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01 Family Medicine > Pulmonolgy > Flashcards

Pulmonolgy Flashcards

43,44,45

1
Q

What is COPD (4 words)?

A

Chronic
Progressive
Airway
Obstruction

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2
Q

What is the the pathophysiology of COPD?

A

irritant/toxin ->

Inflammation/oxidation ->

Airflow limitation:
Loss of elasticity, air sacs destroyed, airways narrowed, fibrosis ->

Symptoms:
Mucus hyper-secretion, cough, dyspnea, recurrent infections

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3
Q

What are the risk factors for COPD?

A

Smoking

Increased age

Women > Men

Pollutants exposure

Genetics- Alpha-1 antitrypsin deficiency

Hx of asthma, chronic bronchitis, recurrent infections

Socioeconomic status

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4
Q

What are the hallmark symptoms of COPD?

A

Cough

Dyspnea

Chronic sputum production

Wheezing

Recurrent respiratory infections

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5
Q

Who should be screened for COPD?

A

Patients (ages 40+) with current or past smoking history with respiratory symptoms

-Dyspnea, cough, chronic sputum, recurrent lower respiratory infections

*Per USPSTF do NOT screen asymptomatic patients regardless of risk factors

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6
Q

What are the 4 key steps for assessing COPD?

A

Assess airflow limitation with spirometry

Assess symptom severity

Assess risk of exacerbations

Assess and manage co-morbidities

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7
Q

What is the main test for evaluation COPD?

A

Spirometry to:

-confirm diagnosis
-Measure obstruction severity
-Monitor progression, response to therapy

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8
Q

In spirometry what is FEV1?

A

Volume of air expired in one second after a full inspiration

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9
Q

In spirometry what is FVC?

A

Maximum volume of air exhaled after a full inspiration

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10
Q

What is the best spirometric criterion to diagnose COPD?

A

FEV1/FVC ratio < 0.70, post-bronchodilator

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11
Q

How does FEV1, FVC and FEV1/FVC ratio change in obstructive v. restrictive lung disease?

A

Obstructive:
FEV1 reduced
FEV1/FVC ratio reduced

Restrictive:
FEV1 and FVC equally reduced
FEV1/FVC ratio around 1

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12
Q

How can you distinguish COPD from asthma on spirometry?

A

COPD shows no improvement with bronchodilation

(aka not reversible)

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13
Q

How is COPD classified?

A

Gold Staging based on FEV1

*Must have FEV1/FVC ratio less than 0.7, after bronchodilation

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14
Q

Classify COPD severity based on FEV1 percent predicted: mild, moderate, severe, very severe

A

*Must have FEV1/FVC ratio less than 0.7, after bronchodilation for all stages

Mild: FEV1 greater than 80% of predicted

Moderate: FEV1 50-80% of predicted

Severe: FEV1 30-50% of predicted

Very severe (“end stage”): FEV1 less than 30% of predicted

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15
Q

How are COPD symptoms assessed?

A

-Patient reporting- COPD Assessment Test (CAT)

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16
Q

Who is considered to be at increased risk for COPD exacerbations?

A

2 or more exacerbations in the past year

One or more hospitalizations for COPD exacerbation

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17
Q

Which cardiovascular disease are patients with COPD at higher risk for?

A

Atrial fibrillation

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18
Q

What co-morbidity is an independent risk factor for COPD exacerbations?

A

GERD

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19
Q

How often should spirometry be done to monitor patients with COPD?

A

Repeat every year or if a sudden decline in status

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20
Q

What are the 5 “A”s of smoking cessation?

A

Ask about use

Advise to quit

Assess readiness to quit

Assist with pharmacotherapies

Arrange follow up

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21
Q

What are the only 2 interventions proven to prolong survival of patients with COPD?

A

Tobacco cessation

Oxygen therapy (use greater than 15 hours/day, if chronically hypoxic)

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22
Q

What are some pharmacotherapies for smoking cessation?

A

1st line: Nicotine Replacement Therapy

Varenicline (Chantix)- Nicotine blockade

Buproprion

Counseling and medications more effective together than either alone

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23
Q

What is the role of E cigarettes in tobacco cessation?

A

Effectiveness and safety unproven

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24
Q

What is the first step of COPD treatment?

A

Beta 2 agonists- relax smooth muscle, lower airway resistance, increase FEV1

Long acting beta agonist (LABA) preferred over Short acting beta agonist (SABA)

Side effects- tachycardia, arrhythmia, tremor

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25
Q

What is the second step of COPD treatment?

