Pulmonolgy Flashcards
43,44,45
1
Q
What is COPD (4 words)?
A
Chronic
Progressive
Airway
Obstruction
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
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
4
Q
What are the hallmark symptoms of COPD?
A
Cough
Dyspnea
Chronic sputum production
Wheezing
Recurrent respiratory infections
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
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
7
Q
What is the main test for evaluation COPD?
A
Spirometry to:
-confirm diagnosis
-Measure obstruction severity
-Monitor progression, response to therapy
8
Q
In spirometry what is FEV1?
A
Volume of air expired in one second after a full inspiration
9
Q
In spirometry what is FVC?
A
Maximum volume of air exhaled after a full inspiration
10
Q
What is the best spirometric criterion to diagnose COPD?
A
FEV1/FVC ratio < 0.70, post-bronchodilator
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
12
Q
How can you distinguish COPD from asthma on spirometry?
A
COPD shows no improvement with bronchodilation
(aka not reversible)
13
Q
How is COPD classified?
A
Gold Staging based on FEV1
*Must have FEV1/FVC ratio less than 0.7, after bronchodilation
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
15
Q
How are COPD symptoms assessed?
A
-Patient reporting- COPD Assessment Test (CAT)
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
17
Q
Which cardiovascular disease are patients with COPD at higher risk for?
A
Atrial fibrillation
18
Q
What co-morbidity is an independent risk factor for COPD exacerbations?
A
GERD
19
Q
How often should spirometry be done to monitor patients with COPD?
A
Repeat every year or if a sudden decline in status
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
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)
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
23
Q
What is the role of E cigarettes in tobacco cessation?
A
Effectiveness and safety unproven
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
25
What is the second step of COPD treatment?
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
26
What is the third step of COPD treatment?
Combination therapy
LAMA/LABA (preferred)
-improved lung function, quality of life. Reduce exacerbations
or
LABA/ICS
27
COPD treatment by ABCD groups?
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
28
Name some LAMA/LABA combination medications
Stiolto (tiotropium/olodaterol)
Bevespi (glycopyrrolate/formoterol)
*Just some examples, there are others
29
What is the role of corticosteroids in COPD?
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
30
Which category of medications has a greater effect on COPD exacerbation reduction and decreased hospitalizations, LAMAs or LABAs?
LAMAs
31
Which category of medications has the highest increase in FEV1 and reduces more symptoms of COPD, LAMAs or LABAs?
Combined LAMA/LABAs
*Better combined than monotherapy
32
Which combination therapy reduces more COPD exacerbations, LAMA/LABA or LABA/ICS?
LAMA/LABA
33
Is there any benefit in triple inhaled therapy v. combined double therapy in COPD management?
Triple therapy (LAMA/LABA/ICS), improves lung function, reduces exacerbations more than ICS/LABA or LAMA/LABA
34
What is the role of steroids in long term treatment of COPD?
35
What is the role of theophyline in COPD treatment?
Not recommended!
limited evidence of benefit- high toxicity
36
What is the role of PDE4 inhibitors (Roflumilast) in COPD treatment?
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
37
What is an over the counter medication to reduce the risk of COPD exacerbations?
N-acetylecystine, mucolytics
Loosens phlegm
38
What is the role of Azithromycin in COPD management?
Long term use can reduce exacerbations (250mg/day) in high risk patients
Associated with bacterial resistance, hearing impairment, prolonged QT
39
What is the indication for supplemental oxygen in COPD treatment?
O2 sat <88% at rest
40
What is the indication for pulmonary rehabilitation in COPD treatment?
For all stages of COPD
Exercise training, education, nutrition, psychosocial support
Improves symptoms, exercise tolerance
Reduces hospitalizations, anxiety, depression
41
What is one important factor to keep in mind when prescribing inhalers?
Ensure correct inhaler technique
42
What is the role of antitussives and vasodilators in COPD management?
Not helpful
43
What are the goals of COPD management?
Reduce symptoms
-Improve exercise tolerance and health status, relieve dyspnea
Reduce risk
-Prevent progression and exacerbations, prolong life
44
How is COPD classified based on the GOLD ABCD criteria?
