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*Pance Re-Up * > Pulmonology #1 (Obstructive Diseases) > Flashcards

Pulmonology #1 (Obstructive Diseases) Flashcards

1
Q

What are two risk factors for chronic obstructive pulmonary disease (COPD)?

What two conditions does this umbrella include?

A

Smoking***
Alpha-1-Antitrypsin Deficiency (suspect if COPD and younger than 40 years old)

Emphysema and Chronic Bronchitis

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2
Q

Explain emphysema pathophysiology

A

-Destruction of alveoli –> enlargement of terminal airspaces

-Alveolar capillary destruction + alveolar wall destructions leads to loss of surface area so oxygen exchange cannot occur as much
-Loss of elastic recoil –> airway collapse –> difficulty getting air out (expiration) –> pursed lips, tripod positioning to push air out

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3
Q

In emphysema, the patient likely has retained ______ because they cannot push it out.

This leads to a _____ defect. Explain this.

A

Retained Co2 because they cannot push it out

V/Q Mismatch: have oxygen problem, but the body compensates by decreasing CO –> less blood –> increases RR. They can still become oxygenated and have no cyanosis.

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4
Q

Explain the two types of emphysema and how they differ in WHO they occur in, WHAT they affect, and WHERE they affect.

A

Centrilobar: MC in smokers (C for cigarettes); proximal alveoli involved because smoke can’t make it distally. Upper lobes of lungs.

Panacinar: MC in alpha-1-antitrypsin deficiency (A1 sauce in pan). Entire acinus affected. Lower lobes of lungs.

Think “CP”

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5
Q

Symptoms of emphysema (also explain what they look like)

A

-Dyspnea (initially with exertion then at rest)
-Prolonged expiration
-Pursed lip and tripod position
-Chronic cough
-Hyperinflation: decreased breath sounds, increased AP diameter (barrel chest), hyper resonance to percussion, wheezing
-Non cyanotic
-Muscle wasting (cachetic), thin

Pink Puffers = non cyanotic

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6
Q

What is the GOLD standard diagnostic for eymphymsea and what does it show?

A

Pulmonary function test (PFT):
–Obstructive pattern that is not reversible
–FEV1 Decreased
–FVC Decreased
–FEV1/FVC Decreased
–DLCO Decreased

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7
Q

What is seen on CXR for emphysema?

What other diagnostic can help distinguish between types of emphysema?

A

CXR: hyperinflation, flattened diaphragm, increased AP diameter, decreased vascular markings, bullae

CT scan can help differentiate

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8
Q

What occurs on a bronchodilator challenge for emphysema that helps you distinguish from asthma?

A

Only increases FEV1/FVC ratio MILDLY. In asthma, it gives a DRAMATIC change, so you can differentiate that way.

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9
Q

What is chronic bronchitis defined as? What is the MCC?

A

Productive cough for at least 3 months out of a year for 2 consecutive years

Smoking MCC

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10
Q

What is the pathophysiology of chronic bronchitis?

Explain what happens to the V/Q Mismatch here. How does this lead to RHF?

A

-Overproduction and hyper secretion of mucus by goblet cells in response to chronic inflammation (caused by cigarette smoke)
-Mucus gland hyperplasia, goblet cell mucus production, dysfunctional cilia –> susceptible to infection

-Poor ventilation –> difficulty getting air through inflamed bronchioles –> alveolar hypoxia (not enough oxygen to lungs)–> body compensates (decreased ventilation and increased CO) –> lots of blood sent to poorly ventilated lung –> hypercapnia and respiratory acidosis –> pulmonary vascular constriction –> pulmonary hypertension –> RHF

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11
Q

Symptoms of chronic bronchitis?

A

-Dyspnea, chronic productive cough with sputum

-Crackles (rales)
-Wheezing, rhonchi
-Cyanosis (Blue Bloaters)
-RHF Symptoms: increased JVP, peripheral edema, enlarged/tender liver

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12
Q

What is the gold standard diagnostic for chronic bronchitis and what does it show?

A

PFT
–Decreased FEV1/FVC
–Decreased FEV
–Decreased FVC
–Normal DLCO (this differentiates)

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13
Q

Other diagnostics for chronic bronchitis?

A

-CXR: pulmonary HTN, increased AP diameter)
-ECG: Cor Pulmonale (RVA, RA enlargement)
-CBC: Increased Hgb and Hct due to hypoxia
-ABG: Respiratory acidosis (cannot move Co2 out)

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14
Q

What are the only two treatments shown to improve mortality in COPD patients?

