Obstructive Pulmonary Diseases Flashcards
This condition is defined as an inflammatory disease of the airways characterized by hyperresponsiveness of the tracheobronchial tree to various stimuli (largely reversible)
Asthma
Asthma is an obstructive airway disease with what 3 components?
Inflammation (treat this first)
Airway hyper-responsiveness
Allergic or immunologic mediated
The strongest identifiable factor for someone developing asthma is what?
atopy
What are the components of the atopic triad?
Asthma
Eczema
Seasonal rhinitis
List some asthma triggers
Allergens (seasonal and environmental)
Infection
Exercise
Pharmacological Stimuli
Occupational Factors
Emotional Stress
80% of asthma cases are which type?
Slow-Onset Asthma
What is typically the first sign in asthma?
Cough – worse particularly at night
What is the standard testing used for diagnosing asthma?
Spirometry (Pulmonary function studies)
What tool is used for monitoring in asthma patients?
Patients can take home and keep track of their own flow rates (handheld devices)
Peak Expiratory Flow meters
What if you suspect patient has asthma but the PFT is normal? What test can you run?
Obtain a bronchial provocation test
What are the types of asthma?
Allergic (extrinsic)
Idiosyncratic (Intrinsic)
Exercise-Induced
Industrial and Occupational
What are the classifications in asthma?
Intermittent asthma
Mild persistent asthma
Moderate persistent asthma
Severe persistent asthma
What is the importance of classifying asthma?
to know where they are to guide treatment
Which asthma classification is described below?
Intermittent daytime symptoms occurring less than twice a week
Brief exacerbations
Nocturnal symptoms occurring less than twice a month
Asymptomatic with normal lung function between exacerbations
Intermittent Asthma
Which asthma classification is described below?
Symptoms occurring more than once a week but less than once a
day
Exacerbations affect activity or sleep
Nocturnal symptoms occurring more than twice a month
Mild Persistent Asthma
Which asthma classification is described below?
Daily symptoms
Exacerbations affect activity and sleep
Nocturnal symptoms occurring more than once a week
Moderate Persistent Asthma
Which asthma classification is described below?
Continuous symptoms
Frequent exacerbations
Frequent nocturnal asthma symptoms
Physical activities limited by asthma symptoms
Severe Persistent Asthma
These results show what classification of asthma?
FEV1 or PEF rate greater than 80% predicted with less than 20%
variability
Less than 80% = obstructive pattern
Intermittent Asthma
These results show what classification of asthma?
FEV1 or PEF rate greater than 80% predicted with variability of
20-30%
High variability
Mild Persistent Asthma
These results show what classification of asthma?
FEV1 or PEF rate 60-80% predicted with variability greater
than 30%
Moderate Persistent Asthma
These results show what classification of asthma?
FEV1 or PEF rate less than 60% predicted with variability greater
than 30%
Severe Persistent Asthma
What is the goal of treatment in asthma?
to gain control - only manage to make their lives as normal as
possible
All of the levels will have what type of medication/treatment?
albuterol inhaler for rescue
How often should you review asthma treatment?
every 1-6 months
General exacerbation Disposition in asthma: when can you discharge an asthma patient home? What factors must be met generally?
Discharge home if FEV1>70% and symptoms minimal or absent – monitor first to ensure stability (if less than 70, admit patient)
A patient being discharged from the hospital after asthma exacerbation should go home with what?
steroid prescription 3-10 days
short acting bronchodilator scheduled dosing 24-48 hours
increase oral corticosteroid dose
follow up and action plan instructions
What is a late sign in asthma that is worrisome?
cyanosis
Patient’s taking their meds but still have wheezing, an exacerbation – we call it what?
Asthma Attack
What are the initial treatment/goals of an Asthma Attack?
Maintain the airway at all times
Maintain SaO2 >90% - Give supplemental O2
Intubate if respiratory failure - Be prepared to intubate at any moment
What medication class is contraindicated in an asthma attack?
NSAIDs
Severe bronchospasm that does not respond to aggressive therapies within 30-60 minutes
Status Asthmaticus
What is the most concerning complication of an asthma attack?
