Respiratory - MIDTERM CONTENT Flashcards
4 most common causes of chronic cough in those referred to pulmonary specialists are (according to the US article we had to read):
postinfectious bronchial inflammation, GERD, postnasal drip, asthma
” postnasal drip, asthma and/or GERD were found to be the cause of cough in 99 percent of immunocompetent nonsmokers who were not taking an ACE inhibitor and who had a normal or stable, near-normal chest radiograph.”
Your patient has a chronic cough. There must be only one explanation/cause, right?
Wrong! Not uncommon for there to be multiple causes (eg: asthma and postnasal drip common)
Your patient has a chronic cough and no other symptoms. Should you worry that they have lung CA?
Don’t sweat it! Between 70-90& of patients with lung cancer develop cough at some time during the course of the disease, but isolated chronic cough is an infrequent presentation of occult bronchogenic carcinoma (have other s&S of CA as well)
Nocturnal wheezing is common sign of what two conditions?
Asthma, congestive heart failure
A Cough following upper respiratory infection or exposure to allergen may be due to __________
Postnasal drip
A patient has a cough, facial pain, and tooth pain. What is a likely diagnosis?
Sinusitis
T/F A person with asthma may only present with a cough?
True
(this article says 28% of those diagnosed with asthma is some study…)
T/F A person with GERD may present solely with a cough?
True! This article says some study found 43% of patient with GERD only had a cough
What is a positive predictive value? Negative predictive value?
Positive predictive value is the probability that a patient with a positive (abnormal) test result actually has the disease.
Negative predictive value is the probability that a person with a negative (normal) test result is truly free of disease.
T/F I should expect to solve someone’s chronic cough in 1-2 visit
False - it commonly takes months to diagnose. May need to layer several types of treatment before establish what works
Muscarinic antagonists end in what?
“ium” (“ipatroprium”)
“late” (glycopyrrolate)
Beta agonists end in what?
“ol”
Albuterol
Salbutamol
ICS (inhaled corticosteroids) end in what?
“one”
Fluticasone
Mometasone
SABA stands for? Examples?
Short-acting beta agonists
Ventolin (Salbutamol)
Albuterol
LABA stands for? Examples?
Long-acting beta agonists
“ol” endings
Formoterol
LAMA stands for? Examples?
Long-acting muscarinic antagonists
“ium” (ipratropium) and glycopyrrolate
1st line treatment for asthma?
ICS as controller
SABA as rescue medication
Your patient is on an ICS and SABA. They report they used their SABA as a rescue med 5 times this week. How do you proceed?
This means their symptoms are not well controlled. You need to add a LABA to the ICS.
1-2x/week is considered well controlled
You add a LABA but their still use their SABA 3 times per week. What now?
Add LAMA to LABA and ICS
A different patient is on an ICS, LABA, and LAMA. The report they have never used their SABA as rescue medication. How do you proceed?
Can take away LAMA and see how it’s tolerated.
What long-acting medication is 1st line for COPD?
LAMA
In what order do you escalate controller medications in COPD? How does this compare to asthma?
COPD: LAMA –> LABA –> ICS
Asthma (opposite): ICS –> LABA –>LAMA
You see your patient is on Advair, which is a combination of an ICS and a LABA. Is it more likely they have COPD or asthma?
Asthma (they are the 1st line and 2nd line tx for asthma so may be combined)
A LAMA/LABA combo is probably prescribed for what condition?
COPD
Are nebulizers encouraged for patient use at home?
No, MDI is just as effective and nebulizers carry more infection risk
DPIs - who are they not appropriate for?
Contraindicated in young children (<6 years) and adult patients with comorbidities such as neuromuscular weakness or frailty
(need strong inhalation)
For 18+ patients with asthma, what does the BC guidelines recommend for controller and reliever medications? (slide 24 from lecture)
Start with PRN low-dose budesonide-formoterol (symbicort) for both controller/reliever (basically no controller). If that fails, add controller of low-dose of same. If that fails, increase to medium dose maintenance of same.
What kind of medication may a specialist add to asthma treatment for severe asthma?
Biologics
Does asthma typically get better or worse during pregnancy? How is it managed?
1/3 of pregnant people with asthma experience worsening asthma symptoms.
