Case 1 - Respi Flashcards by Nicola Faye B. Bron

Which of the following risk factors of chronic obstructive pulmonary disease (COPD) is modifiable but anatomically damaged for alleviation therapy of symptoms?

a. Tuberculosis
b. Asthma
c. Alpha 1-antitrypsin
d. Tobacco smoking

d. Tobacco smoking

Modifiable risk factors

smoking or exposure to environmental tobacco smoke
exposure to fumes and smoke from -carbon-based cooking and heating fuels, such as charcoal and gas
occupational hazards (f example, exposure to pollutants and chemicals)
poor nutrition
pneumonia or childhood respiratory infection

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Which of the following ABG results indicates the need for intubation and mechanical ventilation in acute exacerbation of B. asthma?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

c. Respiratory acidosis

Initial blood gas results indicate respiratory alkalosis with hypoxemia. Developing respiratory acidosis or elevated PCO2 are indicators of status asthmaticus that indicate the need for ventilatory support.

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Which of the following environmental factors are common triggers of asthma symptoms associated with allergic sensitization, such as domestic pets?

a. Hygiene hypothesis
b. Dietary
c. Air pollution
d. Allergens

d. Allergens

(Allergens) House dust mite (HDM) allergens HDMs are ubiquitous pyroglyphidae that live in human dwellings. The mite’s gut contains potent digestive enzymes, notably proteases that persist in the feces, and these are thought to induce allergic sensitization and asthma

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In a patient with mild persistent asthma, which is the preferred treatment?

a. Low dose ICS
b. Low dose ICS + LABA
c. Medium dose ICS
d. Medium dose ICS + LABA

a. Low dose ICS

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Which one of the following increases the clearance of theophylline?

a. Childhood
b. Congestive Heart Failure
c. Liver disease
d. Pneumonia

a. Childhood

Increased clearance of theophylline are caused by the consumption of barbecued meats; youth (age 1-16 years); low-carbohydrate, high-protein diets; acidosis; and smoking cigarettes and marijuana. [1, 4, 5] Concomitant administration of phenytoin, phenobarbital, and rifampin can lead to increased clearance of and therefore low levels of theophylline Decreased theophylline clearance are caused by pneumonia; heart failure; infections; influenza vaccination; liver disease; chronic obstructive pulmonary disease (COPD); obesity; a high carbohydrate, low-protein diet; high levels of dietary methylxanthines (eg, caffeine); and the extremes of age.

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Patient AS has a cough and difficulty of breathing that wakes him up 2 days per week and requires use of Salbutamol MDI once daily to relieve his symptoms. What is the category of his bronchial asthma?

a. Intermittent
b. Mild persistent
c. Moderate persistent
d. Severe persistent

c. Moderate persistent

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Which of the following types of hypersensitive reactions does extrinsic asthma belong, according to Gell and Coomb classification?

a. Antibody mediated cytotoxic hypersensitivity
b. Cell mediated hypersensitivity
c. Immunoglobulin E mediated hypersensitivity
d. Immune complex mediated hypersensitivity

C. Immunoglobulin E mediated hypersensitivity

Type I immune reaction; immediate allergic reaction

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Jen is a known asthmatic. She experiences daytime symptoms of >2x per week with limitation in usual activities. This requires her to have >2x/week rescue treatment for symptom relief. Her asthma control status is said to be:

a. Controlled
b. Partly controlled
c. Uncontrolled
d. Severely controlled

B. Partly controlled
Controlled - No daytime symptoms, no limitations, no nocturnal symptoms, no need for rescue meds, normal lung function

Partly controlled - >2/week daytime symptoms, >2/week need for rescue med, with limitations in activity, and nocturnal symptoms.

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Which of the following statements about the use of Mepolizumab is/are correct?

a. It is an add on therapy for severe eosinophilic asthma
b. The treatment of other eosinophilic conditions as atopic dermatitis, eosinophilic esophagitis and nasal polyposis.
c. It is used as treatment of status asthmaticus in established allergic asthma phenotype.
d. Any of the options.

