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RRCCPA Clinical Medicine I > Pulmonary COPD - Jaynstein Final > Flashcards

Pulmonary COPD - Jaynstein Final Flashcards

1
Q

COPD is a preventable disease state characterized by airflow ____ due to chronic bronchitis and/or emphysema that is ____ fully reversible.

A

COPD is a preventable disease state characterized by airflow obstruction due to chronic bronchitis and/or emphysema that is not fully reversible.

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2
Q

What percentage of smokers develop COPD? What percentage of COPD is from smoking?

A

25% of smokers develop COPD

80% of COPD is from smoking

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3
Q

What is chronic bronchitis?

A

Increased mucus production and inflammation 2/2 to swelling and mucous

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4
Q

What are signs and symptoms of chronic bronchitis?

A

“Blue Bloater”

  • productive cough
  • dyspnea
  • cyanosis
  • hypoxia
  • coarse rhonchi
  • peripheral edema
  • abnormal lung excursion
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5
Q

Clinical diagnosis of chronic bronchitis?

A
  • Productive cough daily for at least 3 months in 2 consecutive years
  • Ongoing
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6
Q

Emphysema is abnormal ____ enlargement of distal airways with destruction of their walls.

A

Emphysema is abnormal permanent enlargement of distal airways with destruction of their walls.

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7
Q

What are signs and symptoms of emphysema?

A

“Pink Puffer”

  • progressive dyspnea
  • mild, dry cough
  • cachectic
  • hypoxia
  • prolonged expiration
  • hyper resonant chest on percussion
  • barrel chest
  • fatigue
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8
Q

Pathologic diagnosis of emphysema?

A

Evidence of abnormally enlarged or damaged airways without evidence of fibrosis

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9
Q

What is the work up of a COPD patient? What differences will you see between chronic bronchitis and emphysema patients?

A
  1. PFTs - obtain baselines (may be normal in early stages)
    * Late: obstructive pattern - Inc. TLC, RV, Dec. FEV1, FVC/FEV1 ratio < 0.7
  2. CBC
  • Chronic bronchitis = Hgb may be elevated
  • Emphysema = Hgb normal
  1. ABG (not always indicated for initial eval)
  • Late: Inc PaCo2 –> Dec. pH
  • Resp acidosis
  1. CXR
  • Chronic bronchitis = may show bronchial thickening
  • Emphysema = may show hyperinflation, flattened diaphragm
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10
Q

What classification is used for COPD patients and what is the assessment test patients fill out?

A

GOLD classification

Patients fill out the CAT (COPD Assessment Test) - symptoms scoring that helps measure the impact of COPD

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11
Q

What is the most important aspect of treatment for COPD?

A. O2 supplementation

B. Prescribing an Anticholinergic

C. Smoking cessation

D. Prescribing a Corticosteroid

A

C. Smoking cessation

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12
Q

With O2 supplementation for COPD patients, what do you need to ensure you obtain and record?

A

A walking O2 sat - keep record of > 88%

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13
Q

T/F: O2 is the only drug therapy shown to improve the natural h/o COPD?

A

True!

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14
Q

What bronchodilators are used to treat COPD?

A
  1. LAMA - Spiriva, Ellipta - 1st line!
  2. LABA - Serevent
  3. SABA
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15
Q

Other than bronchodilators, what medications can be used to treat COPD?

A
  1. Anticholinergics - reduce sputum
  2. Corticosteroids - reduce inflammation (inhaled or as adjunt therapy)
  3. ABX - limit
  • increased purulent sputum, fever, dyspnea = ABX use
  • Zpack if “well”
  • Doxy, Levaquin/Cipro, Augmentin if “sick”
  1. PO steroids - more beneficial than ABX
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16
Q

Bronchiectasis is a/an congential or acquired disorder characterized by ____ ____ and widening of the large airways.

A

Bronchiectasis is a/an congential or acquired disorder characterized by irreversible destruction and widening of the large airways.

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17
Q

What are some causes of bronchiectasis?

A

Inflammatory and infectious disorders:

  • Cystic fibrosis
  • TB
  • PNA (pneumonia)
  • Immunodeficiency
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18
Q

What are the signs and symptoms of bronchiectasis?

