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Clin Med II Unit II > 3 Pulmonary Function Tests And Asthma > Flashcards

3 Pulmonary Function Tests And Asthma Flashcards

1
Q

What are the three basic PFTs?

A

Airflow spirometry

Lung volumes

Diffusion Capacity of the Lungs for Carbon Monoxide (DLCO)

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2
Q

Preferred patient position during spirometry

A

Sitting (because less likelihood of syncope)

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3
Q

How do you perform spirometry?

A

Patient sits

Tight seal over mouthpiece must be maintained

Visualization may be provided for motivation (ie candles)

Coaching is encouragaed (pt ed is key - useless if they don’t do it right)

Repeat testing at least 3X

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4
Q

How do you determine Forced Vital Capacity (FVC)

A

Deep breath in (full inspiration)

Blow out air as fast as possible (forced expiration)

FVC = total volume of air with maximal effort

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5
Q

Why do we use Forced Expiratory Volume in first second (FEV1)

A

Most useful information for obstruction

The FEV1/FVC ratio defines severity of obstruction - assists in differentiating obstruction and restrictive disease

<0.7 = obstructive pattern (<5th percentile LLN)

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6
Q

What does FEF 25-75% mean?

A

Airflow measurement during middle half of forced expiration

No specific for small airway obstruction but may be an early indicator of disease

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7
Q

Why do we do bronchodilator testing with spirometry?

A

Reversibility testing - if FEV1 increases by 12% and 200 ml after bronchodilator

If positive - aids in diagnosis, provides Tx options, improves compliance

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8
Q

How is reversibility testing performed?

A

Nebulizer or inhaler

Technique needs to be monitored - 2-4 puffs (preferably with chamber), and hold inhaled meds in lungs for 5-10 sec

Spirometry completed 15 min after meds provided

3-8 rounds of testing and possibly repeated during flare

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9
Q

What is bronchoprovocation and how is it performed?

A

Methacholine Challenge Test

  1. Dilute solution of methacholine given via nebulizer
  2. Spirometry conducted at 30 and 90 seconds
  3. Concentration increases

Positive test: FEV1 decreases by 20% (may have false positive)

RISK - must be closely monitored

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10
Q

Volume of air within the lung after maximal inhalation

A

Total Lung Capacity (TLC)

TLC = VC + RV

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11
Q

Volume of air we breathe out following maximal inhalation

A

Vital Capacity (VC)

TLC = VC + RV

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12
Q

Volume of air remaining in the lungs following maximal exhalation

A

Residual Volume (RV)

TLC = VC + RV

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13
Q

Measurement of the ability of the lungs to transfer gas and saturate the hemoglobin (alveolar-capillary membrane)

A

Diffusion Capacity (DLCO)

Can be misleading if a person is anemic (false reduction) and must be adjusted for hemoglobin level

CO is used as a surrogate for oxygen transfer

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14
Q

Technique for measuring DLCO

A

Patient inhales a single breath of gas consisting of helium/CO, then expires, and measurement of exhalation is taken

When lungs are healthy, little CO is collected during exhalation

When lungs are diseased, less CO diffuses into lungs, higher levels are measured in exhaled gas

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15
Q

Obstructive disease is characterized by …

A

Airway narrowing —> limits airflow with EXPIRATION

Reduced airflow with HIGH lung volumes (air trapping)

Inspiration likely normal

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16
Q

PFT results with obstructive disease

TLC: \_\_\_\_\_\_\_
FVC: \_\_\_\_\_\_\_
RV: \_\_\_\_\_\_\_\_\_
FEV1: \_\_\_\_\_\_\_
FEV1/FVC: \_\_\_\_\_\_\_\_
A 
TLC: Increased 
FVC: Normal
RV: Increased
FEV1: Decreased
FEV1/FVC: Decreased
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17
Q

Restrictive disease is characterized by…

A

Reduction in lung volume and reduced lung expansion

INSPIRATION & EXPIRATION will overall look normal but flow and volume are significantly reduced

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18
Q

PFT results for restrictive disease

TLC: \_\_\_\_\_\_\_
FVC: \_\_\_\_\_\_\_
RV: \_\_\_\_\_\_\_\_\_
FEV1: \_\_\_\_\_\_\_
FEV1/FVC: \_\_\_\_\_\_\_\_
A

Everything decreased except the ratio

TLC: Decreased

FVC: Decreased

RV: Decreased

FEV1: Decreased

FEV1/FVC: Normal or increased

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19
Q

Examples of obstructive lung disease

A 
Asthma
Asthmatic bronchitis
Bronchitis
COPD
CF 
Emphysema
Upper Airway Obstruction
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20
Q

Examples of Restrictive lung disease

A 
Pulmonary fibrosis
Infectious Lung Disease
Thoracic deformities
Pleural effusion
Tumors
Neuromuscular diseases
Obesity
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21
Q

5 steps to approaching PFT interpretation

A
  1. Examine the flow-volume curve
  2. Examine the FEV1 value
  3. Examine the FEV1/FVC ratio
  4. Examine the response to bronchodilator
  5. Examine the DLCO
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22
Q

What are we looking for when we examine the flow-volume curve?

