Medicine Marrow Pg 241-250 (Pulmonology)
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Which of the following is NOT a known trigger for inflammation according to the content?

  • Obesity
  • Upper respiratory infection (URI)
  • Paint fumes
  • Exercise (correct)

    • The hygiene hypothesis suggests that less exposure to antigens in childhood leads to better immunity.

    False

    Name one type of granule found in eosinophils.

    1° Granules or 2° Granules

    In response to triggers, TH2 cells primarily produce _____ which increases IgE levels.

    <p>IL-4</p> Signup and view all the answers

    Match the following mediators with their roles:

    <p>Histamine = Vasodilation and increased permeability Tryptase = Tissue remodeling Leukotriene B4 = Eosinophil recruitment Prostaglandin ε1 = Inhibition of platelet aggregation</p> Signup and view all the answers

    Which of the following histopathology findings is NOT associated with bronchial asthma?

    <p>Alveolar collapse</p> Signup and view all the answers

    Which of the following conditions is NOT associated with upper-lobe interstitial lung disease (ILD)?

    <p>Chronic bronchitis</p> Signup and view all the answers

    Intrinsic asthma is commonly associated with a family history of atopic conditions.

    <p>False</p> Signup and view all the answers

    Pulmonary alveolar proteinosis (PAP) is most commonly acquired due to antibodies against GM-CSF.

    <p>True</p> Signup and view all the answers

    What is the primary mechanism leading to airway inflammation in bronchial asthma?

    <p>Chronic airway inflammation with eosinophils and mast cells</p> Signup and view all the answers

    What is the characteristic appearance of a chest X-ray in pulmonary alveolar proteinosis?

    <p>Batwing appearance</p> Signup and view all the answers

    _________ is a common organism associated with extrinsic (atopic) asthma.

    <p>Dermatophagoids (House dust mite)</p> Signup and view all the answers

    The clinical features of pulmonary alveolar proteinosis include chunky gelatinous sputum that is ______ positive.

    <p>PAS</p> Signup and view all the answers

    Match the type of asthma with its characteristic feature:

    <p>Extrinsic/Atopic = Positive skin tests Intrinsic = Triggers include respiratory infections</p> Signup and view all the answers

    Match the following conditions with their corresponding treatments:

    <p>Silicosis = No definitive treatment Pulmonary alveolar proteinosis = Whole lung lavage Sarcoidosis = Corticosteroids Hypersensitivity pneumonitis = Avoiding the trigger</p> Signup and view all the answers

    Which of the following is a characteristic feature of bronchial asthma?

    <p>Reversible bronchoconstriction</p> Signup and view all the answers

    Chronic airway inflammation in asthma leads to irreversible changes in airflow obstruction.

    <p>False</p> Signup and view all the answers

    What testing method is often used to determine bronchodilator reversibility in asthma?

    <p>FEV1 testing after administration of SABA</p> Signup and view all the answers

    Asthma symptoms are often worse at __________ and with __________ infections.

    <p>night; viral</p> Signup and view all the answers

    Match the asthma symptoms with their descriptions:

    <p>Shortness of breath = Difficulty in breathing Chronic cough = Persistent cough that may be worse at night Wheeze = High-pitched whistling sound during breathing Chest tightness = Feeling of constriction in the chest</p> Signup and view all the answers

    Which organism is most commonly associated with Loeffler Syndrome?

    <p><em>Ascaris lumbricoides</em></p> Signup and view all the answers

    Tropical Pulmonary Eosinophilia (TPE) does not respond to anti-filarial treatment.

    <p>False</p> Signup and view all the answers

    What is the mechanism of action for the organisms responsible for Tropical Pulmonary Eosinophilia?

    <p>Hypersensitivity to microfilarial larvae</p> Signup and view all the answers

    Eosinophilic lung disease characterized by pleural eosinophilic effusion and lung cavitation nodules is associated with the organism _____ .

    <p><em>Paragonimus westermani</em></p> Signup and view all the answers

    Match the following features of Eosinophilic Lung Disease to their corresponding condition:

    <p>Loeffler Syndrome = Type I hypersensitivity to larvae Tropical Pulmonary Eosinophilia = Hypersensitivity to microfilarial larvae Lung Fluke Infection = Pleural eosinophilic effusion</p> Signup and view all the answers

    Which of the following is NOT a known cause of eosinophilic lung disease?

