Ancc Board Review: Asthma/copd

Front 1

Four hallmark symptoms of asthma

Back 1

Recurrent wheezing
Recurrent chest tightness
Recurrent cough
Recurrent difficulty breathing

Front 2

Characteristic timing of symptoms that suggests asthma:

Back 2

Cough at night

Wheezing or chest tightness after exercise

Symptoms worse after exposure to allergens, smoke, pollutants.

Symptoms worse during strong emotions (laughing, crying) and influenced by menstrual cycle

Front 3

A worsening of asthma symptoms may be seen after:

Back 3

Viral illness.

Front 4

What is necessary to make the diagnosis of asthma:

Back 4

Spirometry.

Front 5

When is peak flow metering done re: asthma?

Back 5

For monitoring, not for diagnosis.

Front 6

What is the cornerstone of asthma therapy?

Back 6

Inhaled Corticosteroids (ICS). This is the best choice for controller therapy and is needed for all but the mildest asthma.

Front 7

What are three classes of medications used in asthma for their anti-inflammatory properties?

Back 7

Inhaled corticosteroids (ICSs)

leukotriene antagonists (LTRAs)

Mast Cell stabilizers

Front 8

How much of an ICS dose is absorbed systemically?

Back 8

20%

Front 9

why is montelukast superior to zafirlukast?

Back 9

montelukast is not an CYP inhibitor. Zafirlukast is.

Front 10

What are three classes of medications used in asthma for their bronchodilating properties?

Back 10

Beta-2 agonists

Anticholinergics

Theophylline

Front 11

Mechanism of action of theophylline.

Back 11

Bronchodilator. Prevents the breakdown of cAMP (which causes bronchial relaxation) by phosphodiesterase. AKA phopsphodiesterase inhibitor.

Front 12

What are two methylxanthine bronchodilators?

Back 12

theophylline (PO)

aminophylline (IV)

Front 13

Facts to know about theophylline prescribing.

Back 13

Different preparations are NOT interchangeable mg to mg.

Blood levels must be monitored.

Front 14

Clinical uses of anticholinergics (ipratropium and tiotropium)

Back 14

Maintenance therapy in COPD.

Not used for asthma maintenance. May be used WITH SABAs for acute attacks.

Front 15

Clinical use of LABAs

Back 15

Not to be used as monotherapy. Can be used in combination with ICS for long-term control of asthma symptoms.

Front 16

Rationale for tapering corticosteroid dose:

Back 16

Long-term use causing adrenal insufficiency.

Expect cause of inflammation to return.

Front 17

What type of gastric problem is caused by long term corticosteroid use?

Back 17

Gastric ulcer

Front 18

Is there evidence to support tapering PO CS dose after asthma flare?

Back 18

No

Front 19

Which of the following is not consistent with the diagnosis of asthma:
a) troublesome nocturnal cough
b) cough or wheeze after exercise
c) morning sputum production
d) colds "go to my chest" or take more than 10 days to clear.

Back 19

c) morning sputum production

Front 20

How long does it take for clinical effects to be seen from ICS or LTRA therapy?

Back 20

1-2 weeks.

Front 21

About prescribing omalizumab

Back 21

It can be used in asthma that is uncontrolled on optimized conventional therapy. Requires specialty consult.

Front 22

Assessment of asthma symptoms.

Back 22

Assess based on last 4 weeks. Severity is based on most bothersome symptom.

Inquire about:
Symptom frequency
SABA frequency
nighttime symptom frequency

Front 23

What is a normal FEV1/FVC?

Back 23

70-85%, depending on age. A decrease is seen with aging.

Front 24

What are criteria for well-controlled asthma or asthma that is intermittent and does not require controller therapy?

Back 24

Symptoms <=2 days/week
SABA use <=2 days/week
nighttime awakenings <=2/month
no interference with normal activity
FEV1>80% predicted
FEV1/FVC normal
0-1 exacerbation with oral CS/year

Front 25

Outline asthma controller therapy.

Back 25

For intermittent asthma, none needed.

Step 2: low dose ICS
OR
mast cell stabilizer, LTRA, or theophylline

Step 3: medium dose ICS
OR
low-dose ICS + LABA
OR
low-dose ICS +
LTRA, theophylline, or zileuton

From here keep increasing ICS dose. Omalzimam can be used in severe persistent asthma in patients with allergies.

Front 26

T/F: all patients with asthma should have a SABA inhaler.

Back 26

True.

Front 27

Name two LABAs

Back 27

salmeterol

formoterol

Front 28

Name 3 SABAs.

Back 28

albuterol

pirbuterol

levalbuterol

Front 29

Management of an asthma flare.

Back 29

Oral prednisone at 40-60 mg/day for 5-7 days.

Increased use of rescue therapy.

Front 30

most common severity of asthma seen in clinical practice

Back 30

Moderate severe: daily symptoms, daily SABA use, nighttime symptoms >1/week but not nightly and about 2 exacerbations/year.

