{"version":"1.0.0","segments":[{"startTime":1.677,"endTime":3.197,"body":"♪ (music) ♪"},{"startTime":3.197,"endTime":5.632,"body":"(Cathy) Hi. Welcome"},{"startTime":3.197,"endTime":5.632,"body":"to Harrison's Podclass,"},{"startTime":5.632,"endTime":8.738,"body":"where we discuss important concepts"},{"startTime":5.632,"endTime":8.738,"body":"in internal medicine."},{"startTime":8.738,"endTime":9.881,"body":"I'm Cathy Handy."},{"startTime":9.881,"endTime":11.124,"body":"(Charlie) And I'm Charlie Wiener,"},{"startTime":11.124,"endTime":14.122,"body":"and we're coming to you"},{"startTime":11.124,"endTime":14.122,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"(Cathy) Welcome to Episode 13","startTime":16.402,"endTime":20.0,"body":"A 24-year-old with Asthma."},{"speaker":"(Charlie) Here's the question","startTime":21.602,"endTime":24.743,"body":"A 24-year-old woman was diagnosed"},{"speaker":"(Charlie) Here's the question","startTime":21.602,"endTime":24.743,"body":"with asthma, four months ago,"},{"speaker":"(Charlie) Here's the question","startTime":24.743,"endTime":27.917,"body":"and was treated"},{"speaker":"(Charlie) Here's the question","startTime":24.743,"endTime":27.917,"body":"with inhaled albuterol, as needed."},{"speaker":"(Charlie) Here's the question","startTime":27.917,"endTime":30.178,"body":"Since your last visit,"},{"speaker":"(Charlie) Here's the question","startTime":27.917,"endTime":30.178,"body":"she feels generally well"},{"speaker":"(Charlie) Here's the question","startTime":30.178,"endTime":33.996,"body":"and typically requires using her inhaler"},{"speaker":"(Charlie) Here's the question","startTime":30.178,"endTime":33.996,"body":"approximately 4-7 times a week"},{"speaker":"(Charlie) Here's the question","startTime":33.996,"endTime":38.115,"body":"when around pollen or cats,"},{"speaker":"(Charlie) Here's the question","startTime":33.996,"endTime":38.115,"body":"or when she's exercising in cold air."},{"speaker":"(Charlie) Here's the question","startTime":38.115,"endTime":40.149,"body":"The inhaled albuterol generally helps,"},{"speaker":"(Charlie) Here's the question","startTime":40.149,"endTime":42.487,"body":"and she only requires"},{"speaker":"(Charlie) Here's the question","startTime":40.149,"endTime":42.487,"body":"a repeat round of inhalations"},{"speaker":"(Charlie) Here's the question","startTime":42.487,"endTime":44.577,"body":"approximately two times a week."},{"speaker":"(Charlie) Here's the question","startTime":44.577,"endTime":47.855,"body":"She's on no other medications"},{"speaker":"(Charlie) Here's the question","startTime":44.577,"endTime":47.855,"body":"and is a non-smoker."},{"speaker":"(Charlie) Here's the question","startTime":47.855,"endTime":50.784,"body":"Her only pet is a goldfish named Puffer."},{"speaker":"(Charlie) Here's the question","startTime":50.784,"endTime":52.91,"body":"Cathy, what do you think so far?"},{"speaker":"(Charlie) Here's the question","startTime":52.91,"endTime":55.858,"body":"(Cathy) What we hear so far"},{"speaker":"(Charlie) Here's the question","startTime":52.91,"endTime":55.858,"body":"is that we have a young woman with asthma"},{"speaker":"(Charlie) Here's the question","startTime":55.858,"endTime":57.875,"body":"as her main diagnosis."},{"speaker":"(Charlie) Here's the question","startTime":57.875,"endTime":59.168,"body":"This can be a hard diagnosis"},{"speaker":"(Charlie) Here's the question","startTime":59.168,"endTime":61.862,"body":"because there's really no single way"},{"speaker":"(Charlie) Here's the question","startTime":59.168,"endTime":61.862,"body":"to diagnose asthma."