MKSAP 2: Airways Disease Flashcards
Define asthma
chronic respiratory condition characterized by reversible airway obstruction that is caused by airway inflammation and bronchial hyperresponsiveness
What are the strong associations/risk factors for allergic asthma?
personal or family history of allergies or atopy, maternal smoking while pregnant and exposure to environmental tobacco smoke in childhood
What can predispose individuals to asthma?
exposure to indoor environmental allergens, environmental tobacco smoke and viruses
What is the list of differentials that could be asthma mimics?
COPD Vocal cord dysfunction Heart failure Bronchiectasis ABPA CF Mechanical obstruction Churg Strauss syndrome
What are the classic presentation symptoms in someone wiht asthma?
Episodic symptoms of cough, chest tightness, shortness of breath and wheezing
What is the first step in someone with suspected asthma?
Spirometry to assess assess presence and severity of airway obstruction and reversibility
What is the most common form of asthma in adults?
What is the typical clinical course?
allergic asthma
Patients with atopy may present with allergic asthma early in life, experience a period of stability, and then may have recurrence later. Family history usually positive for allergies and asthma. Symptoms may be seasonal and require trigger avoidance and stepping up therapy during times of known exacerbation. Superimposed viral infections or other nonallergic triggers may exacerbate allergic asthma
How is cough variant asthma different?
Present with persistent or episodic cough in the absence of other common symptoms usually associated with asthma. Extrinsic triggers such as cold air or irritants. Spiro and bronchial challenge testing help confirm
Define exercise induced bronchospasm
In EIB, symptoms occur in patients with asthma with exercise that requires increased respiratory ventilation
In a patient with dyspnea with exertion but normal spirometry, what test helps diagnose the patient?
methacholine challenge testing will help assess the degree to which symptoms are related to hyperactivity of the lungs
What is the treatment for EIB?
If symptoms occur only a few times per week, EIB can be managed with inhaled short acting B2 agonists such as albuterol given 5-20 min prior to exercise which is protective 2-4 hrs
Which drug is helpful in minimizing the number and severity of EIB asthma episodes?
Inhaled glucocorticoids
What other nonpharmacologic strategies are helpful for EIB?
Warming and humidifying inhaled air with nasal breathing as well as covering the nose and mouth during exercise in cold environments. Also a 10 minute pre-exercise warmup can help decrease occurrence of EIB for up to 4 hrs
What is occupational asthma?
Asthma symptoms related to workplace exposures, agents associated with airway hyperactivity
What workers are at risk?
farmers, factory workers, hairdressers
What test can be a helpful screening tool for occupational asthma?
serial monitoring of peak flows throughout the workday, with a comparison to a baseline time period away from exposures
What is the confirmatory test for occupational asthma?
spirometry before and after rechallenge with workplace exposures is helpful to confirm the diagnosis
What are the general treatment guidelines for occupational asthma?
Follow guidelines for typical asthma. Allergen exposure should be controlled or eliminated
Name the triad of aspirin exacerbated respiratory disease or Samter triad?
severe persistent asthma, aspirin sensitivity, and hyperplastic eosinophilic sinusitis with nasal polyposis
What is the pathophysiology of aspirin induced asthma?
Exposure to aspirin or other NSAIDs leads to inhibition of cyclooxygenase and increase leukotriene synthesis
what is the treatment for aspirin induced asthma?
avoid aspirin and typical asthma management
What do you do with patients that require aspirin (cardiac patients) with aspirin sensitive asthma?
aspirin desensitization procedure
Define reactive airways dysfunction syndrome (RADS)
Development of respiratory symptoms in the minutes or hours after a single inhalation of a high concentration of irritant and airway hyperresponsiveness persists for an extended period of time
What are examples of irritants in patients with RADS?
inhalation of strong fumes, particulate matter, chemical irritants
What does spirometry show in a patient with RADS?
may reveal evidence of bronchocontriction that is reversible
What is the intitial treatment of RADS?
Same as treatment for asthma
What is virus induced bronchospasm?
a viral respiratory infection leading to airway hyperresponsiveness and obstruction through nonallergic mechanisms in patients without a hx of asthma
How long typically does virus induced bronchospasm take to resolve?
