Pulmo Flashcards
1
Q
To which house dust mite are asthmatics in affluent countries with allergic sensitization to?
A
Dermatophagoides pteronyssinus
2
Q
Asthma peak age of presentation
A
3 years old
3
Q
Asthma gender predisposition
A
Childhood - twice as many males
Adulthood - equal
4
Q
Major risk factor for asthma
A
Atopy
5
Q
Genes associated with asthma
A
Adam 33
Dpp10
Ormdl3
6
Q
Variant of b2 receotor associated with poor response to beta receptor in asthma
A
Arg-glyc-16 variant
7
Q
Most common allergen to trigger asthma
A
Dermatophagoides
8
Q
Most comnon trigger of acute severe exacerbation of asthma
A
Urti
Rhinovirus, coronavirus, rsv
9
Q
Food additive that can trigger asthma by release of sulfur dioxide in the stomach
A
Metabisulfite
10
Q
Cytokine responsible for eosjnophilic infiltration in asthma
A
Interleukin 5 (from th2 cells)
11
Q
Cytokines responsible for increased IgE formation
A
Interleukin 4 and 13 (from th2 cells)
12
Q
Cytokines responsible for increased IgE formation
A
Interleukin 4 and 13 (from th2 cells)
13
Q
Antiinflammatory cytokines which may be deficient in asthma
A
Interleukin 10 and 12
14
Q
Chemokines involved in asthma
A
Eotaxin (ccl 11) - selectively attractant to eosinophils via ccr 3
Tarc (ccl17) and mdc (ccl22) - attract th2 cells via ccr 4
15
Q
Increasingly used in the diagnosis and monitoring of asthma which banks on the principle of increased levels of a vasodilator in the expired of patients with asthma nd is related eosinophilic inflammation
A
Feno
fractional exhaled nitric oxide
16
Q
Growth factors responsible for the hypertrophy And hyperplasia and airway smooth muscles
A
Pdgf and endothelin 1
17
Q
Cytokine responsible for increased mucus secretion in asthmatics
A
Interleukin 13 (from th2)
18
Q
Characteristic physiologic abnormality of asthma
A
Airway hyperresponsiveness
- excessive bronchoconstrictor response to multiple inhaled triggers that would have no effect on normal airways
- linked to frequency of symptoms
- reducing ahr is an important therapeutic goalAirway hyperresponsiveness
- excessive bronchoconstrictor response to multiple inhaled triggers that would have no effect on normal airways
- linked to frequency of symptoms
- reducing ahr is an important therapeutic goal
19
Q
Direct bronchoconstrictors in asthma
A
Histaminne and metacholine
20
Q
Indirect bronchoconstrictor in asthma
A
Allergens, exercise, hyperventilation, fog (via mast cell activation), irritant dust, sulfur dioxide (via cholinergic effect)
21
Q
Lung function test findings of asthma
A
Reversibility of obstructive ventilatory defect: increase by >12% or 200ml increase of fev1
- 15 min after inhaled saba (400mcg salb)
- pef bid: confirm diurnal variation
- 2- 4 wk trial of corticosteroids (prednisone or prednisolone 30-40mg od)Reversibility of obstructive ventilatory defect: increase by >12% or 200ml increase of fev1
- 15 min after inhaled saba (400mcg salb)
- pef bid: confirm diurnal variation
- 2- 4 wk trial of corticosteroids (prednisone or prednisolone 30-40mg od)
22
Q
Used to diagnose airway hyperresponsiveness in asthma
A
Metacholine and histamine challenge with calculation of provocative concentration that reduces fev1 by 20%
23
Q
Typically elevated levels of this test in asthma is reduced by ICS therapy so this test may be a test of compliance with therapy
A
Feno (fraction of exhaled nitric oxide)
- also useful in demonstrating insufficient antiinflammatory therapy
- useful in downtitrating ics
24
Q
Percentage of copd patients with features of asthma
A
15%
25
Most effective class of bronchodilators in asthma
Beta 2 agonist
26
Beta agonist according to duration of action
3-6h - salbutamol
12h - salmeterol and formoterol
24h - indacaterol, olodaterol and vilanterol
27
Long acting anticholinergics
Glycopyrronium and tiotropium
28
Mc ae of anticholinergics
Dry mouth, glaucoma, urinary retention
29
Mc ae of beta agonist
Tremors and palpitations
30
Nuclear enzyme activated by theophylline which is a critical mechanism for switching off activated inflammatory genes which may therefore reduce corticosteroid insensitivity in severe asthma