45
COPD differential diagnoses?
Asthma
CHF
Lung cancer
Interstitial lung disease/fibrosis
Bronchiectasis
Sarcoidosis
TB/pulmonary infections
Bronchopulmonary dysplasia
46
What is the most common cause of Acute COPD exacerbations?
URI: viral or bacterial
47
What should be ordered in the work up of acute COPD exacerbation?
ABG/VBG
CXR or US
EKG
CBC, CMP
*spirometry not recommended
48
What is the treatment of mild acute COPD exacerbation?
SABA
49
What is the treatment of moderate acute COPD exacerbation?
SABA
plus
Antibiotics +/- oral steroids
50
What is the treatment of severe acute COPD exacerbation?
Hospitalization or ED eval needed
51
What are indications to admit a patient for COPD exacerbation?
-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
52
What are the treatment options for acute COPD exacerbations?
Oxygen: titrate to goal of 88-92%
Bronchodilators: SABA +/- anticholinergics
Corticosteroids: Prednisone 40 mg PO for 5 days
53
When should antibiotics be added for treatment of acute COPD exacerbation?
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
54
What is the role of systemic steroids in COPD exacerbation?
Improve lung function and oxygenation
Shorten recovery and hospital stays
*Treat for 5-7 days (Prednisone 20 mg BID for 5 days)
55
What bugs need to be covered for acute COPD exacerbation antibiotic treatment?
S. pneumo, H. flu, M. catarrhalis, M. Pneumo
Similar tx to CAP (amoxicillin, augmentin, macrolides, cephalosporins, quinolones)
56
What is the #1 cause of cancer deaths in men and women?
Lung cancer
57
How is small cell lung cancer different than nonsmall cell, in terms of location, treatment prognosis?
Small Cell:
-Central, mediastinal
-Chemo
-Aggressive, early mets, poor prognosis
Nonsmall Cell:
-Peripheral
-Resection
-Better prognosis
58
What are 3 types of Nonsmall cell lung cancer?
40% Adenocarcinoma
25% Squamous cell
10% Large cell
59
What is the USPSTF recommendation for lung cancer screening?
Low dose CT annually
Ages 55-80
30 or more pack year history
Can stop when patient has quit smoking for 15 years
60
What are the risk factors for Obstructive Sleep Apnea?
Obesity
Sex (M > F)
Age (40+)
61
What are some consequences of OSA?
HTN
CVD
Sleep disturbance- daytime sleepiness
Memory problems
Weight gain
Headaches
62
What are the 3 "S"s of OSA symptoms?
Snoring
Sleepiness (Excessive)
Significant other complaints
63
How is OSA diagnosed?
Sleep study (polysomnography)
Apnea-hypoxia index
64
What is the treatment of OSA?
Weight loss
CAP
Nasal decongestant
Position therapy
Surgery
65
What is sarcoidosis?
Inflammatory auto immune disease
Usually affects lungs
Cause unknown
66
Who is more likely to get Sarcoidosis?
More common in African american women
Ages 20-40
67
What are the symptoms of sarcoidosis?
-Often asymptomatic
-Waxing and waning symptoms
-SOB, cough
-Red bumps/patches on skin
-Enlarged lymph nodes
-Fever, weight loss, night sweats, malaise
68
What is Lofgren's syndrome?
Acute form of sarcoidosis
-Erythema nodosum
-Fever
-Arthritis
Self limited
69
How is sarcoidosis diagnosed?
Noncaseating granulomas on lung tissue biopsy
Clinical symptoms
Abnormal CXR/ CT
70
What are some non-lung related complications of sarcoidosis?
Anterior uveitis
Erythema nodosum
Neurosarcoidosis- intracranial lesions, peripheral neuropathy
Cardiomyopathy-granulomas
71
What is the treatment of sarcoidosis?
Observation- if asymptomatic, follow closely
Corticosteroids are mainstay of treatment
Methotrexate, azathioprine, chloroquine, etanercept, infliximab
Consider consulting pulmonology
72
What is Wegener's granulomatosis?
Necrotizing granulomatous vasculitis
Affects upper and lower respiratory tract
Associated with focal segmental glomerulonephritis
73
Who is most likely to get Wegener's granulomatosis?
