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IM RCPSC 2024 > Respirology > Flashcards

Respirology Flashcards

1
Q

Samter’s triad of ASA exacerbated respiratory disease

A

Asthma
Nasal polyps
ASA/NSAID sensitivity

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2
Q

Asthma Diagnosis requires these 2 features

A
  1. History of variable respiratory symptoms that vary over time and intensity
  2. Confirmed variable expiratory airflow limitation:
    NEED SPIROMETRY TO HAVE DIAGNOSIS OF ASTHMA
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3
Q

spirometry variability criteria for asthma diagnosis

A
  1. > 12% AND 200ml change in FEV1 with bronchodilator
  2. > 12% AND 200ml change in FEV1 after 4 weeks of treatment with anti inflammatory
  3. Excessive FEV1 variation in lung function between visits (>12% and 200 cc variation)
  4. Peak Flow Variability – Average daily diurnal PEF variability >10%
    – Excessive variability in twice daily PEF over 2 weeks
  5. Positive Bronchial Challenge Test or Exercise challenge test
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4
Q

Positive methacholine challenge for asthma

A

Methacholine Challenge – look for drop in FEV1 by 20%
– PC20 <4mg/mL = POSITIVE
– PC20 4-16 = borderline
– PC20 >16 = negative

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5
Q

Positive exercise challenge for asthma

A

Fall in FEV1 of >10% and >200mL from baseline

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6
Q

Assessing Asthma Control based on CTS 2021 guidelines

A

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%

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7
Q

Risk factors for severe asthma

A

any 1 of:
* Any history of a previous severe asthma
exacerbation (any of: requiring systemic
steroids, ED visit or hospitalization)
* Poorly controlled asthma per CTS criteria
* Overuse of SABA (=use of more than 2 SABA
inhalers per year)
* Current smoker

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8
Q

Severe asthma Exacerbation criteria as per CTS 2021

A

any 1 of
- Requiring systemic steroids
- Requiring ED visit
- Requiring hospital admission
Mild exacerbation = 0/3 above criteria

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9
Q

Asthma Treatment Step 1 and 2
(CTS 2021)

A

Low dose ICS and fometerol (LABA)
examples:
Symbicort
Zenhale
Fostair

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10
Q

Asthma treatment Step 3
(CTS 2021)

A

Low dose
maintenance ICS-formoterol
+ PRN

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11
Q

Asthma treatment Step 4
(CTS 2021)

A

Medium dose
maintenance ICS-formoterol
+ PRN Lose Dose ICS Formoterol

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12
Q

Asthma Treatment step 5
(CTS 2021)

A

Refer for phenotypic assessment,
+/- LAMA add on,
AntinIgE, Anti IL5, Anti IL4, Anti-TSLP.
Consider high dose ICS Formoterol.
PRN lose dose ICS formoterol

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13
Q

Non pharmacological management of Asthma

A

Educate + Written Asthma Action Plan
Weight loss, exercise training
Allergen / trigger avoidance / allergen
immunotherapy
Smoking cessation
Vaccinations
Avoid NSAIDs (and maybe beta blockers)
Comorbidities management (GERD, PND, Obesity)

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14
Q

indications for Leukotriene receptor agonist

A

Those intolerant of ICS
aspirin-exacerbated asthma,
exercise-induced symptoms,
allergic rhinitis
*Less effective than ICS at preventing exacerbations

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15
Q

Black box warning for leukotriene receptor agonists

A

Increased suicidality

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16
Q

LANCET AMAZES Trial 2017
Standpoint of Macrolides in severe Asthma

A

“In individuals >18 w severe asthma there is limited evidence that chronic use of macrolides may
decrease frequency of exacerbations

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17
Q

Indications for Anti-IgE (Omalizumab) in Asthma

A

allergic asthma IgE 30 – 700,
sensitive to at least 1 perennial allergen, severe despite high dose ICS and one other
controller
(CTS 2017)

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18
Q

Indications for IL-5 (mepolizumab, resilzumab, benralizumab) in asthma

A

severe eosinophilic asthma (generally >300) and
recurrent exacerbation despite high dose ICS and one other controller
(CTS 2017)

19
Q

Indications for IL-4/IL-13 (Dupilumab) in asthma

A

add-on option for severe eosinophilic asthma or
those with nasal polyposis or
moderate-severe atopic dermatitis

20
Q

how to make diagnosis of COPD

A

Spirometry is required to make the diagnosis, with a post-bronchodilator FEV1/FVC<0.70

21
Q

criteria for Mild Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Mild: FEV1 > 80% predicted