    <p>Pneumonia due to bacteria</p> Signup and view all the answers

    Peripheral blood eosinophil counts are always elevated in all types of eosinophilic lung disease.

    <p>False</p> Signup and view all the answers

    What is one defining feature of eosinophilic lung disease?

    <p>Increased eosinophils on Broncho Alveolar Lavage (BAL)</p> Signup and view all the answers

    Eosinophilic lung disease can be triggered by _________ and toxins.

    <p>drugs</p> Signup and view all the answers

    Match the conditions related to eosinophilic lung disease with their descriptions:

    <p>Loeffler syndrome = Parasite-related condition leading to lung involvement Acute eosinophilic pneumonia (AEP) = Acute inflammation of lung with eosinophils Chronic eosinophilic pneumonia (CEP) = Chronic inflammation with eosinophils Allergic granulomatosis with polyangiitis (AGPA) = Systemic vasculitis with eosinophilic infiltration</p> Signup and view all the answers

    What is the mainstay treatment for bronchial asthma?

    <p>Inhaled corticosteroids</p> Signup and view all the answers

    Short-acting β2-agonists play a critical role in the management of persistent asthma.

    <p>False</p> Signup and view all the answers

    Name one example of an inhaled corticosteroid used in asthma management.

    <p>Beclomethasone</p> Signup and view all the answers

    The Methacholine challenge test is used to assess __________.

    <p>airway hyperresponsiveness</p> Signup and view all the answers

    Match the following treatments with their functions:

    <p>Omalizumab = Anti-IgE Mepolizumab = Anti IL-5 receptor antagonist Tiotropium = Long-acting muscarinic antagonist Dupilumab = Anti IL-4 receptor antagonist</p> Signup and view all the answers

    What is the recommended nebulization dose of Albuterol for acute severe asthma?

    <p>2.5-5 mg every 20 minutes</p> Signup and view all the answers

    Hydrocortisone is administered at a dosage of 50 mg for acute severe asthma management.

    <p>False</p> Signup and view all the answers

    What is the first step in managing acute severe asthma in the emergency room?

    <p>Nasal O2 to maintain SpO2 &gt;95%</p> Signup and view all the answers

    During reassessment after 1 hour, you should evaluate _____ and O2 saturation.

    <p>PEFR</p> Signup and view all the answers

    Match the following treatments with their associated types of asthma:

    <p>Oral corticosteroids = Type 1 (Brittle Asthma) S/C adrenaline = Type 2 (Brittle Asthma) 500 mg Ipratropium = Acute Severe Asthma 100 mg Hydrocortisone = Acute Severe Asthma</p> Signup and view all the answers

    What is a characteristic of moderate asthma?

    <p>Symptoms occurring 2-6 days a week</p> Signup and view all the answers

    Severe asthma is described as having intermittent symptoms.

    <p>False</p> Signup and view all the answers

    What is the PEFR variability for mild asthma?

    <p>80% predicted</p> Signup and view all the answers

    In cases of impending respiratory failure, the patient often exhibits __________ breathing.

    <p>paradoxical</p> Signup and view all the answers

    Match the types of asthma with their characteristics:

    <p>Mild = 2-6 days/week symptoms Moderate = Daily symptoms Severe = Continuous symptoms Acute Exacerbation = Breathlessness at rest</p> Signup and view all the answers

    Which feature indicates acute severe exacerbation of asthma?

    <p>Tachycardia</p> Signup and view all the answers

    Accessory muscle use is present in impending respiratory failure but absent in acute severe exacerbations.

    <p>False</p> Signup and view all the answers

    What is a common characteristic of night-time symptoms in mild asthma?

    <blockquote> <p>2 monthly</p> </blockquote> Signup and view all the answers

    Which of the following findings is characteristic of Interstitial Lung Disease on HRCT scans?

    <p>Consolidation</p> Signup and view all the answers

    Mosaic attenuation (air trapping) is a specific feature associated only with hypersensitivity pneumonitis.

    <p>False</p> Signup and view all the answers

    Name two diseases associated with nodular shadows on HRCT scans.

