Health Ass 4: Obstructive alternative questions Flashcards
Infectious nasopharyngitis is predominantly caused by which type of pathogen?
A) Bacteria
B) Viruses
C) Fungi
D) Parasites
Correct Answer: B) Viruses
Rationale:
Infectious nasopharyngitis, contributing to approximately 95% of all acute upper respiratory tract infections (URIs), is primarily viral in origin. This question evaluates the understanding of the etiological agents behind URIs, with rhinovirus, coronavirus, influenza, parainfluenza, and respiratory syncytial virus (RSV) being the most common pathogens, as indicated indirectly by the slide.
Which of the following is not typically a contributing factor to noninfectious nasopharyngitis?
A) Allergies
B) Vasomotor responses
C) Bacterial infection
D) Environmental irritants
Correct Answer: C) Bacterial infection
Rationale:
The slide suggests that noninfectious nasopharyngitis can be allergic or vasomotor in its origin. The presence of a bacterial infection would generally indicate an infectious process, not a noninfectious one. This question challenges the understanding of the different etiologies of nasopharyngitis and their distinction, which is critical for appropriate diagnosis and management.
What is the main reason for the infrequent use of viral cultures and lab tests in diagnosing URIs?
A) High cost and specificity
B) Lack of availability in clinical settings
C) Time consumption and lack of sensitivity
D) High false-positive rates
Correct Answer: C) Time consumption and lack of sensitivity
Rationale:
Diagnosis of URIs is commonly clinical because viral cultures and lab tests are time-consuming and lack sensitivity, making them impractical in busy clinical settings. The question checks for comprehension of diagnostic challenges in clinical practice and why symptomatic diagnosis remains prevalent, despite the availability of laboratory tests.
Which age group has the highest annual incidence rate of the common cold, based on the provided information?
A) 0-24 years
B) 25-44 years
C) 45-65 years
D) Over 65 years
Correct Answer: B) 25-44 years
Rationale:
According to the information provided, individuals aged 25-44 experience the common cold at the highest rate of 19% annually. This question prompts the recollection of specific epidemiological data which is essential when considering the demographic distribution of URIs, a factor that may influence perioperative management and infection control measures in a clinical setting.
Why is the COLD score significant in perioperative assessment for patients with an acute URI?
A) It assesses the severity of common cold symptoms
B) It helps to determine the nutritional status of the patient
C) It predicts the risk of anesthesia-related complications in patients with URIs
D) It evaluates the patient’s ability to consent to surgery
Correct Answer: C) It predicts the risk of anesthesia-related complications in patients with URIs
Rationale:
The COLD scoring system is specifically used to predict the risk of proceeding with surgery in patients with an acute upper respiratory infection (URI) by taking into account several factors that can increase the likelihood of perioperative respiratory complications.
What is the recommended minimum postponement duration for surgery in a patient whose procedure was canceled due to an acute URI?
A) 1 week
B) 2 weeks
C) 4 weeks
D) 6 weeks
Correct Answer: D) 6 weeks
Rationale:
Surgery cancellation due to an acute URI suggests that rescheduling should not occur within 6 weeks, as airway hyperreactivity can persist for this duration.
A pt who has had a URI for weeks and is stable or improving can be safely managed without postponing surgery
Which factor is not considered in the COLD scoring system for evaluating surgical risk in the context of a URI?
A) Duration of symptoms
B) Presence of diabetes mellitus
C) Use of an airway device
D) Underlying lung disease
Correct Answer: B) Presence of diabetes mellitus
Rationale:
The COLD scoring system includes factors such as current symptoms, the onset of symptoms, presence of lung disease, and the planned use of an airway device in its risk stratification. Diabetes mellitus is not mentioned as a factor in the scoring system, highlighting the focus on respiratory-related conditions and risks in the context of URIs.
Based on the information provided, which group of patients has been studied most extensively regarding the effects of URI on anesthesia outcomes?
A) Adult patients
B) Pediatric patients
C) Geriatric patients
D) Patients with chronic respiratory diseases
Correct Answer: B) Pediatric patients
Rationale:
The statement highlights that most research on the effects of URI on anesthesia has involved pediatric patients. This suggests a relative scarcity of data on adult populations, pointing towards a potential need for further research in this demographic.
What is a potential consequence of proceeding with surgery in a pediatric patient with an active URI?
A) Decreased risk of postoperative nausea and vomiting
B) Increased risk of perioperative respiratory adverse events
C) Reduced incidence of postoperative cognitive dysfunction
D) Enhanced wound healing post-surgery
Correct Answer: B) Increased risk of perioperative respiratory adverse events
Rationale:
Children with URIs are at a higher risk for perioperative respiratory adverse events such as transient hypoxemia, laryngospasm, breath holding, and coughing. Recognizing these potential complications is essential for anesthetic management and decision-making regarding the timing of surgery.
What is a key strategy in the anesthetic management of patients with an acute URI to minimize perioperative respiratory complications?
A) Aggressive fluid restriction
B) Liberal use of muscle relaxants
C) Adequate hydration and reduced airway manipulation
D) Prophylactic antibiotic administration
Correct Answer: C) Adequate hydration and reduced airway manipulation
Rationale:
Adequate hydration is essential for maintaining mucociliary function and reducing secretions, while limiting airway manipulation can decrease the risk of triggering a reflex response such as coughing or laryngospasm. This approach is in line with the principles of minimizing irritation to the airways in the presence of an URI, which may be more sensitive.
What effect might the application of nebulized or topical local anesthetic to the vocal cords have in patients with an acute URI?
A) It can increase the risk of aspiration pneumonia.
B) It may reduce the sensitivity of the upper airway.
C) It can lead to an increased incidence of postoperative sore throat.
D) It may cause vocal cord paralysis.
Correct Answer: B) It may reduce the sensitivity of the upper airway.
Rationale:
Applying local anesthetic to the vocal cords can attenuate the airway’s sensitivity, potentially reducing the risk of reflex airway responses like coughing or laryngospasm, which are heightened in the setting of an acute URI. This tactic aims to make airway management smoother and decrease the likelihood of perioperative respiratory complications.
Which airway device is suggested to be preferable for patients with an acute URI to lower the risk of laryngospasm?
