Airway Disease Flashcards
What is symbicort?
Budesonide-formoterol
What is Singulair?
Monteleukast
What is Spiriva?
Tiotropium
What is Flovent?
Fluticasone
What are the two components of a diagnosis of asthma?
- History of respiratory symptoms that vary over time and intensity.
- Confirmed variable expiratory airflow limitation (on spirometry)
What are the symptom characterisitics that have been shown to decrease the likelihood of asthma (5)?
- Isolated cough w/no other respiratory symptoms.
- Chronic production of sputum
- SOB associated with dizziness, light-headed ness and parathesia.
- Chest pain
- Exercise-induced dyspnea with noisy inspiration.
How can you confirm variability on spirometry in individuals with suspected asthma to make the diagnosis?
- Positive bronchodilator reversibility (10-15 minutes after 200-400 mcg of salbutamol).
- Improvement in lung function with anti-inflammatory treatment x 4 weeks.
- Excessive FEV1 variation in lung function between visits.
- Peak flow variability (average daily diurnal PEF variability > 10%)
- Positive bronchial challenge test or exercise challenge test.
What is considered reversibility in lung obstruction on PFTs?
Improvement in FEV1 by > 12% AND 200 mL post bronchodilator
What is considered to be an excessive variation in FEV1 between lung-function tests?
> 12% AND 200 cc variation
How long do you have to hold a SABA before PFTs in order to ensure you can measure baseline lung function?
At least 4 hours before the test.
How do you interpret a methacholine challenge test?
PC20 < 4 mg/mL = POSITIVE
PC20 4-16 = Borderline
PC20 > 16 = NEGATIVE
What are the criteria that must be met to consider asthma controlled (9)?
- Daytime Sx < 4 days/wk
- Night-time Sx < 1 night/wk
- Physical Activity Normal
- Exacerbation = Mild, infrequent
- Absence from work or school = None
- Need for a SABA = < 4 doses/week
- FEV1 or PEF > or = 90% personal best
- PEF Diurnal Variation < 10-15%
- Sputum Eosinophils < 2-3%
What are the options for Step 1 in asthma treatment per the GINA 2020 guidelines?
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
What are the options for Step 2 for asthma treatment per the GINA 2020 guidelines?
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
What are the asthma treatment options for Step 3 in the GINA 2020 guidelines?
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
What is the recommended Step 4 asthma treatment per the 2020 GINA Guidelines?
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
What is the recommended asthma treatment for Step 5, as per the GINA 2020 guidelines?
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
What symptoms/signs correlate to each step of the GINA 2020 guidelines for initiation of asthma treatment?
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.
What did SYGMA 1 show?
Patients were randomized to receive:
- BID placebo + PRN SABA
- BID placebo + PRN budesonide-formoterol
- 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.
What did SYGMA 2 show?
Pragmatic trial. Patients randomized to:
- BID placebo + PRN budesonide/fomoterol
- 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.
In which asthma patients is treatment of with azithromycin recommended?
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.
What asthma substypes is an LTRA most effective for?
Aspirin-exacerbated asthma
Exercise-induced asthma
What is the black box warning on LTRAs?
Increased suicidal ITP in adolescents and adults.
What is the definition of severe asthma?
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.
What are the indications for IgE therapy in asthma?
Need to meet the following criteria:
- Allergic Asthma (IgE 30-700)
- Sensitive to at least one perennial allergen
- Severe asthma despite high dose ICS and one other controller
What are the indications for anti-IL5 therapy in asthma?
Severe eosinophilia asthma (generally > 300) and recurrent exacerbation despite high-dose ICS and one other controller
What is Samter’s triad?
- Asthma
- Nasal Polyps
- ASA/NSAID Sensitivity
How is the severity of airflow limitation in COPD defined?
Mild: FEV1 > or = 80% predicted
Moderate: 50% < or = FEV1 < 80 % predicted
Severe: 30% < or = FEV1 < 50% predicted
Very Severe: FEV1 < 30% predicted.
What is Grade 1 on the mMRC Dyspnea scale?
SOB when hurting on the level or walking slightly uphill.
What is Grade 0 mMRC?
SOB with strenuous activity.
What is mMRC Grade 2?