Status Asthmaticus
Rule of thumb in asthma:
Who Needs Preventative Care? Rule of twos - list them
Two beta agonist canisters a year (each bottle contains 70 pumps)
Two doses of beta agonists per week
Two nocturnal awakenings per month
Two unscheduled visits to the doctor per year (3-4 scheduled visits with a doctor per year is expected for asthma – unscheduled/more visits because of flare ups is a concern)
Two prednisone bursts per year
List the risk factors for death from asthma
Asthma history
Previous severe exacerbation (ICU or intubation)
Two or more hospitalizations for asthma in the past year
Hospitalization or an ED visit for asthma in the past month (The majority of people who die from asthma have been in the ER within the
previous 30 days)
Current use of or recent withdrawal from systemic corticosteroids
Use of >2 MDI short-acting beta2 agonist canisters per month
Social history (Low socioeconomic status or inner-city residence, serious psychosocial problems)
Comorbidities (CV disease, COPD, Emphysema, etc)
What condition is an all inclusive and nonspecific term applied to a spectrum of disease (most patients have mixed disease)?
COPD
In the US, what disease is the most rapidly increasing health problem?
COPD
What are the two classic forms of COPD?
Chronic bronchitis is a clinical condition
Emphysema is a pathological entity
What is a major difference between COPD and asthma?
COPD -you have irreversible damage/changes
Asthma - has reversible components
Disease state characterized by airflow limitation that is not fully reversible, is usually progressive, and is associated with abnormal inflammatory response of the lungs to inhaled noxious particles or gases (chronic smoking)
COPD
What is the hallmark of COPD?
Expiratory flow limitation (Can bring the air in but can’t get out)
What is the major risk factor for COPD that accounts for 80-90% of risk in US?
Cigarette smoking
What is the hereditary risk factor for COPD?
Alpha-1-antitrypsin deficiency
What is the autosomal recessive condition that affects mostly Northern European whites, causes lung and liver disease, and accounts for 2-3% of patients with COPD?
Alpha-1-antitrypsin deficiency
What is the pathophysiology of Alpha 1 Antitrypsin Deficiency?
Abnormally decreased levels of protease inhibitor
Patients with Alpha 1 Antitrypsin Deficiency are also at risk for developing this non-lung disease?
hepatocellular carcinoma
List some co-morbid conditions of COPD
Pneumonia
Multifocal atrial tachycardia
Ventricular dysfunction (Cor pulmonale)
Pulmonary hypertension
Secondary pneumothorax
Respiratory failure
Bronchogenic lung cancer
What are the three major categories of COPD?
Chronic bronchitis
Emphysema
Asthma
What stage of COPD is described below?
Chronic cough and sputum production, some SOB
FEV1 ≥ 80% predicted
Stage I - Mild COPD
What stage of COPD is described below?
Chronic cough and sputum production; SOB may limit exertion
FEV1 50-79% predicted
Stage II - Moderate COPD
What stage of COPD is described below?
Involves progressive airway limitation 🡪 clinical signs and
symptoms worsen, more frequent exacerbations
FEV1 30-49% predicted
Stage III - Severe COPD
What stage of COPD is described below?
Chronic respiratory failure
Hypercapnia and hypoxia with severe, recurrent exacerbations 🡪 affects quality of life and threaten survival
These are the patients will see walking around with oxygen tanks
FEV1 <30% predicted or FEV1<50% predicted PLUS chronic respiratory failure
Stage IV - Very severe COPD
In early disease in COPD, what is the typical first complaint/manifestation?
decreased exercise tolerance
In COPD, what is felt to be a better predictor of mortality than
spirometry?
exertional dyspnea
COPD typically presents with what characteristic symptoms?
chronic cough (85%)
dyspnea
copious expectoration (45%)
wheeze (40%)
fatigue
Pink Puffer
Emphysema
Blue Bloater
Chronic Bronchitis
Type of COPD:
Abnormal permanent enlargement of air sacs distal to terminal bronchioles, with destruction of alveolar walls and no obvious fibrosis
Degradation of lung matrix by lung proteases – released by neutrophils attracted by cigarette smoke
Decrease in elastic recoil and collapse of airways during exhalation
Emphysema
Type of COPD:
Presence of chronic productive cough occurring on most days for
at least three months in each of two successive years
“smoker’s cough”
Diagnosis can only be made when ALL other causes of chronic cough
are excluded (TB, lung cancer, congestive heart failure, etc)
Chronic Bronchitis
What testing should be done on all suspected patients of COPD to assess and stage disease state?
spirometry
What is the main diagnostic strategy that quantifies airflow obstruction in COPD?
spirometry
Why is spirometry important in COPD?
