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Disease 2 > Cystic Fibrosis > Flashcards

Cystic Fibrosis Flashcards

1
Q

What is the name of the gene disorder that causes cystic fibrosis?

A

Cystic fibrosis transmembrane conductance regulator

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2
Q

What are the systems affected by CF?

A

Upper and lower respiratory tract
Pancreas
Gastrointestinal tract
Female/Male reproductive tract

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3
Q

What criteria must be met in order to diagnose cystic fibrosis?

A

Clinical symptoms consistent with CF in at least one organ system
Clinical evidence of CFTR dysfunction

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4
Q

Describe the ethnic distribution of CF

A

Most prevalent in caucasians by a wide margin
Least prevalent in asians
No fucking clue why
Being pasty as fuck may be a contributing factor

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5
Q

When are most cases of CF diagnosed?

A

Most are caught at birth via standard testing

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6
Q

Mutations on which chromosome are responsible for CF?

A

7

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7
Q

How many different mutations can cause CF?

A

According to steves slides, 2400. According to steves other slides, 24000. According to google, over 2000

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8
Q

CF is an autosomal recessive gene disorder. What is the significance of this

A

In order to be affected by the disease, both parents have to have the disease causing mutation, even if neither parent has the disease. Both parents can be carriers, but not be affected by the mutation since it is recessive

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9
Q

T/F: CF is a classical autosomal dominant gene disorder

A

False. CF is a classical autosomal recessive gene disorder

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10
Q

If one parent is a carrier, and one parent has CF, what are the chances that their children will be affected by the mutation?

A

50% chance of being affected
50% chance of being an unaffected carrier

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10
Q

If both parents are carriers, what are the chances that their offspring will be affected by the mutation?

A

25% unaffected
50% unaffected carrier
25% chance affected

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11
Q

If one parent is a non carrier, and one parent has CF, what are the chances their children will be affected by the mutation?

A

100% chance unaffected carrier

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12
Q

If one parent is a non-carrier, and one parent is an unaffected carrier, what are the chances that their children will be affected by the mutation

A

50% unaffected
50% unaffected carrier

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13
Q

What physiologic process does the CFTR gene regulate?

A

It regulates the conductance of chloride ions across the membrane

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14
Q

What effect does a mutation of the CFTR gene have?

A

It interferes with the production of the CFTR gene in a way that either completely halts the creation of the protein, completely or partially inhibits its ability to conduct ion transport, causes production of the protein to be significantly less than normal, or causes the protein to deteriorate at an advanced rate

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15
Q

What are the primary organs/areas that experience issues as a result of CFTR dysfunction?

A

Lining of of bronchial airways
Intestines
Pancreas
Liver ducts
Sweat glands

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16
Q

Describe the primary effect a mutation of the CFTR gene has on the respiratory tract

A

The mutation interferes with chloride transport in the bronchial airways. This in turn interferes with how fluid moves across the membrane from the mucus into the epithelium. As a result, there is a very low concentration of ions in the mucus resulting in fluid moving out of the mucus and into the epithelium creating a very tenacious mucus that is very difficult to clear

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17
Q

Describe how CF can affect infants before they are born

A

The mutation results in the infants meconium becoming dehydrated and sticky. This material is very difficult to pass and can create an ileus (blockage) in the intestines

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18
Q

What percentage of infants with CF are affected by meconium ileus?

A

About 20%

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19
Q

At birth, an infant with CF may have lungs that appear normal, however structural changes can develop quickly. What are examples of these structural changes?

A

Bronchial gland hypertrophy
Metaplasia of goblet cells

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19
Q

Infants with CF might exhibit what problems aside from meconium ileus?

A

Poor weight gain
Failure to thrive
Multiple respiratory infections per year
Consistent cough with sputum production
Pancreatic insufficiency

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20
Q

T/F: CF has obstructive and restrictive characteristics

A

True

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21
Q

CF results in mucus that is incredibly hard for individuals to clear. Besides airway restrictions, describe what other effects this incredibly thick mucous can have on patients

A

The mucus traps bacteria, however because patients are not able to clear this bacteria via normal means, the trapped bacteria becomes a food source for retained bacteria in the airway such as staph, haemophilus and pseudomonas

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22
Q

What are restrictive characteristics of CF?

