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Clinical Medicine II > Obstructive Pulmonary Disorders > Flashcards

Obstructive Pulmonary Disorders Flashcards

1
Q

What are the obstructive pulmonary disorders?

A 
Asthma
Bronchiectasis
Chronic Bronchitis
Cystic Fibrosis
Emphysema
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2
Q

Reversible hyper irritability of the tracheobronchial tree, resulting in bronchoconstriction and inflammation

A

Asthma

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3
Q

Sumter’s triad/Atopic triad for asthma

A

Asthma
Nasal Polyps
ASA/NSAID allergy
Associated eczema

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4
Q

Which disorders have a pathologic low V:Q ratio?

A

Asthma, chronic bronchitis, acute pulmonary edema

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5
Q

Which disorders have a pathologic high V:Q ratio?

A

Emphysema, pulmonary embolism, or foreign body

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6
Q

What is the most common chronic disease in childhood?

A

Asthma

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7
Q

What are the three components of asthma?

A

Bronchoconstriction, Inflammation, airway hyper reactivity

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8
Q

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

A

Bronchoconstriction in asthma

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9
Q

Occurs secondary to cellular infiltration (T lymphocytes, neutrophils, eosinophils) and their inflammatory cytokines as well as IgE mediated histamine release from mast cells

A

Inflammation in asthma

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10
Q

Occurs from extrinsic (allergic) or intrinsic (idiosyncratic) exposure in asthma

A

Airway hyper reactivity

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11
Q

What are the most common extrinsic allergen triggers for airway hyperactivity in asthma?

A

Pollen, ragweed, dander, dust, mold, aerosols, tobacco, smoke

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12
Q

What are the most common intrinsic nonallergic triggers for airway hyperactivity in asthma?

A

Infection (esp viral URI/Sinusitis), pharmacologic, occupational, exercise, emotional, cold air

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13
Q

What is the classic triad to look for when gathering a history on a patient with asthma?

A

Dyspnea, wheezing, cough (esp @ night)

These could be with or without chest tightness, prolonged expiration, and fatigue

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14
Q

What are some clues you could gather from patient history that would help you measure the severity of a patient who has asthma?

A

Steroid use

Previous intubations/ICU/hospital admissions

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15
Q

What should you look for when assessing physical clinical manifestations in a patient with asthma?

A

Prolonged expiration with wheezing, hyper resonance, use of accessory muscles

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16
Q

What should you look for when assessing physical clinical manifestations in a patient with SEVERE asthma?

A

Inability to speak in full sentences
Low peak flow reading
Tripod position
“Silent chest”

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17
Q

What is the strongest predisposing factor to asthma?

A

Atopy or sumters triad

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18
Q

What are some drugs that can cause asthma?

A

Beta blockers, angiotensin-converting enzyme (ACE) inhibitors, aspirin, NSAIDs

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19
Q

What is the gold standard to diagnose asthma with reversible obstruction?

A

PFT

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20
Q

What pulse oximetry reading is indicative of respiratory distress?

A

Less than 90%

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21
Q

What is the best OBJECTIVE way to assess severity of asthma and patient response to medication in the ED*?

A

Peak flow meter (PEFR)

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22
Q

How do you tell if a patient with asthma is responding to treatment using a peak flow meter? What is a normal reading?

A

If PEFR is 15% greater from initial attempt

Normal: 400-600

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23
Q

Bronchoprovocation test that uses a cholinergic drug to cause bronchospasm

A

Metacholine challenge test (+ is >20% decrease in FEV1)

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24
Q

What results from a bronchodilator test (bronchoprovocation tests) are consistent with asthma?

A

+ if >12% decrease in FEV1 (>200cc)

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25
Q

What results from an exercise challenge test (bronchoprovocation tests) are consistent with asthma?

A

+ if >15% decrease in FEV1

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26
Q

What is classically associated with asthma exacerbation?

A

Respiratory alkalosis

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27
Q

What is the purpose of getting a chest x-ray on an asthma patient?