A

Smoking cessation and oxygen therapy

-Smoking cessation is the SINGLE MOST important intervention

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15
Q

Explain why you should exercise caution if giving oxygen to a patient with COPD?

A

Only get oxygen between 88-92%. The body no longer responds to high levels of Co2 because it is used to it, so it responds to oxygen instead. If you give them a LOT of oxygen, the body changes the way it breathes and it can lead to acidosis.

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16
Q

What two vaccines are recommended in those with COPD?

A

Flu and Pneumo vaccines to prevent pulmonary infections

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17
Q

What is the treatment for COPD? Remember there are four groups

Based on GOLD Score!

A

-Group A (minimally symptomatic): SABA, or SABA + SAMA
-Group B (More Symptomatic): SABA + LABA/LAMA
-Group C (High Exacerbation Risk): SABA + LAMA +/ Inhaled Glucocorticoid (Fluticasone)
-Group D (High Risk): SABA + LAMA + LABA OR SABA + LABA + inhaled glucocorticoid

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18
Q

Name the SABA’s

A

Albuterol and Levalbuterol

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19
Q

Name the SAMA’s and give some side effects

A

Ipratropium

Anticholinergic side effects (dry mouth, dry eyes, etc.)

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20
Q

Name the LABA’s

A

Salmeterol, Formoterol

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21
Q

Name the LAMA’s and give some side effects

A

Tiotropium

Anticholinergic Side effects (dry mouth, dry eyes, etc.)

22
Q

An ABX is given for an acute exacerbation of chronic bronchitis. What are your options?

A

Macrolides (Azithromycin or Clarithromycin)

23
Q

What cardiac arrhythmia is associated with COPD?

A

Multifocal atrial tachycardia

24
Q

Cystic Fibrosis is an ______________ trait that has pathophysiology of….

A

Autosomal recessive

Exocrine glands become clogged up due to mutation on CFTR gene –> abnormal chloride and water transport leading to thick, viscous secretions of the lungs, sinuses, etc.

25
Q

What condition should you remember is associated with Cystic Fibrosis?

A

Pancreatic Insufficiency (scarring and cyst formation in the pancreas)

26
Q

Symptoms of cystic fibrosis

A

-Meconium ileus, failure to thrive, malabsorption
-Bronchiectasis (MCC is CF)
-Diarrhea (ADEK vitamin malabsorption)
-Steatorrhea
-Infertility due to azoospermia
-Sinusitis, Clubbing, Hyperresonance to percussion
-Salty skin

27
Q

PFT for CF shows: _______
CXR shows: _______
What is the diagnostic of choice and what does it show to be positive?

A

PFT: Obstructive pattern (TLC and FEV1 decreased)

CXR: hyperinflation

Elevated sweat chloride: >60mmoL on 2 occasions after Pilocarpine administration

28
Q

Treatment for CF

A

-Airway clearance: chest percussion, physiotherapy, coughing
-ADEK and pancreatic enzyme replacement
-Flu and Pneumo Vaccines
-ABX often needed: macrolide, Amox-Clav, etc.

29
Q

There is one other treatment that can be given to patients with CF. This is inhaled recombinant human deoxyribonuclease. What does this do?

A

Breaks down large amounts of DNA in mucus that clogs up the airway

30
Q

Bronchiectasis is irreversible thickening of the bronchial tubes caused by destruction of tissue. What is the MCC?

A

Cystic Fibrosis

31
Q

Organisms associated with bronchiectasis if:

Associated with CF:
Not associated with CF:

A

Pseudomonas Aeruginosa (CF)

H. Influenzae (not CF)

32
Q

What is the pathophysiology of bronchiectasis

A

-Dilation of airways and impaired mucociliary escalator –> repeat infections (recurrent PNA)

33
Q

Symptoms of bronchiectasis

A

-Chronic productive cough (thick sputum)
-Hemoptysis
-Pleuritic Chest Pain
-Dyspnea, wheezing, crackles, clubbing

34
Q

Gold standard diagnostic for bronchiectasis and what does it show?

A

PFT: Obstructive pattern
–FEV1/FVC, FEV1, FVC Decreased

35
Q

What is shown on CXR for bronchiectasis?

A

Dilated, thickened bronchioles (tram track appearance)

36
Q

On the other hand, what is shown on CT scan for bronchiectasis?

What is the diagnostic of choice?

A

Thickened, bronchial walls, airway dilation, lack of tapering of airway
-Tram track appearance
-Signet Ring Sign: increased airway diameter > adjacent vessel diameter

High Resolution CT Scan DOC

37
Q

Treatment for bronchiectasis

A

-Conservative: chest physiotherapy, mucolytics, bronchodilators
-ABX: Macrolides, Amox-Clav
-Surgery: Resection in severe cases

38
Q

Asthma is reversible, intermittent obstructive lung disease. What are the three pathophysiology factors that play a role in this condition?

