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MB1: Respiratory > Obstructive airways disease > Flashcards

Obstructive airways disease Flashcards

1
Q

large airways are how big and in what zone?

A

> 2mm

Conducting zone

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2
Q

small airways are how big and in what zone?

A 
<2mm
Acinar zone (gas excahnge
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3
Q

what is the exception to the rule of airway size and zone

A

They are small airways but in the conducting zone

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4
Q

4 causes of obstruction in asthma and COPD

A

Infolding of mucosa due to oedema and hypertrophy
lumen obstruction
spasm of outer smooth wall
Tear of alveolar walls

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5
Q

The infolding of musosa due to hypertrophy and oedema is inflammatory. in asthma this is eosinophilic/neutrophilic and in COPD it is eosinophilic/neutrophilic

A

Asthma - eosinophilic

COPD - both but mainly neutrophilic

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6
Q

What is the asthma triad

A

airway inflammation
airway hyperresponsiveness
reversible airflow obstruction

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7
Q

What are the 3 stages of asthma dynamically evolving

A

Bronchoconstriction
Chronic inflammation
Airway remodelling

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8
Q

What is the clinical syndrome of asthma (signs)

A 
Diurinal variability 
Non productive cough and wheeze 
Triggers - allergen or other 
Family history 
Blood eosinophilia >4%
Responsiveness to beta agonists
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9
Q

what is the disease process of COPD

A

smoke and other irritants activate macrophages and airway epithelial cells - release IL-* and leukotrine B4. these cause chemotaxis of neutrophils and macrophages that secrete proteases to break down connective tissues.
Cytotoxic t cells destroy alveolar walls

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10
Q

What counters the protease production triggered by cigarette smoke

A

Antiprotease, from genes. it is rarely fully effective

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11
Q

what does chronic bronchitis cause

A

Chronic neutrophilic inflammation
smooth muscle spasm and hypertrophy
Altered microbiome
Mucus hypersecretion and mucociliary dysfunction

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12
Q

What does emphysema cause

A

impaired gas exchange due to alveolar destruction

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13
Q

How is COPD diagnosed?

A

Gold grading - FEV1 graded 1-4

Grid plotting of exacerbation vs symptoms

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14
Q

What is ACOS

A

COPD with blood eosinophilia >4%
more reversible to salbutamol
hard to distinguish from asthmatic smokers

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15
Q

Name an effort dependent test

A

Spirometry

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16
Q

Name 4 effort independent tests

A

Relaxed vital capacity
Nitrogen washout
exhaled breath nitric oxide
Impulse oscillometry

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17
Q

Name 3 gas diffusion tests

A

CO transfer factor
ABG
SaO2 during exercise

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18
Q

What is bronchial challenge testing

A

use of exercise or allergens to cause a decrease in FEV1

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19
Q

how much should FEV1 decrease by in bronchial challenge testing

A

20% reduction

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20
Q

how do methacholine and mannitol cause airway hyperresponsiveness

A

mannitol - destroys mast cells to degranulate - so immune mediators released
Methacholine stimulates the parasypathetic system via M3

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21
Q

A person can have asthma without hyperreactivity. true/false

A

false - they must be hyperreactive

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22
Q

how does DLCO measure gas diffusion across the alveolar-arterolar barrier

A

small dose Co is given and observed how much is absorbed into blood as Hb has high affinity for it

