Respirology (10-20%) Complete Flashcards
Asthma Diagnosis requires:
- History of variable respiratory symptoms (e.g. wheeze, SOB, chest tightness, cough) that vary over time and intensity
- Confirmed variable expiratory airflow limitation:
NEED SPIROMETRY TO HAVE A DIAGNOSIS OF ASTHMA
Positive bronchodilator reversibility (10-15 minutes after 200-400 mcg salbutamol) – Improvement in FEV1 by ____ AND _____ post-Bronchodilator
Improvement in FEV1 by >12% AND 200ml post-Brochodilator
Asthma is suspected but normal spirometry, next step?
– May repeat SPIROMETRY during times of symptoms
– Can perform methacholine or exercise testing
Methacholine Challenge – look for a drop in FEV1 by ______
– PC20 <4mg/mL = _______
– PC20 4-16 = _________
– PC20 >16 = ________
Methacholine Challenge – look for drop in FEV1 by __20%__
– PC20 <4mg/mL = __POSITIVE__
– PC20 4-16 = __borderline__
– PC20 >16 = __negative__
Exercise Challenge
– Fall in FEV1 of ____ and ____ from baseline
Exercise Challenge
– Fall in FEV1 of >10% and >200mL from baseline
ASTHMA CONTROL: MUST MEET ALL CRITERIA
Characteristic and Cut off
Daytime symptoms ______ per week
Nighttime symptoms ______ per week
Physical activity ______
Exacerbations ______
Absence from work/school due to exacerbation ______
Need for a reliever (SABA or bud/fom) ______ per week
FEV1 or PEF ______ of personal best
PEF diurnal variation ______
Sputum eosinophils ______
Daytime symptoms ≤ 2 d/week
Nighttime symptoms < 1d/ week and mild
Physical activity Normal
Exacerbations Mild (not requiring systemic steroids or ED visit) and infrequent
Absence from work/school due to exacerbation None
Need for a reliever (SABA or bud/fom) ≤ 2 doses per week
FEV1 or PEF ≥ 90% of personal best
PEF diurnal variation <10-15%
Sputum eosinophils <2-3%
ASTHMA: If the patient has symptom control for 2 months and has a low risk of exacerbations. NEXT STEP?
Consider stepping down therapy
ASTHMA: Before STEP UP Therapy: Assess and confirm?
_________
_________
- Inhaler technique and adherence
- All of the Non-Pharm management
LTRAs: Most effective in ______, ______ and ______
Most effective in aspirin-exacerbated asthma, exercise-induced symptoms, allergic rhinitis
LTRAs: FDA Black Box Warning?
FDA Black Box Warning: increased suicidality in adolescents and adults
Samter’s triad?
ASA/NSAIDs allergy
Asthma
Nasal polyps
For patients with Sampter’s Triad whose
asthma is not well controlled on low dose ICS – would you add LTRA or increase ICS dose?”
Answer: Offer LTRA given ASA-exacerbated asthma
WORKUP FOR SEVERE ASTHMA:
Peripheral eosinophil count
1. Eosinophils >0.3 – consider _______ before _______ [GINA 2022]
2. Eosinophils >1.5 – consider investigate for conditions such as _______ [GINA 2022]
Peripheral eosinophil count
1. Eosinophils >0.3 – consider strongyloides serology before systemic steroids [GINA 2022]
2. Eosinophils >1.5 – consider investigate for conditions such as EGPA [GINA 2022]
For severe asthma:
1. If high IgE and allergies: think
about ________
- If high eosinophil count, think
about ________
For severe asthma:
1. If high IgE and allergies: think
about omalizumab
- If high eosinophil count, think
about all the other biologics
Seasonal allergic asthma: start _______ immediately when symptoms commence and continue for _______
Start ICS immediately when symptoms
commence, and continue for four weeks after the relevant pollen season ends
Exercise-induced ASTHMA: ________ pre-exercise, if insufficient then ________ pre-exercise, if still insufficient try ________
salbutamol pre-exercise, if insufficient then LTRA pre-exercise, if still insufficient try regular ICS
Treatment of ABPA?