- need to involve specialist (OB and possibly asthma specialist)
- During exacerbations, need OB involvement to manage fetal well-being
Reliver medication -=
For symptom relief, or before exercise or allergen exposure
What is an Anti-inflammatory reliever (AIR) - as used in GINA
Provider rapid symptom relief plus a small dose of ICS
Reduces risk of exacerbations compared with using a SABA reliever
- Ex: ICS–formoterol or ICS-SABA
What is AIR-only vs MART (Maintenance and reliever therapy with ICS formoterol) - as used in GINA
AIR only = as-needed only ICS-formoterol
MART = low dose of ICS-formoterol used as patient’s maintenance treatment plus as reliever medication
filling more than _____ canisters of reliever therapy per year is a flag for uncontrolled asthma and need for reassessment
2
Etiology of CAP. What is the most common bacterial cause?
Commonly viral (Influenza, Adenovirus, rhinovirus, SARS-CoV-2, and others)
Streptococcus Pneumoniae = most common bacterial cause (but is in decline d/t more vax)
Other bacterial causes: Moraxella catarrhalis, Haemophilus infuenzae, S. aureus (and more)
Atypical bacterial causes: mycoplasma pneumoniae, chlamydia pneumoniae, legionella, pneumophilia
Which medications put a person at higher risk of CAP?
acid reducing agents
antipsychotics
What xray findings are consistent with CAP
lobal consolidations, interstitial infiltrates and/or cavitations
When would we order a CT for CAP?
CT if CAP suspected but CXR negative (as in those who are immunocompromised or don’t mount strong immune response)
Why is it important to ask a person with CAP if they’ve been on abx recently?
If any in the last 3 months, consider selecting alternate class (as per MUMs)
What is the first line abx for CAP?
amoxicillin (active against 90-95% of S. penumoniae)
(if comorbidities, will give with another abx as well)
**see pg 30 of MUMs for more info
You have a patient with CAP and you can’t decide if they’re sick enough to need to go to hospital. What can you use to help you decide?
There are decision support tools for that!
Pneumonia Severity Index (PSI) or CURB-65 to aid with decision to hospitalize
What questionnaire can be used to screen for OSA?
STOP-Bang
Risks of leaving OSA untreated?
Untreated or undertreated OSA pose serious risks and have been associated with: daytime sleepiness, impaired quality of life, motor vehicle crashes, occupational injury, systemic hypertension, type 2 diabetes, cardiac arrhythmia, aortic dilatation/dissection, coronary artery disease, heart failure, stroke, depression, cognitive impairment, cancer, ocular disease, pneumonia, renal dysfunction, dementia, seizures, hypogonadism, maternal/fetal health, post-operative complications, and premature death.
T/F Males are twice as likely as females to be diagnosed with OSA
True
What groups are high risk for OSA?
Older adults (60-79y.o are 3x more likely)
- Males reporting snoring, trouble breathing, or high neck circumference
- Females reporting fatigue, insomnia, or high BMI
Other risk factors:
down syndrome
family hx
mandibular hypoplasia
low-lying soft palate
large tongue
tonsillar hyperstrophy
Upper body obesity with large neck side
East asian origin
Parkinsons
TBI
Nasal obstruction
Marfan syndrome
PCOS
What tool can we use to evaluate daytime sleepiness in OSA?
Request completion of the Epworth Sleepiness Scale. A score of greater than 10 suggests significant daytime sleepiness, although a score of 10 or less does not exclude daytime sleepiness or OSA.
S&S of OSA
fatigue
habitual loud snoring
choking, gasping, or pauses in breathing during sleep
morning headache
recurrent night-time awakenings
unrefreshing or restless sleep
impaired concentration
nocturia
Grumpiness
What is an important safety consideration to inquire about with someone with OSA?
All patients should be questioned about driving or safety critical occupation (e.g., truck, taxi, bus drivers, railway engineers, commercial pilots22) where sleepiness could be a hazard, whether they operate heavy equipment, the class of their driver’s license and whether they have fallen asleep at the wheel or have come close to doing so in the past 5 years.
**Also need to consider when are referring for surgery as have increased perioperative morbidity
What diagnostic test can we order for someone we identify to be at risk of moderate to severe OSA?
HSAT: Home Sleep Apnea Test
What are the criteria for ordering an HSAT?
