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Respirology > Airway Disease > Flashcards

Airway Disease Flashcards

1
Q

What is symbicort?

A

Budesonide-formoterol

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2
Q

What is Singulair?

A

Monteleukast

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3
Q

What is Spiriva?

A

Tiotropium

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4
Q

What is Flovent?

A

Fluticasone

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5
Q

What are the two components of a diagnosis of asthma?

A
  1. History of respiratory symptoms that vary over time and intensity.
  2. Confirmed variable expiratory airflow limitation (on spirometry)
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6
Q

What are the symptom characterisitics that have been shown to decrease the likelihood of asthma (5)?

A
  1. Isolated cough w/no other respiratory symptoms.
  2. Chronic production of sputum
  3. SOB associated with dizziness, light-headed ness and parathesia.
  4. Chest pain
  5. Exercise-induced dyspnea with noisy inspiration.
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7
Q

How can you confirm variability on spirometry in individuals with suspected asthma to make the diagnosis?

A
  1. Positive bronchodilator reversibility (10-15 minutes after 200-400 mcg of salbutamol).
  2. Improvement in lung function with anti-inflammatory treatment x 4 weeks.
  3. Excessive FEV1 variation in lung function between visits.
  4. Peak flow variability (average daily diurnal PEF variability > 10%)
  5. Positive bronchial challenge test or exercise challenge test.
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8
Q

What is considered reversibility in lung obstruction on PFTs?

A

Improvement in FEV1 by > 12% AND 200 mL post bronchodilator

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9
Q

What is considered to be an excessive variation in FEV1 between lung-function tests?

A

> 12% AND 200 cc variation

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10
Q

How long do you have to hold a SABA before PFTs in order to ensure you can measure baseline lung function?

A

At least 4 hours before the test.

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11
Q

How do you interpret a methacholine challenge test?

A

PC20 < 4 mg/mL = POSITIVE
PC20 4-16 = Borderline
PC20 > 16 = NEGATIVE

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12
Q

What are the criteria that must be met to consider asthma controlled (9)?

A
  1. Daytime Sx < 4 days/wk
  2. Night-time Sx < 1 night/wk
  3. Physical Activity Normal
  4. Exacerbation = Mild, infrequent
  5. Absence from work or school = None
  6. Need for a SABA = < 4 doses/week
  7. FEV1 or PEF > or = 90% personal best
  8. PEF Diurnal Variation < 10-15%
  9. Sputum Eosinophils < 2-3%
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13
Q

What are the options for Step 1 in asthma treatment per the GINA 2020 guidelines?

A

Preferred Controller: As needed low dose ICS-formoterol.
Others Controlled Options: Low dose ICS taken whenever SABA is taken.

Preferred Reliever: ICS-formoterol
Other Reliever Options: As needed SABA

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14
Q

What are the options for Step 2 for asthma treatment per the GINA 2020 guidelines?

A

Preferred Controller: Daily low dose inhaled ICS or PRN low dose ICS-formoterol.
Other Controller Options: Daily leukotriene receptor antagonist (LRTA), OR low dose ICS taken whenever SABA taken.

Preferred Reliever: Low dose ICS-fomoterol PRN
Other Reliever option: SABA

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15
Q

What are the asthma treatment options for Step 3 in the GINA 2020 guidelines?

A

Preferred Controller: Low dose ICS-LABA
Other Controlled Options: Medium dose ICS or low dose ICS + LTRA

Preferred Reliever: As needed low dose ICS-formoterol
Other: SABA PRN

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16
Q

What is the recommended Step 4 asthma treatment per the 2020 GINA Guidelines?

A

Preferred Controller: Medium dose ICS-LABA
Other Controller Options: High dose ICS, add-on trio-Gropius, or add-on LTRA

Preferred Reliever: As needed low dose ICS-formoterol
Other Options: PRN SABA

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17
Q

What is the recommended asthma treatment for Step 5, as per the GINA 2020 guidelines?