6-8 weeks after a respiratory infection
Up to half of asthma exacerbations are related to what viral pathogen?
rhinovirus
How to asthmatic patients present with influenza infections? Therefore what is the recommendation in treating these patients/
Present with more severe symptoms and recommendation is to get annual flu vaccine
What is ABPA?
Which patients are at increased risk for it?
Allergic bronchopulmonary aspergillosis. Chronic hypersensitivity reaction that occurs in response to colonization of the lower airways with Aspergillus species
What are the presenting signs and symptoms of ABPA?
Impaired mucociliary clearence with expectoration of mucus plugs, destruction of pulmonary parenchyma with broncheictasis, difficult to control asthma and weight loss.
Atopic asthma or CF
What are the lab and imaging findings of ABPA?
positive skin testing to Aspergillus antigens high IgE titers to Aspergillus peripheral eosinophilia Proximal bronchiectasis Pleural thickening transient infiltrates atelectasis
What is the scale up in treatment for ABPA?
systemic glucocorticoids
inhaled glucocorticoids can reduce need for higher doses of systemic glucocorticoids
antifungal therapy (fluconazole)
anti-IgE therapy - omalizumab
How can GERD make underlying asthma worse?
Direct reflux of asidic gastric contents in to the respiratory system resulting in upper airway inflammation or direct lung injury; reflux in lower esophagus causing bronchoconstriction
What do you do with a patient with suboptimal control of asthma and history consistent with GERD?
empirically start an antacid
How should patients with uncontrolled asthma be evaluated in the context of the unified airway concept?
Evaluated for occult sinus disease, possible treatment of bacterial sinusitis or allergic sinusitis with nasal glucocorticoids
How are OSA treatment and asthma treatment related? What factors for asthma control are improved with OSA treatment?
The relationship between asthma and OSA treatment appears to be bidirectional.
CPAP improves asthma symptoms, frequency of rescue inhaler use and quality of life scores.
Paradoxical fold motion disorder = vocal cord dysfunction. What presentation symptoms are highly suspicious of VCD?
- mid chest tightness with exposure to particular triggers such as strong irritants or emotions
- difficulty breathing in
- symptoms that only partially respond to asthma meds
What is the gold standard of diagnosis for VCD?
adduction of vocal cords during inspiration as seen on laryngoscopy
How can VCD be diagnosed on flow volume loop?
If spirometry happens to capture a flat inspiratory limb on the flow volume loop
What treatment options are recommended for VCD?
speech therapy training exercises to control laryngeal area and maintain airflow and treatment of GERD
How is obesity related to asthma?
Obesity is one of the strongest risk factors, may have a causal role, and affects prognosis and outcomes.
What pathogenesis factors are affected in obese patients with nonallergic asthma?
mechanical strain (breathing against the pressure of added chest or abdominal girth) and obesity related cytokines, called adipokines
Name the 4 classifications of asthma based on the Natl’ Heart, Lung, and Blood Institute.
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Name the clinical findings for mild intermittent asthma and name the therapy
2 or less symptomatic days a week 2 or less nighttime awakenings per month 2 or less days needing SABA per week No interference with normal activity Normal FEV1 b/w exacerbations FEV1 80% or greater of predicted, ratio normal 0-1 exacerbations a year Step 1 therapy: SABA PRN
Name the clinical findings for mild persistent asthma based on NHL institute and name the therapy
Greater than 2 symptomatic days a week but not daily
3-4 nighttime awakenings per month
Greater than 2 days a week SABA use but not more than 1x per day
Minor limitation in daily activity
FEV1 80% or greater of predicted, ratio normal
Greater than 2 exacerbations a year
Step 2 therapy: Low dose ICS, SABA PRN
Alternative: Cromolyn, LTRA, nedocromil or theophylline
Name the clinical findings for moderate persistent asthma and name the therapy
Daily symptoms
Greater than once a week nighttime symptoms but not nightly
Daily SABA use
Some limitation in daily activity
FEV1 between 60-80% predicted, Ratio reduced less than or equal to 5% compared to predicted
Greater than 2 exacerbations a year
Step 3 therapy and consider short courses of systemic glucocorticoids: Medium dose ICS + LABA, SABA PRN
Alternatives: Medium dose ICS + LTRA, theophylline, or zileuton
Name the clinical findings for severe persistent asthma and name the therapy
Symptoms throughout the day
Nighttime awakenings often 7x a week
SABA use several times a day
Extremely limited normal activity
FEV1 less than 60% predicted
Ratio reduced more than 5% compared to predicted
Greater than 2 exacerbations a year
Step 4 or 5 therapy - consider short course of systemic glucocorticoids
Step 4: Medium dose ICS + LABA. Alternative: medium dose ICS + LRTA, theophylline, or zileuton
Step 5: High dose ICS + LABA AND consider omalizumab for patients who have allergies
What is step 6 according to NHL therapy?
