Part 11 - Pulmonology Flashcards
True or false: Asthma can present at any age
True
p. 1669
_____ variant in the beta2-receptor has been associated with reduced response to beta 2 agonists in asthma
Arg-Gly-16
p. 1670
Genetic predisposition to asthma: the most consistent findings have been associations with polymorphism of genes on what chromosome?
5q
p. 1670
What is the “hygiene hypothesis” in asthma?
Lack of infections in early childhood preserves the T helper 2 (TH2) cell bias at birth, while exposure to infections and endotoxins result in a shift towards a predominant protective TH1 immune response
(p. 1670)
True or false: The presence of intestinal parasite infection may be associated with a reduced risk for asthma
True
p. 1670
Diets low in what substances/vitamins are associated with an increased risk for asthma?
Vitamins A, C, D Magnesium Selenium Omega-3 polyunsaturated fats (p. 1670)
Diets high in what substances/vitamins are associated with increased risk for asthma?
Sodium
Omega-6 polyunsaturated fats
(p. 1670)
True or false: Obesity is an independent risk factor for asthma
True
p. 1670
When is occupational asthma suspected?
When symptoms improve during weekends and holidays
p. 1670
Endogenous risk factors for asthma
Genetic predisposition Autopsy Airway hyperresponsiveness Gender Ethnicity Obesity Early viral infections (p. 1670)
Environmental risk factors for asthma
Allergens (Indoor and outdoor) Occupational sensitizers Passive smoking Respiratory infections Diet Acetaminophen (Paracetamol) (p. 1670)
Asthma triggers
Allergens Upper respiratory tract viral infections Exercise and hyperventilation Cold air Sulfur dioxide and irritant gases Drugs (beta blockers, aspirin) Stress Irritants (household sprays, paint fumes) (p. 1670)
True or false: Patients with nonatopic or intrinsic asthma usually show later onset of disease and have more severe, persistent asthma
True
p. 1671
What is the most common allergen to trigger asthma?
Dermatophagoides species
p. 1671
What is thunderstorm asthma?
When pollen grains are disrupted in thunderstorms and particles that may be released can trigger severe asthma exacerbations
(p. 1671)
True or false: The use of beta blockers in asthma is dangerous, including topical medications
True
p. 1671
Mechanism for worsening asthma with the use of beta blockers
Cholinergic bronchoconstriction (p. 1671)
When does exercise-induced asthma typically begin and when does it resolve?
Begins after exercise has ended and resolves spontaneously within about 30 minutes
(p. 1671)
How can exercise-induced asthma be prevented?
Prior administration of beta 2 agonists and anti-leukotrienes
Regular treatment with ICS (best)
(p. 1671)
True or false: Laughter may be an asthma trigger
True
p. 1671
Food preservative that may trigger asthma through the release of sulfur dioxide gas in the stomach
Metabisulfite
p. 1671
In occupational asthma, there is usually complete recovery if removed from exposure within the first ____ months of symptoms
6
p. 1671
True or false: Very severe stress (eg. bereavement) may improve asthma symptoms
True
p. 1671
Inflammation in asthma is found in what anatomical structures?
Respiratory mucosa from the trachea to the terminal bronchioles, with predominance in the bronchi (cartilaginous airways)
(p. 1672)
Mast cells are activated by allergens through what mechanism?
IgE-mediated
p. 1672
Bronchoconstrictor mediators released by mast cells
Histamine
Prostaglandin D2
Cysteine-leukotrienes
(p. 1672)
What cytokine is released from epithelial cells in asthmatic patients and instructs dendritic cells to release chemokines that attract T helper 2 cells?
Thymic stromal lymphopoietin (TSLP)
p. 1672
What cytokine/s released from T helper 2 cells is/are associated with eosinophilic inflammation?
IL-5
p. 1673
What cytokine/s released from T helper 2 cells is/are associated with increased IgE formation?
IL-4
IL-13
(p. 1673)
What is the action of inflammatory mediators (eg. histamine, prostaglandin D2, cysteinyl-leukotrienes) in asthma?
1) Contract airway smooth muscle
2) Increase microvascular leakage
3) Increase airway mucus secretion
4) Attract other inflammatory cells
(p. 1673)
What are the pathophysiologic mechanisms in asthma?
