Pulmonary COPD - Jaynstein Final Flashcards
COPD is a preventable disease state characterized by airflow ____ due to chronic bronchitis and/or emphysema that is ____ fully reversible.
COPD is a preventable disease state characterized by airflow obstruction due to chronic bronchitis and/or emphysema that is not fully reversible.
What percentage of smokers develop COPD? What percentage of COPD is from smoking?
25% of smokers develop COPD
80% of COPD is from smoking
What is chronic bronchitis?
Increased mucus production and inflammation 2/2 to swelling and mucous
What are signs and symptoms of chronic bronchitis?
“Blue Bloater”
- productive cough
- dyspnea
- cyanosis
- hypoxia
- coarse rhonchi
- peripheral edema
- abnormal lung excursion
Clinical diagnosis of chronic bronchitis?
- Productive cough daily for at least 3 months in 2 consecutive years
- Ongoing
Emphysema is abnormal ____ enlargement of distal airways with destruction of their walls.
Emphysema is abnormal permanent enlargement of distal airways with destruction of their walls.
What are signs and symptoms of emphysema?
“Pink Puffer”
- progressive dyspnea
- mild, dry cough
- cachectic
- hypoxia
- prolonged expiration
- hyper resonant chest on percussion
- barrel chest
- fatigue
Pathologic diagnosis of emphysema?
Evidence of abnormally enlarged or damaged airways without evidence of fibrosis
What is the work up of a COPD patient? What differences will you see between chronic bronchitis and emphysema patients?
- PFTs - obtain baselines (may be normal in early stages)
* Late: obstructive pattern - Inc. TLC, RV, Dec. FEV1, FVC/FEV1 ratio < 0.7 - CBC
- Chronic bronchitis = Hgb may be elevated
- Emphysema = Hgb normal
- ABG (not always indicated for initial eval)
- Late: Inc PaCo2 –> Dec. pH
- Resp acidosis
- CXR
- Chronic bronchitis = may show bronchial thickening
- Emphysema = may show hyperinflation, flattened diaphragm
What classification is used for COPD patients and what is the assessment test patients fill out?
GOLD classification
Patients fill out the CAT (COPD Assessment Test) - symptoms scoring that helps measure the impact of COPD
What is the most important aspect of treatment for COPD?
A. O2 supplementation
B. Prescribing an Anticholinergic
C. Smoking cessation
D. Prescribing a Corticosteroid
C. Smoking cessation
With O2 supplementation for COPD patients, what do you need to ensure you obtain and record?
A walking O2 sat - keep record of > 88%
T/F: O2 is the only drug therapy shown to improve the natural h/o COPD?
True!
What bronchodilators are used to treat COPD?
- LAMA - Spiriva, Ellipta - 1st line!
- LABA - Serevent
- SABA
Other than bronchodilators, what medications can be used to treat COPD?
- Anticholinergics - reduce sputum
- Corticosteroids - reduce inflammation (inhaled or as adjunt therapy)
- ABX - limit
- increased purulent sputum, fever, dyspnea = ABX use
- Zpack if “well”
- Doxy, Levaquin/Cipro, Augmentin if “sick”
- PO steroids - more beneficial than ABX
Bronchiectasis is a/an congential or acquired disorder characterized by ____ ____ and widening of the large airways.
Bronchiectasis is a/an congential or acquired disorder characterized by irreversible destruction and widening of the large airways.
What are some causes of bronchiectasis?
Inflammatory and infectious disorders:
- Cystic fibrosis
- TB
- PNA (pneumonia)
- Immunodeficiency
What are the signs and symptoms of bronchiectasis?
- Chronic, productive cough
- Hemoptysis
- Pleuritic chest pain
- Dyspnea and wheezing
What would you find during the PE of a patient with bronchiectasis?
- Crackles/rhonchi at lung bases
- Wheezing
- Copious, foul-smelling sputum
- Hypoxia
What would you expect to see when working up a patient with bronchiectasis?
- PFT will reveal an obstructive pattern
- +/- sputum culture
- CXR - “tram tracks” (thickened or dilated bronchi), atelectasis
- Gold standard: CT chest - airways wide and filled with mucus
What is the treatment for bronchiectasis?
