Obstructive Pulmonary Disorders Flashcards
What are the obstructive pulmonary disorders?
Asthma Bronchiectasis Chronic Bronchitis Cystic Fibrosis Emphysema
Reversible hyper irritability of the tracheobronchial tree, resulting in bronchoconstriction and inflammation
Asthma
Sumter’s triad/Atopic triad for asthma
Asthma
Nasal Polyps
ASA/NSAID allergy
Associated eczema
Which disorders have a pathologic low V:Q ratio?
Asthma, chronic bronchitis, acute pulmonary edema
Which disorders have a pathologic high V:Q ratio?
Emphysema, pulmonary embolism, or foreign body
What is the most common chronic disease in childhood?
Asthma
What are the three components of asthma?
Bronchoconstriction, Inflammation, airway hyper reactivity
Airway narrowing secondary to smooth muscle constriction, bronchial wall edema, and thick mucous secretions; the obstruction leads to a decrease in expiratory air flow, a decrease in airway resistance (increase work of breathing), and V/Q mismatch
Bronchoconstriction in asthma
Occurs secondary to cellular infiltration (T lymphocytes, neutrophils, eosinophils) and their inflammatory cytokines as well as IgE mediated histamine release from mast cells
Inflammation in asthma
Occurs from extrinsic (allergic) or intrinsic (idiosyncratic) exposure in asthma
Airway hyper reactivity
What are the most common extrinsic allergen triggers for airway hyperactivity in asthma?
Pollen, ragweed, dander, dust, mold, aerosols, tobacco, smoke
What are the most common intrinsic nonallergic triggers for airway hyperactivity in asthma?
Infection (esp viral URI/Sinusitis), pharmacologic, occupational, exercise, emotional, cold air
What is the classic triad to look for when gathering a history on a patient with asthma?
Dyspnea, wheezing, cough (esp @ night)
These could be with or without chest tightness, prolonged expiration, and fatigue
What are some clues you could gather from patient history that would help you measure the severity of a patient who has asthma?
Steroid use
Previous intubations/ICU/hospital admissions
What should you look for when assessing physical clinical manifestations in a patient with asthma?
Prolonged expiration with wheezing, hyper resonance, use of accessory muscles
What should you look for when assessing physical clinical manifestations in a patient with SEVERE asthma?
Inability to speak in full sentences
Low peak flow reading
Tripod position
“Silent chest”
What is the strongest predisposing factor to asthma?
Atopy or sumters triad
What are some drugs that can cause asthma?
Beta blockers, angiotensin-converting enzyme (ACE) inhibitors, aspirin, NSAIDs
What is the gold standard to diagnose asthma with reversible obstruction?
PFT
What pulse oximetry reading is indicative of respiratory distress?
Less than 90%
What is the best OBJECTIVE way to assess severity of asthma and patient response to medication in the ED*?
Peak flow meter (PEFR)
How do you tell if a patient with asthma is responding to treatment using a peak flow meter? What is a normal reading?
If PEFR is 15% greater from initial attempt
Normal: 400-600
Bronchoprovocation test that uses a cholinergic drug to cause bronchospasm
Metacholine challenge test (+ is >20% decrease in FEV1)
What results from a bronchodilator test (bronchoprovocation tests) are consistent with asthma?
+ if >12% decrease in FEV1 (>200cc)
What results from an exercise challenge test (bronchoprovocation tests) are consistent with asthma?
+ if >15% decrease in FEV1
What is classically associated with asthma exacerbation?
Respiratory alkalosis
What is the purpose of getting a chest x-ray on an asthma patient?
To rule other things out (pneumonia, CHF, etc.)
What is the recommended treatment for mild asthma?
Low dose ICS
What is the recommended treatment for moderate asthma?
Low ICS + LABA
or increase ICS to medium
or add Leukotriene modifiers/receptor agonists
What is the recommended treatment for severe asthma?
High dose ICS + LABA +/- omalizumab (anti-IgE drug)
Normal FEV1/FVC ratio
> .70-.75 of predictive value
FEV1/FVC ratio in obstructive lung diseases; what increase shows response to treatment?
10% increase
Normal FEV1
80-120
What are the most effective anti-inflammatory medications for the management of chronic asthma?
Inhaled corticosteroids
What is the rescue medication indicated for asthma?
B-adrenergic agonists that induce bronchodilation
Irreversible bronchial dilation secondary to transmural inflammation of medium sized bronchi. This leads to destruction of muscular and elastic tissues of the bronchial wall, causing airways to collapse easily. This leads to obstruction of airflow and impaired clearance of mucous secretions –> lung infections
Bronchiectasis
What can recurrent/chronic lung infections cause?
Bronchiectasis
Common bacterial causes of bronchiectasis
H. Influenza* most common cause if not M. Catarrhalis S. aureus S pneumonia Mycobacterium (TB/atypical/MAC)
Most common viral cause of bronchiectasis
Aspergillus
CF is a common cause of bronchiectasis - which bacteria is most common to cause infection with CF?
