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COPD, Asthma, Bronchiectasis Flashcards

1
Q

RF for COPD

A

Cigarette smoking

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2
Q

Pack years

A

Ave. no. of packs of cigarettes/day x total no. of years of smoking

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3
Q

Early onset COPD

genetic consideration

A

alpha 1 antitrypsin deficiency

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4
Q

Abnormal permanent enlargement of air spaces distal to the terminal bronchiole accompanied by destruction of walls of airways

A

Emphysema

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5
Q

Gene associated with COPD

A

HHIP Hedge hog interacting protein ch4

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6
Q

2 most important pathologic types of emphysema

A

Centriacinar emphysema

Panacinar emphysema

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7
Q

Central or proximal parts of the acini
Distal alveoli are spared

Consequence of cigarette smoking

Most common type

A

Centriacinar Centrilobular/Focal Emphysema

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8
Q

The acini are uniformly enlarged, from the level of respiratory bronchiole to the terminal blind alveoli

More common: lower lung zone

More common: a-1 antitrypsin deficiency

A

Panacinar (Panlobular) Emphysema

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9
Q

3 most common symptoms of COPD

A

Cough
Sputum production
Exertional dyspnea - increased effort to breathe, heaviness, air hunger or gasping

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10
Q

COPD PE

A 
Prolonged expiratory wheeze
Expiratory wheezing
Signs of hyperinflation: barrel chest
Use of accessory muscles
Sitting in tripod position 
Cyanosis - lack of cyanosis in emphysema
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11
Q

Significant weight loss
Bitemporal wasting
Diffuse loss of subcutaneous adipose tissue
Hoover sign

A

Advance COPD

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12
Q

Independent poor prognostic factor in COPD

A

Bitemporal muscle wasting

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13
Q

Paradoxical inward movement of the rib cage with inspiration

A

Hoover sign

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14
Q

COPD Diagnostic

A

Pulmonary function testing
shows airflow obstruction with

dec FEV1
dec FEV1/FVC ratio

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15
Q

Hallmark of COPD

A

Airflow obstruction

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16
Q

Emphysema

A

Pinf puffer

Not cyanotic

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17
Q

Blue bloater

A

Chronic bronchitis

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18
Q

Persistent cough with sputum production for:

at least 3 months in
at least 2 consecutive years

A

Chronic bronchitis

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19
Q

Increased size of bronchial mucous glands (Reid index)
Squamous metaplasia of bronchial epithelium
Bronchiolar narrowing from mucous plugging
Inflammation and fibrosis

A

Chronic bronchitis

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20
Q

Increased size of bronchial mucous glands

A

Reid index

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21
Q

Ratio of thickness of mucous gland layer to the thickness of bronchial wall

A

Reid index

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22
Q

Current definitive test for establishing presence or absence of emphysema in living subjects

