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Respiratory > Airway And Lung Diseases > Flashcards

Airway And Lung Diseases Flashcards

1
Q

Dynamic evolution of asthma (3)

A

Brief Symptoms-Bronchoconstriction
Exacerbations AHR- Chronic airway inflammation
Fixes airway obstruction-Airway remodelling

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2
Q

Hallmarks of remodeling in asthma (3)

A

Thickening of basement membrane
Collagen deposition on submucosa
Hypertrophy of smooth muscle

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3
Q

Asthma- The clinical syndrome (9)

A 
Episodic symptoms and signs
Diurnal variability
Non-productive cough
Triggers
Associated atopy increase in IgE (rhinitis, conjunctivitis, eczema)
Blood eosinophilia >4%
Responsive to steroids or beta-agonists
Family history of asthma 
Wheezing due to turbulent airflow
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4
Q

Diagnosis of Asthma (5)

A

History and examination
Diurnal variation of peak flow rate
Reduced forced expiratory ratio (FEV1/FVC<75%)
Provocation testing to trigger bronchospasms (exercise, histamine, methacholine, mannitol)
Reversibility to inhalation of salbutamol (>15%)

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5
Q

Components of COPD (3)

A

Mucociliary dysfunction
Inflammation
Tissue damage

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6
Q

Causes of airflow limitation in COPD

A

Mucous hypersecretion
Disrupted alveolar attachments
Inflammatory instruction

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7
Q

Characteristics of Chronic bronchitis in COPD (6)

A 
Chronic neutrophilic inflammation
Mucus hypersecretion
Mucociliary dysfunction
Altered lung microbiome
Smooth muscle spasm and hypertrophy
Partially reversible
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8
Q

Characteristics of Emphysema in COPD

A

Alveolar Destruction
Impaired gas exchange
Loss of bronchial support
Irreversible

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9
Q

Assessment of COPD

A

Assess symptoms
Assess degree of airflow limitation using spirometry (FEV<50% indicates high risk)
Assess risk of exacerbations (2 or more withing past year indicates high risk)
Assess comorbidities (IHD/HF)

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10
Q

Clinical Syndrome COPD (8)

A 
Chronic symptoms-not episodic
Smoking
Non-atopic
Daily productive cough
Progressive breathlessness
Frequent infective exacerbations
Chronic bronchitis-wheezing 
Emphysema-reduced breath sounds
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11
Q

Causes of Thoracic Restriction outwith the lungs

A

Skeletal
Muscle weakness
Abdominal obesity/ascites

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12
Q

Skeletal causes of thoracic restriction

A

Vertebrae e.g. Thoracic kyphoscoliosis, Ankylosing spondylitis
Ribs e.g. Traumatic multiple rib injury

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13
Q

Muscle weakness causes of thoracic restriction

A

Intercostal or diaphragmatic e.g. myaesthenia gravis, guillan barre, motor neurone disease, poliomyelitis

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14
Q

Classification of DLPD (5)

A

Acute DLPD
Episodic DLPD (all of which may present acutely)
Chronic DLPD due to occupational or environmental hazards/drugs
Chronic DLPD with evidence of systemic disease
Chronic DLPD without evidence of systemic disease

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15
Q

Causes of fluid in alveolar air spaces

A 
Cardiac pulmonary oedema
Non-cardiac pulmonary oedema
Infective pneumonia
Infarction
Alveolitis
Dust-disease
Carcinomatosis
Eosinophilic
Other causes - rheumatoid disease, drugs, cryptogenic
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16
Q

Types of alveolitis in DLPD

A 
Extrinsic-Allergic-Alveolitis                                                    
Sarcoidosis
Drug induced alveolitis
Toxic gas/fumes
Pulmonary fibrosis
Autoimmune
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17
Q

Clinical syndrome of DLPD

A 
Breathless on exertion
Cough but no wheeze
Finger clubbing
Inspiratory Lung crackles
Central cyanosis (if hypoxaemic)
Pulmonary fibrosis
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18
Q

Types of drugs for airway obstruction (2)

A

Preventers (anti-inflammatory)

Relievers (bronchodilators)

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19
Q

Corticosteroids

A

Anti-inflammatory drugs used in asthma and COPD

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20
Q

Oral steroid

A

E.g. Prednisolone
Low therapeutic ratio
Only used for acute exacerbations not for maintenance

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21
Q

Inhaled steriod

A

E.g.Beclomethasone
High therapeutic ratio
Used for maintenance monotherapy in asthma
Used in ICS/ LABA combo in COPD not as monotherapy
Reduces exacerbations in eosinophilic COPD

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22
Q

What is the risk of using corticosteroids for COPD

A

May cause pneumonia in COPD due to local immune suppression & impaired mucociliary clearance
Especially with fluticasone due to prolonged lung retention

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23
Q

What size must particles be to enable them to travel down past the carina?

A

<5 microns

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24
Q

What size must particles be to get past the 7th generation of bronchial tree?

