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Self-Assessment Questions

Family Medicine

Emergency Department Management of Acute Asthma Exacerbations: Review Questions

Adam Flowers, MD, MPH, and Sally Weaver, MD, PhD

Dr. Flowers is a family physician, Providence Health Center Emergency Department, Waco, TX.
Dr. Weaver is a family physician and faculty member, Waco Family Medicine Residency Program, Waco, TX.

Choose the single best answer for each question.

Questions 1 to 3 refer to the following case.

A 10-year-old boy with mild persistent asthma presents to the emergency department (ED) with cough and wheezing. He has no signs of significant respiratory distress. On examination, the patient has loud bilateral expiratory wheezing with no inspiratory wheezes, is able to speak in phrases, and is mildly tachypneic at rest.

1. What is the most appropriate initial step in this patient’s management?

  1. Administer subcutaneous terbutaline
  2. Obtain a chest radiograph, complete blood count, and blood cultures
  3. Perform rapid-sequence intubation
  4. Provide oxygen, check pulse oximetry, and administer 3 nebulized short-acting β-blockers in 20-minute intervals
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2. After an hour of appropriate treatments, the patient’s status is reassessed. The patient’s mother states that his personal best peak flow is 280 L/min. Currently, his best peak flow out of 3 attempts is 140 L/min. The patient appears to be in no respiratory distress, and his oxygen saturation is 96% on 2 L via nasal cannula. He has some mild expiratory wheezes bilaterally. How would you classify this patient’s exacerbation using the current NHLBI definitions1?

  1. Mild
  2. Moderate
  3. Severe
  4. Life-threatening
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3. What is the next best step in the management of this patient?

  1. Add theophylline to the medical regimen
  2. Administer oral systemic corticosteroids and continue treatment with albuterol in the ED
  3. Admit to the hospital
  4. Discharge home
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  4. All of the following statements about response to emergency therapy in children are correct EXCEPT
  1. Repeated pulse oximetry below 92% to 94% after 1 hour of treatment is predictive of the need for hospitalization
  2. Children aged 2 to 5 years are generally not able to perform spirometry or peak flow measures when coached
  3. If the child responds poorly to initial therapy and requires admission, ipratropium should be continued in the inpatient setting
  4. Infants have a higher risk of respiratory failure from asthma exacerbations, and response to short-acting ß2-agonist (SABA) therapy is unpredictable
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5. A 27-year-old woman who currently is at 18 weeks of gestation and has a history of mild intermittent asthma presents to the ED with cough and wheezing. She was unable to relieve her symptoms with her albuterol inhaler. Her peak flow at her last 2 prenatal care visits was 460 L/min, but at home it was 200 L/min. How should this patient be managed?

  1. Administer both inhaled and oral systemic corticosteroids
  2. Administer inhaled corticosteroids only
  3. Administer terbutaline
  4. No course of action is indicated at this time
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6. Which of the following diagnostic studies should be obtained initially for a patient who presents to the ED with an acute asthma exacerbation?

  1. Arterial blood gas
  2. Chest radiography
  3. Complete blood count
  4. No initial laboratory studies are required
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7. Based on the most recent NHLBI report,1 all of the following are risk factors for death from asthma EXCEPT

  1. Chronic use of inhaled corticosteroids
  2. Low socioeconomic status
  3. Prior intubation or intensive care unit admission for asthma exacerbation
  4. Three or more visits to the ED in the past year
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