(Directly from requisition for ordering HSAT)
Increased risk of moderate-to-severe OSA is indicated by the presence of excessive daytime
sleepiness or fatigue and at least two of the following three criteria:
1) Witnessed apneas or gasping or choking
2) Habitual loud snoring
3) Diagnosed hypertension
Is patient at increased risk of moderate-to-severe OSA?
* If Yes, patient requires a diagnostic test.
* If No and the patient is symptomatic, they may have another sleep disorder and should
be referred for a sleep disorder consultation
**There are exclusion criteria but I won’t get into those
Your patient does an HSAT test and it comes back negative but you really feel like they have OSA. What do you do now?
A negative or equivocal HSAT does not exclude OSA. If an HSAT is negative, inconclusive or technically inadequate, and OSA is suspected, polysomnography is recommended
Treatment for OSA
- Possibly surgery if issue is something like tonsillar hypertrophy or craniofacial abnormalities
- Exercise, weight loss (don’t use as stand alone therapy though!).
CPAP - most effective tx
Positional therapy: don’t sleep supine
Other devices (oral, etc) can help, especially if not willing to use CPAP
You get your patient a CPAP and they seem all better. DO you need to follow up with them ever again?
Yes, need regular follow up to ensure compliance and continued response to treatment
- no need to re-tets if patient doing well & no change to clinical status
- Annual f/u recommended with CPAP download
Whatever treatment is used, the patient should be followed until the AHI is normal (less than 5 events per hour), the Epworth Sleepiness Scale score is 10 or less, the patient feels rested, and a bed partner reports no residual snoring. Ideally, the patient is using the treatment every night, all night
The 5 A’s of smoking cessation?
-Ask (about tobacco use/ smoking, purpose of smoking),
advise (to quit),
assess (willingness to quit),
assist (if interested),
arrange (follow up)
The 5 R’s of motivational interviewing to use with smoking cessation?
- Relevance to patient (disease status, family, health concerns, etc)
- Risks of smoking
- Rewards/benefits
- Road blocks (what is stopping them?)
- Repetition (reassure often takes several times to really quit)
Short term risks of smoking?
SOB, asthma, impotence, infertility, pregnancy complications, heartburn, URTI
Long term risks of smoking? Risks to others?
MI, stroke, COPD, lung ca, other ca
higher risk in spouse/ child for lung Ca, sIDS, asthma, RTI
Nicotine Replacement Therapy. Is it effective? How does it work?
Nicotine replacement therapy (NRT) works by providing the body with nicotine to help reduce withdrawal symptoms and cravings (without some of other harmful products in cigarettes).
NRT is one of the most effective tools to help people quit tobacco and can increase your chances of quit success.
It’s even more effective when combined with counselling.
*Gum, lozenges and patch are covered by BC pharmacare
What antidepressant can be used to assist with smoking cessation. What effect does it have?
Buproprion (marketed as Zyban in this context)
- Makes smoking less pleasurable
- Similar effectiveness to NRT
**Tricyclic antidepressant Nortriptyline also an option according to RxFiles but not covered in BC smoking cessation program
Common side effects of buproprion
Insomnia, dry mouth, agitation, seizures (CI’d if hx of seizures!)
When you prescribe buproprion or champix for smoking cessation, how should you organize a plan for quitting with the patient?
- Decide on quit date
- Continue to smoke for first 1-2 weeks of treatment and then completely stop (therapeutic levels reached in 1 wk)
Varenicline (Champix) - how does it work in smoking cessation?
Blocks effects of nicotine & reduces cravings
- generally more effective than buproprion but has significant side effects (nausea, HA, drowsiness, unusual dreams, neuropsych symptoms) that may limit compliance
Champix prescription is cautioned in what condition?
Pre-existing psych conditions
What is an effective way of mixing NRT routes?
Mix long and short acting route:
Long-acting NRT (nicotine patch) to provide steady levels of nicotine
Short-acting NRT (gum, lozenge, inhaler or spray) to help reduce breakthrough cravings or deal with challenging situations
*Is more effective than single NRT product
When do withdrawal symptoms improve with smoking cessation?
after 1-3 week
Can a person still smoke if they’re using NRT?
Yes
Instructions for applying nicotine patch
Apply new patch to clean, dry, non-hairy area every day in the morning
Are you supposed to just chew nicotine gum like normal gum?