A

<2microns

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25
Q

Actions of a spacer device (6)

A

Avoids coordination problems with pMDI
Reduces oropharyngeal and laryngeal side effects
Reduces systemic absorption from swallowed fraction
Acts a holding chamber for aerosol
Reduces particle size and velocity
Improves lung deposition

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26
Q

Cromones

A

Only used in asthma (eg Cromoglycate)
Mast cell stabiliser - weak anti-inflammatory cf steroids
Cromoglycate effective in atopic children (EIB)
Inhaled route only
Not used much due to poor efficacy

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27
Q

Leukotriene receptor agonists

A

Anti-inflammatory used in asthma
E.g. Montelukast - oral route, once daily, high therapeutic ratio
Less potent anti-inflammatory than inhaled steroid
2nd line: complimentary non steroidal anti-inflammatory additive to inhaled steroid
Effective in EIB
Also effective in allergic rhinitis ( with anti-histamine )

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28
Q

Anti-IgE monoclonal antibody

A

E.g. Omalizumab (Xolair)
Inhibits the binding to the high-affinity IgE receptor Inhibits TH2 response and assoc mediator release from basophils/mast cells
Injection every 2-4 weeks for asthma only
For patients with severe persistent allergic asthma (raised IgE) despite max therapy.
Very expensive
Little effect on pulmonary function but reduces exacerbations and oral steroid sparing effect

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29
Q

Anti-IL5

A

Mepolizumab (Nucala )/Reslizumab (Cinquero)
Blocks the effects of the TH2 cytokine IL-5 which is responsible for eosinophilic inflammation in asthma
Injection every 4 weeks –for asthma only
For patients with severe refractory eosinophilic asthma (raised blood eosinophils >4%) – despite max therapy
Very expensive
Little effect on pulmonary function or symptoms but reduces exacerbations and oral steroid sparing effect

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30
Q

B2-agonists

A

Stimulate bronchial smooth muscle B2-receptors
Bronchodilators
Short-acting - salbutamol
Long-acting – bid :salmeterol/formoterol
Used in asthma [as ICS/LABA dual ]
Used in COPD [as ICS/LABA dual or LAMA/LABA dual or ICS/LABA/LAMA triple ]
High therapeutic ratio when given by inhaled route
Systemic B2 effects when given systemically or at high inhaled doses

31
Q

Combination inhalers

A

Beclometasone/formeterol

Single Maintenance And Reliever Therapy

32
Q

Muscarinic antagonists (anticholinergics)

A

Muscarinic antagonists (aka Anticholinergics)
Block post junctional end plate M3 receptors
Short acting: Ipratropium
Long acting: Tiotropium,Glycopyrronium, Umeclidinium, Aclidinium
Inhaled route only - high therapeutic ratio
Used mostly in COPD to reduce exacerbations
Also used in asthma as triple therapy at step 4 (only tiotropium) as ICS/LABA/LAMA
High nebulised doses of ipratropium used in acute COPD and in acute asthma

33
Q

Methylxanthines

A

Anti-inflammatory/ Bronchodilator

Used in asthma and COPD

34
Q

Oral Methylxanthine

A

Theophylline for maintenance therapy
Sustained release formulation useful for nocturnal dips
Used as add to inhaled steroid as complimentary non steroidal anti-inflammatory

35
Q

IV methylxanthine

A

Aminophylline for acute attacks
Non selective phosphodiesterase inhibitor
Also act as adenosine antagonist
Low therapeutic ratio -metabolised by P450 in liver

36
Q

PDE4 inhibitors

A

Roflumilast oral tablet
Indicated for COPD only
Minimal effect on FEV1 –anti-inflammatory action
Reduces exacerbations –additive to LABA or LAMA
Adverse effects : Nausea/Diarrhoea/Headache/Weight loss

37
Q

Mucolytics

A

Oral carbocisteine , erdosteine
To reduce sputum viscosity and aide sputum expectoration [and reduce exacerbations ] in COPD
Rarely used –only as add on to other treatments

38
Q

Aims in treatment of chronic asthma (7)

A 
Abolish symptoms, 
Minimise B2-use, 
Normalise FEV1,
Reduce PEF variability, 
Reduce exacerbations, 
Prevent long term  airway remodeling
Avoid triggers
39
Q

Treatment of chronic asthma

A

Suppress inflammatory cascade with inhalatory steroid
+/- Non steroid anti-inflammatory therapy –eg theophylline ,anti-leukotriene,cromoglycate
+/- Stabilise smooth muscle with LABA/LAMA

40
Q

Treatment of acute asthma

A 
Oral prednisolone (or iv hydrocortisone )
Nebulised high dose salbutamol, ± Neb ipratropium, ± iv aminophylline/magnesium 
At least 60% O2
ITU Assisted mechanical intubated ventilation if falling PaO2 and rising  PaCO2
41
Q

Aims of treatment of COPD

A

Reduce exacerbations
Improve pulmonary function
Improve QOL
Prevent pulmonary heart disease