A) Endotracheal tube (ETT)
B) Laryngeal mask airway (LMA)
C) Nasopharyngeal airway
D) Oropharyngeal airway
Correct Answer: B) Laryngeal mask airway (LMA)
Rationale:
The use of a laryngeal mask airway (LMA) instead of an endotracheal tube (ETT) may reduce the risk of laryngospasm in patients with an acute URI. The LMA is less stimulating to the airway, which aligns with the strategy to limit airway manipulation in these patients.
The induction and maintenance of anesthesia in patients with an acute URI should follow guidelines similar to which other medical condition?
A) Diabetes mellitus
B) Coronary artery disease
C) Asthma
D) Chronic kidney disease
Correct Answer: C) Asthma
Rationale:
Considerations for induction and maintenance of anesthesia in patients with an acute URI are similar to those with asthma, as both conditions involve increased reactivity of the airways. This requires careful planning to avoid exacerbating airway responsiveness and ensure hemodynamic stability.
Deep extubation is recommended in patients with an acute URI under which condition?
A) When it is a pediatric patient
B) In the presence of bronchospasm
C) When there are no contraindications
D) When local anesthetic has been applied to the cords
Correct Answer: C) When there are no contraindications
Rationale:
When there are no contraindications, deep extubation—removing the airway device while the patient is still under deep anesthesia—may be beneficial as it can help avoid coughing and other airway reflexes upon emergence from anesthesia. This practice is especially considered in cases where coughing at the end of the procedure needs to be minimized, such as after a rhinoplasty.
Which of the following is not considered an adverse respiratory event associated with URIs in the perioperative setting?
A) Bronchospasm
B) Atelectasis
C) Pulmonary embolism
D) Airway obstruction
Correct Answer: C) Pulmonary embolism
Rationale:
Pulmonary embolism is a vascular event and is not listed among the common respiratory complications of URIs in the perioperative setting such as bronchospasm, airway obstruction, laryngospasm, postintubation croup, and atelectasis. Recognizing the respiratory events that are specifically associated with URIs is critical for planning appropriate perioperative care and interventions.
In the management of intraoperative and postoperative hypoxemia in patients with URIs, what is the primary treatment modality?
A) Initiation of inotropic support
B) Administration of supplemental oxygen
C) Prophylactic antibiotics
D) Immediate reintubation
Correct Answer: B) Administration of supplemental oxygen
Rationale:
Intraoperative and postoperative hypoxemia can be common in patients with URIs, and the primary treatment is the administration of supplemental oxygen. This management strategy is aimed at addressing reduced oxygenation which can occur due to respiratory complications associated with URIs.
Postintubation croup is a known adverse event in patients with URIs. What characteristic symptom would indicate this condition?
A) Hemoptysis
B) Wheezing
C) Stridor
D) Pleuritic chest pain
Correct Answer: C) Stridor
Rationale:
Postintubation croup is characterized by stridor, which is a high-pitched, wheezing sound caused by disrupted airflow. In the context of a URI, this condition can be caused by inflammation and edema of the upper airway after extubation, and recognizing this symptom is important for timely and appropriate management.
What is the primary distinguishing symptom between acute respiratory infection and influenza as highlighted in the visual aid?
A) Fever
B) Chest pain with a dry cough
C) Cough
D) Sore throat
Correct Answer: B) Chest pain with a dry cough
Rationale:
The visual aid provides a side-by-side list of symptoms for acute respiratory infection and influenza. While many symptoms overlap, chest pain with a dry cough is highlighted under influenza and not under the general symptoms of an acute respiratory infection, serving as a distinguishing feature in this context.
Which of the following cellular components is not involved in the inflammatory cascade of asthma?
A) Platelets
B) Eosinophils
C) Neutrophils
D) Mast cells
Correct Answer: A) Platelets
Rationale:
The inflammatory cascade in asthma involves the infiltration of the airway mucosa by eosinophils, neutrophils, mast cells, T cells, B cells, and the release of leukotrienes.
Airway remodeling in asthma is characterized by thickening of which structures?
A) Alveolar walls
B) Bronchial glands
C) The basement membrane and smooth muscle mass
D) The tracheal cartilage
Correct Answer: C) The basement membrane and smooth muscle mass
Rationale:
Airway remodeling in asthma leads to a thickening of the basement membrane and an increase in smooth muscle mass. This is a pathophysiological change associated with chronic inflammation and contributes to the characteristic narrowing and hyperreactivity of the airways in asthmatic patients.
Which of the following is not listed as an asthma-provoking stimulator on this slide?
A) Sulfiting agents
B) Respiratory virus infections
C) Emotional stress
D) Changes in atmospheric pressure
Correct Answer: D) Changes in atmospheric pressure
Rationale:
The slide lists allergens, pharmacologic agents like aspirin, beta antagonists, nonsteroidal anti-inflammatory drugs, sulfiting agents, infections (specifically respiratory viruses), exercise, and emotional stress as provoking factors for asthma attacks. Changes in atmospheric pressure are not mentioned among the asthma-provoking stimulators.
What is the role of leukotrienes in asthma?
A) They provide protection against respiratory infections.
B) They are involved in the mediation of inflammation in the airways.
C) They inhibit the action of inflammatory cells.
D) They reduce the mucosal edema in the airways.
Correct Answer: B) They are involved in the mediation of inflammation in the airways.
Rationale:
Leukotrienes are one of the main inflammatory mediators implicated in asthma and play a key role in mediating inflammation in the airways. They contribute to bronchoconstriction, airway edema, and increased secretion of mucus, which are characteristic features of asthma.
Histamine, implicated in asthma, primarily contributes to which of the following pathophysiological processes?
A) Bronchodilation
B) Decreased mucus production
C) Increased airway sensitivity
D) Alveolar repair
Correct Answer: C) Increased airway sensitivity
Rationale:
Histamine is a key inflammatory mediator in asthma that contributes to increased airway sensitivity, bronchoconstriction, and mucosal edema. It is released from mast cells and plays a significant role in the early and immediate reactions in asthma pathophysiology.
Also, prostaglandin D2 is released
Which of the following is not typically associated with an acute exacerbation of asthma?
A) Expiratory wheezing
B) Productive cough
C) Air hunger
D) Sneezing
Correct Answer: D) Sneezing
Rationale:
Sneezing is not typically associated with an acute exacerbation of asthma. Symptoms of an asthma exacerbation commonly include expiratory wheezing, cough (which can be productive or nonproductive), dyspnea, chest tightness, and air hunger due to difficulty in breathing.
What is the characteristic duration of most asthma attacks?