A

Is it normal appearing?

Is the curve scooped out, indicating an obstructive pattern?

Is the slope increased/peaked, indicating a restrictive process?

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23
Q

FEV1<80% suggests…

A

Suggestive of obstructive disease but NOT diagnostic

Could also examine FEF 25-75% as it is more sensitive for detecting early airway obstruction

If TLC available, correlate with this measurement. If it is also increased by 15-20% predicted, this favors obstructive disease

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24
Q

FEV1/FVC ratio of ________ indicates obstructive disease

A

≤ 70% LLN

If the ratio is normal or increased, possibly a restrictive disorder

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25
Q

If FEV1 increases by 12% and 200 ml in response to a bronchodilator, it suggests…

A

Suggestive of hyper reactive, reversible airways

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26
Q

What is DLCO for?

A

Measures the ability of O2 to get to the blood and be transported

27
Q

How often do we perform PFTs?

A

Assessment at diagnosis

After 3-6 months of controller treatment (is FEV1 improved?)

Periodic assessments at least every 1-2 years (may need to be more often if higher risk patients and in children)

28
Q

How is Asthma defined?

A

Chronic airway inflammation

Intermittent and Reversible Airway Obstruction (may test normally if not acute)

Bronchial hyperresponsiveness

29
Q

80% of asthma patients develop symptoms before….

A

Age 5

But often misdiagnosed

30
Q

Symptoms of asthma

A

Coughing - NOCTURNAL, seasonal, response to specific exposures, duration longer than 3 weeks

Wheezing - hallmark symptom (may be heard with inspiration AND expiration)

Other Sx: CP, chest pressure, dyspnea, SOB

31
Q

Important DDx for asthma

A

GERD - especially if patient experiences nighttime cough right after laying down

32
Q

Asthma Sx are episodic and often associated with characteristic triggers, such as…

A 
URI
Exercise
Weather
Stress
Irritant exposure (tobacco, pets, etc)
Meds (BB, ASA, NSAIDs)
33
Q

Risk factors for Asthma

A 
Atopy
Med intolerance (ASA/NSAID)
Food allergies
GERD (also a DDx)
RSV
(+) FMH
Maternal smoking (prenatal and second hand exposure)
Obesity
34
Q

Physical exam findings in asthma

A

Increased AP diameter

Wheezing with PROLONGED EXPIRATORY PHASE - wheezing most commonly heard during forced expiratory phase but may also be heard during inspiration

Associated signs of rhinitis, sinusitis, conjuctivitis, URI, atopic dermatitis

Signs of severe obstruction: tachypnea, tachycardia, tripod positioning, accessory muscle use, pulses paradoxus

35
Q

Aspirin-exacerbated respiratory disease is characterized by what triad?

A

Samter’s Triad

Sinus disease with nasal polyps
ASA sensitivity
Severe asthma

36
Q

What should patients with ASA-exacerbated respiratory disease avoid?

A

NSAIDS

Alcohol (b/c 75% also have respiratory response to alcohol)

37
Q

What is the atopic triad?

A

Atopic Dermatitis
Allergic Rhinitis
Asthma

38
Q

Asthma DDx in infants and children

A 
GERD****
Allergic rhinosinusitis
URI
CF
Pertussis
FB or mass
RAD (reactive airway disease)
CHD
Laryngotracheomalacia
Eosinophilic bronchitis
39
Q

Asthma DDx in adolescents and adults

A 
GERD
COPD
CHF
PE
Vocal Cord Dysfunction
Obstructive sleep apnea
Chronic upper airway syndrom (post nasal drip)
Cough secondary to ACE inhibitor
40
Q

Initial presentation of asthma

A

Hx, PE, and variable expiratory airflow limitation

Spirometry helps confirm Dx of asthma if >5 years of age

May need to be repeated on several occasions or during symptoms to confirm Dx

FEV1<80%
FEV1/FVC: Normal or decreased relative to predicted values (70-85%) (Note, it’s <70% for COPD)
Reversibility >12% (>8% in young children) in FEV1 with bronchodilator

41
Q

Name the Asthma Step:

Sx ≤ 2 days/week

Nighttime awakenings:
Ages 0-4 - None
Ages ≥ 5 - ≤ 2 nights/month

A

Intermittent Asthma (Step 1)

Normal PFTs in between exacerbations

FEV1 >80%

FEV1/FVC normal (>85% ages 5-19)

Normal activity

≤ 2 days/week SABA use

42
Q

Name the asthma step

Sx >2 days/week (not daily)

Nighttime awakening:
Ages 0-4: 1-2 nights/month
Ages ≥5: 3-4 nights/month

A

Mild Persistent Asthma (Step 2)

