Preparing to recertify (or certify for the first time) is an arduous process for which there is never enough time to practice and test one's knowledge. The Quick Recertification Series (QRS) is one way PAs who are preparing to take the exam can meet their informational needs. In a condensed review format, the QRS addresses critical topics included on the exam. It also provides practice questions, answers, and their explanations. Successful completion of the NCCPA examination requires a variety of tactics. The QRS offers one more to add to your test-taking armamentarium.
ASTHMA
GENERAL FEATURES
• The prevalence of asthma has doubled in the past 2 decades; more than 22 million people in the United States have asthma.
• One of the most common chronic diseases of childhood, representing a huge burden in terms of morbidity, lost work and school days, and avoidable trips to the emergency department.
• Triggered by numerous factors, including airborne allergens, such as house-dust mites and Alternaria, as well as viral upper respiratory infections, exercise, reflux, and stress.
• Pathophysiology consists of airflow obstruction, bronchial hyperresponsiveness, and inflammation.
• Inflammation leads to recurrent wheezing and coughing, accompanied by reversible airflow obstruction. Airway narrowing, in response to irritants or allergens, is the result of bronchiole smooth-muscle contraction. As inflammation progresses edema develops, further obstructing the airway.
CLINICAL ASSESSMENT
• History
• Typical symptoms are recurrent, intermittent cough; breathlessness; chest tightness; and wheezing. Nighttime cough may be the only manifestation in children.
• Determine pattern of symptoms and exacerbations and precipitating factors or triggers.
• A positive family history of asthma, allergy, eczema, rhinitis, sinusitis, or nasal polyps is common.
PHYSICAL EXAMINATION
• Focus on signs of atopy, such as dermatitis; allergic manifestations, such as increased nasal secretions and abnormal breath sounds (wheezing, rhonchi); the use of accessory muscles of respiration in acute exacerbations; and detecting a prolonged phase of forced exhalation. Normal chest examination does not exclude asthma.
• Not all that wheezes is asthma! Consider “cardiac asthma” from heart failure.
DIAGNOSIS
• Spirometry is a useful objective measure.
• Measure forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC before and after inhalation of a short-acting beta2-agonist (SABA). Asthma is defined as an FEV1/FVC >70%, reversibility >12%, and FEV1 <80%.
• Measuring peak flow is not always diagnostically reliable. Education and a written plan on how to deal with symptomatic exacerbations are more important.
• Baseline chest radiography may exclude other diagnoses.
• Patients with persistent asthma may need to be tested for sensitivity toperennial allergens by skin testing or in vitro testing.
SEVERITY CLASSIFICATION
• To best guide therapy, the patient's asthma needs to be characterized and the severity classified.
• Classification consists of intermittent, mild persistent, moderate persistent, and severe persistent categories (see “Table. Classification of asthma severity in persons 12 years and older”). (For practical tables on severity classifications and a stepwise approach for long-term asthma management for infants and children, see www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf).
MANAGEMENT
• Management focuses on medications, periodic assessment and monitoring, patient education, and control of environmental factors to prevent exacerbations.
• Treatment takes a stepwise approach, based on severity and subsequent response to therapy.
• Reducing bronchiole inflammation is the primary aim of long-term asthma treatment. Inhaled corticosteroids (ICS) are the most effective; these medications block late-phase reactions to allergens, decrease airway hyperresponsiveness, and reduce inflammation.
• For patients with mild persistent asthma, cromolyn sodium, nedocromil, or leukotriene modifiers can be considered for step 2 management. However, these agents are less effective and should be used as a second-line treatment or in addition to an ICS.
• Step 3 management calls for a longacting inhaled beta2–agonist (LABA), to be combined with an ICS in persons 12 years or older. Note that use of a LABA without the concomitant use of an ICS is likely to increase mortality.
• The preferred treatment for infants and children younger than 12 years who need symptomatic treatment more than twice a week or who have severe exacerbations less than 6 weeks apart is low-dose ICS (in nebulizer), progressing to medium-dose ICS combined with a LABA.