A) Seconds to minutes
B) Minutes to hours
C) Hours to days
D) Weeks
Correct Answer: B) Minutes to hours
Rationale:
Most asthma attacks are described as short-lived, usually lasting from minutes to hours. This information is relevant for distinguishing between typical asthma attacks and more severe conditions such as status asthmaticus, which is characterized by a prolonged, life-threatening bronchospasm.
In the context of asthma, the term ‘status asthmaticus’ refers to which of the following scenarios?
A) A mild asthma attack that responds well to inhaled bronchodilators
B) An asthmatic period with symptoms less than twice a week
C) A life-threatening bronchospasm that is unresponsive to usual treatments
D) A completely asymptomatic period of asthma
Correct Answer: C) A life-threatening bronchospasm that is unresponsive to usual treatments
Rationale:
Status asthmaticus is a severe and dangerous condition characterized by a life-threatening bronchospasm that does not respond to standard treatments. It is an asthma emergency that requires immediate medical intervention, often in an intensive care setting.
When obtaining a patient’s history, which of the following factors is crucial to assess in an individual with asthma?
A) Number of pets at home
B) Previous intubations and hospitalizations for asthma
C) Preferred type of inhaled corticosteroid
D) Time of the day when symptoms are least bothersome
Correct Answer: B) Previous intubations and hospitalizations for asthma
Rationale:
A patient’s history of previous intubations, ICU admissions, frequency of hospitalizations for asthma in the past year, and the presence of coexisting diseases provide crucial information about the severity of the patient’s asthma, their response to treatment, and the risk of future exacerbations. This assessment is essential for managing asthma and preparing for potential complications.
Eosinophilia is often associated with which of the following asthma symptoms?
A) Chest tightness
B) Cough
C) Dyspnea
D) All of the above
Correct Answer: D) All of the above
Rationale:
Eosinophilia is a condition characterized by a higher than normal level of eosinophils, a type of white blood cell. It is often associated with various asthma symptoms, including cough, chest tightness, and dyspnea. Eosinophilia in the context of asthma suggests an allergic component or a particular type of inflammation associated with the condition.
Which component is essential for the objective measurement in the diagnosis of asthma?
A) Complete blood count (CBC)
B) Pulmonary function tests (PFTs)
C) Electrocardiogram (ECG)
D) Echocardiography
Correct Answer: B) Pulmonary function tests (PFTs)
Rationale:
The diagnosis of asthma relies on both clinical history and objective measurements of airway obstruction, which are provided by pulmonary function tests (PFTs). PFTs, including spirometry, can demonstrate airflow obstruction that is at least partially reversible with bronchodilators, a hallmark of asthma.
A diagnosis of asthma is supported by PFTs that show airflow obstruction that is:
A) Fully reversible with antihistamines
B) Partially reversible with bronchodilators
C) Not reversible with any medications
D) Only reversible with corticosteroids
Correct Answer: B) Partially reversible with bronchodilators
Rationale:
The diagnosis of asthma includes the demonstration of airflow obstruction on PFTs that is at least partially reversible with the use of bronchodilators. This reversibility is a key feature that distinguishes asthma from other respiratory conditions that may not show such a response to bronchodilators.
In the classification of asthma severity, which factors are considered?
A) Symptoms frequency and antihistamine usage
B) Symptoms frequency, PFT results, and medication usage
C) Only PFT results
D) Only medication usage
Correct Answer: B) Symptoms frequency, PFT results, and medication usage
Rationale:
The severity of asthma is classified based on a comprehensive assessment that includes the frequency and severity of symptoms, results from PFTs, and the amount and frequency of medication usage. This classification is important for guiding treatment decisions and management strategies.
Which spirometric test is primarily used to assess airflow limitation in patients with conditions such as asthma?
A) Forced vital capacity (FVC)
B) Forced expiratory volume in 1 second (FEV1)
C) Diffusing capacity (DLCO)
D) Maximum voluntary ventilation (MVV)
Correct Answer: B) Forced expiratory volume in 1 second (FEV1)
Rationale:
FEV1 is the volume of air that can be forcefully exhaled in one second and is a key indicator of airflow limitation, which is characteristic of obstructive lung diseases such as asthma. It is commonly used in the diagnosis and monitoring of these conditions.
What is the significance of the FEV1/FVC ratio in spirometric evaluation?
A) It assesses the lung’s capacity to expand.
B) It evaluates the speed of air movement out of the lungs.
C) It indicates the presence of restrictive lung disease when reduced.
D) It suggests obstructive lung disease when reduced.
Correct Answer: D) It suggests obstructive lung disease when reduced.
Rationale:
The FEV1/FVC ratio is a calculated ratio used in spirometry to differentiate between obstructive and restrictive lung disease patterns. A reduced ratio (less than the normal 75%-80% in healthy adults) is indicative of obstructive lung disease, such as asthma or chronic obstructive pulmonary disease (COPD), because it reflects a disproportionate reduction in FEV1 relative to FVC.
In the diffusing capacity (DLCO) test, what substance is measured to assess the lungs’ ability to transfer gas?
A) Oxygen
B) Nitrogen
C) Carbon monoxide
D) Carbon dioxide
Correct Answer: C) Carbon monoxide
Rationale:
The diffusing capacity (DLCO) test measures how well oxygen and other gases are absorbed into the blood from the lungs. Specifically, carbon monoxide (CO) is used because it is rapidly taken up by hemoglobin, and its transfer can be measured to assess the efficiency of gas exchange in the lungs.
normal is 17-25 mL/min/mmHg
For what purpose is the Maximum Voluntary Ventilation (MVV) test used in spirometry?
A) To measure the largest volume of air inhaled and exhaled in one minute
B) To determine the lung’s ability to transport oxygen to the bloodstream
C) To evaluate the maximum airflow during the middle half of the FVC maneuver
D) To assess the total volume of air that can be exhaled after maximal inhalation
Correct Answer: A) To measure the largest volume of air inhaled and exhaled in one minute
Rationale:
The MVV test measures the maximum amount of air that can be inhaled and exhaled within one minute. For patient comfort, it is typically measured over a shorter time period and extrapolated to a minute. It provides information on the endurance of the respiratory muscles and the overall capacity for sustained ventilation.
In the setting of an acute asthma exacerbation, what would be considered a severe impairment in the Forced Expiratory Volume in 1 second (FEV1)?