Prednisone +/- itraconazole.
COPD Diagnosis: ______ is required to make the diagnosis, with a ______ FEV1/FVC _______
COPD Diagnosis: Spirometry is required to make the diagnosis, with a post-bronchodilator FEV1/FVC <0.70 or <LLN
COPD: Spirometry result is borderline. Next Step?
Rrepeat measurement if
borderline
The severity of Airflow Limitation in COPD:
In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Mild: FEV1 ______
* Moderate: ______ < FEV1 < ______ predicted
* Severe: ______ < FEV1 < ______ predicted
* Very Severe: FEV1 < ______ predicted
- Mild: FEV1 > 80% predicted
- Moderate: 50% < FEV1 < 80% predicted
- Severe: 30% < FEV1 < 50% predicted
- Very Severe: FEV1 < 30% predicted
COPD: Determine the Impact on patients’ health status ?
mMRC and/or CAT scores
Test those diagnosed with COPD for __________
Alpha-1 antitrypsin ONCE
Three interventions that improve survival in certain subsets of COPD?
- Smoking cessation
- Pulmonary rehabilitation
- Supplemental O2 in severe resting hypoxemia
Long-term Oxygen Therapy in COPD? Indications? * Should be offered to patients with PaO2 < _________ or when PaO2< ____ mmHg in the presence of ______, _______ or ________
Long-term Oxygen Therapy: increased survival in severe resting hypoxemia
Should be offered to patients with:
1. Severe hypoxemia (PaO2<55 mmHg), or
2. PaO2<60 mmHg in the presence of bilateral ankle edema, cor pulmonale, or Hct >56% (CTS guidelines)
COPD: Moderate resting or exercise-induced moderate desaturation. Oxygen indications?
No benefit (NEJM LOTT Trial 2016)
COPD and Pulmonary rehabilitation: Increased survival compared with usual care ______ post AECOPD
Increased survival compared with usual care
< 4 weeks post AECOPD
In stable COPD:
Start with ____ monotherapy, If symptoms persist then _____ dual therapy, if still persist then, ______triple therapy
Start with LAMA monotherapy, If symptoms persist then LAMA/LABA , if still persist then LAMA/LABA/ICS
In COPD:
DO NOT GIVE _____ monotherapy.
Increases risk of _____
DO NOT GIVE:
– ICS monotherapy: increases risk of pneumonia
COPD Rx to Prevent Acute Exacerbations
Asthma-COPD Overlap. First-line treatment?
LABA-ICS combo
NIV in Stable COPD with Hypercapnia
– CTS 2022: Suggest chronic NIV for patients with severe COPD on home oxygen and chronic hypercapnia (PaCO2 ≥52) – Consult your Respirologist!
– Several trials showing reduction in hospital re-admission rates; some showing mortality benefit
Severe emphysema patients with upper-lobe predominant disease and low post-rehabilitation exercise capacity. What increases survival in these patients?
Lung Volume Reduction Surgery
1-year mortality after AECOPD?
~ 30%
When to give Antibiotics for COPD?
Antibiotics should be given in COPD in the presence of three cardinal symptoms (or two of the following if increased purulence* is one of them):
1. Increase in dyspnea
2. Increase in sputum volume
3. Increase in sputum purulence
BIPAP in AECOPD?
Recommended (GOLD 2022) if any of:
* pH ≤7.35 with pC02 ≥ 45
* severe dyspnea (impending respiratory failure)
* persistent hypoxemia despite supp oxygen
Does BIPAP have a mortality benefit in AECOPD?
Yes, Significant mortality benefit and reduction in intubation rate
Initiating Pharmacologic Treatment in Tobacco-Dependent Adults (ATS 2020)
Treat everyone with varenicline (+/- nicotine patch) even if they are not ready to quit
What are the radiographic features of Usual Interstitial Pneumonia commonly seen in Idiopathic Pulmonary Fibrosis?