},{"speaker":"(Charlie) Here's the question","startTime":61.862,"endTime":63.123,"body":"It's really a syndrome"},{"speaker":"(Charlie) Here's the question","startTime":63.123,"endTime":66.401,"body":"characterized by mostly reversible"},{"speaker":"(Charlie) Here's the question","startTime":63.123,"endTime":66.401,"body":"narrowing of their airways,"},{"speaker":"(Charlie) Here's the question","startTime":66.401,"endTime":70.602,"body":"and that leads to reduced airflow"},{"speaker":"(Charlie) Here's the question","startTime":66.401,"endTime":70.602,"body":"and symptomatic wheezing and dyspnea."},{"speaker":"(Charlie) Here's the question","startTime":70.602,"endTime":72.987,"body":"Clinically, we use the history"},{"speaker":"(Charlie) Here's the question","startTime":70.602,"endTime":72.987,"body":"to help guide us."},{"speaker":"(Charlie) Here's the question","startTime":72.987,"endTime":76.184,"body":"So, for example, episodic wheezing"},{"speaker":"(Charlie) Here's the question","startTime":72.987,"endTime":76.184,"body":"is a classic story."},{"speaker":"(Charlie) Here's the question","startTime":76.184,"endTime":80.24,"body":"And also, sometimes we hear"},{"speaker":"(Charlie) Here's the question","startTime":76.184,"endTime":80.24,"body":"that a person would have atopy as a child."},{"speaker":"(Charlie) Here's the question","startTime":80.24,"endTime":82.221,"body":"Another way we can help"},{"speaker":"(Charlie) Here's the question","startTime":80.24,"endTime":82.221,"body":"guide the diagnosis"},{"speaker":"(Charlie) Here's the question","startTime":82.221,"endTime":84.393,"body":"is with pulmonary function lab tests."},{"speaker":"(Charlie) Here's the question","startTime":84.393,"endTime":87.331,"body":"And there we would be looking"},{"speaker":"(Charlie) Here's the question","startTime":84.393,"endTime":87.331,"body":"for a reduced peak flow during episodes,"},{"speaker":"(Charlie) Here's the question","startTime":87.331,"endTime":90.261,"body":"or the presence"},{"speaker":"(Charlie) Here's the question","startTime":87.331,"endTime":90.261,"body":"of an obstructive ventilatory defect."},{"speaker":"(Charlie) Here's the question","startTime":90.261,"endTime":92.665,"body":"(Charlie) I'll also point out"},{"speaker":"(Charlie) Here's the question","startTime":90.261,"endTime":92.665,"body":"there are some newer techniques"},{"speaker":"(Charlie) Here's the question","startTime":92.665,"endTime":94.414,"body":"that are used to diagnose asthma"},{"speaker":"(Charlie) Here's the question","startTime":94.414,"endTime":97.535,"body":"and are focusing on detecting"},{"speaker":"(Charlie) Here's the question","startTime":94.414,"endTime":97.535,"body":"airway inflammation."},{"speaker":"(Charlie) Here's the question","startTime":97.535,"endTime":99.356,"body":"The most commonly used one right now"},{"speaker":"(Charlie) Here's the question","startTime":99.356,"endTime":102.297,"body":"is measurement of exhaled"},{"speaker":"(Charlie) Here's the question","startTime":99.356,"endTime":102.297,"body":"nitric oxide concentration,"},{"speaker":"(Charlie) Here's the question","startTime":102.297,"endTime":105.597,"body":"although this is not yet"},{"speaker":"(Charlie) Here's the question","startTime":102.297,"endTime":105.597,"body":"in routine clinical practice."},{"speaker":"(Charlie) Here's the question","startTime":105.597,"endTime":109.379,"body":"Also, recall that while the airway"},{"speaker":"(Charlie) Here's the question","startTime":105.597,"endTime":109.379,"body":"obstruction is the hallmark of asthma,"},{"speaker":"(Charlie) Here's the question","startTime":109.379,"endTime":114.174,"body":"the sensitivity of a single spirometric"},{"speaker":"(Charlie) Here's the question","startTime":109.379,"endTime":114.174,"body":"examination for obstruction is low"},{"speaker":"(Charlie) Here's the question","startTime":114.174,"endTime":117.015,"body":"because this is by definition"},{"speaker":"(Charlie) Here's the question","startTime":114.174,"endTime":117.015,"body":"an episodic disease."},{"speaker":"(Charlie) Here's the question","startTime":117.525,"endTime":120.443,"body":"So Cathy, what about the reported"},{"speaker":"(Charlie) Here's the question","startTime":117.525,"endTime":120.443,"body":"triggers in this patient?"