Obstructive d/o Flashcards
What is the pathophys of asthma?
obstructive airflow, hyperreactivity, and inflammation
What causes asthma?
allergens, cold air, exercise, drugs, URI, etc.
often there is a trigger, often genetic predisposition
When do people get diagnosed with asthma?
Can be at any age, but most commonly before 18y
What is the atopic triad?
asthma, allergies, eczema
What are the common symptoms of asthma?
Cough, tight chest, dyspnea, use of accessory muscles
wheezing
pulsus paradoxus
How will you diagnose asthma?
decreased FEV1/FVC ratio
Reversible (10% increase after bronchodilators like B agonists)
Can be induced by Ach agonists like methyl choline
What will ABG show in asthma?
respiratory alkalosis
Suppore you suspect asthma, but PFTs are normal every time the pt sees you. What test can you give to induce sx?
Methacholine challenge
Give methacholine, and see if FEV1 decreases by 20% or more.
if it doesn’t, it’s unlikely asthma
What is Stage 1 asthma?
attacks:
< 2 times / wk during day
< 2 times / mo during night
FEV1 is 80%
What is stage 2 asthma?
attacks:
< 1 times / day during day
< 1 times / wk during night
FEV1 is 80%
What is stage 3 asthma?
attacks:
> 1 times / d during day
> 1 times / wk during night
FEV1 is 60-80%
What is stage 4 asthma?
attacks:
> 1 times / d during day
Frequent during night
FEV1 is < 60%
How do you best assess severity of asthma?
Peak Expiratory Flow Rate (PEFR)
Best for baseline and monitoring
How do you treat asthma?
a) Intermittent (1)
b) Mild persistant (2)
c) Moderate Persistant (3)
d) Severe persistant (4)
a) short acting beta agonist
b) short acting beta agonist + inhaled corticosteroid
c) short acting beta agonist + inhaled corticosteroids + long acting beta agonist
d) short acting beta agonist + HD inhaled corticosteroid + long acting beta agonist
consider PO steroids
How do you treat exercise induced asthma?
stabilizers (cromolyn, nedocromyl)
albuterol [ventolin hfa] 5 min before exercise
(just to reiterate)
How do you treat asthma attack?
How do you treat asthma long term?
attack: DOC is SABA, MC albuterol
- also anticholinergics, MC ipratroprium, but less effective
long term: DOC is inhaled corticosteroids, MC fluticasone
- also LABA, esp for night sx, MC salmeterol or formoterol
For asthma, what is an alternative to ICS in mild persistant asthma?
leukotriene receptor antagonists and inhibitors like zafirlukast
What drug is given to patients with uncontrolled asthma in adjunct to ICS?
long acting inhaled anticholinergic like tiotroprium
What is DOC for severe persistant asthma that is triggered by allergies?
Omalizumab (anti-igE drug)
At what level of asthma should you consider hospitalization?
Moderate to severe
What is COPD in general?
progressive, irreversible airway obstruction due to
a) loss of elastic recoil
b) increased airway resistance
includes emphysema and chronic bronchitis (usually coexist)
What is emphysema (pathyphys)?
destroyed alveoli that are big and floppy
caused by chronic inflammation, a decrease of protective enzymes/increase of destructive enzymes, leading to alveolar destruction
usually steady decline
What is chronic bronchitis (pathophys)?
airways clog with mucus
“mucociliary escalator” destroyed and patients are prone to infection
usually episodic
What causes COPD (emphysema and chronic bronchitis)?
Smoking!
Also recurrent URIs, other pollutants
Rarely, alpha antitrypsin deficiency
Who gets COPD?
Typically age 55+
(if <40y consider genetic cause)
What are the signs and symptoms of emphysema?
Exertional dyspnea and hyperventilation
Non-productive cough
dec or absent breath sounds, dec fremitus
NO peripheral edema
Pt often thin with weight loss
Barrel chest
Tripod position with pursed lip
What are the signs and symptoms of chronic bronchitis?
