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DEN303 - IHD > Respiratory Disorders and their Management > Flashcards

Respiratory Disorders and their Management Flashcards

Gain knowledge about the symptoms, signs and management of COPD Asthma Lung Cancer Fibrotic Lung Disease Obstructive Sleep Apnea Appreciate the action of different drugs used to manage patients with Asthma or COPD

1
Q

Statistics of resp disorders

A

3M prevalence

Majority diagnosed in 1950s

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2
Q

Diagnosis of COPD via…

A

Spirometry
FEV1/FVC less than 70%
Suboptimal predictor

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3
Q

FVC

A

Continuing volume breathed out

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4
Q

FEV1

A

Volume breathed out in 1 sec

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5
Q

Symptoms of COPD

A

Wheeze
Cough
Weight loss
Shortness of breath on exercise

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6
Q

Acute symptoms

A

Acute sob
Worsening sputum production
Fever
Drowsiness/CO2 narcosis

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7
Q

Signs of COPD

A 
Cachexia
Use of accessory muscles
Pursed lips
Cyanosis
CO2 flap 
Drowsiness in CO2 narcosis
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8
Q

Chest related signs

A 
Hyper expanded chest 
Hyper resonant 
Reduced breath sounds 
Wheeze
Elevated JVP and peripheral oedema in late disease
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9
Q

Disease severity defined by

A

clinical parameters

  • lung fx
  • symptoms
  • exacerbation frequency
  • BODE index
  • FEV1/FVC < 70
  • CAT score where patient answers q on scale of 1-5
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10
Q

Inhaled treatment of COPD

A

Short acting B agonists
Short acting muscarinic agonists
Inhaled steroid treatment never given alone

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11
Q

Management of stable COPD - smoking cessation

A

Nicotine replacement therapy
Bupropion
Varenicline

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12
Q

Management of stable COPD - Oral Theophylline

A

Trial of therapy

Risk of side effects

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13
Q

Management of stable COPD - Oral mucolytic therapy

Name of common anti mucolytic

A

Carbocisteine - antioxidant

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14
Q

Management of stable COPD - vaccination therapy

A

Annual flu and 5 yearly pneumococcal vaccine

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15
Q

Management of stable COPD - Pulmonary rehab

Involves?

A

Muscle reconditioning
Improves QoL, exercise tolerance
Non-pharm intervention
Diet support - BMI 20-25

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16
Q

Management of stable COPD - surgery

A

Only really in patients with severe disease
Lung volume reduction surgery - i.e removal of hyper expanded areas
Placement of endobronchial valves
Bullectomy - removal of bullet shaped regions of tissue

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17
Q

Oxygen therapy

A

Long term oxygen therapy
Ambulatory service
Short Burst oxygen therapy

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18
Q

LTOT

A 
Long term oxygen therapy
MIn. 14 hrs/day continuous o2 therapy
Prognostic 
For patients with consistent respiratory failure 
PO2 < 7.3 kPa 
PO2 7.3-8kPA + secondary polycythaemia 
Nocturnal O2 levels < 90 for > 30% of the night 
Peripheral oedema
Pulmonary hypertension
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19
Q

Management of stable COPD - ambulatory oxygen/SBO2

A

Desaturation on exercise
Can increase exercise with Supplemental o2
delivered by cylinder
SBO2 for palliative care

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20
Q

Prevention of exacerbation

A

Seasonal flu vaccination
Inhaled steroids
Other agents e.g anticholinergics/mucolytics
Pulmonary rehabilitation

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21
Q

Case 1

A

History
Duration of onset
Change in volume and colour of sputum
Use of o2?
Occupational history
PYH - pack year history - (cigs consumption/day) X no. years smoked // 20
Significant if >10
Significance of breathing through pursed lips
Increasing pressure within windpipe and bronchioles to increase gas exchange and splints alveoli open for longer
Advice
Visit GP
Antibiotics given if 2/ increasing dyspnoea , sputum vol/purulence