- No cure - control infections and secretions
- Chest physiotherapy
- ABX (for infectious etiologies - based on sputum culture)
- Inhaled corticosteroids and bronchodilators
What are Interstitial Lung Diseases?
- 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
What is the most common cause of interstitial lung disease?
Idiopathic Interstitial Pneumonia (IIP)
- “non infectious PNA”
- interstitial space of lungs becomes infested with inflammatory cells –> pulmonary fibrosis
How do you diagnose Idiopathic Interstitial Pneumonia (IIP)?
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
What is the treatment for Idiopathic Interstitial Pneumonia?
- No medication proved successful
- Definitive tx = lung transplant
- O2 supp
- Refer to pulm
*MC complication = pneumothorax
Sarcoidosis is a systemic, inflammatory syndrome characterized by disposition of ____ (inflammatory cell collections) into multiple organs.
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
Diagnosis of sarcoidosis is often by what?
Incidental bilateral hilar adenopathy on routine CXR
Definitive = biopsy - showing noncaseating granulomas
Treatment for sarcoidosis?
- Require continued monitoring for dz progression (labs, ocular testing, CXR)
- 1/3 of cases undergo spontaneous remission
- Systemic corticosteroids
* Prednisone 20-40mg QD x 4-6 wks - if effective: taper to 5mg QD x 12 months - Symptom based tx
Pneumoconiosis is an ILD caused by chronic ____ of ____
Pneumoconiosis is an ILD caused by chronic inhalation of dust
- Asbestos
- Coal miners “the black lung”
What is the clinical presentation of pneumoconiosis?
- Hx of occupational exposure
- Progressive dyspnea and decreased exercise tolerance
- Chronic dry cough
- May show hypoxia, clubbing, diminished breath sounds
What is the work up for pneumoconiosis?
- A good Hx is your best work up!
- CXR - irregular and will depend on type of dust
* patchy, subpleural, bibasilar interstitial infiltrates, small cystic radiolucencies, calcifications, irregular opacities - PFTs = restrictive pattern
What is the treatment for pneumoconiosis?
- No cure, progressive loss of lung function
- Exposure avoidance
- Supportive - Supp O2, smoking cessation, vaccinations, prevention of illness
- Refer to pulm/specialist
If your patient presents with progressive dyspnea and PFT is suggestive of restrictive process what should you do?
- Review medications
- CXR
- Refer to pulm
What is the normal pressure in the pulmonary arteries? What is the pressure in the pulmonary arteries in a patient with pulmonary HTN?
12-16 mmHg
Pulm HTN is >25 mmHg at rest or > 30 mmHg with exertion
What does the persistent elevation of pressure in the pulmonary arteries cause?
- Dec. amount of blood circulating –> Dec. gas exchange (hypoxemia, hypercapnea)
- Inc. work to circulate blood –> RVH and strain
- Stagnates blood –> Inc. risk for thrombosis
What is the clinical presentation of pulmonary HTN?
- 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
What is the work up for pulmonary HTN? What is the definitive diagnosis?
- PFTs - normal or restrictive
- CXR - dilation of pulmonary vasculature, hypertrophy
- CT PE or VQ scan (if concerned for PE)
- Labs
- EKG - R atrial enlargement, RVH, R axis deviation
- TTE
Definitive = Swan-Ganz Catheter (evals pressure)
What is the treatment for pulmonary HTN?
- Diuretics - caution to avoid dec. cardiac output
- Vasodilators
- O2
- Digoxin
- Exercise
- Transplant
- Need to be under care of pulm and cards
Etiologies for URIs?
- Rhinoviruses (30-35%)
- Coronaviruses (10%)
- Influenza and adenovirus (30%)
- Undiscovered viruses (35%)
- Miscellaneous virus (20%)
- Group A strep (5%)
90% of all URIs = VIRAL
How can an URI be transmitted and what is the most efficient means of transmission?
- Transmitted by aerosol, droplet, or direct contact
- Direct contact is the most efficient means of transmission (40-90% recovery from hands)
What is the incubation period of an URI? How long do they typically last?