A) FEV1 > 80% of predicted
B) FEV1 60-80% of predicted
C) FEV1 35-60% of predicted
D) FEV1 < 35% of predicted
Correct Answer: D) FEV1 < 35% of predicted
Rationale:
A typical symptomatic asthmatic patient presenting to the hospital with an acute exacerbation would have an FEV1 less than 35% of the predicted value, indicating severe respiratory obstruction. This measurement is crucial in assessing the severity of an asthma attack and guiding treatment decisions.
What spirometric finding is suggestive of an asthma diagnosis when a patient presents with expiratory obstruction?
A) A decrease in total lung capacity (TLC)
B) No change in diffusing lung capacity for carbon monoxide (DLCO)
C) Improvement in obstruction after a bronchodilator administration
D) A permanent decrease in functional residual capacity (FRC)
Correct Answer: C) Improvement in obstruction after a bronchodilator administration
Rationale:
Relief of expiratory obstruction after the administration of a bronchodilator is indicative of asthma, as it suggests reversible airway obstruction, which is a hallmark of the condition. It supports the diagnosis of asthma in the context of appropriate clinical symptoms.
How can flow-volume loops be interpreted in patients with asthma during an attack?
A) Presence of a restrictive pattern
B) Downward scooping of the expiratory limb
C) A flattened inspiratory limb
D) Increased diffusing lung capacity for CO
Correct Answer: B) Downward scooping of the expiratory limb
Rationale:
Flow-volume loops in asthmatic patients, particularly during an attack, often show a characteristic downward scooping of the expiratory limb of the loop. This pattern reflects the dynamic compression of airways that occurs during forced expiration in the presence of airway obstruction.
Post-asthma attack, how long can abnormalities in pulmonary function tests (PFTs) persist despite the resolution of symptoms?
A) Hours
B) 1 day
C) Several days
D) Weeks to months
Correct Answer: C) Several days
Rationale:
Abnormalities in PFTs can persist for several days after an asthma attack even when clinical symptoms have subsided. This indicates that objective measures of lung function can lag behind clinical recovery and supports the need for ongoing assessment after an acute exacerbation.
Considering asthma’s episodic nature, under what condition can the diagnosis of asthma still be suspected?
A) When PFTs show a consistent restrictive pattern
B) When PFT results are within normal limits
C) When DLCO is significantly increased
D) When total lung capacity is persistently decreased
Correct Answer: B) When PFT results are within normal limits
Rationale:During moderate or severe asthma attacks, the functional residual capacity (FRC) may increase substantially, but total lung capacity (TLC) usually remains normal
What arterial blood gas (ABG) findings are typically associated with mild asthma?
A) Elevated PaO2 and decreased PaCO2
B) Normal PaO2 and PaCO2
C) Decreased PaO2 and elevated PaCO2
D) Respiratory acidosis
Correct Answer: B) Normal PaO2 and PaCO2
Rationale:
Mild asthma is often characterized by normal arterial blood gases, including both PaO2 (partial pressure of oxygen) and PaCO2 (partial pressure of carbon dioxide). This reflects the adequacy of ventilation and gas exchange in mild cases.
During an acute asthma attack, what is the common cause of tachypnea and hyperventilation?
A) The body’s attempt to correct hypoxemia
B) Neural reflexes of the lungs
C) Compensatory response to metabolic acidosis
D) The effort to reduce elevated PaCO2
Correct Answer: B) Neural reflexes of the lungs
Rationale:
Tachypnea and hyperventilation during an acute asthma attack are usually caused by neural reflexes of the lungs rather than hypoxemia. This response can lead to hypocarbia and respiratory alkalosis, particularly in the early stages of an attack.
Which ABG abnormalities are most common in symptomatic asthma?
A) Hypoxemia and respiratory acidosis
B) Hypercarbia and metabolic alkalosis
C) Hypocarbia and respiratory alkalosis
D) Metabolic acidosis and hypoxemia
Correct Answer: C) Hypocarbia and respiratory alkalosis
Rationale:
In symptomatic asthma, particularly during an acute exacerbation, the common ABG findings include hypocarbia (low PaCO2) due to hyperventilation and respiratory alkalosis as the body loses CO2 faster than it is produced, leading to an increase in blood pH.
Severe expiratory obstruction in asthma can lead to PaO2 levels dropping below what threshold?
A) 50 mmHg
B) 60 mmHg
C) 70 mmHg
D) 80 mmHg
Correct Answer: B) 60 mmHg
Rationale:
As expiratory obstruction severity increases, the associated ventilation/perfusion mismatching may result in a PaO2 of less than 60 mmHg. This indicates a severe gas exchange impairment requiring urgent medical attention.
What condition is likely to contribute to the development of hypercarbia in the context of severe asthma exacerbation?
A) Hyperventilation
B) Fatigue of the respiratory muscles
C) Increased metabolic demand
D) Administration of oxygen
Correct Answer: B) Fatigue of the respiratory muscles
Rationale:
In severe asthma, the fatigue of the skeletal muscles necessary for breathing can contribute to the development of hypercarbia (elevated PaCO2). This occurs because the respiratory muscles can no longer compensate for the increased work of breathing, leading to inadequate ventilation.
The PaC02 is likely to increase when the FEV1 is <25% of predicted
What radiographic finding is commonly seen in patients with severe asthma?
A) Pleural effusion
B) Hyperinflation and hilar vascular congestion
C) Kerley B lines
D) Consolidation
Correct Answer: B) Hyperinflation and hilar vascular congestion
Rationale:
Patients with severe asthma may exhibit chest radiographic findings of hyperinflation, characterized by flattened diaphragms and increased retrosternal air space, and hilar vascular congestion. These findings are due to air trapping and mucous plugging, which can also contribute to pulmonary hypertension (pulmonary HTN).
Why might an electrocardiogram (EKG) be performed during an asthma attack?
A) To detect underlying myocardial infarction
B) To evaluate for signs of right ventricular (RV) strain or ventricular irritability
C) To confirm the diagnosis of asthma
D) To assess for atrial fibrillation
Correct Answer: B) To evaluate for signs of right ventricular (RV) strain or ventricular irritability
Rationale:
An EKG may be performed during an asthma attack to evaluate for signs of RV strain or ventricular irritability, which can occur due to increased pulmonary pressures from severe bronchospasm and hypoxemia. This assessment helps to detect any cardiac complications that might arise during severe respiratory distress.
Which of the following conditions is not included in the differential diagnosis of asthma?
