Clin Med: Pulm I Flashcards
What kind of disorder is asthma?
chronic inflammatory airway disorder w/ obstruction
What can predispose you to asthma? (endogenous)
- genetic predisposition
- atopy
- airway hyperresponsiveness
- gender
- ethnicity
- obesity
- early viral infx
What can predispose you to asthma? (environmental)
- indoor & outdoor allergens
- occupational sensitizers
- passive smoking
- respiratory infxs
- air pollution
- diet
- dampness & mold exposure
- acetaminophen
Asthma triggers
- allergens
- viral URI
- exercise & hyperventilation
- cold air
- sulfur dioxide & irritant gases
- drugs (B-blockers, aspirin)
- stress
- irritants
Asthma pathophysiology
1) trigger
2) airway inflammation
3) combo: hypersecretion of mucus, airway muscle constriction, swelling bronchial membranes
4) narrow breathing passages
— small & large airways
5) wheezing, cough, SOB, tightness in chest
Asthma: History
- recurrent wheezing
- difficulty breathing
- chest tightness
- cough
- can be WORSE AT NIGHT
- family history of asthma, allergy, atopy
It is unlikely asthma if
- lack of improvement after Tx w/ bronchodilator
- onset after 50
- Hx of >20 pack year history smoking
Asthma: clinical findings
- EXPIRATORY wheezing
- multiple pitches starting & stopping in the resp cycle
Asthma: clinical finding if severe airflow obstruction
- tachypnea
- tachycardia
- decreased 02 saturation
- accessory muscle usage
- tripod position
Asthma: signs of atopy
- cobblestone appearance of pharynx (allergic rhinitis)
- nasal polyps
- atopic derm
Which cell has an excessive reaction during asthma
TH2 cells (involved in atopic triad)
What does IL-4 do?
- activated IgE antibodies
- they bind to mast cells & release histamines, leukotrienes, & prostaglandins
What does IL-5 do?
- activates eosinophils
- stimulates release of cytokines & leukotrienes
With obstructive disorders, patients cannot fully ___.
exhale
With restrictive disorders, patients cannot fully ___.
inhale
Test to run when there is clinical suspicion of asthma.
- PFT or chest x-ray
Pulmonary Function testing involves___
- spirometry measuring FEV1 & FVC
- bronchodilator response
- Bronchoprovocation testing
What is spirometry measuring
how much air is being exhaled at any time
Chest x-ray involves___
- done if Dx is unclear
- CXR almost always normal in asthma
- Helpful if Pt. has fever, chronic purulent sputum, hemoptysis, weight loss (rules things in/out)
- Possible CT if CXR abnormal
Review: FEV1 & FVC
- forced expiratory volume in 1 sec
- forced vital capacity (total exhaled air)
Describe Asthma: intermittent
- symptoms </= 2x a week
- night symptoms </= 2x monthly
- rescue meds </= 2days/week
- asymptomatic b/t flares
- FEV1 > 80% of predicted
Describe asthma: mild persistent
- symptoms > 2x a week but not daily
- night symptoms 3-4x monthly
- rescue meds > 2 days/wk but not > 1x/day
- minor limitations b/t flares
- FEV1 > 80% predicted
Describe asthma: moderate persistent
- symptoms are daily
- night symptoms > 1x a week, but not nightly
- rescue meds daily
- some limitation b/t flares
- FEV1 > 60% predicted
Describe asthma: severe persistent
- symptoms throughout the day
- night symptoms several times per day
- rescue meds several times/day
- extremely limitations
- FEV1 < 60% predicted
GINA cycle of asthma care - 3 steps
- Assess: dx, inhaler comprehension, Pt. preferences, symptom control
- Tx: meds, non pharm strategies, Treat modifiable risk factors
- Review: symptoms exacerbations, SEs of meds, lung function, Pt. satisfaction
What are the two goals of asthma care?
