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Family Medicine Notes > Respirology > Flashcards

Respirology Flashcards

1
Q

Emphysema etiology

A

Destruction of alveoli

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2
Q

Chronic bronchitis etiology

A

Inflammation of the bronchioles

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3
Q

Chronic bronchitis diagnosis

A

Clinical diagnosis

Chronic cough + sputum >3 months/year x 2 years

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4
Q

COPD risk factors

A

Smoke exposure/inhaled chemicals

Alpha 1 antitrypsin deficiency

Severe childhood respiratory disease/asthma

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5
Q

COPD epidemiology

A

4.4% Canadians

Female more common than male

4th leading cause of death

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6
Q

COPD screening

A

Spirometry if

  1. Smoker/ex smoker, >40 y/o and sx (persistent cough, phlegm, wheeze, recurrent URTI, exertional SOB)
  2. > 40 y/o with resp symptoms AND environmental exposure/frequent resp infections/family history of COPD
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7
Q

COPD diagnosis

A
  1. Spirometry
    Fixed post bronchodilator FEV1/FVC < 0.7
  2. Alpha1 antritrypsin serum level if <65 y/o or smoking history of <20 pack years
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8
Q

COPD classifications

A

COPD Assessment Tool (CAT) or modified Medical Research Council (mMRC)

Mild - SOB with hurried walk, recurrent chest infections, FEV1>80%

Moderate - SOB requiring rest ~100m/few mins, limits in daily activities, exacerbations requiring corticosteroids +/- abx, FEV1 50-79%

Severe - Breathless after dressing, resp/cardiac failure, FEV1 30-49%

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9
Q

Routine management/prevention of AECOPD

A

Smoking cessation - single most effective intervention

Vaccines - annual influenza + pneumococcal (+booster @5 years)

Puffers - review technique + action plan

Activity - negative repercussions of inactivity (ESOB is not life threatening!!), stay indoors when air quality is poor

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10
Q

Which pharmocological agent slows progression of COPD

A

None

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11
Q

Pharmacotherapy evaluation follow up time frame

A

6 months or 12 months if it includes an ICS

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12
Q

Pharmacotherapy approach COPD

A

Mild

  1. Short acting bronchodilator (SABD) prn only
  2. LAMA (preferred) or LABA

Moderate/Severe and low risk of AECOPD 0-1 moderate AECOPD in last 12 months

  1. LAMA (preferred) or LABA
  2. LAMA/LABA
  3. LAMA/LABA/ICS

Moderate/Severe and high risk of AECOPD 2+ moderate AECOPD or 1+ severe AECOPD

  1. LAMA/LABA (preferred) or ICS/LABA (consider if blood eosinophil 300 uL+ or concomitant asthma)
  2. LAMA/LABA/ICS
  3. Oral therapies (macrolide, Raflumilast, N-acetylcysteine)
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13
Q

Examples of short acting bronchodilators

A

Short acting muscarinic antagonists
Ipratropium (Atrovent) 2 puffs QID

Short acting beta 2 agonists
Salbutamol (Ventolin) 1-2 puffs QID
Terbutaline (Bricanyl) 1 puff QID

SAMA/SABA
Ipratropium + salbutamol (Combivent) 1 puff QID

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14
Q

Examples of LAMAs

A

Long acting antimuscarinic antagonist
Tiotropium (Spiriva) 1 cap/2 puffs once daily
Aclidinium (Tudorza) 1 puff BID
Glycopyrronium (Seebri) 1 cap once daily
Umeclidinium (Incruse) 1 puff once daily

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15
Q

Examples of LABAs

A 
Long acting beta2 agonists 
Salmeterol (Serevent) 1 puff BID 
Formoterol (Oxeze) 1 cap/6-12 ug BID 
Indacaterol (Onbrez) 1 cap inahled once daily  
Olodaterol 2 puffs once daily
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16
Q

Examples of LAMA/LABAs

A

Umeclidinium + vilanterol (Anoro) 1 puff once daily
Glycopyrronium + Indacaterol (Ultibro) 1 puff once daily
Tiotropium + Olodaterol (Inspiolto) 2 puffs once daily
Aclidinium + Formoterol (Duaklir) 1 puff BID

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17
Q

Examples of LABA/ICS

A

Formoterol + budesonide (Symbicort) 12/400 mcg BID
Salmeterol + fluticasone (Advair) 50/250 mcg BID
Vilanterol + fluticasone (Breo) 1 puff once daily

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18
Q

Role of ICS in COPD

A

No monotherapy!