A. It is an add-on therapy for severe eosinophilic asthma.

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The female and male ratio of the incidence of bronchial asthma in children is

a. 1:2
b. 1:1
c. 2:1
d. 3:1

A. 1:2 ????
Female-to-male ratio -> 1:2
Asthma predominantly occurs in boys in childhood, with a male-to-female ratio of 2:1 until puberty, when the male-to-female ratio becomes 1:1. Asthma prevalence is greater in females after puberty, and the majority of adult-onset cases diagnosed in persons older than 40 years occur in females. Boys are more likely than girls to experience a decrease in symptoms by late adolescence.

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Which of these clinical features of COPD is often the most concerning early symptoms due to persistence, progressiveness, and is usually worse with physical exertion?

a. Breathlessness
b. Chronic cough
c. Sputum
d. Wheeze

A. Breathlessness

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All the following are B2 agonist drugs available as metered dose inhalers EXCEPT

a. Albuterol
b. Terbutaline
c. Metaproterenol
d. None of the options

D. None of the options

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Which of the following is the median age of onset of bronchial asthma?

a. 2years old
b. 3years old
c. 5years old
d. 7years old

B. 3 years old

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Which of these relievers of B. asthma is the LEAST potent against bronchoconstriction due to reflex inhibition?

a. Albuterol
b. Formoterol
c. Ipratropium bromide
d. Theophylline

C. Ipratropium bromide

Muscarinic receptor antagonists, such as ipratropium bromide, prevent cholinergic nerve-induced bronchoconstriction and mucus secretion. They are less effective than β2-agonists in asthma therapy as they inhibit only the cholinergic reflex component of bronchoconstriction, whereas β2-agonists prevent all bronchoconstrictor mechanisms.

❌Theophylline - inhibit phosphodiesterase in airway
smooth muscle cells
❌Albuterol (Salbutamol) - short-acting B2-agonist
❌Formoterol - long-acting B2-agonist

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In the pathogenesis of extrinsic asthma, which of the following sequences allow eosinophils to release major basic protein and cationic protein to damage epithelial cells and produce airway constriction?

a. Hypersensitive reaction with exposure to extrinsic allergens.
b. Initial sensitization to an inhaled allergen.
c. Inhaled antigens cross-link antibodies on mast cells on mucosal surfaces.
d. Late phase reaction with recruitment of leukocytes

D Late phase reaction with recruitment of leukocytes.
Extrinsic = Allergic (?) Asthma
Allergen inhalation results in a marked increase in activated eosinophils in the airways at the time of the late reaction.

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Which of the following drugs produce modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial oxygen and carbon dioxide levels in patients with moderate to severe COPD?

a. Albuterol
b. Prednisone
c. Theophylline
d. Ipratropium bromide

Theophylline produces modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial oxygen and carbon dioxide levels in patients with moderate to severe COPD

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All of the following are risk factors for developing bronchial asthma EXCEPT.

a. Tobacco
b. Prematurity
c. URI
d. None of the options

d. None of the options

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Which of the following controllers of asthma inhibits mast cell and sensory nerve activation and effective in blocking trigger induced asthma?

a. Nedocromil sodium
b. Omalizumab
c. Cysteinyl leukotrienes
d. Budesonide

A. Nedocromil sodium

Omalizumab - Anti-IgE. It is a blocking antibody that neutralizes circulating IgE without binding to cell-bound IgE and, thus, inhibits IgE-mediated reactions.
Cysteinyl leukotrienes - these are potent bronchoconstrictors. They cause microvascular leakage and increase eosinophilic inflammation through activation of cys-LT1 receptors. (Antileukotrienes like montelukast and zafirlukast block cys-LT1 receptors)
Budesonide is a corticosteroid.