- decrease impairment
- decrease risk of severe attack
Non-pharm Tx for asthma
- encourage exercise
- stop smoking
- Pt. edu
- control triggers
What are the starting points for treatment in asthma: stages and which severity stage
Stage 1: mild intermittent
Stage 2: mild persistent
Stage 3: moderate persistent
Stage 4: severe persistent
Asthma: stage 1 Tx
- mild intermittent
- low dose ICS - formoterol OR
low dose ICS
-control & rescue are the same b/c this is the mild intermittent asthma
Asthma: stage 2 Tx
- mild persistent
- Con: low dose inhaled corticosteroid (ICS)
- Res: ICS - formoterol
Asthma: stage 3 Tx
- moderate persistent
- Con: low dose ICS-LABA
- Res: ICS formoterol or SABA
Asthma: stage 4 Tx
- severe persistent
- Con: medium dose ICS-LABA
- Res: ICS - formoterol or SABA
Asthma: stage 5 Tx
- Con: high dose ICS-LABA
- Res: ICS-formoterol or SABA
Asthma is being controlled if…
- daytime symptoms None (</= 2/wk)
- no limits to activities
- no night awakenings
- rescue meds (</= 2/week)
- normal lung function
Asthma is partially controlled if…
- daytime symptoms >/= 2/week
- any limits to activities
- any night awakenings
- rescue meds >2x/wk
- < 80% predicted
Asthma: w/ kids, what is the preferred method of rescue?
SABA (albuterol)
Say you are in a primary care office and a patient comes in with the following symptoms, what would your treatment be?
broken sentences, not agitated, inc RR, HR 100-120, no acc. m. use, RA = 90-95%
- mild/moderate asthma
- SABA via MDI or neb
prednisolone: oral or IV
O2 if needed - reassess at 1 hour: if improved discharge with at home instructions
Say you are in a primary care office and a patient comes in with the following symptoms, what would your treatment be?
speaking in words, tripoding, rr>30, acc. m. use, HR= > 120
-severe asthma
- call 911
- SABA
- ipratropium
- O2
- prednisolone
Asthma: mild (dyspnea w/ activity) Exacerbations Tx
- SABA (inhaled or nebulizer)
- short course oral corticosteroids
Asthma: moderate (dyspnea interferes w/ activity–> symptoms improve in 1-2 days) exacerbations Tx
- SABA (may add ipratropium)
- Oral corticosteroids
Asthma: severe (dyspnea at rest) last longer than 3 days exacerbations Tx
- req hospitalization
- SABA/ipratropium hourly or continuously
- oral corticosteroids
- adjunctive tx (02 therapy, IV MgSO4, intubation/mechanical ventilation)
When do you refer a patient w/ asthma to a specialist?
- S/S are atypical
- Difficulty achieving or maintaining control of asthma
- Persistent asthma requiring step 4 care or higher
Asthma: Pt. Edu
- smoking cessation
- avoid triggers
- pneumococcal/flu vaccine recommended
- caution w/ NSAIDS/ASA (esp. aspirin)
- asthma diary
- properly use inhalers
- clear asthma tx plan w/ an emergency care plan in place
Risk of asthma related death increased if ___
- previous severe exacerbation
- 2 or more hospitalization in the past year
- 3 or more ED visits in the past year
- 2 or more canisters of SABA per month
- low socioeconomic status or inner-city resident
COPD is characterized by
persistent respiratory symptoms & airflow limitation that is not fully revisible
COPD includes what 3 conditions? (that occur together)
- chronic bronchitis
- emphysema
- small airway disease
Chronic bronchitis clinical dx is defined by___
excessive secretion of mucous & daily cough for 3 months or more in 2 consecutive year
Emphysema is a pathologic dx with ___
abnormal enlargement of air spaces distal to the terminal bronchiole, w/ destruction of alveolar walls
(Look at lung tissue itself. can be seen on CT)
Risk factors for COPD
- cigarette smoking
- occupational exposures
- ambient air pollution
- 2nd hand smoke
- genetic (alpha 1 antitrypsin deficiency)
Chronic bronchitis large airways pathophys
oxidants from cigarette smoke cause mucous gland hyperplasia –> increased mucous production–> chronic cough
chronic bronchitis small airways pathophys
edema/increases mucous production/fibrosis–> airway narrowing/airway resistance
Chronic bronchitis alveoli pathophys
- macrophages release enzymes that digest alveolar walls–> decreases area for gas exchange–> damage to capillaries
- damage to elastin fibers causes airway collapse
Emphysema pathophys
- structural changes in alveoli
- inflammatory reaction in the alveoli attract immune cells, release chemicals/enzymes–> breaks down collagen & elastin
- airways collapse during exhalation, causing air trapping
- alveoli eventually coalesce into large air filled spaces (reduced surface area for gas exchange)
Chronic bronchitis: pink puffer s/s
-CO2 retention*
-min cyanosis*
-pursed lip breathing*
-dyspnea
-hyperressonance
-barrel chest*
-prolonged expiration
-anxious
-accessory muscle use
-thin
Chronic bronchitis: blue bloater s/s
-airway flow problem
-cyanotic
-recurrent cough and sputum
-hypoxia
-hypercapnia
-resp. acidosis
-inc Hgb
-digital clubbing
-enlarged heart
-accessory m use
-right side heart failure: bilateral pedal edema, JVD
Age when COPD presents…
40-50 years old
COPD Hx symptoms that may be present for months-years…
- cough
- sputum production
- exertional dyspnea
- physical activity changes?