A

Total obstruction of airways
Atelectasis
Bronchiectasis

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23
Q

What are obstructive characteristics of CF?

A

Partial obstruction of the airway
Overdistention of the alveoli

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24
Q

What are some bacteria that tend to be distinctively found in CF patients?

A

Stenotrophomonas maltophilia
Burkholderia cepacia complex

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25
Q

What are the results of respiratory infection in a patient with CF?

A

Increased mucus production (same as healthy individuals) but it remains thick, hard to clear, and continues to compromise mucociliary transport

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26
Q

What disease processes are common in patients with advanced CF?

A

Recurrent PNA
Chronic bronchitis
Bronchiectasis
Lung abscesses

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27
Q

Patient with CF often have digestive problems. Describe why they have these problems and what can happen as a result

A

Thick viscous mucous also accumulates in the passageways of the pancreas which prevents enzymes from being able to leave the pancreas and enter the intestines. This causes digestive issues (ie cant digest fat) and can lead to patients developing CF-associated diabetes mellitus

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28
Q

Describe the effects CF has on the pancreas and how that can affect individuals suffering from CF in relation to their nutrition

A

Loss of pancreatic enzymes inhibits digestion of fats and proteins
Inability to digest fats leads to deficiencies in fat soluble vitamins, ADEK
Diarrhea
Malnutrition
Failure to thrive

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29
Q

How does CF affect the bones?

A

Patients with CF have a significant decrease in bone density due to not being able to absorb vitamin D (fat soluble) which increased their risk of bone fractures and kyphoscoliosis

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30
Q

How can CF affect the upper airways and liver?

A

Upper airways = Sinusitis, nasal polyps
Liver = cirrhosis and neonatal jaundice

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30
Q

Describe how CF affects patients reproductive systems

A

In women, it results in accumulation of thick, viscous mucous at the cervix
In men, in results in azoospermia (no sperm) and a missing or underdeveloped vas deferens (sperm transport?)

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31
Q

How can CF affect the gallbladder and salivary glands?

A

Gallbladder = cholelithiasis
Salivary glands = altered electrolyte concentrations

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32
Q

What are the 2 assays used to test newborns for CF?

A

Serum immunoreactive trypsinogen (IRT)
DNA analysis for mutations in CFTR

33
Q

Describe immunoreactive trypsinogen testing

A

MOST infants with CF have elevated levels of immunoreactive trypsinogen
Its a blood test
Catches 90% of infants with CF

34
Q

If an infant tests positive for IRT, what test will likely follow?

A

DNA analysis to identify the specific gene mutation

35
Q

What is the gold standard for CF testing?

A

Sweat chloride testing
Reliably identifies CF in about 98% of cases

36
Q

Describe the sweat produced by CF patients

A

The sweat glands and amount of sweat produced will be normal, but the concentration of sodium and chloride will be more than 4x the normal amount

37
Q

Describe how the sweat chloride test is administered

A

Pilocarpine (sweat producing chemical) is placed on the skin and an electrode is attached to the chemically prepared area. A mild electric current is then applied to simulate sweat production
The test is normally applied twice

38
Q

In infants, what would a result of between 30-50 mmol/L mean?

A

CF possible, further testing required

39
Q

In infants, what would a result of less than or equal to 29 mmol/L mean?

A

Normal

40
Q

In infants, what would a result of greater than or equal to 60 mmol/L mean?

A

This level is sufficient to diagnose CF

41
Q

In infants >6 months, children and adults what would a result of less than or equal to 39 mmol/L mean?

A

CF unlikely

42
Q

In infants >6 months, children and adults what would a result of between 40-50 mmol/L mean?

A

CF possible

43
Q

In infants >6 months, children and adults what would a result of equal to or greater than 60 mmol/L mean?

