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Asthma Flashcards

1
Q

MOA of beta agonists

A
  1. Bind to g protein coupled receptors and activate adenylyl cyclase resulting in cAMP
  2. This activates PKA leading to phosphorylation and muscle relaxation (bronchodilation)
  3. Non-bronchodilation actions: increased mucociliary clearance, protect epithelium against bacteria, suppress microvascular permeability, inhibit cholinergic transmission, primes glucocorticoid receptors leading to enhanced nuclear translocation and some mild anti inflammatory effects
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2
Q

List adverse effects of B-agonists

A
  1. Tremor
  2. Tachycardia
  3. Prolonged QT
  4. Hyperglycemia
  5. Hypokalemia
  6. Hypomagnesemia
  7. Densensitization
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3
Q

What is cromolyn sodium?

A
  • Cromolyn sodium is a mast cell stabilizer, available as an inhalation or opthalmic drop - pregnancy category B
  • Requires QID dosing
  • works by inhibiting IgE-mediated calcium channel activation, which prevents mast cell release of histamine, leukotrienes, and cytokines (therefore blocks activation of eosinophils, inhibits neutrophil activation, chemotaxis and mediator release, and inhibits IgE production)
  • commonly used in allergic eye disease and in the treatment of GI symptoms in mastocytosis
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4
Q

Approval criteria for Xolaire in asthma

A

Asthma

  1. Age 6+
  2. Moderate to severe asthma inadequately controlled with ICS
  3. Allergic sensitization by SPT or RAST to a perennial allergen
    - Total serum IgE 30-700 IU/mL for >12s, and 30-1300 for 6- 12 years old

CRSwNP
- add on therapy for adults age 18+ with CRSwNP not adequately controlled on INCS

CSU
- Patients age 12+ with CSU who remain symptomatic despite anti histamine therapy

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5
Q

MOA of Xolaire:

A
  1. Omalizumab binds to the third constant domain of the IgE heavy chain (Cε3), which is the same site at which IgE normally binds to both high and low affinity IgE receptors on mast cells, basophils, and other cell types
  2. Omalizumab forms complexes with free IgE and prevents its interaction with these receptors. The omalizumab-IgE complexes are subsequently cleared by the hepatic reticuloendothelial system
  3. The antibody is specific to IgE and does not bind to IgG or IgA. An important property of omalizumab is that it cannot bind to IgE receptors or to IgE already attached to FcεRI, and therefore does not interact with cell-bound IgE or activate mast cells or basophils by interacting with FcεRI.
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6
Q

Adverse effects of Xolair

A
  1. anaphylaxis (0.2%); FDA recommendations: should be observed for xolair injections X 60 minutes for first three and then X 30 minutes after and have epipen for 24 hours after each injection.

Unclear associations: CSS, cardiovascular disease, susceptibility to parasitic infection.

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7
Q

Xolair dosing

A

0.016 mg/kg per IU IgE/mL per month. Cost about $10,000 per year.

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8
Q

Efficacy of Xolair in asthma

A

Reduction in ICS, decreased exacerbations, decreased hospitalizations. Smaller reduced FEV1 upon acute allergen exposure (such as cat). Duration of therapy not determined - if respond, generally continue for long-term.

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9
Q

Management of asthma in pregnancy

A
  1. Follow spirometry Qmonthly
  2. avoid asthma triggers, don’t smoke
  3. if on AIT can continue if on maintenance but otherwise stop.
  4. ICS preferred controller therapy; if moderate persistent asthma can use either medium dose ICS or ICS/LABA.
  5. Unusual to have asthma attack during labor/delivery but should stay on meds. If recently on OCS should be stress dosed.
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10
Q

Discuss the mechanism of theophyllines

A

Theophylline inhibits PDE resulting in elevated cAMP and also acts as an adenosine receptor antagonist (may account for s/e of CNS stimulation, gastric hypersecretion, diuresis).

Clinical effects: increases IL10, increases apoptosis of inflammatory cells (eos, T lymphocytes), increases histone deacetylase activity (synergy with CS), prevents nuclear translocation of NFKB (anti-inflammatory). Is both bronchodilator and anti-inflammatory.

Decreased clearance with macrolides, CHF, liver disease, older age, high CHO diet.

Increased clearance with young age, high protein diet, ETOH, smoking, antiepileptics.

