Chapter 281 - Asthma Flashcards
1
Q
Prevalence of asthma in adults
A
10-12%
2
Q
Prevalence of asthma in children
A
15%
3
Q
Increasing prevalence of asthma in developing countries is due to
A
increased urbanization
4
Q
Most patients with Asthma in affluent countries are due to
A
Atopy
5
Q
Peak age of Asthma
A
3 years old
6
Q
Prevalence of asthma according to sex
A
Children: 2:1
Adults: 1:1
7
Q
The severity of asthma does not vary significantly within a given patient
A
True
8
Q
Major risk factors for asthma deaths
A
- poorly controlled disease with frequent use of bronchodilator inhalers
- lack of or poor compliance with ICS therapy
- previous admissions to hospital with near-fatal asthma.
9
Q
These are environmental factors which worsen asthma in a patient with established asthma
A
Triggers
10
Q
Major risk factor for Asthma
A
Atopy
11
Q
Allergic rhinitis is found in how many percent of asthmatic patients
A
> 80%
12
Q
How many percent of the population in affluent countries are atopic
A
40-50%
13
Q
Most common allergen to trigger asthma
A
Dermatophagoides pteronyssinus
14
Q
Severity of Asthma is genetically determined
A
true
15
Q
Most consistent finding in gene polymorphism of which chromosome
A
chromosome 5q
16
Q
Th2 cells in asthma secrete these interleukins which are associated with atopy
A
IL-4
IL-5
IL-9
IL-13
17
Q
Novel genes associated with Asthma but their function in disease pathogenesis is not yet clear
A
ADAM 33
DPP 10
ORMDL3
18
Q
genetic polymorphism associated with reduced response to B2 agonists
A
Arg-Gly-16 variant in the B2 receptor
19
Q
Epigenetic mechanisms associated
A
DNA methylation
Histone modification
20
Q
Virus implicated in the development of asthma
A
RSV
21
Q
What is the Hygiene hypothesis
A
Lack of infections in early childhood: preserves Th2
exposure to infectionsL shift to protective Th1
22
Q
Infection with which intestinal parasite is associated with a reduced risk of asthma
A
Hookworm
23
Q
Dietary factors associated with an increased risk of asthma
A
Low in antioxidants (Vit C, Vit A, Mg, Se, omega 3 PUFA)
High in Na and Omega 6 PUFA
24
Q
Air pollutants triggering asthma symptoms
A
Diesel
Ozone
Sulfur dioxide
25
Rigorous allergen avoidance have shown reduced risk of asthma development
False
26
Which domestic pet has been associated with allergic sensitization
Cats
27
Which chemicals lead to sensitization independent of atopy
Toluene diisocyanate
| Trimellitic anhydride
28
Asthma occurs more frequently in obese which which BMI?
>30
29
Other factors implicated in asthma etiology
```
Low birth weight
Low maternal age
Duration of breastfeeding
Prematurity
Inactivity
```
30
How many percent of asthmatic patients have negative skin tests to common inhalant allergens and normal serum concentration of IgE
10%
31
Characteristic of Intrinsic asthma
```
non atopic
adult onset
aspirin sensitive
nasal polyps
more severe, persistent asthma
```
32
pollens usually trigger allergic rhinitis than asthma.But when disrupted, pollen grains may be released and can trigger what kind of asthma
Thunderstorm asthma
33
Most common triggers of acute severe exacerbation of asthma
URTI by rhinovirus, RSV, coronavirus
34
Mechanism of beta blockers causing asthma exacerbation
increased cholinergic bronchoconstriction
35
All beta blockers would be avoided including selective and topical BB
True
36
ACE-I induced cough is no more frequent in asthmatics than in non asthmatics
true
37
Mechanism of asthma in Exercise
Hyperventilation, resulting in increased osmolality, triggering mast cell release
38
Exercise induced asthma occurs when?
begins AFTER exercise has ended and recovers SPONTANEOUSLY within 30 mins
39
Sports commonly associated with asthma
cross country running in cold weather
overland skiing
ice hockey
40
EIA is best prevented how?