Histone deacetylase - 2 (hdac2)
31
Moa theophylline
Phosphodiesterase inhibitor -> increased camp
| Histone deacetylase -2 (hdac-2) inhibition -> gene transcription modification
32
Phosphodiesterase mediated Ae theophylline
Nausea, vomiting, headaches
33
Adenosine 2 receptor amtagonism mediated ae of theophylline
Diuresis, palpitations, arrhythmias, epileptic seizures, death
34
Theophylline ae rarely observed whe plasma levels are
<10mg/L
35
Most effective controllers in asthma
Ics
36
Theophylline clearance cyp450 isoform
Liver - cyp 1a2
37
Ics moa
- inhibits nuclear factor kappa b
- increase in antiinflammatory map kinase phosphodiesterase
- activates hdac2 (histone deacetylase 2)
38
Intramuscular triamcinolone is used in noncompliant asthma patients. What is the major side effect?
Proximal myopathy
39
Moa of montelukast and zafirlukast
Cysteinyl leukotrienes: potent bronchoconstrictors and cause microvascular leakage
Antileukotrienes
Montelukast and Zafirlukast - block cyst-LT1 receptors
Zileuton - 5-lipoxygenase inhibitor (inhibits formation if leukotriene ltb4 ltc4 ltd4 lte4)
40
Cromolyn sodium and nedocromyl sodium
| Moa
- Mast cell stabilizer
- effective in blocking trigger induced asthma (exercised induced asthma, allergen and sulfur dioxide induced symptoms)
- short duration of action (qid administration)
- very safe
41
Omalizumab moa
- IgE neutralizer
- need 3-4 month trial to ascertain benefit
- sq injection every 2-4wks
- few ae, sometimes anaphylaxis
42
Anti-Interleukin 5 (eosinophil stimulation) antibodies
Mepolizumab, reslizumab
43
Anti interleukin 5 receptor
Benralizumab
44
Umabs and lukasts in asthmap
Omalizumab - anti IgE
Reslizumab, mepolizumab - anti Interleukin 5 antibodies
Montelukast and zafirlukast - cys-LT1 receptor inhibitor
Zileuton - inhibits lipoxygenase 5
45
Indication for need for controller therapy in asthma
Use of reliever more than twice weekly
46
Asthma treatment stepwise approach
Mild intermittent - saba
Mild persistent - saba + low dose ics
Mod persistent - saba + low dose ics + laba
Severe persistent - saba + high dose ics + laba
Very severe persistent - saba + high dose ics + laba + ocs
47
Indication for o2 support (ie face mask) in acute asthma
O2 sat <90%
| Target >90%
48
Refractory asthma percentage
5%
49
2 patterns of refractory asthma
- persistent symptoms and poor lung function despite appropriate therapy
- normal or near normal lung function but intermittent severe exacerbations
50
Mcc of poor asthma control
Poor adherence
51
How to measure ocs adherence
Suppression of plasma cortisol
52
Systemic disease that may worsem asthma control
Hypo/hyperthyroidism
53
Incidence and definition of complete resistance to steroids in asthma
<1:1000
| Failure to respond to high dose oral pred/prednisolone (40mg od × 2 wks)
54
Mechanism of steroid resistance in asthma
- defect in il10 production
- increase in alternatively spliced form of glucocorticoid receptor beta
- abnormal pattern of histone acetylation
- reduced hdac2 activity
55
Brittle asthma most effective treatment
- chaotic variations in lung function espite appropriate tx
| - sq epinephrine
56
Aspirin sens asthma proportion
1-5%
57
Percentage asthma
- aspirin sensitive asthma
- refractory asthma
- copd overlap
Percentage asthma
- aspirin sensitive asthma - 1-5%
- refractory asthma - 5%
- copd overlap - <1:1000
58
Aspirin sensitive asthma genetic polymorphism
- functional polymorphism of cysteinyl leukotriene synthase
59
Pregnancy asthma prognosis
- 1/3 improve
- 1/3 deteriorate
- 1/3 unchanged
60
Safe meds pregnancy asthma and breastfeeding
- saba, ics, theophyllines
- if steroids will be used prednisone better because fetus cant convert pred to prednisolone which is active form
- no contraindication to breast feeding
61
How does smoking interfere with antiinflam action of corticosteroids
Reduced hdac2
| - may give laba or theophylline to reduce steroid resistance
62
Temporary worsening of asthma on smoking cessation due to?