A

CT scan

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23
Q

Most important intervention in chronic bronchitis

A

Smoking cessation

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24
Q

Has been demonstrated to have a significant impact on mortality rate

A

Oxygen supplementation

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25
In general, used for symptomatic benefit B2 agonists
Bronchodilators
26
Improves symptoms and produces acute improvement in FEV Decreases mucous secretions
Anticholinergics | Ipratropium bromide
27
Pharmacotherapy Emphysema
Beta agonist Oral glucocorticoids Antibiotics
28
GOLD Criteria for Severity of Airflow Obstruction GOLD I
Mild FEV1/FVC <0.7 FEV1 >/= 80% predicted
29
GOLD II
Moderate (50-80) FEV1/FVC <0.7 FEV1 >/= 50% but <80% predicted
30
GOLD III
Severe (30-50%) FEV1/FVC <0.7 FEV1 >/= 30% but <50% predicted
31
GOLD IV
Very severe FEV1/FVC <0.7 FEV1 <30% predicted
32
Stable COPD Tx
Smoking cessation (Buproprion antidepressant, nicotine replacement therapy, varenicline) Oxygen supplementation Long acting beta 2 agonist the only interventions proven to influence natural history of COPD
33
Syndrome characterized by airflow obstruction that varies markedly both spontaneously and with treatment
Asthma
34
Acute narrowing of bronchioles due to bronchospasm which causes obstruction to airflow maximal in expiration
Asthma
35
Risk factors in Asthma
Endogenous Environmental Triggers
36
``` Genetic predisposition Atopy Airway hyperresponsiveness Gender Ethnicity Obesity Early viral infections ```
Endogenous factors
37
``` Indoor allergens Outdoor allergens Occupational sensitizers Passive smoking Respiratory infections Diet Acetaminophen (paracetamol) ```
Environmental factors
38
``` Allergens Upper respiratory tract viral infections Exercise and hyperventilation Cold air Sulfur dioxide and irritant gases Beta blockers, Aspirin Stress Irritants (household sprays, paint, fumes) ```
Triggers
39
Single largest risk factor of Asthma
Atopy 40-50% 80% asthmatics have allergic rhinitis
40
Central to the disease pathophysiology and causes airway dysfunction through inflammatory mediators airway wall remodelling
Airway inflammation
41
asthma sputum cytology
Curschmann spirals Eosinophils Charcot-leyden crystals
42
Twisted mucous plugs admixed with sloughed epithelium Results from extrusion of mucous plugs from subepithelial mucous gland ducts or bronchioles
Curschmann spirals
43
Eosinophil membrane proteins in asthma
Charcot-leyden crystals
44
Most striking gross finding in asthma
Occlusion of bronchi and bronchioles by thick, tenacious mucus plugs which often shed epithelium
45
Ciliated columnar cells sloughed from the bronchial linings
Creola bodies
46
Cough Wheeze Dyspnea Inspiratory and expiratory rhonchi
Asthma
47
Most common stimuli that evoke asthma exacerbations
Infection
48
The only stimuli that can produce constant symptoms of asthma for weeks
Respiratory viruses Young children: RVS, parainfluenza Older children and adults: Rhinovirus, influenza
49
Abnormal and irreversible dilatation of the bronchial tree proximal to the terminal bronchioles
Bronchiectasis
50
Causes can be infectious or noninfectious ``` May be focal (bronchiectatic changes in a localized area of the lung) or Diffused (widespread bronchiectatic changes throughout the lung) ```
Bronchiectasis
51
Most common clinical presentation of bronchiectasis
Persistent, productive cough with | thick, tenacious sputum
52
Bronchiectasis hallmark
Honeycomb lung | Cystic spaces
53
Modality of choice for diagnosis of Bronchiectasis Displays tram tracks Bronchial wall thickening
Chest computed tomography (CT)
54
Bronchiectasis Tx
Treatment directed at control of active infection improvement in secretion clearance bronchial hygiene
55
Bacterial infection implicated in severe asthma
Mycoplasma | Chlamydophila
56
Hypothesis proposes that lack of infection in early childhood preserves the TH2 cell bias at birth, whereas exposure to infections and endotoxin results in a shift towards a predominant protective TH1 immune response
Hygiene hypothesis
57
More severe persistent asthma Later onset of disease Nasa polyps Aspirin-sensitive
Intrinsic or Non-atopic asthma
58
Most common allergen to trigger asthma
Dermatophagoides species | Dust mite
59
Exercise induced asthma is triggered by
Hyperventilation Increased osmolality in airway lining fluid and triggers mast cell mediator release resulting in Bronchoconstriction.
60
Typically begins after exercise has ended Recovers spontaneously within about 30 mins Worse in cold, dry climates than in hot, humid conditions More common in crosscountry running in cold weather, overland skiing and ice hockey M
Exercise-induced asthma
61
Exercise-induced asthma is best prevented by