• Subcutaneous allergen immunotherapy should be considered, particularly in children, if asthma is triggered by allergens like pollen, animal dander, or house-dust mites.
• Frequent monitoring and patient education are critical components of controlling asthma symptoms. Every patient should have a written asthma plan that outlines daily management and steps to take if symptoms worsen. Self-assessment of asthma control should be routinely monitored with peak flow measurements.
• Take every opportunity to teach and reinforce asthma action plans, whether it be reviewing inhaler/spacer technique or how to reduce environmental exposures to allergic triggers.
ACUTE EXACERBATIONS
• Never underestimate the severity of an acute exacerbation. The written asthma action plan instructs patients on how to treat symptoms of exacerbations, how to intervene early at home, and when to seek care in the urgent care or emergency department setting.
• If the peak expiratory flow (PEF) falls below 80% of predicted or if the patient feels short of breath, then the patient should administer a SABA, such as albuterol, via inhaler or nebulizer. If the PEF drops to 50% to 79%, the patient should contact his or her clinician and monitor medication response. A short-course oral systemic corticosteroid is particularly effective for regaining control during acute exacerbations. The outpatient dose for adults is 40 to 60 mg daily for 5 to 10 days; for children, 1 mg/kg daily to a maximum of 60 mg/d for 3 to 10 days. No advantage is seen with IV or IM administration over oral administration; whichever route is easily available should be used.
• All patients who are corticosteroiddependent should receive additional systemic corticosteroids for any exacerbation.
• Initiate supplemental oxygen and repetitive or continuous SABA in the urgent care setting. Continuous nebulization is safe and effective and often reduces the pulse rate, which is being increased by hypoxia/physiologic stress. Ipratropium bromide (an anticholinergic) can be added to the nebulized albuterol solution for severe attacks. Admit a child who has a persistent oxygen saturation of less than 94%. Use clinical judgment! The oxygen saturation may drop as the patient gets better and unoxygenated portions of the lung are perfused, thereby increasing the V/Q mismatch. JAAPA
QUESTIONS & ANSWERS
1. What maneuver or test most reliably establishes the diagnosis of asthma?
a. Chest radiography
b. Chest auscultation
c. Spirometry
d. Allergy testing
Answer: c
Explanation: Spirometry identifies a hallmark of asthma, the reversibility of bronchospasm; helps establish severity; and distinguishes asthma from chronic obstructive pulmonary disease. Hearing wheezes when auscultating the lungs heightens the likelihood of asthma, but the diagnosis cannot be excluded by chest examination alone. Many asthmatics have normal baseline chest radiographs and equivocal allergy tests.
2. What are the four components of asthma care?
a. Assessment and monitoring, education, control of environmental factors and comorbid conditions, and medications
b. Peak flow monitoring, albuterol inhalers, allergen immunotherapy, and removing all carpeting from the residence.
c. Referral to an allergy specialist, avoidance of inhaled allergens, discontinuing exercise, elimination diet
Answer: a
Explanation: Only the first answer encompasses the multipronged approach for monitoring and managing asthma.
3. The most preferred agent for initiating long-term control in a nonallergic adult with mildly persistent asthma is
a. Ipratropium bromide nebulizer solution
b. Cromolyn sodium
c. A leukotriene modifier
d. Low dose ICS
Answer: d
Explanation: Studies demonstrated that treatment with low-dose ICS reduces the frequency of exacerbations. Ipratropium, an anticholinergic bronchodilator, is usually reserved as an adjuvant for resolving severe asthma exacerbations. The mastcell stabilizer cromolyn sodium is used as a preventive agent, particularly in children, and benefits patients with allergentriggered asthma. A leukotriene modifier may be considered as alternative therapy to low-dose ICS and has a role in preventing exercise-induced asthma.
The QRS is not meant to replace in-depth studying for the recertification exam and should be used only as an adjunct. The information contained here may not be sufficient to provide diagnosis and treatment in the clinical setting.