DIP Episode 402 - Pulmonary Pathophysiology Series 4

Okay welcome my name is Divine this is episode 402 of the Divine Intervention Podcasts and to this podcast I'll be continuing the series on pulmonary pathophysiology. This is going to be series number four.

I have done series number one two and three and as I said earlier on the goal with these podcasts is to really really really help you understand pulmonology because pulmonology just has a lot of physiology with it and also a lot of the pathology that comes alongside come from a deep understanding of good physiology so my goal is for the person preparing for any of these USML exams to really bring these things down for you so that as you're reading or going through pulmonary related questions you're able to see right through the question because really after all is said and done there's nothing that can replace having good understanding right many times you hear me talk about these derivative questions where it's something you know but you see answer choices that have words you don't recognize the best way to counter those kinds of questions is to have them on the standing of the pathophys if you have an understanding of the pathophys then it's not going to be as tedious or as terrible as people make it out to be okay and again as a reminder if you're taking your step to see if you have step three exams anything within like the next two weeks or thereabouts if on beyond that I'll encourage you and do have a review course starting today it's going to be from five to nine p.m.

pacific standard time today tomorrow Thursday Friday and Saturday so you can still sign up again we'll go over internal medicine will be going psych neuro peds surgery ethics biostatistics multi-systems processes and disorders communications healthcare systems and things of that nature there's tons of people that have attended these courses and they found it to be profoundly helpful in fact I've had people take it even up to a day before the exams and they still find it to be super helpful although it's also very helpful for building a foundation because again I'm not going to just going to be throwing facts at you we're going to be using vignettes but I'm going to be breaking down pathophysiology and then I also have a biostatistics bootcamp it's four hours long it's going to be taking place on the 21st of July from four to eight p.m.

Pacific standard time again biostat is not a plug and shock science is a science where you actually have to understand what's going on so if you want to sign up for any of these courses they're going to be held over zoom just shoot me an email through the website and I'll be happy to give you some more information okay so continuing on this Poinary Pathophysiology business where so what if they give you a question about a patient and they tell you that this guy is you know he's 30 years old and for the past two weeks he has been having a lot of rain or yeah and he has been having like shudeness or breath that is in termitent you know he kind of has it for a few hours at night that's you know he kind of keeps him up at night and then tell you that he chee hee enty exam so like you know like ear nose and throat or whatever exam shows uh excessive mucuso tissue within his nose and things of that nature right if you see that and the person they tell you that he has like some redness and tear in of both eyes bilaterally and the person also has like a family he sure of like auditory and things of that nature if you see stuff like that what do you want to think about I really hope you're saying oh divine and then let's see maybe they tell you that you know this person uh had a minor accident right or you know as he was lifting heavy boxes um he felt this twinge in his back so he has been taking a medication for the pain and over the counter medication for the pain if you see this what should you be thinking about I really really hope you're saying oh divine sounds like this person has aspirin induced asthma aspirin induced asthma remember another name for aspirin induced asthma on NBM Es is aspirin exacerbated respiratory disease it felt that's the more recent term aspirin exacerbated respiratory disease so how do all these things I mentioned relates together all these things

I mentioned relates together um because aspirin inserting people with certain susceptibilities aspirin or other insets can cause them to have a smart exempt so what's the pathophysiology there again the pathophysiology there is again you've probably heard me say this adnosimondous podcast because it's a pretty high yield pathophys to kind of make sure you understand but essentially what happens is we know that our acidonic acid can take one of two pathways it can take the cycloxygenic pathway and it can take the lipoxygenase pathway the cycloxygenic pathway uh communicated by N-sets by aspirin right so our acidonic acid when he sees that that already is blocked it's gonna take the path of list resistance which is the lipoxygenase pathway now the lipoxygenase pathway right lipoxygenase will convert that our acidonic acid to luchotriens and you know there are a few luchotriens you probably want to know for your exam you know there's luchotriens C4 there's luchotriens D4 there's luchotriens E4 right now another luchotriens should probably also know is LTB4 luchotriens B4 especially for those that are studying for step one luchotriens B4 is a pathochymotactic factor for neutrophils okay it's a pathochymotactic factor for neutrophils that's something I want to know for your test right and then these luchotriens you know the ethanol luchotriens receptor right and then they cause things like bronchoconstriction and things of that nature right just remember that another term you may see for luchotriens receptor in your exam can be CYS LT1 CYS LT1 that's another term for luchotriens receptors okay so luchotriens again they can cause bronchoconstriction they can increase vasculoprimability they can cause inflammatory cell recruitment so they can cause quite a number of problems so you can already begin to see that oh these things can cause asthmatic symptoms so you see a perso

