Asthma

Question 1

Why would moving to Denver potentially help someone’s asthma?

Answer 1

• Air is Dryer and is at Lower Pressure so there is less viscosity and less pressure to exhale against

(sometimes hospital rooms contain He/O2 to help people breathe)

Question 2

What is the definition of Asthma?
• what is implied about the treatment of asthma given this definition?

Answer 2

Chronic inflammatory disorder characterized by episodic reversible bronchospasm resulting from an exaggerated bronchoconstrictor response to various stimuli

• Asthma can be treated effectively with anti-inflammatories because its an inflammatory condition

Question 3

What are the main cells mediating inflammation in asthma?
• why does this make sense?

Answer 3

• Mast cells, Eosinophils, and T-lymphocytes - Chronically

• Neutrophils - acutely

why this makes sense:
• TH2 cells are responsible for this disease regardless if its allergic or not. TH2 cells send out IL-4 (for IgE) and IL-5 (eosinophil chemotractant).

Question 4

What happens when inflammation is persisent in the airways regardless of the cause (COPD, Asthma, etc.)?

Answer 4

• Persistent changes cause FIBROSIS and SMOOTH MUSCLE HYPERTROPHY as well as ANGIOGENESIS => collectivley this is airway remodeling.

Question 5

What is the suspected mechanism by which children “outgrow” asthma in adulthood?
• do adults experience remission in the same way?

Answer 5

Asthma probably still exists in these people, but their airways have grown so that the bronchospasm doesn’t take up a significant portion of their airway (30-50% of children w/ asthma will outgrow it)

• 20-30% of adults will outgrow asthma

Question 6

T or F: in both childhood and in adulthood being a black female puts you at a higher risk of asthma related death.

Answer 6

True, females tend to get asthma more commonly than boys in childhood across all ages being black puts you at an elevated risk of asthma related death

Question 7

**While asthma may occur at different rates among different age, sex, and races prevalance is approximately the same** the only real difference is that African Americans are more likely to die from it

Question 8

Differentiate Extrinsic, Intrinsic, and Drug induced asthma.

Answer 8

Extrinsic (atopic, allergic):
• a definite stimulus or time of year can be identified as the cause of the asthma - implies that something from outside is irritating the respiratory tract

Intrinsic (idiosyncratic, non-allergic):
• No known stimulus of the asthma it persists throughout the year

Drug induced:
• Asthma stimulus is drugs (aspirin, NSAIDs)

Question 9

How do you treat someone with intermittent bouts of asthma?
• What if their asthma is mild and persistent?
•What if the asthma ismoderate?
• What if the ashma is severe?

Answer 9

Intermittent: Albuterol as needed
Persistent and Mild: Inhaled Steroids
Moderate: add Long Acting Beta Agonist OR LA Anti-muscarinics
Severe: add leukotriene modifiers

Question 10

Why should you be cautious to identify somone as having moderate asthma?

Answer 10

Identifying someone as having moderate asthma means putting them on a LABA which puts them at a higher risk of mortality - This is a BBW.

Question 11

Extrinsic Asthma is the MOST COMMON type of asthma it is _____________ (a) mediated and likelihood of getting it is highly dependent on ____________ (b).

Answer 11

(a) IgE mediated (in response to an environmental stimulus)
(b) Family History

Question 12

How can people try to limit the number of exacerbations they have of Extrinsic asthma?

Answer 12

Remove possible triggers:
• Get ride of things that hold dust mites
• Avoid food sources and things that might attract roaches
• Reduce exposure to Pets
• Eliminate mold

Question 13

People with Intrinsic Asthma _______________ levels in serum and will have a _________ skin antigen test. Moreover, the family history is ___________. It is most likely to onset sometime during _________.

Answer 13

People with Intrinsic Asthma NORMAL IgE levels in serum and will have a NEGATIVE skin antigen test. Moreover, the family history is NONCONTRIBUTORY. It is most likely to onset sometime during ADULTHOOD.

