Term
Asthma Mortality:
Know Risk Factors (there's 14 of them!) |
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Definition
1. Past hx of sudden, severe exacerbations
2. Prior intubation and ICU mgmt
3. 2 or more hospitalizations for asthma in the past year
4. 3 or more Ed visits for asthma in the past year
5. Hospitalization or ED visit in the past month
6. Use of 2 or more canisters of rescue inhaler per month
7. Current use of or recent withdrawal from oral steroid
8. Poor perception of dyspnea
9. Psych co-morbidity
10. Low SES
11. Inner city residence
12. African-American race or Hispanic-American ethnicity
13. Illicit drug use
14. Sensitization (IgE) to Alternaria |
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Term
Common allergens in inner-city homes
Which allergen is associated with asthma morbidity in inner city children? |
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Definition
cockroach (associated with asthma morbidity in persons who are both sensitized and exposed)
mouse
rat
cat
mold
dust mite |
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Term
Airway remodelling in asthma: is it related to progressive loss of lung fxn?
What is the significance of ADAM 33? |
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Definition
Yes
In addition to mucus in the bronchial lumen, alteration in airway epithelium and inflammation, there is airway smooth muscle hypertrophy and angiogenesis.
ADAM 33 is assoc with increased risk for asthma, airways hyperresponsiveness, severe asthma nd asthma disease progression. |
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Term
Know the types of agents used for bronchoprovocation challenge
and know the patterns for change in FEV1 |
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Definition
Types:
Non-Selective: direct (methacholine, histamine) and indirect (exercise, mannitol)
Selective: immunologic (allergen) and non-immunologic (aspirin) |
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Term
| Name clinical conditions/diseases in which one can see increased airways hyperresponsiveness without asthma |
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Definition
Allergic rhinitis
Normal subjects with family hx of asthma
Sibs of asthmatics
COPD
CF
Viral URI
Cigarette smokers |
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Term
FENO
1. What is the sens and spec of FENO > 29 ppb?
2. What is the PPV and NPV?
3. What is the effect of ICS on FENO? |
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Definition
1. 88% sens and 79% spec
2. 70% PPV and 92% NPV
3. ICS decreased FENO (so this is a potential way to assess for noncompliance with ICS) |
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Term
| Know the factors that increase or decrease FENO levels |
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Definition
Increase: Viral URI, Allergic Rhinitis, Nitrate-rich diet
Decrease: CF, smoking, pulm hypertension, alcohol consumption, spirometric maneuvers |
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Term
Know the ranges of normal FEV1:FVC ratio by age group
8-19y
20-39y
40-59y
60-80y |
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Definition
8-19y: 85%
20-39y: 80%
40-59y: 75%
60-80y: 70% |
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Term
| Name the 3 validated tools used to assess asthma control? |
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Definition
1. Asthma Control Questionnaire (ACQ)
2. Asthma Control Test (ACT)
3. Asthma Therapy Assessment Questionnaire (ATAQ) |
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Term
Patients on a controlled med are classified as having "not well controlled" asthma for all but of the following except...?
Albuterol use > 2 days/wk
Asthma sx > 2 days/wk
Nighttime awakenings 1-3x/wk
Limitation of normal activity
FEV1 btwn 60-80% predicted
ACT score > 20 |
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Definition
| All are true except for the last one. ACT score < 20 indicates poor control. |
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Term
| Know the preferred and alternative step therapies from the NAEPP guidelines for patients aged 12 or older |
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Definition
Step 1 preferred: SABA prn
Step 2 preferred: low dose ICS. Alternative: cromolyn, nedocromil, LTRA or theophylline
Step 3 preferred: medium dose ICS or low dose ICS + LABA.
Alternative: low-dose ICS and either LTRA, theo or Zileuton
Step 4 preferred: medium dose ICS + LABA.
Alternative: medium dose ICS + LTRA, theo or Zileuton
Step 5 preferred: high dose ICS + LABA and consider omalizumab for pts with allergies
Step 6 preferred: high dose ICS + LABA + oral steroid and consider omalizumab for pts with allergies |
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Term
| Know the NAEPP stepwise mgmt strategies for children aged 5-11 years |
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Definition
Step 1 preferred: SABA prn
Step 2 preferred: low dose ICS.
Alternative: LTRA, cromolyn, nedocromil or theophylline
Step 3 preferred: medium dose ICS or low dose ICS + LABA, LTRA or theo
Step 4 preferred: medicum dose ICS + LABA
Alternative: medium dose ICS + LTRA or theo
Step 5 preferred: High dose ICS + LABA.
Alternative: high dose ICS + LTRA or theo AND consider omalizumab
Step 6 preferred: high dose ICS + LABA + oral steroid.