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11
Q

3 causes of cough

A

chronic cough = >4 weeks (children), >8 weeks (adults)

1. Upper airway cough syndrome (UACS)
prev known as post-nasal drip syndrome
most common cause of chronic cough
may be attributed to combination of upper airway inflammation, nasobronchial reflex, cold dry air stimulation, central and peripheral neuroplasticity
2. Asthma
3. GERD
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12
Q

Risk factors for AR

A
  • AAAAI 2008 PP Risk factors for allergic rhinitis:
    - family hx of atopy
    - serum IgE >100 before age 6
    - higher SES
    - presence of a positive SPT
    • Unknown effect:
      • early childhood infections (might reduce atopy)
      • early childhood exposure to animals (might reduce atopy)
      • secondary tobacco smoke exposure (might increase atopy)
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13
Q

MOA of INCS

A
  • reduce influx of inflammatory cells into the nasal mucosa in response to allergic stimuli
  • this reduces the release of inflammatory mediators and the development of nasal hyperresponsiveness
  • block the synthesis and release of cytokines and chemokines from T cells, epithelial cells, eosinophils, and mast cells
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14
Q

Who is suitable for step 1 of GINA guidelines?

(Age 12+)

A

Step 1: As needed low dose ICS- formoterol (Age 12+)

patients with symptoms less than twice a month, and no exacerbation risk factors

<12 years is PRN SABA or ICS whenever PRN saba is taken

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15
Q

What is step 2 of GINA guidelines? (Age 12+)

A

sx more than 2x a month, but less than daily

  1. daily low dose ICS and PRN SABA
  2. PRN ICS-formoterol
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16
Q

What is step 3 GINA guidelines? (Age 12+)

A 
low dose ICS- fom maintenance and reliever 
or 
low dose ICSLABA and PRN SABA
Med dose ICS and PRN SABA
Low dose ICS and LTRA

reasons to go to step 3

  • sx most days
  • waking more than once per week

step 2
- >2 x per month, but less than daily

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17
Q

What is step 4 of GINA guidelines? (Age 12+)

A

medium dose ICS-LABA maintenance and PRN

Other options: high dose ICS, add on tiotropium or add on LTRA

if HDM - do SLIT if FEV>70%

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18
Q

What is step 5 of GINA guidelines? (Age 12+)

A

high dose ICS-LABA
Refer for phenotypic assessment
add on therapy like tiotropium, anti IgE, anti IL5/5R, and anti IL4R

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19
Q

What is the modified asthma predictive index and compare it to the original asthma predictive index

A

Modified API
4 episodes of wheeze with 1 MD confirmed episode AND
1 Major OR 2 minor
Major:
- Parental history of asthma
- MD dx atopic derm
- Allergic sensitization to at least 1 aeroallergen
Minor
- allergic sensitization to milk, egg or peanuts
- wheezing unrelated to colds
- blood eos > 4%

Original API
Major 
- Parental asthma 
- MD dx atopic derm 
Minor 
- AR 
- wheezing unrelated to colds
- blood eos >4%
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20
Q

Absolute contraindications for bronchoprovocation testing

A
  1. FEV1 <50% predicted or 1.0L
  2. ACS within 3 months
  3. Severe Htn (>200 sBP or >100dBP)
  4. cerebral or aortic aneurysm

Relative contraindications

  1. inability to perform spirometry
  2. pregnant or nursing
  3. hypoxemia
  4. recent resp infection
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21
Q

Medications to stop before methacholine challenge

A

Inhaled bronchodilators

  • salbutamol (8 hours)
  • ipratropium (24 hours)
  • salmeterol/formoterol (48 hours)
  • tiotropium (1 week)

Oral bronchodilators - theophylline (24 hours)
Inhaled/oral steroids (2-3 weeks)
mast cell stabilizers (cromolyn 8 hours)
antihistamines (72 hours)
LTRA (24hours)

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22
Q

Name the three types of bronchoprovocation testing

A
  1. Specific airway irritants
    - allergens and occp. exposures
  2. Non specific pharmacological agents
    - methocholine
  3. Indirect stimuli
    - exercise, cold air, mannitol
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23
Q

What type of hypersensitivity reaction is APBA

A

It is a combo of type 1 and type 3 responses (IgE and IgG)

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24
Q

Describe the immunology of ABPA

A

Increase in th2 response
generation of cytokines IL-4, IL-5 and IL-13
this causes increase in eosinophilia and IgE

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25
Q

Diagnosis of ABPA ISHAM Criteria

A

Obligatory criteria

  • total IgE elevated >1000 IU/mL
  • skin test positive or specific IgE to aspergillus elevated

Other criteria 2 of

  • precipitating serum antibodies to A.fumigatus
  • radiographic pulmonary opacities consistent with ABPA
  • total eos count of >500
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26
Q

Beclamethasone is…?

