Obstructive Lung Dz Flashcards
Indications for bronchial thermoplasty and contraindications
- Stable severe asthma on optimal medical therapy (at least ICS-LABA) with poor control.
- No trials in those with >3 exacerbations/year, FEV1 <60% pred, or chronic sinus disease.
Contraindications:
1. Active implantable electronic device
2. Acute myocardial infarction <6 weeks ago
3. Prior BT
4. Coagulopathy
5. Allergies to anesthestics for BT
Indications for antibiotics in COPD exacerbation
increased dyspnea, sputum volume and sputum purulence
Also if severe exacerbation needing invasive or noninvasive MV
Dynamic extrathoracic obstruction on flow volume loop
Dynamic intrathoracic obstruction on flow volume loop
Fixed upper air way obstruction on flow volume loop
Indication for O2 therapy in COPD
PaO2 </=55 or SaO2 </=88%
OR
PaO2 </= 59 or SaO2 </=89% AND
- EKG with signs of cor pulmonale
- HCT >55
- Evidence of RH failure
OR
Exercise desat to </=88% and documented improvement with O2
Indication for NIV for COPD
GOLD Stage 4 w/ PaCO2 ≥52mmHg and pH>7.35 a few weeks (2-4) after hospital discharge.
In RCTs, NIV settings were titrated to achieve at least 20% reduction in PCO2, typically EPAP 4 to 5 cm H2O and IPAP 22 to 26 cm H2O and backup RR 14 to 16/min (ie, high-intensity NIV).
Goal of NIV for COPD
decrease PaCO2 by >= 20% from baseline or <48
Improved 1 year mortality
Who has survival benefit from lung volume reduction surgery?
Upper lobe predominant emphysema and low baseline exercise capacity
Most common risk of endobronchial valve insertion
Pneumothorax 20-30%
ICS/LAMA/LABA benefit
In pt with hx frequent or severe exacerbations
improves lung function, symptoms, health status, reduces exacerbation, all cause mortality
How to best predict COPD related hospitalizations and mortality on PFTs?
FEV1/FVC <0.7 more accurate than LLN
treatment of hereditary angioedema
Icatibant (bradykinin receptor antagonist)
Replacement of plasma-derived C1 inhibitor
Ecallantide (inactivation of plasma kallikrein)
ppx with plasma derived C1 inhibitor, lanadelumab, plasma kallikrein
Steroids not effective
Most common cause of nonCF bronchiectasis
Post infectious
Idiopathic
Immunodeficiency
ABPA
PCD
CTD/RA
Chronic aspiration
yellow nail syndrome
When is allergen immunotherapy not recommended for pt with asthma?
if asthma is uncontrolled - risk of bronchospasm
Pregnancy
Unstable CV disease
concurrent treatment with beta blocker
Effect of allergen immunotherapy for asthma
very minimal benefit for asthma outcomes
If mild to mod asthma controlled on ICS then can reduce asthma symptoms
No known effect on exacerbations
Definition of bronchial atresia
focal obliteration of lobar, segmental or subsegmental bronchus complicated by mucous impaction and/or air trapping distal to atretic bronchus
Which segment is frequently affected by bronchial atresia
left upper lobe
DDx for Perihilar tubular lesion and hyperinflation
Congenital lobar emphysema
AVM
intralobar pulm sequestration
Bronchogenic cyst
mucoid impaction
Imaging findings for AVM
tubular lesion that enhances with contrast
No bronchial obs, hyperluciency or hyperinflation
Gene that determines azithromycin resistance in M. abscessus complex?
erm(41) gene
rpoB gene mutation can lead to what resistance?
rifampin
rrs gene mutation leads to which resistance
Aminoglycosides
Only in those w/ lots of exposure to amikacin or other AG
embB leads to what kind of drug resistance in M abscessus?
ethambutol
Effect of flu vaccine for pts with COPD?
reduces # exac and flu hospitalization frequency
Goal VO2 max for lobectomy?
VO2>20
When to prescribe O2 for flying?
- resting SpO2 <92% –>2L
- SpO2 <84% 6MWT –> get HAST or empiric 2L
- If <4L O2 baseline then increase 1-2L for flight
- If on >4L at rest at baseline then dont fly
When to get 6MWT prior to a pt flying if suspicious for hypoxia?
if SpO2 >95% RA and a mMRC 3 or greater
What can cause the PRISm pattern on PFTs
- Air trapping w or w/o hyperinflation (pseudoresriction)
- simple restriction (FVC<LLN)
- Nonspecific pattern
- complex restriction
What are the associated issues with PRISm?
increased risk resp symptoms
reduced exercise tolerance
respiratory related hospitalizations
increased mortality
What is a nonspecific pattern on PFTs?
VC<80%, TLC nl
can be airway hyperresponsiveness, chronic lung dz, obesity , Neuromsk impairment, chest wall restriction, poor testing
Initial inhaler for pts with COPD?
LAMA/LABA
Best treatment for pt with CF and F508del mutation
elexacaftor plus tezacaftor plus ivacaftor
Placental transmogrification of the lung treatment
bronchodilators, ICS, smoking cessation and vaccines.
If that fails then bullectomy
Congenital causes of unilateral cystic or bullous lesions
- bronchogenic cysts
- Congenital lobar emphysema
- placental transmogrification of the lung
- Swyer-James-MacLeod syndrome (reduced pulmonary vasculature and alveolar hyperdistention +/- bronchiectasis)
CT scan findings of RML and lingular bronchectais in older pt w/o history of pulmonary disease
nontuberculous mycobacteria
how long can people continue to benefit from long term maintenance PR?
24 months
CT findings of bronchopulmonary sequestration
focal areas of lucency or irregular cystic spaces w or w/o fluid
CT angio can identify the arterial blood supply
Most common form of bronchopulmonary sequestration
Intralobar sequestrations
Located in posterior basal segment of lower lobe 60%
Presentation: recurrent pneumonia
What is the prevalence of undiagnosed COPD in pts >40yo with >10pkyrhx
70-78%
Effect of deesclation of triple inhaler therapy to LAMA/LABA in non-frequent exac pts with FEV1 40-80% and no asthma
Reduction in lung function
No increased AECOPD and no change in QoL or mortality
When to continue patient on triple inhaler therapy despite being GOLD B?
Blood eos >300
- higher risk of AECOPD
- Greater lung function loss off of ICS
When to NOT use ICS in COPD?
Recurrent PNA
Eos <100
hx mycobacterial infection
Prior to starting augmentation therapy for AAT def what lab?
IgA
What are some of the adverse effects and contraindications of roflumilast?
- Weight loss
- Nausea, vomiting, diarrhea
- Contraindicated moderate-to-severe hepatic impairment (Child-Pugh class B or C)
- Drug interactions with inducers and inhibitors of CYP 3A4 (inducers: rifampicin and carbamazepine; inhibitors: erythromycin, cimetidine, and protease inhibitors)
What are the direct and indirect agents for bronchoprovocation testing and the thresholds for a positive test in each respective category?
Cystic fibrosis patients with a new pseudomonas aeruginosa should receive what treatment?
Inhaled tobramycin solution for 28 days
(Grade A recommendation - CF Foundation Guidelines)
Indications for O2 prescription:
1) Resting room air Pao2 ≤55 mm Hg or Spo2 ≤88%
2) Resting room air Pao2 56 to 59 mm Hg or Spo2 ≤89% if there is evidence of dependent edema, or cor pulmonale or pulmonary hypertension, or erythrocythemia >56%
3) Exercise desaturation to Spo2 ≤88% and documented improvement of hypoxemia during exercise with oxygen.
