Respirology

Question 1

Asthma: Methacholine challenge test. What is the % change needed?

Answer 1

> 20% in FEV1 with 4mg of methacholine
PC20 <4mg/ml = positive
PC20 4-16 = borderline
PC20 >16 = negative

Question 2

ways to diagnose asthma

Answer 2

FEV 1 improves by 12% AND 200 cc with bronchodilator/or 4 weeks of anti-inflammatories or over the course of repeat testing
Challenge
- methacholine: drop in FEV1 >20%
- drop in FEV1 >10% AND 200 ml with exercise
Peak expiratory flow: PEF variability on avg is 10%, if excessive variability when measured BID for 2 weeks then that is diagnostic

Question 3

Examples of SABA

Answer 3

Ventolin

Question 4

Examples of LABA

Answer 4

formoterol or salmeterol or vilanterol or alocleterol

Question 5

Examples of SAMA

Answer 5

ipratropium bromide

Question 6

examples of LAMA

Answer 6

umeclidiunium bromide OR glycopyronium bromide OR tiotropium bromide OR aclidinium bromide

Question 7

What did SYGMA 1 and 2 trials show?

Answer 7

Compared PRN ICS/LABA (budesonide/formeterol) and found that when compared to
1) PRN SABA (ventolin)
- it was superior
2) Maintenance ICS (budesonide) + PRN SABA (ventolin)
- it was non inferior
PRN ICS decreased symptoms+exacerbation+hospitalization/Death
and improved PFTs/QOL

PRN ICS-LABA i.e. buds/formet is preferred reliever!
Only time you can use PRN SABA is for pt. with well controlled asthma and no risk of severe exacerbation

Question 8

Generally ICS-LABA (bud/form) is better than ICS-LTRA. But when are LTRAs most useful?

Answer 8

LTRAs most useful for ASA induced asthma, exercise induced asthma, allergic rhinitis
LTRA: montelukast

Question 9

Management of severe asthma? Investigations and treatment

Answer 9

IgE level, serum eosinophil count and sputum eosinophils
If high IgE (30-700): Use omalizumab (Anti-IgE) AKA Xolair
If high eosinophils (>300): think about all the other biologics

Question 10

Asthma Mimics

Answer 10

Eosinophillic granulomatosis with polyangitis (EGPA/Churg Strauss)
- asthma, eosinophilia, granulomatous vasculitis
- 30-60% have p-ANCA positive
Tx: prednisone, or cyclophosphamide if severe

Other mimics:
Vocal cord dysfunction
ABPA: allergic bronchopulmonary aspergillosis
- brown sputum casts, aspergillum IgE >1000, pulm infilt
RADS: Reactive airways dysfunction syndrome: large single exposure usually occupational causing irritant induced asthma