What are some risk factors?

A

IgE mast cell response –> bronchoconstrition, hypersensitivity, and inflammation (exaggerated response to the pathogen)

Male gender, Atopy, Family history, obesity, tobacco smoke, air pollution

39
Q

Samter’s Triad:
Atropic Triad:

What are some triggers for asthma?

A

-Samter: Asthma + Nasal Polyps + Allergic Rhinitis + Aspirin/NSAID Sensitivity
-Atopic: Asthma + Eczema + Allergic Rhinitis

Pet hair, exposure to cold air, anxiety, stress, exercise

40
Q

Symptoms of asthma

A

-Wheezing on exhalation
-Cough especially at night
-Dyspnea

-Prolonged expiration, hyper resonance to percussion, decrease breath sounds
-Tachycardia, tachypnea
-Use of accessory muscles

41
Q

What is status asthmaticus

A

-Inability to speak full sentences
-Altered mental status
-Silent chest (no air movement)
-Tripod positioning

42
Q

What are some extra pulmonary findings of asthma?

A

-Pale or swollen nasal turbinates
-Cobblestone appearance to pharynx
-Nasal polyps
-Atopic Dermatitis: itchy plaques on flexor surfaces

43
Q

Gold standard diagnostic for asthma and what does it show?

A

PFT
-Decreased FEV1/FVC and FEV1

44
Q

Explain the bronchodilator challenge for asthma

When should you be doing this?

A

Give albuterol and reassess PFT in 10-15 minutes
-if FEV1 > 12% or higher, likely asthma
-Do this if PFT is positive but you want to ensure this is asthma

45
Q

Explain the bronchoprovocation challenge to determine if the patient has asthma.

A

Methacholine Challenge

-Methacholine causes bronchoconstriction and mimics an asthma attack
-Do this if PFT negative but you have a suspicion for asthma
->20% decrease on FEV1 followed by bronchodilator challenge (increase of FEV1 > 12% expected)

46
Q

What blood gas is expected in an acute asthma attack and why?

A

Respiratory alkalosis from tachypnea

47
Q

Explain the four classes of asthma and the treatments needed for each.

A

Intermittent:
–Symptoms: <2x/day, <2x/week
–SABA use: <2x/day, <2x/week
–Night: <2x/month
–Activity: NONE
–Lung Function: Normal
–SABA as needed

Mild Persistent:
–Symptoms: >2 days/week but not daily
–SABA: >2 days/week but not >1x/day
–Night: 3-4x/month
–Activity: MINOR
–Lung Function: Normal
-SABA + Low Dose ICS

Moderate Persistent:
–Symptoms: Daily
–SABA: Daily
–Night: >8 nights/month (not nightly)
–Activity: SOME
–Lung Function: FEV1 60-80%
-Low ICS + LABA

Severe Persistent:
–Symptoms: Throughout day
–SABA: Several times/day
–Night: Often nightly
–Activity: Very Limited
–Lung: FEV1 < 60% Predicted
–LABA + ICS (Medium/high Dose) +/- Omalzimuab

48
Q

What is the pneumonic to remember for asthma and how does it apply?

A

SILI to memorize it, but remember 2-4-8 and then 8 on it’s side

-SABA, ICS, LABA, Increase ICS
-2 or less nights/month, 4x/month, 8 nights/month, 8 on side = infinity (every single day an night)

49
Q

What is the pneumonic to remember for asthma and how does it apply?

A

SILI to memorize it, but remember 2-4-8 and then 8 on it’s side

-SABA, ICS, LABA, Increase ICS
-2 or less nights/month, 4x/month, 8 nights/month, 8 on side = infinity (every single day an night)

50
Q

Name the following medications in the classes

SABA:
ICS:
LABA:

A

SABA: Albuterol, Levalbuterol, Terbutaline, Epinephrine

ICS: Triamcinolone, Beclomethasone, Flunisolide

LABA: Salmeterol, Formoterol

51
Q

Random Questions:

-Side effect of ICS and how to prevent
-What asthma med should you NEVER use as mono therapy?
-What other medication should you consider in asthma in smokers and why?

A

ICS: Oral candidiasis (use spacer and mouth rinse after)

Never use a LABA alone!

Theophylline (bronchodilator that improves respiratory muscle endurance.) Smoking decreases theophylline so higher doses are needed in smokers.

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