Pulmonary- Obstructive Disease Flashcards by Mappy Castro

Describe the difference between obstructive and restrictive pulmonary disease on pulmonary function test?

Obstructive: FEV1/FVC is less than normal (<75-80)

Restrictive: FEV1/FVC in often normal.

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What is COPD?

Progressive inflammatory lung disease leading to lung destruction and decrease elastic recoil that causes air flow obstruction. Encompasses chronic bronchitis and emphysema.

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what are the characteristics of chronic bronchitis vs emphysema?

Chronic bronchitis: inflammation of the bronchi and bronchioles

Emphysema: destruction of the alveoli and poor gas exchange.

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Signs and symptoms of COPD?

Dinished breath sounds
Rhonchi
Wheezing
Increased total lung capacity
Barrel Chest
Muscle wasting

CXR:
Hyper-inflated Hyperlucent lungs
Elongated and narrow mediastinum
Flattened diaphragms

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How is COPD diagnosed?

BIT: chest Xray.

Most accurate: Pulmonary function test or spirometry. Severity graded by the GOLD criteria.

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What is the GOLD criteria?

0-1 Exacerbations/yr without hospitalization:
GOLD 1 (Class I)	Mild  ≥ 80% FEV1
GOLD 2 (Class II)	Moderate :50% ≤ FEV1 < 80%

2+ exacerbations/yr or 1+ with hospitalization:
GOLD 3 (Class III)	Severe : 30% ≤ FEV1 < 50%
GOLD 4 (Class IV)	Very severe: < 30%

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Tx COPD

Symptomatic: SABA; LABA w/ inhaled steroids; LAMAs
Not responding: theophylline and roflumilast

Chronic hypoxia: ambulatory oxygen
O2 imporves mortality

Avoid: beta blokers

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Tx COPD exacerbation

Inhaled Bronchodilators 
Inhaled anticholinergics (ipratropium)
Steroid Burst
Antibiotics 
Repiratory support

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What is the concern with over-oxygenating COPDers?

If they are CO2 retainers their respiratory drive can be inhibited. Over oxygenation further compromises ventilation and precipitates hypercarbic respiratory failure. Only use enough to raise pO2 above 90%

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What are the fibers that are damaged in COPD?

Elastin fibers. Passive recoil allows for exhalation.

Tobacco destroys these fibers. Ina young non smoker. alpha 1-antitrypsin deficiency can also destroy these fibers.

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What antibiotics should be considered in acute exacerbation of COPD?

Coverage for: S. pneumoniea, H. flu, Moraxella catarrhalis.

Macrolides, Cephalosporins, Quinolones
Amoxi/clavulanic acid.

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What LABAs can be used in COPD?

Salmeterol
Formoterol
Arformoterol
Indacaterol
Vilanterol
Olodaterol

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What LAMAs can be used in COPD?

Tiotropium
Ipretopium 
Umeclidinium
Aclidinium 
Glycopyrrolate

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Signs and symptoms of asthma

Chronic Wheezing
Eczema or atopic dermatitis
Family history of asthma, allergies, or eczema
Nasal Polyps and sensitivity to aspirin
Increased expiratory phase
Increased work of breathing (RR best indicator of severity)
Worse at night

Can present as a solitary cough

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Define Asthma

reactive airway disease that causes abnormal bronchoconstriction of the airways. reversible obstructive lung disease (unlike COPD which is irreversible)

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What are the diagnostic test for asthma

BIT during exacerbation: Peak expiratory flow or ABG
Most accurate: PFTs with albuterol or methacholine (normal between exacerbations)

CBC: eosinophilia, increased IgE.
Skin: allergen test

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Medication challenged PFTs in asthma

(symptomatic patients) Albuterol: FEV1 increased >12%

(asymptomatic patients) Methacholine/ Histamine: FEV1 decreased >20%

Stepwise Tx of Asthma

SABA
Low dose Inhaled corticosteroid (ICS)
Alt: Cromolyn; Theo; LTRA
Low ICS & LABA or Medium ICS
Alt: Cromolyn; Theo; LTRA
Med-Max ICS+ LABA; Alt:+ LAMA
Monoclonal IL or IgE antibody
Uncontrolled: oral corticosteroid (last resort)