n they're taking medication for back pain or whatever and then you notice that it's not having asthmatic symptoms you see that association that oh wow after they started taking these meds they got in trouble right think about aspirin exacerbated respiratory disease and now you know and understand the pathophysiology so how should we treat this problem well if we know that oh going after the pathophysiology we understand the pathophysed and how how do you treat it the treatment should make perfect sense you should be able to decipher that oh divine well let's show down this luchotriens pathway you can shut it down in one of two ways you can shut it down by killing the enzyme right like oxygen is that makes things go down that pathway you can use a drug called xyloton ZILEUTON to accomplish that purpose or alternatively you can use drugs that can block the luchotriens receptor so drugs like Monte Luchast and Zerfeluchast they block that CYSLT1 receptor they're CYSLT1 receptor antagonists right luchotriens receptor antagonists and they are helpful the thing is most times are you know people prefer to use the luchasts the Monte Luchast those are the luchasts because they just have less toxicity than ZILEUTON right and again people that have aspirin exacerbated respiratory disease it's pretty high you to know that these people can have nasal polyposes on exams okay it's pretty high you to know that they can have nasal polyposes actually just in general it's pretty high you to know people that can have nasal polyposes on tests right so like I said already aspirin exacerbated respiratory disease can be associated with nasal polyposes cystic fibrosis can also be associated with nasal polyposes right webinars which we call granolomatosis with polyangitis can also be associated with nasal polyposes and then another thing that's associated with nasal polyposes that you want to k

eep in mind is this disorder called chronic rhinocronic rhino is a mouthful trust me chronic rhino sinusitis with nasal polyposes chronic rhino sinusitis with nasal polyposes that's something called like the abrivision I guess can be CRNSP or something like that right it's just gonna be the first thing that just has this pretty detailed allergic history there's a lot of asthma kind of running the family a lot of allergies kind of running the family and you notice that you know there's no you won't see like an aspirin trigger and insect trigger but these people just seem to have like running nose like really bad go on for weeks on end right and these have these nasal polyps nasal polyps nasal polyps and again instead of saying nasal polyps on exams our friends at the mbms can say mucosal tissue overgrowth right on mucosal overgrowth that's a polyp that's another term we can use for it how do we treat CRNSP typically these people on exams the respond pretty well to inhale cortical steroids inhale cortical steroids you can try and anti-histamine but anti-histamines are just not as effective in these people the thing that's really gonna help them is I inhale cortical steroids obviously you can try and oral steroid but we try to avoid that right because you're beginning to mix steroid and they can have all these side effects remember if you're using a ill cortical steroids don't forget that can cause you to have esophageal or oral candidiasis especially if you don't use it right right that's why again using a metadose inhaler is pretty helpful and also just kind of rinsing your mouth drinking some water after you take a steroid those are interventions you could employ to reduce the risk of oral or esophageal candidiasis that can be an in-bimmy question right there something you definitely want to keep in mind okay now one of the way that our friends at the mbms can kind of

bring in this local train pathway to bear right they can talk about a person that has had like just very prolonged prolonged prolonged asthma symptoms really really bad asthma symptoms and they tell you that while this person's asthma symptoms you started them on you know they've been on steroids for it and those oral steroids have been really helping them like their asthma steroids have been just really amazing they've been feeling better they think that you're doing such a good job as a doctor and that's all well and good but then in the question you know they'll make it this long vignette and the question they'll see the story about wow this person that has had this asthma you know been taking steroids they can tell you that wow this person has study having some systemic side effects of the steroid therapy so they say that all you know what for your asthma instead of taking this systemic steroid therapy let's try something that is steroid spirit right and then they see that all the patient is instituted on wanting locust or zafi locust or something like that and then you then notice in the question that this person after they instituted on some of these are local trying agents anti-local trying agents you notice that the asthma symptoms come back in full force you notice that they start having peripheral neuropathy you notice that they start having cardiac issues you notice that they start having a renal issues you they start having like an ephratic syndrome there's that same red blood cell cuss dysmorphic erythrocytes in the urethral what do you want to think about when you think about church trials when you think about church trials remember another info church trials is eGPA you'll see no philly granolomatosis with polyngitis you'll see no philly granolomatosis with polyngitis remember it has a he has a p-enca association right the anti myeloperoxylase anca ass