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Which of the following diagnostic findings is the best measure of bronchial asthma severity?

a. Arterial blood gas
b. Forced expiratory volume in 1 second
c. Forced vital capacity
d. Eosinophilia

B. FEV1 and C. FVC are both correct?????

Lung function, measured by spirometry: FEV1, FVC (or FEV6), FEV1/FVC (or FEV6 in adults). Spirometry is the preferred method for measuring lung function to classify severity

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Which of the following statements best describes a paradoxical pulse?

a. It is an increase in pulse wave amplitude during inspiration.
b. It is a decrease in pulse wave amplitude during expiration.
c. It is an increase in pulse wave amplitude during expiration.
d. It is a decrease in pulse wave amplitude during inspiration

D. It is a decrease in pulse wave amplitude during inspiration.

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Which of the following is the most common cause of bronchiolitis in <2 years old?

a. GBS
b. H. influenza
c. Adenovirus
d. Respiratory syncytial virus

D. Respiratory syncytial virus

Which of the following statements regarding Methacholine Provocation Test for asthma is/are correct?

a. It is useful in diagnosing a patient whose main symptom is wheezing.
b. It is done for patient whose FEV1<1.5L.
c. It is usually done for research purpose.
d. Any of the options

A. It is useful in diagnosing a patient whose main symptom is wheezing.

Indications for testing include evaluating symptoms clinically suggestive of asthma and response to therapy. Contraindications of Methacoline Provocation test: FEV <1.5L (Therefore choice B is wrong).

Which of the following lung volumes/capacities will increase in COPD during pulmonary function test?

a. Expiratory reserve volume (ERV) + residual volume (RV)
b. Inspiratory capacity (IC) + ERV
c. IC + RV
d. ERV + RV + IC

A. Expiratory reserve volume + residual volume

All of the following are histological changes in bronchi with extrinsic asthma. Which one is the EXCEPTION?

a. Edema and a mixed inflammatory infiltrate
b. Hypertrophy of submucosal glands
c. Hypertrophy/hyperplasia of smooth muscle cells
d. Patchy loss of epithelial cells, goblet cell metaplasia

B. Hypertrophy of submucosal glands

> Increased mucus secretion contributes to the viscid mucous plugs that occlude asthmatic airways, particularly in fatal asthma. There is hyperplasia of submucosal glands that are confined to large airways and of increased numbers of epithelial goblet cells. IL13 induces mucus hypersecretion in experimental models of asthma.
> In asthmatic airways there is also a characteristic hypertrophy and hyperplasia of airway smooth muscle…
> Airway epithelial shedding may be important in contributing to AHR (airway hyperresponsiveness)

Which of the following timing of dyspnea is associated with B. asthma? ``` a. Acute episodes of nocturnal dyspnea b. Progressive dyspnea c. Sudden onset of dyspnea d. Slowly progressive dyspnea ```

A. Acute episodes of nocturnal dyspnea Elimination: A. Acute episodes of nocturnal dyspnea - ->Asthma. The characteristic symptoms of asthma are wheezing, dyspnea, and coughing, which are variable, both spontaneously and with therapy. Symptoms may be worse at night and patients typically awake in the early morning hours. (Harrison’s. Ch 281. pg. 1963) -> Paroxysmal nocturnal dyspnea often attributed to CHF. B. Progressive dyspnea - COPD (?) C. Sudden onset - CVS condition, Asthma( typically follows a triggering event) D. Slowly progressive dyspnea - COPD