Question 14

How does eosinophilia in Intrisic Asthma compare to that of Extrinsic Asthma?

Answer 14

Much less eosinophilia is seen in Intrinsic Asthma (more like 15%) compared to 30% or so in Extrinsic Asthma.

Question 15

What age group usually gets Drug-induced Asthma?
• what syndrome is associated with drug induced asthma?
• what is proposed to be the pathophysiology of the defect in asprin induced asthma?

Answer 15

ADULTS typically get this

Samter’s Syndrome:
•Associated with Asthma, Aspirin Sensitivity (flushing, angioedema, urticaria), and Nasal Polyps

Defect in asprin/NSAID sensitive asthma:
• NSAIDs block COX1/2 and more arachiodonic acid gets shunted to 5-lipooxygenase (5-LO) so the increased amounts of leukotrienes and 5-HETE are

• Leukotrienes and 5-HETE are potent bronchoconstricotors

Question 16

Given the proposed mechanism of Asprin induced asthma, what do you suppose the best treatment option would be?

Answer 16

Zileuton or drugs that block Leukotriene receptors - b/c this is not IgE mediated anti-IgE drugs would not be effective

Question 17

Occupational asthma is caused by ________ and occurs after ____________ and it is mediated by ________ and _________ mechanisms.

Answer 17

Occupational asthma is caused by Shit in the air at the workplace and occurs after Sensitization to the allergin developes and it is mediated by both IgE and non-IgE mechanisms.

Question 18

What treatment is typically given to people with excercise induced bronchospasm?

Answer 18

Pre-treat with ß-agonist or Cromolyn is used
• Slow warm up also helps with this

Question 19

Excercise-Induced Bronchospasm:
• When do symptoms typically occur?
• What is the pathophysiology behind this?

Answer 19

Excercised Induced bronchoconstriction typically occurs 5 - 10 minutes AFTER workout is completed.
Its thought that drying of the airway mucosa causes mast cells to release histamine

Question 20

What is Cough-Variant asthma?
•how does it present?
• how would you diagnose this?

Answer 20

Cough-Variant Asthma
• people may present with chronic cough that presents in response to some stimulus (cigarette smoke, fumes, excercise), but cough may be the only symptom they have

Diagnosis:
• Positive reaction to asthma therapy or Methalcholine challenge

Question 21

What causes people to get nocturnal asthma?

Answer 21

Decline of circulating catecholamines and cortisol between midnight and 8am. Usually this occurs in your sleep

Question 22

T or F: Allergic Bronchopulmonary Aspergillosis (ABPA) presents as asthma.

Answer 22

True, this is an IgE mediated type III immune response

Question 23

How will people with ABPA (allergic bronchopulmonary aspergillosis) present?
• what are some key tip-offs for diagnosis?

Answer 23

ABPA - poorly controlled ASTHMA and lots of EOSINOPHILIA (30-45%) and and IgE of >1000ng/ml and may have chest X-rays that are fleeting (aka they change everytime you do it).

Question 24

John has been on albuterol, corticosteroids, and a long acting beta 2 agonist for treatment of his asthma but it appears to be unrelieved. CXR shows fleeting infiltrates from his last 3 visits.
• what might be going on?
• What is the treatment?

Answer 24

ABPA - is treated with PREDNISONE typically
• note in these patients you may also see central bronchietasis

Question 25

What is the consequence of epithelial denudation seen in asthmatics?

Answer 25

It allows even more of the allergin into the subepithelial layers promoting hyperresponsiveness and increased secretions

Question 26

Asthmatic patients have ___________ tone and relex _________.

Answer 26

Asthmatic patients have elevated parasympathetic tone and relex bronchoconstriction.

