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PT: Hematology & Pulmonary > Asthma/COPD > Flashcards

Asthma/COPD Flashcards

1
Q

Obstructive Chest Conditions:

A

disturbance of ventilation due to increased resistance to airflow in the airways (Asthma/COPD

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2
Q

Restrictive Chest Conditions:

A

disturbance of ventilation due to decreased chest wall or lung movement (fibrosis)

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3
Q

What are the selected obstructive chest disorders?

A
  1. Asthma
  2. COPD-Chronic Bronchitis, Emphysema
  3. Atelectasis
  4. Consolidation
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4
Q

What are the first five symptoms of obstructive chest disease?

A
  1. Chest pain
    * 2. Dyspnea*
    * 3. Wheezing*
    * 4. Cough*
  2. Hemoptysis
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5
Q

What is the etiology of dyspnea?

A

difficulty breathing
1. CV (left-sided heart failure)
2. Lungs (asthma, COPD, pneumonia)
3. Anxiety
SOB related to activity vs. difficulty taking deep breaths, smothering sensation, paresthesia

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6
Q

What is the etiology of wheezing?

A
  • relatively high pitched adventitious sounds with hissing or shrill, musical quality*
    1. May be audible without stethoscope
    2. Etiology: narrowed bronchi
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7
Q

What is etiology of cough?

A

Reflex response to endogenous or exogenous irritants in larynx, trachea, or large bronchi (lung/heart disease)

  • Dry vs. productive cough
  • If productive, volume, color, odor, consistency important
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8
Q

What are pulmonary function tests used for?

A
  1. help d/x and determine severity of chest conditions

2. monitor patients with chest conditions (disease progression, effect of treatment)

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9
Q

What does a pulmonary function test assess?

A
  1. Lung volumes
  2. Air flows rates
  3. Gas exchange
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10
Q

What is spirometry?

A
  • Measurement of breathing*

1. Used to measure volumes/capacities and flow rates

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11
Q

How do you complete spirometry?

A
  1. Pt. inhales maximally, then exhales forcibly and completely into spirometer
  2. May continue through maximal forced inspiration, depending on test performed
  3. May record volume as function of time as function of volume
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12
Q

Why use spirometry in obstruction?

A

individuals have a reduced ability to move air through the conducting airways of the lung (Asthma, COPD)

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13
Q

Why use spirometry in restriction?

A

individuals have most difficulty getting air into the lung and typically have decreased lung volumes (fibrosis)

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14
Q

Spirometry: FEV1

A

forced expiratory volume in first second of expiration

  • -pre/post bronchiodilator
  • ->12% improved = asthma
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15
Q

Spirometry: FVC

A

forced vital capacity

-helpful to determine fixed obstruction

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16
Q

Spirometry: TLC

A

total lung capacity

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17
Q

Spirometry: RV

A

residual volume (left after FVC)

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18
Q

Spirometry: DLco

A

diffusing capacity for carbon monoxide

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19
Q

Spirometry: FEV1/FVC

A

ratio to standardized and interpret results

Normal: > 75%

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20
Q

What effective do obstructive processes have on spirometry parameters?

A

decrease airway flow rates with relative preservation of forced vital capacity

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21
Q

What effective do restrictive processes have on spirometry parameters?

A

decreased forced vital capacity with relative preservation of flow rates

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22
Q

If disease is likely check the spirometry % FEV1/FCV:

A
  1. If the ratio 88-90% or higher = restrictive disease likely
  2. If the ratio is <75% = obstructive disease likely
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23
Q

What occurs with FEV1/FVC in asthma?

A

<75%

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24
Q

What occurs with FEV1/FVC in COPD?

A

<75%

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25
Q

What is asthma?

A
  1. a heterogenous clinical disorder characterized by episodic wheezing and hyper-responsiveness of the airway to a variety of stimuli
  2. largely reversible obstruction of the airways
  3. inflammation is present in the airways and over time remodeling may occur that in turn can cause permanent structural changes and decline liver function
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26
Q

What are the smooth muscle dysfunctions that occur during asthma?