Bronchodilating effect of NO in cigarette smoke
63
Bromchopulmomary aspergillosis tx
Oral itraconazole
64
Indication for continuous o2 support in copd
Resting hypoxemia (o2 sat <88% in any patient or <89% in px with signs of pulmo htn or cor pulmonale)
65
Strongest single predictor of exacerbations in copd
Previous exacerbation
66
Average number of axacerbations for copd with severe (fev1 <50%) and very severe (fev1 <30%) air obstruction
1-3/year
67
Single greatest risk of hospitalization with an exacerbation
History of previous hospitalization
68
Target o2 sat in copd in acute exacerbation
>90%
69
Percentages copd hospitalized
Mortality during hospitalization if on mech vent
Mortality during hospitalization if >65 and icu
Risk of rehospitalization in next 30 days
Risk of rehospitalization in the next year
Risk of mortality after discharge for 1 yr
Percentages copd hospitalized
Mortality during hospitalization if on mech vent - 17-30%
Mortality during hospitalization if >65 and icu - 60%
Risk of rehospitalization in next 30 days - 20%
Risk of rehospitalization in the next year - 45%
Risk of mortality after discharge for 1 yr - 20%
70
Chronic cough
>8wks
71
How much of hemoglobin must be deoxygenated before cyanosis occurs?
5g
72
Prevalence of osa
2% women
4% men
Men >women
73
Osa triad
Chronic snoring - most sensitive
witnessed apneas - most specific
excessive daytime sleepiness - marks clinical severity
74
Best documented risk factor for osa
Based on guidelines- Obesity
Based on harrisons - obesity and male gender
75
Neck circumference suggestive of osa
Male: >17 inches
Female: >16 inches
76
Bmi at risk for osa in asians
General: bmi >30
Asian: bmi >27.5
```
Other pe findings:
1. Mallampati score 3 or 4
2. Neck circumference m >17 inches, f >16inches
3. Bmi >30 (asians >27.5)
4. High arched/narrow hard palate
Etc
```
77
Osa screening questionaire with the highest internal validity, sensitivity, ppv, npv
Stopbang questionnaire
- snoring, tiredness, observed apneas, bp, bmi, age (>50) neck circumference, gender
- surgery patients
78
Which osa screening tool is used to monitor osa symptoms
Epworth sleepiness scale
79
Gold standard osa diagnosis
Polysomnogram
80
When can portal monitors be used to diagnose osa
- high pretest probability of mod to severe osa
| - no comorbid or medical sleeping disorders
81
Rdi vs ahi in osa
Respiratory disturbance index = (apnea + hypopnea + rera (respiratory events related arousals) )/total recording time
Apnea hypopnea index = apnea + hypopnea/total monitoring time
82
Diagnostic criteria osa
- ahi >5 with symptoms
| - ahi >15 with or without symptoms
83
Definition of mild moderate and severe osa
Mild - ahi 5-14/hr
Moderate - ahi 15-30/hr
Severe - ahi >30/hr
84
Treatment of choice for osa
Cpap
85
Standard initial tx for osa
Standard initial tx for osa
Cpap at fixed pressure at least 4 hrs/night
Goal adherence - >4hrs per night at least 70% of nights
86
Conservative treatment for osa
Weight loss
Avoid supine sleeping position
Nasal corticosteroids if with allergic rhinitis
87
Effect of 10% weight loss on osa
Guidelines:
Weight loss 10% - decrease ahi by 26%