FEV1 > 80%

FEV1/FVC normal (>80% ages 5-19)

Minor limitation in activity

> 2 days/week of SABA use to control Sx (not daily)

43
Q

Name the asthma step:

Daily Sx

Nighttime awakenings:
Ages 0-4: 3-4x/month
Ages ≥5: >1x/week (not nightly)

A

Moderate Persistent Asthma (Step 3)

FEV1 60-80%

FEV1/FVC reduced by 5%

Some activity limitations

Daily use of SABA

44
Q

Name the asthma step:

Sx throughout the day

Nighttime awakenings:
Ages 0-4: >1x/week
Ages ≥5: Nightly

A

Severe Persistent Asthma

FEV1 <60%

FEV1/FVC reduced by >5%

Extremely limited physical activity

SABA used to control Sx several times daily

45
Q

Different meds used to manage asthma

A 
SABA: inhaled short acting ß2 agonist
LABA: long activity ß2 agonist
ICS: Inhaled corticosteroid
LTRA: Leukotriene receptor antagonist - Montelukast (used in ages 0-4)
Monoclonal Antibodies (Omalizumab or Benralizumab)
Methylxanthines (Theophyline)
Mast Cell Stabilizers
Anticholinergics
46
Q

Step 1 asthma treatment

A

SABA prn

47
Q

Step 2 asthma treatment

A

Low dose ICS daily
(Or LTRA/Cromolyn in younger patients)

SABA prn

48
Q

Step 3 Asthma treatment

A

Medium dose ICS OR
Low dose ICS + LABA (or LTRA if ≥ 5 years)

SABA prn

Refer to specialist

49
Q

Step 4 asthma treatment

A

Medium dose ICS + LABA (or LTRA in 0-4 YO)

SABA PRN

50
Q

Step 5 asthma treatment

A

High dose ICS + LABA

SABA PRN

Consider adding Omalizumab (Xolair) for ages ≥ 12

51
Q

Step 6 asthma treatment

A

High dose ICS + LABA + oral steroids

SABA PRN

Consider adding Omalizumab (Xolair) for ages ≥ 12

52
Q

Rule of Twos for determining if asthma is under control

A

Asthma Sx > 2x/week

Night Sx > 2x/month

Refill SABA > 2x/year

Peak flow meter measures less than 2 x 10 (20%) from baseline

53
Q

How often do we follow up with asthma patients?

A

Initially 1-3 monthns then every 3-12 months depending on severity

54
Q

Stats for well controlled asthma

A

Sx ≤ 2 days/week

Nighttime awakenings ≤ 1x/month for ages 0-11, ≤ 2x/month for ages ≥ 12

FEV1 >80%

FEV1/FVC >. 80%

55
Q

Stats for not well controlled asthma

A

Sx ≥ 2 days/week

Nighttime awakenings >1x/month for ages 0-4, ≥ 2x/month for ages 5-11, 1-3x/week for ages ≥12

FEV1 60-80%

FEV1/FVC 75-80%

56
Q

Stats for very poorly controlled asthma

A

Sx daily

Nighttime awakenings >1x/week for ages 0-4, ≥2x/week for ages 5-11, ≥4x/week for ages ≥ 12

FEV1: < 60%

FEV1/FVC < 75%

57
Q

Signs of severe obstruction in asthma patients

A 
Tachypnea
Tachycardia
Tripod positioning
Accessory muscle use
Pulses paradoxus
58
Q

What are the different “zones” when using Peak Expiratory Flow Rate?

A

> 80% = Green (good control)

50-80% = Yellow (Caution - SABA and Med increase)

<50% = Red (Med alert - go to ED)

59
Q

When should you go to the ER based on Peak Flow Meter?

A

If less than 50% (the red zone)

60
Q

Other diagnostics considered in asthma

A

ABG - Respiratory alkalosis initially due to hyperventilation (if PaCO2 normal, consider patient getting tired/breathless)

CXR - only if ruling out infection or obstruction (may show hyperinflation)

61
Q

Treatment for Asthma Exacerbation

A

O2

SABA/SVN (Albuterol or Xopenex +/- Ipratropium Bromide)

Systemic corticosteroids (Prenisolone 1mg/kg/day with max dosing based on weight)

Other possibilities:
• Abx PRN
• Respiratory monitoring if in ED or inpatient
• Severe may warrant C-PAP, BiPAP, or intubation

62
Q

The main goal of asthma treatment?

A

Prevent persistent symptoms and asthma progression with appropriate medication management

63
Q

Key patient ed points for asthma patients

A

Smoke free home

Regular bedding washing

No pets

Remove triggers if possible

Allergy testing and immunotherapy may be beneficial

Write out care plan with specific meds and routine follow up

Demonstrate appropriate technique for inhaled meds

Clin Med II Unit II (7 decks)

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