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22
Q

Treatment of COPD - antibiotic

A 
Antibiotic - oral prednisolone
7-10 days 
More rapid improvement in physiology 
Shortens hospital discharge 
Must weigh severity against side effects
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23
Q

Ventilation is stimulated by

A

Small rise in PCO2 with large fall in PO2

Too much supplemental O2 can result in lack of ventilation stimulation

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24
Q

Treatment of COPD - Non-invasive ventilation

A

Delivered by face/nasal mask
Supplemental o2 supply
Lungs can deflate properly - expiration of CO2
Transcutaneous CO2 monitoring on ear

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25
Q

Asthma

A

Constricted airways during attack and production of excess mucus

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26
Q

Diagnosis of asthma

A

Peak flow amplitude
FEV1/FVC ratio <70%
Bronchodilators response

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27
Q 
Asthma case 1
25 y/o
anxiety
shortness of breath on sitting down
blue inhaler doesn't help
A

History
Duration/onset
Triggers
Severity of illness

Signs on examination 
Elevated resp rate
Inability to complete sentence
Peripheral cyanosis - bluish discolouring - hypoxia
Audible wheeze

Bedside tests
Heart rate
Respiratory rate
Peak flow rate

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28
Q

Symptoms of asthma and potential triggers

A 
Wheeze
Cough, chest tightness, dyspnoea (laboured breathing), nocturnal duration 
Exertion 
Dust
Change in temp
Emotional situations 
Occupation
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29
Q

Signs of asthma and exacerbations

A

Eczema
Nasal polyps
Cushingoid (on steroids)
Wheeze

Assess RR
Heart rate
SpO2
Speaking ability

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30
Q

Method of delivery of inhaled drugs

A

Metered Dose inhaler -SABA
Inhale with simultaneous depression of canister with breath hold for 10 secs

MDI via spacer - 10puffs of salbutamol via spacer equivalent to nebuliser
Give 4 puffs initially then 2 puffs every 2mins up to max of 10puffs

Breath actuated

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31
Q

Patients at risk of developing near fatal/fatal asthma

A

Not taking correct treatment
Failure to attend appts
Self discharge

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32
Q

Lung cancer stats

A

Main cause of cancer related death

2nd most common in UK

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33
Q

Lung cancer spread

A

Risk of spread from primary tumours

Enlargement of lymph nodes is indicative of malignant infiltration

34
Q

Lung cancer - NON SMALL CELL LUNG CANCER

A

85%
Squamous cell
Adenocarcinoma
Adenocarcinoma in situ

35
Q

Lung cancer - CHEST SYMPTOMS

A 
Dependant upon stage of disease 
Sometimes very minor
Sob
Chest pain 
Cough 
Haemoptysis
36
Q

Lung cancer - constitutional symptoms

A

Weight loss
Low appetite
Low energy levels

37
Q

Lung cancer - paraneoplastic syndromes

A

High calcium (PTH release or bone involvement) - nausea, confusion, abdo pain, constipation
SIADH - confusion, fits, lethargy
Hypertrophic pulmonary osteoarthropathy
Neuromuscular weakness

38
Q

Lung cancer - metastatic disease

A

SVCO due to mediastinal disease
Brain metastasis - confusion nausea
Bone mets - path fracture, pain
Liver mets - abdo pain

39
Q

Lung cancer -signs

A 
Finger nail clubbing
Cachexia
Horner’s syndrome
Neck nodes
Chest signs
Palpable liver
SVCO
40
Q

Diagnosis of lung cancer

A

Radiographs, CT

41
Q

Diagnosis of lung cancer - CT

A

Staging tool
Detailed
Contrast

42
Q

Diagnosis of lung cancer - PET Scan

A

Infusion of FD glucose

Detects cancer, infection and vasculitis

43
Q

Diagnosis of lung cancer - tissue biopsy

A

Image guided - chest, liver, nodes
Bronchoscopy
Thoracoscopy for pleural disease
Surgical