Alternative high dose ICS + LTRA or theo AND oral steroid AND consider omalizumab |
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Term
| Know the NAEPP stepwise approach to mgmt for children aged 0-4 years |
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Definition
Step 1 preferred: SABA prn
Step 2 preferred: low dose ICS
Alternative montelukast or cromolyn
Step 3 preferred: medium dose ICS
Step 4 preferred: medium dose ICS + montelukast or LABA
Step 5 preferred: high dose ICS + montelukast or LABA
Step 6 preferred: high dose ICS + montelukast or LABA AND oral steroid |
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Term
| What is the effect of ICS on asthma exacerbations? |
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Definition
| ICS reduce risk for asthma exacerbations. Meta-analysis in JAMA 2004 found RR 0.46, 95%CI 0.34-0.62 |
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Term
What lessons were learned from SMART study re: LABAs?
Does regular use of LABA in those with Arg/Arg at codon 16 of ADRB2 result in worsening lung function? |
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Definition
1. Avoid LABA as monotherapy
2. Do not use LABA as "reliever"
No, Regular use of albuterol has been shown to lead to worsening lung function in those with Arg/Arg. This has not been shown for regular LABA use. |
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Term
Know the mechanism of action for:
Zileuton
Zafirlukast
Montelukast |
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Definition
Zileuton: 5-LO inhibitor
Zafirlukast and Montelukast are LT receptor antagonists |
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Term
| Know which drugs increase/decrease theo levels |
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Definition
Increase: alcohol, cimetidine, ciprofloxacin, clarithromycin, erythromycin, oral contraceptives, verapamil, zileuton
Decrease: aminoglutethamide, carbamazepine, isoproterenol, phenobarbital, phenytoin, rifampin, sulfinpyrazone |
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Term
Which of the following are major criteria of ABPA?
Asthma
CXR infiltrates
Aspergillus in the sputum
History of expectorated brown plugs
Proximal bronchiectasis
Eosinophilia > 1000/mm3
Markedly elevated serum IgE
Delayed (Arthus) skin test reaction to Aspergillus antigen
Positive immediate skin test to Aspergillus
IgG precipitins to Astpergillus antigens |
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Definition
Major criteria:
asthma
CXR infiltrates
Proximal bronchiectasis
Eos > 1000/mm3
High serum IgE
Positive immediate skin test to Aspergillus
IgG precipitins against Aspergillus antigens |
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Term
| What is the relationship between serum IgE and FEV1 in ABPA? |
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Definition
| Inverse relationship. When IgE is high, FEV1 is low |
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Term
What is the rate/likelihood of cross-reactivity to the following analygesics in AERD?
Etodolac
Ibuprofen
Indomethacin
Naproxen
Piroxicam
Sulindac
Acetaminophen
Sodium or choline Salicylate
Celecoxib
Rofecoxib
Valdecoxib |
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Definition
| 100% for all but acetaminophen and sodium or Choline Salicylate, which are rarely cross-reactive, and the COX-2 inhibitors (celecoxib, rofecoxib, valdecoxib) which have not been found to be cross-reactive. |
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Term
Asthma and Pregnancy
1. What is the effect on minute ventilation? What is the mechanism?
2. What is the effect on tidal volume, residual volume and FRC? |
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Definition
1. Minute ventilation increases. Causes a compensated resp alkalosis. Caused by increased circulating progesterone.
2. TV increases, RV decreases, FRC decreases |
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Term
Asthma and Pregnancy
1. What is the effect of pregnancy on asthma?
2. Who is most likely to have worsening?
3. How long do the effects of pregnancy last post-partum?
4. When are exacerbations most likely to occur and what are the triggers? |
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Definition
1. 35% worsen, 33% stay same, 28% improve
2. Those with severe asthma are most likely to worsen
3. 3 months
4. Exacerbations are most likely btwn weeks 24-36. Most common triggers: respiratory infxn or UTI (69%), non-adherence to ICS (29%) |
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Term
| What are the pregnancy categories of risk? |
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Definition
A: controlled studies show no risk
B: No evidence of risk in humans
C. Risk cannot be ruled out
D. Positive evidence of risk
X: Contraindicated in pregnancy |
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Term
What is the FDA pregnancy category for each of the following?
Inhaled SABA
Inhaled LABA
Theophylline
Cromones
Leukotriene modifiers
ICS
Oral steroids
Anti-IgE |
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Definition
Inhaled SABA, Inhaled LABA, theo, ICS, oral steroids are C (except for budesonide which is B)
Cromones, Leukotriene modifiers, Anti-IgE are B (except for Zileuton which is C) |
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