- smoking?
Symptoms in Hx for advanced COPD
- hypoxemia
- pneumonia
- pulmonary HTN
- Cor pulmonale
- Respiratory failure
PE findings in early stages of COPD
usually normal exam
PE findings in later stages of COPD
- prolonged expiratory phase
- expiratory wheezing
- signs of hyperinflation
- accessory muscle use/ cyanosis in acute exacerbation
PE findings in advanced COPD
cachexia (very poor Px factor)
PE findings in acute exacerbation of COPD
- wheezing, tachypnea, decreased mental status
Most acute exacerbations of COPD are triggered by___
resp infx
Dx testing for COPD
- PFT
- Chest x-ray
- CT
Dx results of PFT for COPD
reduction in FEV1 & FEV1/FVC
Dx results for chest x-ray in COPD
normal or show hyperinflation w/ emphysema
Why run a CT in pt. with COPD
more sensitive/specific for dx of emphysema
What is used to assess the severity of COPD
“CAT” score
Describe the “CAT” score
used to assess progression, decline in functional status, & gauge effectiveness of pulm rehab
COPDL: initial Tx is based on
GOLD classification:
this is the CAT score + number of exacerbations
COPD: what is the Tx for a pt. w/ a CAT <10 & >2 moderate exacerbations w/ 1 leading to hospitalizations?
LAMA
Group C
COPD: what is the tx for a pt w/ a CAT <10 & 1 or 2 exacerbations w/o hospitalization?
bronchodilator
Group A
COPD: what is the Tx for a pt. w/ a CAT of 10 or more & >2 exacerbations w/ a hospitalization?
LAMA + LABA or
ICS + LABA
Group D
COPD: what is the Tx for a pt. w/ a CAT of 10 or more & 0-1 exacerbations leading to no hospitalizations?
LABA or LAMA
Group B
Describe the group categories for COPD.
- Group A: less symp, low risk
- Group B: more symp, low risk
- Group C: less symp, high risk
- Group D: more symp, high risk
Describe COPD: Group A
less symp, low risk
Describe COPD: Group B
more symp, low risk
Describe COPD: Group C
less symp, high risk
Describe COPD: Group D
more symp, high risk
COPD: medications for acute exacerbations
- albuterol (SABA) (inhale or neb)
- ipratropium (anticholinergic)
- prednisone (oral glucocorticoids)
- Abx (mod or severely ill patients)
- O2, bipap, intubation if needed
COPD: Abx that can be used to treat acute exacerbations
- levofloxacin
- moxifloxacin
- doxycycline
COPD: Pt. Edu
- smoking cessation
- get flu & pneumococcal vaccine
- careful exercise programs
Make a COPD referral if…
- onset before 40yo
- 2+ exacerbations/year
- severe or rapid progression
- need for long term O2 therapy
Make a COPD admission to hospital if…
- failing to respond to outpatient tx
- worsening hypoxemia, peripheral edema
- can’t maintain nutrition/hydration due to symptoms
With COPD, what is alpha 1 antitrypsin (A1AT)deficiency?
an autosomal dominant genetic disorder that leads to an overproduction of elastace
COPD: What is elastace?
an enzyme that breaks down elastin in the lungs & liver
When to suspect A1AT deficiency in a Pt?
develop COPD earlier than age 40
COPD: Dx test for A1AT deficiency
- serum level of A1AT
- genetic testing
COPD: Tx for A1AT deficiency
- COPD Tx + infusions of A1AT
- Lung transplant
Bronchiectasis is a disease of what?
