Respirology Flashcards
Asthma diagnosis?
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
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
Definition of asthma?
- Heterogenous disease characterized by chronic airway inflammation
- Sx: wheeze, SOB, chest tightness, cough, airway wall thickening, increased mucous, and variable expiratory airflow limitation
Asthma phenotypes? (5)
- Allergic: classic asthma, atopy, eosinophilic inflam, responds to ICS
- Non-allergic: neutrophilic, eosinophilic or paucigranulocytic inflam; less response to ICS
- Adult-onset: non-allergic, require higher ICS, r/o occupational asthma
- Associated with obesity: little eosinophilic inflam
- Associated with persistent airflow limitation: longstanding asthma causing fixed obstruction d/t airway remodelling
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
- Chronic upper airway cough syndrome
- Inducible laryngeal obstruction
- Hyperventilation, dysfunctional breathing
- Bronchiectasis
- CF
- CHD
- A1-AT deficiency
- Inhaled FB, PE
- TB, cancer
Asthma treatment?
As needed low-dose ICS-form –> low dose –> med dose –> add-on LAMA
Risks of SABA PRN as sole reliever?
- Increased risk of exacerbation
- Decreased lung function
- Regular use increases airway inflammation
- Over-use associated with increased severe exacerbations and asthma-related death
Benefits of PRN Bud-Form in Asthma?
- Reduces symptoms, exacerbations
- Reduces asthma-related hospitalizations vs. SABA alone
Before stepping up therapy in asthma - what should you do?
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)
If asthma patient unable to tolerate ICS, what can be done instead? But?
LTRA: less effective than ICS at preventing exacerbations
LTRA most effective in which cases of asthma?
- Aspirin-exacerbated
- Exercise-induced symptoms
- Allergic rhinitis
LTRA has a ‘use’ warning - for what?
FDA black box: increased suicidality in teens/adults
What is considered severe vs. mild asthma exacerbation?
Severe: any 1 of
- requiring systemic steroids
- requiring ED visit
- requiring hospital admission
Mild: 0/3 above criteria
Patient with Sampter’s triad (ASA allergy, asthma, nasal polyps), whose asthma not well-controlled on low-dose ICS. What do you add?
LTRA given ASA-exacerbated asthma
Definitions - Asthma: uncontrolled vs. severe
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
If severe asthma, what further investigations should you consider sending?
- 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)
Treatment of severe asthma?
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
Criteria for biologics in Asthma?
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!
- What is ABPA?
- Criteria?
- Treatment?
- 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
COPD Severity Criteria?
- FEV1
- Diagnosis must contain what?
- Mild: >80%
- Mod: 50-80%
- Severe: 30-50%
- Very Severe: <30%
- Spirometry with post-bronchodilator FEV1/FVC <0.70
What is CAT/mMRC? Grading system?
- Dyspnea scales
- mMRC: 0-4 [4 being worst]
- CAT: 0-40
COPD classification systems: GOLD, E, A, B
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
Which test should always be done once when patient diagnosed with COPD?
Alpha-1-antitrypsin
Non-Pharm Tx of COPD?
- Smoking cessation
- Vaccination
- Pulmonary Rehab
- Supplemental O2
- Self-management/education
- Review inhaler technique
- EOL care (palliation, dyspnea mx)
Which non-pharm Tx aid with SURVIVAL benefit in COPD?
- Smoking cessation
- Long-term O2 therapy (for severe hypoxiemia, PaO2 <55)
- Pulm rehab
Treatment of COPD is based on what? (and not on what)
- Level of dyspnea + exacerbations
- NOT: lung function
Overall, inhalers work to improve what?
- Reduce symptoms
- Increased activity level
- Increase health status
COPD treatment escalation?
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
Why is ICS not given as monotherapy?
Increased risk of PNA
Why are oral therapies (PDE-4i, PDE-5i, mycolytics, herbal remedies) are not part of COPD treatment guidelines?
No evidence for symptomatic benefit in stable COPD
If recurrent COPDE, what other therapies can be added? Non-pharm?
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
If starting COPDer on prophylactic Azithromycin, what test should you do at baseline? (2)
- ECG: QTc
- Sputum culture: non-TB mycobacteria (NTM)
What therapies can be instored for dyspnea management in advanced COPD? Which are NOT?
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.
When to suspect Asthma/COPD overlap?
- 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
Asthma/COPD overlap diagnostic criteria?
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)
What is the significance of asthma/COPD overlap?
- Worse prognosis/outcomes
- More exacerbations
- Decreased lung function
- Poorer QoL
- Increased mortality
Asthma/COPD overlap treatment? Caveat?
- 1st line: LABA/ICS
- Refractory sx: add LAMA
- Caveat: no RCT addressing this population (asthma trials exclude smokers, COPD trials exclude asthmatics)
Indications for O2 therapy in stable COPD?
- 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%)]
When should home O2 be reassessed?
60-90 days after initiation
Indications for NIV? (3)
- Resp acidosis (CO2 >45 or <7.35)
- Severe dyspnea (impending resp failure: resp fatigue, WOB)
- Persistent hypoxemia despite supp. O2
What is the 1 year mortality rate after COPDE?
How much mL of FEV1 is lost after AECOPD?
- ~30% vs. 23% with MI!
- ~8mL/yr
Antibiotics in COPDE should be given when?
- 3 cardinal sx: dypnea, sputum volume + purulence
- 2 of above IF purulence is one of them
- If patient require invasive/NIV
What is bronchiectasis?
- Chronic resp disease
- Characterized by clinical syndrome of cough, sputum production, bronchial infection AND imaging of permanent/abnormal dilatation of bronchi
Most common symptoms of bronchiectasis?
- cough
- sputum production and/or hemoptysis
- rhinosinusitis
- thoracic pain
List few causes of bronchiectasis. What are the 2 most common ones which account for 50% of cases?
- postinfectious (prior PNA, pertussis, NTM, TB)
- idiopathic
- Humoral immunodeficiency
- CF
- Autoimmune/CTD
- IBD
- ABPA
- Aspiration
- Congenital
- PCD
- Alpha-1-AT
List workup plan for bronchiectasis.
- 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
Mainstays of treatment for bronchiectasis? Advacned therapies?
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
Bronchiectasis exacerbations: treatment?
- Sputum cultures
- Empiric Abx, typically 14 days
- If major hemoptysis, IV Abx, TXA +/- embolization
Typical UIP pattern on CT?
- reticular changes
- subpleural, basal
- honeycombing
- absence of inconsistent features
What is Light’s criteria?
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
Pleural effusion. Which cancer cannot be diagnosed from cytology?
Mesothelioma. Need pleural biopsy.
Indications for thoracentesis?
- Suspect exudate
- Cause unclear
- Paranpneumonic effusion: if less 1cm fluid on lateral decubitus in context of PNA, can forgo sampling and follow radiographically
Indications for chest drain/tube?
- drainage of pus/cloudy
- positive gram stain/culture
- pH <7.2 (if unavailable, use glucose <3.4)
- > 50% of hemithorax or loculations on imaging