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23
Q

What conditions cause DLCO to decrease

A

anaemia, emphysema, interstitial lung disease, pulmonary oedema, PE

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24
Q

what interleukin mediates nitric oxide production

A

IL-13

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25
what do high levels of exhaled nitric oxide suggest
uncontrolled asthmatic inflammation | Patients not correctly taking ICS medication
26
where is exhaled breath NO not useful
Smokers or patients with COPD as cigarette smoke suppresses NO
27
Where can ICS be used
Asthma | ECOS (eosinophilic COPD)
28
What can ICS cause and why
Pneumonia | Causes local immunosuppression and impaired mucociliary clearance
29
Where can prednisolone be used
acute asthma exacerbations
30
Oral steroids have a low/high therapeutic ratio and ICS have a low/high therapeutic ratio
Oral - low | ICS - high
31
ICS is used in combination with what in COPD
ICS/LAMA/LABA
32
true/false - ICS work in eosinophilic and neutrophilic COPD
false - it only works in eosinophilic COPD
33
How small does a particle have to be to get past the carina
less than 5 microns
34
How small does a particle have to be to get past generation 7 of the respiratory tree
less than 2 microns
35
Why is a spacer good to use?
it reduces oropharyngeal and laryngeal side effects and reduces systemic absorption of drug
36
What drug is good as an add on for exercise induced bronchoconstriction
Cromones
37
In who are cromones most effective
atopic children
38
Roughly how do cromones work | How good are they in terms of duration and efficacy
stabilise mast cells | Short acting and poor efficacy
39
What is the main leukotriene in asthma and what does it do?
LTD4 Chemotaxis of eosinophils Oedema Bronchoconstriction
40
Name the main LTRA used, how it is taken | High/low therapeutic ratio
Montelukast, oral and once daily | High
41
how does omalizumab work to treat asthma
Inhibits IgE binding to IgE receptor to prevent TH2 response as well as basophil and mast cell mediator release
42
Where would anti-IgE be used
severe persistent allergic asthma (raised IgE)
43
how does benralizumab work to treat asthma
blocks effects of IL-5, responsible for eosinophilic inflammation
44
Where would anti IL-5 be used
severe refractory eosinophilic asthma (blood eosinophil >300 cell/ul)
45
how does dupilumab work to treat asthma
Block effects of TH2 cytokines IL-4/13, which produce eosinophilic inflammation, IgE, airway hyperreactivity and mucin production
46
where would anti IL-4a be used
severe refractory eosinophilic asthma (blood eosinophil >150 cells/ul and a FeNO>25ppb)
47
What does anti IL-4a suppress
IgE and FeNO
48
beta agonists are combined with ____ to make a duo
ICS
49
beta agonists can be combined with what for COPD
ICS/LAMA/LABA - eosinophilic COPD | LABA/LAMA - neutrophilic COPD
50
how does tachyphylaxis play a part in beta agonists
Chronic use of LABAs can cause a tolerance
51
Name a short and long acting muscarinic antagonist
SAMA - ipratropium | LAMA - Tiotropium
52
true/false - muscarinic antagonists can be used for COPD and asthma
true - usually used in COPD as a LAMA/LABA or ICS/LAMA/LABA but tiotropium can also be used in more severe asthma as triple therapy
53
how does theophylline work and what is it used for
inhibits PDE to sustain cAMP levels. maintenance therapy in asthma
54
where is IV aminophylline used
acute asthma attack
55
xanthines - high/low therapeutic ratio | Contraindications?
contraindicated with P450 drugs | low therapeutic ratio
56
What is roflumilast and when is it used
PDE4 inhibitor used in COPD as an add on to LABA/LAMA | Rarely used due to adverse effects
57
what is carbocisteine and erdosteine and when are they used?
COPD - reduces sputum viscosity to aid ejection | Rarely used
58
Name 2 non-pharmacological ways of reducing COPD exacerbation
Smoking cessation | Vaccination against flu and pneumonia
59
how can acute COPD be treated?
``` nebulised salbutamol and ipratropium 24-28% oxygen titrated against SaO2 for T2 resp failure prednisalone (oral) NIV to create higher FiO2 Consider antibiotic in infection ```
60
How can acute asthma be treated?
Nebulised salbutamol and maybe ipratropium High flow oxygen above 60% IV aminophylline (maybe) Prednisalone (oral) PO2 down and PCO2 up consider intubation with mechanical ventilation
61
Easiest way of measuring improvement in community for an asthmatic?
Peak flow chart
62
What dosage would you increase if an asthmatic has repeated exacerbations?
Increase ICS dose
63
The gold guideline states all potential COPD patients must have what?
Spirometry, it is graded 1-4 if FEV1/FVC<0.70
64
symptoms on the gold grid scale of COPD are measured on what scale?
mMRC scale of 0-4
65
what is the only treatment for pulmonary hypertension
lung transplant
66
What is type 1 respiratory failure
Low PO2
67
What is type 2 respiratory failure
Low PO2 and high PCO2
68
Describe mechanism of T1 resp failure
patient begins hyperventilation to reduce PCO2 and increase PO2
69
Why can overoxygenation easily occur
the top of the O2 Hb dissociation curve can show large drops in PO2 without large SaO2 drops
70
A patient on O2 should never have SaO2 greater than _____
98%
71
what conditions predispose T2 resp failure
``` COPD Cystic fibrosis Kyphoscoliosis MS Obesity Motor neurone ```
72
Causes of hypercarbia
V/Q mismatch Haldane effect Hypoxic drive (uncommon)
73
describe how a V/Q mismatch causes hypercarbia
oxygenation causes vasodilation of blood vessels in poorly ventilated alveoli. CO2 exits the blood in these alveoli but cannot be expelled so remains in lung
74
describe how the haldane effect causes hypercarbia
Oxygenation causes all 4 binding sites of Hb to be oxygenated and liberates CO2, which is released into alveolus and reabsorbed into the blood
75
describe how hypoxic drive causes hypercarbia
desensitisation to CO2 chemoreceptors causes oxygen chemoreceptors to be the primary respiratory drive
76
how can you spot an oxygen sensitive patient
look for chronic CO2 retention as it signifies poor ventilation
77
Can patients without CO2 retention become acidotic with excess oxygenation
Yes!
78
How can hypercarbia be treated
increase Vt with NIV | Aim for SaO2 of 88-92%
79
What is tissue hypoxia
where tissues are so deprived of oxygen they switch to anaerobic respiration for energy, become acidotic and die
80
what conditions cause hypoxia
``` circulatory hypoxia anaemic hypoxia toxic hypoxia Hb to met-Hb alveolar hypoventilation hypoxaemic hypoxia V/Q mismatch impaired diffusion ```
81
Ventilation without perfusion is _____
dead space
82
perfusion without ventilation is _____
shunting
83
What can cause impaired diffusion
interstitial thickening | Vasculr dysfunction
84
What causes alveolar hypoventilation
``` Opiate use Kyphoscoliosis Bronchial obstruction laryngeal obstruction obesity Anaesthesia ```
85
What causes hypoxaemic hypoxia
anaesthetic gases | Low barometric pressure
86
Oxidation of iron in Hb produces ____
met-haemoglobin, which cannot bind oxygen
87
Why does anaemic hypoxia cause hypoxaemia
iron deficiency so less oxygen can be bound to Hb
88
Circulatory hypoxia causes 2 types of reduction in oxygen delivery. what are they are example
Global reduction - heart failure | Local reduction - compartment syndrome, vessel occlusion, oedema
89
How does CO cause toxic hypoxia
Co irreversibly binds to Hb at high affinity to prevent oxygen release
90
How does cyanide cause toxic hypoxia and how is it treated
inhibits ATP so cells shift to anaerobic respiration, do not take up oxygen so it remains in the blood Treated with amyl nitrite
91
Where is high flow oxygen beneficial
non drained pneumothorax CO poisoning Sickle cell crisis Cluster headaches

MB1: Respiratory (15 decks)

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