A
  1. bronchoconstriction
  2. bronchial hyperreactivity
  3. hypertrophy/hyperplasia
  4. inflammatory mediator release
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27
Q

What airway inflammation occurs during asthma?

A
  1. inflammatory cell infiltration/activation
  2. mucosal edema
  3. cellular proliferation
  4. epithelial damage
  5. basement membrane thickening
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28
Q

What factors can lead to pre symptomatic/early disease and then onto clinical asthma?

A
  1. Genetic/host susceptibility for asthma

2. Environmental exposures, allergens, air pollutants, viral infections

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29
Q

what happens to the lung morphology in asthma?

A
  1. Bronchial inflammation
  2. Edema, mucus plugging
  3. Bronchospasm
  4. Obstruction
  5. Over inflation/atelectasis
  6. Characteristic of COPD
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30
Q

What is the notable micro pathology of asthma?

A
  1. Patchy necrosis of epithelium
  2. Sub-mucosal glandular hyperplasia
  3. Hypertrophy of bronchial SM
  4. Eosinophils, mast cells, lymphocytes
  5. Mucous plugs
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31
Q

What happens in the bronchial tissue in patients with asthma?

A
  1. Inflammation
  2. Eosinophils
  3. Gland hyperplasia
  4. Mucous plug in lumen
  5. Hypertrophy of muscle layer
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32
Q

What happens at the cellular level in asthma?

A
  1. Initiated by allergens
  2. Recruited to airway by other inflammatory cells
  3. Perpetuate tissue damage and inflammation (mast, Th2, eosinophils, neutrophils)
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33
Q

What are characteristic features of persistent asthma?

A
  1. Denudation of airway epithelium
  2. Collagen deposition beneath basement membrane
  3. Mast-cell degranulation
  4. Lymphocyte and eosinophil infiltration
  5. Release of cytokines and chemokines
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34
Q

What are the most common predisposing factors associated with asthma?

A
  1. History of atopy
  2. Initiation of asthma in early life
  3. Respiratory viral infections
  4. Exposure to airborne allergens
  5. Positive family history
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35
Q

Normal FEV1

A

> 80%

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36
Q

Normal FVC

A

> 80%

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37
Q

Mild obstruction FEV1/FVC and FEV1

A

<75%

70-100%

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38
Q

Moderate obstruction FEV1/FVC and FEV1

A

<75%

60-70%

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39
Q

Moderate/severe obstruction FEV1/FVC and FEV1

A

<75%

50-60%

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40
Q

Severe obstruction FEV1/FVC and FEV1

A

<75%

34-50%

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41
Q

well controlled asthma

  1. symptoms
  2. nighttime awakenings
  3. interference with normal activity
  4. SABA use
  5. FEV1 or peak flow
  6. exacerbations
A
  1. <2 days/week
  2. <2/month
  3. none
  4. <2 days/week
  5. > 80% predicted/personal best
  6. 0-1 per year
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42
Q

Not well controlled asthma

  1. symptoms
  2. nighttime awakenings
  3. interference with normal activity
  4. SABA use
  5. FEV1 or peak flow
  6. exacerbations
A
  1. > 2 days/week
  2. 1-3 per week
  3. some limitation
  4. > 2 days/week
  5. 60-80% predicted/personal best
  6. 2-3 per year
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43
Q

Very poorly controlled asthma

  1. symptoms
  2. nighttime awakenings
  3. interference with normal activity
  4. SABA use
  5. FEV1 or peak flow
  6. exacerbations
A
  1. Throughout the day
  2. > 4/week
  3. extremely limited
  4. several times per day
  5. <60% predicted/personal best
  6. > 3 per year
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44
Q

Questionnaires for asthma

A

ATAQ (asthma therapy assessment questionnaire)
ACQ (asthma control questionnaire)
ACT (asthma control test)