},{"speaker":"(Charlie) Here's the question","startTime":120.443,"endTime":123.024,"body":"(Cathy) So, in her history"},{"speaker":"(Charlie) Here's the question","startTime":120.443,"endTime":123.024,"body":"we hear that pollen, cats,"},{"speaker":"(Charlie) Here's the question","startTime":123.024,"endTime":126.905,"body":"and exercise done in cold air,"},{"speaker":"(Charlie) Here's the question","startTime":123.024,"endTime":126.905,"body":"usually require her inhaler."},{"speaker":"(Charlie) Here's the question","startTime":126.905,"endTime":129.831,"body":"These are typical triggers"},{"speaker":"(Charlie) Here's the question","startTime":126.905,"endTime":129.831,"body":"for asthma exacerbations."},{"speaker":"(Charlie) Here's the question","startTime":129.831,"endTime":131.735,"body":"But we also think about cigarette smoke"},{"speaker":"(Charlie) Here's the question","startTime":131.735,"endTime":134.259,"body":"and infections"},{"speaker":"(Charlie) Here's the question","startTime":131.735,"endTime":134.259,"body":"as other common precipitants."},{"speaker":"(Charlie) Here's the question","startTime":134.259,"endTime":136.499,"body":"(Charlie) How do we approach"},{"speaker":"(Charlie) Here's the question","startTime":134.259,"endTime":136.499,"body":"the treatment of asthma?"},{"speaker":"(Charlie) Here's the question","startTime":136.499,"endTime":138.297,"body":"(Cathy) There are"},{"speaker":"(Charlie) Here's the question","startTime":136.499,"endTime":138.297,"body":"two main goals of treatment."},{"speaker":"(Charlie) Here's the question","startTime":138.297,"endTime":140.567,"body":"So, the first goal is to treat"},{"speaker":"(Charlie) Here's the question","startTime":138.297,"endTime":140.567,"body":"the acute symptoms,"},{"speaker":"(Charlie) Here's the question","startTime":140.567,"endTime":143.808,"body":"and we typically do this"},{"speaker":"(Charlie) Here's the question","startTime":140.567,"endTime":143.808,"body":"with short-acting bronchodilators."},{"speaker":"(Charlie) Here's the question","startTime":143.808,"endTime":146.358,"body":"These strategies"},{"speaker":"(Charlie) Here's the question","startTime":143.808,"endTime":146.358,"body":"are called \u003ci\u003erescue therapy\u003c/i\u003e."},{"speaker":"(Charlie) Here's the question","startTime":146.358,"endTime":149.862,"body":"And the second goal is to avoid"},{"speaker":"(Charlie) Here's the question","startTime":146.358,"endTime":149.862,"body":"the acute symptoms altogether,"},{"speaker":"(Charlie) Here's the question","startTime":149.862,"endTime":152.414,"body":"and this we call the \u003ci\u003econtroller therapy\u003c/i\u003e."},{"speaker":"(Charlie) Here's the question","startTime":152.414,"endTime":154.769,"body":"This is done by reducing"},{"speaker":"(Charlie) Here's the question","startTime":152.414,"endTime":154.769,"body":"airway inflammation"},{"speaker":"(Charlie) Here's the question","startTime":154.769,"endTime":157.62,"body":"and using long-acting drugs,"},{"speaker":"(Charlie) Here's the question","startTime":154.769,"endTime":157.62,"body":"like bronchodilators."},{"speaker":"(Charlie) Here's the question","startTime":158.04,"endTime":160.499,"body":"In this case, our patient"},{"speaker":"(Charlie) Here's the question","startTime":158.04,"endTime":160.499,"body":"was only on albuterol,"},{"speaker":"(Charlie) Here's the question","startTime":160.499,"endTime":162.674,"body":"which is a short-acting bronchodilator,"},{"speaker":"(Charlie) Here's the question","startTime":162.674,"endTime":165.379,"body":"and that quickly relaxes"},{"speaker":"(Charlie) Here's the question","startTime":162.674,"endTime":165.379,"body":"the airway smooth muscle."