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Internal Medicine Subspecialties > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

What is Bronchiectasis?

A

The irreversible and abnormal dilatation of the bronchi

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2
Q

What is the pathophysiology of Bronchiectasis?

A

Cycles of bronchial inflammation/infection and inadequate clearance of secretions/airway obstruction/impaired host immune defenses

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3
Q

What causes Bronchiectasis?

A

Congenital
Acquired (children)
Acquired (adults)

Review notes

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4
Q

What are common causative pathogens associated with bronchiectasis?

A

Pseudomonas aeruginosa, S. aures, H influenze, TB

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5
Q

How does Bronchiectasis present? What are the examination findings

A
  1. Chronic cough with copious purulent sputum
  2. Haemoptysis
  3. Dyspnea
  4. Non-specific (wt loss, anorexia, malaise)
  5. Pleuritic chest pain

O/E: clubbing, coarse inspiratory crepitations/ crackles, wheeze

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6
Q

How is Bronchiectasis investigated?

A
  1. CBC
  2. CXR: tram track lines
  3. HRCT (most sensitive): tram-track lines, signet ring
  4. Sputum cultures
  5. Serum Ig levels
  6. Sweat chloride test
  7. Spirometry
  8. Bronchoscopy
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7
Q

How is a patient with Bronchiectasis managed?

A

Conservative: Physiotherapy

Medical Mx: Abx, Inhaled bronchodilators & Steroids, Vaccinations (Influenza, Pneumococcal)

Surgical Mx: Excision of affected areas if confined to a single lobe or segment on CT

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8
Q

What is the FEV1 (Forced Expiratory Volume in 1 second)?

A

This is the maximum volume of air that can be forcefully expired within 1 second after maximal inspiration. It is normally >/= 80%

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9
Q

What is the Forced Vital Capacity?

A

The maximum volume of air that can be forcefully expired after maximal inspiration

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10
Q

What is the FEV1//FVC?

A

Ratio of FEV1 to FVC expressed as a percentage. This is normally 75-80%

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11
Q

What is Obstructive Lung Disease?

A

A lung disordet that results in increased resistance to airflow due to narrowing of airways

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12
Q

What is restrictive lung disease?

A

Impaired ability of the lungs to expand due to reduced lung compliance

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13
Q

Define COPD

A

COPD is a common, progressive, non-reversible disorder characterized by airway obstruction

N.B Spirometry needed for diagnosis

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14
Q

What are the risk factors for COPD?

A

1 factor is Smoking!!!

Environmental: Air pollution, occupational exposure (silica, cadmium), Exposure to biomass fuel for cooking

Demographic factors: Age, FH, Male sex, H/o childhood respiratory infections, Low SES

Others: Alpha 1 antitrypsin deficiency, airway hyperactivity

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15
Q

Define Chronic Bronchitis

A

(Defined clinically:) Productive cough on most days for at least 3 consecutive months in each of 2 consecutive years

Obstruction is due to narrowing of the airway lumen by thickening of the mucosa and excess mucus production

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16
Q

Define Emphysema

A

(Defined pathologically):
Enlarged air spaces distal to the terminal bronchioles with destruction of the alveolar walls; no obvious fibrosis

Decreased elastic recoil of lung parenchyma causes decreased expiratory driving pressure, airway collapse & air trapping

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17
Q

What are the types of Emphysema?

A

Centriacinar: typical form seen in smokers. primarily affects upper lung zones

Panacinar: acounts for 1% of emphysema cases. Alpha 1 antitrypsin deficiency. Primarily lower lobes

18
Q

What is a “pink puffer”?

A

A thin patient
Predominant emphysema
C/o severe dyspnea (use of accessory muscles of respiration esp on exertion)
Pursed lip breathing
Cough is rare. Oedema and polycythemia absent

19
Q

What are examination findings of “pink puffers”?

A

Hyperinflated chest
Hyperresonant PN
Prolonged expiration
Decr BS

20
Q

What are laboratory features of “pink puffers”?

A

Decr FEV1
Decr FEV1/FVC

Incr TLC (hyperinflation)
Incr RV (gas trapping)
21
Q

What is noted on CXR for “pink puffers”?

A

Hyperinflation, flattened diaphragms, diminshed vascular markings, decr heart shadow

22
Q

What is a “blue bloater”?

A

Patient with predominantly chronic bronchitis

Cyanotic but not breathless

23
Q

What are the examination features of a “blue bloater”?

A

Cyanosis (due to hypoxemia and hypercapnea)
Polycythemia
Peripheral Oedema from RVF (cor pulmonale)
Prolonged expiration
Coarse creps, wheeze

24
Q

What is noted on CXR for “blue bloaters”?