- 12-72 hours
- Usually 1 week - can last up to 2-3 wks
Only the parietal plura has pain fibers, supplied by the intercostal nerves, and irritation of these nerves is responsible for the pain of ____ ____
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
Pleuritic pain is described as a sudden onset of ____, ____ pain that is worse with coughing, deep breathing, and movement
Pleuritic pain is described as a sudden onset of sharp, localized pain that is worse with coughing, deep breathing, and movement
What can cause pleuritic chest pain?
- Pleurisy
- Pleural effusion
- Pneumothorax
- Trauma
- MSK pain/strain
- Costochondritis (pain where ribs attach to sternum)
What is pleurisy? How do patients with pleurisy usually present?
- 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
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)?
- Normal = 5-15mL
- Symptomatic at > 300mL
What are the 3 ways a pleural effusion occurs?
- Transudative
- Exudative
- Traumatic
A transudative pleural effusion means there is increased fluid secondary to built up pressure with ____ ____ (CHF, cirrhosis, nephrotic syndrome)
A transudative pleural effusion means there is increased fluid secondary to built up pressure with normal capillaries (CHF, cirrhosis, nephrotic syndrome)
Exudative pleural effusion means there is increased fluid secondary to ____ ____ ____ or decreased lymphatic clearance (CA, trauma, infection, PE, TB, autoimmune, empyema)
Exudative pleural effusion means there is increased fluid secondary to increased capillary permeability or decreased lymphatic clearance (CA, trauma, infection, PE, TB, autoimmune, empyema)
What will the PE show for a patient with pleural effusion? What would imaging show?
- 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
Work up for a pleural effusion?
- Thoracentesis - obtain fluid and determine fluid type (serous, blood, pus, or no fluid)
- Orders = LDH, protein, cell count, gram stain and culture, glucose, TB markers
What would the fluid analysis show for a transudative pleural effusion vs. an exudative effusion?
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
Pleural Effusion: What is Meig’s Syndrome?
Triad of:
- Ascites
- Pleural effusion
- Benign ovarian tumor
Treatment for all 3 types of pleural effusions
- Transudative = treat underlying dz (consider therapeutic tap)
- Exudative
- Malignant - taps for therapuetic relief
- Infectious - ABX, chest tube, SX
- Traumatic = chest tube
What are the 3 types of sleep apnea?
- Obstructive - upper airway flow impeded
- Central - absent signal to breathe from CNS
- Mixed
How do you diagnose sleep apnea?
- Hx
- PE - look for nasal obstruction
- Pulse ox while sleeping?
- Polysomnography (sleep study) - positive is >5-10 events in an hour
Treatment for sleep apnea?
- Behavioral
- CPAP
- Oropharynx - T&A, uvulopalatopharyngoplasty (removal of tissues)
- Life threatening obs = tracheostomy
Etiologies of chronic cough?
- Viral, post-viral
- Post-nasal drip syndrome (PNSD)
- Smoking
- GERD
- Medications
- Asthma
Dangerous = CA, Bronchiectasis, CHF, TB, Sarcoidosis
Work up for chronic cough?
- URI s/s? Nasal congestion? Triggers? GERD? Illness?
- Exam - lungs, heart, ENT, peri. edema
- CXR, CT chest, CT sinus (if indicated)
- Pertussis Swab
- PFTs
What are the treatment steps for chronic cough if a patient has a benign history and exam?
- Treat for PND with decongestants, antihistamines, nasal steroids
* Antitussives: Tessalon pearls, guaifenesin, codeine - Eval for asthma
- CXR, CT chest, sinuses
- Imaging NL –> tx for GERD with PPI
- Bronchoscopy
How is hemoptysis quantified?
By amount
- Mild (blood tinged) or massive >100ml in 24 hrs
- Masive is <5% of cases
Work up for hemoptysis?
- CXR –> if normal w/ small amount and no PMH = done
If indicated:
- Chest CT
- CBC, CMP, UA, coags
- Sputum culture
- Bronchoscopy
Treatment for hemoptysis?
- Mild and stable = watch and wait, antitussives
- Mild, stable, infectious etiology = ABX, antitussives, SABA
- Massive, unstable = maintain airway, correct coags, volume resuscitation, emobilzation
If a patient has prominent dyspnea with no associated features what DDXs should you be thinking about?
- Anemia
- Metabolic acidosis
- Panic disorder
- CO poisoning
