Childhood Asthma

Chapter 110 Childhood Asthma




Clinical Case Problem 1: My Child Is Usually Healthy, but He Wheezes Sometimes


A 2-year-old African American boy presents for his well-child checkup. His parents tell you that he has been doing well, but he has had episodes of wheezing four times during the past year. He is the product of an uncomplicated pregnancy and delivery, but he was hospitalized at the age of 6 months for bronchiolitis. Both parents have a history of allergies, and his father has asthma. His mother smoked during pregnancy but quit smoking last year. The child was never breast-fed.



Select the best answer to the following questions




1. Which of the following is true concerning this child?


a. you cannot diagnose this child with asthma because he is too young

b. children who have four or more episodes of wheezing and a clinical picture consistent with asthma should be diagnosed and treated according to current guidelines once other causes of wheezing have been excluded

c. because his mother quit smoking, this child is at no increased risk for asthma

d. because he had bronchiolitis at 6   months, he cannot be diagnosed with asthma

e. African Americans have much less severe asthma than other races do, so this child does not need to be diagnosed with asthma now

2. Which of the following differential diagnoses should you exclude in this child?


a. foreign body

b. viral bronchiolitis

c. heart disease

d. vocal cord dysfunction

e. all of the above

3. Which of the following is true concerning treatment of this child?


a. there are virtually no studies using inhaled corticosteroids in children of this age

b. inhaled corticosteroids should not routinely be used in children younger than 5   years because of growth retardation

c. because of recurrent episodes of wheezing, with a strong family history, this child should be treated with inhaled corticosteroids

d. levalbuterol is far superior to albuterol in this age group and should be used

e. rescue medication should be avoided in children in this age-group

4. In understanding the pathophysiologic process of asthma, which of the following is not true?


a. asthma is a chronic inflammatory disease of the airways

b. immunohistopathologic features of asthma include inflammatory cell infiltration with neutrophils, eosinophils, lymphocytes, and mast cells

c. airway inflammation contributes to airway hyperresponsiveness

d. persistent changes in airway, such as mucus hypersecretion and epithelial cell injury, do not occur in asthma

e. atopy, the genetic predisposition to an immunoglobulin E (IgE)–mediated response to common allergens, is the most identifiable predisposing factor

5. In discussing treatment plans with the parents, they ask about various medications used in asthma therapy. Which of the following medications has been shown to be most effective in the treatment of persistent asthma in children and should be used as first-line treatment if maintenance therapy is begun?


a. leukotriene inhibitor

b. cromolyn

c. long-acting beta2 agonist inhaler or nebulizer

d. inhaled corticosteroids as an inhaler or nebulizer

e. none of the above

6. Which of the following statements is false concerning asthma in children?


a. 50% to 80% of children with asthma develop symptoms before 5   years of age

b. atopic dermatitis and rhinitis not related to viral infections during the first year are both strongly related to the development of asthma, and atopy is the strongest predictor that wheezing will progress to asthma

c. many young children have elevated IgE levels from 9   months of age

d. perinatal exposure to tobacco smoke is associated with the onset of asthma

e. wheezing and cough are usually worse in the midday, after lunch

7. Which of the following is not included in the diagnosis of asthma in children?


a. symptoms of episodic airflow obstruction

b. at least partially reversible airflow obstruction

c. development of symptoms before the age of 4 years

d. inflammation causing airflow obstruction

e. inflammation causing airway hyperreactivity


Clinical Case Problem 2: A 7-Year-Old with Rhinitis and Chest Tightness


A 7-year-old girl presents to your office with a history of 1   week of gradually increasing chest tightness and mild dyspnea. She has had nasal drainage and a nighttime cough. Her mother states that she has had no fever and has been going to school. Her medical history is significant for only one previous episode of wheezing, for which she was treated with an antibiotic and an inhaler. Her family history is significant for an older brother with asthma. Her father is a smoker.


On examination, she has a temperature of 99.9°   F, blood pressure of 90/50   mm Hg, respiratory rate of 20 breaths/minute, and pulse of 100 beats/minute. She appears in no distress but is audibly wheezing. She has mild nasal turbinate swelling, postnasal drainage, and diffuse expiratory wheezes. After a nebulizer treatment with albuterol, she feels much better, and her lungs are completely clear.