Weight increase 10% - increase ahi by 32%
Harrisons
Weight increase by 10% - increase ahi by 30%Guidelines:
Weight loss 10% - decrease ahi by 26%
Weight increase 10% - increase ahi by 32%
Harrisons
Weight increase by 10% - increase ahi by 30%
88
Indication for cpap titration study
Weight change of >10%
| Reappearance of symptoms
89
Definition of postural osa
- ahi in the supine position is atleast twice of that in lateral decubitus
And
- ahi in lateral position must be mild and <15/hr
90
Maneuver used to diagnose osa
After a forced expiration, an attempt at inspiration is made with closed mouth and nose, whereby the negative pressure in the chest and lungs is made very subatmospheric; the reverse of Valsalva manoeuvre
Muller maneuver
91
Risk of mva for osa patients
2.4
92
Chronic dyspnea duration
>1 month
93
Differentials for platypnea
Hepatopulmonary syndrome
| Left atrial myxoma
94
Pulsus paradoxus definition and differentials
Decrease in sbp >10mmHg during inspiration
Copd
asthma
Pericardial disease
95
Inward movement of the abdomen during inspiration is a sign of what
Diaphragmatic weakness
96
Rounding of the abdomen during exhalation is a sign of what
Pulmonary edema
97
Chest xray findings pulmonary arterial versus venous hypertension
Arterial hypertension - enlarged central pulmonary arteries
| Venous hypertensionries - prominent vasculature in the upper zones
98
Evaluation of dyspnea
| Phase 1 2 3 testing
Phase 1 - cxr, ecg, spirometry, cbc, basic metabolic panel
Phase 2 - chest ct (consider angiography for vte), lung volumes, dlco, neuromuscular fxn, echo, cardiac stress testing
Phase 3 - cardiopulmonary exercise testingPhase 1 - cxr, ecg, spirometry, cbc, basic metabolic panel
Phase 2 - chest ct (consider angiography for vte), lung volumes, dlco, neuromuscular fxn, echo, cardiac stress testing
Phase 3 - cardiopulmonary exercise testing
99
Most common source/location of hemoptysis
Medium sized airways
100
Dual blood supply of the lungs
Pulmonary (low pressure)
Bronchial (systemic pressure) - neovascularize tumors, dilate airways of bronchiectasis, cavitary lesions
**majority of hemopytsis are bronchial, therefore higher pressure -> harder to control bleeding
101
Leading cause of massive hemoptysis
Bronchiectasis
102
Massive hemoptysis volume
400cc/24hrs
100-150cc expectorated at 1 time
Volume of the tracheobronchial tree = 100-200cc
103
Low tv mech vent to prevent ards
Tv 6cc/kg
Plateau pressure 30 cmh2o
Peep no official recommendation
104
Normally, how many percent of cardiac output is dedicated to the lungs?
5%
| Can incresse to 40% in ards
105
Respi failure types
Type 1 hypoxemic
Type 2 hypercarbic
Type 3 postoperative
Type 4 decreased perfusion to respi muscles
106
Use of noninvasive ventilation in patients with failed extubation may be associated with worse outcomes than those with immediate reintubation
Use of noninvasive ventilation in patients with failed extubation may be associated with worse outcomes than those with immediate reintubation
107
Sedation in mechanically ventilated patients
- opiates preferred
| Nonbenzodiazepines are preferred since bzd associated with worse outcomes