Which of the following drugs decreases the clearance of theophylline via enzyme inhibition? a. Rifampicin b. Phenobarbitone c. Ethanol d. Cimetidine

``` D. Cimetidine ❌Rifampicin - increase clearance ❌Phenobarbitone - increase clearance ❓Ethanol - ?? ✔Cimetidine - decrease theophylline clearance by 30% ```

A clenched fist held over the chest to describe ischemic chest pain is a sign known as a. Murphy b. Halstead c. Cullen d. Levine

D. Levine ✔Levine's sign - clenched fist over chest indicating ischemic chest pain ❌Murphy’s sign - acute cholecystitis - examiner’s hand on middle inferior border of the liver. Positive if patient feels pain on mid-inspiration ❌Halstead test - to assess for thoracic outlet syndrome. Positive if there is decrease/absence of radial pulse. ❌Cullen - superficial edema and bruising around the umbilicus; indicates retroperitoneal / intra-abdominal hemorrhage / pancreatitis

A FDA boxed warning issued on March 2020 about the use of montelukast is a. Hepatoxicity b. Kidney impairment with moderately elevated creatinine c. Mental health side effects d. Lactic acidosis

C. Mental health side effects Because of the risk of mental health side effects, the benefits of montelukast may not outweigh the risks in some patients, particularly when the symptoms of disease may be mild and adequately treated with other medicines.

Which of the following is not a histopathologic finding in a small airway in fatal asthma? a. the lumen in occluded with mucus plug b. there is goblet cell metaplasia c. there is an increase in basement membrane thickness and airway smooth muscle d. there is vasoconstriction and increased numbers of blood vessels e. the airway wall is thickened

Number of breaths per minute in infants that are 0-6moths old a. 30-60 b. 24-30 c. 20-30 d. 10-20

A. ``` healthy resting adult: 20 6-11y/o: 20 1-5y/o: 20-30 6-12months: 24-30 0-6months: 30-60 ```

Intermediate expiratory sound than is normally heard in the 1st and 2nd interspaces anteriorly between the scapulae wherein the inspiratory and expiratory sound are almost equal a. vesicular b. bronchovesicular c. bronchial d. tracheal

B characteristics of breath sounds vesicular: inspiratory > expiratory, soft, relatively low, over most of both lungs bronchial: expiratory > inspiratory, loud, relatively high, over the manubrium tracheal: inspiratory = expiratory, very loud, relatively high, over the trachea

An imaginary line of the thoracic wall that indicates the intersection of the median place with the anterior thoracic wall a. Anterior Median Line (AML) b. Anterior Axillary Line (AAL) c. Midclavicular Line (MCL) d. Midaxillary Line (MAL)

A ``` Anterior Axillary Line (AAL) - runs vertically along the anterior axillary fold Midclavicular Line (MCL) - passes through the midpoint of the clavicle, parallel to the AML Midaxillary Line (MAL) - runs from the apex of the axillary fossa, parallel to the AAL Posterior Axillary Line (PAL) - drawn vertically along the posterior axillary fold, spans from back to humerus Posterior Median Line (PML) - vertical line along the tips of the spinous processes of the vertebrae Scapular Lines (SLs) - parallel to the posterior median line and intersect the inferior angles of the scapula ```

The muscles of inspiration that elevates the chest cage, include the following except: a. External intercostals b. Internal intercostals c. Anterior serrati d. Scaleni

B Muscles of inspiration: external intercostals - pull upper ribs forward wc elevates it causing inspiration sternocleidomastoid muscles - lift the sternum anterior serrati - lift many of the ribs scaleni - lift first 2 ribs Muscles of expiration: depress the chest cage abdominal recti internal intercostals

It is the pressure of fluid between lung and chest wall pleura a. recoil pressure b. alveolar pressure c. transpulmonary pressure d. pleural pressure

D a. recoil pressure - measure of elastic forces in the lungs that collapse the lung at each respiration b. alveolar pressure - pressure inside the lung alveoli c. transpulmonary pressure - difference between alveolar and pleural pressures

Infection from which of the following is the most common trigger of asthma exacerbations? a. Mycoplasma b. Coronavirus c. Rhinovirus d. Respiratory syncytial virus