A

To rule other things out (pneumonia, CHF, etc.)

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28
Q

What is the recommended treatment for mild asthma?

A

Low dose ICS

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29
Q

What is the recommended treatment for moderate asthma?

A

Low ICS + LABA

or increase ICS to medium

or add Leukotriene modifiers/receptor agonists

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30
Q

What is the recommended treatment for severe asthma?

A

High dose ICS + LABA +/- omalizumab (anti-IgE drug)

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31
Q

Normal FEV1/FVC ratio

A

> .70-.75 of predictive value

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32
Q

FEV1/FVC ratio in obstructive lung diseases; what increase shows response to treatment?

A

10% increase

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33
Q

Normal FEV1

A

80-120

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34
Q

What are the most effective anti-inflammatory medications for the management of chronic asthma?

A

Inhaled corticosteroids

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35
Q

What is the rescue medication indicated for asthma?

A

B-adrenergic agonists that induce bronchodilation

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36
Q

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

A

Bronchiectasis

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37
Q

What can recurrent/chronic lung infections cause?

A

Bronchiectasis

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38
Q

Common bacterial causes of bronchiectasis

A 
H. Influenza* most common cause if not
M. Catarrhalis
S. aureus
S pneumonia
Mycobacterium (TB/atypical/MAC)
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39
Q

Most common viral cause of bronchiectasis

A

Aspergillus

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40
Q

CF is a common cause of bronchiectasis - which bacteria is most common to cause infection with CF?

A

Pseudamonas

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41
Q

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?

A

Bronchiectasis

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42
Q

Most common cause of massive hemoptysis

A

Bronchiectasis

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43
Q

What are some common clinical manifestations and lung sounds in patients with bronchiectasis?

A

Persistent crackles at bases

Dyspnea, wheezing, rhonchi, clubbing

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44
Q

What is the study of choice to diagnose bronchiectasis?

A

High resolution CT scan: look for airway dilation, lack of tapering bronchi, bronchial wall thickening, “tram track” appearance, mucopurulent plugs, consolidations, Signet ring sign

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45
Q

What should the PFT resemble in a patient with bronchiectasis?

A

Obstructive pattern: decreased FEV1, decreased FVC, decreased FEV1/FVC ratio (

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46
Q

What is the only diagnostic finding of bronchiectasis on X-ray?

A

Tram-track wall thickening

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47
Q

What should the results of a sputum gram stain show in bronchiectasis?

A

Neutrophilia

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48
Q

What can be used with bronchiectasis to evaluate hemoptysis, remove retained secretions, and r/o obstructive airway lesions?

A

Bronchoscopy

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49
Q

What is the cornerstone of treatment for bronchiectasis?

A

Antibiotics - empiric, pseudomonas coverage, or antibiotic cycling (Azithromycin has anti-inflammatory properties)

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50
Q

How would you manage a patient who has bronchiectasis consistent with mycobacterium avian complex (MAC)?

A

Clarithromycin + ethambutol

51
Q

How should you manage mucus in patients with bronchiectasis?

A

Bronchodilators, anti-inflammatory; surgery, embolization for bleeding; chest physiotherapy

52
Q

How long should abx be prescribed to someone with bronchiectasis? What are effective choices?

A

10-14 days

Amox, Amox-Clauv, bactrim, cipro

53
Q

What are the two disorders associated with COPD?

A

Emphysema

Chronic bronchitis

54
Q

Progressive, largely irreversible airflow obstruction due to loss of elastic record and increased airway resistance in those >55 yo

55
Q

With COPD, which disorder is episodic and which is involved with a steady decline?

A

Chronic bronchitis = episodic

Emphysema = chronic decline

56
Q

What is the most important risk of COPD?

A

Smoking! (90% of COPD cases caused by smoking)

57
Q

What is the only genetic disease linked to COPD?

A

Alpha 1-antitrypsin deficiency

58
Q

What is the purpose of alpha 1-antitrypsin in the lungs?