},{"speaker":"(Charlie) Here's the question","startTime":165.829,"endTime":167.625,"body":"Albuterol is a beta2-agonist,"},{"speaker":"(Charlie) Here's the question","startTime":167.625,"endTime":170.955,"body":"and that's the most common"},{"speaker":"(Charlie) Here's the question","startTime":167.625,"endTime":170.955,"body":"bronchodilator used in asthma."},{"speaker":"(Charlie) Here's the question","startTime":170.955,"endTime":174.478,"body":"Short-acting anticholinergic medications,"},{"speaker":"(Charlie) Here's the question","startTime":170.955,"endTime":174.478,"body":"such as glycopyrrolate,"},{"speaker":"(Charlie) Here's the question","startTime":174.478,"endTime":178.396,"body":"may also be used as rescue therapy,"},{"speaker":"(Charlie) Here's the question","startTime":174.478,"endTime":178.396,"body":"but these are generally less effective."},{"speaker":"(Charlie) Here's the question","startTime":178.396,"endTime":182.247,"body":"And these medications have no effect"},{"speaker":"(Charlie) Here's the question","startTime":178.396,"endTime":182.247,"body":"on the underlying inflammatory process"},{"speaker":"(Charlie) Here's the question","startTime":182.247,"endTime":186.55,"body":"so are not sufficient to control asthma"},{"speaker":"(Charlie) Here's the question","startTime":182.247,"endTime":186.55,"body":"in patients with persistent symptoms."},{"speaker":"(Charlie) Here's the question","startTime":186.55,"endTime":189.02,"body":"(Charlie) So, you've mentioned"},{"speaker":"(Charlie) Here's the question","startTime":186.55,"endTime":189.02,"body":"the short-acting medications"},{"speaker":"(Charlie) Here's the question","startTime":189.02,"endTime":190.617,"body":"are called rescue therapies."},{"speaker":"(Charlie) Here's the question","startTime":190.617,"endTime":193.272,"body":"How do we define the controller therapies?"},{"speaker":"(Charlie) Here's the question","startTime":193.272,"endTime":196.513,"body":"(Cathy) So, these are really"},{"speaker":"(Charlie) Here's the question","startTime":193.272,"endTime":196.513,"body":"anti-inflammatory medications mostly,"},{"speaker":"(Charlie) Here's the question","startTime":196.513,"endTime":199.524,"body":"and some guidelines will suggest"},{"speaker":"(Charlie) Here's the question","startTime":196.513,"endTime":199.524,"body":"that all patients with asthma"},{"speaker":"(Charlie) Here's the question","startTime":199.524,"endTime":202.592,"body":"be on at least one"},{"speaker":"(Charlie) Here's the question","startTime":199.524,"endTime":202.592,"body":"anti-inflammatory medication."},{"speaker":"(Charlie) Here's the question","startTime":202.592,"endTime":203.85,"body":"Inhaled corticosteroids"},{"speaker":"(Charlie) Here's the question","startTime":203.85,"endTime":206.275,"body":"are the most effective"},{"speaker":"(Charlie) Here's the question","startTime":203.85,"endTime":206.275,"body":"anti-inflammatory agents"},{"speaker":"(Charlie) Here's the question","startTime":206.275,"endTime":207.779,"body":"that are used in asthma therapy,"},{"speaker":"(Charlie) Here's the question","startTime":207.779,"endTime":210.616,"body":"and they work because they reduce"},{"speaker":"(Charlie) Here's the question","startTime":207.779,"endTime":210.616,"body":"the inflammatory cell numbers"},{"speaker":"(Charlie) Here's the question","startTime":210.616,"endTime":212.978,"body":"and their activation in the airways."},{"speaker":"(Charlie) Here's the question","startTime":212.978,"endTime":216.12,"body":"Another class of medications"},{"speaker":"(Charlie) Here's the question","startTime":212.978,"endTime":216.12,"body":"are the antileukotrienes."},{"speaker":"(Charlie) Here's the question","startTime":216.12,"endTime":218.721,"body":"An example of this being montelukast."},{"speaker":"(Charlie) Here's the question","startTime":218.721,"endTime":221.454,"body":"This blocks the cysteinyl"},{"speaker":"(Charlie) Here's the question","startTime":218.721,"endTime":221.454,"body":"leukotriene receptors"},{"speaker":"(Charlie) Here's the question","startTime":221.454,"endTime":224.279,"body":"and provides modest"},{"speaker":"(Charlie) Here's the question","startTime":221.454,"endTime":224.279,"body":"clinical benefit in asthma."