regular treatment with ICS (reduced mast cell) | prior administration if B2 agonist and antileukotriene
62
Asthma occurs more frequently in obese peopel with this value of BMI more difficult to control
>30kg/m2
63
A food additive and preservative that may trigger asthma through release of sulfur dioxide gas in the stomach
Metabisulfite
64
Physiologic abnormality of asthma
Airway hyperresponsiveness
65
Process allergen into peptides and migrate into lymph nodes and project these allergens into T cells to program allergen-specific T cells
Dendritic cells
66
Inflammatory cell linked to the development of airway hyperresponsiveness due to release of basic proteins and oxygen-deprived free radicals
Eosinophils
67
Which cytokine is deficient in asthma
IL 10 and 12 (antiinflammatory) Mediate allergic inflammation: IL 4,5,9,13
68
Proinflammatory cytokines that amplify inflammatory response and play a role in more severe disease
TNF-a | IL-1B
69
Lung function test that demonstrates reversibilirt of airflow limitation
>12% AND 200 mL increase in FEV1 15 mins after inhaled SABA (inhaled albuterol 400ug) Or 2-4 week trial of oral corticosteroids (Prednisone or Prednisolone 30-40mg daily)
70
Confirms diurnal variation in airflow obstruction in asthma
PEF twice daily measurement
71
Flow-volume loop of asthma show
Reduced peak flow | Reduced maximum expiratory flow
72
Increased airway hyperresponsiveness in asthma with calculation of the provocative concentration that reduces FEV1 by 20%
Metacholine or histamine challenge
73
Chest Xray in asthmatics
Normal (in severe cases, hyperinflated lung) Blood test not helpful Skin prick test are positive in allergic asthma
74
Now being used as noninvasive test to measure eosinophilic airway inflammation May be a test for compliance with therapy
Exhaled NO
75
Aims of asthma therapy
Minimal or no chronic symptom including nocturnal Minimal infrequent exacerbation No emergency visits Minimally (ideally no) use of a required B2 agonist No limitations on acitvities including exercise Peak expiratory flow circadian variation <20% Near normal PEF Minimal or no adverse effect from medication
76
Drugs for asthma
Relievers - B2 agonist, anticholinergics, theophylline Controllers -inhaled steroids, systemic steroids, leukotrienes, steroid sparing therapies, anti-IgE, Anti-IL5, immunotherapy
77
Activate Beta 2 adrenergic receptors in airways Inc cAMP Smooth muscle relaxation Inhibits mast cell Potential problem: tolerance
B2 agonists
78
SABA example Duration: 3-6 hours
Albuterol | Terbutaline
79
LABA example Should be given with ICS therapy
Salmeterol Formoterol Indacaterol Olodaterol
80
Most common side effect of b2 agonist
Muscle tremor palpitations elderly small fall in plasma sodium due to increasef uptake of skeletal muscle
81
Urinary retention from 10 year asthma medication use is caused by
Ipatropium | Anticholinergic
82
Prevent cholinergic nerve-induced bronchoconstriction and mucus secretion Less effective than B2 agonist
Anticholinergics
83
SAMA example
Ipratropium
84
LAMA example
Tiotropium | Glycopyrronium
85
Most common SE of anticholinergic use In the elderly
Dry mouth Urinary retention and glaucoma
86
Inhibition of phosphodiesterase in airway smooth muscle cell Inc cAMP causing smooth muscle relaxation Anti-inflammatory effect
Theophylline
87
Key nuclear enzyme activated by theophylline that is a critical mechanism for switching off activated inflammatory genes and may reduce steroid insensitivity in severe asthma
Histone deacetylase 2 (HDAC2)
88
Increases blood concentration if theophylline
``` Erythromycin (inhibitor) Cimetidine Ciprofloxacin Allopurinol Zafirlukast ``` CHF, liver disease, pneumonia Viral infection, vaccination High carbohydrate diet Old age
89
Increases clearance of theophylline
Inducers Rifampicin Phenobarbitone Ethanol High protein, low carbohydrate diet Barbecued meat Childhood
90
Most effective anti-inflammatory agent used in asthma therapy Reduce eosinophils in the airways and sputum and activated T cells and mast cells in airway mucosa First line therapy for patients with persistent asthma
Inhaled corticosteroids
91
Inhaled corticosteroid SE
Hoarseness | Oral candidiasis
92
Block cys-LT1 receptors by mast cells thereby causing bronchorelaxation Modest clinical benefit in asthma Given once or twice daily orally
Montelukast Zafirlukast Leukotriene inhibitors
93
Inhibit mast cell and sensory nerve activation Effective in blocking trigger-Induced asthma such as EIA and allergen and sulfur dioxide-induced symptoms Little benefit in long term control due to short duration of action
Cromones Cromolyn sodium Nedocromil sodium
94
Antibody that neutralized circulating IgE without binding to cell-bound IgE Reduce the number of exacerbations in severe asthma Very expensive Only suitable for highly selected patients who are not controlled on maximal doses of inhaler therapy
