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3rd year - Family Medicine > Resp > Flashcards

Resp Flashcards

1
Q

What is asthma?

A

asthma is a disease of airflow obstruction due to airway inflammation that varies over time

asthma is characterized by pathophysiology of bronchoconstriction, mucus plugging, airway inflammation and edema hyper-responsiveness to various stimuli

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2
Q

Samter’s triad

A

asthma + nasal polyps + sensitivity / intolerance to NSAID / aspirin

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3
Q

Asthma pathophysiology

A

eosinophilic inflammation causing narrowing of airway as an immune response to allergen

1) allergen taken up by antigen presenting cell (dendritic cell or macrophage)
2) antigen presenting cell activate CD4 Th2 T cell, which secrete IL-4 and activate B cell to produce IgE antibodies
3) IgE antibodies attach to Fc receptors on mast cells, arming mast cells
4) on subsequent exposure, allergen bind to IgE on mast cells, causing mast cell degranulation
5) mast cell degranulation release inflammatory cytokines causing inflammation resulting in early phase asthmatic response (early asthma attack) inflammatory cytokines include histamine, IL-4, IL-5, leukotriene, serotonin, prostaglandin, eotaxin inflammatory cytokines increase vascular permeability, vascular inflammation, bronchospasm, airway hyperresponsiveness
6) inflammatory cytokines recruit leukocytes (including eosinophils) into airway tissue, resulting in inflammation resulting in late phase asthmatic response (late asthma attack) leukocytes cause increased vascular permeability leading to edema, smooth muscle contraction leading to bronchoconstriction, activation of goblet cells leading to increased mucus secretion
7) chronic inflammation cause remodelling of airway resulting in chronic asthma post asthmatic attacks eosinophils and lymphocytes release factors inducing permanent remodelling of airway, resulting in permanent narrowing of airway, such that airway function cannot return to normal level completely in chronic asthma even when treated with bronchodilator

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4
Q

What is status asthmaticus

A

severe asthma attacks that are poorly responsive to bronchodilators

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5
Q

What is the asthma control criteria

A

Good asthma control if all conditions are met
Poor if one isn’t met

Daytime symptoms - <4 days per week
Need for a fast acting beta 2 agonist - <4 doses per week
Nighttime symptoms - <1 night per week

Physical activity - normal
Exacerbations - mild, infrequent
Absence from work or school due to asthma - never

FEV1 or PEF - 90% + of personal best
PEF diurnal variation - <10-15%
Sputum eosinophils - <2-3%

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6
Q

PFT results seen in asthma

A

scooped flow volume curve low FEV1 (<80% predicted)

significant improvement in FEV1 with bronchodilator (improvement in FEV >12% provided improvement >200mL)

low FEV1/FVC ratio (<0.7 in adults, <0.8 in children)

disproportionately low FEF25-75 and FEF75

decreased peak flow

DLCO normal

increased airway resistance

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7
Q

What is the methacholine challenge

A

in asthma, with airway challenge with methacholine, usually significant (>20%) drop in FEV1 with small amount of methacholine (<8mg/mL)

PC20 = concentration of methacoline at which FEV decrease by 20%

PC20 <8mg/mL suggest asthma

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8
Q

What is airway challenge with exercise diagnosis

A

in asthma, with airway challenge with exercise, usually significant (>10%) drop in FEV1 by 80% maximum heart rate

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9
Q

Diagnosis of asthma

A

asthma diagnosed based on all of the following

  1. clinical history of asthma symptoms and asthma attacks
  2. PFT showing reversible obstructive lung disease:

scooped flow volume curve

low FEV1 (<80% predicted)

significant improvement in FEV1 with bronchodilator (improvement in FEV >12% provided improvement >200mL)

low FEV1/FVC ratio (<0.7 in adults, <0.8 in children)

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10
Q

What is a parameter that can be used to monitor asthma at home

A

peak flow

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11
Q

Asthma pharmacological management

A

all patients start with fast acting bronchodilator (SABA) PRN and add ICS if require maintenance therapy with ICS

if asthma is not controlled (see asthma control criteria), add in the following order:

increase ICS dosage

add long acting beta-adrenoreceptor agonist (LABA) note that long term use of LABA increase risk of severe asthma attacks
ICS LABA combinations include budesonide/formeterol, fluticasone/salmeterol, mometasone/formoterol
ICS LABA combinations can also replace SABA as emergency puffer but is 2nd line to them

leukotriene receptor antagonist (LTRA) (Montelukast sold as Singulair)

