Pulmonology (COPD, asthma, interstitial lung disease) — MCQs

Question 1: A 35-year-old pregnant woman at 24 weeks gestation with moderate persistent asthma presents with worsening symptoms over 3 days. She has been using albuterol 6-8 times daily. She discontinued her ICS/LABA inhaler when she learned she was pregnant due to concerns about fetal safety. Current medications include prenatal vitamins only. Vital signs: respiratory rate 24/min, oxygen saturation 94% on room air, heart rate 98/min. Peak flow is 60% of her personal best. Fetal heart monitoring is reassuring. Synthesizing the management approach that balances maternal asthma control and fetal safety, what is the most appropriate treatment plan?

• A. Continue albuterol only until delivery to minimize fetal medication exposure
• B. Start oral prednisone and continue albuterol only
• C. Restart ICS/LABA, give oral prednisone burst, close monitoring (Correct Answer)
• D. Give IM corticosteroids and restart ICS after delivery
• E. Hospitalize for IV corticosteroids and continuous monitoring

Explanation: ***Restart ICS/LABA, give oral prednisone burst, close monitoring*** - For a patient with **moderate persistent asthma** experiencing an exacerbation, an **oral corticosteroid burst** is necessary to reduce inflammation, while **ICS/LABA** must be resumed to provide long-term control. - Maintaining maternal asthma control is vital for preventing **fetal hypoxia**; the risks of uncontrolled asthma to the fetus far outweigh the potential risks of these medications. *Continue albuterol only until delivery to minimize fetal medication exposure* - Relying solely on a **SABA** for persistent asthma is dangerous and increases the risk of **preterm birth**, **low birth weight**, and maternal respiratory failure. - **Suboptimal control** of asthma during pregnancy is more harmful to the fetus than the medications used to manage it. *Hospitalize for IV corticosteroids and continuous monitoring* - The patient’s oxygen saturation (94%) and **peak flow (60%)** indicate a moderate exacerbation that can typically be managed in the **outpatient setting** with close follow-up. - Hospitalization is reserved for those with **severe respiratory distress**, failed outpatient therapy, or signs of **fetal compromise**. *Start oral prednisone and continue albuterol only* - While prednisone clears the acute flare, failing to restart maintenance **controller therapy** (ICS/LABA) will likely lead to another exacerbation as soon as the steroid burst ends. - Chronic airway inflammation in **moderate persistent asthma** requires daily preventive treatment, not just episodic rescue medication. *Give IM corticosteroids and restart ICS after delivery* - **IM corticosteroids** are not the standard of care for acute asthma flares; **oral prednisone** is preferred for its predictable absorption and efficacy. - Delaying the resumption of controller therapy until **after delivery** leaves the mother and fetus at high risk during the remainder of the pregnancy.