A

Preferred Controller: High dose ICS-LABA & refer all for phenotypic assessment +/- add on therapy with tiotropium or a biologic agent.
Other Controller Options: Add low dose oral corticosteroid

Preferred Reliever: As needed low dose ICS-formoterol for patients prescribed maintenance and reliever therapy
Other Reliever: PRN SABA

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18
Q

What symptoms/signs correlate to each step of the GINA 2020 guidelines for initiation of asthma treatment?

A

Step 1 - Symptoms < 2x per months
Step 2 - Symptoms 2x per month or more, but less than daily.
Step 3 - Symptoms most days or waking with asthma once a week or more.
Step 4 - Symptoms most days, or waking with asthma once a week or more, with low lung function.

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19
Q

What did SYGMA 1 show?

A

Patients were randomized to receive:

  1. BID placebo + PRN SABA
  2. BID placebo + PRN budesonide-formoterol
  3. BID budesonide + PRN SABA (terbutaline)

PRN budesonide-formoterol better than PRN SABA and non-inferior to maintenance budesonide. Maintenance ICS group had better asthma control but higher cumulative ICS.

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20
Q

What did SYGMA 2 show?

A

Pragmatic trial. Patients randomized to:

  1. BID placebo + PRN budesonide/fomoterol
  2. BID budesonide + PRN terbutaline (SABA)

PRN budesonide-fomoterol non-inferior to budesonide maintenance + PRN SABA to prevent exacerbation and loss of lung function. PRN budesonide = less total daily dose of ICS, but ICS had better Sx control QOL and pre-bronchodilator FEV1 on maintenance.

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21
Q

In which asthma patients is treatment of with azithromycin recommended?

A

Recommended in patients with persistent symptoms of asthma despite moderate-high dose ICS & LABA. In this setting, azithromycin has been show to reduce exacerbations and improves asthma-related QOL.

Need to treat for at least 6 months and check QTc as well as sputum mycobacterium before initiation.

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22
Q

What asthma substypes is an LTRA most effective for?

A

Aspirin-exacerbated asthma

Exercise-induced asthma

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23
Q

What is the black box warning on LTRAs?

A

Increased suicidal ITP in adolescents and adults.

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24
Q

What is the definition of severe asthma?

A

Asthma that requires treatment with high dose ICS + 2nd controlled for previous the previous year, or oral steroids for > 50% of the year, to prevent it from becoming uncontrolled, or uncontrolled despite this therapy.

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25
Q

What are the indications for IgE therapy in asthma?

A

Need to meet the following criteria:

  1. Allergic Asthma (IgE 30-700)
  2. Sensitive to at least one perennial allergen
  3. Severe asthma despite high dose ICS and one other controller
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26
Q

What are the indications for anti-IL5 therapy in asthma?

A

Severe eosinophilia asthma (generally > 300) and recurrent exacerbation despite high-dose ICS and one other controller

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27
Q

What is Samter’s triad?

A
  1. Asthma
  2. Nasal Polyps
  3. ASA/NSAID Sensitivity
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28
Q

How is the severity of airflow limitation in COPD defined?

A

Mild: FEV1 > or = 80% predicted
Moderate: 50% < or = FEV1 < 80 % predicted
Severe: 30% < or = FEV1 < 50% predicted
Very Severe: FEV1 < 30% predicted.

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29
Q

What is Grade 1 on the mMRC Dyspnea scale?

A

SOB when hurting on the level or walking slightly uphill.

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30
Q

What is Grade 0 mMRC?

A

SOB with strenuous activity.

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31
Q

What is mMRC Grade 2?

A

Walks slower than people the same age or has to stop for breath while walking on the level at own pace.

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32
Q

What is mMRC Gr. 3?

A

Steps for breath after walking ~ 100 m or after a few minutes walking on the level.

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33
Q

What is mMRC Gr. 4?

A

The patient is too breathless to leave the house or breathless with dressing and/or undressing.