A

Long Acting Muscarinic Antagonists (LAMA)- block bronchoconstrictor effect of acetylcholine on muscarinic receptors

Ex: Tiotropium

-improve symptoms, reduce exacerbations and hospitalizations

Side effects- dry mouth

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26
Q

What is the third step of COPD treatment?

A

Combination therapy

LAMA/LABA (preferred)
-improved lung function, quality of life. Reduce exacerbations

or
LABA/ICS

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27
Q

COPD treatment by ABCD groups?

A

A: LABA or SABA
B: LABA or LAMA
C: LAMA

D:
LAMA
if CAT score >20: LAMA/LABA
if eosinophils >300 or also have asthma: LABA/ICS
last resort LAMA/LABA/ICS

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28
Q

Name some LAMA/LABA combination medications

A

Stiolto (tiotropium/olodaterol)

Bevespi (glycopyrrolate/formoterol)

*Just some examples, there are others

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29
Q

What is the role of corticosteroids in COPD?

A

Benefit is more limited (compared to asthma)

Regular use of ICS or oral steroids alone not recommended due to risk of pneumonia, thrush and hoarseness
-use ICS in combination therapies

Patients with COPD and Asthma or eosinophils >300, more likely to benefit

*oral steroids only for exacerbations

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30
Q

Which category of medications has a greater effect on COPD exacerbation reduction and decreased hospitalizations, LAMAs or LABAs?

A

LAMAs

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31
Q

Which category of medications has the highest increase in FEV1 and reduces more symptoms of COPD, LAMAs or LABAs?

A

Combined LAMA/LABAs

*Better combined than monotherapy

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32
Q

Which combination therapy reduces more COPD exacerbations, LAMA/LABA or LABA/ICS?

A

LAMA/LABA

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33
Q

Is there any benefit in triple inhaled therapy v. combined double therapy in COPD management?

A

Triple therapy (LAMA/LABA/ICS), improves lung function, reduces exacerbations more than ICS/LABA or LAMA/LABA

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34
Q

What is the role of steroids in long term treatment of COPD?

A
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35
Q

What is the role of theophyline in COPD treatment?

A

Not recommended!
limited evidence of benefit- high toxicity

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36
Q

What is the role of PDE4 inhibitors (Roflumilast) in COPD treatment?

A

Can help reduce exacerbations

Useful add on for GOLD 3-4

Side effects: use caution in patients with depression or liver impairment, sleep disturbance, Nausea, abdominal pain, diarrhea, weight loss

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37
Q

What is an over the counter medication to reduce the risk of COPD exacerbations?

A

N-acetylecystine, mucolytics

Loosens phlegm

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38
Q

What is the role of Azithromycin in COPD management?

A

Long term use can reduce exacerbations (250mg/day) in high risk patients

Associated with bacterial resistance, hearing impairment, prolonged QT

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39
Q

What is the indication for supplemental oxygen in COPD treatment?

A

O2 sat <88% at rest

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40
Q

What is the indication for pulmonary rehabilitation in COPD treatment?

A

For all stages of COPD

Exercise training, education, nutrition, psychosocial support

Improves symptoms, exercise tolerance
Reduces hospitalizations, anxiety, depression

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41
Q

What is one important factor to keep in mind when prescribing inhalers?

A

Ensure correct inhaler technique

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42
Q

What is the role of antitussives and vasodilators in COPD management?

A

Not helpful

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43
Q

What are the goals of COPD management?

A

Reduce symptoms
-Improve exercise tolerance and health status, relieve dyspnea

Reduce risk
-Prevent progression and exacerbations, prolong life

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44
Q

How is COPD classified based on the GOLD ABCD criteria?

A
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45
Q

COPD differential diagnoses?

A

Asthma
CHF
Lung cancer
Interstitial lung disease/fibrosis
Bronchiectasis
Sarcoidosis
TB/pulmonary infections
Bronchopulmonary dysplasia

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46
Q

What is the most common cause of Acute COPD exacerbations?

A

URI: viral or bacterial

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47
Q

What should be ordered in the work up of acute COPD exacerbation?

A

ABG/VBG

CXR or US

EKG

CBC, CMP

*spirometry not recommended

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48
Q

What is the treatment of mild acute COPD exacerbation?

A

SABA

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49
Q

What is the treatment of moderate acute COPD exacerbation?