Pseudamonas
If your patient presents with daily chronic cough with thick, mucopurulent foul smelling sputum and pleuritic chest pain, along with hemoptysis, what should you suspect?
Bronchiectasis
Most common cause of massive hemoptysis
Bronchiectasis
What are some common clinical manifestations and lung sounds in patients with bronchiectasis?
Persistent crackles at bases
Dyspnea, wheezing, rhonchi, clubbing
What is the study of choice to diagnose bronchiectasis?
High resolution CT scan: look for airway dilation, lack of tapering bronchi, bronchial wall thickening, “tram track” appearance, mucopurulent plugs, consolidations, Signet ring sign
What should the PFT resemble in a patient with bronchiectasis?
Obstructive pattern: decreased FEV1, decreased FVC, decreased FEV1/FVC ratio (
What is the only diagnostic finding of bronchiectasis on X-ray?
Tram-track wall thickening
What should the results of a sputum gram stain show in bronchiectasis?
Neutrophilia
What can be used with bronchiectasis to evaluate hemoptysis, remove retained secretions, and r/o obstructive airway lesions?
Bronchoscopy
What is the cornerstone of treatment for bronchiectasis?
Antibiotics - empiric, pseudomonas coverage, or antibiotic cycling (Azithromycin has anti-inflammatory properties)
How would you manage a patient who has bronchiectasis consistent with mycobacterium avian complex (MAC)?
Clarithromycin + ethambutol
How should you manage mucus in patients with bronchiectasis?
Bronchodilators, anti-inflammatory; surgery, embolization for bleeding; chest physiotherapy
How long should abx be prescribed to someone with bronchiectasis? What are effective choices?
10-14 days
Amox, Amox-Clauv, bactrim, cipro
What are the two disorders associated with COPD?
Emphysema
Chronic bronchitis
Progressive, largely irreversible airflow obstruction due to loss of elastic record and increased airway resistance in those >55 yo
COPD
With COPD, which disorder is episodic and which is involved with a steady decline?
Chronic bronchitis = episodic
Emphysema = chronic decline
What is the most important risk of COPD?
Smoking! (90% of COPD cases caused by smoking)
What is the only genetic disease linked to COPD?
Alpha 1-antitrypsin deficiency
What is the purpose of alpha 1-antitrypsin in the lungs?
Protects elastin in lungs from damage by WBCs
Which cause of COPD is associated with pan lobular emphysema?
Alpha 1-antitrypsin deficiency
What cause of COPD is associated with centrilobular emphysema?
Smoking
Chronic airway inflammation leads to mucous hyper secretion, airway narrowing, and an increase of air resistance leading to airway obstruction.
Chronic bronchitis
Mucous plugging and mucocilliary escalator destruction in chronic bronchitis makes patients prone to?
Microbial infections
What is characteristic of chronic bronchitis? (Hallmark symptom)
Productive cough >3months x 2 years consecutively
On physical exam, what should you expect in a patient with chronic bronchitis?
Rales (crackles), rhonchi, wheezing, signs of cor pulmonae, peripheral edema, cyanosis
What should you expect to see in ABG/labs in a patient with chronic bronchitis?
Respiratory acidosis**
Increased Hct/RBC count (chronic hypoxia stimulates EPOesis
What should you expect to see with V/Q mismatch in patients with chronic bronchitis?
Severe V/Q mismatch
Severe hypoxemia
Hypercapnia
What is the overall appearance of a person with chronic bronchitis?
Obese and cyanotic “blue bloaters”
How would you manage a patient who has allergic bronchopneumonia caused by aspergillum that causes thick, brown sputum?
Corticosteroids + Itraconazole
Surgery if symptomatic aspergilloma
What FEV1 result shows an increase in mortality in patients with COPD?
What is the gold standard in diagnosing COPD?
PFTs/spirometry
Increase in lung volumes: Increase RV, TLC, RV/TLC, FRC is seen in which disease process?
COPD
An increased AP diameter, increased vascular markings, and an enlarged right heart border are all CXR/CT scans that are consistent with which disease?
Chronic bronchitis
What is seen commonly on ECG with chronic bronchitis?
Cor Pulmonale
Abnormal, permanent enlargement of terminal airspaces
Smoking causes chronic inflammation and decreases protective enzymes (a1-antitrypsin) while increasing damaging enzymes. This leads to alveolar capillary and alveolar wall destruction (decreased gas exchange surface area) which leads to loss of elastic recoil. Air gets trapped due to the airway being obstructed.
Emphysema
Accessory muscle use, tachypnea, prolonged expiration, and mild cough are all symptoms of what disorder? How do you typically diagnose this?
Emphysema
Usually diagnosis of exclusion
On physical exam, if you see hyper resonance to percussion, a decrease or absence of breath sounds, decreased remits, barrel chest, quiet chest, and pursed lip breathing what should you consider?
Emphysema
All of the symptoms of emphysema are consistent with?
Hyperinflation of the lungs
What should you expect to see on ABG or labs in patients with emphysema?
Respiratory alkalosis
The V/Q defects in emphysema should be —?
