Pulmonary 1 Diseases

Question 1

COPD - Definition / Etiology & Risk Factors

Answer 1

Reduced expiratory flow and slow forced emptying of the lungs. This limitation in airflow is only minimally reversible with bronchodilators. 2 forms: Chronic Bronchitis and Emphysema.

General COPD Etiology/Risk factors:

• Tobacco smoke (up to 90% of COPD deaths linked)
• Others: air pollution, second-hand smoke, hx of childhood URI, occupational exposure, alpha-1-antitrypsin deficiency (familial emphysema)

Currently over 1/5 of adults in US dx with COPD - 3rd leading cause of death in America

Question 2

COPD Sign and Symptoms

Answer 2

Barrel Chest
Purse-lip breathing
Cyanosis
*Dyspnea
*Chronic productive cough
*Wheezing
Weight loss
Peripheral Edema
Nail clubbing

Question 3

COPD Diagnostic Work-up

Answer 3

*Pulmonary Function Test - increased total lung capacity
CBC - Concurrent infx
*CXR - show hyperinflation
Alpha-1-Antitrysin level - familial link?
*Pulse oximetry - exacerbated states to see oxy state
Arterial blood gases - if hospitalized
Chest CT

Question 4

Emphysema

Answer 4

“Pink Puffer”
Permanent enlargement of alveolar ducts and air spaces due to loss of recoil and scarring in the distal airways. Going to get progressively worse over time. From SOB to much worse. Smokers and >50yo at risk

AAT deficiency in familial traits - getting emphysema is almost inevitable.
These people tend to naturally reduce their activity level. Limited movement makes effects less.

Sxs: working very hard to breathe, dyspnea from mild exertion to cyanosis at rest.
Exercise intolerance
cough is rare; scant clear mucus

Question 5

PE for Emphysema

Answer 5

Barrel chest from hyper inflated lungs
Cachectic (muscle and fat wasting)
Appear uncomfortable
Purse-lipped breathing
Prominent use of accessory muscles
Hyper resonance on percussion
decreased breath sounds with exacerbations may be expiratory crackles, wheezing
PMI - point of maximal impulse may be deviated towards sternum
No peripheral edema
Hoover’s sign: lower ribs pull together with deep inhale
May see yellowing on fingernails

Question 6

Chronic Bronchitis

Answer 6

“Blue Bloater”
Mucus hyper-secretion secondary to hypertrophy of the glandular elements of the bronchial mucosa producing a cough most days of the month, 3 months of a year for 2 successive years without another explanation.

Smoking, pollutants, dust, microbes, commonly occurs 30s-40s
Sxs: cyanosis, polycythemia and fluid retention.
Chronic productive cough, mucopurulent sputum, dyspnea is mild.

Question 7

PE for Chronic Bronchitis

Answer 7

Larger body habitus, cyanotic
Increased RR and HR
Hyperinflation
Hyper resonance on percussion
Rhonchi, wheezes, decreased breath sounds, prolonged expiration
Early inspiratory cradles
Advanced disease: cyanosis, elevated jugular venous pulse, peripheral edema

Question 8

DDX for COPD

Answer 8

Bronchiectasis, central airway stenosis, congenital problem, mass outside of lung pressing on bronchus, heart failure, CF, constrictive bronchiolitis, bronchopulmonary mycosis

Question 9

Asthma

Answer 9

Reversible obstructive lung disorder with an increased reactivity of airways to various stimuli causing attacks or wide spread broncho-constriction and dyspnea. Features overlap COPD but is different with degree of reversibility.

3 Major features:

1. Airway obstruction - air moving though the tightened airways causes vibration and a whistling sound known as wheezing. Episodic and reversible.
2. Inflammation - red and swollen bronchial tubes
3. Airway irritability - airways extremely sensitive and tend to overreact to triggers such as pollen, animal dander, dust or fumes.

Incidence: increasing prevalence and fatality in past 20 years, common in childhood. M:F 2:1 in childhood, M=F in adults >30. Family hx of allergy, asthma, atopy increase risk of developing.