Walks slower than people the same age or has to stop for breath while walking on the level at own pace.
What is mMRC Gr. 3?
Steps for breath after walking ~ 100 m or after a few minutes walking on the level.
What is mMRC Gr. 4?
The patient is too breathless to leave the house or breathless with dressing and/or undressing.
In what setting does pulmonary rehabilitation improve survival and reduce exacerbations?
If started following a recent (<4 weeks) AECOPD.
How is high risk for AECOPD defined?
Two or more moderate exacerbations in the past year OR 1 or more requiring hospitalization or ED visit.
Who should be offered long term supplemental oxygen therapy (per CTS guidelines)?
- Severe hypoxemia (PaO2 < 55 mmHg) OR
- 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%
Which interventions increase survival in COPD patients?
- Smoking Cessation
- Supplemental O2 in patients with severe RESTING hypoxemia only.
- Pulmonary Rehab when < 4 weeks from recent COPDe.
In mild COPD without high risk of exacerbations, which is better: LAMA or LABA monotherapy?
LAMA monotherapy better prevents exacerbations.
Who is considered low risk for COPDe per CTS guidelines?
If they had 1 or fewer moderate exacerbations in the last year and DID NOT require an ED visit or hospitalization.
Explain which COPD patients with get a pneumococcal vaccination.
- Adults 65 or Older: 13-valent conjugated pneumococcal vaccine (PCV-13)
- Adults < 65: PPSV23 in those with FEV1 < 40% and in those with comorbidities.
What is the pharmacological category of Roflumilast?
Phosphodiesterase-4 Enzyme Inhibitor
In which COPD patients is roflumilast (AKA DAXAS) recommended?
It is recommended in all patients at high risk of AECOPD despite optimal inhales therapy.
In which COPD patients should you prescribe N-acetylcystine?
For patients with chronic bronchitis and high risk of AECOPD despite long-acting inhalers.
In which patients with COPD would you prescribe azithromycin?
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.*
Which therapies are recommended per CTS guidelines for treatment of dyspnea in advanced COPD?
- Oral Opioids
- Neuromuscular Electrical Muscle Stimulation
- Chest Wall Vibration
- Walking-AIDS
- Pursed-lip Breathing
- Continuous oxygen therapy for hyoxemic COPD patients reduces mortality and may reduce dyspnea.
What are the criteria to diagnose asthma-COPD overlap (per CT guidelines)?
- Diagnosis of COPD given risk factors, hx, spirometry.
- Hx of asthma (past hx/diagnosis, current symptoms consistent, or physiological confirmed w/spirometry).
- Spirometry: Post-bronchodilator fixed FEV1/FVC < 0.7
Supportive but not required:
- Documentation of a bronchodilator improvement of FEV1 by 200 mL or 12%
- Sputum eosinophils > 3%
- Blood eosinophils > 300 cells/uL
In which COPD patients has lung volume reduction surgery been shown to be increase survival?
Severe emphysema patients with upper-lobe pre-dominant disease and low post-rehabilitation exercise capacity.
In which COPD patients has lung transplant been show to improve QoL and functional capacity?
Bode 7-10 AND 1 of the following:
- Hospitalized w/COPDe with pCO2 > 50
- Pulmonary HTN/Cor Pulmonale despite supplemental oxygen.
- FEV1 < 20% with DLCO < 20%
Which patients with COPD should receive antibiotics for an exacerbation?
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):
- Increased Dyspnea
- Increased Sputum Volume
- Increased Sputum Purulence
Antibiotics should also be given if a patient requires invasive or non-invasive mechanical ventilation.
What are the benefits of steroids in moderate-severe COPDe?
- Faster recovery time
- Increased FEV1
- Reduce length of stay
When is BiPAP recommended for AECOPD?
- pH < or = 7.35 with pCO2 > or 45
- severe dyspnea (impending respiratory failure)
- persistent hypoxemia despite supplemental oxygen
What do you need to rule out in COPD patients before the initiation of azithromycin?
Sputum culture for NTM
Which non-pharmacological interventions definitely reduce the incidence of COPDe (Grade 1)?
- Annual Flu Vaccine
- Pulmonary Rehab (if RECENT exacerbation)
- Education & Case Management
What are the Grade 2 recommendations (suggested) for preventing COPDe?