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34
Q

In what setting does pulmonary rehabilitation improve survival and reduce exacerbations?

A

If started following a recent (<4 weeks) AECOPD.

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35
Q

How is high risk for AECOPD defined?

A

Two or more moderate exacerbations in the past year OR 1 or more requiring hospitalization or ED visit.

36
Q

Who should be offered long term supplemental oxygen therapy (per CTS guidelines)?

A
  1. Severe hypoxemia (PaO2 < 55 mmHg) OR
  2. PaO2 < 60 mmHg in the presence of one of the following: bilateral ankle oedema, for pulmonary (R-side heart failure d/t pulmonary HTN) or Hct > 56%
37
Q

Which interventions increase survival in COPD patients?

A
  1. Smoking Cessation
  2. Supplemental O2 in patients with severe RESTING hypoxemia only.
  3. Pulmonary Rehab when < 4 weeks from recent COPDe.
38
Q

In mild COPD without high risk of exacerbations, which is better: LAMA or LABA monotherapy?

A

LAMA monotherapy better prevents exacerbations.

39
Q

Who is considered low risk for COPDe per CTS guidelines?

A

If they had 1 or fewer moderate exacerbations in the last year and DID NOT require an ED visit or hospitalization.

40
Q

Explain which COPD patients with get a pneumococcal vaccination.

A
  1. Adults 65 or Older: 13-valent conjugated pneumococcal vaccine (PCV-13)
  2. Adults < 65: PPSV23 in those with FEV1 < 40% and in those with comorbidities.
41
Q

What is the pharmacological category of Roflumilast?

A

Phosphodiesterase-4 Enzyme Inhibitor

42
Q

In which COPD patients is roflumilast (AKA DAXAS) recommended?

A

It is recommended in all patients at high risk of AECOPD despite optimal inhales therapy.

43
Q

In which COPD patients should you prescribe N-acetylcystine?

A

For patients with chronic bronchitis and high risk of AECOPD despite long-acting inhalers.

44
Q

In which patients with COPD would you prescribe azithromycin?

A

For patients at high risk of AECOPD despite optimal inhaled therapy.

  • There is no evidence to suggest efficacy and safety of azithromycin beyond one-year*
  • Guidelines recommend testing QTc and sputum for mycobacteria prior to starting azithromycin.*
45
Q

Which therapies are recommended per CTS guidelines for treatment of dyspnea in advanced COPD?

A
  1. Oral Opioids
  2. Neuromuscular Electrical Muscle Stimulation
  3. Chest Wall Vibration
  4. Walking-AIDS
  5. Pursed-lip Breathing
  6. Continuous oxygen therapy for hyoxemic COPD patients reduces mortality and may reduce dyspnea.
46
Q

What are the criteria to diagnose asthma-COPD overlap (per CT guidelines)?

A
  1. Diagnosis of COPD given risk factors, hx, spirometry.
  2. Hx of asthma (past hx/diagnosis, current symptoms consistent, or physiological confirmed w/spirometry).
  3. Spirometry: Post-bronchodilator fixed FEV1/FVC < 0.7

Supportive but not required:

  1. Documentation of a bronchodilator improvement of FEV1 by 200 mL or 12%
  2. Sputum eosinophils > 3%
  3. Blood eosinophils > 300 cells/uL
47
Q

In which COPD patients has lung volume reduction surgery been shown to be increase survival?

A

Severe emphysema patients with upper-lobe pre-dominant disease and low post-rehabilitation exercise capacity.

48
Q

In which COPD patients has lung transplant been show to improve QoL and functional capacity?

A

Bode 7-10 AND 1 of the following:

  1. Hospitalized w/COPDe with pCO2 > 50
  2. Pulmonary HTN/Cor Pulmonale despite supplemental oxygen.
  3. FEV1 < 20% with DLCO < 20%
49
Q

Which patients with COPD should receive antibiotics for an exacerbation?