A

QVAR

Category C for pregnancy

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27
Q

List 5 mechanisms where cytokines contribute to clinical asthma

A

Th2 lymphocytes release IL-3, IL-4, IL-5, IL-13 and GM- CSF

IL-3 is a survival factor for eosinophils and basophils

IL-4 promotes T cells to become Th2, B cells to class switch to IgE, endothelial cells to express VCAM-1 which promotes eos, baso, and t cell recruitment

IL-5 regulates eos production and survival

IL-13 contributes to airway eos, mucous glad hyperplasia, airway fibrosis and remodeling

GM- CSF- survival factor for eos

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28
Q

What is the role of eosinophils in asthma?

A
  1. mediate smooth muscle contraction
  2. cause damage to airway epithelium and nerves
  3. may be involved in airway remodeling and fibrosis
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29
Q

Effects of tobacco smoke on asthma?

A
  1. May cause development of asthma in some studies
  2. May cause more severe symptoms
  3. May cause an accelerated decline in lung function
  4. may impair short term therapeutic response to corticosteroids
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30
Q

Name the 4 tachykinins that contribute to asthma

A
  1. Substance P
  2. Neurokinin A
  3. Calcitonin
  4. Gene related peptide
    These neurotransmitters effect the airways by initiating bronchoconstriction, causing mucous secretion, causing vasodilation and plasma exudation, and leading to inflammatory cell recruitment
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31
Q

Name 5 features that suggest the diagnosis of asthma in a 3 years old after trying low dose ICS x 2 months and SABA PRN (CTS)

A
  1. Reduction in daytime and nocturnal symptoms
  2. Reduction in the use of rescue SABA
  3. No acute care visits
  4. No hospital admissions for asthma exacer.
  5. No use of rescue OCS
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32
Q

Diagnosis of pre-schooler asthma

A
  1. MD documented airflow obstruction
    (alt: convincing parental report of wheeze)
  2. MD documented reversibility of obstruction
    (alt: convincing parental reports of response to SABA)
  3. No evidence of other diagnosis
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33
Q

4 reasons a teen has poorly controlled asthma

A
  1. Non compliance
  2. not using device properly
  3. smoking
  4. allergy triggers
  5. insufficient dose
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34
Q

Name 6 elements that would indicate well controlled asthma control

A
  1. Daytime sx < 2 days a week
  2. nighttime <1 night/ week
  3. Physical activity normal
  4. exacerbations mild and infrequent
  5. absence from work - none
  6. Need for SABA < 2 doses per week
  7. FEV1 or PEF >90% of personal best
  8. PEF diurnal variation <10-15%
  9. sputum eosinophils <2-3%
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35
Q

How does the mannitol test work?

A

bronchoconstriction by increasing the osmolarity of the airway surface resulting in release of mast cell mediators –> the mast cell mediators (prostaglandins and leukotrines E4) in turn cause broncho constriction

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36
Q

Diagnostic criteria for Churg Strauss/ EGPA

ACR

A

Presence of 4 or more of these criteria had a sens. of 85% and spec. of 99.7% for EGPA

  1. Asthma
  2. Greater than 1% eosin of the differential
  3. Mononeuropathy or polyneuropathy
  4. Migratory or transient pulm. opacities
  5. paranasal sinus abnormality
  6. Biopsy containing a blood vessel should accumulation of eos in extravascular areas
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37
Q

Treatment for EGPA

A
  1. Prednisone 0.5-1.5 mg/kg OD for 6-12 weeks than slow taper (mainstay of treatment)
  2. Consider azathioprine for maintenance
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38
Q

In a child age 6-11 years who is on maintenance ICS, what is their yellow zone step up therapy? (CTS)