},{"speaker":"(Charlie) Here's the question","startTime":224.279,"endTime":227.868,"body":"They are less effective than inhaled"},{"speaker":"(Charlie) Here's the question","startTime":224.279,"endTime":227.868,"body":"corticosteroids in controlling asthma"},{"speaker":"(Charlie) Here's the question","startTime":227.868,"endTime":230.167,"body":"and have less effect"},{"speaker":"(Charlie) Here's the question","startTime":227.868,"endTime":230.167,"body":"on airway inflammation."},{"speaker":"(Charlie) Here's the question","startTime":230.167,"endTime":233.046,"body":"But they can be useful"},{"speaker":"(Charlie) Here's the question","startTime":230.167,"endTime":233.046,"body":"as add-on therapy in some patients"},{"speaker":"(Charlie) Here's the question","startTime":233.046,"endTime":236.229,"body":"who aren't controlled with low doses"},{"speaker":"(Charlie) Here's the question","startTime":233.046,"endTime":236.229,"body":"of inhaled corticosteroids."},{"speaker":"(Charlie) Here's the question","startTime":236.229,"endTime":237.909,"body":"Although, remember"},{"speaker":"(Charlie) Here's the question","startTime":236.229,"endTime":237.909,"body":"that they're not usually"},{"speaker":"(Charlie) Here's the question","startTime":237.909,"endTime":241.157,"body":"as effective as long-acting"},{"speaker":"(Charlie) Here's the question","startTime":237.909,"endTime":241.157,"body":"beta-agonists, such as salmeterol."},{"speaker":"(Charlie) Here's the question","startTime":241.557,"endTime":243.955,"body":"(Charlie) What about new"},{"speaker":"(Charlie) Here's the question","startTime":241.557,"endTime":243.955,"body":"biologic treatments?"},{"speaker":"(Charlie) Here's the question","startTime":243.955,"endTime":246.21,"body":"(Cathy) There are some"},{"speaker":"(Charlie) Here's the question","startTime":243.955,"endTime":246.21,"body":"new biologic treatment options."},{"speaker":"(Charlie) Here's the question","startTime":246.21,"endTime":250.419,"body":"One example is omalizumab,"},{"speaker":"(Charlie) Here's the question","startTime":246.21,"endTime":250.419,"body":"and this binds to circulating IgE,"},{"speaker":"(Charlie) Here's the question","startTime":250.419,"endTime":252.502,"body":"regardless of allergen specificity."},{"speaker":"(Charlie) Here's the question","startTime":252.502,"endTime":256.576,"body":"They form small, biologically"},{"speaker":"(Charlie) Here's the question","startTime":252.502,"endTime":256.576,"body":"inert IgE and anti-IgE complexes,"},{"speaker":"(Charlie) Here's the question","startTime":256.576,"endTime":259.844,"body":"and it does this without activating"},{"speaker":"(Charlie) Here's the question","startTime":256.576,"endTime":259.844,"body":"the complement cascade."},{"speaker":"(Charlie) Here's the question","startTime":259.844,"endTime":261.665,"body":"These drugs are really expensive, though,"},{"speaker":"(Charlie) Here's the question","startTime":261.665,"endTime":265.33,"body":"and there is still controversy"},{"speaker":"(Charlie) Here's the question","startTime":261.665,"endTime":265.33,"body":"about which patients would benefit most."},{"speaker":"(Charlie) Here's the question","startTime":265.33,"endTime":267.532,"body":"(Charlie) So, let's just summarize that."},{"speaker":"(Charlie) Here's the question","startTime":267.532,"endTime":270.749,"body":"We've talked about rescue therapy,"},{"speaker":"(Charlie) Here's the question","startTime":267.532,"endTime":270.749,"body":"and we were mentioning controller therapy"},{"speaker":"(Charlie) Here's the question","startTime":270.749,"endTime":273.235,"body":"which usually starts"},{"speaker":"(Charlie) Here's the question","startTime":270.749,"endTime":273.235,"body":"with an anti-inflammatory."