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Residency > Pulmo > Flashcards

Pulmo Flashcards

1
Q

To which house dust mite are asthmatics in affluent countries with allergic sensitization to?

A

Dermatophagoides pteronyssinus

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2
Q

Asthma peak age of presentation

A

3 years old

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3
Q

Asthma gender predisposition

A

Childhood - twice as many males

Adulthood - equal

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4
Q

Major risk factor for asthma

A

Atopy

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5
Q

Genes associated with asthma

A

Adam 33
Dpp10
Ormdl3

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6
Q

Variant of b2 receotor associated with poor response to beta receptor in asthma

A

Arg-glyc-16 variant

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7
Q

Most common allergen to trigger asthma

A

Dermatophagoides

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8
Q

Most comnon trigger of acute severe exacerbation of asthma

A

Urti

Rhinovirus, coronavirus, rsv

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9
Q

Food additive that can trigger asthma by release of sulfur dioxide in the stomach

A

Metabisulfite

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10
Q

Cytokine responsible for eosjnophilic infiltration in asthma

A

Interleukin 5 (from th2 cells)

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11
Q

Cytokines responsible for increased IgE formation

A

Interleukin 4 and 13 (from th2 cells)

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12
Q

Cytokines responsible for increased IgE formation

A

Interleukin 4 and 13 (from th2 cells)

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13
Q

Antiinflammatory cytokines which may be deficient in asthma

A

Interleukin 10 and 12

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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

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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

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16
Q

Growth factors responsible for the hypertrophy And hyperplasia and airway smooth muscles

A

Pdgf and endothelin 1

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17
Q

Cytokine responsible for increased mucus secretion in asthmatics

A

Interleukin 13 (from th2)

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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
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19
Q

Direct bronchoconstrictors in asthma

A

Histaminne and metacholine

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20
Q

Indirect bronchoconstrictor in asthma

A

Allergens, exercise, hyperventilation, fog (via mast cell activation), irritant dust, sulfur dioxide (via cholinergic effect)

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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)
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22
Q

Used to diagnose airway hyperresponsiveness in asthma

A

Metacholine and histamine challenge with calculation of provocative concentration that reduces fev1 by 20%

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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
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24
Q

Percentage of copd patients with features of asthma

A

15%

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25
Q

Most effective class of bronchodilators in asthma

A

Beta 2 agonist

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26
Q

Beta agonist according to duration of action

A

3-6h - salbutamol
12h - salmeterol and formoterol
24h - indacaterol, olodaterol and vilanterol

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27
Q

Long acting anticholinergics

A

Glycopyrronium and tiotropium

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28
Q

Mc ae of anticholinergics

A

Dry mouth, glaucoma, urinary retention

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29
Q

Mc ae of beta agonist

A

Tremors and palpitations

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30
Q

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

A

Histone deacetylase - 2 (hdac2)

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31
Q

Moa theophylline

A

Phosphodiesterase inhibitor -> increased camp

Histone deacetylase -2 (hdac-2) inhibition -> gene transcription modification

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32
Q

Phosphodiesterase mediated Ae theophylline

A

Nausea, vomiting, headaches

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33
Q

Adenosine 2 receptor amtagonism mediated ae of theophylline

A

Diuresis, palpitations, arrhythmias, epileptic seizures, death

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34
Q

Theophylline ae rarely observed whe plasma levels are

A

<10mg/L

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35
Q

Most effective controllers in asthma

A

Ics

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36
Q

Theophylline clearance cyp450 isoform

A

Liver - cyp 1a2

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37
Q

Ics moa

A
  • inhibits nuclear factor kappa b
  • increase in antiinflammatory map kinase phosphodiesterase
  • activates hdac2 (histone deacetylase 2)
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38
Q

Intramuscular triamcinolone is used in noncompliant asthma patients. What is the major side effect?