Theophylline

oral prednisone

if patient ever had an asthma attack, automatically add ICS and LABA upon discharge

if SABA is used more frequent than Q4H, then send to emergency

SABA should be used sparingly, because frequent use of bronchodilator results in tolerance and increases frequency of asthma attacks

all medications are safe to use during pregnancy

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12
Q

Management of acute asthma exacerbation

A
  1. Assess for current state and complications
  2. SABA and short acting anti-cholinergic (SAAC) to relieve dyspnea

if symptoms still uncontrolled, can use IV SABA in ICU

setting systemic oral or IV corticosteroid to reduce inflammation, which aborts exacerbation, prevent relapse, speeds recovery and decrease need for hospitalization

proper hydration

if hypoxemia, then oxygen therapy

if respiratory failure, mechanical ventilation

  1. Treat underlying cause (ex. infection, beta blocker…), treat cormobidities
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13
Q

Why is ICS not used during asthma attack

A

ICS is slow acting and may not be breathed in during respiratory distress, so not used during asthma attack

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14
Q

Metered dose inhaler (MDI) procedure

A

1) shake inhaler
2) take off cap
3) sit up straight or stand with chin lifted up
4) exhale completely
5) seal with lips on the inhaler tightly and start inhaling slowly
6) depress top of inhaler once
7) hold breath for >10 seconds
8) wait 45-60 seconds between puffs
9) rinse mouth

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15
Q

Dry powder inhaler (DPI) procedure

A

1) hold disk level with one hand
2) push notch away from user as far as possible with other hand, such that the mouth piece appears
3) push lever away from user as far as possible with other hand until it clicks
4) lock lips onto the mouth piece
5) breath deeply with mouth
6) hold breath for >10 seconds
7) slide notch and lever back to original position, such that disk is ready for another dose

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16
Q

Common ICS

A

Budesonide (Pulmicort)

Fluticasone (Flovent)

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17
Q

What is the only asthma medication shown to decrease mortality

A

ICS

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18
Q

ICS MOA

A

late onset with greatest effect within 3 months

inhibit production of cytokine resulting in anti-inflammatory effects (reduce eosinophil infiltration, inhibit macrophage function and reduce production of leukotrienes)

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19
Q

ICS adverse effects

A

ICS is inhaled, so its effect is localized to lung and do not have any systemic adverse effects

thrush oral candidiasis, which can be reduced by using inhaler with spacer and followed by mouth rinse

dysphonia (impaired ability to produce voice)

osteoporosis (only for high dose steroid in high risk patient population who need to be monitored regularly with bone mineral density scan)

decreased growth velocity in short term for children, but no change in adult height

adrenal suppression

worsening of glaucoma (only in high risk patient with glaucoma who need to be monitored regularly in terms of intra-ocular pressure)

increased risk of cataract, which is rare and does not require routine surveillance

skin thinning

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20
Q

Long acting beta 2 agonist LABA examples

A

Salmeterol (Serevent), green diskus DPI

Formeterol (Oxeze), green turbuhaler MDI

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21
Q

LABA MOA

A

same mechanism as SABA, but with longer lasting effect

1) beta agonist binds beta adrenergic receptor, which activate intracellular adenyl cyclase to convert ATP to cAMP
2) increased cAMP relaxes bronchial smooth muscle, resulting in bronchilation

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22
Q

LABA adverse effects

A

similar to SABA

sympathetic effects: tachycardia, tremor, headache, agitation, irritability

metabolic: hypokalemia, hyperglycemia

prolonged QT, which can lead to arrythmia

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23
Q

Commonly used combined ICS/LABA

A

Fluticasone/Salmeterol (Advair), MDI or diskus DPI

Budesonide / Formoterol (Symbicort), turbuhaler MDI

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24
Q

Indication for LTRA use

A

used as controller (i.e. taken regularly no matter if symptoms appear) and 2nd or 3rd line therapy

usually added to ICS for uncontrolled symptoms

can substitute LABA with LTRA, but usually added to ICS and LABA

preferred treatment and more effective for asthmatic patient with more allergic profile of eczema, nasal polyps, rhinitis, aspirin allergy

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25
Q

Commonly used LTRA

A

Montelukast (Singulair), PO

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26
Q

LTRA MOA

A

LTRA has anti-inflammatory and bronchodilator properties

1) LTRA is a selective antagonist of cysterinyl leukotriene receptor
2) blocking cysterinyl leukotriene receptor decreases airway edema, relaxes smooth muscle (bronchodilator) and decrease mucus secretion

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27
Q

LTRA adverse effects

A

LTRA usually very well tolerated with rare adverse effects

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28
Q

Theophylline MOA

A

theophylline is a methylxanthine, which directly relaxes smooth muscle around bronchi and pulmonary blood vessels, causing bronchodilation

also block phosphodiesterase, increasing cAMP causing bronchodilation

decrease eosinophil infiltration into bronchial mucosa

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29
Q

Theophylline adverse effects

A

theophylline is last line controller, because it has narrow therapeutic range, it has many drug interaction and there are individual differences in metabolic clearance

patients on theophylline require regular monitoring of serum theophylline due to potential toxicities if outside therapeutic range

adverse effects at therapeutic dosages include
insomnia
hyperactivity 
gastric upset 
difficulty urinating with prostatism

adverse effect due to high dose
sympathetic effects: tachycardia, tachyarrhythmia, headache
metabolic effects: hypokalemia, hyperglycemia
seizure
hematemesis

