4. Pulmonology Flashcards
What are the classic types of chronic obstructive pulmonary disease (COPD) ?
chronic bronchitis and emphysema.
Chronic bronchitis is ?
A clinical diagnosis: chronic cough productive of sputum
for at least 3 months per year for at least 2 consecutive years.
Emphysema is ?
A pathologic diagnosis: permanent enlargement of air spaces
distal to terminal bronchioles due to destruction of alveolar walls.
Risk factors of COPD ?
A. Tobacco smoke (indicated in almost 90% of COPD cases)
B. α1-Antitrypsin deficiency—risk is even worse in combination with smoking
C. Environmental factors (e.g., second-hand smoke)
D. Chronic asthma—speculated by some to be an independent risk factor
Pathogenesis of chronic bronchitis ?
- Excess mucus production narrows the airways, patient often have a productive cough.
- Inflammation and scarring in Airways, enlargement in mucous glands, and smooth muscle hyperplasia lead to obstruction
Pathogenesis of Emphysema ?
- Destruction of alveolar walls is due to relative excess in protease (elastase) activity, OR relative deficiency of antiprotease (alpha-antitrypsin) activity.
Respiratory function test results in COPD ?
- The FEV1/FVC ratio is <0.70. (decreassed)
- FEV1 is decreased.
- TLC is increased.
- Residual volume is increased.
- Functional reserve capacity is increased.
Predominant Chronic Bronchitis (“Blue Bloaters”) features ?
- Patients tend to be overweight and cyanotic.
- Chronic cough and sputum production are characteristic.
Predominant Emphysema (“pink puffers”) features ?
- Patients tend to be thin due to increased energy expenditure during breathing.
- When sitting, patients tend to lean forward.
- Patients have a barrel chest (increased AP diameter of chest).
- Patient is distressed and uses accessory muscles (esp. strap muscles in neck).
Diagnosis of COPD ?
- Pulmonary function testing (spirometry):
- This is the definitive diagnosis test. - CXR:
- only severe, advanced emphysema will show the typical changes. - Measure alpha-antitrypsin levels. (in pts with hx of premature emphysema <50 yrs).
- ABG.
How to stage COPD and what are the stages ?
- Staging is based on FEV1:
- Mild disease: FEV1 >80% of predicated value.
- Moderate disease: 50-80% of predicated value.
- Severe disease: 30-50% of predicated value.
- Very severe disease: <30% of predicated value.
What are the interventions that lowers mortality in COPD?
Smoking cessation and home oxygen.
Treatment of Mild to moderate COPD ?
- Begin with a bronchodilator in a metered-does inhaler (MDI) formulations: Anticholinergic drugs and/or β-agonists are first-line agents.
- Inhaled glucocorticoids may be used as well. (low dose)
- Theophylline may considered if above not adequately control.
Treatment of Severe COPD ?
- Triple inhaler therapy ( long acting B-agonist plus a long-acting anticholinergic plus an inhaled glucocorticoid) is an option for severe disease.
- Continous oxygen therapy (if pts is hypoxemic).
- Pulmonary Rehabilitation.
Management of acute COPD exacerbation ?
- Def: increased dyspnea, sputum production and/or cough.
- order CXR.
1. Bronchodilators (β2-agonist) alone or in combination with anticholinergics are first-line therapy.
- systemic corticosteroids are used for patients requiring hospitalization (IV methylprednisolone is a common choice).
- Antibiotics (azithromycin, levofloxacin, doxycycline).
- Supplemental oxygen is used to keep saturation 90% to 93%.
- NPPV if needed.
Complication of COPD?
- Acute exacerbations.
- 2ndary polycythemia.
- Pulmonary HTN and cor pulmonale
Asthma triad ?
- Airway inflammation.
- Airway hyperresponsivness.
- Reversible airflow obstruction.
Clinical features of asthma ?
- SOB, wheezing, chest tightness, and cough.
- Symptoms are typically worse at night.
- Wheezing is the most common finding on PE.