Question 27

Differentiate Asthma and COPD on the basis of:
• Age of Onset
• Type of Inflammation
• Relevant Lymphocyte
• Relevant Interleukins

Answer 27

Asthma onsets at a younger age and presents with eosinophilic inflammation (charcot-leyden crystals) with CD4 (TH2) cells mediating the inflammation, thus IL-5 is the major interleukin causing the eosinophilia

COPD presents at an older age and the inflammation is typically neutrophilic because cigarette smoke is a chemoattractant for neutrophils along with IL-8 that is released from damaged respiratory cells. CD8 cells are also present because of forgein antigens present.

Question 28

Differentiate Asthma and COPD on the basis of:
• Allergy History
• Reversibility of Bronchospam
• Response during exacerbation

Answer 28

Asthma patients usually have a history of having allergies with the bronchospam being reversible and exacerbation inflammation flipping to neutrophilic response

COPD patients don’t usually have an allergy history and the reversibility of their bronchospasm is limited and variable. Bronchspasm results in an eosinophilic inflitrate>

Question 29

Someone comes into your office complaining of Dyspnea and wheezing that occurs seasonally or after exposure to allergens. How do you confirm this diagnosis?

Answer 29

Confirm diagnosis by giving them medication and seeing if it works

Question 30

What is the typical cause of asthma related death?

Answer 30

Diffuse mucous plugging

Question 31

How can you diagnose someone with Nocturnal Asthma?
• what causes it?

Answer 31

Noctural Asthma:
• Diagnosis is a reduction in peak flow by 20% or more at two different points in the day (usually this is highest at 4pm and lowest at 4am)

Question 32

Spironmetry in an asthma patient will have a decreased __________ that reverses with ___________ to an improvement of ___________ or _______.

Answer 32

Spironmetry in an asthma patient will have a decreased FEV1/FVC that reverses with bronchodilators to an improvement of 12% in FEV1 or 200cc.

Note: gas exchange is typically normal in these patients

Question 33

Notice that in COPD or and Asthma attack people’s ribs will be more separated in CXR.

Question 34

Will patients with asthma have a scoop on their Volume/Flow charts?
• can this be reversed?

Answer 34

Yes any obstructive disease will have a scooped volume-flow chart that corrects significantly with bronchodilators

Question 35

What is the methalcholine challenge?
• what indicates a positive test?
• how sensitive is this test?

Answer 35

PC20 - the concentration at which there is a 20% reduction in flow tells you whether that have asthma or not. This test is very sensistive if you have a negative methylcholine challenge then you most likey do not have asthma

Question 36

What are some common triggers of asthma?

Answer 36

• Humidity
• Dust mites
• Cockroaches
• Molds
• Occupational
• GERD
• Cigarette Smoking

Question 37

You diagnose someone with asthma. What are 3 things you should do?

Answer 37

1. Make and action plan
2. assess severity and control with PFTs
3. Pharmacologic therapy

Question 38

Asthma Relievers:
• SABA
• SAMA

Controller:
• Inhaled corticosteroids
• Inhaled LABA
• Leuketriene Modifiers
• Systemic steroids
• Anti IgE

Answer 38

Asthma Relievers:
• SABA
• SAMA

Controller:
• Inhaled corticosteroids
• Inhaled LABA
• Leuketriene Modifiers
• Systemic steroids
• Anti IgE

Question 39

IMPORTANT SHIT

•Asthma is an inflammatory disorder

•Prevalence of Asthma may be increasing

•There are different types of Asthma. Causes are multi-factorial and triggers are numerous

• Airway hyperresponsiveness is due to several mechanisms causing airflow obstruction

Answer 39

•Diagnosis: compatible symptoms and lung function tests (PEFR, Pulmonary Function Test)

•Methacholine challenge test has a high NPV

•Management of asthma: good patient education and appropriate pharmacologic treatments

•ICS -> LABA-> LTRA

•LABA are associated with increased Mortality – use cautiously, with regular follow up

Question 40

What cells are specifically targeted by cromolyn?

Answer 40

MAST CELLS