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Obstructive Lung Disease Flashcards

1
Q

What is the definition of asthma?

A

Intermittent wheeze and SOB secondary to reversible bronchoconstriction

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2
Q

What are classical symptoms of asthma?

A

Diurnal variation
Exacerbated by cold, allergens and exercise
Hx of hayfever and eczema

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3
Q

What two medications can exacerbate asthma?

A

NSAIDS

BB

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4
Q

What is the first line investigation to diagnose asthma?

A

Spirometry with reversibility testing with bronchodilators

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5
Q

What method is used to monitor asthma severity between attacks?

A

PEF

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6
Q

What are other investigations can be used if spirometry is inconclusive diagnosis for asthma ?

A

Challenge testing - use of histamine or methacholine in a safe enviromonent to produce symptoms

Fractional exhaled nitric oxide - indirect marker of airway inflammation

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7
Q

What is first line management for asthma?

A

Short acting Beta 2 agonist e.g. Salbutamol

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8
Q

What is second line treatment for asthma and when would it be indicated?

A

Inhaled corticosteroid

Using SABA >3x a week or night waking with asthma symptoms

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9
Q

What are the 3rd and 4th line treatment for asthma when not controlled by SABA and ICS?

A
  1. Addition of Montelukast - LTRA

2. Start LABA, Stop LTRA

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10
Q

What are side effects of Beta 2 agonists?

A

Tachycardia
Hypokalaemia
Tremor - activation of B2 in skeletal muscle

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11
Q

When would you refer to a respiratory physician for asthma?

A

Frequent use of oral steroids

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12
Q

What monoclonal antibody therapy can be initiated in severe asthma and what are its indications and actions ?

A

Omilizumab - IgE receptor inhibitor

When oral steroids are required >4 times in 12 months

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13
Q

An improvement of what percentage would indicate asthma in a bronchodilator reversibility challenge?

A

200ml or 12% increase in FEV1

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14
Q

If asthma is uncontrolled on SABA, ICS and LABA what is the next line of management and what does it mean?

A

Start MART - Maintenance and reliever therapy

Combined ICS and LABA in single inhaler

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15
Q

What is the definition of COPD?

A

Chronic condition where there is airflow limitation secondary to inflammation due to exposure to substances or stimuli.

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16
Q

What is the difference between the emphysematous lung destruction in patients who smoke in comparison to patients who have alpha-1 antitripsin deficiency?

A

Alpha-1 antitripsin deficiency tends to effect the lower lobes and it is panlobular

Smokers tend to develop centrilobular which typically impacts the upper lung and proximal acini

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17
Q

What diagnosis should you consider in a younger patient presenting with Emphysema and what organs would you want to investigate?

A

Alpha 1 antitripsin deficiency

Liver function

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18
Q

What is the pathophysiology of alpha 1 antitripsin deficiency?

A

Alpha-1 antitripsin prevents the breakdown of elastin by neutrophil elastase resulting in the sub sequential breakdown of alveolar cells

Congestion of the liver with the enzyme alpha-1 antitripsin which is produced there in an attempt to compensate eventually causes hepatocyte destruction.

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19
Q

What two syndromes involve the development of asthma?

A

Churgg Strauss - 90% of patients. Inflammatory vasculitis effecting small to medium blood vessels

Someter syndrome - Triad of nasal polyps, aspirin insensitivity and asthma

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20
Q

What are the classical symptoms of COPD?

A 
Recurrent chest infection 
Wheeze 
SOB 
Weight loss 
Sputum production - classically white
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21
Q

What are important investigations in the diagnosis of COPD and what would you expect to see?

A

Spirometry - Reduced FEV1 and FVC, Increased RV. Consider reversibility testing with SABA to rule out asthma if diagnostic uncertainty

FBC - ? Polycythemia due to reduced O2

XRAY - Hyperinflation >10 posterior ribs, Bullae and flattened hemidiaphragm

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22
Q

What are symptoms of an exacerbation of COPD and what is the most common causative organism?

A

Increased SOB and cough
Increased sputum production or change in sputum colour

Haemophilus influenzae

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23
Q

What is the management of an acute exacerbation of COPD?

A

Increase SABA use
Add 30mg of Prednisolone for 7 to 14 days
If purulent sputum or other sx of pneumonia - Add amoxicillin or doxy

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24
Q

What is first and second line inhaled therapy for stable COPD?