A

Diagnosis of CF

44
Q

When testing for CF, what patient populations generally receive the sweat chloride test?

A

Infants with positive CF newborn screening adults
Infants with symptoms suggestive of CF ie meconium ileus
Adolescents and adults with symptoms suggestive of CF
Sibling with confirmed CF…why would they test again?

45
Q

How is the nasal potential difference performed?

A

A voltmeter is used to measure charge
Nasal passages bathed with different salts
Different salts should provoke predictable ion movement across the epithelial membrane
Abnormalities in this ion movement suggest a dysfunction of the CFTR

46
Q

What is the nasal potential difference test?

A

CF patients obviously suffer from impaired sodium and chloride transport. This results in changes in the electrical potential difference in the nasal passages

47
Q

What does the stool fecal fat test evaluate?

A

The stool fecal fat test evaluates the function of the liver, gallbladder pancreas and intestines
An elevated stool fecal fat value shows a defect in digestive functioning

47
Q

Who receives the nasal potential difference test?

A

Patients with clinical features of CF who have a borderline or normal sweat test values and nondiagnostic CF genotyping

48
Q

Why is the stool fecal fat test used?

A

Individuals with CF have trouble digesting fat and as a result their stools will carry more fat than the stools of normal people

49
Q

Besides fat content, how else can stool be used to support a CF diagnosis?

A

Individuals (or infants, according to the book) will have decreased amount of the fecal elastase 1 enzyme that gives information about pancreatic function
This is however, not CF specific

50
Q

What tests can be performed prenatally to determine whether or not a fetus may have CF?

A

Test amniotic fluid after first trimester
This can only test for at most 85 of the 2400 mutations that cause CF

51
Q

What happens to the FVC and FEV1 of patients with CF?

A

Decreased FVC and FEV1
Decreased FEV1/FVC ratio
Decreased flow measurements across the board

52
Q

Describe the lung volume and capacity findings of a patient with CF

A

Increased or Normal VT, TLC
Normal or decreased IRV, ERV, IC
Increased RV and FRC

53
Q

Describe the ABG of a patient with cystic fibrosis

A

Can present as acute respiratory alkalosis in mild to moderate stages of the disease
Can also present as compensated respiratory acidosis in the later severe stages

54
Q

‘Which oxygenation indices are significantly impacted by the CF disease process?

A

Delivery of oxygen is decreased significantly

55
Q

Describe the effect CF has on the hemodynamic indices

A

Inc CVP
Inc RAP
In PA
N PCWP
Inc PVR
N SVR

56
Q

What would a CBC of a CF patient look like?

A

Increased hematocrit
Increased white blood cell count

57
Q

Describe what serial CXRs would show as a patient with CF ages

A

Toddler - pneumonias
Adolescent - hyperinflation and bronchial wall thickening
Teenager - progressing hyperinflation, bronchiectasis and enlargement of the hila
Late 20s - marked hyperinflation and barrel chest, severe bronchiectasis and tubular opacities consistent with mucus plugs

57
Q

When would the application of bronchodilators be appropriate for individuals with CF?

A

When they have hyperreactive airways
Before treatment with medications such as hypertonic saline which cause irritation

57
Q

Airway clearance is incredibly important for individuals with CF. What is the main way airway clearance is accomplished?

A

The vest

58
Q

What are basic practices individuals with CF utilize in their every day lives to attempt to mitigate the risk of infection?

A

Physical distancing
Hand hygiene
Masking
Ceiling and disinfecting nebulizers
Not sharing personal items
Avoiding frequent contact with dust and dirt

59
Q

What does dornase alpha do?

A

CF sputum is different than normal sputum as it is exceptionally thick and viscous. Bacteria will get trapped in this viscous sputum and neutrophils will move it to kill the bacteria, but die in the process as well leaving long strands of DNA which increase the viscosity of the sputum. Dornase alpha breaks up these strands of DNA and makes the sputum easier to clear

59
Q

What is the main mucolytic drug utilized by individuals with CF?

