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Internal Medicine: PGY-1 > Respirology > Flashcards

Respirology Flashcards

1
Q

Asthma diagnosis?

A

1) History of variable resp sx

2) Confirmed variable expiratory airflow limitation:
Expiratory airflow limitation:
- confirm reduced FEV1/FVC (below lower limit of normal)

Excessive variability in lung function
- Spirometry: reduced FEV1/FVC; improves FEV1 by >12% AND 200mL post-BD or after 4 weeks of anti-inflam tx
- Excessive variability in BID PEF over 2 weeks (>10%)
- Exercise challenge: FEV1 drop >10% + >200mL from baseline
- Methacholine challenge: look for FEV1 drop by 20% [PC20 < 4mg/ml = POSITIVE; PC20 4-16 = borderline; PC20 >16 = NEGATIVE]

3) Airflow limitation may not be present at time of initial assessment [normal Spiro, but still have asthma), repeat spiro at time of symptoms

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2
Q

Asthma symptoms cutoff?
- Daytime symptoms
- Nighttime symptoms
- Physical activity
- Exacerbations
- Absence from work/school d/t exacerbations
- Need for a reliever (SABA or bud/fom)
- FEV1 or PEF
- PEF diurnal variation
- Sputum eosinophils

A
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3
Q

Definition of asthma?

A
  1. Heterogenous disease characterized by chronic airway inflammation
  2. Sx: wheeze, SOB, chest tightness, cough, airway wall thickening, increased mucous, and variable expiratory airflow limitation
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4
Q

Asthma phenotypes? (5)

A
  1. Allergic: classic asthma, atopy, eosinophilic inflam, responds to ICS
  2. Non-allergic: neutrophilic, eosinophilic or paucigranulocytic inflam; less response to ICS
  3. Adult-onset: non-allergic, require higher ICS, r/o occupational asthma
  4. Associated with obesity: little eosinophilic inflam
  5. Associated with persistent airflow limitation: longstanding asthma causing fixed obstruction d/t airway remodelling
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5
Q

DDx - Asthma:
- Sneezing, itching, blocked nose, throat clearing
- Dyspnea, inspiratory wheezing
- Dizziness, paresthesia, sighing
- Productive cough, recurrent infections
- Excessive cough + mucus
- Cardiac murmurs
- SOB, FHx emphysema
- Sudden onset sx
- Chronic cough, hemoptysis, SOB, b-sx

A
  • Chronic upper airway cough syndrome
  • Inducible laryngeal obstruction
  • Hyperventilation, dysfunctional breathing
  • Bronchiectasis
  • CF
  • CHD
  • A1-AT deficiency
  • Inhaled FB, PE
  • TB, cancer
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6
Q

Asthma treatment?

A

As needed low-dose ICS-form –> low dose –> med dose –> add-on LAMA

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7
Q

Risks of SABA PRN as sole reliever?

A
  • Increased risk of exacerbation
  • Decreased lung function
  • Regular use increases airway inflammation
  • Over-use associated with increased severe exacerbations and asthma-related death
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8
Q

Benefits of PRN Bud-Form in Asthma?

A
  • Reduces symptoms, exacerbations
  • Reduces asthma-related hospitalizations vs. SABA alone
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9
Q

Before stepping up therapy in asthma - what should you do?

A

Confirm inhaler technique and adherence
All non-pharm:
- confirm dx, educate, written asthma action plan
- weight loss, exercise training
- allergen/trigger avoidance; allergen immunotherapy
- stop smoking
- vaccinations
- avoid NSAIDs +/- BB
- co-morbidities (GERD, PND, obesity)

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10
Q

If asthma patient unable to tolerate ICS, what can be done instead? But?

A

LTRA: less effective than ICS at preventing exacerbations

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11
Q

LTRA most effective in which cases of asthma?