Help determine the severity of disease to tailor treatment and predict/follow course
What is the primary importance for treatment in COPD?
Smoking Cessation
What are the treatment goals of COPD?
Prevent further damage
Prevent and treat acute exacerbations
Maximize current function
Why is smoking cessation so important even in COPD patients with current damage?
Will halt further damage to lungs
What is the only treatment in COPD that prolongs survival?
Correct hypoxia with O2 therapy
The mainstay of drug therapy for COPD
Inhaled Bronchodilators
First line treatment in COPD
Anticholingerics (inhaled)
What is the most common etiology of acute exacerbations of COPD?
Infectious: 70-80%
In COPD, what is the BEST intervention shown to slow disease
progression?
Smoking cessation
Condition that is both restrictive and obstructive (but for our purpose we’ll consider it obstructive)
Multisystem autosomal recessive disorder that leads to abnormalities in membrane chloride channel (CFTR) 🡪 altered chloride transport and water flux across epithelial cells (affects all exocrine tissue)
Cystic Fibrosis
Genetic – autosomal recessive disorder
Abnormality is CFTR
Cystic Fibrosis
What is the most common cause of severe chronic lung disease in young adults?
Cystic Fibrosis
What is the most common fatal hereditary disorder of whites in US?
Cystic Fibrosis
What is the pathophysiology of Cystic Fibrosis?
Abnormal membrane chloride channels result in altered chloride and
water transport across epithelial cells
Inadequate hydration results in impaired mucociliary clearance
Exocrine glands produce abnormal amounts of mucus that obstructs glands and ducts – resulting in obstruction and tissue damage
What extrapulmonary condition of Cystic fibrosis is virtually pathognomonic?
Meconium ileus
What pathogen is associated with Cystic Fibrosis in pneumonia cases?
Pseudomonas
What diagnostic method is used to diagnose cystic fibrosis?
Pilocarpine iontophoresis sweat test
What is a positive result for pilocarpine iontophoresis sweat test?
Increase in sodium chloride (>60 meq/L) in the sweat of a patient
on two occasions
What is important to keep in mind when interpreting a Pilocarpine iontophoresis sweat test?
Normal sweat test doesn’t rule out CF 🡪 CFTR mutation analysis for
patients with normal or borderline sweat chloride levels
What is the definitive diagnostic testing for cystic fibrosis?
Genetic Testing
True or false:
All states now mandate newborn screening for CF
True
Congenital or acquired disorder of the large bronchi characterized by permanent, abnormal dilation and destruction of bronchial walls
Key: permanently enlarged or dilated
Bronchiectasis
A complication of cystic fibrosis
(Other causes but mainly see with CF)
Bronchiectasis
What is the most common cause for Bronchiectasis?
Cystic Fibrosis
What is the HALLMARK sign of Bronchiectasis?
Chronic cough, copious foul smelling purulent sputum (“3-phase sputum”)
What is the key to telling apart COPD from bronchiectasis?
imaging
CXR finding is seen in what condition?
Show dilated and thickened bronchi that appear as “tram tracks”
Dilated bronchi with ring-like markings
Bronchiectasis
What is the diagnostic study of choice in bronchiectasis?
CT
breath cessation for at least 10 seconds
Apnea
Airway becomes obstructed during sleep (various etiologies)
Pathologic if obstruction lasts >10 seconds and occurs >7-10x/hr (start to get concerned)
Characterized by loud snoring punctuated with episodes of silence leading to microarousals
Obstructive sleep apnea
Obstructive sleep apnea is more common in which patients with?
Obesity
Adenotonsillar enlargement
Craniofacial dysmorphogenesis (ex: Down Syndrome and macroglossia)
List some risk factors for obstructive sleep apnea
Micrognathia
Macroglossia
Obesity
Tonsillar hypertrophy
EtOH
Sedatives before going to bed
Large neck
hypothyroidism
Cigarette smoking
Common cold
List some conditions and situations that patient’s with obstructive sleep apnea are at risk for
Accidents
HTN
IND
Cardiac ectopy
CVA
Cardiac arrhythmias
Severe hypoxemia during sleep
Excessive daytime sleepiness
Pulmonary hypertension
Cor pulmonale
In suspected obstructive sleep apnea, what should be obtained?
a polysomnography (PSG) 🡪 “sleep study”
What is the best treatment for obstructive sleep apnea?
CPAP