Mild dyspnea
productive cough
ronchi, crackles and wheezing
peripheral edema
overweight with cyanosis
loud, raspy breaths
How do you diagnose COPD?
(What diagnostic factor is the same between both emphysema and chronic bronchitis?)
Spirometry is gold standard.
DECREASED FEV1 so decreased FEV1/FVC ratio
Non-reversible
DLCO decreased
What will ABG labs look like for
a) emphysema
b) chronic bronchitis
a) respiratory alkalosis
b) respiratory acidosis w/ inc Hct and RBC
Which COPD disorder has the most severe v/q mismatch?
Chronic bronchitis, w/ severe hypoxemia and hypercapnia
Why would you order a CXR/CT scan in COPD?
to help diagnose emphysema and to assess extent of damage
What will you see in CXR/CT of
a) emphysema
b) chronic bronchitis
Emphysema: hyperinflation of lungs, flat diaphragm, droopy heart, increasing markings bullae or subpleural blebs (pathognomonic)
Chronic bronchitis: hyperinflation of lungs without flat diaphragms, enlarged R heart border, increased markings
How do you treat COPD?
Similar to asthma.
1. Smoking cessation
- Anticholinergic inhalers is DOC (ipratroprium; tiotropium)
- ST bronchodilators for acute exacerbations (b2 agonist drugs like albuterol; salmeterol)
Frequenty, oral abx for chronic bronchitis
Other: O2, aerobic exercise, steroids (with caution), alpha1 antitrypsin replacement therapy, vaccinations
What is bronchiectasis?
permanent dilation of airways; destruction of bronchiole walls
airways are easily collapsable & mucus clearance impaired
What causes bronchiectasis?
chronic bronchial injury due to infection or inflammation
MC with cystic fibrosis
What are the signs and sx of bronchiectasis?
Foul, purulent sputum w/ chronic cough
pleuritic chest pain, dyspnea
hemoptosis
recurrent pneumonia
local chest crackles (at bases), also wheezing, rhonchi
clubbing of fingers
What is the diagnostic test of choice for bronchiectasis?
What will you see?
Chest CT - dilated, tortuous airways
“tram track” appearance (wall thickening), plugs, consolidations
Signet Ring sign (pulm artery coupled with dilated bronchus)
What will you see on PFT for bronchiectasis?
On CXR?
PFT: obstructive pattern so dec ratio
CXR: very similar to CT scan with basal cystic spaces (small cysts @ lung bases), atelectasis, honeycombing
What are the 3 most common pathogens seen in bronchiectasis?
pseudomonas (MC with CF)
mycobacterium avium complex (MAC)
aspergillus
How do you treat bronchiectasis?
Abx: amox, augmentin, Bactrim, ciprofloxacin (empiric)
FQs, cephalosporins (pseudomonas coverage)
Bronchodilators
Chest physiotherapy
If severe: lung transplant
What is cystic fibrosis?
increased mucus and problem with chloride transport
What causes CF?
autosomal recessive disease
Who gets CF more often?
Caucasians, northern Europeans
In whom should you suspect CF?
someone with a hx of chronic lung dz, pancreatitis, and infertility
What are the clinical manifestations of CF?
GI: meconium ileus at birth (failure to pass 1st stool); foul steatorrhea due to decreased fat absorption
Pulm: recurrent resp infections, prod cough, dyspnea, chest pain, wheezing, chronic sinusitis
Other: failure to thrive
How do you diagnose CF?
Chloride sweat test on 2 different days
DNA testing for CFTR gene
PFT obstructive (prob irreversible)
CXR - hyperinflation, bronchiectasis, mucus plugging, increased interstitial markings, small/round peripheral opacities, atelectasis, blah blah blah
Tx of CF?
- mucolytics (pulmozyme or dornase)
- bronchodilators
- chest percussion
- abx
Others: pancreatic enzyme replacement, dietary supps, lung transplant