A

SABA
plus
Antibiotics +/- oral steroids

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50
Q

What is the treatment of severe acute COPD exacerbation?

A

Hospitalization or ED eval needed

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51
Q

What are indications to admit a patient for COPD exacerbation?

A

-Increased symptoms (dyspnea, tachypnea, confusion)

-New physical signs (cyanosis, edema)

-Acute respiratory failure

-Failure of initial treatment

-Older age

-Serious co-morbidities

-Lack of home support

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52
Q

What are the treatment options for acute COPD exacerbations?

A

Oxygen: titrate to goal of 88-92%

Bronchodilators: SABA +/- anticholinergics

Corticosteroids: Prednisone 40 mg PO for 5 days

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53
Q

When should antibiotics be added for treatment of acute COPD exacerbation?

A

Not routinely recommended

Must have all three:
Increased dyspnea, sputum volume, sputum purulence
or
Requiring mechanical ventilation

*Treat for 5-7 days

Can shorten recovery, reduce relapse and hospital stays

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54
Q

What is the role of systemic steroids in COPD exacerbation?

A

Improve lung function and oxygenation

Shorten recovery and hospital stays

*Treat for 5-7 days (Prednisone 20 mg BID for 5 days)

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55
Q

What bugs need to be covered for acute COPD exacerbation antibiotic treatment?

A

S. pneumo, H. flu, M. catarrhalis, M. Pneumo

Similar tx to CAP (amoxicillin, augmentin, macrolides, cephalosporins, quinolones)

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56
Q

What is the #1 cause of cancer deaths in men and women?

A

Lung cancer

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57
Q

How is small cell lung cancer different than nonsmall cell, in terms of location, treatment prognosis?

A

Small Cell:
-Central, mediastinal
-Chemo
-Aggressive, early mets, poor prognosis

Nonsmall Cell:
-Peripheral
-Resection
-Better prognosis

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58
Q

What are 3 types of Nonsmall cell lung cancer?

A

40% Adenocarcinoma

25% Squamous cell

10% Large cell

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59
Q

What is the USPSTF recommendation for lung cancer screening?

A

Low dose CT annually
Ages 55-80
30 or more pack year history

Can stop when patient has quit smoking for 15 years

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60
Q

What are the risk factors for Obstructive Sleep Apnea?

A

Obesity

Sex (M > F)

Age (40+)

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61
Q

What are some consequences of OSA?

A

HTN
CVD
Sleep disturbance- daytime sleepiness
Memory problems
Weight gain
Headaches

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62
Q

What are the 3 “S”s of OSA symptoms?

A

Snoring

Sleepiness (Excessive)

Significant other complaints

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63
Q

How is OSA diagnosed?

A

Sleep study (polysomnography)

Apnea-hypoxia index

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64
Q

What is the treatment of OSA?

A

Weight loss

CAP

Nasal decongestant

Position therapy

Surgery

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65
Q

What is sarcoidosis?

A

Inflammatory auto immune disease

Usually affects lungs

Cause unknown

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66
Q

Who is more likely to get Sarcoidosis?

A

More common in African american women

Ages 20-40

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67
Q

What are the symptoms of sarcoidosis?

A

-Often asymptomatic

-Waxing and waning symptoms

-SOB, cough

-Red bumps/patches on skin

-Enlarged lymph nodes

-Fever, weight loss, night sweats, malaise

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68
Q

What is Lofgren’s syndrome?

A

Acute form of sarcoidosis

-Erythema nodosum
-Fever
-Arthritis

Self limited

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69
Q

How is sarcoidosis diagnosed?

A

Noncaseating granulomas on lung tissue biopsy

Clinical symptoms

Abnormal CXR/ CT

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70
Q

What are some non-lung related complications of sarcoidosis?

A

Anterior uveitis

Erythema nodosum

Neurosarcoidosis- intracranial lesions, peripheral neuropathy

Cardiomyopathy-granulomas

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71
Q

What is the treatment of sarcoidosis?

A

Observation- if asymptomatic, follow closely

Corticosteroids are mainstay of treatment

Methotrexate, azathioprine, chloroquine, etanercept, infliximab

Consider consulting pulmonology

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72
Q

What is Wegener’s granulomatosis?

A

Necrotizing granulomatous vasculitis

Affects upper and lower respiratory tract

Associated with focal segmental glomerulonephritis

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73
Q

Who is most likely to get Wegener’s granulomatosis?

