Pulmonology #1 (Obstructive Diseases) Flashcards
What are two risk factors for chronic obstructive pulmonary disease (COPD)?
What two conditions does this umbrella include?
Smoking***
Alpha-1-Antitrypsin Deficiency (suspect if COPD and younger than 40 years old)
Emphysema and Chronic Bronchitis
Explain emphysema pathophysiology
-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
In emphysema, the patient likely has retained ______ because they cannot push it out.
This leads to a _____ defect. Explain this.
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.
Explain the two types of emphysema and how they differ in WHO they occur in, WHAT they affect, and WHERE they affect.
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”
Symptoms of emphysema (also explain what they look like)
-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
What is the GOLD standard diagnostic for eymphymsea and what does it show?
Pulmonary function test (PFT):
–Obstructive pattern that is not reversible
–FEV1 Decreased
–FVC Decreased
–FEV1/FVC Decreased
–DLCO Decreased
What is seen on CXR for emphysema?
What other diagnostic can help distinguish between types of emphysema?
CXR: hyperinflation, flattened diaphragm, increased AP diameter, decreased vascular markings, bullae
CT scan can help differentiate
What occurs on a bronchodilator challenge for emphysema that helps you distinguish from asthma?
Only increases FEV1/FVC ratio MILDLY. In asthma, it gives a DRAMATIC change, so you can differentiate that way.
What is chronic bronchitis defined as? What is the MCC?
Productive cough for at least 3 months out of a year for 2 consecutive years
Smoking MCC
What is the pathophysiology of chronic bronchitis?
Explain what happens to the V/Q Mismatch here. How does this lead to RHF?
-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
Symptoms of chronic bronchitis?
-Dyspnea, chronic productive cough with sputum
-Crackles (rales)
-Wheezing, rhonchi
-Cyanosis (Blue Bloaters)
-RHF Symptoms: increased JVP, peripheral edema, enlarged/tender liver
What is the gold standard diagnostic for chronic bronchitis and what does it show?
PFT
–Decreased FEV1/FVC
–Decreased FEV
–Decreased FVC
–Normal DLCO (this differentiates)
Other diagnostics for chronic bronchitis?
-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)
What are the only two treatments shown to improve mortality in COPD patients?
Smoking cessation and oxygen therapy
-Smoking cessation is the SINGLE MOST important intervention
Explain why you should exercise caution if giving oxygen to a patient with COPD?
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.
What two vaccines are recommended in those with COPD?
Flu and Pneumo vaccines to prevent pulmonary infections
What is the treatment for COPD? Remember there are four groups
Based on GOLD Score!
-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
Name the SABA’s
Albuterol and Levalbuterol
Name the SAMA’s and give some side effects
Ipratropium
Anticholinergic side effects (dry mouth, dry eyes, etc.)
Name the LABA’s
Salmeterol, Formoterol
Name the LAMA’s and give some side effects
Tiotropium
Anticholinergic Side effects (dry mouth, dry eyes, etc.)
An ABX is given for an acute exacerbation of chronic bronchitis. What are your options?
Macrolides (Azithromycin or Clarithromycin)
What cardiac arrhythmia is associated with COPD?
Multifocal atrial tachycardia
Cystic Fibrosis is an ______________ trait that has pathophysiology of….
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.
What condition should you remember is associated with Cystic Fibrosis?
Pancreatic Insufficiency (scarring and cyst formation in the pancreas)
Symptoms of cystic fibrosis
-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
PFT for CF shows: _______
CXR shows: _______
What is the diagnostic of choice and what does it show to be positive?
PFT: Obstructive pattern (TLC and FEV1 decreased)
CXR: hyperinflation
Elevated sweat chloride: >60mmoL on 2 occasions after Pilocarpine administration
Treatment for CF
-Airway clearance: chest percussion, physiotherapy, coughing
-ADEK and pancreatic enzyme replacement
-Flu and Pneumo Vaccines
-ABX often needed: macrolide, Amox-Clav, etc.
There is one other treatment that can be given to patients with CF. This is inhaled recombinant human deoxyribonuclease. What does this do?
Breaks down large amounts of DNA in mucus that clogs up the airway
Bronchiectasis is irreversible thickening of the bronchial tubes caused by destruction of tissue. What is the MCC?
Cystic Fibrosis
Organisms associated with bronchiectasis if:
Associated with CF:
Not associated with CF:
Pseudomonas Aeruginosa (CF)
H. Influenzae (not CF)
What is the pathophysiology of bronchiectasis
-Dilation of airways and impaired mucociliary escalator –> repeat infections (recurrent PNA)
Symptoms of bronchiectasis
-Chronic productive cough (thick sputum)
-Hemoptysis
-Pleuritic Chest Pain
-Dyspnea, wheezing, crackles, clubbing
Gold standard diagnostic for bronchiectasis and what does it show?
PFT: Obstructive pattern
–FEV1/FVC, FEV1, FVC Decreased
What is shown on CXR for bronchiectasis?
Dilated, thickened bronchioles (tram track appearance)
On the other hand, what is shown on CT scan for bronchiectasis?
What is the diagnostic of choice?
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
Treatment for bronchiectasis
-Conservative: chest physiotherapy, mucolytics, bronchodilators
-ABX: Macrolides, Amox-Clav
-Surgery: Resection in severe cases
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?
IgE mast cell response –> bronchoconstrition, hypersensitivity, and inflammation (exaggerated response to the pathogen)
Male gender, Atopy, Family history, obesity, tobacco smoke, air pollution
Samter’s Triad:
Atropic Triad:
What are some triggers for asthma?
-Samter: Asthma + Nasal Polyps + Allergic Rhinitis + Aspirin/NSAID Sensitivity
-Atopic: Asthma + Eczema + Allergic Rhinitis
Pet hair, exposure to cold air, anxiety, stress, exercise
Symptoms of asthma
-Wheezing on exhalation
-Cough especially at night
-Dyspnea
-Prolonged expiration, hyper resonance to percussion, decrease breath sounds
-Tachycardia, tachypnea
-Use of accessory muscles
What is status asthmaticus
-Inability to speak full sentences
-Altered mental status
-Silent chest (no air movement)
-Tripod positioning
What are some extra pulmonary findings of asthma?
-Pale or swollen nasal turbinates
-Cobblestone appearance to pharynx
-Nasal polyps
-Atopic Dermatitis: itchy plaques on flexor surfaces
Gold standard diagnostic for asthma and what does it show?
PFT
-Decreased FEV1/FVC and FEV1
Explain the bronchodilator challenge for asthma
When should you be doing this?
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
Explain the bronchoprovocation challenge to determine if the patient has asthma.
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)
What blood gas is expected in an acute asthma attack and why?
Respiratory alkalosis from tachypnea
Explain the four classes of asthma and the treatments needed for each.
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
What is the pneumonic to remember for asthma and how does it apply?
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)
What is the pneumonic to remember for asthma and how does it apply?
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)
Name the following medications in the classes
SABA:
ICS:
LABA:
SABA: Albuterol, Levalbuterol, Terbutaline, Epinephrine
ICS: Triamcinolone, Beclomethasone, Flunisolide
LABA: Salmeterol, Formoterol
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?
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.
