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Old 09-15-2011
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Lungs Asthma Steps of Management

25 YO male with moderate asthma following up with you, presented with acute asthmatic episode after you successfully managed his acute episode, which of the following is best management for this patient.
  1. As needed MDI beta- agonist (short acting).
  2. As needed inhaled steroid.
  3. Daily MDI beta- agonist (short acting) + as needed inhaled steroid.
  4. Daily inhaled steroid + as needed MDI beta- agonist (short acting).
  5. Any respiratory infection can precipitate an asthmatic episode, he has to watch out for that.
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Old 09-15-2011
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daily inhaled steriod n as needed b agonist inhaler
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Daily inhaled steroid (should be low dose)+ as needed beta agonist (short acting).
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Old 09-15-2011
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Correct answer is 4.

Side effects of inhaled steroid:

1. Oral candidiasis.

2. Nasty taste after inhalation.

Ask the patient to wash out his mouth after steroid inhaler use, that will take care of both complication or can use turbo inhaler, that pushes the material all the way down to the lung,
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Old 09-15-2011
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Acute Asthmatic attack management:
  • First give O2 supplement.
  • Short acting bronchodilators: like beta agonist, albuterol. Anticholinergic are long acting good for COPD. Aminophylline only in status asthmaticus.
  • Evaluate the prior history of the disease, how many times the patient was admitted or even intubated- to see severity.
  • Drug history: if he takes any drug that will exacerbate the disease. Nasal polyposis & sensitivity to aspirin (20% have cross reactivity with other NSAIDs) may present with edematous nasal turbinate
Sever attack: edematous nasal turbinate, cyanosis, intercostal muscles retraction, silent lung, lab finding like hypercapnia, pulsus paradoxus > 20, and diaphoresis.

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Old 09-15-2011
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Asthma management continues:
Long acting beta agonists: Once or twice a day (short acting ones used 4 to 5 times a day). Indications: 1. Nocturnal asthma 2. Public speaker jobs ex lawyers (to reduce symptoms during the day time).
Systemic steroid: orally, only in small group of patients (steroid dependent asthmatic) sever asthma, should be followed by specialist. Daily oral steroid, so systemic side effects (osteoporosis & blunting of growth in young patients, increased risk of cataract).
Leukotriene modifiers reduce the need for systemic steroids or at least reduce the dose of steroids in these patients, this the indication for their use, only in steroid dependent asthmatics. (They associated withChurg-Strauss vasculitis).

Mast cells stabilizers (Cromolyn, nedocromil), not used in acute exacerbation (contraindicated), b/c they paradoxically provoke the acute exacerbation. Used in chronic setting to prevent asthma exacerbation (like steroid). Generally not used in adults, b/c adult asthma usually sever, so patient will not benefit (exception is exercise induced asthma, b/c its generally mild alternatively you can use bronchodilator instead). Works well in children, b/c have generally mild asthma & to avoid inhaled steroids in kids.
Epinephrine, Aminophylline & theophylline (some times in COPD): are not used routinely, only in status asthmaticus.


Last edited by ag2011n; 09-16-2011 at 12:01 AM. Reason: typo
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Old 09-16-2011
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Quote:
Originally Posted by ag2011n View Post
Asthma management continues:
Long acting beta agonists: Once or twice a day (short acting ones used 4 to 5 times a day). Indications: 1. Nocturnal asthma 2. Public speaker jobs ex lawyers (to reduce symptoms during the day time).
Systemic steroid: orally, only in small group of patients (steroid dependent asthmatic) sever asthma, should be followed by specialist. Daily oral steroid, so systemic side effects (osteoporosis & blunting of growth in young patients, increased risk of cataract).
Leukotriene modifiers reduce the need for systemic steroids or at least reduce the dose of steroids in these patients, this the indication for their use, only in steroid dependent asthmatics. (They associated withChurg-Strauss vasculitis).

Mast cells stabilizers (Cromolyn, nedocromil), not used in acute exacerbation (contraindicated), b/c they paradoxically provoke the acute exacerbation. Used in chronic setting to prevent asthma exacerbation (like steroid). Generally not used in adults, b/c adult asthma usually sever, so patient will not benefit (exception is exercise induced asthma, b/c its generally mild alternatively you can use bronchodilator instead). Works well in children, b/c have generally mild asthma & to avoid inhaled steroids in kids.
Epinephrine, Aminophylline & theophylline (some times in COPD): are not used routinely, only in status asthmaticus.
Nice collection of info...
but would u explain how leukotriene modifiers r ass with churg strauss vasculitis...?? r they used to treat cs vasculitis associated asthma or do they cause cs??
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Old 09-16-2011
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Patient with new onset asthma, with renal involvement, mononeuritis, other feature of vasculitis, think of Churg Straus syndrome. When given Leukotriene modifiers will develop full blown symptoms of Churg Straus syndrome, b/c they pulled out of steroids. The purpose of Leukotriene modifier is to reduce the need for steroids in steroid dependent asthma, so by reducing the steroid dose, feature of vasculitis will show up. These drugs (Leukotriene modifiers are not a causative agent for the vasculitis).
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