A

Young to middle age

Males > females

Unknown cause

Fatal without treatment

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74
Q

What are the symptoms of Wegener’s granulomatosis?

A

Cough, chest pain, dyspnea, malaise

Blood in urine

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75
Q

How is Wegener’s granulomatosis diagnosed?

A

ESR

Anti-neutrophil cytoplasmic bodies (ANCA)

CBC

UA

76
Q

What is the treatment of Wegener’s granulomatosis?

A

Corticosteroids

Azathioprine, methotrexate, rituximab

Consult pulmonology and nephrology

77
Q

What are the 3 causes (routes) of community acquired pneumonia?

A

Inhalation

Aspiration

Hematogenous spread

78
Q

What are the most common pathogens that cause community acquired pneumonia?

A

Strep pneumo

Mycoplasma pneumoniae

Chlamydia pneumoniae

Haemophilus influenzae

Legionella

Moraxella catarrhalis

Viruses

MRSA

Pseudomonas aeruginosa

TB

79
Q

How is community acquired pneumonia diagnosed?

A

History, clinical picture

Chest X-ray

80
Q

What are findings of community acquired pneumonia on Chest X-ray?

A

Lobar consolidation

Effusion

Bilateral interstitial infiltrates

81
Q

After someone is diagnosed with community acquired pneumonia on chest X-ray, how often should CXR be repeated ?

A

No need to repeat if symptoms resolve within 7 days

82
Q

Besides chest X-ray, what are other other modalities used to diagnose community acquired pneumonia?

A

Ultrasound

CT

83
Q

In adults with community acquired pneumonia, should gram stain and culture of lower respiratory secretions be collected at time of diagnosis?

A

Yes if:

-Severe CAP

-Concern for MRSA or pseudomonas

-Hospitalization in the past 90 days or intubation

84
Q

In adults with community acquired pneumonia, should blood cultures be collected at time of diagnosis?

A

Yes if:

-Hospitalized for community acquired pneumonia

-On treatment for MRSA or pseudomonas

-Hospitalization in the past 90 days

85
Q

In adults with community acquired pneumonia, should legionella and pneumococcal urinary antigen testing be done at time of diagnosis?

A

No

Unless:

-Severe community acquired pneumonia

-Known local outbreak

86
Q

In adults with community acquired pneumonia, should influenza testing be done at time of diagnosis?

A

No

Unless:

-Flu is suspected

-High prevalence in the community

87
Q

In adults with community acquired pneumonia, should serum procalcitonin be used as a factor to determine antibiotic initiation?

A

No

Procalcitonin testing not recommended

Do NOT withhold antibiotics based on procalcitonin levels

88
Q

Which tool should be used to predict prognosis of community acquired pneumonia?

A

Pneumonia Severity Index

(CURB-65 is inferior)

89
Q

What is the treatment for community acquired pneumonia in an adult with no comorbidities or risk factors?

A

Amoxicillin 1 g TID

Or

Doxycycline 100 mg BID

Or

Azithromycin 500mg then 250 mg daily (only in areas of low macrolide resistance)

90
Q

What is the treatment for community acquired pneumonia in an adult with comorbidities?

A

Augmentin 875 mg BID or Cefpodoxime 200 mg BID or Cefuroxime 500 mg BID

AND

Azithromycin 500 mg then 250 mg daily or doxycycline 100 mg BID

OR

Levofloxacin 750 mg daily (Monotherapy)

91
Q

What is the standard regimen for inpatient community acquired pneumonia treatment (no risk factors)?

A

B lactam and macrolide

Or

Respiratory fluroquinolone

92
Q

What is the inpatient treatment of community acquired pneumonia if the patient has a hx of prior MRSA respiratory infection?

A

B lactam and macrolide
Or
Respiratory fluroquinolone

ADD MRSA coverage
Order blood and sputum cultures, nasal PCR

*Deescalate if negative

93
Q

What is the inpatient treatment of community acquired pneumonia in patients with prior pseudomonas respiratory infection?

A

B lactam and macrolide
Or
Respiratory fluroquinolone

ADD pseudomonas coverage
Order blood and sputum cultures

*Deescalate if negative

94
Q

What is the inpatient treatment for community acquired pneumonia in patients with recent hospitalization and parenteral antibiotics use?

A

B lactam and macrolide
Or
Respiratory fluroquinolone

Order nasal PCR, cultures

Only initiate MRSA and/or pseudomonas treatment if positive results

95
Q

What is the role of corticosteroids in the treatment of community acquired pneumonia in the inpatient setting?