- Reticular Changes
- Subpleural/Basal predominant
- Honeycombing
- Absence of inconsistent features (LONG LIST)
No role for ___________ or ___________ in Idiopathic Pulmonary Fibrosis due to ___________
No role for corticosteroids or immunosuppression in IPF given increased mortality (PANTHER-IPF) !
Drug-induced ILD
Associated drugs?
Methotrexate
Amiodarone
Nitrofurantoin/Macrobid
Bleomycin
Vaping
When to do a thoracentesis?
- Suspect exudate
- Cause unclear
- Parapneumonic effusion (as per CHEST guidelines, if less than 1 cm of fluid on lateral decubitus in the context of pneumonia can forgo sampling and instead follow radiographically)
Light’s Criteria?
Pleural fluid is an exudate if ≥ 1 of the following criteria are met:
* Protein in fluid : serum > 0.5
* LDH in fluid : serum >0.6
* Pleural fluid LDH >2/3 the upper limit of normal value for serum LDH
Pleural effusion:
Chylothorax – (TGs >1.24mmol, +CM)
Think of?
– Malignancy #1 (most commonly lymphoma)
– Trauma/surgery, TB, LAM /Lymphangioleiomyomatosis, a young woman with cystic lung disease/PTX)
Pleural effusion:
Pleural fluid eosinophilia - (>10%)
Think of?
- Asbestos-related (BAPE)
- Drugs (ex. nitrofurantoin)
- Malignancy (lung)
- Infection (parasites)
- PE
- eGPA
Pleural effusion:
Low glucose - (glc<3, eff/serum<0.5)
Think of?
* <1 mmol: ___________________
- 1-3mmol: ___________________
- <1 mmol – RA, empyema
- 1-3mmol – malignancy, TB, SLE
Pleural effusion:
Lymphocytosis:
1. >80%?
2. Others?
Think of?
– >80% TB vs lymphoma, TB often AFB negative and would suggest sputum AFB
– Carcinoma, yellow nail, sarcoidosis, RA
TB suspected?
Pleural fluid is AFB negative. Next step?
TB often AFB negative and would suggest sputum AFB
The yield of 3 induced sputum is comparable to bronchoscopy
Chest drain needed if (does not need to be surgical chest tube)?
– drainage of frank pus/cloudy
– positive gram stain or culture
– pH <7.2 (if unavailable use glucose <3.4 mmol/L)
– >50% of hemithorax or loculations on imaging
ENSURE THAT YOU PAY ATTENTION TO THE SIDE OF THE EFFUSION – IPSILATERAL TO PNEUMONIA
Antibiotic duration for Parapneumonic Effusions?
Usually prolonged antibiotic course (often at least 3 weeks, based on clinical and radiographic response)
Primary spontaneous pneumothorax (PSP): Absence of lung disease
Risk Factors?
Smoking*
Family history
Marfan syndrome
Thoracic endometriosis
- Reoccur 25-50%, most in first year
Primary spontaneous pneumothorax (PSP):
<2cm with minimal signs and symptoms?
Next Step?
= monitor
Primary spontaneous pneumothorax (PSP):
> 2cm or signs and symptoms
Next Step?
= needle aspiration +/- chest tube insertion
Secondary spontaneous pneumothorax (SSP): Presence of lung disease (Often COPD).
Small SSP:
Next Step?
Even small SSP can lead to significant symptoms; often requires admission
More likely to require chest drain given underlying lung abnormalities and risk of
air leak, consult Resp/Thoracic Surgery
Conservative (monitoring for 4 hrs in ED, then discharge home with close follow-up) versus Interventional Treatment for moderate-to-large primary spontaneous pneumothorax?