regular treatment with ICS
41
Mechanism of asthma in cold air and hyperventilation
increased osmolality triggering mast cell release
42
Food additive that may trigger asthma through the release of sulfur dioxide gas in the stomach
metabisulfite
43
How many months should a person be removed from he work exposure before complete recover in occupational asthma
within the first 6 months
44
Mechanism of premestrual worsening of asthma
fall in progesterone
45
Mechanism of stress induced asthmas
bronchoconstriction through cholinergic reflex
46
Degree of inflammation is poorly related to disease severity
true
47
Characteristic finding in Remodeling
thickening of the basement membrane due to subepithelial collagen deposition
48
Pathology of asthma is remarkably uniform in different phenotypes of asthma
true
49
Physiologic abnormality of asthma
airway hyperresponsiveness
50
Indistinguishable pattern of inflammation seen in intrinsic asthma
Neutrophilic pattern
51
Characteristic feature of asthmatic airways
Eosinophilic infiltration
52
Interleukin associated with eosinophilic inflammation
IL-5
53
Interleukin associated with increased IgE formation
Il-4 and 13
54
Major sources of mediators that drives chronic inflammation in asthmatic airways
Structural cells-- epithelial cells, fibroblasts, airway smooth muscle cells
55
Th2 cytokines that mediate allergic inflammation
IL-4
IL-5
IL-9
IL-13
56
Th2 cytokines that amplify the inflammatory response and play a role n a more severe disease
TNF-a
| IL-1B
57
Anti-inflammatory cytokines that are deficient in asthma
IL-10
| IL-12
58
Oxidative stress in asthma is provided by the increased concentration of which product ?
8-isoprostane
59
Increased oxidative stress is related to disease severity, it may amplify the inflam- matory response, and may reduce responsiveness to corticosteroids.
true
60
Diagnostic test used in the diagnosis and monitoring of asthmatic inflammation
Fractional excretion of NO
61
How does Epithelial damage contribute to AHR?
1. loss of its barrier function
2. loss of enzymes inflammatory mediators
3. loss of a relaxant factor
4. exposure of sensory nerves
62
Subepthelial fibrosis n th basement membrane is associated with deposition of which collagen types
III and V
63
Which interleukin is associated with with increased number of goblet cells contributing to mucus hypersecretion
IL-13
64
Characteristic structural changes in asthma
1. increased airway smooth muscle
2. fibrosis
3. angiogenesis
4. mucus hyperplasia
65
Direct bronchoconstrictors
histamine
| methacholine
66
Most triggers for asthma symptoms appear to act INDIRECTLY
True
includes allergens, exercise,, hyperventilation, fog, irritant dusts, sulfur dioxide
67
Prodromal symptoms of an asthma attack
1. itching under the chin
2. discomfort between the scapulae
3. inexplicable fear (impending doom)
68
Airflow limitation in simple spirometry shows what findngs
reduced FEV1
reduced FEV1/FVC ratio
reduced peak expiratory flow
69
How is reversibility demonstrated in asthma
>12% AND 200-mL increase in FEV1 15 min after an inhaled SABA (albuterol 400 μg) or after a 2–4 week trial of OCS (prednisone or prednisolone 30–40 mg daily)
70
What does the Flow volume loops show
reduced peak flow
| reduced maximum expiratory flow
71
Whole body plethysmography show which findings (although rarely necessary)
increased airway resistance
increased total lung capacity
increased residual volume
72
increased AHR is normally mea- sured by methacholine or histamine challenge with calculation of the provocative concentration that reduces FEV1 by how much?
20%
73
FEV1/FVC ratio diagnostic of asthma and copd
<70%
74
Typical appearance of the flow volume loop indicating a widespread airflow obstruction
scalloped appearance
75
CXR in asthma
normal
| but may show hyperinflated lungs in more severe patients
76
noninvasive test to measure eosinophilic airway inflammation and may be useful in demonstrating compliance with ICS therapy
FeNO
77
How many percent of COPD patients have features of asthma ?