},{"speaker":"(Charlie) Here's the question","startTime":273.235,"endTime":275.611,"body":"There are some other classes"},{"speaker":"(Charlie) Here's the question","startTime":273.235,"endTime":275.611,"body":"of agents that are used."},{"speaker":"(Charlie) Here's the question","startTime":275.611,"endTime":278.48,"body":"But it's also important to point out"},{"speaker":"(Charlie) Here's the question","startTime":275.611,"endTime":278.48,"body":"that the most commonly used"},{"speaker":"(Charlie) Here's the question","startTime":278.48,"endTime":283.106,"body":"second line of controller therapy"},{"speaker":"(Charlie) Here's the question","startTime":278.48,"endTime":283.106,"body":"is a long-acting bronchodilator;"},{"speaker":"(Charlie) Here's the question","startTime":283.106,"endTime":287.209,"body":"and typically, those are the long-acting"},{"speaker":"(Charlie) Here's the question","startTime":283.106,"endTime":287.209,"body":"beta-agonists, such as salmeterol."},{"speaker":"(Charlie) Here's the question","startTime":287.209,"endTime":289.124,"body":"Alright, so let's summarize this case."},{"speaker":"(Charlie) Here's the question","startTime":289.484,"endTime":291.337,"body":"(Cathy) So, we have"},{"speaker":"(Charlie) Here's the question","startTime":289.484,"endTime":291.337,"body":"a 24-year-old asthmatic"},{"speaker":"(Charlie) Here's the question","startTime":291.337,"endTime":294.541,"body":"on an inhaled short-acting"},{"speaker":"(Charlie) Here's the question","startTime":291.337,"endTime":294.541,"body":"beta-agonist, as needed."},{"speaker":"(Charlie) Here's the question","startTime":294.541,"endTime":298.205,"body":"With this treatment, she's still using"},{"speaker":"(Charlie) Here's the question","startTime":294.541,"endTime":298.205,"body":"her inhaler 4-7 times a week,"},{"speaker":"(Charlie) Here's the question","startTime":298.205,"endTime":300.473,"body":"which is pretty regular use"},{"speaker":"(Charlie) Here's the question","startTime":298.205,"endTime":300.473,"body":"and points to the fact"},{"speaker":"(Charlie) Here's the question","startTime":300.473,"endTime":302.97,"body":"that her disease"},{"speaker":"(Charlie) Here's the question","startTime":300.473,"endTime":302.97,"body":"is not adequately controlled."},{"speaker":"(Charlie) Here's the question","startTime":303.39,"endTime":306.363,"body":"Once a patient is using a rescue inhaler"},{"speaker":"(Charlie) Here's the question","startTime":303.39,"endTime":306.363,"body":"more than twice a week,"},{"speaker":"(Charlie) Here's the question","startTime":306.363,"endTime":309.034,"body":"they should start"},{"speaker":"(Charlie) Here's the question","startTime":306.363,"endTime":309.034,"body":"an anti-inflammatory medication."},{"speaker":"(Charlie) Here's the question","startTime":309.034,"endTime":311.164,"body":"(Charlie) Okay."},{"speaker":"(Charlie) Here's the question","startTime":309.034,"endTime":311.164,"body":"Let's get to the question now."},{"speaker":"(Charlie) Here's the question","startTime":311.164,"endTime":312.336,"body":"The question asks,"},{"speaker":"(Charlie) Here's the question","startTime":312.336,"endTime":316.08,"body":"based on this information,"},{"speaker":"(Charlie) Here's the question","startTime":312.336,"endTime":316.08,"body":"you advise which of the following?"},{"speaker":"(Charlie) Here's the question","startTime":316.08,"endTime":319.172,"body":"a) Add inhaled beclomethasone;"},{"speaker":"(Charlie) Here's the question","startTime":319.172,"endTime":322.714,"body":"b) Add inhaled salmeterol, twice a day;"},{"speaker":"(Charlie) Here's the question","startTime":322.714,"endTime":325.765,"body":"c) Add inhaled tiotropium;"},{"speaker":"(Charlie) Here's the question","startTime":325.765,"endTime":328.155,"body":"d) Continue the present therapy;"},{"speaker":"(Charlie) Here's the question","startTime":328.155,"endTime":331.661,"body":"or e) Think of a new name"},{"speaker":"(Charlie) Here's the question","startTime":328.155,"endTime":331.661,"body":"for the goldfish named Puffer."