Respiratory Disease

Question 1

Diagnosis of COPD?

Answer 1

Clinical suspicion CONFIRMED by spirometry FEV1/FVC < 0.7

Question 2

Differential for COPD?

Answer 2

-Asthma (trigger related) -Bronchiectasis (recurrent lobar PNA) -CHF (edema, heart dx, cardiomegaly) -Chest wall disorders -Cystic fibrosis (lifelong symptoms) -Interstitial lung dx (restrictive pattern( -Lung cancer -Pulmonary hypertension -Tuberculosis -Vocal cord dysfunction

Question 3

How to assess severity of COPD?

Answer 3

GOLD combined assessment Includes 1) spirometry 2) # of exacerbations 3) MMRC or CAT score

Question 4

Assess; Spirometry 60%, one exacerbation requiring hospitalization, MMRC of 1?

Answer 4

GOLD 2/A

Question 5

Treatment for COPD?

Answer 5

Step up Therapy

A: SABA or SAMA (albuterol/levalbuterol, ipratroprium/atrovent)

then add

B: LABA or LAMA (salmeterol/formeterol, tiotroprium/spiriva)

then add

C: ICS and/or PDE4 inhibitor (fluticasone, roflumilast)

Question 6

What does smoking cessation do for COPD?

Answer 6

Decreases rate of decline of FEV1 AND mortality

Question 7

For COPD, what effect do B2 agonist and anticholinergics have?

Answer 7

Decrease rate of FEV1 decline

Decrease hospitalizations

Question 8

When should anticholinergics be avoided in COPD patients?

Answer 8

those with underlying heart disease b/c they increase cardiovascular events

Question 9

When to avoid LABA monotherapy in COPD?

Answer 9

those with comorbid Asthma

Question 10

What about ICS in COPD?

Answer 10

Decrease FEV1 decline, hospitalizations, and improve quality of life BUT increase risk of pneumonia

Question 11

What role does O2 therapy play in long term COPD?

Answer 11

Decreases mortality in select patients (resting measures)

Pa oxygen < 55mmHg

or

SpO2 88% or less

Need to use it for at least 15hrs daily with target SpO2 88 to 92%

Question 12

What role does pulmonary rehab play in COPD?

Answer 12

Meta-analysis shows it can reduce dyspnea and increase exercises ability/quality of life

Mainly for peeps w/ FEV1 less than 50% of predicted

Must do it for at least 6 months

Question 13

What role does surgery play in COPD?

Answer 13

Can help only in select populations

Severe upper-lobe predominant emphysema and low post-rehab exercise capacity

Lung volume reduction surgery can improve survival in these pts over 5yrs vs medical therapy

Question 14

What vaccinations whould COPD people get?

Answer 14

• yearly influenza
• one dose pneumovax 19 to 64 years of age who smoke or have COPD
• after 65yo both prevnar and pneumovax should be given a year apart

Question 15

What is not currently recommended for long-term treatment of COPD?

Answer 15

Mucolytics, antitussives, antibiotics

Question 16

How to determine risk of death in COPD patients?

Answer 16

BODE index, its an estimated 4yr survival rate, MDcalc

Question 17

What are some signs of acute respiratory failure?

Answer 17

RR > 30

Accessory muscle use

PaCO2 increased from baseline or 50-60mmHg

Acidosis?

Question 18

Do methylxantines play a role in COPD exacerbation?

Answer 18

No

Question 19

Can COPD exacerbations be managed at home?

Answer 19

Yes

Around 80% of them are

Question 20

What signs might warrant admission for COPD exacerbation?

Answer 20

Severe COPD at baseline; FEV1 <50% of predicted

Hix of frequent exacerbations or hospitalization

Comorbidities

Failure of outpt therapy

Inadequate response to ED management

Marked increase in intensity of symptoms over baseline

Frail or no home support

Question 21

Prednisone dose and length for exacerbation of COPD?

Answer 21

40mg for 5 days

Question 22

GOLD guidelines recomennd antibiotics for which exacerbations?

Answer 22

Moderately or severely ill patients (those requiring admission)

Azithromycin

Question 23

What therapies DO NOT work in COPD?

Answer 23

Mucolytics

Methylxanthines

Nebulized magnesium

Chest physiotherapy

Question 24

Before mechanically ventilating a COPD exacerbation, should consider what?

Answer 24

NIPPV

Improves outcomes, preferred method

Pins 10cm H20/Pexp 5cmH20

Question 25

IDSA recommendations for outpatient CAP without comorbidities? (2019)

Answer 25

Amoxicillin or

Doxycycline or

Azithromycin monotherapy (if local resistance < 20%)

Question 26

IDSA recommendations for outpatient CAP WITH comorbidities?

Answer 26

Combination therapy

Augmentin or cephalosporin

AND

Macrolide or doxy or FQ

Question 27

Should you use Procal to guide your CAP diagnosis/abx decisions?

Answer 27

IDSA 2019 recommends against it

Question 28

Which patients with CAP go directly to ICU?

Answer 28

Hypotension requiring vasopressors

Respiratory failure requiring mechanical ventilation

Mortality is increased if these guys go to general floor first

Question 29

Best test to screen for TB in child < 5yo?

Answer 29

TST, per ATS guidelines

Question 30

Best test to screen for TB in child >5yo who is likely to be infected?

Answer 30

IGRA, per ATS guidelines

Question 31

Do healthcare workers need serial TB screening?

Answer 31

Depends

Per CDC guidelines 2019, US HC workers should not undergo serial testing if initial negative, unless in high risk field (ex pulmonologists, ED workers)

In high incidence areas, probably wise

Question 32

Latent TB treatment?

Answer 32

*per CDC, shorter regimens are effective, safe, and have higher completion rates than 6-9mo regimens*

3HP; 3mo of weekly INH + rifapentine

4R; 4mo of daily rifampin

3HR; 3mo of daily INH + rifampin