High dose ICS + LABA + oral glucocorticoids
What are the recommendations regarding frequency of spirometry in management of asthma?
If changes in symptoms occur, it is reasonable to reevaluate lung function.
During times of symptom stability, spirometry should be performed yearly
What concurrent psychologic condition is associated with asthma?
Depression, underrecognized and associated with increased ED visits, hospitalizations, decreased lung function, higher medication nonadherence and increased asthma related deaths
What are the side effects to watch out for with LABAs?
anxiety, tremor, and headaches. It is beneficial to step down LABA therapy when asthma control is obtained
What is omalizumab?
What are the indications for its use in asthma according to FDA approval?
humanized monoclonal ab directed at IgE
Approved for use in patients with moderate to severe persistent asthma with the following:
1) symptoms uncontrolled on inhaled glucocorticoids
2) evidence of allergies to perennial aeroallergens
3) serum IgE levels between 30-700
What are factors that increase the risk of poor outcomes in asthma?
Hx of frequent ED visits
Need for intubation and MV
Poor perception of reduced lung function
What are important factors to consider in patients with asthma exacerbation in terms of their inpatient management and evaluation?
Pulse ox may be falsely reassuring because patients maintain normal oxygen levels despite high WOB
Hypoxia is a late sign of pending respiratory failure
Initial blood gases may show hyperventilation and low pCO2 but normalization of pCO2 is early indicator of muscle fatigue and impending failure
What defines severe refractory asthma and how should they be managed?
If they have multiple exacerbations per year, a need for high dose ICS or oral glucocorticoids, an inability to step down therapy without compromising asthma control or a hx of multiple hosp or intubations
They require multidisciplinary evaluation
What are the risks of lack of asthma control in pregnancy?
increases risk of preeclampsia and preterm labor for mothers and low birth weight, small gestational age and preterm delivery for the infant
What agents are safe in pregnancy for asthma?
Inhaled glucocorticoids and much safety evidence exists for Budesonide, most LTRA are considered safe
What is the single most clinically efficacious and cost effective way to prevent COPD?
smoking cessation
What are predictors of M&M for COPD in patients who smoke?
age starting smoking, total pack years smoked and current smoking status are cumulative
What are frequent comorbid conditions related to COPD?
cardiovascular disease, weight loss, muscle wasting, weakness and osteopenia
How do you diagnose COPD
Postbronchodilator fixed FEV1/FVC less than 70%
Which patients do you assess for adequacy of oxygenation?
FEV1 less than 35%, check ABG or measurement of oxyhemoglobin saturation with pulse ox
Patient that develops symptoms of COPD and has a reduced FEV1/FVC at a young age (less than 40 years) should be assessed for what condition?
alpha 1 antitrypsin deficiency
How can patient symptoms and impact on function be objectively assessed with COPD?
mMRC or CAT tests
Name the 4 GOLD categories and their associated severity and spirometry levels
GOLD 1 - mild; FEV1 > or equal to 80%
GOLD 2 - moderate; 50-80
GOLD 3 - severe; 30-50
GOLD 4 - very severe; less than 30%
How are patients classified in the 2017 GOLD guidelines?
Degree of symptoms based on CAT or mMRC
Exacerbation risk
Presence of comorbidities
What constitutes high risk in COPD patients?
