Pulmonology - Obstructive lung disease - DONE

Question 1

What is COPD?

Answer 1

Chronic airflow limitation secondary to chronic bronchitis or emphysema that is usually progressive, may be accompanied by airway hyperreactivity, and is sometimes partially reversible.

Question 2

What is the global impact of COPD?

Answer 2

COPD is the 12th leading cause of disease burden worldwide and is predicted to rise to the 4th leading cause by 2020.

Question 3

What PFT results suggest COPD?

Answer 3

• The gold criteria use a FEV1/FVC < 70% that persists after the maximal therapy (irreversible airflow obstruction).
• The American Thoracic Society has recently changed the diagnosis to be a value of FEV1/FVC that is below the lower limit of normal prediction for the patient based on age, ethnicity, gender, and height.

Question 4

What PFT results suggest asthma?

Answer 4

FEV1/FVC < 70% that typically normalizes after treatment, significant improvement with bronchodilator (increase in FEV1 or FVC of ≥ 12% and at least a 200-mL change in either), with a normal DLCO

Question 5

What is emphysema?

Answer 5

• Defined anatomically as abnormal, permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by destruction of their walls.
• Traditionally, this definition includes the absence of fibrosis, though there is controversy.

Question 6

What is chronic bronchitis?

Answer 6

Chronic sputum production every day for at least 3 months per year for 2 consecutive years

Question 7

What is a “pink puffer”?

Answer 7

• A thin patient with predominant emphysema, complaining of severe dyspnea and often using accessory muscles of respiration, especially with exertion.
• Cough is rare.
• Edema and polycythemia are absent.

Question 8

What are the physical examination features of “pink puffers”?

Answer 8

Breath sounds are diminished; adventitial sounds are absent.

Question 9

What are the laboratory features of “pink puffers”?

Answer 9

PFTs demonstrate normal to slightly diminished PaO2 and PaCO2, an increased TLC, and diminished DLCO.

Question 10

What is noted on the chest radiographs in these patients?

Answer 10

Hyperinflation, flattened diaphragms, and diminished vascular markings, particularly at the apices

Question 11

What is a “blue bloater”?

Answer 11

A patient with predominantly chronic bronchitis, a chronic productive cough, and frequent exacerbations caused by chest infections

Question 12

What are the physical examination features of “blue bloaters”?

Answer 12

• Cyanosis, polycythemia, and edema are often present.

- Chest exam is very noisy, with rhonchi and wheezing.

Question 13

What are the laboratory features of “blue bloaters”?

Answer 13

ABG with PFTs reveals hypoxemia, an elevated PaCO2, and normal TLC and DLCO.

Question 14

What is seen on the chest radiograph in these patients?

Answer 14

Reveals increased interstitial markings, particularly at the bases and thickening of the bronchial walls; diaphragms are not flattened.

Question 15

Which category do most patients with COPD fall into?

Answer 15

The majority of patients with COPD have both chronic bronchitis and emphysema

Question 16

List 5 risk factors for COPD:

Answer 16

Smoking, genetic predisposition, occupational exposure to dusts and chemicals, smoke from home cooking and heating fuels, and air pollution

Question 17

What is cor pulmonale?

Answer 17

Right-sided heart failure secondary to a pulmonary process, that is, not from a left heart problem

Question 18

What are the physical examination features of cor pulmonale?

Answer 18

May include increased P2, right-sided S4 and S3, tricuspid regurgitation murmur, jugular venous distention with a large V wave, hepatomegaly, hepatic tenderness, ascites, and edema

Question 19

What may the chest radiograph demonstrate in COPD?

Answer 19

Hyperinflation, increased size of the retrosternal airspace, decreased vascular markings and hypolucency of the apices, bullae, interstitial markings, predominantly at the bases (“dirty lungs” secondary to peribronchiolar fibrosis/inflammation), low, flat diaphragms, and enlarged pulmonary arteries

Question 20

What pathologic changes occur with cigarette smoking?

Answer 20

Upper lobe centrilobular emphysema

Question 21

What is the first laboratory test to check when looking for a genetic cause of COPD?

Answer 21

α1-Antitrypsin levels

Question 22

What is the pathologic change that occurs with α1-antitrypsin disease?

Answer 22

Panacinar emphysema that favors the lower lobes

Question 23

What other organ systems are affected in α1-antitrypsin disease?