No: Chew and Park Strategy: chew gum few times until taste “peppery” flavour, then hold in side of mouth x1min; repeat
- Peak level at 30 mins
Can someone use both medication and NRT for smoking cessation?
Yes, but only one or the other will be covered (x3 months)
Champix has more of what symptoms associated with it than Zyban (Buproprion)
Nausea
Weight gain
Before adjusting asthma treatments, what 3 things do you need to check?
adherence, inhaler
technique, environmental control, &
comorbidities.
~50% of pts are nonadherent!
NOnpharm treatments of asthma?
Smoking cessation
Encourage physical activity (treat EIB where necsssary)
Breathing exercises (physio, yoga)
Reduce stress - stress can be trigger
Healthy diet (fruits & veggies)
Avoid triggers
What medications are common asthma triggers?
Beta blockers
ASA/NSAIDs
ACEI cough
What vaccines should a person with asthma get?
Covid-19
influenza;
PNEUMOVAX-23 x 1 dose
I get mixed reviews on whether all people with asthma should get the Pneumovax-23. For sure if they are over 65. Canadian guidelines say asthma if has required medical care in last 12 months. BCCDC says asthma only if unless management involves ongoing
high dose oral corticosteroid treatment)
What 3 components must a written asthma action plan include?
daily preventive management strategies
when and how to
adjust reliever & controller treatment
when to seek urgent medical attention.
Using a spacer with an inhaler decreases local adverse effects, such as? Why else is it great at any age?
Thrush
Dysphonia
*Increased delivery of med
* decreased need for hand breath coordination
A patient uses their rescue inhaler to prevent exercise induced asthma. How long before exercising should they use it?
15 mins
There are 4 choices for first-line approaches to asthma in adults. What are they?
1) Daily inhaled ISC with rescue SABA PRN (preferred choice for most patients according to Rx Files). Low dose ICS preferred
2) PRN ICS-formolerol (Symbicort) - controller is reliever, only takes when has symptoms
3) PRN SABA (only suitable for very mild cases, such as symptoms <2days/wk)
4) Daily montekulast
What is step 2 for asthma treatment if needing to escalate approach?
Switch to ICS-LABA combo
If bud-form BID chosen, can use bud-form PRN as reliever.
If on different ICS-LABA, use SABA as reliever
What are the indicators of controlled asthma?
- Daytime symptoms max 2 days/week
- Need for reliever symptoms max 2 doses/week
- Nighttime symptoms <1 night/week and mild (should NOT be waking d/t asthma)
- Normal physical activity
- Mild, infrequent exacerbations
-No absence from work or school d/t asthma - FEV1 or PEF > or equal to 90% of best
Risk factors for asthma
Low socioeconomic status
exposure to smoke in infancy or in utero
RSV infection
lack of exposure to common childhood infectious agents
low birth weight
family history
presence of atopy or allergic sensitization.
How is asthma diagnosed?
Confirmed with spirometry ± methacholine challenge.
Decreased FEV1/FVC with reversibility after a bronchodilator (FEV1 increase > or equal to12%, with a minimum of 200mL increase in adults) - measured 10-15mins after bronchodilator given
FeNO useful if available
Symptoms of asthma
Dyspnea (shortness of breath)
chest tightness, wheezing, and cough.
Sputum production may or may not be present.
Symptoms may be paroxysmal (occasional) or persistent (>2 days/wk)
How do we define asthma?
Airway hyperresponsiveness causing variable and reversible airflow obstruction
- airway edema: walls of airways become thickened and inflamed
- bronchial smooth muscle constriction
- plugging of airways with mucus or cellular debris
What time of day are asthma symptoms typically the worst?
At night or early in morning
Risk factors for future asthma attack?
- 1 or more severe attacks in last 12 months (required hospitalization, oral steroid use)
- Uncontrolled symptoms
- Comorbidities (obesity, rhinosinusitis, food allergy)
Ever intubation or in ICU for astham
Excessive SABA use (>1 x 200 dose canister/month)
Exposure to tobacco smoke
Inadequate ICS, poor technique, poor adherence
Low FEV1 especially <60% of predicted
Major psychological or socioeconomic problems (eg: depression)
Sputum or blood eosinophilia
Pregnancy
Describe the wheezes classically heard in asthma
- most commonly on expiration but can also occur during inspiration.