What constitutes high symptoms?
greater than or equal to 2 exacerbations a year and/or 1 or more requiring hospital admission
> or equal 10 CAT
>2 or equal 2 mMRC
Name the degree of airflow obstructions in COPD according to ACP, ATS and CHEST and the associated recommended treatments
FEV1 60-80%: Inhaled bronchodilators
FEV1 <60%: Monotherapy either LAMA, LABA
Combination therapy: LAMA, LABA or ICS
FEV <50%: Pulm rehab in addition to meds
What adverse drug effects do patients taking inhaled glucocorticoids need to be monitored for?
osteopenia, hyperglycemia and cataracts
What is the most recent studies show in regards to IV vs PO steroids during exacerbation and length of therapy for PO?
IV and PO are noninferior inpatient for AECOPD althoug critically ill patients or those with nausea are candidates for IV
No difference in outcomes <7 days vs 14 days PO steroid therapy with 40mg
What are the pneumonia vaccination guidelines for COPD?
All patients 19-64 with COPD receive 23-valent pneumonia vaccine with revaccination at 65 if 5 years have elapses since the previous immunization
All patients with or without COPD should also receive 13 valent pneumonia vaccine at age 65, but vaccines should be given sequentially
What is Roflumilast and what are its indications?
Oral selective PDE-4 inhibitor and its use should be limited to add on therapy in severe COPD associated with chronic bronchitis and a history of recurrent exacerbations
What are the recommendations for pulmonary rehab?
Pulm rehab is recommended for all symptomatic patients with an FEV1 less than 50% and specifically for those hospitalized with AECOPD.
Also consider in symptomatic or exercise limited patients with FEV1 greater than or equal to 50%
What are the conditions for screening COPD patients for oxygen therapy?
All stable patients with FEV1 less than 35% or in patients with clinical symptoms or signs of respiratory failure or right sided heart failure
How do you determine the need for long term oxygen therapy?
Resting arterial PO2 or oxygen saturation levels, should be repeated and confirmed over a 3 week period.
If resting ox sat is less than 88%, ABG should be performed and long term oxygen therapy should be initiated. A 6 minute walk test should be performed to assess and titrate oxygen levels with activity.
What are the criteria for long term oxygen therapy?
1) chronic respiratory failure and/or severe resting hypoxemia defined as ABG PO2 less than or equal to 55mmHg or oxygen sat less than or equal to 88% breathing ambient air, with or without hypercapnia and/or
2) if there is evidence in combination with an arterial PO2 less than or equal to 59 mmHg or oxygen sat less than or equal to 89% breathing ambient air
What are the eligibility criteria for lung volume reduction surgery in patients with COPD?
- Severe COPD
- Remain symptomatic despite maximal pharmacologic therapy
- Completed pulm rehab
- Evidence of bilat predominant upper lobe emphysema on CT scan
- Postbronchodilator TLC of >100% AND residual lung volume > 150% of predicted
- Max FEV1 >20% and less than or equal to 45% of predicted and DLCO greater than or equal to 20% of predicted
- Ambient air art PCO2 less than 60 mmHg AND arterial PO2 greater than or equal to 45mmHg
What are the eligibility criteria for lung transplantation in patients with COPD?
- Hx of exacerbation associated with acute hypercapnia (PCO2 > 50)
- Pulmonary HTN
- Cor pulmonale
- Pulmonary HTN and cor pulmonale
- FEV1 < 20% with DLCO < 20% OR homogenous distribution of emphysema
What are common complications of lung transplantation?
acute rejection, opportunistic injections (CMV), fungal infections (Candida, Aspergillus, Cryptococcus, Pneumocystis), bacterial infections (Pseudomonas, Staphylococcus), bronchiolitis ogliterans, lymphoproliferative disease
What are absolute contraindications to lung transplant?
malignancy within the last 2 years, infection with HepC or C with histologic evidence of significant liver damage, active or recent cigarette smoking, drug or alcohol abuse, severe psychiatric illness, documented nonadherence with medical care and absence of social support. Age > 65 is a relative contraindication as well as multiple comorbid conditions.
Define an exacerbation of COPD and how is it graded?
Defined as sustained worsening of the patient’s COPD.