44
Q

WHO performance status

A

0: able to carry out all normal activity without restriction
1: restricted in strenuous activity
2: ambulatory and capable of all self care
3: symptomatic in chair/bed >50% day
4: completely disabled

45
Q

Treatment is dependent upon

A 
Stage 
WHO performance status 
Chemotherapy for extensive 
RT for limited disease
Immunotherapy
46
Q

Interstitial lung disease examples - 3

A

ILD
Diffuse parenchymal lung disease
Lung fibrosis

47
Q

Classifications of ILD

A

Idiopathic
Drug reaction
Extrinsic allergies

48
Q

Symptoms of ILD

A

Difficult breathing
Cough
Onset of symptoms may identify aetiology
EAA - extrinsic allergic alveolitis – post exposure
IPF – chronic
AIP - ACUTE INTERSTITIAL PNEUMONIA – rapid onset

49
Q

Signs of ILD

A 
Signs of CTD
Nail clubbing 
Sclerodactyly - symptomatic sclerosis 
Lower zones - AIP 
Upper zone crackles for EAA
Chest squeaks suggest small airway disease
50
Q

IPF
Features
Survival
Diagnostics

A 
Idiopathic pulmonary fibrosiskFEV1/FVC ratio preserved 
Male
Older population 
Median survival 3 years
Lower zone 
Restrictive spirometry 
Diagnosis can be made from CT
51
Q

IPF Treatment

A 
Supportive
Rehab
Pirfenidone when FVC < 80%
Nintenadib FVC 50-80%
Opiates
Role of steroids is controversial
52
Q

EAA
Definition
Trigger

A

Extrinsic allergic alveolitis
Trigger not clear
classic - baking, mould exposure
predominant upper zone predominance

53
Q

EAA treatment

A

Avoid antigen
Trial of corticosteroid
Ca and vit supplements
Bisphosphonates maybe

54
Q

Sleep apnoea

A

Excessive daytime sleepiness
Cessation of flow for 10 secs
Hypopnea - reduction of flow for 10 secs by >30%

55
Q

3 types of sleep apnoea

A

Obstructive sleep apnoea -OSA
Central
Mixed

56
Q

risk factors for OSA

A 
Obesity 
>17 inch collar
Men 2-3x more likely 
Age 
Craniofacial abnormalities e.g short mandible
57
Q

Sleep apnoea signs

A 
Excessive daytime sleepiness
Snoring 
Restless sleep 
Nocturia 
Decreased libido 
Impaire concentration
58
Q

OSA

DEFINITION

PROCESS

A

Reduction of flow primarily due to obstruction at posterior pharynx
Upper airway collapse

59
Q

Epworth sleepiness scale

A

0-24 scale
11-14 mild sleepiness
15-18 moderate sleepiness
>18 severe

60
Q

Diagnosis of OSA - use pulse oximetry

A

Cheap
Easy to use
Can be used at home
Can show false negative
Less sensitive in thin patients/issues with tissue perfusion
Measure 4% desaturation rate (ODI) - >10 events per hours suspicious

61
Q

Diagnosis of OSA - use polysomnography

A

Limited vs Full
Full considered Gold standard
Full PSG requires hospital admission
Measurement of EEG, eye & limb movements, nasal flow, thoraco-abdominal movement, ECG & oxygen saturation

62
Q

Morbidity associated with OSA

A

Untreated x2-3 risk of RTAs
CHD, CCF, hypertension and CVD
Insulin resistance and T2 diabetes

63
Q

OSA Treatment

A

Weight loss
Continuous positive airway pressure
Mandibular advancement device
Pharmacotherapy and surgery

64
Q

OSA Treatment - CPAP

A

Delivery of constant pressure by face/nasal mask
Abolition of apnoeas and hypopnoeas with improvement in o2 sat
effective

65
Q

OSA treatment - MAD

A 
Role when CPAP not tolerated 
Mild-moderate OSA
Anterior displacement of the mandible 
Variable results of trials 
MAD better than no-MAD 
CPAP better than MAD for 
Reduction of AHI/ODI 
Sleep fragmentation 
MAD better than CPAP for patient preference

MAD better than UPPP for AHI/ODI but snoring same for both.