A) Pulmonary embolism
B) Sarcoidosis
C) Tracheal stenosis
D) COPD
Correct Answer: A) Pulmonary embolism
Rationale:
The differential diagnosis of asthma typically includes conditions that present with similar respiratory symptoms such as wheezing or airflow obstruction. These can include viral tracheobronchitis, sarcoidosis, rheumatoid arthritis with bronchitis, airway compression, vocal cord dysfunction, tracheal stenosis, chronic bronchitis, COPD, and foreign body aspiration. Pulmonary embolism, while it can cause shortness of breath, is not typically confused with asthma because it presents with different clinical and diagnostic findings.
In the context of severe asthma, what can a chest x-ray (CXR) help to determine?
A) The type of asthma medication required
B) The presence of a pneumothorax
C) The specific allergen causing the asthma exacerbation
D) The cause of an asthma exacerbation and ruling out other causes
Correct Answer: D) The cause of an asthma exacerbation and ruling out other causes
Rationale:
A CXR can be instrumental in determining the cause of an asthma exacerbation by identifying any complications or alternate diagnoses that might present with similar symptoms, such as pneumonia or pneumothorax, and thereby ruling out other causes of respiratory distress.
The presence of which condition may cause an EKG to show signs of right ventricular strain during an asthma attack?
A) Acute bronchitis
B) Pulmonary hypertension
C) Left heart failure
D) Myocardial ischemia
Correct Answer: B) Pulmonary hypertension
Rationale:
During a severe asthma attack, increased resistance to airflow can lead to elevated pressure in the pulmonary circulation, potentially causing pulmonary hypertension. This condition may result in right ventricular strain, which can be detected on an EKG.
For patients with mild asthma, what is the first-line treatment?
A) Oral corticosteroids
B) Short-acting inhaled β2 agonists
C) Systemic corticosteroids
D) Long-acting muscarinic antagonists
Correct Answer: B) Short-acting inhaled β2 agonists
Rationale:
A short-acting inhaled β2 agonist is recommended as the first-line treatment for patients with mild asthma, particularly for those experiencing less than two exacerbations per month. This treatment rapidly relaxes bronchial smooth muscle and provides quick relief of symptoms.
What is the indication for the addition of daily inhaled corticosteroids in the management of asthma?
A) When asthma symptoms are well-controlled with a short-acting β2 agonist alone
B) When there are more than two exacerbations per month despite a short-acting β2 agonist
C) As the initial treatment for severe asthma
D) In place of short-acting β2 agonists in mild asthma
Correct Answer: B) When there are more than two exacerbations per month despite a short-acting β2 agonist
Rationale:
Daily inhaled corticosteroids are added to the treatment regimen when asthma symptoms are not well-controlled with a short-acting β2 agonist alone, which is often indicated by more than two exacerbations per month. Inhaled corticosteroids work by reducing airway inflammation, thus improving symptoms and decreasing the risk of future exacerbations.
Which therapeutic option is reserved for severe asthma uncontrolled by inhalational medications?
A) Leukotriene modifiers
B) Systemic corticosteroids
C) Mast cell stabilizers
D) Short-acting β2 agonists
Correct Answer: B) Systemic corticosteroids
Rationale:
Systemic corticosteroids are reserved for cases of severe asthma that remain uncontrolled with inhalational medications. They are potent anti-inflammatory agents that can help control severe and persistent asthma symptoms and prevent exacerbations.
What is the role of subcutaneous (SQ) immunotherapy in the treatment of asthma?
A) It is a first-line treatment for all asthma types.
B) It decreases the use of long-term medications and may improve the quality of life.
C) It is used to rapidly relieve asthma symptoms during an exacerbation.
D) It replaces the need for inhaled β2 agonists.
Correct Answer: B) It decreases the use of long-term medications and may improve the quality of life.
Rationale:
SQ immunotherapy can decrease the need for long-term medications in some patients with asthma by modifying the immune response to allergens. Over time, this treatment may lead to an improvement in asthma symptoms and the overall quality of life for patients with allergen-driven asthma.
In the management of asthma, what other therapies might be considered alongside β2 agonists and corticosteroids?
A) Antibiotics and antiviral medications
B) Inhaled muscarinic antagonists, leukotriene modifiers, and mast cell stabilizers
C) Oral diabetic medications and antihypertensives
D) Antidepressants and anti-anxiety medications
Correct Answer: B) Inhaled muscarinic antagonists, leukotriene modifiers, and mast cell stabilizers
Rationale:
Other therapies used in the management of asthma may include inhaled muscarinic antagonists, which act as bronchodilators; leukotriene modifiers, which reduce inflammation; and mast cell stabilizers, which prevent the release of histamine and other mediators from mast cells. These are considered when symptoms persist despite the use of β2 agonists and corticosteroids.
What is bronchial thermoplasty (BT) and in which asthma patients is it indicated?
A) A pharmacologic treatment used in mild asthma
B) A nonpharmacologic treatment used in refractory asthma
C) A surgical procedure used in all asthma patients
D) A diagnostic tool used in asthma exacerbations
Correct Answer: B) A nonpharmacologic treatment used in refractory asthma
Rationale:
Bronchial thermoplasty (BT) is a recently approved nonpharmacologic treatment option for patients with refractory asthma who do not respond to standard treatments. It uses bronchoscopy to deliver radiofrequency ablation to the airway smooth muscles, reducing their mass and thus the ability to constrict, leading to fewer symptoms.
How is the BT procedure typically administered?
A) In a single session targeting all lung fields
B) In two sessions, one for each lung
C) In three sessions excluding the right middle lobe
D) In multiple sessions until asthma symptoms are resolved
Correct Answer: C) In three sessions excluding the right middle lobe
Rationale:
BT is performed in three sessions and targets all lung fields except the right middle lobe. The division into three sessions allows for a controlled approach to reduce the risk of complications and manage potential side effects, such as transient exacerbation of symptoms.
What is a potential risk associated with bronchial thermoplasty?
A) Persistent pneumothorax
B) Chronic bronchitis
C) Airway fire due to the use of intense heat
D) Immediate resolution of asthma symptoms
Correct Answer: C) Airway fire due to the use of intense heat
Rationale:
Bronchial thermoplasty involves the application of intense heat to the airway smooth muscles, which carries an inherent risk of airway fire. This is a rare but serious complication, hence the careful monitoring during the procedure.
What outcome is bronchial thermoplasty (BT) thought to achieve by reducing airway smooth muscle mass?