1) Hypertrophy/hyperplasia of airway smooth muscle cells
2) Mucus hyperplasia
3) Angiogenesis
4) Subepithelial fibrosis
(p. 1673)
Anti-inflammatory cytokine/s that may be deficient in asthma
IL-10
IL-12
(p. 1674)
Evidence for increased oxidative stress in asthma
Increased concentrations of 8-isoprostane and increased ethane
(p. 1674)
What proinflammatory transcription factors are activated in asthmatic airways and orchestrate the expression of multiple inflammatory genes?
Nuclear factor-KB
Activator protein-1
GATA-3
(p. 1674)
Subepithelial fibrosis in asthma is due to deposition of what type/s of collagen?
Type III and V
p. 1674
What cytokine induces mucus hypersecretion in asthma?
IL-13
p. 1674
What is the characteristic physiologic abnormality of asthma?
Airway hyperresponsiveness
p. 1675
What are examples of direct bronchoconstrictors (in asthma)?
Histamine
Metacholine
(p. 1675)
Spirometry findings in asthma
Reduced FEV1, FEV1/FVC, PEF
p. 1675
Spirometry: Reversibility in asthma is demonstrated by?
1) >12% and 200 ml increase in FEV1 15 minutes after an inhaled SABA OR
2) 2-4 week trial of oral corticosteroids (prednisone or prednisolone 30-40 mg daily)
(p. 1675)
What test can be used for differential diagnosis of chronic cough or when suspecting asthma but with normal pulmonary function tests?
Metacholine or histamine challenge
p. 1675
CXR finding/s in asthma
Usually normal
Hyperinflated lungs (in more severe patients)
Possible pneumothorax (in exacerbations)
(p. 1675)
Non-invasive test to measure airway inflammation
Exhaled nitric oxide (FeNO)
p. 1676
Pharmacologic therapy for rapid relief of symptoms of asthma but has little or no effect on the underlying inflammatory process
Bronchodilators
p. 1676
Three classes of bronchodilators in current use for asthma
Beta 2 adrenergic agonists
Anti-cholinergic
Theophylline
(p. 1676)
Mode of action of beta 2 agonists for treatment of asthma
1) Relax airway smooth muscle cells of ALL airways
2) Inhibition of mast cell mediator release
3) Reduction in plasma exudation
4) Inhibition of sensory nerve activation
(p. 1676)
What is the duration of action of SABAs?
3-6 hours
p. 1676
What is the duration of action of LABAs?
Over 12 hours
p. 1676
For asthma treatment, how many times is Indacaterol given per day?
Once daily
p. 1676
Common side effects of beta 2 agonists
Muscle tremor
Palpitations
(p. 1676)
What can be used as an additional bronchodilator in patients with asthma that is not controlled by ICS and LABA combinations?
Anticholinergics
p. 1676
Most common side effect of anticholinergics (used in asthma)?
Dry mouth
p. 1677
Side effects of anticholinergics (seen in asthma treatment)?
Dry mouth
Urinary retention
Glaucoma
(p. 1677)
What is the mechanism of action of theophylline in asthma treatment?
Inhibition of phosphodiesterases in airway smooth muscle cells
Activates the key nuclear enzyme histone deacetylase-2 (HDAC2)
(p. 1677)
IV medication that may be used in patients with severe asthma exacerbations that are refractory to SABA
IV aminophylline
p. 1677
What is/are the most effective controller medication/s for asthma?
Inhaled corticosteroids
p. 1677
Local side effects of use of inhaled corticosteroids in asthma
Hoarseness (dysphasia)
Oral candidiasis
(p. 1677)
How can local side effects of inhaled corticosteroids be reduced?
Use of a large-volume spacer device
p. 1677
Course of oral corticosteroids used to treat exacerbations of asthma with no tapering of the dose needed (according to Harrison’s)
Prednisone or prednisolone 30-45 mg once daily for 5-10 days
p. 1677
Asthma controller drugs that inhibit mast cell and sensory nerve activation
Cromones (Cromolyn sodium and nedocromil sodium)
p. 1678
Asthma medication used to neutralize circulating IgE and thus inhibits IgE-mediated reactions
Omalizumab
p. 1678
Asthma medication usually given as a subcutaneous injection every 2-4 weeks
Omalizumab
p. 1678
Arterial blood gas finding/s indicating impending respiratory failure in asthma
Normal or rising PCO2
p. 1679
What is the most common reason for poor control of asthma?
Non-compliance with medications
p. 1679
What is type 1 brittle asthma?
Persistent pattern of variability that may require oral corticosteroids or continuous infusion of beta 2 agonists
(p. 1680)
What is type 2 brittle asthma?
