Review Question - QID 203299

This patient's asthma symptoms are most consistent with a diagnosis of moderate persistent asthma.

In order to determine the recommended treatment steps for a patient with asthma, it is critical to first determine their category of disease. These categories of severity are based on frequency of asthma symptoms, frequency of rescue inhaler usage (i.e., short-acting beta agonists (SABAs), such as albuterol), degree of interference with normal activity, and objective lung function (i.e., FEV1) as determined by pulmonary function tests (PFTs). The prognosis of asthma is excellent when attacks are responsive to low level medical management; however, any exacerbation can be fatal if not treated appropriately or if recognized too late. Prevention is key in the management of asthma by reducing environmental exposures to pollution and allergens, taking preventative medication appropriately to avoid flares, and responding quickly to "attacks" by escalating inhaled therapy or adding oral corticosteroid bursts to prevent respiratory arrest.

To answer this question, it is necessary to have some prior knowledge of the asthma severity categories. There are 4 such categories: intermittent, mild persistent, moderate persistent, and severe persistent. Intermittent asthma is not described as "mild" or "moderate", so answers 1 and 2 are distractors. In order to determine which category is most appropriate for this patient, consider his key pieces in the history: daily symptoms, twice weekly awakenings, daily albuterol use, and an FEV1 of 65%. In mild persistent asthma, patients have symptoms > 2 days/week (but not daily), nighttime awakenings 3-4 times/month, use a SABA > 2 days/week (but not daily), have minor interference with normal activity, and have an FEV1 > 80%. In moderate persistent asthma, patients have symptoms daily, nighttime awakenings > 1 night/week (but not every night), use SABA daily, and have an FEV1 60-80% predicted. In severe asthma, patients have symptoms throughout the day, nighttimes awakenings every night, use a SABA multiple times per day, have extreme interference with normal activity, and have FEV1 < 60%. Based on thes categorizations, the above patient fits in the category of moderate persistent asthma.

Incorrect Answers:
Answers 1 and 2: Intermittent asthma is the classification if a patients has symptoms < 3 days/week, nighttimes awakenings < 3 times per month, uses a SABA < 3 days/week, has no interference with normal activity, and has normal FEV1 function between exacerbations. Exacerbations occur 0-1 times/year. Intermittent asthma is NOT described as "mild" or "moderate" - these descriptions are distractors.
Answers 3: Mild persistent asthma is the classification if a patient has symptoms > 2 days/week (but not daily), nighttimes awakenings 3-4 times/month, uses a SABA > 2 days/week (but not daily), has minor interference with normal activity, and has FEV1 > 80%.
Answer 4: Severe persistent asthma is the classification if a patient has symptoms throughout the day, nighttimes awakenings nightly, uses a SABA multiple times perday, has extreme interference with normal activity, and has FEV1 <60%.

The immediate goals of asthma management are correcting hypoxemia, reversal of airflow obstruction, and reduction of relapse. They specifically noted that inhaled anticholinergic medication combined with beta-2 agonists improve lung function and decrease hospitalization based on a review of asthma exacerbations in school-age children. (1)