A) Increase bronchoconstriction
B) Reduce bronchoconstriction
C) Decrease airway clearance
D) Intensify inflammatory response
Correct Answer: B) Reduce bronchoconstriction
Rationale:
The loss of airway smooth muscle mass as a result of BT is thought to reduce bronchoconstriction. By decreasing the amount of muscle available to constrict the airways, BT can help in alleviating the severity and frequency of asthma symptoms.
Following bronchial thermoplasty treatment, at what level of FEV1 improvement do patients typically experience minimal or no asthma symptoms?
A) About 25% of normal
B) About 50% of normal
C) About 75% of normal
D) About 100% of normal
Correct Answer: B) About 50% of normal
Rationale:
When the FEV1 improves to about 50% of normal following BT, patients usually experience minimal or no symptoms. This level of improvement signifies a significant positive response to the treatment, indicating its efficacy in reducing asthma-related airflow obstruction.
What is the mainstay of emergency treatment for acute severe asthma?
A) Antihistamines and decongestants
B) High-dose, short-acting β2 agonists and systemic corticosteroids
C) Antibiotics and antitussives
D) Bronchial thermoplasty
Correct Answer: B) High-dose, short-acting β2 agonists and systemic corticosteroids
Rationale:
In acute severe asthma, emergency treatment typically includes high doses of short-acting β2 agonists to rapidly relax bronchial smooth muscle and systemic corticosteroids to reduce inflammation. This combination is critical for managing life-threatening bronchospasm.
Why are inhaled β2 agonists preferred over other routes during an acute asthma attack?
A) They have a delayed onset of action.
B) They provide systemic anti-inflammatory effects.
C) They can be administered frequently without adverse hemodynamic effects.
D) They are less effective than oral agents.
Correct Answer: C) They can be administered frequently without adverse hemodynamic effects.
Rationale:
Inhaled β2 agonists are preferred because they can be administered frequently (every 15-20 minutes for several doses) without causing adverse hemodynamic effects, though patients may still experience sensations of adrenergic overstimulation. The inhaled route provides direct delivery to the lungs, leading to a rapid onset of bronchodilation with fewer systemic effects compared to oral or intravenous administration.
In the management of acute severe asthma, when are IV corticosteroids initiated?
A) Immediately on presentation
B) After β2 agonists fail to relieve symptoms
C) Only if the patient requires hospitalization
D) After the patient recovers from the acute attack
Correct Answer: A) Immediately on presentation
Rationale:
Intravenous corticosteroids are administered early in the treatment of acute severe asthma because their onset of action takes several hours. Early initiation ensures that the anti-inflammatory effects are underway as soon as possible, as they are essential for managing severe inflammation associated with acute severe asthma.
Which two corticosteroids are most commonly used in the treatment of acute severe asthma?
A) Prednisone and dexamethasone
B) Beclomethasone and fluticasone
C) Hydrocortisone and methylprednisolone
D) Triamcinolone and budesonide
Correct Answer: C) Hydrocortisone and methylprednisolone
Rationale:
The two corticosteroids most commonly used in the emergency management of acute severe asthma are hydrocortisone and methylprednisolone. These medications are selected for their effectiveness in reducing airway inflammation when rapid action is needed.
Besides β2 agonists and corticosteroids, which additional medication might be used to manage severe asthma cases?
A) Oral leukotriene inhibitors
B) Calcium channel blockers
C) Oral antifungal medications
D) Intravenous antivirals
Correct Answer: A) Oral leukotriene inhibitors
Rationale:
Other drugs used in more severe cases of asthma include magnesium, which can relax the bronchial smooth muscles, and oral leukotriene inhibitors, which block the effects of leukotrienes and further reduce inflammation within the airways.
What is the target saturation level for oxygen therapy in the treatment of acute severe asthma?
A) SaO2 ≥ 80%
B) SaO2 ≥ 85%
C) SaO2 ≥ 90%
D) SaO2 ≥ 95%
Correct Answer: C) SaO2 ≥ 90%
Rationale:
Supplemental oxygen is administered to maintain an oxygen saturation (SaO2) of ≥90%. This level ensures adequate tissue oxygenation while avoiding the potential harmful effects of hyperoxia, particularly oxygen toxicity.
When might tracheal intubation and mechanical ventilation be considered in the management of acute severe asthma?
A) When PaCO2 > 55 mmHg
B) When PaO2 < 70 mmHg
C) When PaCO2 > 50 mmHg
D) In all cases of acute severe asthma
Correct Answer: C) When PaCO2 > 50 mm Hg
Also, use Sevo- Potent Bronchodilator
Rationale:
Tracheal intubation and mechanical ventilation may be considered in acute severe asthma when PaCO2 exceeds 50 mm Hg, which indicates respiratory failure. Mechanical ventilation is used to support the patient’s breathing until the acute phase of the exacerbation is under control.
What is the role of anticholinergic medication in the treatment of acute severe asthma?
A) It is used to induce rapid sedation.
B) It helps reduce mucosal edema and inflammation.
C) It is administered to reduce airway smooth muscle constriction.
D) It is given to stimulate mucociliary clearance.
Correct Answer: C) It is administered to reduce airway smooth muscle constriction.
Rationale:
Anticholinergic medications, such as ipratropium bromide, are inhaled to reduce airway smooth muscle constriction. They block the action of acetylcholine, a neurotransmitter that causes bronchoconstriction, thus aiding in opening the airways during an asthma attack.
Why might permissive hypercarbia be allowed during mechanical ventilation in severe asthma cases?
A) To reduce the risk of nosocomial infections
B) To improve oxygenation
C) To reduce sedation requirements
D) To avoid barotrauma from high ventilatory pressures
Correct Answer: D) To avoid barotrauma from high ventilatory pressures
Rationale:
Permissive hypercarbia involves allowing higher than normal levels of carbon dioxide (hypercarbia) during mechanical ventilation to avoid the high pressures necessary to achieve normal CO2 levels, which could lead to barotrauma (lung injury due to overdistension).
What is considered a last resort treatment option for acute severe asthma that is unresponsive to conventional therapies?
A) Inhaled corticosteroids
B) Extracorporeal membrane oxygenation (ECMO)
C) Oral β2 agonists
D) IM adrenaline injections
Correct Answer: B) Extracorporeal membrane oxygenation (ECMO)
Rationale:
Extracorporeal membrane oxygenation (ECMO) may be used as a last resort treatment for acute severe asthma when all conventional therapies have failed. ECMO provides cardiac and respiratory support by oxygenating the patient’s blood outside the body, allowing the lungs to rest and recover from severe exacerbation.