Young to middle age
Males > females
Unknown cause
Fatal without treatment
74
What are the symptoms of Wegener's granulomatosis?
Cough, chest pain, dyspnea, malaise
Blood in urine
75
How is Wegener's granulomatosis diagnosed?
ESR
Anti-neutrophil cytoplasmic bodies (ANCA)
CBC
UA
76
What is the treatment of Wegener's granulomatosis?
Corticosteroids
Azathioprine, methotrexate, rituximab
Consult pulmonology and nephrology
77
What are the 3 causes (routes) of community acquired pneumonia?
Inhalation
Aspiration
Hematogenous spread
78
What are the most common pathogens that cause community acquired pneumonia?
Strep pneumo
Mycoplasma pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Legionella
Moraxella catarrhalis
Viruses
MRSA
Pseudomonas aeruginosa
TB
79
How is community acquired pneumonia diagnosed?
History, clinical picture
Chest X-ray
80
What are findings of community acquired pneumonia on Chest X-ray?
Lobar consolidation
Effusion
Bilateral interstitial infiltrates
81
After someone is diagnosed with community acquired pneumonia on chest X-ray, how often should CXR be repeated ?
No need to repeat if symptoms resolve within 7 days
82
Besides chest X-ray, what are other other modalities used to diagnose community acquired pneumonia?
Ultrasound
CT
83
In adults with community acquired pneumonia, should gram stain and culture of lower respiratory secretions be collected at time of diagnosis?
Yes if:
-Severe CAP
-Concern for MRSA or pseudomonas
-Hospitalization in the past 90 days or intubation
84
In adults with community acquired pneumonia, should blood cultures be collected at time of diagnosis?
Yes if:
-Hospitalized for community acquired pneumonia
-On treatment for MRSA or pseudomonas
-Hospitalization in the past 90 days
85
In adults with community acquired pneumonia, should legionella and pneumococcal urinary antigen testing be done at time of diagnosis?
No
Unless:
-Severe community acquired pneumonia
-Known local outbreak
86
In adults with community acquired pneumonia, should influenza testing be done at time of diagnosis?
No
Unless:
-Flu is suspected
-High prevalence in the community
87
In adults with community acquired pneumonia, should serum procalcitonin be used as a factor to determine antibiotic initiation?
No
Procalcitonin testing not recommended
Do NOT withhold antibiotics based on procalcitonin levels
88
Which tool should be used to predict prognosis of community acquired pneumonia?
Pneumonia Severity Index
(CURB-65 is inferior)
89
What is the treatment for community acquired pneumonia in an adult with no comorbidities or risk factors?
Amoxicillin 1 g TID
Or
Doxycycline 100 mg BID
Or
Azithromycin 500mg then 250 mg daily (only in areas of low macrolide resistance)
90
What is the treatment for community acquired pneumonia in an adult with comorbidities?
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
What is the standard regimen for inpatient community acquired pneumonia treatment (no risk factors)?
B lactam and macrolide
Or
Respiratory fluroquinolone
92
What is the inpatient treatment of community acquired pneumonia if the patient has a hx of prior MRSA respiratory infection?
B lactam and macrolide
Or
Respiratory fluroquinolone
ADD MRSA coverage
Order blood and sputum cultures, nasal PCR
*Deescalate if negative
93
What is the inpatient treatment of community acquired pneumonia in patients with prior pseudomonas respiratory infection?
B lactam and macrolide
Or
Respiratory fluroquinolone
ADD pseudomonas coverage
Order blood and sputum cultures
*Deescalate if negative
94
What is the inpatient treatment for community acquired pneumonia in patients with recent hospitalization and parenteral antibiotics use?
B lactam and macrolide
Or
Respiratory fluroquinolone
Order nasal PCR, cultures
Only initiate MRSA and/or pseudomonas treatment if positive results
95
What is the role of corticosteroids in the treatment of community acquired pneumonia in the inpatient setting?
Not indicated
96
In adults with community acquired pneumonia who also test positive for influenza should treatment still include antibiotics?
