5) Pulmonary (Part 1) Flashcards
3 most important measures in Spirometry
- FVC
- FEV1
- FEV1/FVC ratio
Spirometry normal values vs. COPD
- Normal is 80%
- The diagnosis of COPD is an FEV1/FVC ratio less than 70%
The greatest value of the flow-volume loop is to assess for
- Upper airway obstruction (for example, a laryngeal cancer)
DLCO
- Measure of the ability of the lungs to transfer gas
Diffusion in the lungs is most efficient when
- Surface area for gas transfer is high and the blood is readily & able to accept the gas being transferred
Decreased DLCO seen in
- COPD
- Infiltrative lung disease
- Pulmonary HTN
- PE
- Sarcoidosis
- Scleroderma
Normal DLCO seen in
- Asthma
Examples of obstructive pulmonary diseases
- Asthma
- COPD
- Cystic fibrosis
Examples of restrictive pulmonary diseases
- Idiopathic pulmonary fibrosis
- Pneumoconiosis
- Coal worker’s pneumoconiosis
- Silicosis
- Asbestosis
- Sarcoidosis
Asthma
- Reversible airway obstruction, airway inflammation, and increased airway responsiveness to various stimuli
Asthma symptoms
- Wheezing
- Chest tightness
- Dyspnea
- Cough (range from mild to severe)
Asthma physical exam findings
- Tachypnea
- Wheezing
Asthmatic spirometry findings
- Decreased FEV1/FVC ratio
- Obstruction will typically improve with a bronchodilator (significant bronchodilator response)
- Normal DLCO
- If FEV1/FVC ratio is normal, order a methacholine challenge test/ bronchoprovocation test
Asthma medication classes
- Short acting inhaled beta agonists (SABA)
- Inhaled corticosteroids (ICS)
- Long acting inhaled beta agonists (LABA)
- Combination inhaled corticosteroids and long term beta agonists
Short acting inhaled beta agonists (SABA)
- Albuterol
- levalbuterol (Xopenex)
Inhaled corticosteroids (ICS)
- flunisolide (Aerospan)
- ciclesonide (Alvesco)
- fluticasone furoate (Arnuity Ellipta)
- mometasone furoate (Asmanex)
- fluticasone propionate (Flovent)
- budesonide (Pulmicort)
- beclomethasone dipropionate (Qvar)
Long acting inhaled beta agonists (LABA)
- formoterol (Foradil)
- salmeterol (Serevent)
Combination inhaled corticosteroids and long term beta agonists
- fluticasone propionate
- salmeterol (Advair)
- mometasone furoate
- formoterol fumarate (Dulera)
- budesonide
- formoterol fumarate dihydrate (Symbicort)
Never prescribe a long-acting beta agonist without an inhaled corticosteroid
- Has been associated with increased mortality
Most important cause of COPD
- Smoking
COPD symptoms
- Progressive shortness of breath with exertion
- Chronic cough
- Sputum prodction
COPD physical exam findings
- Increased AP diameter
- Scattered wheezes
COPD CXR findings
- Flattened diaphragms
- Hyperinflated lungs
- Increased AP diameter (on lateral CXR)
COPD Dx
- Requires spirometry
- Post-bronchodilator FEV1/forced vital capacity <0.7 (confirms the presence of airflow limitation that is not fully reversible)
American Thoracic Society COPD staging
- Mild disease: FEV1/FVC <70%, FEV1 >80% predicted
- Moderate disease: FEV1/FVC <70%, FEV1 50-80% predicted
- Severe disease: FEV1/FVC <70%, FEV1 30 to 50% predicted
- Very severe disease: FEV1/FVC <70%, FEV1 <30% predicted
COPD treatment
- Smoking cessation
- Long-term oxygen therapy improves survival, exercise, sleep and cognitive performance
COPD long term oxygen therapy indications
- PaO2 <55mgHg (per ABG) or cor pulmonale, Pulmonary HTN present.