Omalizumab
95
Reduce blood and tissue eosinophils and reduce exacerbations in patients with persistently increased sputum eosinophils despite maximal ICS therapy
IL 5
96
``` Daytime symptoms: None or = 2/week No limitation in activity No nocturnal symptom/awakening No or =2/week need for reliever/rescue treatment Normal lung function (PEF or FEV1) ```
Controlled
97
Daytime symptoms >2/week Any limitation of activities Any nocturnal symptom/awakening Need for reliever/rescue treatment >2/week Lung function (PEF1 or FEV1) <80% predicted or personal best if known
Partly controlled
98
>/= 3 ``` Daytime symptoms >2/week Any limitation of activities Any nocturnal symptom/awakening Need for reliever/rescue treatment >2/week Lung function (PEF or FEV1) ```
Uncontrolled
99
ABG picture consistent with impending respiratory failure
ph 7.4, pCO2 40, PaO2 80, HCO3 35 Hpoxemia and PCO2 usually low due to hyperventilation But a normal or rising PCO2 is an INDICATION OF IMPENDING RESPIRATORY FAILURE and requires immediate monitoring and therapy.
100
Laboratory test to confirm compliance to asthma therapy
Fractional NO may identify adherence to ICS
101
Type of asthma that presents with chaotic variations in lung function despite appropriate therapy and may have precipitous, unpredictable falls in lung function which may result in death Generally normal of near-normal lung function but precipitous, unpredictable falls may result in death Difficult to manage
Type 2 brittle asthma
102
Chaotic variations in lung function despite taking appropriate therapy. Persistent pattern of variability and may require OCS or at times, continuous infusion of B2 agonist
Type I Brittle asthma
103
Brittle asthma Tx
Subcutaneous Epinephrine | localized airway anaphylactic reaction with edema
104
1/3 improve during the course of pregnancy 1/3 deteriorate 1/3 remain unchanged Drugs that are safe and without teratogenic potential
Asthma and pregnancy
105
Drugs that are safe and without teratogenic potential in pregnants with asthma
SABA, ICS and theophylline | Prednisone >> Prednisolone
106
Mosy common form of bronchiectasis
Cylindrical/tubular | Varicose/cystic
107
Bronchiectatic changes in a localized area of the lung and can be consequence of obstruction of the airway - either extrinsic (lymphadenopathy, parenchymal tumor) or intrinsic (airway tumor, aspirated body, stenotic airway)
Focal bronchiectasis
108
Widespread bronchiectatic changes throughout the lung and often rises from an underlying systemic or infectious disease process
Diffuse bronchiectasis
109
Upper lung field bronchiectasis may be due to More common
Cystic fibrosis | Post radiation fibrosis
110
Lower lung field bronchiectasis may come from
Chronic recurrent aspiration End-stage fibrotic lung disease Recurrent immunodeficiency association
111
Causes bronchiectasis in midlung fields
Mycobacterium avium intracellulare complex | Dyskinetic/immotile cilia syndrome (Kartegener)
112
Bronchiectasis of central aways is due to
Allergic bronchopulmonary aspergillosis Tracheobronchomegaly (Mounier-Kuhn Syndrome and Williams-Campbell syndrome)
113
Most widely cited mechanism of infectious bronchiectasis that states that susceptibility to infection and poor mucociliary clearance result in microbial colonization of the bronchial tree
Vicious cycle hypothesis
114
Dilated airways arising from parenchymal distortion as a result of lung fibrosis (eg. postradiation fibrosis or idiopathic pulmonary fibrosis)
Traction bronchiectasis
115
Crackles and wheezing Clubbing of digits PFT: mild to moderate airflow obstruction Acute exacerbation: Changes in the nature of sputum production with increased volume and purulence
Bronchiectasis
116
Bronchiectasis Xray reveal
Tram tracks indicating dilated airways
117
Cross sectional area of the airway with a diameter of at least 1.5 times that of the adjacent vessel in CT Bronchiectasis
Signet ring sign
118
Inspissated secretions on CT of a bronchiectatic lung
Tree-in-bud appearance | Cyst eminating in a bronchial wall in cystic bronchiectasis
119
Diagnosis of a true non-tuberculous mycobacterial infection in a patient with bronchiectasis is seen in
One bronchioalveolar lavage sample positive on culture Diagnostic criteria for true clinical infection with NTM should be considered in patients with symptoms and radiographic findings of lung disease who have at least 2 sputum samples positive on culture. At least one BAL fluid sample postive on culture A biopsy sample displaying histopathologic features of NTM infection (granuloma, positive stain for acid-fast bacilli) along with one positive sputum culture Pleural fluid sample (or a sample from another sterike extrapulmonary site) positive