ociation so some of you may be like what divine like what sort of question is this i have no idea where you're kind of going with this your thoughts so any kind of break it down so the thing is the nbm means the love integration that's the first fact you want to establish your mind a friend that the nbm means the love integration that's fact number one fact number two is when people have asthma right and they have really bad symptoms sometimes we're just like you know what instead of giving a wrong steroids or you know let's try a steroid sparing agent many times when you see the words steroid sparing agent with regards to asthma therapy they are talking about drugs like Monte Lucas those are for Lucas right so those drugs are pretty good in some people that you know have had to just be using steroids for asthma right but the nbm is they can take advantage of that fact and bring in what i call the on masking conundrum what do i mean by the on masking conundrum the masking conundrum is where one issue at taking like it's almost like a person has something going on that is covering over the presence of something else right the nbm is the love that kind of concept is is one of the classic ways on integration that the nbm is love to go after where you have one disorder but that the disorder that you're seeing right or you're really focused lesering on is actually just the symptom of something completely different that they have right so what do i mean by this so this person has had really bad asthma they've been taking steroids right this just intractable asthma doesn't seem to be getting better with usual therapy so they took steroids they got like dramatically better but then you stop the steroids try a steroid sparing agent all this badness that's happening you see this think of the steroids as suppressing not just the asthma that they had both other issues that they h

ad because remember church trials as a disorder right it's a vascular kind of it's a kind of thing that can cause nephritic syndrome cause long problems cause you know perforal neuropathy and all these things those symptoms can be suppressed pretty effectively by steroids right because remember asthma is a component of church trials most people that have church trials on nbm is will have asthma so if you're like okay let's stop taking the steroids let's try a steroid sparing agent and then you see an exacerbation of their symptoms with all these other things thrown in for good measure and let's say the nbm is a kind but again they're not always going to be this kind and they throwing that the pnk is positive we're going to think about church trials because look what trying to antagonize like Monte Lucas or Felucas those I looted just really have no ability to completely suppress church trials or again egpa symptoms so in that circumstance that's exactly what's happening there right so this long question I just give you with all these moving parts is literally just going after a concept that you know what you see a person the on steroids you stop it you put them on Monte Lucas for the Lucas for their asthma symptoms and you see the asthma symptoms come back in a big bad form with other stuff like perforal neuropathy and cardiac issues and renal dysfunction you really want to think about you know xenophilic granulomatosis with polyhengeitis right again that's just something you kind of want to keep in mind for example and again please don't forget that you know egpa responds really well to ster not just steroids alone but also cyclophosphamide right not just steroids alone but also cyclophosphamide and church trials is a prominent cause of your xenophilia just make sure that for mbm example it's you know your causes of new xenophilia right so like drugs new plasmids ast

hma allergies allergic in test tissue on a fritis right um collagen vascular disease or something like lupus for example um and then parasites right these are all things that can cause your xenophilia right you just want to make sure you know those things pretty solidly for for exams okay and then I guess one other way you can also treat or say probably more so just prevent let's say a person has like certain high risk features let's say they have like 65 verses or whatever or you know they just have like a high risk early and you want to try to prevent asthma attacks in these people a one way you can kind of fix it is by giving a drug called umalesium up right so umalesium up is a drug that we used to treat asthma or used to prevent asthma attacks and how does it work especially people that have asthma that has a stronger association with a high ige component that's actually pretty high you to know you see people that have asthma that it has a very strong high ige component umalesium up may be the answer to those people's prayers literally because remember as I spoke earlier I said that um we have ige that has is already prebound on the surfaces of mast cells where it's bound to the fc epsilon receptor right it's prebound to those fc epsilon receptors on the surfaces of mast cells so when and those you know those ige receptors are just kind of chilling but when when something comes in right so let's say um like an allergen comes in and it binds to the you know hyper variable regions on those ige antibodies is going to cause cross linking of those ige antibodies and when you cross link those ige antibodies the mast cell is going to degranulate release all this bad nasty stuff that causes many of those asthmatic symptoms so we said that again the ige is they are prebound to these fc epsilon receptors to find on mast cells so is there any way and those fc epsilon recept

