Pulmonology #2 (Bronchiectasis, Asthma, Sarcoidosis) Flashcards
MCC of bronchiectasis in the US
Cystic fibrosis
Bronchiectasis is due to recurrent lung infections. If the patient has CF, what is the likely pathogen?
Pseudomonas aeruginosa
If bronchiectasis is NOT due to CF, what is the likely cause?
H. Influenzae
What is the pathophysiology of bronchiectasis?
Dilatation of the airways and impairment of the mucociliary escalator leads to repeat infections, airway obstruction, and peribronchial fibrosis
Symptoms of bronchiectasis
-persistent productive cough with thick sputum
-dyspnea
-Pleuritic chest pain
-Hemoptysis
-Crackles, wheezing, rhonchi
Preferred imaging of choice for bronchiectasis
High resolution CT scan
What do you see on CT scan for a patient with bronchiectasis?
-Thickened bronchial walls, airway dilatation, lack of tapering of the airway (tram track appearance) and signet ring sign (increased airway diameter)
However, the GOLD standard diagnostic for bronchiectasis is
PFT (obstructive pattern)
-Decreased FEV1, FEV1/FVC
Treatment for bronchiectasis
-Chest physiotherapy, mucolytics, bronchodilators
-ABX often needed: Macrolides, Cephalosporins, Augmentin, Fluoroquinolones.
What is asthma defined as?
Reversible, often intermittent obstructive disease of the small airways
What are the three components of the pathophysiology of asthma?
Airway hyperreactivity
Bronchoconstriction
Inflammation
Strongest risk factor for asthma
Atopy
Other risk factors for asthma
-Family history
-Air pollution
-Obesity
-Tobacco Smoke
-Male gender
What are the three components of Samter’s Triad?
Aspirin sensitivity, asthma, chronic rhinosinusitis
What are the three components of the atopic triad?
Asthma + Atopic Dermatitis (Eczema) + Allergic Rhinitis
Triggers for an asthma attack?
-Anxiety, stress, exercise, cold air, dry air
-Animal dander, pollen, mold, dust mites
-Increased IgE
-medications (aspirin, BB)
-GERD
Symptoms of asthma (there is a classic triad)
-Dyspnea
-Wheezing
-Cough (especially at night)
What are other physical exam findings of a patient who is having an asthma attack?
-Prolonged expiration with wheezing
-hyperresonance to percussion
-tachypnea
-Tachycardia
-Use of accessory muscles
What are some symptoms of status asthmaticus or severe asthma?
-AMS
-Inability to speak full sentences
-Tripod positioning
-Silent chest (no air movement)
Gold standard in making the diagnosis of asthma
PFT
-Shows reversible obstruction (decreased FEV1, FEV1/FVC, increased RV and TLC)
What other method is used to diagnose asthma, besides a PFT?
Bronchoprovocation: Methacholine challenge (>20% decreased on FEV1) followed by bronchodilator challenge (increase by 12% or more is expected)
What ABG is expected in a patient with an asthma exacerbation?
Respiratory alkalosis (from tachypnea)
What is the BEST and most objective way to assess asthma exacerbation severity and patient response to treatment?
Peak expiratory flow rate
-If > 70% predicted or improvement by 15%, patient can be discharged
Explain what intermittent asthma is
Symptoms: <2 days/week
SABA use: <2x/days/week
Nighttime awakenings: <2x/month
Normal lung function
SABA as needed
Explain what mild persistent asthma is
Symptoms: > 2/week but not daily
SABA use: >2/week but not >1 daily
Nighttime awakenings: 3-4/month
FEV1> 80% predicted
SABA and low dose ICS
Explain what moderate persistent asthma is
Symptoms: Daily
SABA: Daily
Nighttime awakenings: >1/week but not nightly
FEV1 60-80% predicted
Low ICS + LABA or Medium ICS
Explain what severe persistent asthma is
Symptoms: Throughout the day
SABA: Several times a day
Nighttime: Often, nightly
FEV1 < 60%
High dose ICS + LABA +/- Omalizumab
When can you take a step DOWN in the asthma treatment tree?
If symptoms are controlled > 3 months
Name the SABAs and some side effects
Levalbuterol
Epinephrine
Albuterol
Terbutaline
Tachycardia, muscle tremors, CNS stimulation
LABAs, such as ______ and _________, are only used if symptoms are not controlled with ICS alone
Salmeterol
Budesonide/Formoterol
Explain what theophylline is and when it is used
Bronchodilator that improves respiratory muscle endurance
Higher doses needed in smokers because smoking decrease Theophylline levels
Risk factors for sarcoidosis
Females
AA
Northern Europeans
What is the pathophysiology of sarcoidosis
-Exaggerated T cell response to a variety of antigens or self-antigens
Symptoms of Sarcoidosis (there are MANY)
-50% are asymptomatic
-Dry, nonproductive cough, dyspnea, rales
-Erythema nodosum, lupus pernio, maculopapular rash, parotid gland enlargement
-Anterior uveitis
-Restrictive cardiomyopathy
-Arthralgias, fever, weight loss, hepatomegaly
-Cranial nerve palsies
What is Lofgren Syndrome?
Triad of Erythema Nodosum + Bilateral hilar LAD + polyarthralgias with fever
What is erythema nodosum?
Rash on shins
What is lupus pernio?
Butterfly (malar) rash on face
Best initial test for sarcoidosis?
Chest radiographs: bilateral hilar lymphadenopathy (batwing appearance)
-Ground glass appearance
-Eggshell calcifications
-Fibrosis
On PFT for sarcoidosis, what is classic?
Restrictive pattern
Normal or increased FEV1/FVC
Decreased FEV1
Decreased lung volumes
However, what is the most accurate test for sarcoidosis?
Tissue biopsy: noncaseating granulomas
On labs, what is seen in sarcoidosis?
Increased ACE levels is hallmark
If symptomatic sarcoidosis, what is the treatment?
oral corticosteroids are first-line
Methotrexate, Hydroxychloroquine are for skin lesions