15%
78
Bronchodilator therapies in asthma
B2 agonists
Anticholinergics
Theophylline
79
Aims of asthma therapy
* Minimal chronic symptoms, including nocturnal
* Minimal exacerbations
* No emergency visits
* Minimal use of a required β2-agonist
* No limitations on activities, including exercise
* Peak expiratory flow circadian variation <20%
* (Near) normal PEF
* Minimal adverse effects
80
Mode of action of B2 agonists
1. relax airway smooth muscles
2. inhibition of mast cell release
3. reduction in plasma exudation
4. inhibition of sensory nerve activation
81
Duration of action of LABA (salmeterol and formoterol)
12 h
82
LABA given on a once a day dosing
Indacaterol
Olodaterol
Vilanterol
83
How is bronchodilator tolerance by mast cells reduced?
concomitant administration of ICS
84
muscarinic receptor antagonists are less effective than B2 agonists
True
they inhibit only the cholinergic reflex component of bronchoconstriction, whereas β2-agonists prevent all bronchoconstrictor mechanisms
85
Side effects of antimuscarinics
dry mouth
urinary retention
glaucoma
86
Bronchodilator which acts by inhibiting the phosphodiesterase in airway smooth muscles
Theophylline
87
anti-inflammatory effect of theophylline is mediated through which mechanism?
activation of HDAC2
88
Theophylline level associated with an additional bronchodilator effect in severe asthma
10-20 mg/L
89
Theophylline level associated with additive effects to ICS in severe asthma
5-10 mg/L
90
Side effects of theophylline are rarely observed at plasma concentrations of what?
<10 mg/L
91
Most effective anti-inflammatory agent in asthma therapy
ICS
reduces inflammatory cell numbers, eosinophils, activated T lymphocytes, surface mast cells
92
Increases/Decreases clearance of theophylline
Rifampicin
Increase
93
Increases/Decreases clearance of theophylline
Phenobarbitone
increase
94
Increases/Decreases clearance of theophylline
Ethanol
Increase
95
Increases/Decreases clearance of theophylline
Smoking
Increase
96
Increases/Decreases clearance of theophylline
High protein, low carbohydrate diet
increase
97
Increases/Decreases clearance of theophylline
Barbecued meat
increase
98
Increases/Decreases clearance of theophylline
Childhood
increase
99
Decreases clearance of theophylline
```
cimetidine
erythromycin
ciprofloxacin
allopurinol,
zafirlukast
Congestive heart failure
Liver disease
Pneumonia
Viral infection and vaccination
High carbohydrate diet
Old age
```
100
Side effects of ICS
hoarseness and oral candidiasis
101
How many percent of asthma patients may require maintenance treatment with OCS
1%
102
asthma therapy that blocks activation of cys-LT1-receptors which causes microvascular leakage and increase eosinophilic inflammation
Antileukotrienes
103
Asthma therapy that inhibits mast cell and sensory nerve activation therefore effective in blocking trigger induced asthma such as EIA and allergen/sulfure dioxide induced symptoms
Cromones
104
Methotrexate, cyclosporin A, azathioprine, gold, and IV gamma globulin have all been used as steroid-sparing therapies, but none of these treatments has any long-term benefit
True
105
blocking antibody that neutralizes cir- culating IgE without binding to cell-bound IgE and, thus, inhibits IgE-mediated reactions
omalizumab
SQ every 2-4 weeks
106
Drugs that block IL-5
mepolizumab
| reslizumab
107
Drug that blocks the IL-5 receptor
Benralizumab
108
Nonpharmacologic treatments, including hypnosis, acupuncture, chiropraxis, breathing control, yoga, and speleotherapy lacks efficacy
true
109
bronchoscopic treatment using thermal energy to ablate airway smooth muscle which reduce exacerbations and improve asthma control in patients not controlled on maximal inhaler therapy
Bronchial thermoplasty
110
drug that blocks against the common receptor for IL-4 and IL-13 (IL-4Ra) showing promise in reducing exacerbations and improving asthma control
Dupilumab
111
Partly controlled asthma
```
daytime symptoms >2x/wk
any limitation of activities
any nocturnal sx/awakening
need for reliever >2x/wk
FEV1 <80% predicted
```
112
How many features are needed for uncontrolled asthma
3 or more
113
in acute severe asthma, what is the goal oxygen saturation?