- Conservative management was non-inferior to interventional management
for radiographic resolution within 8 weeks - Bottom line: conservative observational approach may be reasonable in young, healthy patients with a spontaneous pneumothorax that would have otherwise warranted intervention
Extrapulmonary sarcoid:
_______, _______, and _______ need urgent
treatment
- Heart, CNS, eyes* need urgent
treatment!
Lofgren’s Syndrome?
– Bilateral hilar adenopathy
– Erythema nodosum
– Migratory polyarthralgias
– Fever
– Seen primarily in women
– High likelihood of spontaneous remission
Heerfordt’s syndrome?
– Anterior uveitis
– Parotid enlargement
– Facial palsy
– Fever (uveoparotid fever)
What are the three organs that can cause life-threatening sarcoidosis and how would you work them up?
- Neurologic: Cranial nerve palsy, headache, ataxia, weakness, LP nonspecific lymphocytic inflammation, MRI imaging chest of choice
- Ocular: Anterior uveitis most common
- Cardiac: ~5% of patients clinically (more at autopsy), cardiomyopathy, arrhythmia, heart block, screen with ECG +/- echo, then cardiac MRI and PET scan if concern
Sarcoid:
Erythema nodosum treatment?
Erythema nodosum usually good response to NSAIDs alone
Sarcoid:
Fatigue? First-line treatment?
Pulmonary rehab is 1st line treatment for fatigue
Pulmonary Hypertension (PH)
- Defined as mean pulmonary artery pressure >______ mmHg on right heart
catheterization and PVR >_____ WU is consistent with precapillary PH - Typically presents with _________ and eventually ________
- Defined as: mean pulmonary artery pressure > 20mmHg on right heart
catheterization and PVR >2WU (previously PVR > 3WU), is consistent with precapillary
PH - Typically presents with slowly progressive dyspnea on exertion and eventually right
ventricular failure
Pulmonary Hypertension Types
Dyspnea on exertion, isolated reduced DLCO
Suspect?
The most important screening is?
Pulmonary Hypertension
The most important screening is an echocardiogram – Assess how RV is doing!
Screen patients with scleroderma annually for ______ with ______ and ______
Screen patients with scleroderma annually for PH with echo and DLCO
If dyspnea or exercise intolerance after at least 3 months of uninterrupted anticoagulation post-acute PE assess for _______ with _______ and _______
If dyspnea or exercise intolerance after at least 3 months of uninterrupted anticoagulation post-acute PE assess for CTEPH with echo and V/Q lung scan
Patients with CTEPH
Test for?
If positive? then?
APLAS (Antiphospholipid antibodies)
Warfarin
Idiopathic Pulmonary Arterial Hypertension in Women?
Avoid Pregnancy
Use contraceptives
In patients with SSc and unexplained dyspnea
following non-invasive assessment, ______ is
recommended to exclude __________
In patients with SSc and unexplained dyspnea
following non-invasive assessment, RHC is recommended to exclude PAH
A-a gradient?
Calculation?
Normal range?
A-a = [150- (PaCO2/0.8)]– PaO2
Normal A-a Gradient for reference:
(Age (yrs)/4)+4
Hypoxemia with Normal A-a gradient:
Means?
Causes?
Normal A-a gradient means (normal gas exchange)
– Hypoventilation
1. CNS depression (drugs, stroke, tumor-bleed, meningitis), spinal cord injury, chest wall abnormality, diaphragm dysfunction (ie phrenic nerve injury or myopathy), neuromuscular disorder, obesity hypoventilation
2. Check PaCO2 – if elevated think of hypoventilation
– Low-inspired FiO2 (e.g. altitude)
Hypoxemia with Widened A-a gradient:
Means?
Causes?
- V/Q mismatch (improves with 100% FiO2): E.g. COPD, PE
- Shunt (does not improve completely with the administration of 100% FiO2): CAUSE:
- intracardiac with R->L shunt (eg PFO, ASD, VSD)
- intrapulmonary (ie pulmonary AVM)
- physiologic (ie severe pneumonia with perfused alveoli that are not ventilated)
3 Diffusion Abnormality: E.g. ILD
Home O2 Requirements (Ontario)?