A
  • Aspirin-exacerbated
  • Exercise-induced symptoms
  • Allergic rhinitis
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12
Q

LTRA has a ‘use’ warning - for what?

A

FDA black box: increased suicidality in teens/adults

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13
Q

What is considered severe vs. mild asthma exacerbation?

A

Severe: any 1 of
- requiring systemic steroids
- requiring ED visit
- requiring hospital admission

Mild: 0/3 above criteria

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14
Q

Patient with Sampter’s triad (ASA allergy, asthma, nasal polyps), whose asthma not well-controlled on low-dose ICS. What do you add?

A

LTRA given ASA-exacerbated asthma

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15
Q

Definitions - Asthma: uncontrolled vs. severe

A

Uncontrolled:
- poor sx control
- frequent exacerbations (>2/yr) requiring OCS
- >1/yr serious exacerbation requiring admission

Severe:
- asthma requiring high-dose ICS-LABA + 2nd controller
- OCS for >50% of year to maintain control
- asthma worsens when therapy decreased

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16
Q

If severe asthma, what further investigations should you consider sending?

A
  • CBC, CRP, ESR, IgG, IgA, IgM, IgE, fungal precipitins (including aspergillus) +/- ANCA, BNP, TTE, CT sinuses
  • CXR, DLCO, DEXA scan, HRCTC
  • Allergy IgE testing for relevant allergens
  • Consider screening for adrenal insufficiency in patients on OCS of high-dose ICS
  • If blood eosinophils >300, look for non-asthma causes (parasites, strongyloides, blood, stool); if >1500, consider EGPA
  • Sputum eosinophils, FeNO (to look for type 2 airway inflam)
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17
Q

Treatment of severe asthma?

A

Should be on at least mod ICS/LABA before considering:
- LAMA, LM/LTRA
- Low-dose Azithro
- Biologics (must meet criteria)
- Low-dose OCS
- Bronchial thermoplasty

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18
Q

Criteria for biologics in Asthma?

A

1) Anti-IgE (omalizumab)
2) Anti-IL5 / Anti-IL5R (benralizumab, mepolizumab)
3) Anti-IL4R (dupilumab)
4) Anti-TSLP (tezepelumab)

  • If allergies + high IgE = think Omalizumab
  • If high eosinophils, think about all other biologics
  • TEZEPELUMAB = does NOT require any biomarkers to Rx so Resp excited about this!
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19
Q
  • What is ABPA?
  • Criteria?
  • Treatment?
A
  • Chronic exposure to Aspergillus causing S&S
  • Asthma, pulm. infiltrates, skin+serum precipitins to aspergillus, increased total IgE + aspergillus specific IgE >1000, increased eosinophils, central bronchiectasis
  • Prednisone +/- itraconazole
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20
Q

COPD Severity Criteria?
- FEV1
- Diagnosis must contain what?

A
  • Mild: >80%
  • Mod: 50-80%
  • Severe: 30-50%
  • Very Severe: <30%
  • Spirometry with post-bronchodilator FEV1/FVC <0.70
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21
Q

What is CAT/mMRC? Grading system?

A
  • Dyspnea scales
  • mMRC: 0-4 [4 being worst]
  • CAT: 0-40
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22
Q

COPD classification systems: GOLD, E, A, B

A

1) GOLD
- 1: >80%
- 2: 50-80%
- 3: 30-50%
- 4: <30%

2) E, A, B
- E: >2 mod COPDE or >1 leading to hospitalization
- A: 0-1 mod COPDE not leading to admission; mMRC 0-1
- B: 0-1 mod COPDE not leading to admission; mMRC >2

23
Q

Which test should always be done once when patient diagnosed with COPD?

A

Alpha-1-antitrypsin

24
Q

Non-Pharm Tx of COPD?

A
  • Smoking cessation
  • Vaccination
  • Pulmonary Rehab
  • Supplemental O2
  • Self-management/education
  • Review inhaler technique
  • EOL care (palliation, dyspnea mx)
25
Q

Which non-pharm Tx aid with SURVIVAL benefit in COPD?