A
  • Chronic, productive cough
  • Hemoptysis
  • Pleuritic chest pain
  • Dyspnea and wheezing
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19
Q

What would you find during the PE of a patient with bronchiectasis?

A
  • Crackles/rhonchi at lung bases
  • Wheezing
  • Copious, foul-smelling sputum
  • Hypoxia
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20
Q

What would you expect to see when working up a patient with bronchiectasis?

A
  1. PFT will reveal an obstructive pattern
  2. +/- sputum culture
  3. CXR - “tram tracks” (thickened or dilated bronchi), atelectasis
  4. Gold standard: CT chest - airways wide and filled with mucus
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21
Q

What is the treatment for bronchiectasis?

A
  1. No cure - control infections and secretions
  2. Chest physiotherapy
  3. ABX (for infectious etiologies - based on sputum culture)
  4. Inhaled corticosteroids and bronchodilators
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22
Q

What are Interstitial Lung Diseases?

A
  • Sometimes referred to as restrictive lung diseases or diffuse parenchymal lung dz
  • Cause breathlessness and/or cough
  • Lung compliance is decreased and lung volumes are small
  • PFTs show restrictive pattern = FVC < 80% of predicted
  • Inflammation–> desctruction –> repair –> fibrosis
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23
Q

What is the most common cause of interstitial lung disease?

A

Idiopathic Interstitial Pneumonia (IIP)

  • “non infectious PNA”
  • interstitial space of lungs becomes infested with inflammatory cells –> pulmonary fibrosis
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24
Q

How do you diagnose Idiopathic Interstitial Pneumonia (IIP)?

A

Dx is >90% accurate in pts over 65 with:

  • inspiratory crackles with no obvious cause
  • restrictive pattern on PFTs
  • radiologic evidence of pulmonary fibrosis that is increasing over years

Definitive = lung biopsy

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25
Q

What is the treatment for Idiopathic Interstitial Pneumonia?

A
  1. No medication proved successful
  2. Definitive tx = lung transplant
  3. O2 supp
  4. Refer to pulm

*MC complication = pneumothorax

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26
Q

Sarcoidosis is a systemic, inflammatory syndrome characterized by disposition of ____ (inflammatory cell collections) into multiple organs.

A

Sarcoidosis is a systemic, inflammatory syndrome characterized by disposition of granulomas (inflammatory cell collections) into multiple organs.

*MC site for granulomas = lungs and lymph nodes

27
Q

Diagnosis of sarcoidosis is often by what?

A

Incidental bilateral hilar adenopathy on routine CXR

Definitive = biopsy - showing noncaseating granulomas

28
Q

Treatment for sarcoidosis?

A
  1. Require continued monitoring for dz progression (labs, ocular testing, CXR)
  2. 1/3 of cases undergo spontaneous remission
  3. Systemic corticosteroids
    * Prednisone 20-40mg QD x 4-6 wks - if effective: taper to 5mg QD x 12 months
  4. Symptom based tx
29
Q

Pneumoconiosis is an ILD caused by chronic ____ of ____

A

Pneumoconiosis is an ILD caused by chronic inhalation of dust

  • Asbestos
  • Coal miners “the black lung”
30
Q

What is the clinical presentation of pneumoconiosis?

A
  • Hx of occupational exposure
  • Progressive dyspnea and decreased exercise tolerance
  • Chronic dry cough
  • May show hypoxia, clubbing, diminished breath sounds
31
Q

What is the work up for pneumoconiosis?

A
  1. A good Hx is your best work up!
  2. CXR - irregular and will depend on type of dust
    * patchy, subpleural, bibasilar interstitial infiltrates, small cystic radiolucencies, calcifications, irregular opacities
  3. PFTs = restrictive pattern
32
Q

What is the treatment for pneumoconiosis?

A
  1. No cure, progressive loss of lung function
  2. Exposure avoidance
  3. Supportive - Supp O2, smoking cessation, vaccinations, prevention of illness
  4. Refer to pulm/specialist
33
Q

If your patient presents with progressive dyspnea and PFT is suggestive of restrictive process what should you do?