- bronchi & bronchioles
- permanent dilation & destruction of bronchial walls
Bronchiectasis: focal development
obstruction (aspirated foreign body, mass)
Bronchiectasis: diffuse development
infection
immunodeficiency (AIDs)
genetic
autoimmune
recurrent aspiration
idiopathic (most common)
Bronchiectasis: infectious pathophysiology
poor mucociliary clearance results in microbial colonization
Bronchiectasis: non infections pathophysiology
immune mediated reactions that damage the bronchial wall
Bronchiectasis: biggest pathophys concern
IMPAIRED SECRETION CLEARANCE
Bronchiectasis: History
persistent productive cough w/ ongoing production of thick sputum
Bronchiectasis: Physical
- crackles & wheezing on lung auscultation
- In later stages, may have clubbing of digits
Bronchiectasis: Dx labs/imaging
- CXR: “tram tracks”–> lacks sensitivity
- Chest CT: “tram tracks” or “signet ring” appearance–> more more sensitive & specific
Bronchiectasis: treatment
-treat underlying disease
-hospitalization if tachy, hypotensive, fever, hypoxemia, failure to improve with abx
-mucolytic agents/airway hydration
-bronchodilators, oral/inhaled glucocorticoids
Bronchiectasis: acute exacerbation Tx
(based on culture results)
fluoroquinolone empirically (levofloxacin, moxifloxacin)
CF: genetic factor
autosomal recessive exocrinopathy
CF is a ___, ___, & ___ disease
respiratory, pancreatic, hepatobiliary
CF: which gene regulates chloride
CFTR
CF: pathophys
CFTR gene is affected–> Cl- channels don’t function right–> abnormal transport of Cl- & NA+ across epithelium–> results in abnormal secretions in the lungs & GI tract
CF: clinical findings
- resp findings: productive cough, very thick sputum, wheezing, recurrent pneumonia, exercise intolerance, dyspnea
- chronic airway infx begin in infants leading to bronchiectasis
- severe sinus disease
CF: What is the cause of chronic airway infx?
- S. aureus
- pseudomonas
- h. influenzae
CF: acute exacerbations hx/PE
increased cough, sputum production
CF: Dx - labs/imaging
- ** Elevated sweat chloride (>60mmol/L)
- genetic testing: presence of 2 dz causing mutations
- abnormal nasal potential difference if other results are inconclusive
CF: Tx for airway clearance
- inhaled tx (albuterol, hypertonic saline, Dnase)
- Chest PT
- Exercise
CF: prevention of infx tx
- seasonal flu vaccine
- pneumococcal vaccine
Influenza A & B cause seasonal epidemics during what time of the year?
October to May
Flu: Pathophys has what two types of glycoproteins in the outer membrane?
- Hemagglutinin
- Neuraminidase
Flu viruses are exceptionally good at:
- Antigenic drift: mutations during replication that occur in HA & NA
- Antigenic shift: complete change in HA, NA, or both
How is the flu spread?
via air droplets or contaminated hands
The flu virus ____ viscosity of ___, promoting _____.
lowers; mucous, spread of the virus
Flu: incubation time & viral shedding time
Incubation: 1-4 days
Viral shedding: from one day prior to sx to day 5
Flu: History/Physical
- Sudden onset fever, chills, fatigue, myalgia, malaise
- appears ill w/ sweating, coughing, diffuse pharyngeal erythema
- lung exam w/ scattered rales, rhonchi, wheezes
- may have muscle pain elicited w/ pressure
Flu: Dx - Labs/Imaging
- largely based on clinical findings
- nasal swab for rapid test
- nasal swab for PCR
Flu: tx
oral oseltamivir
Who should get vaccinated for the flu?