What percentage of asthmatics may experience bronchospasm during general anesthesia (GA)?
A) 0.2-0.5%
B) 0.2-4.2%
C) 5-10%
D) Over 10%
Correct Answer: B) 0.2-4.2%
Rationale:
Bronchospasm during general anesthesia is a known risk for asthmatic patients, with reported incidences ranging from 0.2% to 4.2%. It is a potentially serious complication that requires prompt recognition and treatment.
Which types of surgery are associated with a higher risk of bronchospasm in asthmatic patients?
A) Orthopedic and dermatologic surgery
B) Ophthalmic and ENT surgery
C) Upper abdominal and oncologic surgery
D) Lower abdominal and plastic surgery
Correct Answer: C) Upper abdominal and oncologic surgery
Rationale:
The risk of bronchospasm in asthmatic patients undergoing general anesthesia is correlated with the type of surgery, being higher with upper abdominal and oncologic surgeries. This may be due to the proximity of the surgical site to the respiratory structures and the potential for reflex-mediated bronchospasm.
What general anesthesia (GA) mechanisms can increase airway resistance in patients with asthma?
A) Increased mucociliary function and palatopharyngeal muscle tone
B) Depression of cough reflex and reduction of palatopharyngeal muscle tone
C) Stimulation of diaphragmatic function
D) Decreased fluid in the airway wall
Correct Answer: B) Depression of cough reflex and reduction of palatopharyngeal muscle tone
Rationale:
General anesthesia can increase airway resistance through several mechanisms, including depression of the cough reflex, impairment of mucociliary function, reduction of palatopharyngeal muscle tone, depression of diaphragmatic function, and increased fluid in the airway wall. These effects can contribute to increased difficulty in breathing and risk of bronchospasm.
Which medication, often used in the context of general anesthesia, can stimulate airway resistance and potentially lead to bronchospasm?
A) Antibiotics
B) Neostigmine
C) Beta-blockers
D) Diuretics
Correct Answer: B) Neostigmine
Rationale:
Neostigmine, a medication used to reverse the effects of non-depolarizing muscle relaxants, can stimulate the parasympathetic nervous system, leading to bronchoconstriction. For asthmatic patients, this can increase the risk of bronchospasm, particularly upon emergence from anesthesia.
What is a common factor between the timing of the most recent asthma attack and the risk of bronchospasm during surgery?
A) The more time that has passed since the last attack, the lower the risk.
B) The risk is unrelated to the timing of the last attack.
C) Morning surgeries carry a higher risk of bronchospasm regardless of the last attack.
D) The risk of bronchospasm is highest when surgery occurs on the anniversary of the last attack.
Correct Answer: A) The more time that has passed since the last attack, the lower the risk.
Rationale:
The risk of bronchospasm during general anesthesia is correlated with how recent the last asthma attack occurred. The closer in time a surgery is to a recent asthma exacerbation, the higher the risk of intraoperative bronchospasm, as the airways may still be inflamed and hyperresponsive.
Why is it important to evaluate eosinophil counts during the preoperative assessment of an asthmatic patient?
A) To determine the need for antibiotic prophylaxis
B) To assess the degree of airway inflammation
C) To evaluate the risk of anesthetic drug reactions
D) To check for the presence of infection
Correct Answer: B) To assess the degree of airway inflammation
Rationale:
Eosinophil counts are often reflective of the degree of airway inflammation in asthmatic patients. High levels of eosinophils can indicate increased inflammation, which may affect the management of asthma perioperatively.
What is indicated by a preoperative FEV1 or FVC less than 70% of predicted in asthmatic patients?
A) Normal pulmonary function
B) Risk for perioperative respiratory complications
C) The patient is well-controlled and ready for surgery
D) No risk for anesthesia-related complications
Correct Answer: B) Risk for perioperative respiratory complications
Rationale:
A reduction in FEV1 or FVC to less than 70% of predicted, or an FEV1:FVC ratio less than 65% of predicted, suggests significant airflow limitation and is considered a risk for perioperative respiratory complications. It indicates that the patient’s asthma may not be well-controlled, which can increase the risk of bronchospasm and other respiratory issues during surgery.
What aspect of the history is crucial to note during the preoperative assessment for asthma?
A) Previous travel history
B) Symptom control and history of exacerbations
C) Dietary preferences
D) Exercise routine
Correct Answer: B) Symptom control and history of exacerbations
Rationale:
During preoperative assessment, it’s important to note the history of symptom control, frequency of exacerbations, and any need for hospitalization or intubation, as well as previous tolerance to anesthesia. This information helps in predicting the risk of perioperative asthma complications and in planning anesthesia management.
What is the significance of auscultation of the chest in the preoperative assessment of an asthmatic patient?
A) It is a routine procedure with no specific significance for asthmatics.
B) It helps to assess cardiac function preoperatively.
C) It is performed to detect wheezing or crepitations indicative of current asthma control.
D) It is used to confirm the diagnosis of asthma.
Correct Answer: C) It is performed to detect wheezing or crepitations indicative of current asthma control.
Rationale:
Auscultation of the chest is an important part of the preoperative respiratory assessment for asthmatic patients. Detecting wheezing or crepitations can provide insight into the current level of asthma control and the presence of active airway inflammation or obstruction, which can influence anesthetic management.
In asthma patients, what is the purpose of performing preoperative pulmonary function tests (PFTs) before and after administering a bronchodilator?
A) To measure the patient’s response to stress
B) To determine the baseline lung function and reversibility of airway obstruction
C) To evaluate the need for postoperative ventilation support
D) To identify potential allergies to anesthetic agents
Correct Answer: B) To determine the baseline lung function and reversibility of airway obstruction
Rationale:
Preoperative PFTs, especially FEV1, are used to assess baseline lung function and determine the reversibility of airway obstruction with a bronchodilator. This helps in evaluating the severity of asthma and the effectiveness of the patient’s current treatment regimen, which is crucial for perioperative planning.
What preoperative interventions can often improve reversible components of asthma?