Matched
What should the CO2 level be in patients with emphysema
Should be normal
What do patients with emphysema appear to look like physically?
Cachectic with pursed lip breathing “pink puffers”
What should you expect the DCLO level to be in a patient with emphysema?
Decreased
CXR/CT scan that revelas hyperinflation, a flat diaphragm, increased AP diameter, decreased vascular markings with or without bullae is consistent with which obstructive disorder?
Emphysema
What are some exacerbation triggers for COPD?
Pollutants, bronchospasm, cardiopulmonary dz meds, infections
Which viruses cause bronchitis and pneumonia in patients with COPD?
S. pneumoniae, H. influenzae, M. catarrhalis
What is the most important step in the management of COPD?
Smoking cessation
What are the 3 main types of management with COPD?
- Bronchodilators
- Corticosteroids
- Oxygen
What is the only medical therapy proven to decrease mortality in COPD?
Oxygen
What is the goal O2 sat in patients with COPD?
> 90%
What are the 4 types of prevention of exacerbation with COPD?
- Smoking cessation single most important intervention for COPD
- Vaccinations: Pneumococcal and influenza
- Pulmonary rehab
- Surgery to remove damaged lung or lung transplantation
What is the best therapy for mild COPD? What is the predicted FEV1% for this type of COPD?
FEV1 > 80%
Bronchodilators SABA
What is the FEV1% for moderate COPD? What is the best treatment?
FEV1 50-79%
Bronchodilator short acting + LABA
What is the predicted FEV1% for very severe (Stage IV) COPD?
FEV1
What is commonly seen with Stage IV COPD? What is the treatment?
Cor pulmonale**
Right heart failure
Respiratory failure
Short and long acting bronchodilator, O2 therapy
Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.
Cor pulmonale
What type of disease is cystic fibrosis?
Autosomal recessive inherited
What is defective in cystic fibrosis?
Cystic fibrosis transmembrane receptor
Disorder in which genetic defect prevents chloride transport (water movement out of the cell) which leads to a buildup of thick, viscous, mucous in lungs, pancreas, liver, intestines, and reproductive tracts
Cystic fibrosis
Where does mucous build up in cystic fibrosis?
Lungs, pancreas, liver, intestines, reproductive tract
Cystic fibrosis is an obstructive lung disease as well as a _____ _____ dysfunction disease
exocrine gland
Pancreatic insufficiency
Who is most often affected by cystic fibrosis? What is the average life expectancy?
Caucasians, N. Europeans
36.8 years
What is the “classic” CF scenario?
Young patient with bronchiectasis, pancreatic insufficiency, growth delays, and infertility
Full term infant that is born with meconium ileus at birth should lead you to test for which disorder?
CF
What does pancreatic insufficiency cause in patients with CF?
Decreased fat absorption which leads to steatorrhea, bulky pale/foul smelling stools
Which vitamins are CF patients often deficient in?
A, D, E, and K
Due to pancreatic insufficiency, which pancreas related illnesses are CF patients prone to?
Pancreatitis
CF-induced diabetes mellitus
What pulmonary complications are CF patients likely to suffer from?
Recurrent respiratory infections, productive cough, dyspnea, chest pain, wheezing, chronic sinusitis
Which bacteria often infect patients affected with CF?
Pseudamonas and s. aureus
What percentage of CF patients suffer from infertility?
95%
What ist he primary test done to diagnose CF? What are the results of a positive diagnosis?
Sweat chloride test
Positive if greater than 60mmol/L on two separate occasions
What is administered to patients who are having a CF sweat test done?
Pilocarpine –> Cholinergic that increases sweating
What should a CXR show on a patient with CF?
Bronchiectasis (CF most common cause in US)
Hyperinflation of lungs
What should PFT results show in a patient with CF?
Obstructive (often reversible)
What do sputum cultures often grow in patients with CF?
Pseudomonas aeruginosa, H. influenzae, s. aureus
How do you manage a patient with CF?
Airway clearance treatments: Bronchodilators, mucolytics, abx, decongestants
Pancreatic enzyme replacements, Vitamin A, D, E, and K
Lung and pancreas transplantation
INCREASED TLC, RV, RV/TLC, FRC are all consistent with
Hyperinflation obstructive disorders
DECREASED FEV1, FVC; FEV1/FVC area ll consistent with
Obstruction obstructive disorders
What are the obstructive lung disorders?
Asthma
COPD
Bronchiectasis
Cystic fibrosis
What can provide definitive diagnosis of CF, even when sweat chloride test is negative?
DNA testing
A sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. Characterized by recurrent episodes of upper airway collapse during sleep. These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.
Obstructive sleep apnea
Can result in daytime drowsiness due to frequent waking during the night
Obstructive sleep apnea
Treatment for obstructive sleep apnea
CPAP
What are the 3 “S’s” for obstructive sleep apnea?
Snoring
Sleepiness
Significant-others reporting sleep apnea episodes
Most common type of sleep-disordered breathing
Obstructive Sleep Apnea