A

Not indicated

96
Q

In adults with community acquired pneumonia who also test positive for influenza should treatment still include antibiotics?

A

Yes with antiviral therapy

97
Q

What is the most common pathogen for community acquired pneumonia in patients age 4 months to 4 years?

A

RSV

98
Q

What is the most common pathogen for community acquired pneumonia in patients age 5-18 years?

A

Mycoplasma pneumoniae

Tx with macrolide

99
Q

What are some risk factors for MRSA in terms of community acquired pneumonia?

A

-Hx of previous MRSA

-Hospitalization and IV antibiotics in the last 90 days

-MRSA infected wounds

-Immunocompromised

100
Q

In patients with alcoholism, what additional etiologies of community acquired pneumonia should be considered?

A

Anaerobes

Klebsiella pneumoniae

101
Q

In patients with high aspiration risk, what additional etiologies of community acquired pneumonia should be considered?

A

Anaerobes

102
Q

In patients in situations concerning for bioterrorism, what additional etiologies of community acquired pneumonia should be considered?

A

Bacillus anthracis (Anthrax)

Francisella tularensis

Yersinia pestis (Black plague)

103
Q

In patients with COPD, what additional etiologies of community acquired pneumonia should be considered?

A

H. Influenzae

M. Catarrhalis

104
Q

In patients with exposure to farm animals or animal droppings, what additional etiologies of community acquired pneumonia should be considered?

A

Histoplasma

Blastomyces

Coccidioides

105
Q

In patients with recent travel (hotels, cruise ships) in the past 2 weeks, what additional etiologies of community acquired pneumonia should be considered?

A

Legionella

106
Q

In patients with hx of influenza in the past week, what additional etiologies of community acquired pneumonia should be considered?

A

Staph aureus

107
Q

In patients with recent travel outside of the US, what additional etiologies of community acquired pneumonia should be considered?

A

Avian influenza

108
Q

What are the components of CURB-65?

A

Confusion

Uremia

Respiratory rate >30

Blood pressure SBP <90 or DBP <60

Age >65

Severe is score >2

*Not the preferred scoring tool

109
Q

Who gets the PCV13 vaccine?

A

Everyone at 2, 4, 6 months and booster at 12-15 months

Adults > 19 years need 1 dose if have CSF leaks, cochlear implants, functional asplenia, sickle cell, immunosuppression or high risk elderly

110
Q

Who gets a single dose of the PPSV 23 vaccine?

A

Everyone at >65 years

2-64 years old if:
-Chronic cardiac disease
-Cirrhosis, alcoholism
-Cochlear implants
-Cerebrospinal fluid leak
-Diabetes
-Chronic lung disease, asthma
-Tobacco use
-Residents of chronic care facilities

111
Q

Who gets 2 doses of PPSV23, 5 years apart?

A

2-64 years old if:
-Chronic renal disease
-Asplenia, sickle cell
-Immunocompromised

112
Q

If a patient needs both PCV13 and PPSV23 how should they be administered?

A

19-64 years old:
-PCV13 first then PPSV23 8 weeks later

Age >65:
-PCV13 first then PPSV23 1 year later
Or
-PPSV23 first then PCV13 1 year later

113
Q

If a high risk patient gets a dose of PPSV23 at age 64, when should their next dose of PPSV23 be given?

A

5 years after first dose

(In this example age 69)

114
Q

Who needs TB testing?

A

-Contact with TB patient
-Immunosuppressed
-People from are where TB is common
-Living in homeless shelter, jail
-Use of illicit substances
-Symptomatic (Weight loss, night sweats, hemoptysis)

115
Q

What are the types of testing for TB?

A

Tuberculin skin test
-delayed hypersensitivity reaction

Interferon gamma release assay
-Quant gold
-Measure INF-gamma released by blood cells

116
Q

What are the pro/cons of the Quant gold TB test v. The skin tuberculin test?

A

Pros:
-1 visit
-Fast, clear result
-Not affected by BCG vaccine

Cons:
-Expensive
-Need proper collection/transportation within 8-16 hours
-Limited use in kids <5 yrs, Immunocompromised, recent TB exposure

117
Q

How is a tuberculin skin test read?

A

Measure induration (not erythema) in 48-72 hours

Record finding by measurement (not positive, negative)

118
Q

Which patients are considered positive for TB if the tuberculin skin test is >5mm induration?