    <p>UIP and NSIP</p> Signup and view all the answers

    The ________ appearance on HRCT may indicate endobronchial obstruction or infection.

    <p>tree-in-bud</p> Signup and view all the answers

    Match the following HRCT findings with their descriptions:

    <p>Reticular &amp; linear shadows = Pulmonary fibrosis indicators Consolidations = Dense areas indicating alveolar filling Cysts = Air-filled spaces in the lung parenchyma Honeycombing = End-stage lung disease characteristic</p> Signup and view all the answers

    Which condition is NOT commonly associated with nodular shadows?

    <p>Pulmonary Hypertension</p> Signup and view all the answers

    Traction bronchiectasis is a finding associated with advanced interstitial lung diseases.

    <p>True</p> Signup and view all the answers

    What is a non-specific feature observed on HRCT scans that can be associated with multiple lung diseases?

    <p>Nodular shadows</p> Signup and view all the answers

    Study Notes

    Active Space

    • Upper lobe interstitial lung disease (ILD) is associated with occupational lung disorders, like silicosis, berylliosis, and coal-worker's pneumoconiosis.
    • Sarcoidosis, ankylosing spondylitis, allergic bronchopulmonary aspergillosis (ABPA), hypersensitivity pneumonitis, tuberculosis, and Langerhans cell histiocytosis (LCH) also involve upper lobe ILD.

    Pulmonary Alveolar Proteinosis (PAP)

    • PAP is a rare lung disorder affecting primarily males between the ages of 30 and 50.
    • It involves the accumulation of surfactant in the alveoli, often due to antibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF).
    • A mutation in the gene for surfactant protein B (SP-B) can also contribute to PAP.
    • Chest X-rays may show a "batwing" appearance, a characteristic of PAP.
    • The condition can be confused with silicosis due to similarities in X-ray findings.
    • Treatment involves whole lung lavage to remove the excess surfactant.
    • Clinical features include thick, gelatinous mucus in the sputum, which stains positive with periodic acid-Schiff (PAS) reagent.
    • Reticular shadows in the lower lobes are a common finding in idiopathic pulmonary fibrosis (IPF) but are suggestive of a different condition in PAP.

    Etiopathogenesis

    • The underlying cause of asthma is unknown.
    • Several triggers can exacerbate asthma including upper respiratory infection, aspirin, beta blockers, sulfur dioxide, obesity, diet, 5q polymorphism, hyperventilation, and paint fumes.
    • The hygiene hypothesis posits that increased exposure to antigens in childhood strengthens the immune system by promoting the conversion of T helper 2 (TH2) cells to T helper 1 (TH1) cells.
    • TH2 cells secrete IL-4, which increases immunoglobulin E (IgE) production, IL-5, which recruits eosinophils via eotaxin, and IL-13.
    • Asthma involves two phases: an early phase response and a late phase, occurring 4-6 hours after the initial trigger.
    • The following mediators are involved in asthma: histamine, tryptase, prostaglandin D2 (PGD2) and basophils.
    • Eosinophils play a significant role in asthma.
    • Newly synthesized membrane-derived mediators from eosinophils include leukotriene B4, platelet-activating factor, 15-hydroxyeicosatetraenoic acid (15-HETE), prostaglandin E1 (PGE1), prostaglandin E alpha (PGE alpha) and thromboxane B (TXB).

    Histopathology

    • Bronchial asthma is characterized by chronic airway inflammation, involving the presence of eosinophils, mucus plugs, mast cells, Curschmann spirals, and Charcot-Leyden crystals.
    • Other histopathological features include bronchial smooth muscle hypertrophy, submucosal gland (goblet cell) hyperplasia, and patchy epithelial necrosis.

    Bronchial Asthma

    • Bronchial asthma is a chronic inflammatory condition with reversible bronchoconstriction, primarily affecting the airways without involving the lung parenchyma or leading to heart failure.
    • Asthma is a reversible airway disease.
    • After administering four puffs of a short-acting beta-agonist (SABA), the forced expiratory volume in one second (FEV1) should increase by at least 12% and 200 ml.
    • Global Initiative for Asthma (GINA) defines asthma as chronic airway inflammation with reversible bronchoconstriction, variable expiratory airflow obstruction, and symptoms related to bronchoconstriction, including shortness of breath, chronic cough, wheezing, and chest tightness.
    • Asthma symptoms vary in timing and intensity, typically worsening at night and with viral infections.
    • Common asthma triggers include exercise, laughter, allergens, and cold air.

