NMS Q&A Family Medicine

226 NMS Q&A Family Medicinepreviously, albuterol alone is not adequate in persistentasthma. Immunotherapy would have no application fortreating symptoms in the present or near future. Albuterolalone is not appropriate as a stable plan, as was pointedout in the definition of stage 2 asthma. Long-acting beta-2agonists, inhaled high-dose glucosteroids, and oral glucosteroids,all three, would be appropriate in stage 4 disease(i.e., as step 4 therapy). Below is a table outlining thestages of asthma, modified slightly from the scheme ofNAEPP, Expert Panel Number 2, in the NIH PublicationNo. 97–4951.TABLE 36–1 Stages of Asthma Modified from NAEPP Expert Panel No. 2 NIH Publication 97-4951Stage Symptoms Night Symptoms Lung Function1. Mild 2 /wk 2 /mo FEV 1 or PEF intermittent none; normalPEF 80%; PEF between bouts var 20%2. Mild 2 /wk 1 daily 2 /mo FEV 1 or PEF persistent 80 PEF var 20%–30%3. Moderate persistent Daily short beta-2 Ag 1 /wk FEV 1 or PEF 60%, 80% PEF var 30%Activity affectedAttacks 2 /wkMay last for days4. Severe persistent Contin symptoms Frequent FEV 1 or PEF 60%Limited physical activity PEF var 30%Source : The table is modified slightly from the scheme shown by the National Asthma Education and Prevention Program (1997).var , variability; beta-2 Ag , beta-2 agonist.15. The answer is D. Respiratory syncytial virus. Up to50% of children with bronchiolitis caused by respiratorysyncytial virus will have recurrent wheezing until theyreach the age of 3 years, although most children with thiscombination of circumstances have atopic constitutionsand family histories of similar problems. Bacteria are lesslikely than viruses to provoke asthma. In the case ofS . pneumoniae , the organism is the most likely bacteriumto complicate symptomatic lower respiratory tract infections,especially those that are community acquired, andsometimes asthma, but it is not an initiator of reactive airwaydisease. However, the 50% rate of such sequelae torespiratory syncytial virus is far above the expected rate inthe population.16. The answer is E. Salmeterol, a long-acting beta-2agonist. The patient has moved to the moderate persistentstage or, one could say, stage 3. The effects of salmeterolmay last up to 30 hours and salmeterol is many timesstronger than albuterol as a beta-2 agonist. Terbutalineand pirbuberol are beta-2 agonists that are intermediatein their duration of activity. Anticholinergic medications(e.g., ipratropium) are rather short in length of activity(4 to 6 hours). The following is a table outlining step carethat corresponds to the four stages of asthma.TABLE 36–2 Therapeutic Modalities for StepsAnalogous to the Stages of AsthmaStep Long-Term Control Quick Relief1 None Short beta-2 Ag2 Daily inh Ster LD 2 /wk beta-2 Ag/daysignifies or cromolyn ornedocromil move to step 33 Daily MD inh Ster, long See step 2beta-2 Ag or both4 Same as step 3 POSterSee step 2beta-2 Ag , beta-2 agonist; inh , inhaled; Ster , (gluco) steroid; LD andMD , low and medium dose (steroids); PO , oral.ReferencesBoguniewicz M . Allergic disorders . Chapter in Current PediatricDiagnosis and Treatment , 17th ed . McGraw-Hill ; 2003 .Family Medicine Review . Kansas City , Missouri; May 3–10; 2009 .McPhee SJ , Papadakis MA . Current Medical Diagnosis and Treatment2010 , 49th ed . New York/Chicago : Lange; McGraw-Hill ; 2000 .Mengel MB , Schw ieber t LP , eds. Family Medicine Ambulatory Care& Prevention; 5th ed . New York : Lange; McGraw-Hill ; 2009 .Schwer WA . Atopic, food, and contact allergies . In: Rudy DR ,Kurowski K , eds. Family Medicine: House Officer Series .Baltimore : Williams & Wilkins ; 1997 : 591 – 604 .