A

Abx should be given in COPD in the presence of three cardinal symptoms (or two of the following if increased purple cells is one of them):

  1. Increased Dyspnea
  2. Increased Sputum Volume
  3. Increased Sputum Purulence

Antibiotics should also be given if a patient requires invasive or non-invasive mechanical ventilation.

50
Q

What are the benefits of steroids in moderate-severe COPDe?

A
  • Faster recovery time
  • Increased FEV1
  • Reduce length of stay
51
Q

When is BiPAP recommended for AECOPD?

A
  • pH < or = 7.35 with pCO2 > or 45
  • severe dyspnea (impending respiratory failure)
  • persistent hypoxemia despite supplemental oxygen
52
Q

What do you need to rule out in COPD patients before the initiation of azithromycin?

A

Sputum culture for NTM

53
Q

Which non-pharmacological interventions definitely reduce the incidence of COPDe (Grade 1)?

A
  1. Annual Flu Vaccine
  2. Pulmonary Rehab (if RECENT exacerbation)
  3. Education & Case Management
54
Q

What are the Grade 2 recommendations (suggested) for preventing COPDe?

A

Evidence dose not actually support reduced exacerbations at this time.

(1) Pneumococcal Vaccination
(2) Smoking Cessation

55
Q

In which patients with COPD would you recommend the pneumococcal vaccine?

A

All COPD > 65
Significant Comorbidities
All with FEV1 < 40%

56
Q

What are the recommended therapies for treatment of dyspnea in advanced COPD (6)?

A

(1) Oral Opioids
(2) Neuromuscular Electrical Muscle stimulation
(3) Chest Wall Vibration
(4) Walking AIDS
(5) Pursed-lip breathing
(6) Continuous home oxygen for hypoxemic patients.

57
Q

What are the diagnostic criteria for asthma-COPD overlap?

A

REQUIRED:

(1) Diagnosis of COPD given risk factors, hx, spirometry.
(2) History of asthma (past hx/dx, current symptoms consistent or physiology confirmed w/spirometry).
(3) Spirometry: post-bronchodilator fixed FEV1/FVC < 0.7

Sputum eosinophils > 3% or blood eosinophils > 300 is supportive, as well as previous documentation of bronchodilator improvement

58
Q

What is the first line therapy to treat asthma-COPD overlap?

A

LABA-ICS combo is first line.

59
Q

What did the REDUCE trial demonstrate?

A

5 days of prednisone was non-inferior to 14 days in treatment of COPDe.

60
Q

What are there ATS 2020 recommendations for smoking cessation?

A

Treat everyone with varenicline (+/- nicotine patch) even if they are not ready to quit smoking. Recommended duration is > 12 weeks.

61
Q

What is the definition fo bronchiectasis?

A

A chronic respiratory disease characterized by a clinical syndrome of cough, sputum production, and bronchial infection, as well as radiologically abnormal and permanent dilatation of the bronchi.

62
Q

What workup would you send for bronchiectasis?

A

(1) workup for ABPA - blood count, total IgE, sensitization to aspergillosis
(2) serum immunoglobulins
(3) Test for CF (sweat test)
(4) Test for primary ciliary dyskinesia (nasal nitric oxide)
(5) Sputum Cultures
(6) Other - RF, anti-CCP, ANCA, ANA, alpha-1 antitrypsin, HIV testing, videofluoroscopic swallow study to assess for aspiration.

63
Q

What is the duration of treatment recommended for bronchiectasis exacerbation?

A

14d of antimicrobial therapy

64
Q

What are the required criteria for the diagnosis of idiopathic pulmonary fibrosis?

A

Diagnosis requires:

(1) Exclusion of other known cause of ILD
(2) Demonstration of UIP pattern on high-resolution CT
(3) Specific combinations of HRCT pattern and histopathology patterns in patients subject to tissue biopsy.

65
Q

What are the two types of idiopathic interstitial pneumonia’s only see in COPD patients?

