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Inhalers AsthmaAnatomy &Physiology

CancerAll that wheezes is not..

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The technique for breathing in this type of inhaler is very rapid.

Topic I 100 Question

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Topic I 100 AnswerGo To Single

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What is a dry powder inhaler (DPI)?

Mean inspiratory flow rate:Foradil aerolizer >60L/min

Spiriva Handihaler >60L/min

Pulmicort flexhaler >30 L/min

Advair diskus >30L/min

Every patient with asthma should have this type of inhaler.

Topic I 200 Question

What is a quick-relief short-acting beta2-agonist rescue inhaler?

SABAalbuterol (Proair, Ventolin, Proventil)or lev-albuterol (Xopenex)

Topic I 200 AnswerGo To Single

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These 2 inhaled corticosteroids have the smallest particle size and may

result in better efficacy and less side effects.

Topic I 300 Question

What are Qvar and Alvesco?

Topic I 300 AnswerGo To Single

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Beclomethasone (Qvar) and Ciclesonide (Alvesco)Small-particle ICS: 1.1 micron• Reaches small airways (lung deposition 58%)• Improved safety profile; less drug in oropharynx.

Low incidence of candida (<1%)

This combination inhaler for COPD containing a short-acting beta2-agonist

(SABA) and short-acting muscarinic antagonist (SAMA) was reformulated with

a new delivery system.

Topic I 400 Question

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Albuterol + ipratropium: 1 inhalation qid

Topic I 400 AnswerGo To Single

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What is Combivent Respimat?

This combination inhaler is approved for COPD but not asthma

and does not contain an inhaled corticosteroid.

Topic I 500 Question

Topic I 500 AnswerGo To Single

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Combines LAMA Anticholinergic (umeclidinium) + LABA (vilanterol)

What is Anoro Elipta?

Dose: 1 puff daily

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This controller class of drug is the preferred therapy for treating

persistent asthma.

Topic II 100 Question

What are inhaled corticosteroids (ICS)?

Topic II 100 AnswerGo To Single

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This oral medication for asthma is also FDA approved for treating allergic rhinitis and would very helpful in aspirin-induced

asthma.

Topic II 200 Question

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What is Singulair (montelukast)?

Topic II 200 AnswerGo To Single

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Leukotriene receptor antagonist.• Granules (4 mg)• Chew tab (4 mg)• Tabs (5 or 10 mg)Once daily

This complication of acute asthma presents as neck or throat pain with

dyspnea.

Topic II 300 Question

What is a pneumomediastinum?

Topic II 300 AnswerGo To Single

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Characteristic of high-risk asthmatic:•Previous life-threatening attack•Delay in seeking care•Pulsus paradoxus•PEF <100 L/s•Poor response to beta agonist•Diminishing consciousness•PaCO2 normal or rising

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This complication of severe asthma presents as hypoxemia and decreased

breath sounds occurring after mechanical ventilation.

Topic II 400 Question

What is pneumothorax?

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4% of hospitalized asthmatics: mechanical ventilation.

Before 1990; 38% mortality in intubated asthmatics.

Tx: general anesthesia, heliox, ECMO, asthma meds, chest tube

This monoclonal antibody is administered by injection for

treatment of moderate to severe allergic asthma (and now FDA approved for chronic hives).

Topic II 500 Question

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What is Omalizumab (Xolair) anti-IgE antibody?

Topic II 500 AnswerGo To Single

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asthma symptom and attackssteroid use (po and ICS)urgent visits, ED, hospitalization

No increase in FEV1 or improvement in BHRallergy sx; improve QOL

This organ of respiration has 3 lobes on the right and 2 lobes on the left.

Topic III 100 Question

What are the lungs?

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Surface area= >1000 sq ft.Half of tennis court

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This lung disorder is defined by chronic inflammation,

bronchoconstriction and bronchial hyper-reactivity.

Topic III 200 Question

What is Asthma ?

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COPD is made up of these 2 forms of lung disease.

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What is chronic bronchitis andemphysema?

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This microscopic part of the airway can be permanently thickened from uncontrolled airway inflammation

due to asthma.

Topic III 400 Question

What is the basement membrane or airway smooth muscle?

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These diagnoses (obesity, scoliosis, IPF, hypersensitivity pneumonitis, ALS, muscular dystrophy) can show this type of general abnormality on lung function

testing.