A
  1. Review medications
  2. CXR
  3. Refer to pulm
34
Q

What is the normal pressure in the pulmonary arteries? What is the pressure in the pulmonary arteries in a patient with pulmonary HTN?

A

12-16 mmHg

Pulm HTN is >25 mmHg at rest or > 30 mmHg with exertion

35
Q

What does the persistent elevation of pressure in the pulmonary arteries cause?

A
  1. Dec. amount of blood circulating –> Dec. gas exchange (hypoxemia, hypercapnea)
  2. Inc. work to circulate blood –> RVH and strain
  3. Stagnates blood –> Inc. risk for thrombosis
36
Q

What is the clinical presentation of pulmonary HTN?

A
  • Slow onset - determined by vasculature involved
  • Progressive dyspnea - DOE –> then at rest
  • Dull CP
  • Syncope, dizziness
  • Fatigue
  • Cyanosis, clubbing
  • Lung auscultation normal
  • R HF –> L HR symptoms
37
Q

What is the work up for pulmonary HTN? What is the definitive diagnosis?

A
  1. PFTs - normal or restrictive
  2. CXR - dilation of pulmonary vasculature, hypertrophy
  3. CT PE or VQ scan (if concerned for PE)
  4. Labs
  5. EKG - R atrial enlargement, RVH, R axis deviation
  6. TTE

Definitive = Swan-Ganz Catheter (evals pressure)

38
Q

What is the treatment for pulmonary HTN?

A
  1. Diuretics - caution to avoid dec. cardiac output
  2. Vasodilators
  3. O2
  4. Digoxin
  5. Exercise
  6. Transplant
  7. Need to be under care of pulm and cards
39
Q

Etiologies for URIs?

A
  1. Rhinoviruses (30-35%)
  2. Coronaviruses (10%)
  3. Influenza and adenovirus (30%)
  4. Undiscovered viruses (35%)
  5. Miscellaneous virus (20%)
  6. Group A strep (5%)

90% of all URIs = VIRAL

40
Q

How can an URI be transmitted and what is the most efficient means of transmission?

A
  • Transmitted by aerosol, droplet, or direct contact
  • Direct contact is the most efficient means of transmission (40-90% recovery from hands)
41
Q

What is the incubation period of an URI? How long do they typically last?

A
  • 12-72 hours
  • Usually 1 week - can last up to 2-3 wks
42
Q

Only the parietal plura has pain fibers, supplied by the intercostal nerves, and irritation of these nerves is responsible for the pain of ____ ____

A

Only the parietal plura has pain fibers, supplied by the intercostal nerves, and irritation of these nerves is responsible for the pain of pleural diseases

43
Q

Pleuritic pain is described as a sudden onset of ____, ____ pain that is worse with coughing, deep breathing, and movement

A

Pleuritic pain is described as a sudden onset of sharp, localized pain that is worse with coughing, deep breathing, and movement

44
Q

What can cause pleuritic chest pain?

A
  • Pleurisy
  • Pleural effusion
  • Pneumothorax
  • Trauma
  • MSK pain/strain
  • Costochondritis (pain where ribs attach to sternum)
45
Q

What is pleurisy? How do patients with pleurisy usually present?

A
  • Acute inflammation of the lung pleura
  • More common in younger adults
  • Viral cause of 2/2 pneumonia - often occur a few days after an URI
  • Present in severe pleuritic pain, splinting chest, and gaurded breathing
  • Pain may be reproducible on exam - lung with friction rub, normal VS
46
Q

What is the normal amount of fluid that is usually in the pleural space of a healthy adult? At what fluid level would a patient become symptomatic (pleural effusion)?

A
  • Normal = 5-15mL
  • Symptomatic at > 300mL
47
Q

What are the 3 ways a pleural effusion occurs?

A
  1. Transudative
  2. Exudative
  3. Traumatic
48
Q

A transudative pleural effusion means there is increased fluid secondary to built up pressure with ____ ____ (CHF, cirrhosis, nephrotic syndrome)

A

A transudative pleural effusion means there is increased fluid secondary to built up pressure with normal capillaries (CHF, cirrhosis, nephrotic syndrome)

49
Q

Exudative pleural effusion means there is increased fluid secondary to ____ ____ ____ or decreased lymphatic clearance (CA, trauma, infection, PE, TB, autoimmune, empyema)

A

Exudative pleural effusion means there is increased fluid secondary to increased capillary permeability or decreased lymphatic clearance (CA, trauma, infection, PE, TB, autoimmune, empyema)

50
Q

What will the PE show for a patient with pleural effusion? What would imaging show?