A

Dornase alpha

59
Q

Besides dornase alpha, what can be used to decrease the viscosity of mucus in patient suffering from CF?

A

Hypertonic saline
Note, for some reason steve didnt tell us, you should only give hypertonic saline to patients greater than 6 years old

60
Q

Describe the differences in make-up between sputum found in a patient suffering from chronic bronchitis and a patient suffering from CF

A

The patient suffering from chronic bronchitis will have sputum that is primarily made up of mucin polymers which NAC can theoretically cleave. The patient suffering from CF will have sputum that is dominated by DNA polymers which will not be affected by NAC

60
Q

Why is NAC not recommended for patients with CF?

A

NAC can cleave disulfide bonds that make secretions difficult to clear in non-CF patients, however it is markedly less effective in patients with CF while still causing airway irritation, potentially starting bronchospasm and inhibiting ciliar function

60
Q

What concentrations are hypertonic saline administered in and how frequently?

A

3% and 7%
Administered BID

61
Q

You have a CF patient that needs dornase alpha, alburterol and hypertonic saline. What order should you administer these medications and why?

A

Albuterol-mitigate potential airway hyperreactivity
Hypertonic saline to hydrate mucus
Dornase alpha to thin the mucus out
Note-dornase alpha is deactivated if combined with hypertonic saline

61
Q

What are the primary antibiotics utilized by patients with CF to deal with respiratory tract infections?

A

Tobramycin (tobi)
Aztreonam (cayston)
Colistin/colistimethate sodium

62
Q

An altera nebulizer system is used for what kind of medication

A

cayston(aztreonam)

62
Q

aztreonam/cayston requires nebulization via what kind of nebulizer?

A

Altera nebulizer system

63
Q

Individuals with CF are very susceptible to infections and therefore take a lot of antibiotics. What are some problems that could potentially result from this?

A

May develop antibiotic resistant bacteria
May result in fungal infections of the mouth, oral pharnyx and tracheobronchial tree

64
Q

What common over the counter drug has been shown to impede the decline of the lung function in CF patients less than 18 years old?

A

Ibuprofen

65
Q

Ibuprofen is common anti-inflammatory drug shown to help patients suffering from CF under 18, what is another antiinflammatory drug that is also recommended for CF patients?

A

Azithromycin

66
Q

Should patients with CF be given inhaled corticosteroids for their condition?

A

Generally no. unless the patients have a history of airway reactivity or allergic bronchopulmonary aspergillosis

67
Q

What inhaled anti-inflamatory drugs are generally not recommended for CF patients?

A

Leukotriene modifiers
NAC
Inhaled glutathione

68
Q

Why are systemic glucocorticoids not recommend for children and adolescents with CF?

A

Growth retardation
Glucose metabolism
Development of CF-related diabetes
Cataract formation

69
Q

Lung transplants can be very beneficial to CF patients who have very severe versions of the disease. However, despite recieving lungs that do not have CF, the transplant process in of itself creates more problems for the individual. Elaborate on the challenges a lung transplant can bring with it

A

Transplants require the individual to constantly take immunosuppressive medications in order to not reject the new organ. however, this cripples their already fragile immune system and makes them very vulnerable to bacterial infections such as pseudomonas or burkholderia

70
Q

New medications are focused on correcting the function of the CFTR cells. Expound on the categories of these drugs and what they do

A

Correctors - help mutated CFTR reach epithelial surface
Potentiators - improve the function of CFTR protein that have reached the epithelial surface

71
Q

What does ivacaftor do?

A

Improve function of CFTR proteins that have reached epithelial surface
Potentiator

72
Q

What is orkambi?

A

Ivacaftor + lumacaftor
Promises to reduce the rate of exacerbations in qualified patients by 30-39%

73
Q

What are the drug components of trikafta?

A

Elexacaftor+tezacaftor+ivacaftor

74
Q

What are the drug components of symdeko?

A

Tezacaftor + ivacaftor

Disease 2 (16 decks)

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