Questions for Discussion:

1. List the conditions in which one may hear diffuse wheezing, focal wheezing, and stridor.  Answer
   
2. How is pulsus paradox measured? What is the "normal" value for pulsus paradox? What is the significance of a pulsus paradox of 20 mmHg? Answer
   
3. What is a normal peak flow? Answer
   
4. Name the accessory muscles and describe the significance of intercostal retractions. Answer
   
5. What is a nebulizer? What is metered-dose inhaler (MDI)? Describe how to properly use a MDI. Is there data suggesting that either nebulizers or MDI's are more effective than the other? Answer

The patient improves, the peak flow increases to 160, and additional history is obtained:

Her asthma began at the age of seven, resulting in frequent school absences, especially in the spring. At age 17 she had to quit her job in a bakery because the flour dust worsened her asthma. She also reports seasonal rhinitis, most noticeable in the summer months, until the first frost. She has never been able to cut the grass because it brings on an attack of asthma. Nonetheless, she has always been active, participating in sports in high school, and remaining completely asymptomatic for long periods of time. Recently, however, she has noted severe coughing spells, sometimes associated with frank wheezing, after completing her morning jog, especially during the winter months since moving to Chicago. She has a dog and cat at home. Her father and nephew both have asthma. Her mother and grandmother have hay fever. She denies aspirin sensitivity, nasal polyps, or eczema. She also denies symptoms of GERD.

6. What is the definition of asthma? Does this patient have asthma? Answer
   
7. Describe the airway abnormalities found pathologically during an acute attack of asthma. Answer
   
8. What are the common precipitants responsible for inducing an attack of asthma? Answer
   
9. Describe the clinical features of:  
   • Cough-Variant Asthma
   • Exercise-Induced Asthma (EIA)
   • GERD-Associated Asthma
   • Cardiac Asthma
   • Sampter's Triad
   • Allergic Broncho-Pulmonary Aspergillosis (ABPA)
     Answer
     
10. As they relate to asthma, what is the significance of: 
    • family history
    • associated allergic conditions
    • chronic sinus congestion / post-nasal drip
      Answer

Unfortunately, her shortness of breath worsens again, although both the wheezing and pulsus paradox have decreased. Peak Flow is measured to be 60 lpm. The ER physician orders:

• Repeat albuterol nebulization treatment
• 125 mg methylprednisolone IV
• Chest X-ray
• Arterial Blood Gas
• CBC
11. Why, if the patient's shortness of breath has worsened, have the wheezing and pulsus paradox improved?  Answer
     
12. The chest x-ray failed to show evidence of pneumonia or pneumothorax. What findings on chest x-ray would be expected during an exacerbation of asthma? Answer
     
13. ABG (on room air) reveals: pH = 7.38, pCO 2 = 41, pO 2 = 70. 
    • What is the acid-base status of this ABG?
    • What are the classic patterns of pCO 2 /pH changes during mild, moderate, and severe attacks of asthma?
    • How is the A-a gradient calculated? Is the patient's A-a gradient normal?
    • What is the mechanism of hypoxia in asthma?
      Answer
       
14. CBC reveals a hemoglobin of 14.2 and a WBC of 6.8 with 65 polys, 5 bands, 20 lymphs, and 10 eos. What is the possible significance of peripheral eosinophilia?  Answer

The patient was admitted to the hospital, started on a broad-spectrum antibiotic, and continued on albuterol nebulizers and corticosteroids. She improved within 48 hours and was switched to oral medications and discharged.

15. What was the significance of this patient's yellow sputum? Answer

16. What antibiotics would be appropriate in this situation? Answer

17. Discuss the overall long-term management of asthma with reference to:

• “Controller” vs “Reliever” medications
• Daily Home Monitoring of Asthma Severity
  Answer

18. Using the algorithm advocated by NIH Expert Panel in the 1997 NHLBI'a Guidelines for the Diagnosis and Management of Asthma (which is nicely summarized at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm ), what would be the most appropriate medical therapy recommended for the following patients:  

• A patient with very infrequent, non-life-threatening exacerbations, which have always responded well to inhaled B-agonists?
• A patient with exacerbations which occur once or twice a week?
• What options exist for a patient such as that described in “b” above who fails to respond adequately to your initial recommended therapy?
  Answer

19. What are the major potential side effects of long-term inhaled corticosteroid use? How might the oral-pharyngeal side effects be minimized?  Answer

20. When are pulmonary function tests (PFT's) indicated in the diagnosis and/or management of patients with asthma?  Answer

One month after discharge, the patient obtains the following pulmonary function tests (PFT's):

21. Are these PFT's consistent with the diagnosis of asthma?  Answer

22. Is there evidence for emphysema?  Answer

23. If her PFT's had been normal, would the diagnosis of asthma have been excluded? What other testing could be done in the PFT lab to diagnosis asthma?  Answer

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