A

1st - SABA OR SAMA

2nd - Use FEV1 levels to determine: <50% ICS + LABA or LAMA IF >50% add LABA or LAMA

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25
What are additional therapies for COPD?
Mucolytics - Carbocystine | Theophylline - results in bronchodilation and reduction of histamine release
26
What vaccinations should be offered to patients with COPD?
Influenza | Pneumococcal
27
What are indications for long term oxygen therapy in COPD?
PO2 <7.3 when stable OR | PaCO2 7.3 - 8 WITH secondary polycytheamia, Pulm HTN or Nocturnal hypoxima
28
What oxygen saturation should you be aiming for in a patient with COPD?
88 - 92% due to risk of hypercapnic respiratory failure
29
When managing a patient with COPD on oxygen therapy in hospital what approach should you take?
1. Initial management 24% ventri mask prior to ABG 2. ABG pH >7.3 progress to 28% venturi 3. Reassess ABG every 30 to 60 minutes to assess for rising PCO2 or Falling pH 4. If patient is acidotic <7.35 and hypercapnic progress to NIV with targeted O2 therapy.
30
What is the most common cause of bronchiectasis?
Post- infectious states e.g. childhood infections or pneumonia
31
What are genetic causes of bronchiectasis?
Cystic Fibrosis - second most common cause Yellow Nail Syndrome Kartagener Syndrome
32
What are immune causes of bronchiectasis?
RA, IBD and Hypogammaglobulinaemia
33
What is the triad of Kartagener syndrome?
Bronchiectasis Situs invertus Cilary dyskinesia
34
What is the presentation of Yellow Nail Syndrome?
Bronchiectasis Plural Effusion Yellow nails Oedema
35
What is the presentation inc. signs of bronchiectasis?
Recurrent cough. wheeze with COPIOUS sputum production | Signs - clubbing and coarse inspiration crepitations
36
What is first line Ix and what is gold standard for bronchiectasis diagnosis?
CXR first line -Tram lines Gold standard - High resolution CT, Signet ring pattern and tree bud appearance
37
What is the management of bronchiectasis?
1. Aid mucous clearance with chest physio and pulmonary rehab in severe cases 2. Empirical Abx therapy for acute exacerbations 3. Assess response to SABA and LABA
38
What is empirical Abx choice in bronchiectasis?
Amoxicillin or Clarythromycin
39
What is the pathophysiology of CF?
Autosomal recessive condition resulting from defect in CFTR gene on chromosome 7 CFTR mutation effects chloride ion transport resulting in excessively viscous mucous and increased Na+ in sweat. Secretions build up in the pancreas, lungs and GI system.
40
What are peadiatric presentations of CF?
Muconeum ileus, Jaundice and failure to thrive
41
What is the screening programme for CF?
Testing for Immune Reactive Trypsinogen - New born Heel prick
42
What are GI, RESP and REPRODUCTIVE presentations of CF?
GI - steatorrhoea, DM, Gall stones, Low weight Resp - recurrent infection, clubbing, wheeze, SOB and purulent sputum Reproductive - male infertility due to absence of Vas and female subfertility
43
What is diagnostic tests for CF?
Initial - Sweat test - pilocarpine applied to stimulate sweating. Cl- of >60mml on two different occasions is diagnostic Genetic testing
44
What are key management principles for GI pathology in CF?
DAKE replacement | Creon - Pancreatic enzyme replacement + PPI
45
What are key management principles for resp pathology in CF?
Chest physiotherapy Mucolytics - DNAse - Dornase Antibiotic prophylaxis and treatment
46
What is given to patients with CF who have repeated pulmonary exacerbation?
Azythromycin
47
What is given to children between the ages of 3-6 years with CF?
Prophylactic Flucloxacclin
48
What is given to patients with CF who have chronic pseudomonas aeruginosa infection?
Inhaled Tobramycin if >6 years
49
What is given to patients as prophylaxis for pseudomonas aeruginosa infection?
Ciprofloxacin
50
Patients with CF are tested annually. What is tested on these occassions?
DM from 10 YO Liver function Pulmonary assessment Psychological wellbeing
51
What type of respiratory failure does an acute asthma exacerbation present as initially?
Type 1 respiratory failure
52
What are signs of severe asthma?
HR >110 RR >25 PEFT <50% -33% Unable to complete full sentences
53
What are signs of life threatening asthma?
``` Silent chest Cyanosis Poor respiratory effort NORMAL OR HIGH CO2 - evidence of tiring. Can present as coma or drowsy PEF <33%, O2 <92% ```
54
What is pulsus paradoxus and what does it suggest with regard to asthma?
Late and rare classic sign | Abnormally large decrease in systolic blood pressure during inspiration
55
What Ix you should do first line?
If <92% sats or life threatening signs ABG | Peak flow ASAP
56
What is first line management of acute asthma attack?
Oxygen driven nebulised salbutamol WITH ipratropium if severe or life threatening Nebs continued back to back if poor response
57
What should be given to all patients presenting with an acute asthma exacerbation?
Oral Prednisolone within 1 hour | IV if cant swallow
58
What are signs of moderate asthma exacerbation?
Increasing SX | PEF 50-75%
59
What is management of asthma that follows poor response to nebs or life threatening features?
IV magnesium 2g over 20 mins Must inform senior doc and cardiac monitor
60
When should you consider an urgent critical care referral in an acute asthma exacerbation?
If despite treatment there is decreasing PEFR, persisting worsening hypoxia, pH > 7.35 OR NORMAL OR RAISED CO2

Respiratory (7 decks)

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