Pulmonology and Respiratory Tract Infections (PEARLS and BOARD REVIEW Flashcards
What is the best way to assess for asthma? What is the gold standard?
Peak flow. >15% change after treatment + response. Gold standard is pulmonary function testing
What drug is used for bronchoprovocation testing?
Metacholine (cholinergic drug that causes bronchoconstriction)
What acid/base issue is classically associated with asthma?
Respiratory alkalosis. Pts hyperventilate.
What is the atopic triad or asthmatic triad?
Asthma, nasal polyps, ASA/NSAID allergy, eczema.
What drugs should be avoided in asthmatics?
ASA, NSAIDS, BB, ACEI in some cases
When should you admit an asthmatic?
PEFR
When should you be able to discharge an asthmatic?
PEFR > 70% with resolved symptoms. Maintain close followup.
List the rescue drugs and classes.
B2 agonists (albuterol, terbutaline, epinephrine, levalbuterol). Anticholinergics (ipratropium). Systemic corticoids (prednisone, methylprednisone (solumedrol), prednisolone.
What is a duoneb? Why use it?
Albuterol and ipratropium. Albuterol is a peripheral bronchodilator and ipratropium is a central bronchodilator.
What are the drugs of choice for chronic asthma?
Inhaled corticoids. Beclomethasone, flunisolide, triamcinolone.
What is the MOA of ICS?
Inhibit cytokine synthesis and inflammatory response.
What issue can ICS cause?
Thrush (use a spacer)
What would add to an ICS if a person just wasn’t getting enough relief?
Either increase dose OR LABA. Salmeterol.
What other option do you have? What are they?
An ICS and LABA mix. Symbicort (budenoside/formoterol) or Advair (fluticasone and salmeterol)
What are LABA’s especially good at addressing?
Nocturnal asthma
Once asthma is controlled, what should you do with the LABA?
Try to step down off LABA
Are LABA’s used as rescue medications?
NO and they should NEVER BE USED ALONE
What is an asthma prophy option?
Mast cell modifiers like Cromolyn or nedocromil
What do mast cell modifiers do?
Inhibit acute phase reactions to EXERCISE, cold air, sulfites
What medications are especially useful in asthmatics with allergic rhinitis or ASA induced asthma?
LTRA (leukotriene modifiers/receptor antagonists. (Singulair (motelukast)) as an example.
Theophylline is what?
An asthma drug used for chronic control. It is a bronchodilator that helps RESPIRATORY MUSCLE ENDURANCE. (lots of drug interactions). This drug has a NARROW therapeutic index and may cause ARRHYTHMIAS and/or SEIZURES.
What might smokers need when it comes to theophylline?
Higher dosing. Smoking decreases theophylline levels.
What drug would you use in SEVERE UNCONTROLLED ASTHMA?
Oh my God it’s bad…or omalizumab. It’s an anti IGe Ab
Classify asthma symptoms.
Days. 2=mild persistent , daily=moderate persistent, or multiple times throughout the day=severe persistent.
What is the most important risk factor for COPD?
Smoking
What is the only genetic disease linked to COPD in young people?
Alpha 1 antitrypsin deficiency. Causes pan-lobular emphysema as there is no alpha 1 antitrypsin to protect the lung from WBC’s.
Abnormal permanent enlargement of terminal airspaces. Emphysema or Chronic Bronchitis?
Emphysema
Mucous mucous mucous, cough cough cough for >3 months for 2 consecutive years. Emphysema or Chronic Bronchitis?
Chronic bronchitis
Emphysema or Chronic Bronchitis? A woman who experiences increased dyspnea on exertion presents to clinic. On exam you note hyper resonance to percussion, decreased breath sounds, decreased fremitus, and a barrel chest (increased AP diameter). She is breathing through pursed lips. You note respiratory ____ on labs.
Emphysema (pink puffer). She will have respiratory alkalosis
Emphysema or Chronic Bronchitis? An obese woman with a productive cough. On exam you note rales, rhonchi, wheezing and peripheral edema and cyanosis. You note respiratory ____ on labs add well as ____/____ as well as ____capnia.
Chronic bronchitis (blue bloater). She will have respiratory acidosis. Hct/RBC will be increased due to chronic hypoxia stimulating erythropoiesis.
What is cor pulmonale?
Right sided heart failure due to lung disease. May see edema as well as cyanosis.
How do you diagnose COPD?
PFT’s/Spirometry are the gold standards
What measurement is most important when determining severity?
FEV1. If it is less than 1…that is shitty!!!
With obstruction, what will you see with FEV1/FVC
Decrease in both.
A pt has hyperinflation and a flat diaphragm and increased AP diameter, DECREASED vascular markings, and may have bullae
Emphysema
A pt has increased AP diameter, INCREASED vascular markings, and enlarged right heart border.
Chronic bronchitis
When is cor pulmonale usually seen in COPD?
With chronic bronchitis.
What is the number one most important step in COPD management?
STOP SMOKING!!!
What are the first treatment meds for COPD?
A combination of beta 2 agonists and anticholinergics is better than either used alone.
List the main anticholinergics used with COPD
Ipratropium and Tiotropium
What do anticholinergics do again with COPD?
Decrease acetylcholine mediated bronchoconstriction.
Who do you NOT want to give an anticholinergic to?
People with glaucoma and/or BPH because it increases urinary retention and causes pupil dilation.