30
Q

1st line controller medication for COPD

A

LAAC

31
Q

Commonly used LAAC

A

Tiotropium (Spiriva)

32
Q

LAAC MOA

A

long acting M3 muscarinic receptor antagonist, resulting in bronchodilation and decreased mucus secretion

33
Q

LAAC adverse effects

A

anticholinergic effects

worsening of glaucoma and BPH

34
Q

Indications for SAAC or systemic corticosteroid in asthma and COPD

A

SAAC, systemic corticosteroid usually only used for asthma or COPD exacerbations

35
Q

SABA indication in asthma and COPD

A

SABA PRN given to all asthma or COPD patients for respiratory symptoms

36
Q

Commonly used SABA

A

Salbutamol (Ventolin) MDI, blue puffer

Terbutaline (Bricanyl) DPI

37
Q

SABA MOA

A

fast onset within 1-3 minutes and last ~45 minutes

1) beta agonist binds beta adrenergic receptor, which activate intracellular adenyl cyclase to convert ATP to cAMP
2) increased cAMP relaxes bronchial smooth muscle, resulting in bronchilation

38
Q

SABA adverse effects

A

sympathetic effects: tachycardia, tremor, headache, agitation, irritability

metabolic: hypokalemia, hyperglycemia

39
Q

Commonly used SAAC

A

Ipatropium, green puffer MDI

40
Q

SAAC MOA

A

competitive inhibitor of muscarinic cholinergic receptor, decreasing parasympathetic activity and resulting in bronchodilation

SAAC is a less potent bronchodilator than SABA

41
Q

SAAC adverse effects

A

anticholinergic

may increase wheezing

42
Q

Commonly used systemic corticosteroids

A

Prednisone oral pills PO

Solumedrol IV

43
Q

Systemic corticosteroids MOA

A

systemic anti-inflammatory effect, mainly reducing eosinophilic inflammation in asthma

44
Q

Systemic corticosteroid adverse effects

A

unlike ICS, systemic corticosteroid associated with many adverse effects

  1. short term adverse effects include:

metabolic effects: weight gain, increased appetite, hyperglycaemia

psychiatric effects: mood alteration

immune effects: immunocompromise

peptic ulcer disease

fluid retention

  1. long term adverse effects include:

metabolic effects: diabetes, adrenal axis suppression, Cushing’s syndrome

cataract

hypertension

muscle weakness

peptic ulcer disease

osteopenia with increased risk for fracture

skin thinning

45
Q

What is the CURB65 score

A

CURB65 score calculation

confusion = 1 point 
BUN >7mmol/L = 1 point 
respiratory rate >30 = 1 point 
blood pressure low (systolic <90mmHg or diastolic <60mmHg) = 1 point 
age >65 = 1 point

CURB score
0-1 = treat as outpatient
2-3 = hospitalize or monitor closely as outpatient
4-5 = hospitalization including consideration for ICU

46
Q

Outpatient management of pneumonia

A

Azithromycin or clarithromycin or doxycycline

47
Q

Acute cough

A

<3 weeks

48
Q

Subacute cough

A

3-8 weeks

49
Q

Chronic cough

A

> 2 months

50
Q

Normal neck circumference

A
  1. 5 inches women

17. 5 inches men

51
Q

CPAP requirements for driving

A

driving guidelines usually require patients with OSA to be compliant with CPAP treatment for >4 hours of use on >70% of nights they may drive

52
Q

What is a hypopnea

A

decreased airflow (>50% reduction) with decreased oxygen saturation (>4% decrease) or EEG aoursal

53
Q

AHI equation and meaning of results

A

AHI = (# apnea events + # hypopnea events) / time asleep in hours

in adults AHI 
<5 / hour is normal
>5 / hour is OSA 
6-15 / hour is mild OSA
16-30 / hour is moderate OSA
>30 / hour is severe OSA
54
Q

Diagnostic criteria of OSA

A

OSA is diagnosed in a patient who has (A or B) plus C

A - excessive daytime sleepiness that cannot be explained otherwise

B - 2+ of the following with no other explanation recurrent choking or gasping in sleep
recurrent awakening from sleep
daytime fatigue

C - AHI >5

55
Q

Indications for OSA treatment

A

symptomatic (daytime sleepiness, daytime fatigue, recurrent awakening in sleep, choking / gasping in sleep etc)