>90%
114
treatment of acute severe asthma
```
high doses SABA neb/MDI
IV B2 agonists
Anticholinergics neb/IV
MgSO4 IV/neb
Prophylactic intubation
Antibiotics NOT routine unless there are signs of pneumonia
```
115
How many percent of patients are refractory to treatment despite animal inhaled therapy
5%
116
most common reason for poor asthma control
poor adherence with ICS
117
Corticosteroid resistant asthma is defined as?
failure to respond to a high dose of oral prednisone/ prednisolone (40 mg once daily over 2 weeks)
118
Asthma showing a persistent pattern of variability and may require OCS or, at times, continuous infusion of β2-agonists
type 1 brittle asthma
119
asthma showing a generally normal or near-normal lung function but precipitous, unpredictable falls in lung function that may result in death
type 2 brittle asthma
120
Treatment of choice for type 2 brittle asthma
epinephrine SQ
121
Phenotype of asthma prided by perennial rhinitis and nasal polyps in non atopic patients with a late onset of the disease
Aspirin-sensitive asthma
122
In aspirin-sensitive asthma, All nonselective COX inhibitors should be avoided, but selective COX2 inhibitors are safe
true
123
Patterns of asthma during pregnancy
1/3 improve
1/3 deteriorate
1/3 unchanged
124
Drugs allowed during pregnancy
ICS
SABA
Theophylline
125
In asthma in pregnancy, prednisone is preferred over prednisolone
true
126
how many percent of asthmatics smoke?
20%
127
Which can affect the response to antileukotrienes?
Repeats of an Sp1 recognition sequence in the promoter region if 5-Lipoxygenase
128
Which bacteria have been implicated in the mechanism of severe asthma development?
Mycoplasma and Chlamydophila
129
How many percent of young adults are affected by occupational asthma
10%
130
Acetaminophen consumption in childhood increases risk of developing asthma through which mechanism?
Increased oxidative stress
131
Which cytokine released from epithelial cells in asthmatic patients instructs dendritic cells to release chemokines that attract Th2 cells into the airways ?
Thymic stromal lymphopoietin
132
Which chemokine is selectively attractant to eosinophils vis CCR3
Eotaxin
133
Which chemokines attract Th2 cells via CCR4
CCL17 (TAR )
| CCL22(MDC)
134
How is the diurnal variation in air flow obstruction confirmed?
PEF twice daily
135
Increased AHR is measured by methacholine or histamine challenge with calculation of the provocative concentration that reduces FEV1 by how much?
20%
136
What test is done to demonstrate post exercise bronchoconstriction if there is a predominant history of EIA?
Exercise testing
137
Upper airway obstruction is a differential diagnosis of BA that is confirmed how?
Flow volume loop showing reduction in inspiratory and expiratory flow.
138
Theophylline at high concentrations cause cardiac arrhyrhmias, epileptic seizures, death through which mechanism
Adenosine A1-receptor antagonism
139
How is hoarseness and oral candidiasis reduced in patients using ICS
Use of a large volume spacer device
140
Intranuscular triamcinolone acetonide is a depot preparation used in NON COMPLIANT patients but what is the major problem with this therapy?
Proximal myopathy
141
Incidence of steroid resistant asthma
<1 in 1000 patients
142
4 mechanisms of corticosteroid resistant asthma
- increase in GR-B
- Abnormal pattern of histone acetylation
- defect in Il-10 production
- reduction in HDAC2 activity
143
Proportion of asthmatics who become worse with aspirin and other COX inhibitors
1-5%
144
Which set of patients require a boost of OCS prior to surgery?
patients with FEV1 <80%