A

Proximal myopathy

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39
Q

Moa of montelukast and zafirlukast

A

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)

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40
Q

Cromolyn sodium and nedocromyl sodium

Moa

A
  • 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
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41
Q

Omalizumab moa

A
  • IgE neutralizer
  • need 3-4 month trial to ascertain benefit
  • sq injection every 2-4wks
  • few ae, sometimes anaphylaxis
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42
Q

Anti-Interleukin 5 (eosinophil stimulation) antibodies

A

Mepolizumab, reslizumab

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43
Q

Anti interleukin 5 receptor

A

Benralizumab

44
Q

Umabs and lukasts in asthmap

A

Omalizumab - anti IgE
Reslizumab, mepolizumab - anti Interleukin 5 antibodies
Montelukast and zafirlukast - cys-LT1 receptor inhibitor
Zileuton - inhibits lipoxygenase 5

45
Q

Indication for need for controller therapy in asthma

A

Use of reliever more than twice weekly

46
Q

Asthma treatment stepwise approach

A

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
Q

Indication for o2 support (ie face mask) in acute asthma

A

O2 sat <90%

Target >90%

48
Q

Refractory asthma percentage

A

5%

49
Q

2 patterns of refractory asthma

A
  • persistent symptoms and poor lung function despite appropriate therapy
  • normal or near normal lung function but intermittent severe exacerbations
50
Q

Mcc of poor asthma control

A

Poor adherence

51
Q

How to measure ocs adherence

A

Suppression of plasma cortisol

52
Q

Systemic disease that may worsem asthma control

A

Hypo/hyperthyroidism

53
Q

Incidence and definition of complete resistance to steroids in asthma

A

<1:1000

Failure to respond to high dose oral pred/prednisolone (40mg od × 2 wks)

54
Q

Mechanism of steroid resistance in asthma

A
  • defect in il10 production
  • increase in alternatively spliced form of glucocorticoid receptor beta
  • abnormal pattern of histone acetylation
  • reduced hdac2 activity
55
Q

Brittle asthma most effective treatment

A
  • chaotic variations in lung function espite appropriate tx

- sq epinephrine

56
Q

Aspirin sens asthma proportion

A

1-5%

57
Q

Percentage asthma

  • aspirin sensitive asthma
  • refractory asthma
  • copd overlap
A

Percentage asthma

  • aspirin sensitive asthma - 1-5%
  • refractory asthma - 5%
  • copd overlap - <1:1000
58
Q

Aspirin sensitive asthma genetic polymorphism

A
  • functional polymorphism of cysteinyl leukotriene synthase
59
Q

Pregnancy asthma prognosis

A
  • 1/3 improve
  • 1/3 deteriorate
  • 1/3 unchanged
60
Q

Safe meds pregnancy asthma and breastfeeding

A
  • 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
Q

How does smoking interfere with antiinflam action of corticosteroids

A

Reduced hdac2

- may give laba or theophylline to reduce steroid resistance

62
Q

Temporary worsening of asthma on smoking cessation due to?

A

Bronchodilating effect of NO in cigarette smoke

63
Q

Bromchopulmomary aspergillosis tx

A

Oral itraconazole

64
Q

Indication for continuous o2 support in copd

A

Resting hypoxemia (o2 sat <88% in any patient or <89% in px with signs of pulmo htn or cor pulmonale)

65
Q

Strongest single predictor of exacerbations in copd

A

Previous exacerbation

66
Q

Average number of axacerbations for copd with severe (fev1 <50%) and very severe (fev1 <30%) air obstruction

A

1-3/year

67
Q

Single greatest risk of hospitalization with an exacerbation

A

History of previous hospitalization

68
Q

Target o2 sat in copd in acute exacerbation

A

> 90%

69
Q

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

A

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
Q

Chronic cough

A

> 8wks

71
Q

How much of hemoglobin must be deoxygenated before cyanosis occurs?