Yes with antiviral therapy
97
What is the most common pathogen for community acquired pneumonia in patients age 4 months to 4 years?
RSV
98
What is the most common pathogen for community acquired pneumonia in patients age 5-18 years?
Mycoplasma pneumoniae
Tx with macrolide
99
What are some risk factors for MRSA in terms of community acquired pneumonia?
-Hx of previous MRSA
-Hospitalization and IV antibiotics in the last 90 days
-MRSA infected wounds
-Immunocompromised
100
In patients with alcoholism, what additional etiologies of community acquired pneumonia should be considered?
Anaerobes
Klebsiella pneumoniae
101
In patients with high aspiration risk, what additional etiologies of community acquired pneumonia should be considered?
Anaerobes
102
In patients in situations concerning for bioterrorism, what additional etiologies of community acquired pneumonia should be considered?
Bacillus anthracis (Anthrax)
Francisella tularensis
Yersinia pestis (Black plague)
103
In patients with COPD, what additional etiologies of community acquired pneumonia should be considered?
H. Influenzae
M. Catarrhalis
104
In patients with exposure to farm animals or animal droppings, what additional etiologies of community acquired pneumonia should be considered?
Histoplasma
Blastomyces
Coccidioides
105
In patients with recent travel (hotels, cruise ships) in the past 2 weeks, what additional etiologies of community acquired pneumonia should be considered?
Legionella
106
In patients with hx of influenza in the past week, what additional etiologies of community acquired pneumonia should be considered?
Staph aureus
107
In patients with recent travel outside of the US, what additional etiologies of community acquired pneumonia should be considered?
Avian influenza
108
What are the components of CURB-65?
Confusion
Uremia
Respiratory rate >30
Blood pressure SBP <90 or DBP <60
Age >65
Severe is score >2
*Not the preferred scoring tool
109
Who gets the PCV13 vaccine?
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
Who gets a single dose of the PPSV 23 vaccine?
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
Who gets 2 doses of PPSV23, 5 years apart?
2-64 years old if:
-Chronic renal disease
-Asplenia, sickle cell
-Immunocompromised
112
If a patient needs both PCV13 and PPSV23 how should they be administered?
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
If a high risk patient gets a dose of PPSV23 at age 64, when should their next dose of PPSV23 be given?
5 years after first dose
(In this example age 69)
114
Who needs TB testing?
-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
What are the types of testing for TB?
Tuberculin skin test
-delayed hypersensitivity reaction
Interferon gamma release assay
-Quant gold
-Measure INF-gamma released by blood cells
116
What are the pro/cons of the Quant gold TB test v. The skin tuberculin test?
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
How is a tuberculin skin test read?
Measure induration (not erythema) in 48-72 hours
Record finding by measurement (not positive, negative)
118
Which patients are considered positive for TB if the tuberculin skin test is >5mm induration?
-HIV+
-Direct recent TB contact
-CXR with prior inactive TB
-Immunosuppressed patients (Prednisone >15 mg per day, TNF-alpha agonists, Organ transplant recipients
119
Which patients are only considered positive for TB if the tuberculin skin test is >10mm induration?
-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
Which patients are only considered positive for TB if the tuberculin skin test is >15mm induration?
People with no known risk factors
121
What is the next step in work up if a patient has a positive tuberculin skin test or quant gold test?
Order CXR to look for active disease
122
What is the treatment if an adult patient has a positive tuberculin skin test or quant gold test and the CXR is negative?
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
What is the treatment if a patient has a positive tuberculin skin test or quant gold test and the CXR is positive?
Active TB
Four drug therapy:
-Rifampin
-Isoniazid
-Pyrazinamide
-Ethambutol
124
What is the post treatment follow up for patients with latent or active TB?
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
What are the treatment options for influenza?
Oseltamivir (Tamiflu)
Zanamivir (Relenza)
Peramavir (Rapivab)
Xoflusa
126
Which conditions are contraindicated for Zanamivir use?
COPD and asthma due to bronchoconstriction
127
Which opportunistic fungal lung infections are more common in immunocompromised patients?
Aspergillosis
Candidiasis
128
Which fungal lung infection is more common in the Mississippi/Ohio river valley?