Topic III 500 Question

What is Restrictive Lung Disease ?

Topic III 500 AnswerGo To Single

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This single round or oval “spot” in the lungs measuring <3 cm as seen on chest x-ray or CT scan may be

from many different causes.

Topic IV 100 Question

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What is a solitary pulmonary nodule?

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Causes of solitary pulmonary nodules:

>50%: benign lung tumors or granulomas from previous infections (TB, Aspergillus, Coccidiomycosis, Histoplasmosis, cryptococcosis).

<50%: cancer

Topic IV 200 Question

This is the most common group of lung cancer representing 85% of all lung

cancers.

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What is non-small cell lung cancer?

Types

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10-15% of lung cancers are of this type, spread quickly and occur

almost always in smokers

Topic IV 300 Question

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What is small cell or oat cell cancer?

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Risk Factors: smoking and radon

Smoking: >80% smoked

Survival rates:

• Stage I: 31%

• Stage II: 19%

• Stage III: 8%

• Stage IV: 2%

This rare lung tumor (also seen in the GI tract) grows slowly and

releases active hormones leading to flushing, diarrhea and difficulty

breathing.

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What are Lung Carcinoid Tumors?

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AKA: lung neuroendocrine tumorsAge >60 years oldSlow growingSx: bloody cough, wheezing, SOB, chest painCarcinoid Syndrome: Flushing, diarrheaDiagnosis: 5-HIAA, Chromogranin-A

Lung tumors that occur in individuals <40 yrs old, who are nonsmokers and the nodule is small and has

calcium in it are likely to have this type of tumor.

Topic IV 500 Question

What is a Benign Lung Tumor ?

Topic IV 500 AnswerGo To Single

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Risk factors for lung cancer.• Smoking, radon, asbestos exposure• Arsenic, chromium, nickel exposure• Older age• Large size• Non-calcified• Family history of lung cancer

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This genetic lung disease is due to a mutation in delta F508 gene that codes to

transmembrane conductance regulator gene on chromosome 7 (CFTR gene)

Topic V 100 Question

What is Cystic Fibrosis?

Topic V 100 AnswerGo To Single

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• Chronic/recurrent cough

• Prolonged bronchiolitis

• Recurrent wheezing

• Recurrent pneumonia

• Atypical asthma

• Pneumothorax

• Hemoptysis

• Clubbing

• DOE, chest pain

• Other:

– Recurrent sinusitis

– Nasal polyps

– Chronic diarrhea

– FTT

– Meconium ilius

Presentation: by 6-8 months

This rare lung disorder presents as dyspnea with emphysema in <50 year

olds who don’t smoke.

Topic V 200 Question

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What is α1-antitrypsin deficiency?

Topic V 200 AnswerGo To Single

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Emphysema in 20-50 y/o nonsmokers1:1500 to 1:3500; Mutations in the SERPINA1 geneFHx: emphysema and/or liver diseaseHigh prevalence of asthma in ZZ AAT deficient ptsInhibits proteolytic enzyme elastaseDx: serum AAT level <50-80 mg/dLPFT: FEV1 43%; Bronchiectasis: 2-43%Tx: Lifelong weekly IV infusions pooled human AAT

A teenage over-achiever with difficulty breathing on inspiration, this spirometry

and poor response to albuterol may have this condition.

Topic V 300 Question

What is vocal cord dysfunction?

Topic V 300 AnswerGo To Single

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May coexist with asthma! Poor response to asthma medicationsHigh achievers, women, +/- GERDifficulty on “inspiration”Spiro: truncated inspiratory loopLaryngoscopyTx: facilitated breathing exercises

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An asthmatic who presents with worsening asthma, fever, “pneumonia”

brown sputum and eosinophilia may have this.

Topic V 400 Question

What is ABPA (Allergic Bronchopulmonary Aspergillosis)?

Topic V 400 AnswerGo To Single

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In asthma (1-2%) and CF (1-15%)

History of asthma Skin test positive to Aspergillus Precipitating serum antibodies to Aspergillus Serum IgE>1000 ng/mL Blood eosinophilia >500/mm3

Lung infiltrates or bronchiectasis on CXR or HRCT Elevated Aspergillus serum IgE and IgG

A 12 yr old boy had a cold with cough. The nasal symptoms resolved, but the

cough continues every day, but never at night. No treatment has helped. He may

have this.