- Goal: to maintain O2 saturation >90% during rest, sleep and exertion
COPD medications
- Short Acting βeta 2 Adrenoceptor-Agonists (SABA)
- Long Acting βeta 2 Adrenoceptor-Agonists (LABA)
- Short Acting Muscarinic Antagonist (SAMA)
- Long Acting Muscarinic Antagonist (LAMA)
- Inhaled Corticosteroid (ICS)*
- Combination SAMA + SABA
- Combination LABA + LAMA
- Combination ICS + LABA
- Phosphodiesterase Inhibitors
Short Acting βeta 2 Adrenoceptor-Agonists (SABA)
- Albuterol
- Metaproterenol
- Terbutalin
- Isoetharine
- Levalbuterol
- <6 h effect on lung function
Long Acting βeta 2 Adrenoceptor-Agonists (LABA)
Salmeterol, formoterol, olodaterol, vilanterol, = long acting (>12 h) effect on lung
Indaceteraol = ultra long acting
- Salmeterol
- Formoterol
- Olodaterol
- Vilanterol
- > 12 h effect on lung
- Indaceteraol = ultra long acting
Short Acting Muscarinic Antagonist (SAMA)
- Ipratropium (4x /day)
Long Acting Muscarinic Antagonist (LAMA)
- Tiotropium
- Clidinium
- Umeclidinium
- Glycopyrronium
Inhaled Corticosteroid (ICS)
- Beclomethasone
- Budesonide
- Triamcinolone
- Fluticasone
- Flunisolide
Combination SAMA + SABA
- Albuterol/ipratropium
Combination LABA + LAMA
- Vilanterol/umeclidinium
- Olodaterol/tiotropium
- Idacaterol/glycopyrronium
- Formoterol/glycopyrrolate
- Formoterol/aclidinium
Combination ICS + LABA
- Fluticasone propionate/salmeterol
- Mometasone furoate/formoterol fumarate
- Budesonide/formoterol fumarate dihydrate
- Fluticasone furoate/vilanterol
COPD medications for refractory disease
- Phosphodiesterase inhibitors
- Rofluminast
Cystic fibrosis (CF) prevalence
- Most common genetically inherited autosomal recessive disease in Caucasians
CF leads to
- Multi-system organ dysfunction
- Majority of morbidity and mortality related to respiratory and gastrointestinal (GI) systems
CF pathophysiology involving the lungs includes
- Vicious cycle of infection
- Inflammation
- Bronchiectasis
CF diagnosis/clinical course
- Diagnosed with a chloride sweat test
- Clinical course includes acute exacerbations and eventual respiratory failure
Idiopathic pulmonary fibrosis SXS/clinical manifestations
- Progressive dyspnea
- Chronic cough
IPF diagnostic studies
- CXR, PFTs (restrictive pattern), High Resolution CT
- Bronchoscopy: transbronchial biopsy, bronchoalveolar lavage
IPF Tx
- Corticosteroids
- Azathioprine (Imuran)
- Mycophenolate (CellCept)
- O2
- Pulmonary Rehab
Pneumoconiosis
- Occupational lung disease
- Caused by the inhalation of dust
Types of pneumoconiosis
- Coalworker’s pneumoconiosis (aka “black lung”) – coal dust
- Asbestosis – asbestos dust
- Silicosis – silica dust
- Berylliosis – beryllium dust
Pneumoconiosis SXS
- Progressive dyspnea
- Chronic cough
Pneumoconiosis Tx
- D/c offending agent
- Corticosteroids
- O2
- Pulmonary rehab
Pneumoconiosis diagnostic studies
- CXR, PFTs (restrictive pattern), High Resolution CT
- Bronchoscopy: transbronchial biopsy, bronchoalveolar lavage
Sarcoidosis clinical presentation case (50 y/o male example)
- Chronic fatigue, nonproductive cough, dyspnea, anorexia, weight loss, blurred vision, and arthralgias
- Tells you his “liver tests” have been abnormal
- Skin findings: reddish-purple, hard (indurated), painful nodules
Sarcoidosis CXR findings
- Bilateral hilar lymphadenopathy
Sarcoidosis significant lab findings
- AST/ALT, alkaline phosphatase mildly elevated
- Calcium is elevated
- PFTs reveal decreased DLCO and FVC
- ACE level may be elevate
Sarcoidosis biopsy
- Diagnostic
- Non-caseating granulomas
Sarcoidosis Tx
- First line = corticosteroids
CXR in acute respiratory distress syndrome (ARDS) shows
- B/l pulmonary infiltrates
ARDS Tx
- Requires special expertise with mechanical ventilation and management of critical illness
- Tx of underlying condition is essential
- Supportive care: Appropriate ventilator and fluid management
Risk factors for Obstructive Sleep Apnea (OSA)
- Obesity
- Increased neck diameter (>17cm in men >16cm in women)
- Abnormal upper airway abnormalities
Abnormal upper airway abnormalities that increase risk for OSA
- Macroglossia
- Long soft palate and uvula
- Enlarged tonsils
- Micrognathia
- Narrow oropharynx
Clinical manifestations of OSA
- Morning headaches
- Recurrent awakenings
- Daytime somnolence affecting daily activities (including driving)
- Sleeping partner reporting snoring, periods of apnea, gasping for air
- HTN
Manifestations of extreme cases of OSA
- Hypoxemia and pulmonary vasoconstriction –> pulmonary hypertension and right ventricular failure
Sleep Apnea
- Diagnosis = sleep study (Polysomnography)
- Treatment = CPAP machine (most effective)
