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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
Q

What are additional therapies for COPD?

A

Mucolytics - Carbocystine

Theophylline - results in bronchodilation and reduction of histamine release

26
Q

What vaccinations should be offered to patients with COPD?

A

Influenza

Pneumococcal

27
Q

What are indications for long term oxygen therapy in COPD?

A

PO2 <7.3 when stable OR

PaCO2 7.3 - 8 WITH secondary polycytheamia, Pulm HTN or Nocturnal hypoxima

28
Q

What oxygen saturation should you be aiming for in a patient with COPD?

A

88 - 92% due to risk of hypercapnic respiratory failure

29
Q

When managing a patient with COPD on oxygen therapy in hospital what approach should you take?

A
  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
Q

What is the most common cause of bronchiectasis?

A

Post- infectious states e.g. childhood infections or pneumonia

31
Q

What are genetic causes of bronchiectasis?

A

Cystic Fibrosis - second most common cause
Yellow Nail Syndrome
Kartagener Syndrome

32
Q

What are immune causes of bronchiectasis?

A

RA, IBD and Hypogammaglobulinaemia

33
Q

What is the triad of Kartagener syndrome?

A

Bronchiectasis
Situs invertus
Cilary dyskinesia

34
Q

What is the presentation of Yellow Nail Syndrome?

A

Bronchiectasis
Plural Effusion
Yellow nails
Oedema

35
Q

What is the presentation inc. signs of bronchiectasis?

A

Recurrent cough. wheeze with COPIOUS sputum production

Signs - clubbing and coarse inspiration crepitations

36
Q

What is first line Ix and what is gold standard for bronchiectasis diagnosis?

A

CXR first line -Tram lines

Gold standard - High resolution CT, Signet ring pattern and tree bud appearance

37
Q

What is the management of bronchiectasis?

A
  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
Q

What is empirical Abx choice in bronchiectasis?

A

Amoxicillin or Clarythromycin

39
Q

What is the pathophysiology of CF?

A

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
Q

What are peadiatric presentations of CF?

A

Muconeum ileus, Jaundice and failure to thrive

41
Q

What is the screening programme for CF?

A

Testing for Immune Reactive Trypsinogen - New born Heel prick

42
Q

What are GI, RESP and REPRODUCTIVE presentations of CF?

A

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
Q

What is diagnostic tests for CF?

A

Initial - Sweat test - pilocarpine applied to stimulate sweating. Cl- of >60mml on two different occasions is diagnostic
Genetic testing

44
Q

What are key management principles for GI pathology in CF?

A

DAKE replacement

Creon - Pancreatic enzyme replacement + PPI

45
Q

What are key management principles for resp pathology in CF?

A

Chest physiotherapy
Mucolytics - DNAse - Dornase
Antibiotic prophylaxis and treatment

46
Q

What is given to patients with CF who have repeated pulmonary exacerbation?

A

Azythromycin

47
Q

What is given to children between the ages of 3-6 years with CF?

A

Prophylactic Flucloxacclin

48
Q

What is given to patients with CF who have chronic pseudomonas aeruginosa infection?

A

Inhaled Tobramycin if >6 years

49
Q

What is given to patients as prophylaxis for pseudomonas aeruginosa infection?

A

Ciprofloxacin

50
Q

Patients with CF are tested annually. What is tested on these occassions?

A

DM from 10 YO
Liver function
Pulmonary assessment
Psychological wellbeing

51
Q

What type of respiratory failure does an acute asthma exacerbation present as initially?

A

Type 1 respiratory failure

52
Q

What are signs of severe asthma?

A

HR >110
RR >25
PEFT <50% -33%
Unable to complete full sentences

53
Q

What are signs of life threatening asthma?

A 
Silent chest 
Cyanosis 
Poor respiratory effort 
NORMAL OR HIGH CO2 - evidence of tiring. Can present as coma or drowsy 
PEF <33%, O2 <92%
54
Q

What is pulsus paradoxus and what does it suggest with regard to asthma?

A

Late and rare classic sign

Abnormally large decrease in systolic blood pressure during inspiration

55
Q

What Ix you should do first line?

A

If <92% sats or life threatening signs ABG

Peak flow ASAP

56
Q

What is first line management of acute asthma attack?

A

Oxygen driven nebulised salbutamol WITH ipratropium if severe or life threatening

Nebs continued back to back if poor response

57
Q

What should be given to all patients presenting with an acute asthma exacerbation?

A

Oral Prednisolone within 1 hour

IV if cant swallow

58
Q

What are signs of moderate asthma exacerbation?

A

Increasing SX

PEF 50-75%

59
Q

What is management of asthma that follows poor response to nebs or life threatening features?

A

IV magnesium 2g over 20 mins

Must inform senior doc and cardiac monitor

60
Q

When should you consider an urgent critical care referral in an acute asthma exacerbation?

A

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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