},{"speaker":"(Charlie) Here's the question","startTime":331.661,"endTime":333.834,"body":"(Cathy) Obviously, changing"},{"speaker":"(Charlie) Here's the question","startTime":331.661,"endTime":333.834,"body":"the name of the goldfish"},{"speaker":"(Charlie) Here's the question","startTime":333.834,"endTime":335.463,"body":"won't do anything for her asthma,"},{"speaker":"(Charlie) Here's the question","startTime":335.463,"endTime":338.713,"body":"and continuing present therapy"},{"speaker":"(Charlie) Here's the question","startTime":335.463,"endTime":338.713,"body":"isn't a good option either."},{"speaker":"(Charlie) Here's the question","startTime":338.713,"endTime":341.314,"body":"The patient is using"},{"speaker":"(Charlie) Here's the question","startTime":338.713,"endTime":341.314,"body":"her rescue medication frequently,"},{"speaker":"(Charlie) Here's the question","startTime":341.314,"endTime":344.148,"body":"so I think we need to add"},{"speaker":"(Charlie) Here's the question","startTime":341.314,"endTime":344.148,"body":"a controller medication."},{"speaker":"(Charlie) Here's the question","startTime":344.148,"endTime":346.796,"body":"Of the choices listed,"},{"speaker":"(Charlie) Here's the question","startTime":344.148,"endTime":346.796,"body":"inhaled beclomethasone--"},{"speaker":"(Charlie) Here's the question","startTime":346.796,"endTime":348.997,"body":"which, remember,"},{"speaker":"(Charlie) Here's the question","startTime":346.796,"endTime":348.997,"body":"is an inhaled corticosteroid--"},{"speaker":"(Charlie) Here's the question","startTime":348.997,"endTime":350.878,"body":"is the correct answer."},{"speaker":"(Charlie) Here's the question","startTime":350.878,"endTime":354.012,"body":"Inhaled salmeterol--"},{"speaker":"(Charlie) Here's the question","startTime":350.878,"endTime":354.012,"body":"which is a long-acting beta agonist,"},{"speaker":"(Charlie) Here's the question","startTime":354.012,"endTime":357.753,"body":"and inhaled tiotropium-- which is"},{"speaker":"(Charlie) Here's the question","startTime":354.012,"endTime":357.753,"body":"a long-acting anticholinergic drug,"},{"speaker":"(Charlie) Here's the question","startTime":357.753,"endTime":358.997,"body":"can be added subsequently"},{"speaker":"(Charlie) Here's the question","startTime":358.997,"endTime":361.842,"body":"if symptoms aren't controlled"},{"speaker":"(Charlie) Here's the question","startTime":358.997,"endTime":361.842,"body":"with the original therapy."},{"speaker":"(Charlie) Here's the question","startTime":361.842,"endTime":364.332,"body":"So, I would go with"},{"speaker":"(Charlie) Here's the question","startTime":361.842,"endTime":364.332,"body":"a) inhaled beclomethasone."},{"speaker":"(Charlie) Here's the question","startTime":364.332,"endTime":366.544,"body":"(Charlie) And do you typically"},{"speaker":"(Charlie) Here's the question","startTime":364.332,"endTime":366.544,"body":"have a quick order,"},{"speaker":"(Charlie) Here's the question","startTime":366.544,"endTime":369.396,"body":"how you usually"},{"speaker":"(Charlie) Here's the question","startTime":366.544,"endTime":369.396,"body":"sequence these medications?"},{"speaker":"(Charlie) Here's the question","startTime":369.396,"endTime":371.682,"body":"(Cathy) First, I start"},{"speaker":"(Charlie) Here's the question","startTime":369.396,"endTime":371.682,"body":"with an inhaled corticosteroid"},{"speaker":"(Charlie) Here's the question","startTime":371.682,"endTime":373.257,"body":"to reduce airway inflammation."