A
  1. First choice: None

2. 2nd chocie: Oral Prednisone 1 mg/kg x 3-5 days

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39
Q

In a child age 12+ who is one ICS for maintenance therapy, what is their yellow zone step up therapy? (CTS)

A
  1. Increase ICS to 4 x dose for 7-14 days

2. 2nd choice: Pred 30 -50 mg for 5 days

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40
Q

In a child age 12+ who is one ICS/LABA for maintenance therapy, what is their yellow zone step up therapy? (CTS)

A
  1. Increase to 4 inhalation BID or 8 inhalation max daily if Bud/Form is their reliever
  2. Pred 30-50 mg for 5 days
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41
Q

What are the criteria for hypereosinophilia?

A
  1. absolute eosinophil count of >1.5 x 109 on peripheral smears on 2 occasions separated by at least 1 month and
  2. pathologic confirmation of tissue HE
    AND
  3. eosinophil mediated organ damaged and/or dysfunction, provided other causes for damage is excluded
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42
Q

Stages of ABPA

A

Stage 1. Acute - upper lobe or middle lobe involvement with elevated IgE

Stage 2. Remission - No infiltrates, off prednisone with elevated or normal IgE

Stage 3. Exacerbation - upper lobs or middle with markedly elevated IgE

Stage 4- Steroid dependant asthma - infiltrates absent or only intermittent with elevated or normal IgE

Stage 5 - End stage - fibrotic, bullous, or cavitary lesions and IgE may be normal

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43
Q

Name 3 Categories of hypersensitivity pneumonitis

A

acute
subacute
chronic

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44
Q

What 5 features suggest asthma in a patient who has been on ICS x 2 months and beta agonists PRN? (CTS 2012)

A
  1. reduction in daytime nocturnal sx of asthma
  2. reduction in the use of SABA
  3. No acute care visits
  4. No hospital admissions
  5. No use of PO Pred
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45
Q

Name some non specific stimuli used in asthma testing (3)

A
  1. methacholine
  2. histamine
  3. cold air
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46
Q

Name a direct test in asthma dx

A
  1. Methacholine challenge
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47
Q

Name an indirect agent used in asthma testing

A
  1. inhaled mannitol
    causes bronchoconstriction by increasing osmolarity of the airway surface –> release of mast call mediators –> bronchoconstriction
  2. exercise provocation
  3. eucapnic voluntary hyperpnea
48
Q

what is the eucapnic voluntary hyperpnea test?

A

breath dry hypercapnic air for 6 minutes at a RR of 300 x the FEV1
spirometry is performed prior to the test and at 5, 10 and 15 minutes after completion
positive if FEV1 decreases by 10% or more

49
Q

what is the exercise provocation test?

A

exercise for 6-8 minutes at 20-25C while breath dry air at 80-90% of max HR
then measure FEV1 at 5, 10, 15 and 30 minutes
drop in FEV1 by 10% is diagnostic

50
Q

Give some examples of low molecular weight agents, what type of reaction are they likely to cause?

A
  1. dust mite, cleaning products, platinum salts, wood acids

2. likely to cause late or dual responses in bronco-provocation testing

51
Q

Give examples of high molecular weight agents, wha type of reaction do they cause?

A
  1. animals, fish, flours, latex

2. immediate reaction in broncho provocation testing

52
Q

What is reactive airway dysfunction syndrome?

A
  • new asthma occurring as the aftermath of an acute inhalation injury, caused by a single high dose exposure (corrosive gas, vapour, fumes)
  • dx criteria :
    1. absence of prior resp sx
    2. onset of sx after a single irritant exposure
    3. exposure to high conc. of irritant chemical
    4. sx onset within 24 hrs
    5. methacholine +
    6. exclusion of other types of lung disease
    7. documented airflow obstruction
53
Q

What is Churg strauss vasculitis?

A

multi system granulomatous vasculitis of the small and medium sized arteries, characterized by

  1. asthma
  2. rhinosinusitis
  3. blood eosinophilia
54
Q

what are the 3 phases of EGPA?