Adventitious breath sound that is continuous, sinusoidal, musical, prolonged, relatively high-pitched with hissing or shrill quality. a. crackles b. rales c. wheezes d. rhonchi

C crackles or rales: discontinuous, intermittent, nonmusical, and brief (fine: soft, high-pitched; coarse: louder, lower in pitch) rhonchi: adventitious breath sound that is continuous, sinusoidal, musical, prolonged, relatively low-pitched with snoring quality

Major antigen-presenting cells in bronchial asthma that take up allergens and process them into peptides, and migrate to local lymph nodes a. Langerhan cells b. B cells c. dendritic cells d. macrophages

These are the major target cells for inhaled corticosteroids. a. airway smooth muscles b. fibroblasts c. dendritic cells d. epithelial cells

T lymphocytes play an important role in coordinating the inflammatory response in asthma through the following, except: a. recruitment and survival of eosinophils b. release of cytokines c. promote TH2 differentiation d. maintenance of mast cell population in the airways

c. promote TH2 differentiation - role of immature dendritic cells

The following are TH2 cytokines that mediate allergic inflammation, except: a. IL-4 b. IL-5 c. IL-9 d. IL-12 e. none of the options f. two of the options

D should be IL-13 anti-inflammatory: IL-10 and IL-12

The following are effects of inflammation to airway epithelium which causes epithelial damage and may contribute to AHR by: a. loss of its barrier function to allow penetration of allergens b. loss of relaxant factor c. exposure of sensory nerves d. loss of enzymes that degrade certain peptide inflammatory mediators like bradykinin e. two of the options f. all of the options

The following are characteristics of structural changes in airway remodeling, except: a. increased airway smooth muscle b. fibrosis c. angiogenesis d. mucus atrophy

Limitation of airflow that is due to bronchoconstriction results in: a. reduction in FEV1, FEV1/FVC ratio and increase in PEF and airway resistance b. reduction in FEV1/FVC ratio and increase in FEV1, PEF and airway resistance c. reduction in FEV1, FEV1/FVC ratio, PEF and increase in airway resistance d. reduction in airway resistance, FEV1, FEV1/FVC ratio, and increase in PEF

The following statements are true of Airway Hyperresponsiveness, except: a. It is a characteristic physiologic abnormality of asthma b. It describes the excessive bronchodilator response to multiple triggers c. An increase in AHR is linked to the frequency of asthma symptoms d. The multiple asthma triggers when inhaled have no effect on normal airways

Patient CL, 25, with a history of childhood asthma consulted your clinic because he experiences breathlessness while at rest and prefers sitting and is also agitated. During PE, HR is at 115bpm, SaO2 95%, and a loud wheeze is heard throughout exhalation. He is classified to be in: a. Mild Asthma attack b. Moderate Asthma attack c. Severe Asthma attack d. Respiratory Arrest

It is a noninvasive test to measure eosinophilic airway inflammation. a. fractional exhaled nitric oxide (FENO) b. arterial blood gas c. skin tests d. allergen challenge

A arterial blood gas - test that measures the pH and levels of oxygen and carbon dioxide in the blood from an artery skin tests - skin prick tests for common inhalant allergens allergen challenge

It is the first line of treatment for asthma a. long-acting inhaled beta-agonists b. long-acting inhaled anticholinergics c. short-acting inhaled beta-agonists d. inhaled corticosteroid therapy

Short-acting B2 agonist that acts on b2 adrenergic receptors to relax the bronchial smooth muscle with adverse effects of tremors and nervousness a. salmeterol b. albuterol c. arformoterol d. levalbuterol

Lowers free plasma IgE to undetectable levels → significantly reduces the magnitude of both early and late bronchospastic response to antigen challenge. Adverse effect: anaphylaxis a. Omalizumab b. Mepolizumab c. Reslizumab d. Dupilumab

It is all that is required for patients with mild, intermittent asthma. a. long-acting inhaled beta-agonists b. long-acting inhaled anticholinergics c. short-acting inhaled beta-agonists d. inhaled corticosteroid therapy

The following are factors that affect the decrease in clearance of theophylline, except: a. liver disease b. high carbohydrate diet c. barbecued meat d. pneumonia e. vaccination