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45
Q

Well controlled asthma

  1. ATAQ
  2. ACQ
  3. ACT
A
  1. 0
  2. <0.75
  3. > 20
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46
Q

Not well controlled asthma

  1. ATAQ
  2. ACQ
  3. ACT
A
  1. 1-2
  2. > 1.5
  3. 16-19
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47
Q

Very poorly controlled asthma

  1. ATAQ
  2. ACQ
  3. ACT
A
  1. 3-4
  2. N/A
  3. <15
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48
Q

Indirect costs of asthma

A

$5 billion

  • lost productivity at work
  • schooldays lost
  • mortality
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49
Q

Direct costs of asthma

A

$14.7 billion

  • hospital care
  • physical and other health services
  • Rx meds
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50
Q

Treatment success of asthma

A
  • no missed school/work days
  • no sleep disruption
  • maintain normal activity levels
  • no (or minimal) ER visits
  • normal or near normal lung function
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51
Q

Severity

A

intrinsic intensity of disease

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52
Q

Control

A

degree to which asthma is minimized

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53
Q

Responsiveness

A

ease with which asthma control is achieved

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54
Q

impairment

A

frequency and intensity of symptoms and functional limitations

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55
Q

risk

A

likelihood of either exacerbations, progressive decline in lung function or risk of ADEs from meds

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56
Q

When is spirometry recommended for asthma?

A
  • at initial assessment
  • during stabilization phase PRN
  • after treatment has stabilized symptoms
  • at least every 1-2 years
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57
Q

When FEV1 increases ____% after using SABA this is reversible

A

12

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58
Q

Additional tests for asthma

A
  • bronchoprovocation (Histamine challenge, methacholine challenge)
  • exercise/treadmill testing
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59
Q

Alternative strategies for asthma

A
  • FENO
  • sputum eosinophils
  • videolaryngostroboscopy
  • chest X ray
  • allergy skin test
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60
Q

What are common comorbidities that can aggravate asthma?

A

VCD
GERD
allergic rhinitis

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61
Q

Symptom history for asthma should be based on what?

A

2-4 week recall period

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62
Q

How do you monitor lung function in asthma?

A

peak flow monitoring

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63
Q

Red zone

A

<50%

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64
Q

Yellow zone

A

50-80%

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65
Q

Green zone

A

80-100%

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66
Q

t/f partnership in asthma care is important

A

true

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67
Q

A key principle of pharmacologic care in asthma is

A

regulation of chronic airway inflammation

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68
Q

In general ____ medication is superior to ____ in asthma control

A

inhaled

Oral or IV

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69
Q

Low dose fluticasone MDI

A

88-24 mcg

44 mcg per puff = 1-3 puffs/day

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70
Q

Medium dose fluticasone MDI

A

264 - 440 mcg
110 mpg/puff = 2 puffs BID
220 mcg/puff = 1 puff BID

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71
Q

High dose fluticasone MDI

A

> 440mcg

110mcg/puff = 3 puffs BID
220 mcg/puff = 2 or more puffs BID

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72
Q

Low dose fluticasone DPI

A

100 - 300mcg

50mcg per inhaler = 1-3 BID

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73
Q

Medium dose fluticasone DPI

A

300-500 mcg
100mcg per inhalation = 2 BID
250 mcg per inhalation = 1 BID

74
Q

High dose fluticasone DPI

A

500 mcg
100 mcg per inhalation = 3 or more BID
250 mcg per inhalation = 2 or more BID

75
Q

What is the most effective long term anti-inflammatory controller therapy for persistent asthma?

A

ICS

76
Q

T/f all patients respond adequately to ICS

A

false!
smokers, neutrophilic patients may not
1/3 nonresponders

77
Q

Benefits of daily use of ICS

A
  • fewer symptoms
  • fewer severe exacerbations
  • reduced use of quick relief meds
  • improved lung function
  • reduced airway inflammation
78
Q

potential ADE of ICS

A

thrush
osteoporosis or stunted bone growth
HPA axis suppression (at high doses)ty

79
Q

What is typical dosing of ICS?

A

BID typically
QD may be enough for mild
- based on severity

80
Q

How is cromolyn used in asthma?