A
  • Respiratory Bronchiolitis-interstitial disease

- Desquamative interstitial lung disease.

66
Q

What investigations should you send in all patients with evidence of interstitial lung disease?

A

ANA, RF, anti-CCP - send more serology if clinically indicated
HRCT Chest
PFTs

67
Q

What are the classic radiographic findings of usual interstitial pneumonia?

A
  • Subpleural, basal predominant distribution
  • Honeycombing w/ or w/o peripheral traction bronchiectasis or bronchiolectasis
  • Reticular changes
  • Absence of inconsistent features
68
Q

What is the treatment for IPF?

A

Anti-fibrotic medications, including:

(A) Nintendanib
(B) Pirfenidone

69
Q

What is the evidence for corticosteroids in IPF?

A

NO ROLE for corticosteroids because they increase mortality.

70
Q

What is the role for immunosuppression in IPF?

A

NO ROLE for immunosuppression. Increased mortality.

71
Q

What is the role for supplemental oxygen in the treatment of IPF?

A

Supplemental O2 in:

(1) Resting hypoxemia (similar criteria as COPD)
(2) Exertional Hypoxemia (Sat < 88%) with improved walk distance or improved dyspnea on supplemental oxygen.

72
Q

What are the criteria for referral for lung transplant in IPF?

A

FVC < 80%
DLCO < 40%
Need Oxygen
Failed Pharmacotherapy

73
Q

What are the classic drugs that are known to induce ILD (4)?

A

Methotrexate
Amiodarone
Nitrofurantoin
Bleomycin

74
Q

How do you treat drug induced ILD?

A

Corticosteroids and drug withdrawal.

75
Q

What are the criteria for lung transplantation in COPD patients?

A

(1) FEV < or = 25% +/- PaCO2 > or = 55 mmHg

(2) Severe disease with resting hypoxemia < 55 mmHg

76
Q

What are the lung transplant criteria in cystic fibrosis and bronchiectasis?

A

(1) FEV1 < or = 30% +/- PaCO2 > 50 mmHg

77
Q

What value on PFTs tells you that there is gas trapping?

A

RV/TLC > ULN

78
Q

What value on PFTs tells you that there is hyperinflation?

A

TLC > ULN

79
Q

What value on PFTs tells you that there is restriction?

A

TLC < lower limit of normal

80
Q

What are 3 causes of isolated decreased DLCO?

A

(1) Pulmonary HTN
(2) Early ILD or Emphysema
(3) Anemia

81
Q

What are 3 causes of increased DLCO?

A

(1) Pulmonary hemorrhage
(2) Polycythemia
(3) L-sided heart failure

82
Q

What are the contraindications to PFTs (7)?

A

(1) Hemoptysis
(2) PNX
(3) Unstable cardiac status/recent MI
(4) Aneurysms
(5) Recent eye surgery
(6) Recent thoracic or abdominal surgery
(7) Presence of acute illness that may interfere with the test.

83
Q

What are the absolute contraindications to methacholine challenge test?

A
  1. Severe airflow limitation (FEV1 < 50% or < 1L)
  2. Recent MI or stroke (last 3 mon)
  3. Uncontrolled HTN (SBP200/DBP100)
  4. Known aortic aneurysm
84
Q

What are the relative contraindications to methacholine challenge test?

A

(1) moderate airflow limitation (FEV1 < 60%) or < 1.5L
(2) Pregnancy or nursing mothers
(3) Use of cholinesterase inhibitors

85
Q

What are the most important predictors in adverse perioperative pulmonary events?

A

(1) MOST IMPORTANT - surgical site (aortic > intrathoracic > upper abdominal > abdominal)
(2) Age
(3) Lung Disease

86
Q

What has been shown to reduce post-operative respiratory complications?

A

Epidural analgesia

87
Q

What is the most sensitive test for diaphragmatic weakness?

A

MIP

Respirology (6 decks)

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