A

-HIV+
-Direct recent TB contact
-CXR with prior inactive TB
-Immunosuppressed patients (Prednisone >15 mg per day, TNF-alpha agonists, Organ transplant recipients

119
Q

Which patients are only considered positive for TB if the tuberculin skin test is >10mm induration?

A

-Diabetic
-Renal failure
-Cancer
-Recent immigrant in the past 5 years from a high risk country
-Resident or employee from a long term care facility
-Inmate
-IV drug user
-Kids <4 years old
-Mycobacteriology lab personnel

120
Q

Which patients are only considered positive for TB if the tuberculin skin test is >15mm induration?

A

People with no known risk factors

121
Q

What is the next step in work up if a patient has a positive tuberculin skin test or quant gold test?

A

Order CXR to look for active disease

122
Q

What is the treatment if an adult patient has a positive tuberculin skin test or quant gold test and the CXR is negative?

A

Patient has latent TB

-Once weekly isoniazid and rifampentine for 12 weeks (no longer need isoniazid for 9 months)
-Treatment can be self-administered or directly observed

**For Kids 2-11 years old treatment is isoniazid daily or twice weekly for 9 months

123
Q

What is the treatment if a patient has a positive tuberculin skin test or quant gold test and the CXR is positive?

A

Active TB

Four drug therapy:
-Rifampin
-Isoniazid
-Pyrazinamide
-Ethambutol

124
Q

What is the post treatment follow up for patients with latent or active TB?

A

No indication for serial or repeat CXRs unless new symptoms develop

Provide patient will documentation of positive test, CXR, treatment course to provide in case of future testing

125
Q

What are the treatment options for influenza?

A

Oseltamivir (Tamiflu)
Zanamivir (Relenza)
Peramavir (Rapivab)
Xoflusa

126
Q

Which conditions are contraindicated for Zanamivir use?

A

COPD and asthma due to bronchoconstriction

127
Q

Which opportunistic fungal lung infections are more common in immunocompromised patients?

A

Aspergillosis

Candidiasis

128
Q

Which fungal lung infection is more common in the Mississippi/Ohio river valley?

A

Histoplasmosis

Blastomycosis

129
Q

Which fungal lung infection is more common in the Southwest?

A

Coccidioidomycosis

130
Q

How might a fungal lung infection present?

A

Often asymptomatic

Fever, cough

Incidental findings of pulmonary nodules

131
Q

What is the treatment for for fungal lung infections?

A

Not necessary if endemic mycoses

Treat if immunocompromised or symptomatic

132
Q

What is the physiology of asthma?

A

Chronic airway inflammation

Bronchial hyperactivity

Airflow limitation due to bronchiolar obstruction and airway remodeling

133
Q

What is the atopic triad?

A

Genetic IgE mediated immune response

Atopic dermatitis, Allergic rhinitis, Asthma

134
Q

What medications can trigger Asthma?

A

ASA
NSAIDs
Beta Blockers

135
Q

What is the differential diagnoses for wheezing?

A

Asthma
COPD
GERD
Pneumothorax
Pulmonary embolism
Vocal cord dysfunction
Pulmonary edema
Endobronchial obstruction
Acute hypersensitivity pneumonitis
Epiglottitis

136
Q

Compare COPD and Asthma:
Presence of chronic cough and sputum

A

COPD: Very common

Asthma: Variable

137
Q

Compare COPD and Asthma:
Dyspnea on exertion, poor lung function

A

COPD: Persistent

Asthma: Intermittent, reversible

138
Q

Compare COPD and Asthma:
Onset prior to age 40 years

A

COPD: Uncommon

Asthma: Common

139
Q

Compare COPD and Asthma:
History of tobacco use

A

COPD: Almost always

Asthma: Sometimes

140
Q

Compare COPD and Asthma:
Airway hyper-responsiveness

A

COPD: Common

Asthma: Always

141
Q

Compare COPD and Asthma:
Progression

A

COPD: slow progression, little variability in symptoms

Asthma: Episodic and variable symptoms

142
Q

Compare COPD and Asthma:
Identifiable triggers

A

COPD: Uncommon

Asthma: Common

143
Q

Compare COPD and Asthma:
Bronchodilator response

A

COPD: low to none

Asthma: Often strong response

144
Q

What is the best way to diagnose asthma?