AHI >15, which is associated with significant increased risk of cardiovascular disease

occupation in which safety is critical (e.g. pilot)

presence comorbid medical condition of which OSA may contribute to (hypertension, cardiovascular disease, pulmonary hypertension, heart failure)

56
Q

Indication for BiPAP in OSA

A

Bi-level therapy Positive Airway Pressure (BiPAP) may be used instead of CPAP for large size adults requiring more positive pressure

57
Q

Small bowel obstruction top 3 causes

A
  1. Adhesions
  2. Hernia
  3. Malignancy
58
Q

Large bowel obstruction top 3 causes

A
  1. Malignancy

2. Volvulus

59
Q

What is dyspepsia

A

1+ of the following symptoms
post-prandial fullness
early satiety
epigastric pain or burning

60
Q

What tests can be performed to test for H. Pylori in order of sensitivity and specificity

A

sensitivity & specificity: serology < fecal antigen test / urea breath test < EGD biopsy

61
Q

Cause of peptic ulcer from most to least common

A

1) H. pylori infection in 75% of cases
2) NSAID in 5-25% of cases
3) cancer (rare, but important to consider)
4) idiopathic and other stress ulcer in severely ill patients chemotherapy or radiation ulcer acid hyper secretion syndrome crack cocaine

62
Q

H Pylori eradication therapy

A

Treatment only for patients with dyspepia, ulcer, malignancy -> most with H Pylori are asymptomatic

1st line = triple therapy of 2 antibiotics and 1 PPI for 10-14 days

  1. clarithromycin
  2. amoxicillin (or Metronidazole for patients allergic to penicillin)
  3. PPI

2nd line = quadruple therapy of PPI, bismuth and 2 antibiotics for 10-14 days

  1. Metronidazole
  2. Tetracycline (or Doxycycline)
  3. Bismuth
  4. PPI

H. pylori eradication is difficult with success rate of ~90%

4+ weeks after completion of therapy, eradication confirmed by urea breath test, fecal antigen test or EGD biopsy

confirmation of eradication recommended for all patients, but especially for patients with persistent symptoms after eradication therapy, peptic ulcer, gastric lymphoma or gastric cancer

63
Q

Imaging modality of choice for gastric cancer

A

CT

64
Q

Functional dyspepsia diagnosis

A

diagnosis based on Rome criteria fulfilled for >6 months

A) >1 of the following symptoms
post-prandial fullness
early satiety
epigastric pain or burning

B) no evidence of structural disease to explain symptoms

65
Q

Functional dyspepsia management

A
  1. Test and treat PRN H pylori
  2. Anti-secretory therapy trial 4-8 weeks
    1st line - PPI
    2nd line - H2RA
  3. Antidepressants trial of 4-6 weeks
    3rd line = tricyclic antidepressants
  4. Prokinetic agents trial of 4 weeks
    dopamine antagonist: Metoclopramide, Domperidone
66
Q

IBS clinical presentation

A

chronic abdominal pain or discomfort

chaotic defecation (period of normal bowel movement punctuated by episodes of constipation and / or diarrhea)

67
Q

IBS diagnostic criteria

A

ROME III

patients have irritable bowel syndrome if they have all of the following 2 criteria for >3 months with onset >6 months prior to diagnosis

1) recurrent abdominal pain or discomfort

2) 2+ of:
improvement with defecation
onset associated with change in stool frequency
onset associated with change in appearance of stool

68
Q

Definition of constipation

A

defecation <3 times a week of hard and lumpy stool with straining

69
Q

Rome III criteria for functional constipation

A

1) 2+ of the following
straining for >1/4 of defecation
lumpy or hard stool for >1/4 defecation
sensation of incomplete evacuation for >1/4 defecation
sensation of anorectal blockage for >1/4 defecation
manual maneuver for >1/4 defecation
<3 bowel movements per week

2) loose stools rarely present without use of laxative

70
Q

Diagnostic approach to constipation

A

1) always perform history, physical exam and standard work up (laboratory test, decal occult blood test, colonoscopy)
2) after ruling out causes by history, physical exam and standard work up, start trial of lifestyle modification, fiber and laxatives
3) if trial of lifestyle modification, fiber and laxatives were inadequate, consider further work up (anorectal manometry, balloon expulsion test, defecography, colonic transit test)

71
Q

Constipation management

A

1) Treat underlying cause
2) Symptomatic management

lifestyle modification: increase fluid intake, physical exercise, going to washroom regularly

1st line = fiber supplementation including Psyllium (Metamucil)

2nd line = laxative, which are added in the following priority

a) Magnesium Hydroxide (Milk of Magnesia)
b) Bisacodyl (Duclolax)
c) Polyethylene Glycol (Golytely, Colyte)

last line = enema PRN after several days of constipation to prevent fecal impaction

3rd year - Family Medicine (9 decks)

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