Topic V 500 Question

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What is habit cough or factitious cough?

Topic V 500 AnswerGo To Single

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Difficult to diagnoseNo response to appropriate therapySeal bark, coughing fits, harsh “annoying” coughMany pts have medical knowledgeSymptoms do not occur during sleepIf distracted, sxs can resolve temporarilyPsychiatric disease can be severe

This is the official state flower of Montana.

Topic VI 100 Question

What is the bitterroot?

Topic VI 100 AnswerGo To Single

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• Seldom eaten raw, for its bitter taste and resultant swelling caused great discomfort!

• American natives boiled the root, then mixed it with meat or berries.

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At this resort there are 2 oversized swimming pools and 2 soaking pools. They are fed by a virtually unlimited supply of 155o natural hot springs

water, cooled to various temperatures.

Topic VI 200 Question

What is Fairmont Hot Springs Resort?

Topic VI 200 AnswerGo To Single

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This road in Glacier National Park is considered one of the most scenic

drives in America.

Topic VI 300 Question

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What is the Going to the Sun Road?

Topic VI 300 AnswerGo To Single

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What is the only North American gem to be included in the Crown Jewels of

England?

Topic VI 400 Question

What is the Montana Yogo Sapphire?

Topic VI 400 AnswerGo To Single

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Also known as Ursus Arctos Horribilis, this is the official animal of

the state of Montana.

Topic VI 500 Question

What is the Grizzly Bear ?

Topic VI 500 AnswerGo To Single

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LungInfections

ZZZZs Medicine

CoughMore

Asthma Lung

Immunology

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This common winter virus causes bronchiolitis in infants and may be a risk

factor for developing asthma.

Topic VII 200 Question

What is RSV (respiratory syncytial virus)?

Topic VII 200 AnswerGo To Double

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• Most infected by age 2 years

• Bronchiolitis

• Pneumonia

• Apnea

In 2014, the U.S. experienced an outbreak of this virus that was responsible for

triggering severe asthma and paralysis in children.

Topic VII 400 Question

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Topic VII 400 AnswerGo To Double

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What is a Enterovirus D68?

• Most common in summer and fall• One of more than 100 non-polio enteroviruses• 10 cases in Montana

Lung infection with pneumatoceles by this bacteria is common in patients with Job’s

Syndrome (Hyper-IgE Syndrome).

Topic VII 600 Question

What is Staphylococcus?

Topic VII 600 AnswerGo To Double

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Hyper-IgE Syndrome: primary immune deficiencyMutations in transcription factor STAT3Staph abscesses: lung and skin Severe eczema in newbornsTypical facial appearanceJoint hyper-extensibilityRetained primary teethRecurrent bone fractures from minimal traumaVery high IgE levels >100x normal and eosinophilia

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Infection with this organism is responsible for “Walking

Pneumonia” and exacerbating asthma.

Topic VII 800 Question

What is Mycoplasma pneumonia?

Topic VII 800 AnswerGo To Double

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• Community-Acquired Pneumonia (CAP): most common cause in young adults and milder than bacterial infections.

• Precede the development of asthma• Acute asthma attack: 3.3 to 50% of attacks (PCR)• Chronic asthma: 45% of adults + PCR

After weeks of recurrent soaks in a hot tub, a person develops “interstitial pneumonia” with this organism.

Topic VII 1000 Question

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What is Mycobacterium Avium Complex?

Topic VII 1000 AnswerGo To Double

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“Hot Tub Lung” Hypersensitivity PneumonitisCXR: interstitial patternPFT: obstruction or restriction with low DLCOFlu-like symptoms with cough/dyspneaBronch: lymphocytesBx: granulomasTx: avoidance and oral steroids

Topic VIII 200 Question

Major symptoms of this disorder are loud snoring, daytime sleepiness, pauses in breathing while asleep, and episodes of waking at night feeling short of breath or

gasping for air.

Topic VIII 200 AnswerGo To Double

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What is sleep apnea?

Excessive and inappropriate daytime sleepinessLoud snoring virtually every nightApneas witnessed by bed partnerEpisodes of waking feeling short of breath or gasping for airInsomniaProblems with memory and/or concentrationImpotenceChanges in mood, particularly depressionFatigue

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This treatment of sleep apnea is designed to deliver a continuous level of air pressure to keep the

airway open.