ors are essentially the ige receptor so is there any way we could maybe prevent this from happening in the first place well we know that those ige receptors those fc epsilon receptors on the mast cells they bind to the constant region of ige okay they bind to the constant region of ige so the thing is if there was a way you could create a monoclonal antibody that binds to that constant region of ige and makes it impossible for it to bind to that fc epsilon receptor which we also call the ige receptor then you can't have that degranulation or whatever because you've essentially short-circuited the process so how do you do that use a drug like or my lesium up my lesium up is a monoclonal antibody okay it's a monoclonal antibody against the constant region of ige okay it's a monoclonal antibody against the constant region of ige and I know one thing that some people me cannot be frustrated with is divine you repeat yourself so many times I'm actually doing it with intent I like to repeat myself because one it's a good way for people to remember things again sometimes you just need to hear something said over and over again until you're like okay okay I get it for that thing to really register in your mind and again also I love to use examples because when you use examples sometimes I'm used too many examples make too many integrations but again the more examples you know the more integrations you have in mind the more multi-dimensional you're thinking become so that again if they just present something in a needypical way you're not left holding the bag you're remembering you're remembering it correctly and you feel pretty good pretty good about it so what if they give you a question about a 25-year-old woman you know they tell you that she comes to the physician because over the last three months she has been having a lot of shortness of breath they tell you that you kn

ow she has some signs of synosis they tell you that on oscotician of the chest you hear a loud p2 heart sound right and then they tell you that they perform right heart right heart catheterization and you notice that while this person's a pulmonary artery pressure is like 40 like some crazy high number I can't remember what the upper limit of normal is I think it's like in the 20s like mid 20s but it's something you can easily google on your own after you listen to this podcast but basically this young lady unfortunately has pulmonary hypertension right pulmonary hypertension and pulmonary hypertension you know there are many types there are many causes where you can get pulmonary hypertension from COPD from cystic fibrosis from left heart failure from isomanger syndrome there are many causes but the key thing I'm going after here is you can even get pulmonary hypertension from chronic P Es right that's something I think that's called CTF CTE pH um but whatever but you know this one I'm referring to here is idiopathic pulmonary arterial hypertension right so what's the pathophase the pathophase involves a host of things right so one you may see on your exam is that these will maintain to have a BMPR2 mutation BMPR2 mutation right BMPR2 stands for bone morphogenic protein receptor 2 BMPR2 mutation you have this mutation and then they get in getting trouble right they have like a lot of hypertrophy of the smoke muscle that lines the walls of the pulmonary arteries right so they get pulmonary hypertension that way and other thing that also characterizes bone hypertension is these people just have like insanely high levels of endothelene they have very high levels of endothelene endothelene is a very powerful viso constrictor because it's powerful viso constriction so if you constrict your pulmonary arteries that's going to make it really hard for your right ventricle to t

ry you're going to have pulmonary hypertension as a result of that so how do we treat this disorder well I mean there's not really much we can at least as far as I know that can be done on the genetic level right so you have to try more the molecular level so you can start off by kind of don't be down the activity of endothelene right so you can give an endothelene receptor antagonist right so something like BOSENTAN or UNBOSENTAN UNBOSENTAN is spelled EMBRI SETN TEN UNBOSENTAN or BOSENTAN BOSENTAN TEN right these are endothelene receptor antagonists that can really really help in the management of symptoms of idiopathic pulmonary arterial hypertension alternatively you can give viso dilators right like cell denalfel remember cell denalfel is a force for diester is 5 inhibitor when inhibitor phosphodiester is 5 that's going to operate cyclic AMP because it's been broken down less when you have high levels of cyclic AMP that causes smoke muscle relaxation that's going to cause viso dilation that's going to help just remember whenever you're given a presence of denalfel be very careful be very wary of combining that with another viso dilator arterioviso dilator or vino dilator right so you know combining cell denalfel with like nitrate maybe not the best idea in the world or with a tricyclic anti-depressant that has anti-alpha one effects not a good idea or with a straight-up off one blocker like preso saying not a good idea or with arterioviso dilator like hydrolyzino those dihydroperidine calcium general blockers not a good idea either right these are all integrations you want to make sure you can make on exams and also for polar hypertension you can also use a persta glanine analog remember persta glanines they are very good they are very very good right they are very very good at dilating things right so you can give persta glanine analogues like iloprost ILOPROST o