A
  • mild persistent asthma

- used as controller, not rescue

81
Q

Who is cromolyn typically used for?

A
  • meds
  • seasonal allergies
  • steroid intolerant
  • pregnant
82
Q

Typical dosing of cromolyn

A

TID to QID

83
Q

side effects of cromolyn

A

virtually none

84
Q

T/f LABA can be a substitute for anti-inflammatory meds

A

false!

Not for monotherapy

85
Q

When is LABA used?

A

in combo with ICS

86
Q

What are leukotriene modifiers used for?

A

long term therapy in mild persistent asthma

or add on in moderate to severe persistent asthma

87
Q

What asthma med can be used in children as young as 2 and take at bedtime?

A

leukotriene modifiers

88
Q

When would you use a combo asthma med?

A

persistent asthma

require daily anti-inflammatory and bronchodilation therapy

89
Q

How do combo products help with compliance?

A
  • decrease frequency of use
  • decrease need for coordination
  • improve patient inventory control
90
Q

T/f it is okay to use a combo product even if you only need one of the meds

A

false!!

only use if both are necessary for treatment

91
Q

Who would you use Omalizumab in?

A

persistent asthma >1 year

  • inadequately controlled on combo therapy
  • controlled on high dose ICS
92
Q

What should your IgE level be to take omalizumab?

A

30-700

93
Q

T/f you can take omalizumab at home

A

false

- must be administered by provider in office

94
Q

Which drug targets IgE for asthma?

A

omalizumab (Xolair)

95
Q

Which drugs target the IL-4/5 receptors for asthma?

A

eosinophil modifiers

96
Q

What is the most effective medication for PRN relief of asthma?

A

SABA

97
Q

Why is regular schedule of SABA not recommended?

A

may lower effectiveness

may increase airway hyperresponsiveness

98
Q

Should SABA be B1, B2 or nonselective?

A

B2

99
Q

What type of drugs can be used for long term control of asthma?

A 
ICS
Cromolyn
LABA
methylxanthines
Leukotriene modifiers
Combo
Anti-IgE
IL-5 agents
100
Q

What type of drugs can be used for short term control of asthma?

A

SABA
anticholinergics
systemic corticosteroids

101
Q

What type of drug is ipratropium?

A

anticholinergic

102
Q

What type of drug is tiotropium?

A

anticholinergic

103
Q

When is prednisone burst therapy recommended?

A

short term use during moderate to severe exacerbations

104
Q

T/f you can use regularly scheduled prednisone for asthma

A

false!

not recommended, increase risk of ADE

105
Q

Step 1 treatment of asthma

A

mild intermittent

- SABA PRN

106
Q

Step 2 treatment of asthma

A

mild persistent
- low dose ICS

alt: cromolyn, nedocromil, LTRA or theophylline

107
Q

Step 3 treatment of asthma

A

moderate persistent
- medium dose ICS

OR Low dose ICS + LABA

alt: low ICS + either LTRA, theophylline or Ziluetin

108
Q

Step 4 treatment of asthma

A

moderate persistent
- Medium dose ICS + LABA

Alt: med ICS + either LTRA, theophylline or zileuton

109
Q

Step 5 treatment of asthma

A

Severe persistent
- high dose ICS + LABA

AND
Consider omalizumab (allergies)
110
Q

Step 6 treatment of asthma

A

severe persistent
- high dose ICS + LABA + oral corticosteroid

AND 
Consider omalizumab (allergies)
111
Q

When should you step down on asthma treatment?

A

if well controlled for at least 3 months

112
Q

t/f you should start higher and more aggressive in treatment for asthma

A

true

step down as needed

113
Q

What steps should you consider a referral to a specialist?

A

3-4

114
Q

What steps should you recommended a referral to a specialist?

A

5-6

115
Q

2 main goals of asthma treatment

A

reduce impairment

reduce risk

116
Q

How often should you follow up with well controlled asthma patients?

A

every 6 months

more frequently if needed

117
Q

When should you step up asthma treatment?