22
Q

criteria for Moderate Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Moderate: 50% < FEV1 < 80% predicted

23
Q

criteria for Severe Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Severe30% < FEV1 < 50% predicted

24
Q

criteria for very severe Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Very Severe: FEV1 < 30% predicted

25
non pharmacological management of COPD
Smoking cessation Self education management Exercise therapy Vaccinations (Flu, Clovid, Pneumovax)
26
Non-Pharmacology Managent of COPD with SURVIVAL benefit
Smoking cessation -survival for ALL Oxygen -survival for severe resting hypoxia Pulmonary rehab -survival in patient <4 weeks post AECOPD
27
Indications for long term oxygen therapy
PaO2<55mmHg PaO2<60mmHg with bilateral pedal edema PaO2 < 60mmHg with cor pulmonale HCT >56%
28
Modified MRC dyspnea scale
0. Not troubled by breathlessness except on strenuous exercise 1 Shortness of breath when hurrying on level or walking up slight hill 2 Walks slower than people of the same age on the level b/c of breathlessness or has to stop for breath when walking at own pace on the level 3 Stops for breath after walking about 100m or after a few minutes on the level 4 Too breathless to leave the house or breathless when dressing or undressing
29
Initial pharmacological therapy of COPD
LAMA (e.g. Spiriva) Prevents acute exacerbations compared to LABA
30
COPD management for moderate COPD CAT >10
LAMA+LABA combo (e.g. Inspiolto)
31
COPD for severe COPD (already on LABA/LAMA)
LAMA+LABA+ICS (E.G. Trelogy)
32
treatments to AVOID in COPD
– ICS monotherapy : increases risk of pneumonia – Oral therapies (PDE-4i, PDE-5i, mucolytics, herbal remedies) have no evidence for symptomatic benefit in stable COPD
33
Recommended oral therapies if ongoing exacerbations of COPD despite triple therapy
– Azithromycin (care: QTc, hearing impairment, sputum culture for NTM) – Roflumilast if chronic bronchitis phenotype (caution: diarrhea and weight loss) – NAC 600 mg BID if chronic bronchitis phenotype – Recommend AGAINST theophylline to prevent exacerbations!
34
Proposed required criteria for Asthma COPD overlap
1. Diagnosis of COPD given risk factors, history, spirometry 2. History of asthma (past history/diagnosis, current symptoms consistent, or physiology confirmed /w spirometry) 3. Spirometry: post-bronchodilator fixed FEV1/FVC <0.7
35
Supportive but not required criteria for diagnosis of Asthma COPD overlap
1. Documentation of a bronchodilator improvement of FEV1 by 200ml or 12% 2. Sputum eosinophils >3% 3. Blood eosinophils >300 cells/uL (current or prev documented)
36
Indications for antibiotic therapy in 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 Should also be given if requires NIV or Intubation
37
indications for BiPAP in COPD (GOLD 2022)
Recommended if any of: * pH ≤7.35 with pC02 ≥ 45 * severe dyspnea (impending respiratory failure) * persistent hypoxemia despite supp oxygen
38
Diagnosis/characterization of Bronchiectasis
Bronchiectasis is a chronic respiratory disease characterized by a clinical syndrome of cough, sputum production and bronchial infection, and radiologically by abnormal and permanent dilatation of the bronchi.
39
Absolute contraindications to Methacholine challenge
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
40
Relative contraindications to methacholine challenge
1. Moderate airflow limitation FEV1<60% or <1.5L 2. Pregnancy or nursing mothers (methacholine is category C) 3. Use of cholinesterase inhibitor (myesthenia gravis)
41
Contraindications for Pulmonary function tests
* 1. Hemoptysis * 2. Pneumothorax * 3. Unstable cardiovascular status including recent MI * 4. Aneurysms – thoracic, abdominal or cerebral * 5. Recent eye surgery – eg. Cataracts * 6. Recent thoracic or abdominal surgery * 7. Presence of acute illness that may interfere with test performance
42
Definition of obstructive sleep apnea
Symptoms (sleepiness, choking, awakenings etc) and Objective testing (> 5 apnea/hypopnea events during sleep monitoring) * Mild 5-15 (events/h) / Moderate 15-30 / Severe >30
43
Treatment options for obstructive sleep apnea
– Weight loss (diet/exercise) – CPAP * All patients should be offered therapy, asymptomatic patients should be treated if have comorbidities (ie. HTN), AHI >30, critical occupation – Oral appliances – for mild-moderate disease – Surgery (rare) – Tonsillectomy if appropriate, uvulopalatopharyngoplasty in select patients

IM RCPSC 2024 (9 decks)

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