120
Most common nontuberculous mycobacterial pathogens implicated in bronchiectasis
M avium-intracellulare Tx: HIV negative - Macrolide + Rifamin + Ethambutol Check macrolide susceptibility testing
121
Bronchiectasis Tx
Antibiotic treatment Bronchial hygiene (Pulmonary rehabilitation) Anti-inflammatory therapy (OCS/systemic steroids) Surgical interventions for refractory cases
122
Prevention of bronchiectasis
Reversal of an underlying immunodeficient state - IVIg Vaccination -influenza, pneumococcal Smoking cessation
123
Complications of bronchiectasis
Microbial resistance to antibiotics Injury to superficial mucosal vessels with bleeding -> life threatening hemoptysis Endotracheal intubation Identification of source of bleeding Control of bleeding - bronchial artery embolization, surgery
124
Decline rate of FEV1 among patients with non-CF bronchiectasis
50-55 ml per year
125
Worse outcomes in bronchiectasis are associated with this infection
P aeruginosa colonization
126
Disease state characterized by persistent respiratory symptoms and airflow limitation that is not fully reversible
COPD
127
Noxious environmental exposures by spirometry in setting of noxious exposure eg cigarette smoking Chronic airflow obstruction
COPD
128
Subset of COPD
Emphysema Chronic bronchitis Small airway disease
129
A condition characterized by destruction of the lung alveoli with airspace enlargement
Emphysema
130
A clinically defined condition with chronic cough and phlegm
Chronic bronchitis
131
Condition in which small bronchioles are narrowed and reduced in number
Small airway disease
132
Hallmark of advanced COPD
Extensive small airway destruction Small airways may be narrowed by cells (hyperplasia and accumulation), mucus, and fibrosis
133
The elastase:antielastase hypothesis was based on the clinical observation that patients with genetic deficiency of this substance were at increased risk of emphysema
a-1 anti trypsin Elastase > Anti-elastase (a1 antitrypsin)
134
Major site of increased resistance in most individuals with COPD
Small airways <2mm diameter
135
Associated with significant airway inflammation and with centrilobular emphysema Along the pleural margins with relative sparing of the lung core or central regions
Paraseptal emphysema
136
Lung hyperinflation among patients with COPD indicate
Increase in lung volume (inc RV, inc RV/TLC) Increase in elastic recoil pressure (inc TLC) Decrease airway resistance
137
Hypoxemia in COPD is caused by
ventilation-perfusion mismatch reflects heterogenous nature of disease process multiple parenchymal regions with different v/q Dec PO2 Shunting at minimal rate
138
Most highly significant predictor of FEV1 among COPD patients
Pack-years of cigarette smoking But only 15% of the variability in FEV1 is explained by pack-years
139
70/Male Ex smoker FEV1/FVC <0.7 FEV >80% predicted GOLD Criteria?
GOLD stage I
140
Only 3 interventions demonstrated to improve survivals of patients with COPD
Smoking cessation Oxygen therapy Lung volume reduction surgery
141
Only pharmacologic therapy demonstrated to unequivocally decrease mortality rates in patients with COPD
Supplemental O2
142
Patient with resting hypoxemia
Resting O2 saturation =88% in any patient | = 89% with signs of pulmonary hypertension or right heart failure
143
Type of infection most associated with COPD exacerbation
Bacterial | Hib
144
Antibiotic that has demonstrated a reduced exacerbation of frequency and longer time to first exacerbation
Azithromycin
145
COPD patients most likely to benefit from lung volume reduction surgery
Those with upper lobe-predominant emphysema and a low post-rehabilitation exercise capacity Most emphysematous portion of lung
146
Reduce the length of hospital stay, hasten recovery, and reduce the chance of subsequent exacerbation or relapse among admitted COPD patients
Systemic corticosteroids
147
70/F Known smoker, COPD Dyspnea at rest Productive cough with yellowish sputum What makes her unfit for noninvasive positive pressure ventilation a able to expectorate secretion b being obtunded c able to cooperate d normotensive SBP 120 mmHg
Being obtunded
148
Contraindications for Non invasive Positive-Pressure Ventilation (NIPPV)
Cardiovascular instability Impaired mental status Inability to cooperate Copious secretions or inability to clear secretions Craniofacial abnormalities or trauma precluding effective fitting of mask Extreme obesity Significant burns
149
Indications for Invasive Mechanical Ventilation
``` Severe respiratory distress despite therapy Life-threatening hypoxemia Severe hypercarbia and/or acidosis Markedly impaired mental status Respiratory arrest Hemodynamic instability ```

Medicine (29 decks)

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