Pulmonology #2 (Bronchiectasis, Asthma, Sarcoidosis) Flashcards by Tyler Cichowski

MCC of bronchiectasis in the US

Cystic fibrosis

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Bronchiectasis is due to recurrent lung infections. If the patient has CF, what is the likely pathogen?

Pseudomonas aeruginosa

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If bronchiectasis is NOT due to CF, what is the likely cause?

H. Influenzae

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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

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Symptoms of bronchiectasis

-persistent productive cough with thick sputum
-dyspnea
-Pleuritic chest pain
-Hemoptysis
-Crackles, wheezing, rhonchi

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Preferred imaging of choice for bronchiectasis

High resolution CT scan

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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)

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However, the GOLD standard diagnostic for bronchiectasis is

PFT (obstructive pattern)

-Decreased FEV1, FEV1/FVC

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Treatment for bronchiectasis

-Chest physiotherapy, mucolytics, bronchodilators
-ABX often needed: Macrolides, Cephalosporins, Augmentin, Fluoroquinolones.

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What is asthma defined as?

Reversible, often intermittent obstructive disease of the small airways

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What are the three components of the pathophysiology of asthma?

Airway hyperreactivity
Bronchoconstriction
Inflammation

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Strongest risk factor for asthma

Atopy

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Other risk factors for asthma

-Family history
-Air pollution
-Obesity
-Tobacco Smoke
-Male gender

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What are the three components of Samter’s Triad?

Aspirin sensitivity, asthma, chronic rhinosinusitis

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What are the three components of the atopic triad?

Asthma + Atopic Dermatitis (Eczema) + Allergic Rhinitis

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Triggers for an asthma attack?

-Anxiety, stress, exercise, cold air, dry air
-Animal dander, pollen, mold, dust mites
-Increased IgE
-medications (aspirin, BB)
-GERD

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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