A
  1. Prodromal - atopic diseases, AR and asthma
  2. Eosinophilic - eos infiltration of multiple organs
  3. Vasculitic - pot. life threatening phase of systemic vasculitis
55
Q

diagnosis of EGPA

A 
- lung biopsy is gold standard but not practical 
ACR (need 4/6) 
- paranasal sinus abnormality 
- asthma 
- migratory or transient pulm opacities
- mononeuropathy 
- >10% eos on the diff
- biopsy with vessel showing eos
56
Q

name the 3 categories of hypersensitivity pneumonitis

A
  1. acute: pts exposed to a culprit antigen and produce IgG, subsequent exposure leads to immune complex formation and influx of neutrophils
  2. subacute: CD4 Th1 lymphocyte mediated delayed hsn causing granuloma formation
  3. chronic: development of fibrosis, increase of CD4, CD8 T cells
57
Q

Name some precipitants of hypersens. pneumonitis

A
  • mold
  • birds
  • feathers
  • isocyanates
  • pesticides
58
Q

dx of HP:

A
  1. known exposure to offending agent
  2. compatible HRCT findings
  3. BAL lymphocytosis
  4. positive inhalation challenge
59
Q

lung biopsy in HP shows?

A

non caseating granulomas
mononuclear infiltrate
fibrosis

60
Q

How to confirm occupational asthma?

A

confirm reversible airflow obstruction using spiro pre and post OR non specific bronchoprovocation challenge to the sensitizing agent at that work place

61
Q

main allergen in western red cedar?

A

plicantic acid

62
Q

allergen in glues

A

abietic acid

63
Q

allergen in paint

A

isocyanates

64
Q

cytokines that contribute to asthma (4)

A

IL-1b, TNF-a, IL-6, IL-4, IL-13, TGF-b

65
Q

What do eos do in asthma? (3)

A
  1. smooth muscles contraction
  2. airway damage
  3. airway remodeling
66
Q

effects of tobacco on asthma

A
  1. development of asthma
  2. accelerated decline in lung function
  3. impaired short term response to steroids
67
Q

discuss some immunological mechanisms of asthma (4)

A
  1. Upregulation of adhesion molecules
  2. arachidonic acid metabolite production (LTB4)
  3. chemokine synthesis (IL-8)
  4. Cytokine secretion (IL-1b, YNF-a, IL-6)
68
Q

Name some mediators in the pathogenesis of asthma

A
  1. histamine
  2. PGD2
  3. Leukotrines
  4. TNf-a
  5. eosinophils

with allergen exposure, bronchoconstriction occurs within minutes due to release of the above mast cell mediators

69
Q

name 4 tachykinins

A
  1. substance P
  2. neurokinin A
  3. neurokinin B
  4. gene related peptide (GRP)
  5. calcitonin

airway nerve endings contain these tachykinins and then have effects on the airways like bronchoconstriction, mucous secretion, leads to vasodilation and inflammatory cell recruitment

70
Q

MOA of Ipratropium bromide

A

antagonize the actions of the Ach at the parasympathetic cell junction by competing with Ach for M3 receptor sites –> leads to SM relaxation and bronchodilation

71
Q

GINA 2020 on azithromycin

A
  • add on azithromycin for adults with persistent sx asthma despite moderate to high dose ICS/LABA reduced asthma exacerbations in eosinophilic and non-eos asthma and improved QOL
  • tx for 6 months suggested
72
Q

GINA 2020 on Cromolyn sodium

A

favourable safety profile, but low efficacy

the inhalers require burdensome daily washing to avoid blockage, no recommended for routine use

73
Q

5 mechanisms where steroids help in asthma

A
  1. activate anti inflammatory genes
  2. switching off inflammatory gene expression
  3. inhibiting inflammatory cells
  4. enhancement of B2 adrenergic signalling by increasing B2 receptor expression and function
  5. decreasing mucous secretion
74
Q

SE of ICS

A
  1. dysphonia
  2. topical candidiasis
  3. contact hypersensitivity (budesonide)
  4. cough and throat irritiation
  5. adrenal suppression
  6. growth deceleration
75
Q

dosing of beclomethasone diproprionate

A

QVAR
Peds < 200 ug daily
adult <250 ug (low), 250-400 ug (med), > 400 ug is high

76
Q

Leukotrines role in asthma

A

Cys- LTs are produced within mins of exposure to an allergen
asthmatics produce a high levels of cys-Lts and levels of sputum Cys-Lts correlate with asthma severity

Cys- Lts cause smooth muscle contraction and bronchoconstriction, increase permeability leading to bronchovascular leakage and mucous gland secretion and cause fibroblasts to proliferate leading to airway remodelling

