Pulmonology Flashcards
What is the best initial test in an acute exacerbation of asthma?
Peak Expiratory Flow (PEF) or ABG
What is the most accurate diagnostic test in asthma?
Pulmonary function testing (PFT)
Spirometry will show:
- dec. ration of FEV1:FVC (the FEV1 decreases MORE than FVC)
A 15-year-old boy comes to the office because of occasional shortness of breath every few weeks. Currently he feels well. He uses no medications and denies any other medical problems. Physical examination reveals a pulse of 70 and a respiratory rate of 12 per minute. Chest examination is normal.
Which of the following is the single most accurate diagnostic test at this time?
a. Peak expiratory flow.
b. Increase in FEv1 with use of methacoline
c. Diffusion capacity of carbon monoxide
d. >20% decrease in FEV1 with use of methacoline
e. Increased alveolar-arterial oxygen difference (A-a gradient)
f. Increase in FVC with albuterol
g. Flow-volume loop on spirometry
h. Chest CT scan
i. increased pCO2 on ABG
When a patient is currently asymptomatic, it is less likely to find an increase in FEV1 with the use of short-acting bronchodilators like albuterol. The test, when the patient is asymptomatic, may be falsely negative. When the patient is asymptomatic, the most accurate test of reactive airway disease is a 20% decrease in FEV1 with the use of methacholine or histamine. Chest CT, like an x-ray, shows either nothing or hyperinflation. The ABG and PEF are useful during an acute exacerbation. Flow-volume loops are best for fixed obstructions such as tracheal lesions or COPD.
What should you expect in the pulmonary function tests in an asthma patient?
- decreased FEV1 and FVC, decreased FEV1/FVC ratio
- increased in FEV1 of more than 12% and 200 mL with the use of albuterol
- decrease in FEV1 of more than 20% with the use of methacholine or histamine
- increase in the diffusion capacity of the lung for carbon monoxide (DLCO)
What does acetylcholine (methacholine) and histamine provoke in pulmonary function testing?
bronchoconstriction and increase in bronchial secretion
Give 2 side effects of inhaled steroids.
Dysphonia and Oral candidiasis
How would you start treating for asthma?
Inhaled short-acting beta agonist (SABA)
Albuterol
Pirbuterol
Levalbuterol
This leukotriene modifier is hepatotoxic and has been associated with Churg-Strauss syndrome.
Zafirlukast
Patient’s symptoms persisted despite giving inhaled SABA. What should you do?
Add long-term agents to a SABA. Low-dose inhaled corticosteroids are the best initial long-term control agent.
Beclomethasone Budesonide Flunisolide Fluticasone Mometasone Triamcinolone
What are your alternatives as long-term agents for low-dose ICS?
Cromolyn and Nedocromil - inhibit mast cell mediator release and eosinophil recruitment
Theophylline
Leukotriene modifiers: Montelukast, Zafirlukast, or Zileuton (best with atopic patients)
Patient’s symptoms persisted even with combined SABA and low-dose ICS. What should you do?
Add a long-acting beta agonist (LABA) to a SABA and ICS, or increase the dose of ICS.
LABA: Salmeterol or Formoterol
Patient is on Abuterol, Budesonide, and Salmeterol. Symptoms persisted. What should you do?
Increase the dose of ICS to maximum in addition to the LABA and SABA. Add Tiotropium, an antimuscarinic agent.
Patient is on Albuterol, maximum dose of Beclomethasone, Formotero, and Tiotropium. Patient still experiencing symptoms. IgE levels were high. What should you do?
Omalizumab may be added to SABA, LABA, and ICS.
What should you give when all other treatment given for asthma were not sufficient to control symptoms?
Oral corticosteroids
Give the adverse effects of Systemic Corticosteroids
Osteoporosis
Cataracts
Adrenal suppression and fat redistribution
Hyperlipidemia, hyperglycemia, acne, and hirsutism (particularly in women)
Thinning of skin, striae, and easy bruising
These agents are used in asthma management if SABAs, LABAs, and inhaled steroids are not sufficient. It dilates bronchi and decreases secretions. They are also VERY EFFECTIVE in COPD.
Anticholinergics (Ipratropium and Tiotropium)
What vaccines are given in all asthma patients?
Influenza and Pneumoccocal vaccines
A 47-year-old man with a history of asthma comes to the emergency department with several days of increasing shortness of breath, cough, and sputum production. On physical examination his respiratory rate is 34 per minute. He has diffuse expiratory wheezing and a prolonged expiratory phase.
Which of the following would you use as the best indication of the severity of his asthma?
a. Respiratory rate
b. Use of accessory muscles
c. Pulse oximetry
d. Pulmonary function testing
e. Pulse rate
A. A respiratory rate of 34 indicates severe shortness of breath.
How can you quantify the severity of an asthma exacerbation?
Decreased peak expiratory flow (PEF)
ABG with an increased A-a gradient
This electrolyte helps relieve bronchospasm. It is used only in an acute, severe asthma exacerbation not responsive to several rounds of albuterol while waiting for steroids to take effect.
Magnesium
What is the best initial therapy for acute, severe asthma exacerbation?
Oxygen combined by inhaled SABA such as albuterol and a bolus of steroids. Corticosteroids need 4-6 hours to begin to work, so give them right away. Ipratropium should be used, but does not work as rapidly as albuterol.
A patient comes in in acute, severe asthma exacerbation. You gave oxygen, albuterol, and steroids, but is not responding. ABG showed respiratory acidosis. What would you do?
Endotracheal intubation then place in ICU
This is defined as the presence of shortness of breath from lung destruction decreasing the elastic recoil of the lungs.
COPD
What would you expect in the PFT of a patient with COPD?
- Decrease in FEV1 and FVC; dec. FEV1/FVC ratio (under 70%)
- increase in total lung capacity (TLC) because of an increase in residual volume
- decrease diffusion capacity of the lung for carbon monoxide (DLCO) (emphysema, not chronic bronchitis)
- incomplete improvement with albuterol
- little or no worsening with methacholine