    Management of Bronchial Asthma

    • Inhaled corticosteroids (ICS) are the mainstay of asthma treatment, reducing hospitalizations, exacerbations, and symptoms, improving lung function, and potentially enhancing future lung function if administered early on.
    • Examples of ICS drugs include beclomethasone, budesonide, and fluticasone.
    • Short-acting beta-agonists (SABA) have no role in persistent asthma.

    Protocol for Asthma Management

    • The treatment protocol for asthma involves the use of ICS-formoterol combination as needed.
    • If the asthma is not controlled with ICS-formoterol combination, the dosage is escalated to medium-dose ICS plus formoterol, and further escalated to high-dose ICS plus formoterol if needed.
    • Tiotropium, a long-acting muscarinic antagonist (LAMA), can be added if the asthma remains poorly controlled.
    • Biological therapy options include omalizumab (anti-IgE therapy), mepolizumab (anti-IL-5 receptor antagonist), and dupilumab (anti-IL-4 receptor antagonist).

    Investigations for Bronchial Asthma

    • A methacholine challenge test is used to assess airway hyperresponsiveness in asthma.
    • The radioallergosorbent test (RAST) measures IgE levels.
    • Fractional exhalation of nitric oxide is a non-invasive test that measures airway inflammation.
    • Some tests are considered "obsolete" in the text.

    Eosinophilic Lung Disease (ELD)

    • This document focuses on parasite-related causes of Eosinophilic Lung Disease (ELD), including symptoms, findings, and treatment.
    • ELD is characterized by an increased number of eosinophils in the airways and parenchyma of the lungs, although the role of eosinophils in its pathogenesis remains unclear.
    • While peripheral blood eosinophil counts can be elevated in some cases of ELD, they are not elevated in all types.
    • The diagnosis of ELD is based on:
      • Increased eosinophils on bronchoalveolar lavage (BAL)
      • Lung tissue eosinophilia
      • Peripheral blood eosinophilia along with abnormal findings on lung imaging.

    Known Causes of ELD

    • Parasite-related:
      • Loeffler syndrome: caused primarily by Ascaris lumbricoides but may also be caused by Ancylostoma, Necator, or Strongyloides.
      • Lung fluke: Caused by Paragonimus westermani, which matures into adult worm larvae in the lungs.
      • Tropical pulmonary eosinophilia: Caused by Wuchereria bancrofti or Brugia malayi, linked to hypersensitivity to microfilarial larvae.
    • Drug and toxin exposure
    • Allergic bronchopulmonary aspergillosis (ABPA): hypersensitivity reaction to Aspergillus fumigatus.
    • Hypersensitivity:
      • Acute eosinophilic pneumonia (AEP)
      • Chronic eosinophilic pneumonia (CEP)

    Unknown Causes of ELD

    • Allergic granulomatosis with polyangiitis (AGPA)/Eosinophilic GPA (EGPA)/Churg-Strauss syndrome: an autoimmune disorder affecting the blood vessels and respiratory system
    • Idiopathic hypereosinophilic syndrome: a disorder characterized by an abnormally high number of eosinophils in the blood.

    Other Conditions Associated with Eosinophilia

    • It is important to note that the following conditions involve eosinophilia but are not classified as ELD:

      • Bronchial asthma
      • Cytogenic organizing pneumonia
      • Langerhans cell histiocytosis
      • IgG4-related connective tissue disorder
      • Hypersensitivity pneumonitis

    • An eosinophil count on BAL greater than 40% is associated with:

        • Transient eosinophilic pneumonia (TEP)
        • CEP

    Management of Asthma Exacerbation in the Emergency Room

    • This section focuses on acute severe asthma and imminent respiratory failure.

    • The management protocol includes:

        • Nasal oxygen therapy to maintain oxygen saturation (SpO2) above 95%.
        • Administration of short-acting beta-agonists (albuterol) via nebulization or metered-dose inhaler (MDI).
        • Administration of a short-acting muscarinic antagonist (SAMA) like ipratropium.
        • Intravenous (IV) administration of hydrocortisone.
        • Intravenous (IV) magnesium sulfate.