A
  • awakens at night
  • urgent care visit
  • evidence of deceased PEF
  • SABA >2/week
118
Q

Before increasing medications for asthma what should you check?

A
  • inhaler technique
  • adherence to prescribed regimen
  • environmental changes
  • reconsider alternative diagnosis
119
Q

What should an action plan include?

A
  • signs, symptoms, peak flow levels
  • how to adjust meds in response to deteriorating asthma
  • when to seek help
  • emergency phone numbers
120
Q

Home treatment of exacerbation initially

A

inhaled SABA up to 2 treatments of 2-6 puffs at 20 min intervals

121
Q

Good response to initial therapy for exacerbation for home treatment

A

contact clinician
continue SABA
consider oral steroids

122
Q

Incomplete response to initial therapy for exacerbation for home treatment

A

contact clinician urgently
continue SABA
add oral steroid

123
Q

Poor response to initial therapy for exacerbation for home treatment

A

proceed to ER
repeat SABA immediately
add oral steroid

124
Q

systemic corticosteroids in elderly

A

can provoke confusion, agitation, changes in glucose metabolism

125
Q

ICS in elderly should also be treated with what?

A

calcium supplement
Vitamin D
estrogen replacement

126
Q

What other medications may exacerbate asthma?

A

NSAIDs
nonselective B blockers
B blockers in some eye drops

127
Q

What shots should you get if you have asthma?

A

flu vaccine
pneumovax
prevnar 13: routine 2-59 months

128
Q

Diagnosis of exercise induced bronchospasm (EIB)

A

history of symptoms

exercise challenge or do task that provokes symptoms

129
Q

How long can SABA last in EIB?

A

2-3 hours

130
Q

Salmeterol and EIB

A

can prevent for 10-12 hours

NOT PRN use!!

131
Q

t/f you can use cromolyn for EIB?

A

true

132
Q

Managing seasonal asthma symptoms

A
  • start anti-inflammatory before allergy season

- continue during allergy season and use step wise approach to control symptoms

133
Q

Patients with asthma going into surgery are at risk for what type of complications?

A

perioperative

134
Q

How can you reduce risk in asthma patients going into surgery?

A
  • pre-op eval with PFT

- improve lung function before (consider steroid)

135
Q

Maternal asthma can increase risk of

A

perinatal mortality
pre-eclampsia
pre-term birth
low birth weight infants

136
Q

T/f it is safer to be treated with asthma meds than to have asthma symptoms in pregnancy

A

true

137
Q

What is the preferred bronchodilator in pregnancy?

A

albuter

138
Q

What are the preferred controlled therapy in pregnancy?

A

ICS

139
Q

t/f montelukast can be used in pregnancy

A

true

140
Q

t/f you can use burst steroids in pregnancy

A

true

141
Q

Who are high risk asthma patients?

A
  • history of sudden severe exacerbations
  • prior intubation or admin to ICU for asthma
  • 2 or more hospitalizations in past year
  • 3 or more ER visits in past year
  • use >2 canisters per month of SABA
142
Q

t/f males are more likely to have COPD than women

A

false

Women >men

143
Q

What is the main environmental risk factor for COPD?

A

cigarettes

144
Q

what is a permanent air space enlargement with weakened and collapsed air sacs with excess mucus?

A

emphysema

145
Q

What is it when a patient has chronic productive cough for 3 months during 2 consecutive years?

A

chronic bronchitis

146
Q

classic symptoms of COPD

A
  • cough
  • dyspnea
  • wheezing
  • sputum production
147
Q

Emphysema

  1. age
  2. dyspnea
  3. cough
  4. sputum
  5. bronchial infections
  6. respiratory episodes
  7. chest x ray
A
  1. 60+
  2. severe dyspnea
  3. cough after dyspnea
  4. scanty, mucoid sputum
  5. bronchial infection < frequent
  6. respiratory episodes often terminal
  7. increased diameter, flattened diaphragm
148
Q

Chronic bronchitis

  1. age
  2. dyspnea
  3. cough
  4. sputum
  5. bronchial infections
  6. respiratory episodes
  7. chest x ray
A
  1. 50+
  2. mild dyspnea
  3. cough before dyspnea
  4. copious, purulent sputum
  5. bronchial infection > frequent
  6. respiratory episodes repeated
  7. broncovascular mar, enlarged heart
149
Q

Prednisone burst dose

A

60mg QD for 7 days

150
Q

Is cor pulmonate more common in chronic bronchitis or emphysema?