A

History and Physical exam

Pulmonary function test

Assess treatment affect

Repeat PFTs periodically

145
Q

In children younger than 5 years, how is asthma diagnosed?

A

History and Physical exam

Therapeutic trial of medication

146
Q

What spirometry changes are commonly seen in asthma? (FEV1, TLC, FRC, reversibility)

A

FEV1: normal to decreased (<80% of predicted)

TLC: normal to elevated

FRC: usually elevated

After SABA: Airway reversibility changes by at least 12%, FEV1 changes by at least 200mL

147
Q

What are some risk factors for poor outcomes in patients with asthma?

A

Inhaler use: improper technique, poor compliance, not on ICS, frequent rescue inhaler use

Low FEV1 (<60% predicted)

Smoking, allergen exposure

Low SES

Co-morbidities: Obesity, chronic sinusitis, allergies

Eosinophilia

Elevated fractional exhaled nitric oxide (FENO) >50ppb

148
Q

Define mild intermittent asthma

A

Symptoms less than 2 times per week

Nocturnal symptoms less than 2 times per month

149
Q

Define mild persistent asthma

A

Symptoms more than 2 times per week, but not daily

May affect activity

Nocturnal symptoms more than 2 times per month

150
Q

Define moderate persistent asthma

A

Daily symptoms, daily use of SABA

Affects activity and can last several days

Nocturnal symptoms more than 2 times per week

151
Q

Define severe persistent asthma

A

Continual symptoms

Limited activity

Frequent nocturnal symptoms

152
Q

Treatment for upper airway symptoms in patients with asthma?

(nasal congestion, clear nasal discharge, sneezing, itching)

A

Avoid allergens

First line: Intranasal corticosteroids (fluticasone)

Second line: Antihistamines, leukotriene modulators, immunotherapy

*Reducing upper airway inflammation may protect lower airway

153
Q

What are the long term risks of inhaled corticosteroid use in children?

A

NO clinically significant or irreversible effect on growth, bone mineral density or adrenal/pituitary axis

ICS improve health outcomes (benefits outweigh small risks)

154
Q

What is the role of inhaled corticosteroids in early intervention and progression of asthma?

A

Early intervention likely improves overall asthma management

Effects on preventing irreversible airway injury is undetermined

155
Q

What is the role of long acting beta 2 agonists in asthma treatment?

A

Used in combination with inhaled corticosteroids for control of moderate to severe asthma

*Not to be used as monotherapy

156
Q

What is the role of inhaled cromolyn in asthma treatment?

A

An alternative treatment for mild persistent asthma

157
Q

What is the role of Leukotriene modifiers in asthma treatment?

A

An alternative treatment for persistent asthma

158
Q

Which biologics can be used in asthma treatment?

A

Omalizumab (anti-IgE)

Mepolizumab or
Reslizumab (anti-IL5)

159
Q

What are the risks of only using short acting beta 2 agonists (albuterol) for control of asthma symptoms?

A

-Downregulation of beta receptors

-Decreased bronchoprotection and rebound hyperresponsiveness

-Decreased bronchodilator response

-Increased allergic response, eosinophilic airway inflammation

-Higher risk of ED presentations and death

160
Q

What is Step 1 and 2 therapy for asthma treatment in adults (12+)?

A

GINA Steps 1&2: PRN low dose ICS- formoterol

NHLBI
Step 1: PRN SABA
Step 2: Daily low dose ICS and PRN SABA or PRN ICS and SABA

161
Q

What is Step 3 therapy for asthma treatment in adults (12+)?

A

GINA & NHLBI:

Daily and PRN low dose ICS-formoterol

or

Daily medium dose ICS daily and PRN SABA

or

Daily low dose ICS- LABA

162
Q

What is Step 4 therapy for asthma treatment in adults (12+)?

A

GINA and NHLBI:

Daily and PRN medium dose ICS - formoterol

or

Medium/High dose ICS- LABA

163
Q

What is Step 5 therapy for asthma treatment in adults (12+)?

A

GINA and NHLBI:

Daily and PRN medium dose ICS - formoterol and LAMA

or

Medium/High dose ICS- LABA and LAMA

164
Q

How should stepwise therapy for asthma be adjusted?

A
  1. Assess compliance, correct inhaler use
  2. Assess comorbid conditions
  3. If needed go up to next step in therapy, reassess in 2-6 weeks
  4. If symptoms controlled for 3 months, consider stepping down on therapy

*Do not stop ICS completely

165
Q

In treating asthma, What inhalers can be used as relievers?

