Pulmonary - MTB Flashcards
Asthma
abnormal bronchoconstriction of the airways
- reversible obstructive lung disease
Causes of acute exacerbation of symptoms include:
- allergens
- infection and cold air
- emotional stress or exercise
- catamenial (related to menstrual cycle)
- aspirin, NSAIDS, B-blockers, histamine
- GERD
Asthma: Presentation
- clear presence of WHEEZING w/ acute onset of SOB, cough, and chest tightness
- increased sputum though not fever
Asthma: Clinical Symptoms
- symptoms worse at night
- NASAL POLYPS and sensitivity to aspirin
- eczema or atopic dermatitis on PE
- INCREASED LENGTH OF EXPIRATORY PHASE of respiration
- increased use of accessory respiratory muscles (e.g. intercostals)
Asthma: Diagnostic
- CXR (normal in asthma)
- exclude pneumonia
- exclude pneumothorax or CHF
- Peak expiratory flow (PEF) or arterial blood gas (ABG)
- Pulmonary function testing
Best initial test in acute exacerbation
Peak expiratory flow (PEF)
Arterial Blood Gas (ABG)
Most accurate diagnostic test in acute exacerbation
Pulmonary Function Tests (PFTs)
- spirometry shows decrease in FEV1 / FVC
- FEV1 decreases more than FVC
15 y/o boy comes to the office b/c of occasional shortness of breath every few weeks. Currently he feels well. He uses no meds and denies other medical problems. Physical exam reveals pulse of 70 and RR of 12 breaths per minutes. Normal chest exam Most accurate diagnostic test at this time?
> 20 % decrease in FEV1 with use methacholine`
Pulmonary Function Testing in Asthma
- decreased FEV1 and decreased FVC w/ decreased ration of FEV1/FVC
- increased in FEV1 of more than 12% and 200mL w/ use of albuterol
- decrease in FEV1 of more than 20% w/ use of methacholine or histamine
- increase in diffusion capacity of lung for CO
Acetylcholine and histamine
- provoke bronchoconriction and increase in bronchial secretions
- metacholine (artificial form of acetylcholine)
Testing options for asthma
- CBC shows increased eosinophils
- Skin testing to ID specific allergens
- Increased IgE levels suggest allergic etiology
Asthma: Treatment
- Inhaled short-acting B-agonist (ALBUTEROL, pirbuterol)
- Low dose inhaled corticosteroids (e.g. triamcinolone, fluticasone)
- . Alternative long-term control agents (e.g. cromylyn, monteleukast, zileuton)
- Add long acting B-agonist (e.g. salmeterol)
- Oral corticosteroids (e.g. prednisone)
Inhaled steroids (e.g. fluticasone, triamcinolone): adverse effects
- dysphonia
- oral candidiasis
Systemic Corticosteroids: Adverse Effects
- Osteoporosis
- Cataracts
- Adrenal Suppression and Fat Redistribution
- Hyperlipidemia, hyperglycemia, acne, hirsutism
- Thinning of skin, striae, and easy bruising
Anticholinergics
- examples: ipratropium and tiotroprium
- dilate bronchi and decrease secretions
- very effective in COPD
47 y/o man w/ hx of asthma comes to ED w/ several days of increasing SOB, cough, and sputum production. On PE his RR is 34 per minute. He has diffuse expiratory wheezing and prolonged expiratory phase. Which of the following would you use at the best indication of the severity of the asthma?
Respiratory rate
- can indicate shortness of breasths
Severity of asthma exacerbation can be quantified by:
- Decreased peak expiratory flow (PEF)
- ABG w/ an increased A-a gradient
- CXR r/o infeciton leading to exacerbation
**PEF is approximation of FVC, based on height and age
Severe acute asthma exacerbation: treatment
- Oxygen
- Albuterol
- Steroids
Best initial therapy of acute asthma exacerbation
Oxygen w/ inhaled short acting B-agonists (e.g. albuterol) and bolus of steroids
- epinepherine no more effective than albuterol and has potential for adverse effects
Indication for Mg in acute asthma exacerbation
- Helps relieve bronchospasm
- used when in severe asthma exacerbation not responsive to several rounds of albuterol while waiting steroids
If pt in acute asthma exacerbation and not responsive to oxygen, albuterol, and steroids (or develops respiratory acidosis), what’s next step?
Endotracheal intubation for mechanical ventilation
- should be paced in ICU
Chronic Obstructive Pulmonary Disease (COPD)
- presence of shortness of breath from lung destruction decreasing elastic recoil of the lungs
- most of the ability to exhale is from elastin fibers in lungs passively allowing exhalation
- decrease in FEV1 and FVC and increase in TLC
COPD: Etiology
Tobacco smoking leads to almost all COPD
- tobacco destroys elastin fibers
COPD: Presentation
- Shortness of breath worsened by exertion
- Intermittent exacerbations w/ increased cough, sputum, and SOB
- “Barrel chest” from increased air trapping
- Muscle wasting and cachexia