66
Q

Pharmacotherapy in obstructive airway disease

SABD - mechanism

A

Short acting bronchodilators e.g salbutamol
Relief of symptoms
For PRN use
Use in COPD & Asthma
Immediate bronchodilation
4-6hour duration
Increase in cAMP with reduction in cell Ca2+ leading to relaxation of smooth muscle

67
Q

SABD - side effects

A 
Increased HR &amp; palpitations
Tremor
Hypokalaemia
Headache
Nervousness
68
Q

Long acting bronchodilator mechanism

A

LABD - last for >12hrs
Alternative to increasing dose of steroids
Given by inhaled route
Not to be used in monotherapy in Asthma
High selectivity for B2 adenoceptor in pulmonary tissue
Can increase glucocorticord receptor availability
Concern of sudden cardiac death when used in monotherapy

69
Q

Anticholinergic agents - mechanism

A

Relief of symptoms - mainly for COPD
Reduction in exacerbation freq in copd attacks
improvement in FEV1
BLOCK BRONCHOCONSTRICTION EFFECT OF VAGAL STIMULATION ON BRONCHIAL SMOOTH MUSCLE –> DILATION

70
Q

Anticholinergic agents - side effects

A

Possible effect on urinary retention
Dry mouth
Possible adverse cardiovascular effects (seen in severe cardiac disease)
Aggravated glaucoma if deposited in eye

71
Q

Inhalable steroids mechanism

A 
Mainstay of asthma medication
Prevent symptoms
Reduces risk of exacerbations and death
Usually twice daily medication
Not useful in acute attack
Binds to cytosolic GR with reduction in cytokines
Reduces bronchoconstriction and airway inflammation
benefit for 4-6 weeks
72
Q

Inhalable steroids side effects

A

Oral candida due to changes in oral environment
Voice change
Risk of skin bruising
Bone mineral density change and cataracts with high dose

73
Q

Oral steroid mechanism e.g

A

e.g prednisolone
Given in acute asthma or chronically in severe asthma
Avoid if possible as long term therapy but essential if asthma worsens
Clearer role in eosinophilic asthma
Time to efficacy 4hours for IV & PO routes

74
Q

Oral steroid side effects

A 
Weight gain
Hyperglycaemia 
Skin change 
Hyper tension 
Eye change 
Mood change
Reduce bone mineral density
75
Q

Theophyllines -
Route of admin
Given for
mechanism

A 
Tablets and IV
Acute/chronic asthma
Mechanism unclear but involves increased stimulation of beta adrenoceptors by cAMP, due to reduced metabolism 
Serum level monitoring required 
1-2 months
Drug interactions
Increase
76
Q

Theophylline - side effects

A 
Nausea
Vomiting
Palpitations
headaches
dyspepsia 
arrthymias
confusion
77
Q

Antileukotrienes - mech

A

Oral
Chronic asthma
Exercise induced asthma
Leukotrienes produced after breakdown of tissue
Promote smooth muscle contraction and inflammatory changes in airway wall

78
Q

Antileukotrienes - side effects

A 
Headache 
N+V
Sleep disturbance
Sore throat
GI disturbance
79
Q

Oxygen therapy is…

Delivered by?

Highly dependent on?

A 
Potentially dangerous 
Delivered by mask, nasal cannula 
needs to be CONTROLLED
Reservoir bag for very unwelll
Uncontrolled i.e conc guessed - full face mask, cannula - highly dependent of resp  rate
80
Q

Oxygen therapy is used when

A

SpO2 94-98% unless hypercapnia risk

81
Q

Types of respiratory failure

A

1 - hypoxia

2 - hypercapnia/CO2 build up

82
Q

Pink frothy sputum

A

Pulmonary oedema

DEN303 - IHD (58 decks)

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