Diagnosis of Asthma ?
- PFTs are required for diagnosis. (show obstructive pattern).
- Spirometry before and after bronchodilators can confirm diagnosis by proving reversible airway obstruction. (FEV1 increase 12%: albuterol)
- methacholine test (FEV1 decrease 20%)
- —–
* 4. Peak flow. (in acute settings ED when patient is SOB, peak flow measurements is quickest method of diagnosis).
If inhalation of a bronchodilator (b2-agonist) result in an increase in FEV1 or FVC by at least (…..?….), airway obstruction os considered reversible ?
12%
Management of Asthma ?
- STEP1: ICS + SABA.
- STEP2: LABA (salmeterol or formoterol) + (or increase ICS does)
- STEP3: Antimuscarinic (tiotropium).
- STEP4: Omalizumab
- Step5: Oral CS.
Management of acute severe exacerbation of Asthma ?
• Oxygen. • Albuterol. (SABA) • Steroids (orally) • Ipratropium - IV magnesium (not responsive to several rounds of albuterol while waiting for steroids to take effect).
Adverse Effects of Systemic Corticosteroids ?
- Osteoporosis.
- Cataracts.
- Adrenal suppression and fat redistribution.
- Hyperlipidemia, hyperglycemia, acne, and hirsutism (particularly in women) Thinning of skin, striae, and easy bruising
Bronchiectasis?
- There is permanent, abnormal dilation and destruction of bronchial walls with chronic inflammation, airway collapse, and ciliary loss/dysfunction leading to impaired clearance of secretions.
Bronchiectasis causes ?
- Recurrent infections.
- Cystic fibrosis. (is the most common cause).
- Primary ciliary dyskinesia (eg, kartagener syndrome)
- Autoimmune disease.
- Hormonal immunodeficiency.
Clinical features of Bronchiectasis ?
- Chronic cough with large amount of mucopulent, foul-smellin sputum.
- Dyspnea.
- Hemoptysis.
- Recurrent or persistent pneumonia.
Diagnosis of Bronchiectasis ?
- High-resolution CT is the diagnostic study of choice.
- PFTs reveal an obstructive pattern.
- CXR is abnormal in most cases, but findings are nonspecific.
- Bronchoscopy applies in certain cases.
TTT of Bronchiectasis ?
- Antibiotics for acute exacerbations.
2. Bronchial hygiene is very important (hydration, chest physiotherapy, inhaled bronchdilators)
Cystic Fibrosis ?
- Autosomal recessive.
- Defect in chloride channel protein causes impaired chloride and water transport, which leads to excessively thick, viscous secretions in respiratory tract, exocrine pancreas, sweat glands, intestines, and GI.
Risk factors for lung cancer ?
A. smoking. B. Second-hand smoke. C. Asbestos. D. Radon. E. COPD.
Which type of lung cancer has the lowest association with smoking of all lung cancers.?
Adenocarcinoma.
- also its only one gives false negative with PET CT
Staging of lung cancer ?
- NSCLC is staged via the primary TNM system.
- SCLC is staged differently:
a. Limited.
b. Extensive.
Clinical features of lung cancer ?
- Local manifestations:
- cough, hemoptysis, obstruction, wheezing, dyspnea. - Constitutional symptoms:
- Anorexia, weight loss, weakness. - Local invasion:
- SVC syndrome (5%).
- Phrenic nerve palsy.
- Recuurent laryngeal nerve palsy.
- Horner syndrome.
- Pancoast tumor.
Horner syndrome ?
- Due to invasion of cervical sympathetic chain by an apical
tumor. - Symptoms: unilateral facial anhidrosis (no sweating), ptosis, and miosis.
Diagnosis of lung cancer ?
- CXR. (most important)
- CT scan. (very useful for staging)
- Tissue biopsy.
Pleural effusion caused by one of the following mechanisms ?
- Increased drainage of fluid into pleural space.
- Increased production of fluid by cells in the pleural space.
- Decreased drainage of fluid from the pleural space.