A
  • Smoking cessation
  • Long-term O2 therapy (for severe hypoxiemia, PaO2 <55)
  • Pulm rehab
26
Q

Treatment of COPD is based on what? (and not on what)

A
  • Level of dyspnea + exacerbations
  • NOT: lung function
27
Q

Overall, inhalers work to improve what?

A
  • Reduce symptoms
  • Increased activity level
  • Increase health status
28
Q

COPD treatment escalation?

A

1) mMRC 1: LAMA

2) mMRC >2:
- Low risk: LAMA/LABA
- High risk: LAMA/LABA/ICS

Risk Level:
- High: >2 COPDE in < 1yr or > 1 requiring hospitalization

29
Q

Why is ICS not given as monotherapy?

A

Increased risk of PNA

30
Q

Why are oral therapies (PDE-4i, PDE-5i, mycolytics, herbal remedies) are not part of COPD treatment guidelines?

A

No evidence for symptomatic benefit in stable COPD

31
Q

If recurrent COPDE, what other therapies can be added? Non-pharm?

A

1) Pharm
- Azithromycin: high-risk COPDE (QTc, hearing impairm., sputum cx for NTM)
- Roflumilast: chronic bronchitis type (diarrhea, wt loss)
- NAC: chronic bronchitis type

2) Non-Pharm
- Flu vaccine, pneumococcal, TdAP, Covid-19, Shingrix
- Smoking cessation
- Pulm rehab
- Education, inhaler technique

32
Q

If starting COPDer on prophylactic Azithromycin, what test should you do at baseline? (2)

A
  • ECG: QTc
  • Sputum culture: non-TB mycobacteria (NTM)
33
Q

What therapies can be instored for dyspnea management in advanced COPD? Which are NOT?

A

Recommended:
- Oral opioids
- NM electrical muscle stimulation
- Chest physio
- Walking aids
- Pursed-lip breathing
- Continuous O2

NOT recommended:
- Anxiolytics, antidepressants
- Supplemental O2 in non-hypoxemic patients
- Not enough evidence acupuncture, acupressure, distractive auditory stimuli, relaxation, handheld fans, psychotherapy, etc.

34
Q

When to suspect Asthma/COPD overlap?

A
  • COPD risk factors
  • COPD sx (sputum, dyspnea, cough, exercise limitation)
  • Hx of allergy, atopy, asthma (child, MD dx, wheeze, exacerbation, supportive physiology)
  • Pre/post bronchodilator spirometry
35
Q

Asthma/COPD overlap diagnostic criteria?

A

Required
- Dx of COPD given risk fx, hx, spirometry
- history of asthma (PMHx, current sx, confirmed on spiro)
- spirometry: post-broncho fixed FEV1/FVC <0.7

Supportive, but NOT required
- documentation of broncho improvement FEV1 by 200ml or 12%
- sputum eosinphils >3%
- blood eosinophils >300 (current or prev)

36
Q

What is the significance of asthma/COPD overlap?

A
  • Worse prognosis/outcomes
  • More exacerbations
  • Decreased lung function
  • Poorer QoL
  • Increased mortality
37
Q

Asthma/COPD overlap treatment? Caveat?

A
  • 1st line: LABA/ICS
  • Refractory sx: add LAMA
  • Caveat: no RCT addressing this population (asthma trials exclude smokers, COPD trials exclude asthmatics)
38
Q

Indications for O2 therapy in stable COPD?

A
  • PaO2 <55 or sats <88% with or w/o hypercapnia
  • PaO2 55-60 with evidence of right-heart failure [pHTN, peripheral edema to suggest CHF, or polycythemia (hct above 55%)]
39
Q

When should home O2 be reassessed?