Front 31

Findings on exam during an acute asthma or COPD flare:

Back 31

Hyperresonance from air trapping
Decreased tactile fremitus
Wheeze (expiratory leading to inspiratory)

Front 32

What is PEF

Back 32

Peak Expiratory flow. This is measured by a peak flow meter and is used for monitoring.

Front 33

In well-controlled or intermittent asthma, PEF should be

Back 33

>80% normal.

Front 34

Most common reason for an asthma flare:

Back 34

URI.

Front 35

Is asthma a reason to limit physical activity?

Back 35

No.

Front 36

What are the pulmonary symptoms characteristic of COPD?

Back 36

Shortness of breath
Cough
Sputum production

Front 37

What are non-pharmacologic measured to be encouraged in all patients with COPD:

Back 37

SMOKING CESSATION

Avoidance of noxious agents, reduction of indoor pollution, reduction of occupational irritant exposure

Influenza vaccine annually
Pneumococcal vaccine as needed

Front 38

What is considered diagnostic of COPD?

Back 38

FEV1/FVC<70% by spirometry.

Front 39

About FEV1 in diagnosing COPD.

Back 39

FEV1 is usually reduced as the disease progresses, but may be normal in early stages.

Front 40

What interventions are used for all severities of COPD?

Back 40

Risk reduction

Influenza Vaccination

SABA inhalers for PRN use

Front 41

Criteria for round-the clock treatment in COPD.

Back 41

Moderate COPD defined as:

FEV1/FVC<70%
and
FEV1=50-80% of predicted.

Front 42

Initial round-the clock management of COPD:

Back 42

LABA, or an anticholinergic, or both

Front 43

Indication to add ICS to initial COPD management:

Back 43

More than 3 exacerbations in 3 years.

Front 44

ID this common trade name drug: Spiriva

Back 44

tiotropium, an anticholinergic inhaler used for COPD management.

Front 45

Identify this brand name medication used in COPD maintenance: Advair HFA

Back 45

LABA and ICS combo inhaler

Front 46

Identify this brand name medication used in COPD maintenance: Symbacort

Back 46

LABA and ICS comb inhaler

Front 47

Identify this brand name medication used in COPD maintenance: Combivent

Back 47

ipratropium bromide and albuterol (anticholinergic + SABA)

Front 48

Ipratropium bromide, when used in COPD provides which therapeutic effect:
a) increased mucociliary clearnace
b) reduced alveolar volume
c) broncodilation
d) mucolytic action

Back 48

c) bronchodilation

Front 49

COPD encompasses these two conditions

Back 49

Chronic bronchitis

Emphysema

Front 50

How is chronic bronchitis diagnosed?

Back 50

Clinically by:

Excess mucus for 3 or more months/year for 2 consecutive years in the absence of other causes.

Front 51

What is the pathophysiology of emphysema?

Back 51

Enlargement of airspaces distal to the terminal bronchiole.

Front 52

According to GOLD COPD guidelines, what medication is indicated for stages I to IV?

Back 52

A SABA inhaler for PRN use.

Note, Stage II is mild disease that does not require controller therapy

Front 53

What is the most appropriate antibiotic therapy for COPD exacerbation in a patient that failed initial treatment?

Back 53

A respiratory fluroquinolone.

Front 54

What is the best ABX choice for a 52 year old man with an acute exacerbation of Stage II COPD?
a) azithromycin
b) amoxicillin
c) TMP/SMX
d) levofloxacin

Back 54

a) azithromycin

Front 55

What are indications that antibiotic therapy may be needed in COPD flare?

Back 55

Change in purulence or quantity of sputum.

Front 56

Four components of the diagnosis of inhalation anthrax:

Back 56

Dry Cough
Fever
Malaise
Widened mediastinum on CXR

Front 57

What is the goal of oxygen therapy in COPD?

Back 57

To ensure adequate oxygenation of vital organs as evidenced by SpO2 of >=90% or PaO2 >=60 mmHg.

Front 58

Instructions on using oxygen at home.

Back 58

Use for at least 15 hours/day, NOT just in response to dyspnea.

Front 59

Definition of an exacerbation of COPD.

Back 59

Change in a patient's baseline dyspnea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management.

Front 60

Treatment of COPD exacerbation:

Back 60

Use SABA PRN. Add LABA and/or anticholniergic if needed.

Add oral prednisone if FEV1<50% predicted. Consider ICS in non-acidotic exacerbations.

Front 61

Indications for CXR in COPD exacerbation:

Back 61

The presence of fever or low SpO2.

Front 62

Three most common bacterial agents in COPD exacerbation:

Back 62

S. pneumo
H. influenzae
M. catarrhalis

Front 63

Atypicals (M. and C. pneumo, legionella) are associated with what percentage of bacterial COPD flares?

Back 63

10%

Front 64

Best antibiotic choice for mild or moderate COPD flare:

Back 64

Doxycycline, which covers DRSP and atypicals.

Front 65

Best antibiotic choices for severe COPD flare:

Back 65

Azithromycin or Fluoroquinolone

Front 66

If a patient reports orthopnea as part of a pulm problem, what should you consider.

Back 66

90% of orthopnea is cardiac in origin.