Histoplasmosis
Blastomycosis
129
Which fungal lung infection is more common in the Southwest?
Coccidioidomycosis
130
How might a fungal lung infection present?
Often asymptomatic
Fever, cough
Incidental findings of pulmonary nodules
131
What is the treatment for for fungal lung infections?
Not necessary if endemic mycoses
Treat if immunocompromised or symptomatic
132
What is the physiology of asthma?
Chronic airway inflammation
Bronchial hyperactivity
Airflow limitation due to bronchiolar obstruction and airway remodeling
133
What is the atopic triad?
Genetic IgE mediated immune response
Atopic dermatitis, Allergic rhinitis, Asthma
134
What medications can trigger Asthma?
ASA
NSAIDs
Beta Blockers
135
What is the differential diagnoses for wheezing?
Asthma
COPD
GERD
Pneumothorax
Pulmonary embolism
Vocal cord dysfunction
Pulmonary edema
Endobronchial obstruction
Acute hypersensitivity pneumonitis
Epiglottitis
136
Compare COPD and Asthma:
Presence of chronic cough and sputum
COPD: Very common
Asthma: Variable
137
Compare COPD and Asthma:
Dyspnea on exertion, poor lung function
COPD: Persistent
Asthma: Intermittent, reversible
138
Compare COPD and Asthma:
Onset prior to age 40 years
COPD: Uncommon
Asthma: Common
139
Compare COPD and Asthma:
History of tobacco use
COPD: Almost always
Asthma: Sometimes
140
Compare COPD and Asthma:
Airway hyper-responsiveness
COPD: Common
Asthma: Always
141
Compare COPD and Asthma:
Progression
COPD: slow progression, little variability in symptoms
Asthma: Episodic and variable symptoms
142
Compare COPD and Asthma:
Identifiable triggers
COPD: Uncommon
Asthma: Common
143
Compare COPD and Asthma:
Bronchodilator response
COPD: low to none
Asthma: Often strong response
144
What is the best way to diagnose asthma?
History and Physical exam
Pulmonary function test
Assess treatment affect
Repeat PFTs periodically
145
In children younger than 5 years, how is asthma diagnosed?
History and Physical exam
Therapeutic trial of medication
146
What spirometry changes are commonly seen in asthma? (FEV1, TLC, FRC, reversibility)
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
What are some risk factors for poor outcomes in patients with asthma?
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
Define mild intermittent asthma
Symptoms less than 2 times per week
Nocturnal symptoms less than 2 times per month
149
Define mild persistent asthma
Symptoms more than 2 times per week, but not daily
May affect activity
Nocturnal symptoms more than 2 times per month
150
Define moderate persistent asthma
Daily symptoms, daily use of SABA
Affects activity and can last several days
Nocturnal symptoms more than 2 times per week
151
Define severe persistent asthma
Continual symptoms
Limited activity
Frequent nocturnal symptoms
152
Treatment for upper airway symptoms in patients with asthma?
(nasal congestion, clear nasal discharge, sneezing, itching)
Avoid allergens
First line: Intranasal corticosteroids (fluticasone)
Second line: Antihistamines, leukotriene modulators, immunotherapy
*Reducing upper airway inflammation may protect lower airway
153
What are the long term risks of inhaled corticosteroid use in children?
NO clinically significant or irreversible effect on growth, bone mineral density or adrenal/pituitary axis
ICS improve health outcomes (benefits outweigh small risks)
154
What is the role of inhaled corticosteroids in early intervention and progression of asthma?
Early intervention likely improves overall asthma management
Effects on preventing irreversible airway injury is undetermined
155
What is the role of long acting beta 2 agonists in asthma treatment?
Used in combination with inhaled corticosteroids for control of moderate to severe asthma
*Not to be used as monotherapy
156
What is the role of inhaled cromolyn in asthma treatment?
An alternative treatment for mild persistent asthma
157
What is the role of Leukotriene modifiers in asthma treatment?
An alternative treatment for persistent asthma
158
Which biologics can be used in asthma treatment?
Omalizumab (anti-IgE)
Mepolizumab or
Reslizumab (anti-IL5)
159
What are the risks of only using short acting beta 2 agonists (albuterol) for control of asthma symptoms?