Home O2 Requirements (Ontario)
– PaO2 <= 55
– (SaO2 <= 88%)
– PaO2 = 55-59 with:
* Cor pulmonale
* Pulmonary hypertension
* Persistent erythrocytosis
Hemoptysis Differential
Hemoptysis Management
When should take away driver’s license for someone with OSA?
Need one of:
Excessive sleepiness during major wake periods while driving
Crash associated with falling asleep in the last 5 years if not on effective therapy
Noncompliant with therapy
PFT: Flattening of both inspiratory and expiratory curve
Fixed upper-airway obstruction (intrathoracic or extrathoracic)
- Glottic stenosis (prolonged intubation)
- Subglottic stenosis (Wegner’s, sarcoid, polychondritis)
PFT: Flattening of inspiratory curve
Variable extrathoracic obstruction
* Vocal cord dysfunction/paralysis
PFT: Flattening of expiratory curve
Variable intrathoracic obstruction
* E.g. tracheomalacia of intrathoracic airway
Isolated decrease in DLCO?
– Classically pulmonary hypertension, also early ILD/emphysema, anemia.
Increased DLCO?
– Pulmonary hemorrhage/polycythemia
- LV failure
- Asthma
- Obesity
Restrictive pattern varying with position
– Vital Capacity __________ when lying down by >10%
* Gravity eliminated therefore unmasks __________, confirm with ____________
* May be presented as a ___________ or ___________
Restrictive pattern varying with position
– Vital Capacity decreases when lying down by >10%
* Gravity eliminated therefore unmasks diaphragm dysfunction, confirm with MIPs/MEPs
* May be presented as a post-op scenario (e.g. CABG) or NMD (e.g. ALS)
Contraindications to PFTs: (BMJ)
- Hemoptysis
- Pneumothorax
- Unstable cardiovascular status including recent MI
- Aneurysms – thoracic, abdominal or cerebral
- Recent eye surgery – eg. Cataracts
- Recent thoracic or abdominal surgery
- Presence of acute illness that may interfere with test performance
Contraindications to Methacholine Challenge: (ATS)
ABSOLUTE?
RELATIVE?
– Absolute:
* 1. Severe airflow limitation FEV1<50% or <1L
* 2. Recent MI or Stroke in last 3m
* 3. Uncontrolled HTN, SBP >200/100
* 4. Known Aortic Aneurysm
– Relative:
* 1. Moderate airflow limitation FEV1<60% or <1.5L
* 2. Pregnancy or nursing mothers (methacholine is category C)
* 3. Use of cholinesterase inhibitor (myasthenia gravis)
PFTs Perioperatively:
If both predicted post-op ________ and ________ are _______ % predicted no further testing is needed
If both PPO FEV1 and DLCO are > 60% predicted no further testing is needed
- Low risk for perioperative death and cardiopulmonary complications following resection including pneumonectomy
Predictors of adverse perioperative pulmonary events?
- Surgical site (aortic > intrathoracic> upper abdominal> abdominal)
- Age, preexisting lung disease
The most specific and most sensitive test for diagnosis
of diaphragm weakness/paralysis?
Most SENSITIVE = MIP (Maximal inspiratory pressure)
Most SPECIFIC: There isn’t really a good specific test on PFTs for diaphragmatic weakness. Proceed to an ultrasound if you want specificity.
If forced to choose we “guess” FVC… because it’s associated with poor prognosis in diaphragmatic dysfunction as per the ALS CTS guidelines.
PFTs: Pregnancy: Following increase/decrease or the same
Total lung capacity?
Functional residual capacity?
Inspiratory Capacity?
Vital Capacity
Expiratory reserve volume?
Tidal volume?
Minute ventilation?
Total lung capacity? Same
Functional residual capacity? Decrease
Inspiratory Capacity? Increase
Vital Capacity? Same
Expiratory reserve volume? Decrease
Tidal volume? Increase