Topic VIII 400 Question

Topic VIII 400 AnswerGo To Double

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What is CPAP (Continuous Positive Airway Pressure) ?

This scale is used to determine how sleepy a person is during the day.

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What is the Epworth Sleepiness Scale?

Topic VIII 600 AnswerGo To Double

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Situation Chance of Dozing or Sleeping

Sitting and reading ____

Watching TV ____

Sitting inactive in a public place ____

Being a passenger in a car for an hour or more ____

Lying down in the afternoon ____

Sitting and talking to someone ____

Sitting quietly after lunch (no alcohol) ____

Stopped for a few minutes in traffic while driving ____

Total score (This is your Epworth score) ____

0 = would never doze .1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

≥10: sleepy≥18: very sleepy

This “index” in a sleep study is key in diagnosing sleep apnea

when combined with pulse oximetry.

Topic VIII 800 Question

What is the Apnea Hypopnea Index (AHI)?

Topic VIII 800 AnswerGo To Double

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AHI: number of apneas or hypopneas recorded during the study per hour of sleep.

Based on AHI, severity of OSA is classified as:None/Minimal: < 5 per hourMild: 5 to < 15 per hourModerate: 15 to < 30 per hourSevere: ≥ 30 per hour

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This surgical procedure for sleep apnea removes the bell-shaped organ that hangs from the top of

the throat.

Topic VIII 1000 Question

What is a uvulectomy?

Topic VIII 1000 AnswerGo To Double

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This bacterial infection, if not promptly treated, is responsible

for the 100 day cough. The vaccine requires boosters.

Topic IX 200 Question

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What is Bordetella Pertussis?

Topic IX 200 AnswerGo To Double

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“Whooping cough” Whoop on inspiration.Teens and adults don’t whoop!Initial: cold-like symptoms 1-2 weeks.Cough: violent, rapidHighly contagiousTreatment (before cough starts): macrolideVaccine: DTaP

This disorder of the GI tract causing chronic cough can be

primary problem or be a comorbid condition with asthma.

Topic IX 400 Question

What is GE reflux?

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This cause of chronic cough is more common in young children, elderly,

intoxicated, and those with poor dentition.

Topic IX 600 Question

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What is aspiration or inhaled foreign body?

Presentation:CyanosisCough or wheezeIncompletely resolved pneumoniaLocalized bronchiectasis

This blood pressure medication is a frequent cause of chronic cough.

Topic IX 800 Question

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What is an ACE inhibitor?

Topic IX 800 AnswerGo To Double

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Angiotensin-converting enzyme (ACE) inhibitorsAffects 20% or more of pts who receive ACEiDry coughClass effect (may occur with all ACEi). Resolution of cough: within days to weeks. May be associated with URI symptoms.Higher risk: Women, ACE genotype II, black or Asian ethnicity

Topic IX 1000 Question

A patient presents with chronic nasal congestion, post nasal drip, halitosis and chronic cough. He

likely has this condition.

What is chronic sinusitis?

Topic IX 1000 AnswerGo To Double

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When the nose/sinuses produce extra mucus, it can drip down back of the throat triggering cough reflex. This is Upper Airway Cough Syndrome.

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This common perennial allergen mite lead to allergies and asthma

with symptoms worse upon awakening.

Topic X 200 Question

What is house dust mite?

Topic X 200 AnswerGo To Double

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Indoor asthma triggers:Allergens:

Dust mite, animal dander, feathers, cockroach, mold

Irritants: Smoke, cleaning chemicals, fragrance, fireplace

An adult with daytime asthma symptoms 3 days/week, nighttime

symptoms 2 x/week and FEV1 55% has this severity of asthma.

Topic X 400 Question

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What is severe persistent asthma?

Topic X 400 AnswerGo To Double

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This type of asthma results from a high dose exposure from a noxious

substance in a person without a history of asthma.

Topic X 600 Question

What is RADS (Reactive Airways Dysfunction Syndrome)?

Topic X 600 AnswerGo To Double

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Respiratory sxs: minutes or hours after a single accidental inhalation of a high concentration of irritant gas, aerosol, or smoke. Followed by asthma-like symptoms and persistent airway hyper-responsiveness.Example: World Trade Center 9/11.

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Deficiency of this vitamin is associated with decreased responsiveness to

inhaled steroids and difficult-to-control asthma.