-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
What is Step 1 and 2 therapy for asthma treatment in adults (12+)?
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
What is Step 3 therapy for asthma treatment in adults (12+)?
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
What is Step 4 therapy for asthma treatment in adults (12+)?
GINA and NHLBI:
Daily and PRN medium dose ICS - formoterol
or
Medium/High dose ICS- LABA
163
What is Step 5 therapy for asthma treatment in adults (12+)?
GINA and NHLBI:
Daily and PRN medium dose ICS - formoterol and LAMA
or
Medium/High dose ICS- LABA and LAMA
164
How should stepwise therapy for asthma be adjusted?
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
In treating asthma, What inhalers can be used as relievers?
Low dose ICS-formoterol
SABA (Albuterol)
166
What is Step 1 therapy for asthma treatment in kids 5 or 6 to 11?
GINA: PRN SABA with low dose ICS
NHLBI: PRN SABA
167
What is Step 2 therapy for asthma treatment in kids 5 or 6 to 11?
GINA &NHLBI: Daily low dose ICS and PRN SABA
NHLBI:
168
What is Step 3 therapy for asthma treatment in kids 5 or 6 to 11?
GINA: low dose ICS-LABA, medium dose ICS or very low dose ICS-formoterol
NHLBI: Daily and PRN low dose ICS-formoterol
169
What is Step 4 therapy for asthma treatment in kids 5 or 6 to 11?
GINA: Medium dose ICS-LABA or daily and PRN low dose ICS-formoterol
NHLBI: Daily and PRN medium dose ICS- formoterol
170
What is Step 5 therapy for asthma treatment in kids 5 or 6 to 11?
GINA: Higher dose ICS- formoterol
NHLBI: High dose ICS-LABA and PRN albuterol
171
How may acute asthma exacerbation present?
Peak expiratory flow <50% predicted normal
No response to SABA
-Anxiety
-Gasping for air
-Diaphoretic
-Cyanotic
-Rapid deterioration
-Retractions, nasal flaring, leaning forward
172
What are some risk factors for increased risk of death from asthma based on patient's history?
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
What are some risk factors for increased risk of death from asthma based on physical exam?
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
How are asthma exacerbations treated?
Oxygen
SABA by MDI or nebulizer (continuous > intermittent)
Systemic steroids (oral or IV)
Inhaled ipratropium
175
What treatments are not recommended for asthma exacerbation treatment?
Methylxanthines
Chest PT
Mucolytics
Sedation
176
What is the role of antibiotics in treating asthma exacerbation?
Only use if:
-Fever
-Purulent sputum
-CXR with evidence of PNA
*Aggressive steroid treatment should be used before considering antibiotics
177
What is exercise-induced bronchoconstriction?
Caused by dry air, cold air, ozone and/or particulates
Occurs in 90% of patients with asthma and 10% of athletes
178
How is exercise induced bronchoconstriction diagnosed?
Spirometry
10% decrease in FEV1 after exercise
179
How is exercise induced bronchoconstriction treated?
Pre-exercise treatment with ICS-formoterol
Use low dose ICS daily
LABA no longer recommended
180
How is Asthma COPD overlap syndrome treated?
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
What are the goals of asthma therapy?
Minimal or no:
-Chronic day or night symptoms
-Exacerbations
-Limitations on activity
-Adverse medication effects
-SABA use
Maintain near normal pulmonary function
182
How does asthma change in pregnancy?
Variable, may get better, worse or unchanged
183
What are the increased risks of asthma in pregnancy?
Perinatal mortality
Preeclampsia
IUGR
Preterm birth
Low birth weight
184
Low birth weight infant are at greater risk for what conditions later in life?
Diabetes
Hypertension
Heart Disease
185
How is asthma treated during pregnancy?
Albuterol and budesonide are preferred
LABA should not be used as monotherapy
Treat allergic rhinitis, sinusitis or GERD if present
Avoid allergens, irritants
186
Can theophylline be used to treat asthma in pregnancy?
Yes at serum concentrations of 5-12 mcg/mL
Monitor side effects closely