Flu and pneumococcal vaccines always

Side effects of inhaled steroids

Dysphonia

Oral Candidiasis

LTRA drugs

Leukotriene Modifiers:
Montelukast
Zafirlukast (adr: hepatotoxic; churg strauss)
Zileuton (best for atopic)

ICS drugs

Beclomethasone
Budesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone

SABA drugs

Albuterol
Pirbuterol
levalbuterol

Monoclonal Antibodies Asthma drugs

Anti-IL: 
reslizumab
mepolizumab
benralizuman
dupilumab

Anti-IgE:
Omalizumab

Treatment of acute asthma exacerbation

BITx: O2 + Inhaled SABA + Bolus steroids
Albuterol
No response: Intubate

Never use LABA, LTRA, Monoclonals, or Theo in excacerbation

What is the concern with the use of LABA in the treatment of asthma?

LABAs are not to be used as a solo agent due increased risk of death. Do not add if well controlled and remove if possible once control is achieved.

What is a common cause of wheezing in children under the age of 2?

Reactive airways disease due to viral infection, commonly RSV.

What should you think if a patient with acute asthma stops hyperventilating, wheezing, or has a normal CO2 level?

In severe asthma wheezing stops when loss of air movement which normalizes rate and pCO2. Patients are probably crashing. Immediate ABG Intubate (fatigue alone is reason to intubate)

Define Sleep Apnea

Obstructive (OSA): caused by narrowing/ closure of throat Central (CSA): change in breathing control and rhythm. Mild: 5-15 episodes/ hr Moderate: 15-30 episodes/hr Severe: >30 episodes/ hr

Signs and symptoms of OSA:

``` Daytime somnolence Hx of Loud snoring Headaches Impaired memory and judgement Depressiion Hypertension ED "bull neck" ```

Tx OSA

weight loss avoidance of alcohol and sedatives oral appliances that keep the tongue out of the way CPAP Surgery (uvulopalatopharyngoplasty)- widen airway

Distinguish CSA from OSA

CSA presents with similar symptoms. Respiratory drive is repetitively diminished from stoke, heart failure or plates. Unique: lack of abd or thoracic movement during pauses in breathing. Tx: CPAP

Diagnostic test sleep apnea

Most accurate: polysomnography (sleep study) Shows hypopnea episodes during sleep, no daytime hypoventilation.

Define Bronchiectasis

chronic dilation of large bronchi. permanent anatomic abnormality that cannot be reversed or cured.

Causes of bronchiectasis

``` CF (most common-50% cases) Infection (TB, pneumonia, abscess) Foreign body or tumor ABPA Collagen- vascular disease (e.g., RA) Panhypogammaglobulinemia and immune deficiency ```

Signs and symptoms of bronchiectasis

- Recurrent high volume purulent sputum production (key to diagnosis) - Possible hemoptysis - Dyspnea/ wheezinf - weight loss - anemia of chronic disease - crackles - clubbing - Dyskinetic Cilia Syndrome

Diagnostic tests for bronchiectasis

BIT: chest Xray (dilated thickened bronchi; "tram track" thickening of bronchi Most accurate: High resolution CT

S&S obstructive sleep apnea

- Daytime somnolence - Nonrestorative sleep w/ frequent awakenings - Morning Headaches - Affective & Cognitive symptoms - Eretile Dysfunction - Systemic Hypertension - Pulmonary hypertension & RHF

Mechanism of OSA and polycythemia

Short periods of hypopnea--> hypoxia --> renal response--> ↑ EPO --> polycythemia

Evaluation of drowsy drivers

Evaluate high risk behaviors: sedation, alcohol, night/ rotating shift work Sleep disorder: OSA increases risk for MVC 2-3x. Polysomnography

Cardinal symptoms acute COPD excacerbation

↑ dyspnea ↑cough (frequency or severity) sputum production (change color or volume)