Topic X 800 Question

What is Vitamin D?

Topic X 800 AnswerGo To Double

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In children and adults with asthmaLow Vitamin D levels have been associated with:

Abnormal lung function. Increase in asthma flare-ups. Lower response to treatment (inhaled steroids)

This new asthma treatment uses heat delivered through a

bronchoscope to treat refractory asthma.

Topic X 1000 Question

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What is Bronchial Thermoplasty?

Topic X 1000 AnswerGo To Double

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Outpatient procedure3 sessionsReduce asthma attacks by 32% for at least 5 years84% reduction in ER visits

Topic XI 200 Question

This white blood cell is the primary cell involved in allergic asthma.

Topic XI 200 AnswerGo To Double

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What are eosinophils?

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Topic XI 400 Question

This white blood cell (WBC) has been associated with severe asthma and asthma deaths.

What is a neutrophil?

Topic XI 400 AnswerGo To Double

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Neutrophils: • Most abundant (40% to 75%) type of

WBC• An essential part of innate immune

system.• Short-lived and highly mobile. • Controlled by TH17 cells

This antibody is involved in 50% of adults with asthma and most

children with asthma.

Topic XI 600 Question

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What is IgE (immunoglobulin E)?

Topic XI 600 AnswerGo To Double

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The lowest concentration of all immunoglobulinsBinds to allergens and triggers release of substances from mast cells and basophils causing inflammation.

This family of eicosanoid inflammatory mediators produced in leukocytes by the

oxidation of arachidonic acid by the enzyme arachidonate 5-lipoxygenase plays a role in asthma and allergies.

Topic XI 800 Question

What are Leukotrienes?

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Name leukotriene:Introduced in 1979Comes from words leukocyte and triene (indicating the compound's 3 conjugated double bonds).

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Biological targets for treating the immune response in asthma is directed at these 3 Interleukins.

Topic XI 1000 Question

What are IL-4, IL-5, IL-13??

Topic XI 1000 AnswerGo To Double

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• Interleukin 4 (IL-4): a cytokine that induces differentiation of naive helper T cells to TH2 cells

• Interleukin 5 (IL-5) stimulates B cell growth and is a key mediator in eosinophil activation.

• Interleukin 13 (IL-13): effects like IL-4

Topic XII 200 Question

This breathing test should be performed on all patients over 5 years old who need

an asthma evaluation.

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Topic XII 200 AnswerGo To Double

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What is spirometry?

Normal

This breath analysis test can measure airway inflammation

“directly.”

Topic XII 400 Question

What is FeNO (exhaled nitric oxide) ?

Topic XII 400 AnswerGo To Double

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This “light test” estimates the amount of oxygen in a person’s

blood and “normal” results can be found in carbon monoxide

poisoning.

Topic XII 600 Question

What is pulse oximetry?

Topic XII 600 AnswerGo To Double

Quizitor

Normal Oxygen saturation level 95-100%

Factors affecting pulse ox:

• Hypothermia/shivering

• Vasoconstriction

• Hypotension

• Smokers/CO poison: falsely normal

• Methemoglobinemia: falsely low

This test when positive is a classic hallmark of symptomatic

asthma

Topic XII 800 Question

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What is Methacholine challenge?

Topic XII 800 AnswerGo To Double

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Bronchoprovocation: Bronchial hyperresponsiveness

0.05 to 25 mg/ml, Measure FEV1 at 1, 3, 5,10 min

Positive test=PC20 Provocative concentration necessary to cause a 20% fall in FEV1

This measure of lung function on spirometry estimates the “small

airways” by calculating the velocity of flow.

Topic XII 1000 Question

What is the FEF25-75?

Topic XII 1000 AnswerGo To Double

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Forced expiratory flow rate between 25th and 75th%.

Normal >65-70% of predicted.

Lower in asthmatics

A more sensitive way to assess:

early detection, severity and progression of asthma.

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FINAL JEOPARDY

Montana

FINAL QUIZITOR

This woman was married to a Frenchman,Toussaint Charbonneau, a member of

the Lewis and Clark Expedition.

FINAL JEOPARDY:

Who is Sacajawea?

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Credits

Produced by Oregon Health Sciences UniversityDepartment of Internal Medicine

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Use of this software is free. Please maintain the credits so creditCan be given where it is due.

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