A

5g

72
Q

Prevalence of osa

A

2% women
4% men

Men >women

73
Q

Osa triad

A

Chronic snoring - most sensitive
witnessed apneas - most specific
excessive daytime sleepiness - marks clinical severity

74
Q

Best documented risk factor for osa

A

Based on guidelines- Obesity

Based on harrisons - obesity and male gender

75
Q

Neck circumference suggestive of osa

A

Male: >17 inches
Female: >16 inches

76
Q

Bmi at risk for osa in asians

A

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
Q

Osa screening questionaire with the highest internal validity, sensitivity, ppv, npv

A

Stopbang questionnaire

  • snoring, tiredness, observed apneas, bp, bmi, age (>50) neck circumference, gender
  • surgery patients
78
Q

Which osa screening tool is used to monitor osa symptoms

A

Epworth sleepiness scale

79
Q

Gold standard osa diagnosis

A

Polysomnogram

80
Q

When can portal monitors be used to diagnose osa

A
  • high pretest probability of mod to severe osa

- no comorbid or medical sleeping disorders

81
Q

Rdi vs ahi in osa

A

Respiratory disturbance index = (apnea + hypopnea + rera (respiratory events related arousals) )/total recording time

Apnea hypopnea index = apnea + hypopnea/total monitoring time

82
Q

Diagnostic criteria osa

A
  • ahi >5 with symptoms

- ahi >15 with or without symptoms

83
Q

Definition of mild moderate and severe osa

A

Mild - ahi 5-14/hr
Moderate - ahi 15-30/hr
Severe - ahi >30/hr

84
Q

Treatment of choice for osa

A

Cpap

85
Q

Standard initial tx for osa

A

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
Q

Conservative treatment for osa

A

Weight loss
Avoid supine sleeping position
Nasal corticosteroids if with allergic rhinitis

87
Q

Effect of 10% weight loss on osa

A

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
Q

Indication for cpap titration study

A

Weight change of >10%

Reappearance of symptoms

89
Q

Definition of postural osa

A
  • 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
Q

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 ofValsalva manoeuvre

A

Muller maneuver

91
Q

Risk of mva for osa patients

A

2.4

92
Q

Chronic dyspnea duration

A

> 1 month

93
Q

Differentials for platypnea

A

Hepatopulmonary syndrome

Left atrial myxoma

94
Q

Pulsus paradoxus definition and differentials

A

Decrease in sbp >10mmHg during inspiration

Copd
asthma
Pericardial disease

95
Q

Inward movement of the abdomen during inspiration is a sign of what

A

Diaphragmatic weakness

96
Q

Rounding of the abdomen during exhalation is a sign of what

A

Pulmonary edema

97
Q

Chest xray findings pulmonary arterial versus venous hypertension

A

Arterial hypertension - enlarged central pulmonary arteries

Venous hypertensionries - prominent vasculature in the upper zones

98
Q

Evaluation of dyspnea

Phase 1 2 3 testing

A

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
Q

Most common source/location of hemoptysis

A

Medium sized airways

100
Q

Dual blood supply of the lungs

A

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
Q

Leading cause of massive hemoptysis

A

Bronchiectasis

102
Q

Massive hemoptysis volume

A

400cc/24hrs
100-150cc expectorated at 1 time
Volume of the tracheobronchial tree = 100-200cc

103
Q

Low tv mech vent to prevent ards

A

Tv 6cc/kg
Plateau pressure 30 cmh2o
Peep no official recommendation

104
Q

Normally, how many percent of cardiac output is dedicated to the lungs?

A

5%

Can incresse to 40% in ards

105
Q

Respi failure types

A

Type 1 hypoxemic
Type 2 hypercarbic
Type 3 postoperative
Type 4 decreased perfusion to respi muscles

106
Q

Use of noninvasive ventilation in patients with failed extubation may be associated with worse outcomes than those with immediate reintubation

A

Use of noninvasive ventilation in patients with failed extubation may be associated with worse outcomes than those with immediate reintubation

107
Q

Sedation in mechanically ventilated patients

A
  • opiates preferred

Nonbenzodiazepines are preferred since bzd associated with worse outcomes

Residency (6 decks)

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