A

Protects elastin in lungs from damage by WBCs

59
Q

Which cause of COPD is associated with pan lobular emphysema?

A

Alpha 1-antitrypsin deficiency

60
Q

What cause of COPD is associated with centrilobular emphysema?

61
Q

Chronic airway inflammation leads to mucous hyper secretion, airway narrowing, and an increase of air resistance leading to airway obstruction.

A

Chronic bronchitis

62
Q

Mucous plugging and mucocilliary escalator destruction in chronic bronchitis makes patients prone to?

A

Microbial infections

63
Q

What is characteristic of chronic bronchitis? (Hallmark symptom)

A

Productive cough >3months x 2 years consecutively

64
Q

On physical exam, what should you expect in a patient with chronic bronchitis?

A

Rales (crackles), rhonchi, wheezing, signs of cor pulmonae, peripheral edema, cyanosis

65
Q

What should you expect to see in ABG/labs in a patient with chronic bronchitis?

A

Respiratory acidosis**

Increased Hct/RBC count (chronic hypoxia stimulates EPOesis

66
Q

What should you expect to see with V/Q mismatch in patients with chronic bronchitis?

A

Severe V/Q mismatch
Severe hypoxemia
Hypercapnia

67
Q

What is the overall appearance of a person with chronic bronchitis?

A

Obese and cyanotic “blue bloaters”

68
Q

How would you manage a patient who has allergic bronchopneumonia caused by aspergillum that causes thick, brown sputum?

A

Corticosteroids + Itraconazole

Surgery if symptomatic aspergilloma

69
Q

What FEV1 result shows an increase in mortality in patients with COPD?

70
Q

What is the gold standard in diagnosing COPD?

A

PFTs/spirometry

71
Q

Increase in lung volumes: Increase RV, TLC, RV/TLC, FRC is seen in which disease process?

72
Q

An increased AP diameter, increased vascular markings, and an enlarged right heart border are all CXR/CT scans that are consistent with which disease?

A

Chronic bronchitis

73
Q

What is seen commonly on ECG with chronic bronchitis?

A

Cor Pulmonale

74
Q

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.

75
Q

Accessory muscle use, tachypnea, prolonged expiration, and mild cough are all symptoms of what disorder? How do you typically diagnose this?

A

Emphysema

Usually diagnosis of exclusion

76
Q

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?

77
Q

All of the symptoms of emphysema are consistent with?

A

Hyperinflation of the lungs

78
Q

What should you expect to see on ABG or labs in patients with emphysema?

A

Respiratory alkalosis

79
Q

The V/Q defects in emphysema should be —?

80
Q

What should the CO2 level be in patients with emphysema

A

Should be normal

81
Q

What do patients with emphysema appear to look like physically?

A

Cachectic with pursed lip breathing “pink puffers”

82
Q

What should you expect the DCLO level to be in a patient with emphysema?

83
Q

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?

84
Q

What are some exacerbation triggers for COPD?

A

Pollutants, bronchospasm, cardiopulmonary dz meds, infections

85
Q

Which viruses cause bronchitis and pneumonia in patients with COPD?

A

S. pneumoniae, H. influenzae, M. catarrhalis

86
Q

What is the most important step in the management of COPD?

A

Smoking cessation

87
Q

What are the 3 main types of management with COPD?

A
  1. Bronchodilators
  2. Corticosteroids
  3. Oxygen
88
Q

What is the only medical therapy proven to decrease mortality in COPD?

89
Q

What is the goal O2 sat in patients with COPD?

90
Q

What are the 4 types of prevention of exacerbation with COPD?

A
  1. Smoking cessation single most important intervention for COPD
  2. Vaccinations: Pneumococcal and influenza
  3. Pulmonary rehab
  4. Surgery to remove damaged lung or lung transplantation
91
Q

What is the best therapy for mild COPD? What is the predicted FEV1% for this type of COPD?

A

FEV1 > 80%

Bronchodilators SABA

92
Q

What is the FEV1% for moderate COPD? What is the best treatment?