Answer 23

The liver (chronic active hepatitis, cirrhosis), and rarely the skin (necrotizing panniculitis)

Question 24

What is a bulla?

Answer 24

A sharply demarcated area of emphysema, measuring 1 cm or more in diameter and possessing a wall <1 mm in thickness

Question 25

What is a bleb?

Answer 25

Gas-containing space within the visceral pleura

Question 26

What are the treatment options for stable COPD?

Answer 26

Smoking cessation, long- and short-acting anticholinergic agents (ipratropium bromide [Atrovent], tiotropium [Spiriva]) and β-adrenergic agonists (albuterol, salmeterol [Serevent], formoterol [Foradil]), inhaled and oral steroids, theophylline, oxygen, including transtracheal, pulmonary rehabilitation, NIPPV, and anabolic steroids

Question 27

What treatments for COPD have been shown to improve mortality?

Answer 27

Smoking cessation

Question 28

What treatments for COPD have been shown to decrease exacerbations?

Answer 28

Pulmonary rehabilitation and inhaled steroids

Question 29

What are the treatment options for acute COPD exacerbations?

Answer 29

• Give oxygen if the O2 saturation is <90%; monitor for hypercarbia with an ABG.
• Give nebulized albuterol and ipratropium bromide. IV or oral steroids (0.5–1 mg/kg/d up to 125 mg every 6 hours, followed by a taper over 2 weeks). Consider giving antibiotics if the patient has 2 of the following 3 criteria: dyspnea, increased volume of sputum, and purulent sputum.
• Consider NIPPV before endotracheal intubation.
• Consider inhaled corticosteroids at discharge.

Question 30

Are oral or IV steroids better for COPD exacerbations not requiring ICU admission?

Answer 30

There is no difference in outcomes for oral versus IV steroids in COPD patients not requiring ICU admission.

Question 31

List the side effects of theophylline.

Answer 31

Nausea, vomiting, tremors, headache, seizures, tachyarrhythmias, hyperglycemia, hypokalemia, difficulty urinating in elderly males with prostatism, aggravation of peptic ulcer disease and gastroesophageal reflux, and sleep disturbance such as insomnia

Question 32

What organisms are referred to as “smoker’s bugs”?

Answer 32

Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae

Question 33

What antibiotics can be used for outpatient exacerbation of COPD?

Answer 33

• Trimethoprim-sulfamethoxazole, amoxicillin, tetracycline (cost-effective), amoxicillin-clavulanate, cefuroxime, advanced-generation macrolides/azalides, and quinolones.
• Erythromycin is not a good choice because it does not get two-thirds of the most important microorganisms, H. influenzae and M. catarrhalis.
• It does get S. pneumoniae.
• Beware of the interaction of theophylline with erythromycin and clarithromycin.

Question 34

What are the most common precipitants of acute respiratory failure in patients with COPD?

Answer 34

• Infection, CHF, medical noncompliance, sedative medications, pulmonary embolism, and rib fracture.
• Infection is the most common precipitant.

Question 35

When is oxygen therapy indicated?

Answer 35

When the room air PaO2 is ≤55 mm Hg (SaO2 ≤88%) or the PaO2 is <60 mm Hg (SaO2 <89%) in a patient with polycythemia (hematocrit >55 mg/dL) or cor pulmonale. Oxygen may cause worsening hypercarbia.

Question 36

Which is more rapidly lethal, hypoxemia or hypercarbia?

Answer 36

Hypoxemia kills.

Question 37

What vaccinations should be given to patients with COPD?

Answer 37

Pneumovax (if given before age 65 then repeat once after age 65) and influenza vaccine (yearly in the fall)

Question 38

What is the long-term prognosis for COPD patients hospitalized on mechanical ventilation who are discharged to home?

Answer 38

50% 1-year mortality rate

Question 39

What are the indications for lung transplantation for COPD?

Answer 39

• FEV1 <25% of predicted
• Room air, resting PaO2 <55–60 mm Hg
• Hypercapnia (PaCO2 ≥55 mm Hg)
• Secondary pulmonary HTN
• Clinical course: Rapid rate of decline in FEV1 or life threatening exacerbations
• Age criterion for single lung transplantation is generally 65 years.

Question 40

What is the survival rate after lung transplantation?

Answer 40

• 75% at 1 year

- 60% at 2 years

Question 41

What is lung volume reduction surgery?

Answer 41

Lung volume reduction surgery removes a portion of emphysematous lung tissue to improve the function of remaining lung