A) Chest physiotherapy, antibiotics, and bronchodilators
B) Increased fluid intake and bed rest
C) Bronchodilators and anticholinergics only
D) Caffeine cessation and smoking cessation
Correct Answer: A) Chest physiotherapy, antibiotics, and bronchodilators
Rationale:
Chest physiotherapy can aid in mobilizing secretions, antibiotics may be indicated if there is a suspicion of respiratory infection, and bronchodilators help improve airflow—these interventions target reversible components of asthma and optimize the patient’s respiratory status preoperatively.
When are arterial blood gases (ABGs) indicated in the preoperative assessment of asthma patients?
A) Routinely in all asthmatic patients
B) When there is a question about the adequacy of ventilation or oxygenation
C) Only if the patient has chronic obstructive pulmonary disease (COPD)
D) If the patient is currently smoking
Correct Answer: B) When there is a question about the adequacy of ventilation or oxygenation
Rationale:
ABGs are indicated in the preoperative assessment of asthma patients when there is any question regarding the adequacy of ventilation or oxygenation. ABGs provide direct measurement of oxygenation status, carbon dioxide levels, and blood acidity, which can inform the anesthetic plan and need for perioperative respiratory support.
What should be the status of anti-inflammatory and bronchodilator medications in asthmatic patients before surgery?
A) They should be discontinued 24 hours before surgery.
B) They should be tapered off a week before surgery.
C) They should be continued until induction of anesthesia.
D) They should be replaced with short-acting variants on the day of surgery.
Correct Answer: C) They should be continued until induction of anesthesia.
Rationale:
Anti-inflammatory medications and bronchodilators are integral to controlling asthma and should be continued right up until the induction of anesthesia to ensure that the patient’s asthma is as well-managed as possible going into surgery.
In patients with recent systemic corticosteroid use, what is recommended preoperatively?
A) Immediate cessation of corticosteroids
B) Administration of a stress-dose of hydrocortisone or methylprednisolone
C) Switching to inhaled corticosteroids only
D) Administration of antihistamines instead of corticosteroids
Correct Answer: B) Administration of a stress-dose of hydrocortisone or methylprednisolone
Rationale:
For patients who have been on systemic corticosteroids in the past six months, administration of a stress dose of hydrocortisone or methylprednisolone is indicated preoperatively. This is because recent corticosteroid use may have suppressed the patient’s adrenal function, and additional steroids may be needed to cope with the stress of surgery.
What is the goal for asthmatic patients in terms of wheezing and peak expiratory flow rate (PEFR) before surgery?
A) Patients should have minimal wheezing and a PEFR of at least 60% of predicted or their personal best.
B) Patients should have no wheezing and a PEFR of less than 50% of predicted or their personal best.
C) Patients should be free of wheezing and have a PEFR of ≥80% of predicted or their personal best value.
D) It is acceptable for patients to have mild wheezing if they are asymptomatic and the PEFR is ≥90% of predicted.
Correct Answer: C) Patients should be free of wheezing and have a PEFR of ≥80% of predicted or their personal best value.
Rationale:
Before surgery, asthmatic patients should ideally be free of wheezing and have a peak expiratory flow rate (PEFR) of ≥80% of predicted or their personal best value. These criteria indicate that the asthma is well-controlled, which minimizes the risk of perioperative respiratory complications.
What is the global prevalence of Chronic Obstructive Pulmonary Disease (COPD)?
A) 1%
B) 5%
C) 10%
D) 20%
Correct Answer: C) 10%
Rationale:
COPD has a worldwide prevalence of 10%, affecting a significant proportion of the adult population. This highlights the importance of COPD as a major public health concern and its impact on morbidity and mortality globally.
COPD is ranked as which leading cause of death worldwide?
A) First
B) Second
C) Third
D) Fourth
Correct Answer: C) Third
Rationale:
COPD is the third leading cause of death worldwide. This statistic emphasizes the severity of the disease and its significant impact on global health.
Besides cigarette smoking, which of the following is a risk factor for COPD?
A) High altitude living
B) Moderate alcohol consumption
C) Occupational exposure to dust and chemicals
D) Being Rich
Correct Answer: C) Occupational exposure to dust and chemicals
Rationale:
In addition to cigarette smoking, other risk factors for COPD include occupational exposure to dust and chemicals, asbestos exposure, gold mining, biomass fuel use, air pollution, genetic factors, age, female gender, poor lung development during gestation, low birth weight, recurrent childhood respiratory infections, low socioeconomic class, and pre-existing asthma.
What is one of the primary physiological changes in the lungs associated with COPD?
A) Increased pulmonary elastic recoil
B) Hyperactivation of ciliary movement in the bronchi
C) Loss of pulmonary elastic recoil due to bronchio-alveolar destruction
D) Overproduction of surfactant by alveolar cells
Correct Answer: C) Loss of pulmonary elastic recoil due to bronchio-alveolar destruction
Rationale:
COPD is characterized by the loss of pulmonary elastic recoil due to bronchio-alveolar destruction, leading to chronic airflow obstruction. This loss of recoil impairs the lungs’ ability to expel air, contributing to the symptoms and complications associated with the disease.
Which symptom is commonly associated with COPD?
A) Dry cough
B) Wheezing with minimal exertion
C) Productive cough
D) Sudden onset of shortness of breath
Correct Answer: C) Productive cough
Rationale:
COPD symptoms typically include a productive cough, which is a cough that produces phlegm. This is due to the chronic bronchitis component of the disease, which involves inflammation of the bronchi and increased mucus production.
What is a primary effect of COPD on the elasticity or recoil of lung parenchyma?
A) Pathologic improvement in elasticity or recoil
B) No change in elasticity or recoil
C) Pathologic deterioration in elasticity or recoil
D) Intermittent changes in elasticity or recoil
Correct Answer: C) Pathologic deterioration in elasticity or recoil
Rationale:
COPD leads to a pathologic deterioration in the elasticity or recoil within the lung parenchyma. Normally, this elasticity helps keep the airways open, but the loss of recoil in COPD causes the airways to collapse more easily, contributing to airflow obstruction.
What pathologic change in the bronchi contributes to airway collapse in COPD?
A) Increased bronchiolar wall thickness
B) Increased bronchiolar wall strength
C) Decrease in bronchiolar wall structure
D) Calcification of bronchiolar wall
Correct Answer: C) Decrease in bronchiolar wall structure
Rationale:
COPD is associated with pathologic changes that decrease bronchiolar wall structure, reducing their ability to stay open during exhalation and thus contributing to collapse. This change impairs the air flow, especially during the exhalation phase of breathing.