A

Increased vascular markings

Enlarged heart with cor pulmonale

25
Q

What is cor pulmonale?

A

Right sided heart failure due to a pulmonary process

26
Q

What are the physical examination findings of cor pulmonale?

A 
Increased P2
Tricuspid Regurg Murmur
Jugular Venous distention with a large V wave
Hepatomegaly
Ascites
Oedema
27
Q

What is a bulla?

A

A sharply demarcated area of emphysema measuring >/= 1cm in diameter and possessing a wall <1mm thick

28
Q

What investigations should be carried out for COPD?

A

Blood
CBC: anemia, polycythemia
Alpha 1-antitrypsinase

Imaging:
CXR (hyperinflation; R/o Lung ca, CCF)
HRCT (high specificity for diagnosing emphysema as bullae can be outlined)

Spirometry: Permanent Obstructive pattern (post-bronchodilator FEV1/FVC <70%)

ECG: RAH, RVH (cor pulmonale

29
Q

Differentials for COPD include:

A

Chronic Asthma
TB
Bronchiectasis
CCF

30
Q

What are the complications of COPD?

A 
Polycythemia due to hypoxia
Pulmonary HTN from vasoconstriction
Pulmonale (cor pulmonale)
Pneumothorax due to ruptured emphysematous bullae
Chronic Hypoxemia
31
Q

What is the GOLD staging system?

A

System to indicate the severity of COPD in relation to post bronchodilator FEV1

Stage I (mild)

Stage II (moderate)

Stage III (severe)

Stage IV (very severe

32
Q

What is the GOLD staging system?

A

System to indicate the severity of COPD in relation to post bronchodilator FEV1

Stage I (mild): FEV1 >/= 80% of predicted

Stage II (moderate): FEV1 50-79% of predicted

Stage III (severe): FEV1 30-49% of predicted

Stage IV (very severe): FEV1 <30% of predicted or FEV1 <50% predicted if respiratory failure present

33
Q

What is the GOLD staging system?

A

System to indicate the severity of COPD in relation to post bronchodilator FEV1

Stage I (mild): FEV1 >/= 80% of predicted

Stage II (moderate): FEV1 50-79% of predicted

Stage III (severe): FEV1 30-49% of predicted

Stage IV (very severe): FEV1 <30% of predicted or FEV1 <50% predicted if chronic respiratory failure present

34
Q

How is COPD managed?

A

A. Prolong Survival

  1. Smoking Cessation
  2. Vaccination: Influenza, Pneumococcal
  3. Home Oxygen (LTOT)

B. Symptomatic Relief

  1. Bronchodilators (Mild: SABA, anti-cholinergics; Mod-Severe: LABA, anticholinergics)
  2. Corticosteroids
  3. Surgical (LVRS–resection of emphysematous parts of lung, or lung transplant)
  4. Patient education, eliminate respiratory allergens/irritants, exercise rehabilitation to improve physical endurance, Diet
35
Q

What is the Criteria for Long Term Oxygen Therapy in patients with COPD? How should LTOT be administered?

A

ABG measured in clinically stable patients (non-smoker) on optimal medical therapy on at least 2 occasions 3 weeks a part:

  1. PaO2 <55mmHg on room air
  2. PaO2 <60mmHg with polycythemia or pulmonary oedema/HTN

May also be given to terminally ill patients.

It should be administered for at least 15h/day at 2-4Lto achieve a PaO2 of at least 60mmHg

36
Q

What mechanisms can be employed to help patients with smoking cessation?

A
  1. Nicotine replacement
  2. Bupropion
  3. Varenicline (oral selective nicotine receptor partial agonist)
37
Q

What is an acute exacerbation of COPD?

A

This is sustained worsening (>24-48h) of symptoms and deterioration of lung fxn. Usually triggered by a viral/bacterial URTI, air pollution

38
Q

Mx of Acute Exaerbation of COPD?

A
  1. ABCs (start with 24-28% Oxygen)
  2. SaO2 target of 88-92%
  3. Bronchodilators
  4. Systemic corticosteroids
  5. Abx if evidence of bacterial infection
  6. Physiotherapy
39
Q

What is the BODE index?

A

This is a prognostic index for risk of death in COPD:

BMI<21
Obstruction (FEV1)
Dyspnea (MRC scale)
Exercise capacity

40
Q

What are the extrapulmonary features of COPD?

A
  1. Increased circulatory inflammatory markers
  2. Muscular weakness
  3. Wt loss due to altered fat metabolism
  4. Impaired salt and water excretion–> peripheral oedema
  5. Increased prevalence of osteoporosis

Internal Medicine Subspecialties (5 decks)

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