77
Q

Cys-LT1 receptor antagonists role in asthma

A

Monteleukast

- block the cyst-LT1 receptor which are on inflammatory cells like eos, mast, lympho, and macs

78
Q

mAPI

A

Major criteria

  1. parent with asthma
  2. atopic derm (MD dx)
  3. allergic sensitization to at least 1 aero allergen

Minor criteria

  1. elevated eos > 4%
  2. wheezing unrelated to colds
  3. allergic sens to egg, milk, or peanuts
79
Q

GINA guidelines diagnosis of asthma

A
  1. Documented airflow obstruction
  2. Objective excessive variability in lung function using one or more of the tests below
    A. bronchodilator test: >12% or >200 mls 10-15 mins after bronchodilator challenge
    B. Excessive variability in twice daily PEF over 2 weeks
    - adults variability is >10%, kids >15%
    C. significant increase in lung function after 4 weeks of anti inflammatory treatment
    - increase of 12% of 200 mls
    D. Positive exercise challenge
    - decrease in FEV by 10% or 200 mls, kids is 12% or PEF 15%
    E. Positive bronchial challenge
    - fall in FEV1 >20% with methacholine/ histamine or >15% fall with hyperventilation/ hypertonic saline/mannitol
    F. excess variation in lung function between visits
    - adult > 12% or 200 mls between visits
    - kids >12% FEVB1 or 15% PEF between visits
80
Q

when should you do PEF?

A

when spirometry is not available

not rec. for dx of asthma in children

81
Q

Name two indirect challenges for asthma

A

mannitol and exercise

82
Q

Name two direct asthma challenges

A

methacholine and histamine

83
Q

QVAR

A

Beclomethasone

kids, approved for > 5 y.o
low dose 50 ug bid
med dose 100 ug bid

adult
low 50- 100 ug bid
med >100 ug bid
high >200 ug

84
Q

Pulmicort

A

Budesonide

DPI not rec. for kids <6 years 
adult 6-18:
low 100 ug bid
med 200-400 ug bid 
high > 400 ug  bid
85
Q

Alvesco

A

Ciclesonide

kids:
100 ug OD - low
200 ug OD - med dose

adults
100 ug OD - low
200-400 ug OD is med
> 400 ug is high

86
Q

Advair

A

fluticasone/salmeterol
approved > 4 y.o

dosing

  • comes in 125/25 ug or 250/25 2 puffs BID MDI
  • 100/50 ug, 250/50, 500/50 ug diskus 1 puff BID
87
Q

Breo elliptica

A

fluticase furoate/vilanterol
DPI 100/25 ug/day or 200/25 ug/day
not indicated for < 18 years old

88
Q

Zenhale
approval age
dosing

A 
Mometasone/formeterol 
approved for >12 years old 
low dose is 50/5 2 puffs bid 
med dose 100/5 ug 2 puffs bid 
high dose 200/5 2 puffs bid
89
Q

Name a LAMA

A

Tiotropium (spiriva respimate)
not indicated for <18 years of age
1.25 ug 2 puffs BID

90
Q

Name the 3 Anti IL5 therapies and dosing

A
  1. Mepolizumab (Nucala) - 100 mg SC Q4 weeks
  2. Benralizumab (Fasenra) - 3 mg/kg IV Q4 weeks
  3. Reslizumab (Cinqair) - 3 mg/kg IV Q4 weeks

none are indicated for < 18 years of age right now

91
Q

Xolair dosing kids vs adults

A

kids - 150-375 mg SC Q2-4 weeks based on weight and pre tx serum IgE

adults 75-375 mg SC Q2-4 weeks based on weight and pre tx serum IgE

92
Q

What is theophylline?

