Asthma

Question 1

IL responsible for neutrophilic asthma, also present in adipose tissue

Answer 1

IL-17

Question 2

Diagnosis of asthma

Answer 2

Mostly clinical!

Reduced FEV1/FVC
10% increase in FEV1 or FVC (bronchodilator response)
Can have diurnal peak flow variability>20% in adults

Question 3

Direct bronchoprovocation tests and cut off

Answer 3

1. Mathacholine challenge
2. Histamine challenge

> 20% change in FEV1

Has great negative predictive value in symptomatic patients

Question 4

Choosing direct or indirect bronchoprovocation test and their advantages

Answer 4

Indirect: more specific; correlates better with airway inflammation, best choice when exercise bronchospasm is in question

Direct: good negative predictive value if patient is symptomatic

Question 5

Indirect bronchoprovocation tests and cut offs

Answer 5

1. Mannitol
2. Eucapnic hyperventilation

FEV1 >15% change

3. Exercise testing: >10% change and 200 ml

Question 6

Which IL is FeNO testing correlative with and what is the cut off for it to be positive

Answer 6

IL-13
Also correlates with eosinophils and exacerbations

> 50 ppb

Question 7

Benefit of LAMA as an add on to ICS/LABA in asthma

Answer 7

small increase in lung function
NO clinical benefit in sx or QOL
Modest reduction in exacerbation compared to ICS+LABA

Question 8

Indications for Leukotriene modifiers (2)

Answer 8

Aspirin exacerbated disease
Exercise induced bronchoconstriction

Question 9

Black box warning for leukotriene inhibitors

Answer 9

SI/mental health

Question 10

Benefit of ICS+Formoterol AIR therapy vs. scheduled ICS or SABA prn

Answer 10

1. Decrease exacerbations by 40-60%
2. Decreased steroid exposure

Question 11

When to start maintenance therapy: “persistent”

Answer 11

Step 2:
Night awakening 2-3x/mo (Step 3)
OR daily sx >2-3 days/week (Step 2)

Step 3:
FEV 60-80%
night sx more than 1x a week

Question 12

Severe asthma definition

Answer 12

Step 4-5; FEV <60%
Use of corticosteroids >50% of the previous year
Remains uncontrolled despite therapy

Question 13

Omalizumab target & indications

Answer 13

IgE lvl 30-700

Max weight 60-90kg depending on IgE level

Question 14

3 biologics indicated for nasal polyposis

Answer 14

Omalizumab
Mepolizumab
Dupilumab

Question 15

3 anti IL-5 and how they differ

Answer 15

Mepolizumab: indication for EGPA, Hypereosinophilic sd, nasal polyps

Benralizumab: targets RECEPTORS

Reslizumab: IV, weight base, only clinic administration

Question 16

Dupilumab target

Answer 16

IL-4 receptor (shared by IL-4 and IL-13)

Question 17

What does IL-13 do

Answer 17

Increase IgE
Increase mucus
Affect airway epithelium

Question 18

Which biologics are indicated for corticosteroid-dependent asthma

Answer 18

dupilumab
benralizumab
mepolizumab

Question 19

When should we use Tezepelumab

Answer 19

low T2 asthma
Though more effective with high eos

Question 20

Benefit of azithromycin in asthma

Answer 20

when used 500mg 3x/week –> reduction in
1. exacerbation frequency
2. QOL

Question 21

Definition of ASA exacerbated respiratory disease (3 criteria)

Answer 21

1. asthma
2. chronic rhinosinusitis with nasal polyposis
3. ASA sensitivity

Question 22

Treatment of ASA exacerbated respiratory disease

Answer 22

leukotriene modifiers
ASA avoidance if able

Question 23

How does controlling GERD help with Asthma

Answer 23

1. Improves Peak flow
2. QOL
3. Decreases exacerbations

Question 24

How to diagnose occupational asthma

Answer 24

specific exposure inhalation test
PFT

Question 25

What genes are associated with early onset asthma

Answer 25

Chromosomes 17q21
Genes ORMDL3
GSMDB

Question 26

Abs Eos count cut off to qualify for Mepolizumab

Answer 26

> 150

Question 27

Absolute eos count cut off for Reslizumab

Answer 27

> 150

Question 28

Dx of hereditary angioedema

Answer 28

Type I: Low ag and functional C1 esterase
Type II: normal Ag, low C1 inhibitor function

Question 29

Tx of hereditary angioedema and C1 inhibitor deficiency

Answer 29

SQ Icatibant (bradykinin receptor antagonist) - no more than 3 doses in 24h period q6h

Lanadelumab: mAb inhibitor of plasma kallikrein

Question 30

When is allergen immunotherapy safe to start

Answer 30

when someone has controlled asthma

Question 31

in smoker, decreased FVC and FEV1 with normal ratio, think dx of ____

Answer 31

PRISM (presereved ratio impaired spirometry)

Question 32

Those with dx of PRISm have high risk of ____

Answer 32

COPD

and mortality risk, greater respiratory sx and reduced exercise capacity compared to those with normal lung function

Question 33

Influenza vaccine benefit in COPD

Answer 33

frequency of exacerbation

NOT mortality

Question 34

Most common site of bronchial atresia

Answer 34

LUL apicoposterior segment

Question 35

Management of dupilumab-associated hypereosinophilia

Answer 35

usually lasts 16-20 weeks, will persist after 6 mo
Stop dupi if >5000 AEC or end-organ dysfunction

Question 36

Should you step down or use LAMA in pregnancy

Answer 36

no!

LAMA is contraindicated

Question 37

Indication for bronchothermoplasty

Answer 37

2 episodes requiring corticosteroids in the past year, FEV1 has to be >60%

Question 38

Benefit and logistics of bronchothermoplasty

Answer 38

decrease in severe exacerbations

decrease in ED visits

decrease in days off from work/school

3 treatments
likely to have asthma exacerbations in the immediate post-op period 6wk