},{"speaker":"(Charlie) Here's the question","startTime":373.257,"endTime":376.109,"body":"And I also add to that"},{"speaker":"(Charlie) Here's the question","startTime":373.257,"endTime":376.109,"body":"a short-acting beta-agonist,"},{"speaker":"(Charlie) Here's the question","startTime":376.109,"endTime":378.845,"body":"which people take, as needed,"},{"speaker":"(Charlie) Here's the question","startTime":376.109,"endTime":378.845,"body":"for symptom control."},{"speaker":"(Charlie) Here's the question","startTime":378.845,"endTime":381.268,"body":"Then I do a long-acting"},{"speaker":"(Charlie) Here's the question","startTime":378.845,"endTime":381.268,"body":"beta-agonist, if needed,"},{"speaker":"(Charlie) Here's the question","startTime":381.268,"endTime":386.242,"body":"and then high-dose inhaled corticosteroids"},{"speaker":"(Charlie) Here's the question","startTime":381.268,"endTime":386.242,"body":"or oral corticosteroid, or azithromycin."},{"speaker":"(Charlie) Here's the question","startTime":386.242,"endTime":389.536,"body":"And then, less commonly used agents"},{"speaker":"(Charlie) Here's the question","startTime":386.242,"endTime":389.536,"body":"if the disease is still severe."},{"speaker":"(Charlie) Here's the question","startTime":389.536,"endTime":390.961,"body":"(Charlie) And I would just add,"},{"speaker":"(Charlie) Here's the question","startTime":390.961,"endTime":393.478,"body":"if a patient is not well-controlled"},{"speaker":"(Charlie) Here's the question","startTime":390.961,"endTime":393.478,"body":"on those medications,"},{"speaker":"(Charlie) Here's the question","startTime":393.478,"endTime":395.015,"body":"then it's time to involve a specialist"},{"speaker":"(Charlie) Here's the question","startTime":395.015,"endTime":399.334,"body":"because they may be using, or they may"},{"speaker":"(Charlie) Here's the question","startTime":395.015,"endTime":399.334,"body":"need one of the new biologic therapies."},{"speaker":"(Charlie) Here's the question","startTime":399.334,"endTime":402.295,"body":"So, the teaching point here"},{"speaker":"(Charlie) Here's the question","startTime":399.334,"endTime":402.295,"body":"is that you judge asthma control"},{"speaker":"(Charlie) Here's the question","startTime":402.295,"endTime":405.053,"body":"by the frequency of use"},{"speaker":"(Charlie) Here's the question","startTime":402.295,"endTime":405.053,"body":"of rescue inhalers."},{"speaker":"(Charlie) Here's the question","startTime":405.053,"endTime":406.914,"body":"And as the asthma gets worse,"},{"speaker":"(Charlie) Here's the question","startTime":406.914,"endTime":410.321,"body":"you sequentially add therapies,"},{"speaker":"(Charlie) Here's the question","startTime":406.914,"endTime":410.321,"body":"starting with inhaled corticosteroid,"},{"speaker":"(Charlie) Here's the question","startTime":410.321,"endTime":412.609,"body":"to try to improve the control of disease."},{"speaker":"(Charlie) Here's the question","startTime":412.609,"endTime":414.335,"body":"However, as we mentioned earlier,"},{"speaker":"(Charlie) Here's the question","startTime":414.335,"endTime":417.931,"body":"some experts are recommending"},{"speaker":"(Charlie) Here's the question","startTime":414.335,"endTime":417.931,"body":"that you initiate controller therapies"},{"speaker":"(Charlie) Here's the question","startTime":417.931,"endTime":421.673,"body":"even in mild cases of asthma,"},{"speaker":"(Charlie) Here's the question","startTime":417.931,"endTime":421.673,"body":"as part of the initial treatment regimen."},{"speaker":"(Charlie) Here's the question","startTime":421.673,"endTime":423.961,"body":"(Cathy) And for more information,"},{"speaker":"(Charlie) Here's the question","startTime":421.673,"endTime":423.961,"body":"you can read about this"},{"speaker":"(Charlie) Here's the question","startTime":423.961,"endTime":427.357,"body":"in Diseases of the Respiratory System,"},{"speaker":"(Charlie) Here's the question","startTime":423.961,"endTime":427.357,"body":"chapter on asthma."},{"speaker":"(Charlie) Here's the question","startTime":427.357,"endTime":429.82,"body":"♪ (music) ♪"}]}