    • After one hour, reassessment should include:

        • Peak expiratory flow rate (PEFR)
        • Oxygen saturation

    • If there is no improvement, further interventions include:

        • Non-invasive mechanical ventilation
        • Intubation and mechanical ventilation

    Brittle Asthma

    • Brittle asthma, also known as childhood asthma, can be characterized by two main patterns:

        • Type 1: Wide peak flow variation despite intensive medication.
        • Type 2: Well-controlled asthma with sudden severe exacerbations.

    • Treatment for brittle asthma varies depending on the specific type:

        • Type 1: Oral corticosteroids.
        • Type 2: Subcutaneous adrenaline.

    Asthma Assessment

    • This section categorizes asthma into mild, moderate, and severe based on symptom severity.
    • Mild asthma is associated with intermittent symptoms, moderate asthma with persistent symptoms, and severe asthma with frequent and persistent symptoms requiring daily medication.

    Symptoms and Nocturnal Awakenings

    • The severity of asthma is assessed based on:
      • Day symptoms: How often symptoms occur.
      • Nocturnal awakenings: How often the individual wakes up due to asthma symptoms during the night.
      • PEFR variability: The variation in peak expiratory flow rate (PEFR) measurements.
      • FEV1: Forced expiratory volume in one second (FEV1).

    Acute Severe Exacerbation of Asthma vs. Impending Respiratory Failure

    • Critical features that distinguish acute severe exacerbation of asthma from impending respiratory failure include:

        • Breathlessness at rest
        • Speech impairment
        • Altered orientation and cognition
        • Inability to recline
        • Paradoxical breathing
        • Use of accessory muscles for breathing.
        • Loud wheezing
        • Tachycardia

    • Impending respiratory failure is distinguished from acute severe exacerbation of asthma by:

        • Silent chest (absence of wheezing)
        • Rapid breathing (tachypnoea)
        • Relative bradycardia
        • Absence of pulsus paradoxus.

    HRCT Findings in Interstitial Lung Disease (ILD)

    • High-resolution computed tomography (HRCT) is a valuable tool for diagnosing and characterizing ILD.

    HRCT Findings in ILD

    • The following HRCT features are often observed in ILD:
      • Reticular and linear shadows
      • Nodular shadows
      • Ground-glass opacities
      • Consolidations
      • Mosaic attenuation (air trapping)
      • Cysts
      • Traction bronchiectasis
      • Honeycombing.

    Diseases Associated with Nodular Shadows on HRCT

    • Nodular shadows on HRCT scans are commonly observed in the following ILDs:

      • Usual interstitial pneumonia (UIP)
      • Lymphocytic interstitial lung disease (LCH)/ Lymphangioleiomyomatosis (LAM)
      • Nonspecific interstitial pneumonia (NSIP)
      • Cryptogenic organizing pneumonia (COP)
      • Hypersensitivity pneumonitis (HP)

    • Nodular shadows are a non-specific finding on HRCT scans, meaning they can be seen in multiple ILDs, including:

      • LAM
      • LCH
      • Lymphocytic interstitial pneumonia (LIP)
      • Radiation-bronchiolitis-interstitial lung disease (RB-ILD).

    Tree-in-bud Appearance on HRCT

    • The tree-in-bud appearance on HRCT can indicate:
      • Endobronchial obstruction
      • Infections.

    Other HRCT Findings

    • The document references several HRCT images, labeled A-B, exhibiting different characteristic patterns associated with ILDs.

    • The text mentions the observed features in the HRCT images, including:

      • Nodular shadows
      • Mosaic attenuation
      • Ill-defined infiltrates in the lower lobes.

    • The document only provides general descriptions of the images and does not associate them with specific diseases.

    • The included HRCT images showcase the variety of patterns that can be seen in ILD, highlighting the importance of HRCT as a diagnostic tool.

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    Description

    This quiz covers various forms of interstitial lung diseases, focusing on upper lobe ILD and pulmonary alveolar proteinosis (PAP). Participants will learn about associations with occupational lung disorders and the clinical features of PAP. Additionally, it addresses diagnosis and treatment approaches.

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