Evidence dose not actually support reduced exacerbations at this time.
(1) Pneumococcal Vaccination
(2) Smoking Cessation
In which patients with COPD would you recommend the pneumococcal vaccine?
All COPD > 65
Significant Comorbidities
All with FEV1 < 40%
What are the recommended therapies for treatment of dyspnea in advanced COPD (6)?
(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.
What are the diagnostic criteria for asthma-COPD overlap?
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
What is the first line therapy to treat asthma-COPD overlap?
LABA-ICS combo is first line.
What did the REDUCE trial demonstrate?
5 days of prednisone was non-inferior to 14 days in treatment of COPDe.
What are there ATS 2020 recommendations for smoking cessation?
Treat everyone with varenicline (+/- nicotine patch) even if they are not ready to quit smoking. Recommended duration is > 12 weeks.
What is the definition fo bronchiectasis?
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.
What workup would you send for bronchiectasis?
(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.
What is the duration of treatment recommended for bronchiectasis exacerbation?
14d of antimicrobial therapy
What are the required criteria for the diagnosis of idiopathic pulmonary fibrosis?
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.
What are the two types of idiopathic interstitial pneumonia’s only see in COPD patients?
- Respiratory Bronchiolitis-interstitial disease
- Desquamative interstitial lung disease.
What investigations should you send in all patients with evidence of interstitial lung disease?
ANA, RF, anti-CCP - send more serology if clinically indicated
HRCT Chest
PFTs
What are the classic radiographic findings of usual interstitial pneumonia?
- Subpleural, basal predominant distribution
- Honeycombing w/ or w/o peripheral traction bronchiectasis or bronchiolectasis
- Reticular changes
- Absence of inconsistent features
What is the treatment for IPF?
Anti-fibrotic medications, including:
(A) Nintendanib
(B) Pirfenidone
What is the evidence for corticosteroids in IPF?
NO ROLE for corticosteroids because they increase mortality.
What is the role for immunosuppression in IPF?
NO ROLE for immunosuppression. Increased mortality.
What is the role for supplemental oxygen in the treatment of IPF?
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.
What are the criteria for referral for lung transplant in IPF?
FVC < 80%
DLCO < 40%
Need Oxygen
Failed Pharmacotherapy
What are the classic drugs that are known to induce ILD (4)?
Methotrexate
Amiodarone
Nitrofurantoin
Bleomycin
How do you treat drug induced ILD?
Corticosteroids and drug withdrawal.
What are the criteria for lung transplantation in COPD patients?
(1) FEV < or = 25% +/- PaCO2 > or = 55 mmHg
(2) Severe disease with resting hypoxemia < 55 mmHg
What are the lung transplant criteria in cystic fibrosis and bronchiectasis?
(1) FEV1 < or = 30% +/- PaCO2 > 50 mmHg
What value on PFTs tells you that there is gas trapping?
RV/TLC > ULN
What value on PFTs tells you that there is hyperinflation?
TLC > ULN
What value on PFTs tells you that there is restriction?
TLC < lower limit of normal
What are 3 causes of isolated decreased DLCO?
(1) Pulmonary HTN
(2) Early ILD or Emphysema
(3) Anemia
What are 3 causes of increased DLCO?
(1) Pulmonary hemorrhage
(2) Polycythemia
(3) L-sided heart failure
What are the contraindications to PFTs (7)?
(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.
What are the absolute contraindications to methacholine challenge test?
- Severe airflow limitation (FEV1 < 50% or < 1L)
- Recent MI or stroke (last 3 mon)
- Uncontrolled HTN (SBP200/DBP100)
- Known aortic aneurysm
What are the relative contraindications to methacholine challenge test?
(1) moderate airflow limitation (FEV1 < 60%) or < 1.5L
(2) Pregnancy or nursing mothers
(3) Use of cholinesterase inhibitors
What are the most important predictors in adverse perioperative pulmonary events?
(1) MOST IMPORTANT - surgical site (aortic > intrathoracic > upper abdominal > abdominal)
(2) Age
(3) Lung Disease
What has been shown to reduce post-operative respiratory complications?
Epidural analgesia
What is the most sensitive test for diaphragmatic weakness?
MIP