A

FEV1 50-79%

Bronchodilator short acting + LABA

93
Q

What is the predicted FEV1% for very severe (Stage IV) COPD?

94
Q

What is commonly seen with Stage IV COPD? What is the treatment?

A

Cor pulmonale**
Right heart failure
Respiratory failure

Short and long acting bronchodilator, O2 therapy

95
Q

Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.

A

Cor pulmonale

96
Q

What type of disease is cystic fibrosis?

A

Autosomal recessive inherited

97
Q

What is defective in cystic fibrosis?

A

Cystic fibrosis transmembrane receptor

98
Q

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

A

Cystic fibrosis

99
Q

Where does mucous build up in cystic fibrosis?

A

Lungs, pancreas, liver, intestines, reproductive tract

100
Q

Cystic fibrosis is an obstructive lung disease as well as a _____ _____ dysfunction disease

A

exocrine gland

Pancreatic insufficiency

101
Q

Who is most often affected by cystic fibrosis? What is the average life expectancy?

A

Caucasians, N. Europeans

36.8 years

102
Q

What is the “classic” CF scenario?

A

Young patient with bronchiectasis, pancreatic insufficiency, growth delays, and infertility

103
Q

Full term infant that is born with meconium ileus at birth should lead you to test for which disorder?

104
Q

What does pancreatic insufficiency cause in patients with CF?

A

Decreased fat absorption which leads to steatorrhea, bulky pale/foul smelling stools

105
Q

Which vitamins are CF patients often deficient in?

A

A, D, E, and K

106
Q

Due to pancreatic insufficiency, which pancreas related illnesses are CF patients prone to?

A

Pancreatitis

CF-induced diabetes mellitus

107
Q

What pulmonary complications are CF patients likely to suffer from?

A

Recurrent respiratory infections, productive cough, dyspnea, chest pain, wheezing, chronic sinusitis

108
Q

Which bacteria often infect patients affected with CF?

A

Pseudamonas and s. aureus

109
Q

What percentage of CF patients suffer from infertility?

110
Q

What ist he primary test done to diagnose CF? What are the results of a positive diagnosis?

A

Sweat chloride test

Positive if greater than 60mmol/L on two separate occasions

111
Q

What is administered to patients who are having a CF sweat test done?

A

Pilocarpine –> Cholinergic that increases sweating

112
Q

What should a CXR show on a patient with CF?

A

Bronchiectasis (CF most common cause in US)

Hyperinflation of lungs

113
Q

What should PFT results show in a patient with CF?

A

Obstructive (often reversible)

114
Q

What do sputum cultures often grow in patients with CF?

A

Pseudomonas aeruginosa, H. influenzae, s. aureus

115
Q

How do you manage a patient with CF?

A

Airway clearance treatments: Bronchodilators, mucolytics, abx, decongestants

Pancreatic enzyme replacements, Vitamin A, D, E, and K

Lung and pancreas transplantation

116
Q

INCREASED TLC, RV, RV/TLC, FRC are all consistent with

A

Hyperinflation obstructive disorders

117
Q

DECREASED FEV1, FVC; FEV1/FVC area ll consistent with

A

Obstruction obstructive disorders

118
Q

What are the obstructive lung disorders?

A

Asthma
COPD
Bronchiectasis
Cystic fibrosis

119
Q

What can provide definitive diagnosis of CF, even when sweat chloride test is negative?

A

DNA testing

120
Q

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.

A

Obstructive sleep apnea

121
Q

Can result in daytime drowsiness due to frequent waking during the night

A

Obstructive sleep apnea

122
Q

Treatment for obstructive sleep apnea

123
Q

What are the 3 “S’s” for obstructive sleep apnea?

A

Snoring
Sleepiness
Significant-others reporting sleep apnea episodes

124
Q

Most common type of sleep-disordered breathing

A

Obstructive Sleep Apnea

Clinical Medicine II (10 decks)

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