1) Generally normal or near normal lung function but precipitous unpredictable falls in lung function that may result in death
2) Do not respond well to corticosteroids
3) Worsening of asthma does not reverse well with inhaled bronchodilators
(p. 1680)
What is the most effective therapy for type 2 brittle asthma?
Subcutaneous epinephrine
p. 1680
True or false: Anti-TNF therapy is effective in severe asthma
False
p. 1680
Aspirin-sensitive asthma responds to usual therapy with what medication?
Inhaled corticosteroids
p. 1680
Which drugs used in asthma therapy for pregnant patients have been shown to be safe and without teratogenic potential?
SABA
ICS
Theophylline
(p. 1680)
What oral corticosteroid can be used safely in treatment for asthma in pregnant patients?
Prednisone (rather than prednisolone)
p. 1680
What treatment is beneficial in preventing exacerbations of bronchopulmonary aspergillosis?
Oral itraconazole
p. 1681
What are the leading causes of transudative pleural effusion?
Left ventricular failure
Cirrhosis
(p. 1716)
What are the leading causes of exudative pleural effusion?
Bacterial pneumonia Malignancy Viral infection Pulmonary embolism (p. 1716)
What is the Light’s criteria? (Components)
1) Pleural fluid protein/serum protein > 0.5
2) Pleural fluid LDH/serum LDH > 0.6
3) Pleural fluid LDH more than 2/3 the normal upper limit for serum
(p. 1716)
What is the most common cause of pleural effusion?
Left ventricular failure
p. 1716
What test is diagnostic that a pleural effusion is secondary to congestive heart failure?
Pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP)
(p. 1717)
A pleural fluid NT-proBNP level of ______ is diagnostic that effusion is secondary to congestive heart failure.
> 1500 pg/ml
p. 1717
What is the most common cause of exudative pleural effusion?
Parapneumonic effusion
p. 1717
In parapneumonic effusion, a therapeutic thoracentesis should be performed if the free fluid separates the lung from the chest wall by ____ mm.
> 10
p. 1717
In parapneumonic effusion, what factors indicate the likely need for an invasive procedure (rather than thoracentesis)?
1) Loculated pleural fluid
2) Pleural fluid pH <7.2
3) Pleural fluid glucose < 3.3 mmol/L (<60 mg/dl)
4) Positive gram stain or culture of the pleural fluid
5) Presence of gross pus in the pleural space
(p. 1717)
What is the second most common cause of exudative pleural effusion?
Malignancy
p. 1717
What are the three common malignant etiologies of exudative pleural effusion?
Lung carcinoma
Breast carcinoma
Lymphoma
(p. 1717)
What procedures should be considered in a patient with malignant pleural effusion and dyspnea, relieved by thoracentesis?
1) insertion of a small indwelling catheter
2) tube thoracostomy with the instillation of a sclerosing agent such as doxycycline (500 mg)
(p. 1717)
Most mesotheliomas are related to exposure to?
Asbestos
p. 1717
CXR findings in mesothelioma
Pleural effusion
Generalized pleural thickening
Shrunken hemithorax
(p. 1717)
Pleural effusion secondary to pulmonary embolism is almost always ______ (transudative/exudative)?
Exudative
p. 1717
The diagnosis of pleural effusion secondary to pulmonary embolism is established by what test/imaging study?
Spiral CT scan or pulmonary arteriography
p. 1717
Pleural effusion secondary to TB is due to what mechanism?
Hypersensitivity reaction to tuberculous protein in the pleural space
(p. 1718)
The diagnosis of pleural effusion secondary to tuberculosis is established by what test/imaging study?
Adenosine deaminase >40 IU/L OR
Interferon gamma >140 pg/ml
(p. 1718)
What is the most common cause of chylothorax?
Trauma
p. 1718
Pleural fluid findings in chylothorax
Milky fluid with triglyceride level >1.2 mmol/L (110 mg/dl)
p. 1718
What is the treatment of choice for most chylothoraxes?
Insertion of chest tube plus administration of octreotide
p. 1718
Why shouldn’t patients with chylothorax undergo prolonged tube thoracostomy with chest tube drainage?
Because this will lead to malnutrition and immunologic incompetence
(Pp. 1718)
When a diagnostic thoracentesis reveals bloody pleural fluid, what test should be obtained?
Pleural fluid hematocrit
p. 1718
How is a hemothorax diagnosed through pleural fluid findings?
If pleural fluid hematocrit is more than 1/2 of that in the peripheral blood
(p. 1718)
When should thoracoscopy or thoracotomy be considered in the setting of hemothorax/pulmonary hemorrhage?