Everyone
How is pertussis spread
- aka whopping cough
- caused by Bordetella pertussis
- Lasts 6 wks
- vaccine preventable, immunity decreases overtime
How is pertussis spread?
via respiratory droplets
Pertussis: pathophys
bacteria attach to ciliated cells & causes destruction of the cilia
leads to cough & inability to clear secretions
PT: pertussis toxin
TCT: tracheal cytotoxin
LPS: lipopolysaccharides
Pertussis Stage 1: catarrhal stage length
1-2 weeks
Pertussis Stage 1: catarrhal stage symptoms
runny nose, low-grade fever, mild, occasional cough
Highly contagious
Pertussis Stage 2: Paroxysmal stage length
1-6 weeks, may go up to 10
Pertussis Stage 2: Paroxysmal stage symptoms
numerous fits, rapid coughs w/ whoop sound; vomiting & exhaustions after coughing
Pertussis Stage 3: Convalescent stage length
2-3 weeks
Pertussis Stage 3: Convalescent Stage symptoms
recovery is gradual, cough lessens, but fits may return
Pertussis Dx - labs/imaging
- nasopharyngeal swab or nasopharyngeal aspirate (PCR) or culture
- serologic testing
Pertussis Tx: within 3 wks of onset
- Azithromycin, Clarithromycin
- eradicates bacteria , helps to prevent spread
Pertussis Tx: after 3 wks:
- no tx needed - cough is related to tissue damage
Pertussis: Tx for cough
dextromethorphan (DM)
Pertussis: post exposure prophylaxis Tx
- household contacts, regardless of vaccination history
- same medication as tx
(azithromycin, clarthromycin)
Pertussis: vaccine recommendations for infants & children
- 5 doses DTaP 2mo, 4mo, 6mo, 15mo, 18mo, & 4-6 yo
Pertussis: vaccine recommendations for adolescents
single dose of Tdap, 11-12 yo
Pertussis: vaccine recommendations for pregnant women
single dose of Tdap during, 27-36 wks
Pneumonias is what type of dz?
infx of the lung paranchyma
Pneumonias classifications
Infecting organism
- bacteria, viral, fungal
Community acquired vs healthcare/hospital acquired
Lung parenchyma defintion
the portion of the lung involved in gas transfer
the alveoli, alveolar ducts, & respiratory bronchioles
Organisms that cause typical pneumonia.
S. pneumoniae, H. influenzae, S. aureus, Group A strep, Moraxella catarrhalis, anaerobes, & aerobic gram (-) bacteria
Organisms that causes atypical pneumonia
Legionella spp, M. pneumoniae, C. pneumoniae, & Chlamydia psittaci
Pneumonia: pathophys
infection of lung–> inflammatory response–> alveolar edema + exudate formation–> Alveoli & resp bronchioles fill w/ serous exudate, blood cells, fibrin, bacteria–> consolidation of lung tissues
Pneumonia: How is the sterile lower respiratory tract exposed to pathogens?
- aspiration
- inhalation of infective resp droplet or aerosols
Pneumonia: What should you ask pt. about?
- occupation
- animal exposure
- travel history
- tobacco & alcohol
- immune suppressive drugs (steroids & biologics)
- malignancy
- chronic lung disease
Pneumonia: symptoms
- acute or subacute onset of fever, cough, w/ or w/o sputum, & dyspnea
- rigors, sweats, chills, pleurisy, chest discomfort, & hemoptysis
- fatigue, anorexia, HA, myalgias , & abdom pain
Pneumonia: physical findings
- fever or hypothermia
- tachypnea
- tachycardia
- arterial O2 desaturation
- altered breath sounds or rales
- dullness to percussion may be found in lobar consolidation
Pneumonia: Dx - labs/imaging for all patients & what will it show?
chest x-ray( will show infiltrate)
Pneumonia: Dx - labs/imaging for admitted patients
- CBC
- chemistries
- arterial blood gases
- sputum/blood cultures
- UA assay for legionella & strep pneumo
Pneumonia: Treatment Protocol
Slide 96 & 97 notes
Pneumonia: Pt. Edu
Prevention:
- Pneumococcal vaccine
–>PCV13 for children 2-59 mo
–> PPSV23 for all 65+
Quit smoking, early mobilization, flu vaccine
Pneumonia: When to admit?
based on age, comorbidities, altered mental status, vital signs
Pneumonia: complications
- effusion
- empyema
- sepsis
- HF
- increase risk of PE