42
Q

Treatment of COPD

A 
Smoking cessation
Immunisation 
Pharmacotherapy
Pulmonary rehab
Oxygen
43
Q

Acute Treatment of COPD

A

Nebulised high dose salbutamol + ipratropium
Oral prednisolone
Antibiotic (amoxycillin/doxycycline) if infection
24-28% O2 titrated against PaO2/PaCO2
Physio to aide sputum expectoration
Non invasive ventilation to allow higher FiO2
ITU Intubated assisted ventilation only if reversible component (eg pneumonia)

44
Q

Effort dependent pulmonary function test

A

Forced expiratory volumes/flow rates

45
Q

Effort independent pulmonary function test

A 
Relaxed vital capacity -spirometry
Helium/N2 washout static lung volumes
Whole body plethysmography
Impulse Oscillometry 
Exhaled breath nitric oxide
46
Q

Gas diffusion tests

A

CO transfer factor
Arterial blood gases (resting)
SaO2 during exercise

47
Q

Spirometry in patient with asthma

A

FEV1 reduced compared to normal patient

FEV same, just takes longer, so slope is reduced

48
Q

Spirometry of COPD patient

A

Slope gradient more shallow compared to normal patient
FVC and FEV1 reduced
Ratio the same

49
Q

Volume dependent expiratory airway closure

A

Asthma, chronic bronchitis

50
Q

Pressure dependent expiratory airway closure

A

Emphysema

51
Q

Bronchial challenge testing

A

Exercise
Methacholine/Histamine/Mannitol
Allergens/Chemicals

52
Q

Exercise testing

A

FEV1 or PEF decrease post exercise - Asthma

Decreased SaO2 during exercise in interstitial lung disease

53
Q

Transfer Factor (diffusing capacity)

A

CO diffusion across alveolar-capillary barrier
Single breath diffusing capacity
Measured as TLCO
To monitor treatment response in lung disease

54
Q

Indications of decreased TLCO

A 
Anaemia
Emphysema
Int lung disease
Pulmonary oedema
Po emboli
Bronchiectesis
55
Q

Airway resistance

A

Measured by either whole body plethysmography or more commonly/easily with impulse oscillometry
Useful in patients (eg kids) where easier to breathe at tidal volume than doing forced expiratory manoeuvre

56
Q

Exhaled breath condensate

A

Exhaled breath nitric oxide measured at flow of 50ml/s
Non invasive marker of eosinophilic airway inflammation in asthma
Not useful in COPD as nitric oxide suppressed by smoking
High levels of exhaled NO (> 35ppb) reflect uncontrolled asthmatic inflammation
Used as an adjunct to bronchial challenge to assess asthmatic inflammation –especially when spirometry is normal

57
Q

Haemoptysis

A

Coughing up blood

Can be a direct consequence of a primary tumour

58
Q

Why is recurrent episodes of pneumonia considered a symptom of lung cancer?

A

A primary lung cancer can cause obstruction of bronchi

59
Q

Stridor

A

A coarse, audible wheeze during inspiration

60
Q

Symptoms arising from local invasion of the recurrent laryngeal nerve

A

Recurrent laryngeal nerve palsy

61
Q

Symptoms arising from local invasion of the pericardium

A

Breathless
Atrial fibrillation
Pericardial effusion

62
Q

Symptoms arising from local invasion of the oespohagus

A

Dysphagia

63
Q

Symptoms arising from local invasion of the brachial plexus

A

Wasting of small muscles

64
Q

Symptoms arising from local invasion of the pleural cavity

A

Pleural effusion

65
Q

Symptoms arising from local invasion of the vena cava

A

Distended veins

66
Q

Most common sites for metastases in lung cancer

A 
Liver
Brain
Bone
Adrenal
Skin
Lung
67
Q

Paraneoplastic symptoms of lung cancer

A 
Finger clubbing
Hypertrophic pulmonary osteoarthropathy
Weight loss
Thrombophlebitis
Hypercalcaemia
Hyponatraemia
Eaton Lambert syndrome
68
Q

Thrombophlebitis

A

Blood clot

Can present as a red track

69
Q

Hypercalcaemia

A

Stones (Renal/biliary calculi)
Bones (Bone Pain)
Groans (Abdominal pain, Constipation, N+V)
Thrones (Polyuria)
Psychiatric overtones (Depression, anxiety, reduced GCS, Coma)
Cardiac Arrythmia

70
Q

Hyponatraemia (Syndrome of inappropriate antidiuretic hormone SIADH)

A 
Results in low sodium concentration
Nausea/vomiting
Myoclonus
Lethargy/confusion
Seizures/coma
71
Q

Possible Investigations for Lung Cancer

A 
Chest X-ray
CT scan of thorax
PET scan
Bronchoscopy
Endobronchial Ultrasound (EBUS)
Full blood count
Coagulation screen
Na, K, Ca, Alk Phos
Spirometry, FEV1
72
Q

Smoking associated types of lung tumour

A

Adenocarcinoma (35%)
Squamous carcinoma (30%)
Small cell carcinoma (25%)
Large cell carcinoma (10%)

73
Q

What do adenocarcinomas express?

A

TTF (thyroid transcription factor) 1

74
Q

What does SCC express

A

Nuclear antigen p63 and high molecular wt. cytokeratins

Respiratory (19 decks)

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