A

and oral bronchodilator with modest anti inflam. effects reserved fro those >12 years who are intolerant to or continue to be sx despite other therapies

93
Q

What makes a good flow loop curve

A
  1. meeting a good start of test criteria
    - sharp rise in flow
  2. meeting a good end of test criteria
    - pt exhaled to complete RV
    - exhalation of > 6 secs
  3. absence of artifacts
  4. determine whether the repeatability or between-maneuver criteria are met
94
Q

pathophysiology of hypersensitivity pneumonitis

A
  • prolonged exposure to offending agents leads to T cell mediated damage.
  • antigens trigger the inflammatory process mediated by T cells and immune complexes
  • primarily a th1 response which develops into th2 when fibrosis develops
95
Q

ABPA Criteria

A 
Presence of asthma or CF and 
2 obligatory criteria 
1. IgE> 1000 
2. sIgE or SPT to aspergillous 
2 of the other criteria 
- eos > 500 
- serum antibodies to a. fumigatus 
- pulmonary opacities
96
Q

ABPA management

A
  1. steroids
  2. antifungals - voriconazole and intraconazole
  3. Xolair being used in CF patients
97
Q

RFs for asthma

A
  1. male gender
  2. perinatal infections - prematurity, maternal diet
  3. atopy and allergens
  4. pollution
  5. resp infection
  6. rhinitis
  7. smoking and tobacco exposure
98
Q

most common cause for occupational asthma

A
  1. flour

2. diisocyanates (from polyurethane foam)

99
Q

pathogenesis of EGPA

A
  1. overproduction of TH2 cytokines IL-4, IL-5, IL-13
  2. ANCA detected in 40-60% of people
  3. unclear mechanism
100
Q

definition of chronic cough

A

persistent cough > 8 weeks in adults and >4 weeks in children

101
Q

most important causes of chronic cough

A
  1. asthma
  2. UACS
  3. NAEB (non asthmatic eosinophilic bronchitis)
  4. GERD
102
Q

diagnostic criteria for CF

A
  1. clinical sx consistent with CF in at least one organ system AND
  2. Evidence of CFTR dysfunction (any of)
    a. elevated sweat chloride
    b. presence of two disease causing CFTR mutations- one from each parental allele
    c. abnormal nasal potential difference
103
Q

absolute CI to bronchoprovocation testing

A
  1. ACS within 3 months
  2. FEV1 <50%
  3. known brain or aortic aneurysm
  4. severe HTN
104
Q

Meds to stop before methacholine challenge

A
  1. salbutamol - 8 hours
  2. ipratropium - 24 hours
  3. salmeterol/formoterol - 24 hours
  4. tiotropium - 1 week
  5. oral bronchodilators (theophylline) - 24 hrs
  6. inhaled or PO steroids - 2-3 weeks
  7. AH - 72 hours
105
Q

what drugs cause pulmonary eosinophilia

A
  1. NSAIDs
  2. Phenytoin
  3. Antibiotics - sulfa, amp, daptomycin, minocyclin, nitrofurantoin
106
Q

GINA 6-11 years

STEP 1

A

sx < than 2 a month

low dose ICS whenever SABA taken

alt: low dose daily ICS

107
Q

STEP 2 GINA age 6-11

A

sx > 2 a month but less than daily

tx - low dose ICS + PRN SABA

alt: low dose ICS taken when SABA taken
daily LTRA

108
Q

STEP 3 age 6-11

A

sx most days
sx waking more than1 x a week

tx - MART with very low dose Bud-form (100/6 mcg)
low dose ICS/LABA + PRN SABA
Med ICS + SABA
low dose ICS + LTRA

109
Q

STEP 4 age 6-11

A
  1. med dose ICS/LABA +PRN SABA+ refer to expert
  2. low dose bud-form (200/6) MART
  3. med dose ICS/LABA + tiotropium or LTRA
110
Q

STEP 5 for age 6-11 GINA

A
  1. refer for phenotypic assessment and higher dose ICS LABA or add on therapy ie. anti IgE
    alt: add on anti IL5 or add on low dose OCS but consider SEs
111
Q

Name some questionnaires used in asthma

A

the ATAQ - asthma therapy assessment questionnaire for children and adolescents

ACQ - asthma control questionnaire

112
Q

MESNA trial

A
  • mepo tx in severe asthma
  • eos > 150 at screening or > 300 in past year qualified
  • asthma exac reduced by 47%
113
Q

biomarkers for biologics in asthma

A
  1. IgE
  2. FeNO
  3. Periostin
  4. Eosinophils
114
Q

scoring system for rhino sinusitis

A

SNOT 22 - sino nasal outcome test (quality of life score)
Polyp score
visual analog score

115
Q

what was the success of Asteria I and II

A
  • reduced itch severity score by 52%

- 66% reduction in asteria II

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