Mild - change in clinical condition but no change in meds
Moderate - change in clinical condition and med changes made
Severe - requires hospitalization
What are the strongest predictors of exacerbation?
1) hx of previous exacerbation
2) baseline severity of airflow limitation
Which patients are eligible for home treatment of AECOPD?
Less severe lung disease who do not have significant accompanying illnesses and who are experiencing mild to moderate exacerbations
Name criteria for hospital admission for AECOPD
- Marked increase in intensity of symptoms
- severe underlying COPD
- onset of new physical signs (cyanosis, edema)
- exacerbation that fails to respond to initial therapy
- presence of high risk co-morbid conditions (HF, arrhythmias)
- Frequent exacerbations
- Advanced age
- patient unable to care for themself
- inadequate home care available
Name criteria for ICU admission for AECOPD
Despite adequate, appropriate treatment:
- persistent/worsening hypoxemia (arterial PO2 < 40) AND/OR
- severe/worsening respiratory acidosis (pH < 7.25) and requires endotracheal intubation
- severe dyspnea that responds inadequately to therapy
- change in mental status
- hemodynamic instability
Outline therapy for AECOPD
- supplemental oxygen with goal PaO2 > 60 and SpO2 88-92, serial ABGs
- NIPPV
- Short acting bronchodilators : SABA/SAMA
- oral or IV glucocorticoids
- abx (in certain situations_
What are the conditions for abx in AECOPD
Most effective in patients with:
1) increased dyspnea, sputum volume and sputum purulence
2) only 2 of the proceeding symptoms if 1 is increased purulence
3) requirement for MV, noninvasive or invasive
Define bronchiectasis and name how the localization can help define the underlying cause
Irreversible pathologic dilation of the bronchi or bronchioles resulting from an infectious process occurring in the context of airway obstruction, impaired drainage or abnormality in antimicrobial defenses.
Upper lung fields -> CF, ABPA, congenital or autoimmune or connective tissue diseases
Mid-lung fields -> nontuberculous mycobacterial infectino such as MAC
Lower lung -> chronic aspiration, end stage fibrotic disease, recurrent infections
What are presenting symptoms of bronchiectasis and what is the imaging modality of choice?
Chronic cough with purulent sputum and recurrent PNA
HRCT
What are the overall goals in treating bronchiectasis?
What does data say about pulm rehab, short or long acting bronchodilators in bronchiectasis?
How do you treat non-CF bronchiectasis also with COPD?
Treat the underlying cause
No data to support short or long acting bronchodilators in bronchiectasis.
Pulm rehab is effective so is inhaled hypertonic saline and chest phsyio.
Non-CF bronchiectasis with COPD -> inhaled glucocorticoids along with SABA/LABA have a role who have TWO OR MORE exacerbations a year.
Which abx has been shown to be of clinical benefit in bronchiectasis? What needs to be ruled out before starting chronic abx therapy?
Macrolide abx azithromycin
Need to rule out chronic nontuberculous mycobacterial infection
What should guide therapy in acute exacerbation of bronchiectasis?
How long should you treat?
Routine sputum and acid fact bacilli culture results to identify predominant organism.
Empiric therapy should be based on previous cultures until current culture data returns.
2 week course of abx usually recommended
What causes CF?
What is the mean predicted survival age?
Autosomal recessive mutations in CF transmembrane conductance regulator gene causing epithelial mucous dehydration and viscous secretions causing occlusion of respiratory tracts also involving pancreatic ducts, biliary tree and atresia of vas deferens.
Mean age survival now 41.1 and soon adult patients will outnumber pediatric patients
What are the compatible clinical findings in CF and then how is the diagnosis confirmed?
Recurrent pancreatitis, chronic asthma like symptoms, male infertility, chronic sinusitis, severe nasal polyposis, NTM infection, ABPA, bronchiectasis, positive sputum culture for Burkholderia cepacia.
Diagnosis confirmed with sweat testing or CFTR mutational analysis.
What are the pillars of CF treatment
airway clearance, antibiotic therapy, nutritional support, and psychosocial support
What are the chronic meds recommended to improve lung function?
mucolytics, hydrating agents, inhaled antibiotics, oral macrolide abx, CFTR potentiators