r ipoprostinol EPOPROSTEMOL the dilate blood vessels the open blood vessels very very helpful very very helpful right very very helpful remember persta glanines eat a lot of really helpful things right like for example if you want to keep the doctors at your aerosol but you can give a PGE1 analog like alprost ideal many of them have porost in the name right or if a person has like chronic glaucoma right like that uh you know the open angle glaucoma one of the ways you can treat it is by literally just dilating the canal of shlem the canal of shlem responds to viso dilators right so you can give a canal of shlem dilator like a persta glanine analog right when you give those things like traprostinol um they can open up the blood vessels they can open up the canal of shlem and the eachist tumor can can treat okay and then I guess I remember if a person has allergic rhinitis you know those people they'll have usually bilateral symptoms again they'll have a pretty storida allergy history in their families or whatever or you can control the nantihistamine you know a H1 blocker remember antihistamines you know include both the fur the H1 and H1 well the ones that help with you know all these allergic symptoms i'm all the H1 blockers H2 blockers are more for peptic ulcerer disease right so these H1 blockers remember there are two generations there's the first generation and there's the second generation the big thing to know about the first generation you know they're gonna be drugs like diphen hydramine right they're very sedidium they're very very sedidium right they're very very sedidium because the reason they are sedidium is they literally have the ability to cross the blood brain barrier okay they have the ability to cross the blood brain barrier so they can cause problems right but the second generation you know they are more or less sedidium these are things like fexo

fenadine right fexofenadine fexofenadine I believe for like a legra kind of falls under that category just like the treatment or one of the treatments of fexofenadine this probably generic fexofenadine these days but basically those ones are are a lot less sedidium right they're a lot less sedidium and again just remember that they are certain drugs that oh they may not be H1 blockers but they have H1 blocking activity even these for other things right like for example those of first generation low potency anti-psychotics right they have those anti-harm side effects right anti-heat one right anti-histamine so the cost addition they have anti-alpha one so the cause of postatic hypotension and they have anti-moscharinic effects right so like drugs like cloprimazine CHLOR pr o ma z i in e the absolutely can cause those problems right and also the tricyclic anti-depressants right like your nortriptulin and whatnot they also have these anti-harm side effects so they can cause sedition right because they have the ability to block histamine receptors and they remember people that have cystic fibrosis I'm going to be wrapping up here soon because I want to keep this like a 30 minutes or there about I put out cystic fibrosis right again they tend to have a lot of thick mucus that's obstructing their earwings because again their ear reclurances just not good right and a lot of this mucus you know it comes from these public cells just secreting a ton of stuff and you know all these inflammatory cells that are being broken down so they make up a lot of this junk right so the thing is you can break up these mucus plugs you can really help these patients so how do you do that or you can use a drug like enacidocysteine I remember in acidocysteine we can also use it for like a macera-menofintoxic acidity because it kind of replenishes bloodthion right so that you don't mess up you do

n't mess up your you know your dealing with reactive oxygen species system right because any PQI from acetylene of it cause a lot of problems right we can use enacidocysteine to really help it it breaks up diastrophide bonds in mucus you can also use dornies alpha right dornies dornies like they can call it an anti d and A's on mbim exams and anti d and E's on mbim exams and what exactly does it do essentially what it does is it breaks up phosphodistro bonds remember phosphodistro bonds the kinds of bonds that exist in DNA right you know all those DNA that you find in the dead and decaying inflammatory cells really helpful for breaking those down so this will can create those airway secretions you're just gonna keep that in in mind and then one final just tidbit I think I'm gonna mention today and then wrap up is that just remember enacidocysteine many people you can use it to prevent contrasting using the fratathy what is known as first line measure the first line measure for kind of steven off contrasting using the fratathy on mbim exams to be perfectly honest with you is hydration those people just get get a ton of hydration before and after you take the contrast and that can really really help that's probably one of the more effective ways of it to reduce in a contrasting used nephropathy again as I do at the end of every podcast I'll show what I want you to do for all the USML exams step one to three so step one step two CK step three complex level one two and three pre-clean cool mid school exams 30 klure shift shelf exams and also for review courses for step two for a 20 hour review course and mbme testicon strategy scores and also for a four hour bio statistics bio statistics board camp and then I have these podcasts on Apple podcasts on Google podcasts and Spotify I have it on all three of those mediums and also on the You Tube channel actually defining interv

ention USML podcasts and videos that's where I post the videos that I make but again I'm going to be making a big change on those within the next few on the You Tube channel within the next few days I'm trying to basically increase access to my podcast so I'm going to be making some changes very soon so just be on the lookout just go ahead and hit subscribe divine intervention USML podcasts and videos that's the name of the You Tube channel and then again I have my website divineinterventionpodcasts.com if you sign up with a Word Press account although you don't have to but if you do you'll get an email notification whenever I make a new podcast and then I also have a new website called divineinterventionlifelessens.com it's a Bible Bee's website many of you listening to this podcast not my Christian so Bible Bee's website where I discuss a life lesson just something that people a lot of people struggle with and I try to discuss it from a biblical perspective we have almost a hundred episodes actually do have the podcasts on a Apple podcast it's called the divine intervention life lessons podcast and then finally I also help with ira's applications so ira's applications recommendation letters personal statements mock interviews I do all those things with people I've worked with many people that are right now even attendance in particular from residency many competitive specialties, Durham near surgery, neurology, IM OBGYN, psych just many different disciplines so again if you're interested in any of these things with edits, advising and all those things like you just reach out to me through the website I've worked with tons of people more people than than I can remember just reach out to me through the website I feel pretty good about my abilities to really help you out with the application especially if you have a tricky application you know let's say you have like a red