If pulmonary hemorrhage exceeds 200 ml/hr
p. 1718
What should be considered if pleural fluid amylase level is elevated?
Esophageal rupture
Pancreatic disease
(p. 1718)
What is Meigs’ syndrome?
Benign ovarian tumor + ascites + pleural effusion
p. 1718
Primary spontaneous pneumothorax is usually due to what?
Rupture of apical pleural blebs
p. 1719
What is the initial recommended treatment for primary spontaneous pneumothorax?
Simple aspiration
p. 1719
What is the usual cause of secondary pneumothorax?
COPD
p. 1719
Tension pneumothorax usually occurs during what conditions?
Mechanical ventilation
Resuscitative efforts
(p. 1719)
Why is there reduced cardiac output in tension pneumothorax?
The positive pressure is transmitted to the mediastinum resulting in decreased venous return to the heart
(p. 1719)
In OSAHS, the airway may collapse at various anatomical levels, which are?
1) Soft palate (most common)
2) Tongue base
3) Lateral pharyngeal walls
4) Epiglottis
(p. 1723)
OSAHS is most severe during what phase of sleep?
REM
p. 1724
What are the major risk factors of OSAHS?
Obesity
Male sex
(p. 1724)
A 10% weight gain is associated with how many % increase in apnea-hypopnea index (AHI)?
30%
p. 1724
What are the risk factors for OSAHS?
1) Obesity
2) Male sex
3) Mandibular retrognathia and micrognathia
4) Positive family history of OSAHS
5) Genetic syndromes that reduce upper airway patency
6) Adenotonsillar hypertrophy
7) Menopause
8) Various endocrine syndromes
(p. 1724)
What is the most common complaint in OSAHS?
Snoring
p. 1724
What is the most common daytime symptom of OSAHS?
Sleepiness
p. 1724
What is the gold standard for diagnosis of OSAHS?
Overnight polysomnogram (PSG) (p. 1725)
What are key physiologic information collected during a sleep study for OSAHS assessment?
1) Measurement of breathing
2) Oxygenation
3) Body position
4) Cardiac rhythm
(p. 1725)
In a polysomnogram, apnea is defined as what?
Cessation of airflow for > or = to 10 seconds during sleep, accompanied by persistence/absence of respiratory effort
(p. 1725, Table 319-1)
In a polysomnogram, hypopnea is defined as what?
A > or = to 30% reduction in airflow for at least 10 seconds during sleep accompanied by a > or = to 3% desaturation or an arousal
(p. 1725, Table 319-1)
In a polysomnogram, how is respiratory effort-related arousal (RERA) defined?
Partially obstructed breath that does not meet the criteria for hypopnea but with evidence of increasing inspiratory effort punctuated by an arousal
(p. 1725, Table 319-1)
In a polysomnogram, flow-limited breath is defined as what?
Partially obstructed breath, typically within a hypopnea or RERA, identified by a flattened or “scooped out” inspiratory flow shape
(p. 1725, Table 319-1)
Definition of mild OSAHS by number of AHI
5-14 events/hr
p. 1725, Table 319-2
Definition of moderate OSAHS by number of AHI
15-29 events/hr
p. 1725, Table 319-2
Definition of severe OSAHS by number of AHI
> or = to 30 events/hr
p. 1725, Table 319-2
True or false: OSAHS can raise blood pressure to prehypertensive and hypertensive ranges
True
p. 1725
True or false: Depression is commonly reported in OSAHS
True
p. 1726
What is the standard medical therapy with the highest level of evidence for efficacy in OSAHS?
CPAP
p. 1727
Oral appliances can also be used to treat OSAHS however its side effects include what?
Temporomandibular joint pain
Tooth movement
(p. 1727)
True or false: Bariatric surgery is an option for obese patients with OSAHS
True
p. 1727
Central sleep apnea is often caused by what?
1) Increased sensitivity to pCO2 –> hyperventilation alternating with apnea
2) Prolonged circulation delay between the pulmonary capillaries and carotid chemoreceptors
(p. 1727)
What do you call the condition wherein central apnea is induced by the use of CPAP?
Complex sleep apnea
p. 1727
What is a form of ventilatory support used for treatment of central sleep apnea that dynamically changes inspiratory support levels across periods of apnea and hypopnea?
Adaptive seroventilation
p. 1727
Elevations in blood pressure in OSAHS is due to what mechanism/s?
1) Augmented sympathetic nervous system activation
2) Alterations in RAAS and fluid balance
(p. 1725)
