Obstructive Lung Disease Flashcards
What is exhaled NO a measurement of in asthma patients?
Weakly correlated with degree of airway obstruction, specifically in regards to Th2-driven local inflammation causing upregulation of NO synthetase enzymes
What can cause increase exhaled NO?
Asthma with Th2-driven inflammation, allergic rhinitis, nonasthmatic eosinophilic bronchitis, non-CF bronchiectasis, viral URIs
What is the justification of the fixed 0.7 FEV1/FVC ratio for COPD diagnosis?
Better discrimination of COPD-related hospitalization and mortality risk vs LLN
For patients with moderate to severe COPD, what are the benefits of triple therapy over LABA/LAMA?
Improved lung function, QOL, reduces mortality and hospitalizations
How does obesity affect asthma?
Increases asthma exacerbations, and asthma is underdiagnosed in this population, and have reduced response to ICS
Who is a candidate for bronchial thermoplasty?
Severe asthma, stable on at least ICS/LABA with evidence of poor asthma control
Contraindications include under 18, more than 3 exacerbations in a year, FEV1 under 60, chronic sinus dz, active implantable device, AMI within 6 weeks, coagulopathy, incomplete prior response to BT
Who can be considered for roflumilast add-on therapy?
COPD on triple therapy with concomitant chronic bronchitis with 2 exacerbations in the last year and/or one hospitalization, avoid in Child-Pugh B or C. Watch for weight loss and psych issues. Can increase FEV1
What is the difference between sensitizer-induced asthma and work-exacerbated asthma?
Sensitizer- sputum eosinophils decrease in absence from work, airway responsiveness changes, IgE mediated
Work- exacerbated at work but persists at home. Nonspecific irritant exposure
How is hereditary angioedema treated?
With subQ icatibant (plasma-derived C1 inhibitor) or lanadelumab (monoclonal inhibitor of plasma kallikrein- a precursor to bradykinin)
What are the cutoffs for mannitol (indirect) challenge vs methacholine/histamine (direct) challenge?
Mannitol- 15+% change in FEV1 from baseline
Methacholine/histamine- 20+% change in FEV1 from baseline
Contraindicated if FEV1<1.5L
Who is a candidate for endobronchial valves for lung volume reduction?
Overinflated segments
Watch out for PTX
When should pulmonary rehab be started after AECOPD?
within 90 days of discharge to improve all-cause mortality
How does flu vaccination help COPD patients?
Reduces exacerbations and hospitalization, but not mortality benefit
What are the etiologies of non-CF bronchiectasis?
Postinfectious, iodiopathic, immunodeficiency, ABPA, primary ciliary dysfunction, CTD/RA, chronic aspiration, yellow nail syndrome. Has lower lobe predominance as opposed to CF. dornase alfa doesn’t seem to help non-CF bronchiectasis
What are the features of NSAID exacerbated respiratory disease
Hx asthma/chronic rhinosinusitis, nasal polyposis, symptoms exacerbated by NSAIDs/aspirin 30min-3hrs after ingestion
What are the benefits of oxygen therapy in COPD patients?
Mortality benefit if worn at least 16hrs, reduce exacerbations. Did not change lung function or QOL
What are the resistance mechanisms seen in NTMs?
erm(41)- macrolide resistance
rpoB- rifampin resistance in m kansasii
16S ribosomal RNA / rrs- aminoglycoside resistance in MAC
23S rRNA - macrolides in MAC and abscessus
embB- ethambutol resistance
What is the best way to resolve a distal central airway obstruction in an unstable patient?
Rigid bronchoscopy can dilate the airway, allow for debridement, tamponade bleeding while securing the airway. Heliox can be a temporizing modality, and VV ECMO can be considered in certain situations
For proximal lesions, may consider tracheostomy
What are the potential risks of endobronchial valves?
PTX- 27% of patients in first 45days, 34% within the first year. Mostly managed with chest tube, occasionally will need valve removed. No increase in mortality and has similar benefit to those who do not experience PTX
What is associated with “destroyed lung syndrome”?
CF, recurrent infection due to kyphoscoliosis, toxic inhalations causing cylindrical bronchiectasis, and TB. Treat with airway clearance therapies. Only treat with abx if there is objective evidence of severe infection such as fever/chills/night sweats/purulent sputum.
Who are candidates for lobectomy for resectable tumors?
Absence of cardiovascular disease, 400m walk distance, peak Vo2 above 20mL/kg/min, FEV1 above 3.0 and DLCO above 30. In emphysema patients, FEV1 may actually improve post-op due to volume reduction. Don’t delay surgery for smoking cessation
What is the COPD Assessment Test (CAT)?
COPD specific questionnaire quantifying health status. GOLD now recommends assessment and management of COPD to be based on patient’s perception of disease and risk of exacerbation along with spirometry.
How do cardioselective BBers affect COPD control?
It doesn’t! Safe to use. Don’t affect LABAs.
What routine testing should be done for patients with COPD?
Bone density scans. Routine spirometry without concern for worsening lung function is not indicated. LDCT for patients 50-80yo with 20 pack yr Hx, currently/quit within 15 years.
For patients with COPD and chronic hypercapnia, when should NNIV be started?
When patient is stable 2-4 weeks following hospital discharge for AECOPD, or pending sleep study if concern for OSA
What is associated with asthma deaths?
Uncontrolled disease with symptoms days to weeks leading up to death, pathology reveals extensive mucus plugging and eosinophilic infiltration. Previous intubation/ICU admission is associated with increased mortality along with reduced lung function, but can happen in mild disease.
How is chronic endobronchial Pseudomonas treated in CF patients?
Eradication in newly found disease with inhaled tobramycin for 28 days then surveillance of sputum every 3 months. Can achieve 60-90% eradication that can last 12-24 months.