Asthmatic wheezing usually involves sounds of multiple different pitches, or “polyphonic,” starting and stopping at various points in the respiratory cycle and varying in tone and duration over time.
*wheezing indicates airway narrowing but it does NOT tell us the severity
Is clubbing a typical finding in asthma?
Clubbing is not a feature of asthma; its presence should direct the clinician toward alternative diagnoses such as interstitial lung disease, lung cancer, and diffuse bronchiectasis, including cystic fibrosis.
Risk factors for COPD
Smoking #1 risk factor (estimated to cause 90% of cases in Canada; 15-20% of smokers develop COPD)
Environmental: wood smoke/other biomass fuel for cooking, air pollution, occupational
Demographic: age, family history of atopy, history of childhood resp infections, low socioeconomic status
Treatable factors: α1-antitrypsin (AAT) deficiency (rare), concurrent bronchial hyperactivity (asthma-COPD overlap)
Name the 2 phenotypes of COPD
chronic bronchitis and emphysema (usually coexist to variable degrees)
Define emphysema
Emphysema = destruction of alveoli through loss of elastic recoil
Define chronic bronchitis
inflammation of bronchioles causing narrowing of airway caliber and increased airway resistance.
Mucous gland enlargement.
S&S of COPD
Cardinal triad = chronic cough, dyspnea, and sputum production
Chronic cough and sputum
Dyspnea with exertion, progressing to dyspnea at rest
Wheezing
Difficulty speaking or performing tasks
Weight loss
Recurrent lower resp track infections
Later stage: pursed-lip breathing (auto-peep helps keep alveoli open), accessory muscle use, tripod position, barrel chest, cyanosis, tachypnea, tachycardia, abnormal/diminished/absent lung sounds, mental status changes
Diagnostic criteria for COPD?
Spirometry post-bronchodilator FEV1/FVC < 0.7
- CXR may be used to r/o other conditions
What are some important nonpharm treatments in COPD?
Pulmonary rehab has large benefits (NNT=4 to prevent one hospitalization in patients
with recent exacerbation). should be offered to any patient with high symptom burden/frequent exacerbations
12 Tai Chi or yoga may also be effective
Exercise rehabilitation to increase physical endurance
Smoking cessation (or may be pharm if using meds) - still hugely beneficial late in disease
T/F ICS are a first line treatment in COPD
F - usually added last
Vaccines a person with COPD should get?
Pneumococcal
Covid
Flu
When should a patient take antibiotics during a COPD exacerbation?
Only if green (purulent) sputum, along with increased dyspnea and cough
T/F All patients with COPD diagnosis should be screened once for Alpha-1 antitrypsin deficiency
True - is recommended by WHO
Outline the steps in pharmacologic management of COPD
1) Ipratroprium, salbutamol, or terbulatine (short acting bronchodilators, often scheduled)
2) LAMA (or LABA) - long acting bronchodilator, often start with LAMA
3) LAMA + LABA (dual therapy)
4) LAMA + LABA + ICS (trip therapy
*Short-acting bronchodilators are often scheduled in Step 1. As therapy escalates, continue to prescribe as-needed for symptom relief. COMBIVENT(salbutamol + ipratropium) also a reasonable choice anytime a short-acting bronchodilator would be useful.
* Some drug plans require trials of short-acting agents before long-acting agents are covered.
Outline management of AECOPD (acute worsening of symptoms over >48 hours)
❶ Initiate scheduled
salbutamol +/- ipratropium.
(Long-acting inhalers can be
continued but should not replace
short-acting bronchodilators.)
❷ Initiate prednisone
30-50mg po daily
x 5 to 10 days.
❸ Add antibiotic x 5-7 days if both change in sputum purulence (colour) AND at least one of
increased sputum volume or increased dyspnea vs baseline.
Adverse effects of ventolin (Salbutamol)?
tremor, nervousness, inc HR (esp. neb), inc QT, headache.
At high doses: dec K+, inc insulin secretion
Will a SABA or SAMA alone reduce COPD exacerbations? What about a LAMA?
No, not according to Rxfiles.
On the other hand, a LAMA like Tiotropium: may dec COPD exacerbations by 20-30%/yr
This makes me feel like I wouldn’t want to just prescribe a SABA or SAMA like in Step 1 of Rxfiles….I would want to start with LAMA scheduled and a SABA as rescue… (like in the YouTube video that Sarah gave us).