List the main beta 2 agonists used with COPD
Albuterol, terbutaline, salmeterol (long acting).
What drug would you use in refractory cases?
Theophylline. But remember what you already learned about his drug.
Do you use inhaled corticoids for COPD?
No. May use with a long acting (like salmeterol + fluticasone).
What are the SE of inhaled corticoids again?
Osteoporosis, thrush!!!, hyperglycemia, fluid retention, infection
What vaccines should all COPDer’s get?
Pneumococcal and influenza
What is the only treatment proven to decrease mortality with COPD?
O2 baby
FEV1 equal to 80% stage and treatment
Stage I Mild. Treat with short acting bronchodilators.
FEV1 between 30% and 50% stage and treatment
Stage III Severe. Short acting bronchodilators + long acting dilator + pulmonary rehab + steroids for increasing exacerbations.
FEV1 between 50% and 80% stage and treatment
Stage II Moderate. Short acting bronchodilators + long acting dilator
FEV1 between less than 30%, cor pulmonale, right heart failure, respiratory failure, stage and treatment
Stage IV Very Severe. Short acting bronchodilators + long acting dilator + pulmonary rehab + steroids for increasing exacerbations. + O2
You see a CXR with enlarged right heart, normal diaphragm, increase in vascular markings, and prominent pulmonary artery
Chronic bronchitis.
You see a CXR with enlarged lung fields, flattened diaphragm, trapped air (dark lung areas), decrease in vascular markings, and bullae.
Emphysema.
What are bullae and what do they look like?
They signify loss of airspaces. Large bubbles of dark air. No gas exchange.
Talk me through bronchiectasis.
Irreversible bronchial dilation caused by inflammation of the MEDIUM sized bronchi. This then destroys the muscular and elastic tissues of the bronchial walls which then collapse easily. This causes obstruction of airflow and an inability to clear mucous secretions leading to further lung infection and more problems all over again.
What infection is the most common cause of bronchiectasis?
H. Flu (if not caused by cystic fibrosis)
What infection is the most common cause of bronchiectasis in a cystic fibrosis patient?
Pseudomonas (M. Cat also very common. If it’s viral…think aspergillus )
What does a bronchiectasis patient look like?
Daily chronic cough with FOUL SMELLING SPUTUM.
What is bronchiectasis responsible for when it comes to blood?
It is the most common cause of massive hemoptysis. Hemoptysis is EXTREMELY common with bronchiectasis due to the erosion of the bronchial tree
What is the most common cause of hemoptysis in general though?
Acute bronchitis and lung cancer.
Where will you hear crackles with bronchiectasis?
Bases
How would you test for bronchiectasis?
High resolution CT scan
What is the sign you may see?
Signet ring sign. Bronchus and pulmonary artery should be the same size. But with this…the bronchus will be much larger.
What will PFT’s show?
Decrease in FEV1 and FVC
What would you do if they had an aspergillus bronchiectasis? What would it look like?
Thick brown sputum. Treat with corticosteroids and Itraconazole. Surgery if symptomatic
What would you do if they had an Pseudomonas bronchiectasis?
Fluoroquinolone, zosyn, aminoglycoside, or cephalosporin
What if it’s the mycobacterium avium complex or MAC?
Clarithromycin + ethambutol
What are the empiric bronchiectasis drugs?
Ampicillin, amoxicillin, bactrim
What abx has anti-inflammatory properties?
Azithromycin.
Cystic fibrosis is autosomal ____
Recessive
What does cystic fibrosis do?
Prevents chloride movement out of the cell (meaning water can’t leave) making a TON of mucous get stuck in the lungs, pancreas, liver, intestines.
What does a classic CF pt look like?
Young with bronchiectasis, pancreatic insufficiency, growth delays, and infertility. Can’t breath, digest, grow, or make love
What vitamin deficiencies are common?
Ah…Don’t Even Know!!! (ADEK)
What are CF poops like?
Large, greasy, foul smelling turds.
What are the respiratory issues of a CF patient?
Um…everything. Lots of infections (pseudomonas, staph, H. flu, etc.), productive cough, SOB, chest pain, and lots of SINUS INFECTIONS
A full term infant has meconium ileus.
Think CF for shizzle
What test for CF?
Sweat chloride then CXR.
Tell me what causes sarcoidosis
Exaggerated T cell response to antigens or self antigens causing inflammation and granulation formation.
What systems are most commonly affected by sarcoidosis?
Lung, skin, lymph nodes, and eyes in that order
What are granulomas and why are they bad?
They form from a mass of immune cells. They are bad because they take up space and disrupt the normal function of the tissue in which they form
Where are the nodes enlarged? What are the dx findings?
Hilar lymph nodes. Pt will have a dry nonproductive cough, dyspnea, and chest pain.
What skin findings are associated with sarcoidosis? Are the specific to sarcoidosis? What other things might they be found in if not?
Erythema nodosum. Bilateral tender red nodules on anterior legs. They are not specific. May also be seen with coccidiomycosis.
What other skin findings are virtually pathognomonic for sarcoid?
Lupus pernio (violaceous raised discoloration of noes, ear, cheek, that resembles FROST BITE. Think SARCOID = SO COLD (frost bite face) must be LUPEE to go out in this.
What can happen with the eyes with sarcoid?
Uveitis
What nerve palsy can happen more commonly with sarcoid?
7th (facial nerve)
