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Pulmonary and Critical Care Medicine o Occupational: al'oid exposure through respiratory protection or removal from workplace o Vocal cord dysfunction: speech therapy For all patients o pneumococcal and COVID l9 vaccinations and annual influenza vaccination . evaluation for thrush, hoarseness, and osteopenia caused by use of inhaled glucocorticoids . calcium and vitamin D supplements for patients taking chronic glucocorticoid treatment; early screening for osteoporosis with DEXA DOIT'T BE TRICKED . Do not administer theophylline with fluoroquinolones or macrolides (may result in theophylline toxicity) . Do not use LABAs as single agents in asthma (increased mortality rate). Treatment of asthma in pregnancy: r Inhaled glucocorticoids, oral glucocorticoids, SABAs, leukotriene receptor antagonists (montelukast, zafirlukast), and LABAs have all been used extensively during pregnancy without data to suggest fetal harm. Treatment of severe asthma exacerbation begins with home self-treatnlent using increased dose/frequency of controller medi- cations; also add 40 to 50 mg prednisone for 5 to 7 days. For emergency department management: . repeated doses of albuterol by continuous flow nebulizer or metered-dose inhaler with a spacer . early glucocorticoids o inhaled ipratropium may be helpful . IV magnesium sulfate for patients who have life threatening exacerbations may be helpful o hospitalizations for patients who do not respond well after 4 to 6 hours . intubation and mechanical ventilation lbr patients with respiratory failure . oral glucocorticoids, inhaled glucocorticoids, an asthma action plan, and follow up instructions for patients discharged home DOil'T BE TRIGKED . A normal arterial Pco, in a patient with severe symptomatic asthma indicates impending respiratory failure. . Consider vocal cord dysfunction for patients with "asthma" that improves immediately with intubation.

. repeated doses of albuterol by continuous flow nebulizer or metered-dose inhaler with a spacer . early glucocorticoids o inhaled ipratropium may be helpful . IV magnesium sulfate for patients who have life threatening exacerbations may be helpful o hospitalizations for patients who do not respond well after 4 to 6 hours . intubation and mechanical ventilation lbr patients with respiratory failure . oral glucocorticoids, inhaled glucocorticoids, an asthma action plan, and follow up instructions for patients discharged home DOil'T BE TRIGKED . A normal arterial Pco, in a patient with severe symptomatic asthma indicates impending respiratory failure. . Consider vocal cord dysfunction for patients with "asthma" that improves immediately with intubation. TESTYOURSETF A 35 year old woman with asthma has daily coughing and shortness of breath. She uses triamcinolone, 4 puffs twice daily, and albuterol, 2 puffs twice daily as needed. Her sleep is disturbed nightly by coughing. The chest examination shows soft bilateral expiratory wheezing. PEF is 60'x, of predicted. ANSWER: For diagnosis, choose severe persistent asthma. For management, select adding a long acting bronchodilator. The short term addition of an oral glucocorticoid to the inhaled glucocorticoid and a long acting bronchodilator would also be correct. Chronic Obstructive Pu lmonary Disease Screening Screening asymptomatic patients for COPD is not recommended by the USPSTF. 341