#19 - Obstructive lung disease

Question 1

Risk factors for asthma

Answer 1

kids
women
blacks

Question 2

T/F Mortality is increasing for COPD and asthma

Answer 2

false. Mortality is increasing for COPD, but decreasing for asthma.

Prevalence for both is rising.

Question 3

What causes fatal asthma?

Answer 3

Mucus plugs. Therapy tries to prevent mucus formation.

Question 4

define chronic bronchitis

Answer 4

clinical diagnosis; presence of a chronic productive cough for 3 months in 2 consecutive years (other causes excluded)

Question 5

define emphysema

Answer 5

pathological term, describing the abnormal permanent enlargement of airspaces distal to the terminal bronchioles, accompanied by destruction of their walls without “obvious fibrosis”

Question 6

pathologic features of asthma

Answer 6

• goblet cell hyperplasia
• mucus gland hypertrophy
• increased blood vessel numbers
• smooth muscle hyperplasia
• reduced airway lumen area
• subepithelial fibrosis

*note: these factors may all be present in COPD as well

Question 7

What causes wheezing and “air trapping”?

Answer 7

reduced airway lumen area.

Question 8

T/F:

Asthma involves the airway and the parenchyma, whereas COPD only involves the airway.

Answer 8

False.

COPD involves the airway and the parenchyma (emphysema affects the alveoli), whereas asthma only involves the airway

Question 9

What is the most important cell for causing asthma?

Answer 9

eosinophils.

Question 10

Inflammatory overdrive causes which 4 things in asthma?

Answer 10

• bronchoconstriction
• microvascular leak (edema–>shrinkage of airway)
• mucus secretion (shrinkage of airway)
• airway hyper-responsiveness (infections much worse)

Question 11

T/F:

In asthma, once remodeling of the airway happens, changes are permanent and irreversible..

Answer 11

True. However, remember that asthma is primarily a reversible illness. Most of the time it does not progress to remodeling

Question 12

T/F:

Remodeling only occurs in severe cases of asthma.

Answer 12

False. It occurs in “mild” cases (only have symptoms 2/week or 2/month)

Question 13

What lymphocyte type mediates inflammation in asthma?

Answer 13

CD4 T cells

-eosinophils

Question 14

What lymphocyte type mediates inflammation in COPD?

Answer 14

CD8 T cells, along with macrophages and neutrophils.

Question 15

T/F - In asthma, airflow limitation is generally completely reversible; in COPD, it is irreversible

Answer 15

True.

Question 16

Other risk factors for COPD (besides smoking)

Answer 16

• noxious gases
• ambient pollution
• chronic respiratory infections.

Occupational history is very important!!

Question 17

T/F: COPD is not just a lung disease; it has many systemic effects.

Answer 17

True. Among them: osteoporosis, sleep disorders, venous thromboembolic disase, hormonal abnormalities.

Question 18

Important question to ask about coughing in asthma.

Answer 18

Does it occur at night? airways smaller at night (circadian rhythm) - night time symptoms also helps categorize the severity of disease.

Question 19

T/F: Exercise - induced asthma occurs primarily during exercise.

Answer 19

False - it occurs AFTER exercise, NOT during.

Question 20

A patient with GERD might have associated asthma. What symptom would probably be present?

Answer 20

night time symptoms.

Question 21

Physical exam for asthma

Answer 21

-Physical exam of the chest may be normal, due to episodic nature of symptoms.

• wheezing/ prolonged expiration
• hyper-resonance, diminished breath sounds (due to hyperinflation of the lungs. )

-mucosal swelling and polyps in nasal cavity.

Question 22

What is the major differentiating factor for labs between COPD and asthma?

Answer 22

DLCO = diffusion capacity. basically a measure of how many functional alveolar units. Since asthma doesn’t affect the parenchyma, it is normal or increased, whereas in COPD it is reduced.

Note: reaction to bronchodilator is also important.

Question 23

Describe the methacholine challenge test for diagnosis of asthma. What is a positive result?

Answer 23

you give progressively stronger doses of methacholine, measuring the FEV1 after every dose. If it drops more than 20% after the 5th dose (or earlier) that is consistent with asthma. Exclude asthma if this test is completely negative (quite sensitive test)

Question 24

What is a good test if you suspect occupational asthma?

Answer 24

Peak flow variation - they can measure peak flow at work and at home. If it varies more than 20%, this is reactive airway disease

Question 25

How can quitting smoking affect COPD?

Answer 25

you cannot recover whatever function you lost, but you resume a normal trajectory of lung function, greatly increasing your prognosis over time. .

Question 26

T/F: The rate of emphysema (calculated off of CT scans) correlates with airflow obstruction (reduced FEV1).

Answer 26

False. It often does not correlate. Imaging is helpful to “phenotype” disease though - ie, are they emphysema subtype or not?

Question 27

How does treatment of asthma during childhood affect progression of COPD?

Answer 27

If kids are affected by asthma and they don’t reach normal lung capacity, they will reach diability due to COPD much faster.

Question 28

Define mild intermittent, mild persistent, moderate persistent, and severe asthma, in terms of symptoms.

Answer 28

mild intermittent = night symptoms 2 times a month or less

mild persistent = night symptoms more than twice a month.

moderate persistent = night symptoms more than once / week, with daily daytime attacks

Severe = frequent night attacks with continuous daytime symptoms.

Question 29

T/F:

Controlling COPD exacerbations will improve quality of life for patients, but won’t improve their mortality / outcome.

Answer 29

False. “Heart attack to the lung”. Frequent exacerbations worsen prognosis over the long term.

Question 30

T/F

In mild persistent asthma, using exclusively a long-acting beta agonist may be good therapy.

Answer 30

FALSE. Never use a long acting beta agonist alone in asthma, it is contraindicated.

Question 31

Therapy for mild-intermittent asthma

Answer 31

Just a short-acting beta2 agonist (inhaled as needed). ONLY category in which inhaled corticosteroid is not given!!!

Question 32

Therapy for mild persistent asthma.

Answer 32

low dose inhaled corticosteroid, along with a short-acting beta2 agonist, inhaled as needed.

Question 33

Therapy for moderate persistent asthma

Answer 33

low dose inhaled corticosteroid, along with a long acting beta agonist.

Also: short acting inhaled beta2 agonist for episodes

Question 34

Therapy for severe asthma

Answer 34

High dose inhaled corticosteroids, long acting beta agonist, and short acting beta agonist for episodic relief

Question 35

In COPD, using exclusively a long acting beta agonist can be good therapy.

Answer 35

True. (contraindicated in asthma)

Question 36

cornerstone of asthma therapy

Answer 36

inhaled corticosteroids (reduce airway remodeling, reducing permanent damage)

Question 37

non pharmacologic therapy for COPD

Answer 37

O2 therapy (if less than 89% O2 saturation)

• vaccination
• pulmonary rehab

Question 38

Current treatment for COPD exacerbations

Answer 38

PDE-4 antagonist (along with long acting beta agonist)

-azithromycin

Question 39

Exciting treatments for asthma, in the pipeline.

Answer 39

• anti-IgE antibodies

- anti-IL5 antibodies (reduces eosinophilia)

Question 40

T/F:

For COPD, pharmacologic treatment reduces progression of disease mortality.

Answer 40

False. It only helps symptoms. Stop smoking to reduce progression.

Question 41

spirometry for obstructive lung diseases

Answer 41

“scooped” appearance.