Pulm Flashcards
Pathophys of asthma
Airway inflammation via mast cells, eosinophils, epithelial, cells, macrophages, and activated T lymphocytes
Airflow obstruction via acute bronchoconstriction, airway edema, chronic mucous plug formation, and airway remodeling
Hyperinflation to compensate for the airflow obstruction
Factors that can contribute to asthma or airway hyperreactivity
Environmental allergens Viral respiratory tract infections Exercise, hyperventilation Gastroesophageal reflux disease Chronic sinusitis or rhinitis ASA or NSAID hypersensitivity, sulfite sensitivity Use of BBs Obesity Environmental pollutants, tobacco smoke Occupational exposure Irritants Various high and low molecular weight compounds Emotional factors or stress Perinatal factors
FHx of asthma
May be pertinent for: Asthma Allergy Sinusitis Rhinitis Eczema Nasal polyps
Exacerbation history of asthma
Usual prodromal signs or sx
Rapidity of onset
Associated illnesses
Number in the last year
Need for ED visits, hospitalizations, ICU admissions, intubations
Missed days from work or school or activity limitation
General manifestations of asthma
Wheezing is one of the most common sx
-However not necessary for the dx
Cough may be the only symptom of asthma
Other non-specific sx in infants or young children:
-Hx of recurrent bronchitis, bronchiolitis, or PNA
-Persistent cough with colds
-Recurrent croup or chest rattling
Mild episode PE- asthma
Pts may be breathless after physical activity such as walking Able to lie flat RR is increased Accessory muscles are not used HR <100 Pulsus paradoxus not present Moderate wheezing, often end-expiratory
Moderately severe episode PE- asthma
RR is increased Accessory muscles are used In children, supraclavicular and intercostal retractions, nasal flaring, abdominal breathing HR 100-120 Loud expiratory wheezing Pulsus paradoxus may be present SpO2 91-95% Breathless while talking
Severe episode PE- asthma
Pts are breathless at rest Not interested in eating Sit upright Talk in words rather than sentences Usually agitated RR >30 Accessory muscles Suprasternal retractions HR >120 bpm Loud biphasic wheezing Pulsus paradoxus if often present SpO2 <91%
Imminent respiratory arrest PE- asthma
Children- Drowsy and confused
Status asthmaticus- paradoxical thoracoabdominal movement
Wheezing may be absent, and severe hypoxemia may manifest as bradycardia
Pulsus paradoxus may be absent
As it becomes more severe, profuse diaphoresis
Pts may struggle for air, act confused and agitated and pull off their oxygen
Almost no breath sounds may be heard
Nonpulmonary manifestations of asthma
Signs of atopy or allergic rhinitis: Conjunctival congestion and inflammation Ocular shiners Transverse crease on the nose Pale violaceous nasal mucosa Turbinates may be erythematous or boggy Polyps may be present Skin: Atopic dermatitis Eczema
Nocturnal sx of asthma
Bronchoconstriction
Workup of asthma
Labs are not routinely indicated for the dx of asthma, but they may be used to exclude other diagnoses ABG and SpO2 are valuable for assessing severity of exacerbations and following response to tx CXR EKG for severe sx Allergy skin testing PFTs Bronchoprovocation Peak flow monitoring
Tx of asthma
Avoidance of allergens
Avoid tobacco smoke
Consider immunotherapy if a relationship is clear between sx and exposure to an unavoidable allergen to which the pt is sensitive, sx occur all year or during a major portion of the year, or sx are difficult to control with pharmacologic management
Stepwise therapy
Pathophys of acute bronchitis
The cells of the bronchial lining tissue are irritated and the mucous membrane becomes hyperemic and edematous, diminishing bronchial mucociliary function
Consequently, the air passages become clogged by debris and irritation increases
In response, copious secretion of mucus develops
Etiology of acute bronchitis
MC viruses include influenza A and B, parainfluenza, RSV, and coronavirus
Usually called by infections, such as Mycoplasma, C. pneumoniae, S. pneumoniae, M. catarrhalis, and H. influenza and by viruses
Hx of acute bronchitis
Cough generally lasts from 10-20 days Sputum production may be clear, yellow, green, or even blood-tinged Fever relatively unusual Sore throat Runny or stuffy nose HA Muscle aches Extreme fatigue
PE of acute bronchitis
Can vary from nl-to-pharyngeal erythema, localized LAD, and rhinorrhea to coarse rhonchi and wheezes that change in location and intensity after a deep and productive cough
Workup of acute bronchitis
CBC with diff Procalcitonin levles Sputum cytology if cough is persistent CXR in those pts whose PE findings suggest pneumonia Culture
Tx of acute bronchitis
Central cough suppressants, such as codeine and dextromethorphan
NSAIDs
Guaifenesin
Abx recommended in pts >65 years with acute cough if they have had a hospitalization in the past year, have DM or congestive heart failure, or on steroids
Pathophys of COPD- chronic bronchitis
Mucous gland hyperplasia
Airway structural changes include atrophy, focal squamous metaplasia, ciliary abnormalities, variable amounts of airway smooth muscle hyperplasia, inflammation, and bronchial wall thickening
Pahophys of COPD- emphysema
Permanent enlargement of airspaces distal to the terminal bronchioles, leading to a dramatic decline in the alveolar surface area available for gas exchange
Etiology of COPD
Cigarette smoking Environmental factors Airway hyperresponsiveness Alpha1-antitrypsin deficiency IVDU Immunodeficiency syndromes Vasculitis syndrome Connective tissue d/os Salla disease
Hx of COPD
Cough Worsening dyspnea Progressive exercise intolerance Sputum production Alteration in mental status Wheezing Breathlessness Systemic manifestations: Decreased fat-free mass Impaired systemic muscle function Osteoporosis Anemia Depression Pulmonary HTN Cor pulmonale Left-sided heart failure
PE of COPD
Hyperinflation Wheezing Diffusely decreased breath sounds Hyperresonance on percussion Prolonged expiration Coarse crackles beginning with inspiration
PE of COPD specific to chronic bronchitis
Pts may be obese
Frequent cough and expectoration are typical
Use of accessory muscles of respiration is common
Coarse rhonchi and wheezing may be heard on auscultation
Pts may have signs of right heart failure, such as edema and cyanosis
PE of COPD specific to emphysema
Pts may be very thin with a barrel chest
Pts typically have little or no cough or expectoration
Breathing may be assisted by pursed lips and use of accessory respiratory muscles; pts may adopt the tripod sitting position
The chest may be hyperresonant, and wheezing may be heard
Heart sounds are very distant
Overall appearance is more like classic COPD exacerbation
Stagin of COPD
With the caveat that there is also the BODE index
Stage I: FEV1 80% or greater of predicted
Stage II: FEV1 50-79% of predicted
Stage III: FEV1 30-49% of predicted
Stage IV: FEV1 <30% of predicted
Workup of COPD
Formal dx is made with spirometry ABG for exacerbation Serum chemistries Alpha1-antitrypsin in all pts <40 yos, in those with FHx of emphysema at an early age, or pts with emphysematous changes with no smoking hx Sputum eval with exacerbation CXR CT PFTs Six-minute walking distance
Tx of COPD
Smoking cessation
Inhaled corticosteroids as an adjunct to a LABA if necessary
Use antibiotics for exacerbation