Question 10

Common trigger for asthma attacks

Answer 10

URI - cold and flu, bronchitis or sinus infx
Inhalent allergens - pollens, mold, dander, dust mites
Medications - aspirin, NSAIDS
Food and food additives - sulfite sensitivity
Exercise
Irritants
Weather
Strong emotions
GERD

Question 11

Asthma S/Sxs

Answer 11

No signs between attacks
Cough, at night or with exercise with sputum production
Episodic wheezing, SOB
Chest tightness, pain or pressure
Decreased exercise tolerance

Question 12

PE Asthma

Answer 12

With asthma attack: Respiratory distress, increased RR, increased HR, sweating, use of accessory muscles, anxiousness, can’t speak
Pulsus paradoxus- slow HR pulse on inspiration
Chest hyperinflation

Question 13

Labs, imaging, other tests

Answer 13

Pulmonary function tests: spirometry, measurements before or after bronchodilator treatment
CBC: eosinophils >4% or normal
Total serum IgE levels >100 IU

Allergy skin testing
24 hour gastric pH monitoring

Question 14

Asthma Classifications

Answer 14

Allergic/Extrinsic - allergy to external factors: pollen, mold, etc.

Non-allergic/Intrinsic - from infection of upper or lower airways.

Question 15

Naturopathic Treatments of Asthma

Answer 15

Magnesium for smooth muscle relaxation
N-acetyl cysteine for thinning mucus
Attack tools like acute homeopathic
Essential oil steam inhalation
Inhaler to have on hand

Question 16

Bronchiectasis

Answer 16

Bronchial permanent dilation. Thickening of walls or out-pouchings. Mucus secretions and recurrent infx that reactivate the cycle. Mucus traps organisms that set up shop. Progressive scarring and deformity of airways.

Common in >50yo woman

Etiology: Congenital bronchial obstruction, immunodeficiency, abnormal secretion clearance, infections, associated conditions.

Question 17

S/Sxs of Bronchiectasis

Answer 17

Chronic daily productive cough
thick viscous sputum
hemoptysis
dyspnea
wheezing
pleuritic chest pain
chronic fatigue
hyposmia, urinary incontinence

Question 18

PE of Bronchiectasis

Answer 18

Findings are non-specific and may be attributed to other conditions. Fever, weight loss, crackles, clubbing, wheezes, ronchii, nasal polyps.
CHF

Question 19

Imaging/Labs of Bronchiectasis

Answer 19

HRCT - high resolution CT of the chest showing characteristic features of dilated airways
CBC
Spirometry
Sputum cultures
CXR

Question 20

Case 2: 68 yo female with dyspnea, fatigue, and a chronic productive cough.

Answer 20

DDX: Chronic bronchitis, Bronchiectasis, COPD, CHF
How long has it been going on? Has it changed over time? Quantity and quality of sputum. Occupation? Time of day its worse. Worse with activity/exercise? Do you smoke? Lifestyle factors? Blood in sputum?
PE: Vitals, Lung auscultation, percussion, heart auscultation, peripheral edema, check nail beds for clubbing, cyanosis, cap refill, yellowing. PMI to check for deviation. HEENT, lower structures: lymph, nose, sinuses, mouth. Chest expansion. Thyroid. Conjunctival pallor, hand for anemia. Maybe abdominal exam for thoroughness.
Work-up: pulse oximeter, sputum culture, chest film, CBC

Question 21

Cystic Fibrosis

Answer 21

Chronic progressive disorder from a gene defect that causes the body to produce abnormally thick mucus, primarily affecting respiratory and digestive systems. Mutation in the CTFR protein leading to thick mucus.

M=F

Sxs: may exhibit sxs at birth or later. mild to life threatening.

Question 22

CF: multi-system findings

Answer 22

Lungs: persistent, productive cough with sputum
Pancreas: insufficient digestive enzyme production
Bowels: obstruction
Liver: cirrhosis
Skin: salty taste

Question 23

CF: PE

Answer 23

Nose: Nasal Polyps
Pulmonary: Tachypnea, wheezes, crackles, cough, cyanosis
GI: Hepatosplenomegaly, abdominal distention
Others: dry skin, scoliosis, swelling of salivary glands

Question 24

CF: Dx / Labs

Answer 24

Genetic, parents are screened. Child isn’t developing at expected. Salty skin, recurrent infections.

Sweat chloride test. Chest film, Pulmonary function test.
Stool test to see if there is excess fat - steatorrhea
Detection of CF in a fetus is possible through genetic testing.

Prognosis: improving, remains a life-limiting disease, median age is 37.4 years.

Question 25

Bronchiolitis Obliterans

Answer 25

Very rare inflammation of the distal bronchioles caused by a virus or substances like fumes. sudden onset of cough or wheezing. Can look like asthma. Usually because of something inhaled, depending on extent can be damaging or reversible.