A

Low dose ICS-formoterol

SABA (Albuterol)

166
Q

What is Step 1 therapy for asthma treatment in kids 5 or 6 to 11?

A

GINA: PRN SABA with low dose ICS

NHLBI: PRN SABA

167
Q

What is Step 2 therapy for asthma treatment in kids 5 or 6 to 11?

A

GINA &NHLBI: Daily low dose ICS and PRN SABA

NHLBI:

168
Q

What is Step 3 therapy for asthma treatment in kids 5 or 6 to 11?

A

GINA: low dose ICS-LABA, medium dose ICS or very low dose ICS-formoterol

NHLBI: Daily and PRN low dose ICS-formoterol

169
Q

What is Step 4 therapy for asthma treatment in kids 5 or 6 to 11?

A

GINA: Medium dose ICS-LABA or daily and PRN low dose ICS-formoterol

NHLBI: Daily and PRN medium dose ICS- formoterol

170
Q

What is Step 5 therapy for asthma treatment in kids 5 or 6 to 11?

A

GINA: Higher dose ICS- formoterol

NHLBI: High dose ICS-LABA and PRN albuterol

171
Q

How may acute asthma exacerbation present?

A

Peak expiratory flow <50% predicted normal

No response to SABA

-Anxiety
-Gasping for air
-Diaphoretic
-Cyanotic
-Rapid deterioration
-Retractions, nasal flaring, leaning forward

172
Q

What are some risk factors for increased risk of death from asthma based on patient’s history?

A

Hx of severe exacerbations with intubation

Prior ICU admission for asthma

ER visit for asthma in the past year

Current or recent use of systemic steroids

Not using ICS

Hx of psych illness, social issues

Using more than 1 SABA inhaler per month

Poor compliance

173
Q

What are some risk factors for increased risk of death from asthma based on physical exam?

A

Altered mental status

Silent chest - no wheezing/breath sounds heard

Paradoxical chest or abdomen movement

PaCO2 > 42 mm Hg

FEV1 < 40% predicted after initial treatment

174
Q

How are asthma exacerbations treated?

A

Oxygen

SABA by MDI or nebulizer (continuous > intermittent)

Systemic steroids (oral or IV)

Inhaled ipratropium

175
Q

What treatments are not recommended for asthma exacerbation treatment?

A

Methylxanthines

Chest PT

Mucolytics

Sedation

176
Q

What is the role of antibiotics in treating asthma exacerbation?

A

Only use if:
-Fever
-Purulent sputum
-CXR with evidence of PNA

*Aggressive steroid treatment should be used before considering antibiotics

177
Q

What is exercise-induced bronchoconstriction?

A

Caused by dry air, cold air, ozone and/or particulates

Occurs in 90% of patients with asthma and 10% of athletes

178
Q

How is exercise induced bronchoconstriction diagnosed?

A

Spirometry

10% decrease in FEV1 after exercise

179
Q

How is exercise induced bronchoconstriction treated?

A

Pre-exercise treatment with ICS-formoterol

Use low dose ICS daily

LABA no longer recommended

180
Q

How is Asthma COPD overlap syndrome treated?

A

Treat towards predominant symptoms

-Asthma: Emphasis on ICS, no LABA monotherapy

-COPD: Emphasis on combination bronchodilators, no ICS monotherapy

Smoking cessation, Pulmonary rehab, Vaccinations, Treatment of comorbidities

181
Q

What are the goals of asthma therapy?

A

Minimal or no:
-Chronic day or night symptoms

-Exacerbations

-Limitations on activity

-Adverse medication effects

-SABA use

Maintain near normal pulmonary function

182
Q

How does asthma change in pregnancy?

A

Variable, may get better, worse or unchanged

183
Q

What are the increased risks of asthma in pregnancy?

A

Perinatal mortality

Preeclampsia

IUGR

Preterm birth

Low birth weight

184
Q

Low birth weight infant are at greater risk for what conditions later in life?

A

Diabetes

Hypertension

Heart Disease

185
Q

How is asthma treated during pregnancy?

A

Albuterol and budesonide are preferred

LABA should not be used as monotherapy

Treat allergic rhinitis, sinusitis or GERD if present

Avoid allergens, irritants

186
Q

Can theophylline be used to treat asthma in pregnancy?

A

Yes at serum concentrations of 5-12 mcg/mL

Monitor side effects closely

01 Family Medicine (16 decks)

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