A

chronic bronchitis

151
Q

Pulmonary HTN in COPD leads to ____

A

death!

152
Q

symptoms of COPD

A

cough
sputum
SOB

153
Q

_____ is the gold standard for diagnosis of COPD

A

spirometry

154
Q

Chronic symptoms of COPD

A

cough
sputum
production

155
Q

What stage is someone who has normal spirometry with chronic symptoms of COPD?

A

stage 0: at risk

156
Q

What stage is someone who has FEV1/FVC <70%, FEV1 >80% and with or without chronic symptoms of COPD?

A

stage 1: mild COPD

157
Q

What stage is someone who has FEV1/FVC <70%, FEV <80% and with or without chronic symptoms of COPD?

A

stage 2: moderate COPD

158
Q

What stage is someone who has FEV1/FVC <70%, FEV1 between 30-50% with or without chronic symptoms of COPD?

A

stage 3: severe COPD

159
Q

What stage is someone who has FEV1/FVC <70%, FEV1 <30% or <50% with chronic respiratory failure?

A

stage 4: very severe COPD

160
Q

2 assessments in COPD

A

mmrc (medical research council questionnaire)

cat (COPD assessment test)

161
Q

Gold 1

A

FEV1 >80%

162
Q

Gold 2

A

FEV1 50-79

163
Q

Gold 3

A

FEV1 30-49

164
Q

Gold 4

A

FEV1 <30

165
Q

Category A COPD

A
  • less risk (< 1exacerbations/year)
  • less symptoms (<10 CAT; 0-1 mMRC)
  • GOLD 1-2
166
Q

Category B COPD

A
  • less risk (< 1 exacerbations/year)
  • more symptoms (>0 CAT; >2mMRC)
  • GOLD 1-2
167
Q

Category C COPD

A
  • High risk (>2 exacerbations/year)
  • Less symptoms (<10 CAT; 0-1 mMRC)
  • GOLD 3-4
168
Q

Category D COPD

A
  • High risk (>2 exacerbations/year)
  • More symptoms (>10 CAT; >2 mMRC)
  • GOLD 3-4
169
Q

Group A COPD treatment

A

bronchodilator

170
Q

Group B COPD treatment

A

LAMA or LABA

171
Q

Group C COPD treatment

A

LABA + ICS

172
Q

Group D COPD treatment

A

LABA + LAMA + ICS

173
Q

COPD comorbidities

A 
CVD
osteoporosis
Respiratory infections
anxiety
depression
diabetes
lung cancer
174
Q

additional screenings for COPD

A
  • chest x ray (co-morbidities)
  • lung volume capacity
  • oximetry
  • a-1 antitrypsin deficiency screening
175
Q

Salmeterol, formoterol and tiotropium are what type of drug?

A

bronchodilator

ALL DPI

176
Q

What is the GOLD guideline recommendation for first line in management of symptomatic COPD?

A

bronchodilators

177
Q

Long acting inhaled bronchodilators vs short acting

A

long: more convenient, more costly
short: less convenient, less costly

178
Q

T/F ICS withdrawal may lead to COPD exacerbation

A

true

179
Q

Vaccines recommended in COPD

A

flu

pneumovax

180
Q

When should you use antibiotics in COPD?

A

if suspected infection

- azithromycin, erythromycin

181
Q

What are some non-pharmacologic ways to treat COPD?

A
  • exercise training
  • pulmonary rehab
  • oxygen therapy
  • surgical treatments

PT: Hematology & Pulmonary (8 decks)

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