8. Which of the following do you advise the patient and her parent?


a. she may or may not have asthma, but she has symptoms of airway reactivity; you prescribe an albuterol inhaler with a spacer device and advise that her father must stop smoking immediately or ensure that she is not exposed to any cigarette smoke

b. she definitely has asthma; you prescribe an albuterol inhaler, a short course of prednisone, and an inhaled corticosteroid

c. she has acute bronchitis and should respond well to an antibiotic alone

d. she needs to follow up with you in a short time to determine if further treatment is necessary and should call immediately if she is worsening

e. a and d

The child does not keep her follow-up appointment; when your nurse calls to check, her mother states that she is completely well. Four months later, she comes in for a visit because she is having a nighttime cough. After a complete history, you find that she has continued to have chest tightness and dyspnea several days a week, especially after running in gym class, and two or three nights each month she cannot sleep well because of coughing. She has no fever, rhinorrhea, or other symptoms. She finished her inhaler a month ago, after which her symptoms increased.



9. She has a completely normal physical examination, and her peak flow is 90% predicted. Which of the following diagnoses and treatments are correct?


a. diagnose her with asthmatic bronchitis; treat her with an antibiotic and a course of oral steroids

b. diagnose her with mild intermittent asthma; renew her albuterol inhaler

c. diagnose her with mild persistent asthma; renew her albuterol inhaler, begin an inhaled corticosteroid inhaler, and instruct her in asthma management

d. diagnose her with exercise-induced asthma only; renew her albuterol inhaler and instruct her in management of exercise-induced asthma

e. diagnose her with moderate persistent asthma; renew her albuterol inhaler, begin a steroid inhaler and leukotriene inhibitor, and instruct her in asthma management

10. The patient returns for regular follow-up, but she continues to have symptoms that require her to use the rescue medication four or five times a week. She now has daily symptoms and coughs more than one night a week. Which of the following would be appropriate to recommend?


a. review triggers and try to eliminate them

b. continue her inhaled corticosteroid at the recommended dose and add a long-acting beta agonist

c. add a leukotriene receptor antagonist or cromolyn if needed

d. increase her dose of inhaled corticosteroid from low to medium

e. all of the above

11. While discussing elimination of triggers with the child and her parents, you mention all of the following as possible triggers. Which of these is most commonly implicated in causing exacerbations and possibly even influencing the development of asthma in populations as a whole?


a. dust mites and tobacco smoke

b. cockroach antigens

c. animal dander

d. outdoor pollutants

e. violence

12. Disease severity in asthma is not determined by which of the following?


a. nighttime symptoms and their frequency

b. pulmonary function measures

c. use of rescue medications

d. physical symptoms, including chest tightness and dyspnea, and their frequency

e. the presence of nasal eosinophils


Clinical Case Problem 3: Lost Continuity with Revolving Homes


A 13-year-old boy presents to your office, brought by his grandmother. He has been treated by you for allergic rhinitis in the spring, when the pollen count was increased, and now it is winter. He has been living with his mother but spends summers with his father. Because of his living arrangements, his medical care has been inconsistent. According to the child and his grandmother, he was diagnosed with asthma at the age of 8   years. He has had one or two exacerbations a year that have required an emergency department visit. He was hospitalized 3   days for “pneumonia and asthma” at the age of 10   years. He has been prescribed a variety of medications, but he tells you that he left his inhaler at his father’s house, and currently he does not have any medications. He seems to understand very little about asthma.


The patient complains of “a little” fever, nasal congestion, and intermittent wheezing. He tells you that he has taken a bottle of over-the-counter cough syrup in the past 3   days because he coughs so much at night. Vital signs are normal. Physical examination is normal except for nasal congestion without sinus tenderness and scattered expiratory wheezes with no rales, rhonchi, or egophony.




13. Which of the following statements is true?


a. this child probably has an acute exacerbation of asthma due to viral infection, superimposed on untreated mild or moderate persistent asthma

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Childhood Asthma

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