flag you have to explain away or let's say you fill the US email exam or you know one thing or the other I've worked with people that I've had like you just unique problems with the applications that again I've been able to make it into residency in one way or the other and again just a quick life lesson I want to share today is just make sure because many times in medicine we use this term high yield high yield the thing is many people apply the term high yield to you know studying but you don't necessarily apply that term to their lives I kind of want to introduce you to this concept of living a high-yield life you see a lot of people they live low yield lives you look at they have 24 hours in a day and in those 24 hours they are completely almost nothing of note or you look at those 24 hours and they spend like 18 19 of those hours on fluff things that will not move their distance forward at all I'm not saying that you shouldn't spend time resting and enjoying yourself but your rest you should literally plan it out right you you want to live a high-yield life and how do you live a high-yield life you live a high-yield life by just focusing on the right things like things that actually matter right things that actually matter for your future that actually matter for your destiny so I'll just encourage you make sure you're focusing on the right things like what are you doing with your time what are you doing with your time I spend you know your time on like social media on your likes and profile on all these things those things don't add much of anything to your life I would argue very conclusively for that so I'll just encourage you just be wise with the way you leave your life be very very wise with the way you leave your life I live a high-yield life just ask yourself am I spending at least 60 to 70% of my day on things that will actually move me towards where I'm

supposed to be in life if you're not doing that you need to keep up in that percentage the more you opt that percentage the more high your life is going to be because you see some people they are like wow where did this day go where did my dedicated period go blah blah blah blah because they just had a LuYo dedicated period right that's one of the reasons why one of the very first things I do with students that I work with 101 is to make a plan for their dedicated periods or whatever why because again the way when people have no direction that's where problems come right even the bible says you should write the vision and make it plain so that you can run with it so it's almost like you have an ability to run right obviously running is more high your than walking you have an ability to run and get a lot more from your vision if you're already done right so you're having some kind of plan so that you can follow that plan as closely as possible and having a high-yield day and having a high-yield life so I really hope that you found this podcast to be helpful I'll see you in episode 403 have a wonderful day God bless you Shalom thank you

Blockage of COX-1 forces arachidonic acid into the lipoxygenase pathway, leading to excessive leukotriene production ($\text{LTC}_4$, $\text{LTD}_4$).

$\text{Cys LT}_1$ or $\text{CYSLT}_1$.

Montelukast or Zafirlukast (LTR As).

$\text{BMPR2}$ mutation leading to pulmonary artery smooth muscle hypertrophy, and high levels of vasoconstrictors like endothelin.

Bosentan or Unabosentan.

Inhaled corticosteroids.

Dornase alfa (D Nase).

It is a monoclonal antibody that binds to the constant region of $\text{IgE}$, preventing its binding to the $\text{Fc}\epsilon\text{RI}$ receptor on mast cells.

$\text{LTB}_4$.

Esophageal or oral candidiasis (requires rinsing mouth/drinking water).

Aspirin Exacerbated Respiratory Disease, Cystic Fibrosis, and Web Syndrome/Granulomatosis with Polyangiitis.

PDE-5 inhibitors (e.g., Sildenafil).

N-acetylcysteine ($\text{NAC}$).

The "masking conundrum," where asthma symptoms are masking underlying systemic vasculitis.

It is a monoclonal antibody that binds to the constant region of $\text{IgE}$, preventing its binding to the $\text{Fc}\epsilon\text{RI}$ receptor on mast cells.

$\text{LTB}_4$.

Esophageal or oral candidiasis (requires rinsing mouth/drinking water).

Aspirin Exacerbated Respiratory Disease, Cystic Fibrosis, and Web Syndrome/Granulomatosis with Polyangiitis.

PDE-5 inhibitors (e.g., Sildenafil).

N-acetylcysteine ($\text{NAC}$).

The "masking conundrum," where asthma symptoms are masking underlying systemic vasculitis.