A

60-90 days after initiation

40
Q

Indications for NIV? (3)

A
  1. Resp acidosis (CO2 >45 or <7.35)
  2. Severe dyspnea (impending resp failure: resp fatigue, WOB)
  3. Persistent hypoxemia despite supp. O2
41
Q

What is the 1 year mortality rate after COPDE?
How much mL of FEV1 is lost after AECOPD?

A
  • ~30% vs. 23% with MI!
  • ~8mL/yr
42
Q

Antibiotics in COPDE should be given when?

A
  • 3 cardinal sx: dypnea, sputum volume + purulence
  • 2 of above IF purulence is one of them
  • If patient require invasive/NIV
43
Q

What is bronchiectasis?

A
  • Chronic resp disease
  • Characterized by clinical syndrome of cough, sputum production, bronchial infection AND imaging of permanent/abnormal dilatation of bronchi
44
Q

Most common symptoms of bronchiectasis?

A
  • cough
  • sputum production and/or hemoptysis
  • rhinosinusitis
  • thoracic pain
45
Q

List few causes of bronchiectasis. What are the 2 most common ones which account for 50% of cases?

A
  1. postinfectious (prior PNA, pertussis, NTM, TB)
  2. idiopathic
  3. Humoral immunodeficiency
  4. CF
  5. Autoimmune/CTD
  6. IBD
  7. ABPA
  8. Aspiration
  9. Congenital
  10. PCD
  11. Alpha-1-AT
46
Q

List workup plan for bronchiectasis.

A
  • Based on H&P [think of diff. causes of Dx]
  • All: CT chest, PFT
  • Serum Ig
  • Sputum cultures
  • CF (sweat test), Primary ciliary dyskinesia (nasal nitric oxide)
  • ABPA: blood count, total IgE, sensitization to aspergillus (IgE specific Ab or skin prick)
  • Consider: ANA, RF, anti-CCP, ANCA, A-1-AT, videofluoroscopic swallow, HIV
47
Q

Mainstays of treatment for bronchiectasis? Advacned therapies?

A

Maintsay:
- Airway clearence: breathing techniques
- Mucoactive: hypertonic saline
- Abx: inhaled colistin or gent (if PsA colonized), chronic Azithro (if recurrent exacerbations)
- Puffers: unless CI’d; do NOT routinely offer ICS, oral steroids, PDE4-I
- Pulm rehab: if mMRC >1
- Vaccines: flu, pneumococcal, TdAP, Covid)
- Supp. O2 (same criteria as COPD)

Advanced therapies:
- Consider surgery, lung resection
- Transplant: massive hemoptysis, severe PH, ICU admissions or resp failure (require NIV)
- Consider NIV if resp failure with hypercapnia, esp if recurrent admissions

48
Q

Bronchiectasis exacerbations: treatment?

A
  • Sputum cultures
  • Empiric Abx, typically 14 days
  • If major hemoptysis, IV Abx, TXA +/- embolization
49
Q

Typical UIP pattern on CT?

A
  • reticular changes
  • subpleural, basal
  • honeycombing
  • absence of inconsistent features
50
Q

What is Light’s criteria?

A

Exudate if 1 or more met:
- Protein fluid : serum >0.5
- LDH fluid : serum >0.6
- Pleural fluid LDH >2/3 ULN for serum LDH

51
Q

Pleural effusion. Which cancer cannot be diagnosed from cytology?

A

Mesothelioma. Need pleural biopsy.

52
Q

Indications for thoracentesis?

A
  • Suspect exudate
  • Cause unclear
  • Paranpneumonic effusion: if less 1cm fluid on lateral decubitus in context of PNA, can forgo sampling and follow radiographically
53
Q

Indications for chest drain/tube?

A
  • drainage of pus/cloudy
  • positive gram stain/culture
  • pH <7.2 (if unavailable, use glucose <3.4)
  • > 50% of hemithorax or loculations on imaging

Internal Medicine: PGY-1 (17 decks)

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