a park covered in vomit and urine. His temperature is 99.0°F (37.2°C), blood pressure is 107/68 mm Hg, pulse is 120/min, respiratory rate is 13/min, and oxygen saturation is 95% on room air. Physical exam is notable for wheezing in all lung fields without any crackles. The patient is started on 2L/min nasal cannula oxygen and IV fluids. His laboratory values are notable for an AST of 200 U/L and an ALT of 100 U/L. An initial chest radiograph is unremarkable. Which of the following is the most likely explanation for this patient's pulmonary symptoms? Review Topic QID: 102984 1 Aspiration event 0% (0/0) 2 Bacterial infection 0% (0/0) 3 Clot in pulmonary vasculature 0% (0/0) 4 Elastic tissue destruction 0% (0/0) 5 Environmental antigen 0% (0/0) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.PL.4799) A 55-year-old female patient comes to your office complaining of white spots on her tongue. She reports that she first noticed them about one week ago. She denies pain or difficulty swallowing. Her past medical history is significant for asthma, hepatitis C, and heroin abuse. She had previously been homeless and only recently went to the doctor one month ago for the first time in over five years. At that time, her primary care physician prescribed sofosbuvir, an albuterol inhaler, and daily inhaled fluticasone, which she has been using as directed. She is sexually active with one male partner. Her last HIV test was negative, and she does not have a history of sexually transmitted diseases. She denies current alcohol or intravenous drug use. She smokes a pack a day of cigarettes and reports she has been smoking since she was 16. On physical examination, you note lesions on her oral mucosa that are easily scraped off, as shown in Figure A.Which of the following is the best treatment for this patient’s most likely diagnosis? Review Topic QID: 109290 FIGURES: A 1 Acyclovir 0% (0/45) 2 Nystatin suspension 84% (38/45) 3 Smoking cessation 4% (2/45) 4 Surgical removal 9% (4/45) 5 Topical betamethasone 0% (0/45) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.PL.4799) A six-year-old boy with a history of asthma currently uses an albuterol inhaler as needed to manage his asthma symptoms. His mother brings him into your office because she feels she has had to increase the patient’s use of his inhaler to four times per week for the past month. She also reports that he has woken up three times during the night from his symptoms this month. The boy reports that he is upset because he can’t always keep up with his friends in the playground. His past medical history is significant for allergic rhinitis. The patient’s temperature is 98°F (36.6°C), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 98% O2 on room air. Auscultation of his lungs reveals bilateral late expiratory wheezes. What changes should be made to his current asthma treatment regimen? Review Topic QID: 109291 1 Maintain current therapy 0% (0/28) 2 Add cromolyn prior to exercise 4% (1/28) 3 Add fluticasone daily 75% (21/28) 4 Add salmeterol twice daily 18% (5/28) 5 Add zileuton twice daily 0% (0/28) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M2.PL.4799) A 26-year-old male comes into your clinic complaining of worsening asthma symptoms. He reports that when he was first diagnosed with asthma, he experienced shortness of breath and chest tightness around twice a month. Then last month he began to get short of breath three times a week. He uses his albuterol inhaler during these episodes with temporary improvement of his symptoms. He denies nighttime awakenings due to his symptoms, but he does complain that his symptoms are interfering with his marathon training. His past medical history is significant for type I diabetes. His current medications include insulin and his albuterol inhaler. When asked about over-the-counter medications, he reports that he takes a multivitamin and aspirin, which he has been using for muscle soreness associated with his increased training schedule. A review of systems is also notable for headaches, nasal congestion, rhinorrhea and anosmia. The patient’s temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 84/min, and respirations are 14/min with an oxygen saturation of 98% O2 on room air. On physical exam, you note bilateral expiratory wheezing and lesions within the nasal cavity, shown in Figure A.Which of the following is the best initial treatment for this patient’s symptoms? Review Topic QID: 109289 FIGURES: A 1 Aspirin desensitization 33% (20/60) 2 Montelukast 37% (22/60) 3 Omalizumab 10% (6/60) 4 Salmeterol 18% (11/60) 5 Theophylline 2% (1/60) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.PL.192) A 48-year-old male with a history of rhinitis presents to the emergency department with complaints of shortness of breath and wheezing over the past 2 days. He reports bilateral knee pain over the past month for which he recently began taking naproxen 1 week ago. Physical examination is significant for a nasal polyp and disappearance of bilateral radial pulses on deep inspiration. Which of the following is the most likely cause of this patient's physical examination findings? Review Topic QID: 104198 1 Pulmonary hypertension 33% (1/3) 2 Interstitial lung fibrosis 0% (0/3) 3 Asthma 33% (1/3) 4 Pulmonary embolism 0% (0/3) 5 Cardiac tamponade 33% (1/3) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 3