A
  • Diminished breath sounds and dullness to percussion
  • Rales
  • Massive effusion with increased intrapleural pressure may cause contralateral trachea shift and bulging of intercostal spaces
  • CXR = pt in L lateral decubitus, shows effusion, blunted costophrenic angles
  • Consider CT - more info on type of effusion
51
Q

Work up for a pleural effusion?

A
  1. Thoracentesis - obtain fluid and determine fluid type (serous, blood, pus, or no fluid)
  2. Orders = LDH, protein, cell count, gram stain and culture, glucose, TB markers
52
Q

What would the fluid analysis show for a transudative pleural effusion vs. an exudative effusion?

A

Transudative

  • Fluid protein serum < 0.5
  • Fluid LDH < 0.6 or < 2/3

Exudative

  • Fluid protein serum > 0.5
  • Fluide LDH > 0.6 or > 2/3
53
Q

Pleural Effusion: What is Meig’s Syndrome?

A

Triad of:

  1. Ascites
  2. Pleural effusion
  3. Benign ovarian tumor
54
Q

Treatment for all 3 types of pleural effusions

A
  1. Transudative = treat underlying dz (consider therapeutic tap)
  2. Exudative
  • Malignant - taps for therapuetic relief
  • Infectious - ABX, chest tube, SX
  1. Traumatic = chest tube
55
Q

What are the 3 types of sleep apnea?

A
  1. Obstructive - upper airway flow impeded
  2. Central - absent signal to breathe from CNS
  3. Mixed
56
Q

How do you diagnose sleep apnea?

A
  1. Hx
  2. PE - look for nasal obstruction
  3. Pulse ox while sleeping?
  4. Polysomnography (sleep study) - positive is >5-10 events in an hour
57
Q

Treatment for sleep apnea?

A
  1. Behavioral
  2. CPAP
  3. Oropharynx - T&A, uvulopalatopharyngoplasty (removal of tissues)
  4. Life threatening obs = tracheostomy
58
Q

Etiologies of chronic cough?

A
  • Viral, post-viral
  • Post-nasal drip syndrome (PNSD)
  • Smoking
  • GERD
  • Medications
  • Asthma

Dangerous = CA, Bronchiectasis, CHF, TB, Sarcoidosis

59
Q

Work up for chronic cough?

A
  1. URI s/s? Nasal congestion? Triggers? GERD? Illness?
  2. Exam - lungs, heart, ENT, peri. edema
  3. CXR, CT chest, CT sinus (if indicated)
  4. Pertussis Swab
  5. PFTs
60
Q

What are the treatment steps for chronic cough if a patient has a benign history and exam?

A
  1. Treat for PND with decongestants, antihistamines, nasal steroids
    * Antitussives: Tessalon pearls, guaifenesin, codeine
  2. Eval for asthma
  3. CXR, CT chest, sinuses
  4. Imaging NL –> tx for GERD with PPI
  5. Bronchoscopy
61
Q

How is hemoptysis quantified?

A

By amount

  • Mild (blood tinged) or massive >100ml in 24 hrs
  • Masive is <5% of cases
62
Q

Work up for hemoptysis?

A
  1. CXR –> if normal w/ small amount and no PMH = done

If indicated:

  • Chest CT
  • CBC, CMP, UA, coags
  • Sputum culture
  • Bronchoscopy
63
Q

Treatment for hemoptysis?

A
  1. Mild and stable = watch and wait, antitussives
  2. Mild, stable, infectious etiology = ABX, antitussives, SABA
  3. Massive, unstable = maintain airway, correct coags, volume resuscitation, emobilzation
64
Q

If a patient has prominent dyspnea with no associated features what DDXs should you be thinking about?

A
  • Anemia
  • Metabolic acidosis
  • Panic disorder
  • CO poisoning

RRCCPA Clinical Medicine I (49 decks)

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