Blood eosinophil 300 uL+ predicts response to ICS (unlikely to respond if 0-100)

Note increase risk of pneumonia with ICS use but no change in mortality

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19
Q

AECOPD definition

A

Sustained >48h worsening of symptoms (dyspnea, cough, sputum volume/purulence)

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20
Q

Classification of AECOPD severity

A

Mild - change in sx but no abx or steroids needed

Moderate - abx +/- steroids

Severe - hospitalization/ER visit

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21
Q

AECOPD causes

A

Infection (50%)
H. influenza, S. pneumonia, M. catarrhalis

CHF

Irritants

PE

MI

Anemia

22
Q

AECOPD management

A
  1. Ventolin + LAAC (Spiriva)
  2. For moderate to severe give 30-40 mg prednisone/day x 5 days with no taper. Usually must persist >48h before starting oral steroids or abx
  3. Increased purulence (or moderate to severe symptoms) - antibiotics
    If point of care CRP <40 then patient likely does not need abx

Simple - 5 days (FEV1>50%, mild-mod, 0-3 exacerbations/year, no cardiac disease)
First line
a) Amoxicillin 500 mg TID
b) Doxycycline 100 mg BID x 1 day then 100 mg once daily
c) Tetracycline 250-500 mg QID
d) TMP/SMX 2 tabs BID or 1 DS tab BID
Second line
a) Clarithromycin 500 mg BID OR 1000 mg extended release once daily
b) Azithromycin 500 mg x 1 then 250 mg once daily x 4 days OR 500 mg once daily x 3 days
c) Cefuroxime 500 mg BID
d) Cefprozil 500 mg BID

Complicated/high risk 7-10 days (FEV1 <50%, 4+ exacerbations/year, cardiac disease)
First line
a) Amoxicillin/Clavulanate 500 mg TID or 875 mg BID
Second line
a) Levofloxacin 500 mg once daily x 7 days or 750 mg once daily x 5 days
b) Moxifloxacin 400 mg once daily

At risk of Pseudomonas (FEV1<35% predicted, chronic steroids, constant purulent sputum)
1. Ciprofloxacin 500-750 mg BID

23
Q

Indication for pulmonary rehabilitation in COPD

A

Remains dyspneic despite dual therapy LAMA/LABA

24
Q

What is the target oxygenation level in COPD

A

Goal sats >90%

Survival advantage if arterial oxygen <55 mm Hg

25
Q

When to refer COPD cases

A 
Diagnosis uncertain 
Symptoms severe/unproportionate to spirometry 
Failure to respond to therapy 
Accelerated decrease of lung function 
Onset 0-40 y/o 
Complex co-morbidities 
Assessment for pulmonary rehabilitation 
Home oxygen 
Surgical therapy
26
Q

Indications for continuous long-term oxygen therapy (LTOT) for patients with chronic lung disease include

A

●Arterial oxygen tension (PaO2) less than or equal to 55 mmHg (7.32 kPa), or a pulse oxygen saturation (SpO2) less than or equal to 88 percent

●PaO2 less than or equal to 59 mmHg (7.85 kPa), or an SpO2 less than or equal to 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit >55 percent)

For patients with normal awake oxygenation, oxygen may be prescribed during sleep if any of the following occur during sleep:
the PaO2 is 55 mmHg or less
the SpO2 is 88 percent or less
the PaO2 decreases more than 10 mmHg (1.33 kPa), and/or the SpO2 decreases more than 5 percent with signs or symptoms of nocturnal hypoxemia (eg, impaired cognitive function, morning headaches, restlessness, or insomnia). In this setting, portable oxygen would not be covered.

Oxygen may be prescribed during exercise if there is a reduction of
PaO2 to 55 mmHg or less
or SpO2 to 88 percent or less during exercise.
Additionally, oxygen may be warranted during exercise even in those patients who do not significantly desaturate during exercise, if they have dyspnea and ventilatory abnormalities during exercise that suggest supplemental oxygen may permit greater exertion. This is supported by studies that found that hyperoxia increases exercise endurance in a dose-dependent manner, up to an inspired oxygen fraction of 50 percent or a flow rate of 6 L/min.

The use of supplemental oxygen in the palliative treatment of dyspnea in non-hypoxemic patients is not well supported by the literature. Pharmacological management is first line for this

27
Q

Asthma triggers

A 
Cold air
Exercise 
Viral illness 
Allergen 
Irritant 
Food (sulphites, MSG, cold drinks) 
Meds (beta blockers, NSAIDs, aspirin) 
Strong emotion
28
Q

Asthma aggravating comorbidities

A 
Rhinitis/rhinosinusitis
Sleep apnea
GERD 
Obesity 
Stress/depression/anxiety 
Psychosocial issues
29
Q

Asthma prevention

A

Primary
Conflicting evidence for avoiding early life exposure to pets, unless both parents are atopic then stronger evidence

Secondary
Avoid tobacco

Tertiary
Allergens that patients are sensitive to should be identified and systematically removed

30
Q

Diagnosis <6 years old

A

Patient and family history
If refractory to tx exclude other pathology
Assess for atopy which predicts persistent asthma

Age 1-5 years old
Abandon terms such as “reactive airway” “bronchospasm”
Require all 3 of the following during 2+ episodes

  1. Documentation of airflow obstruction (cough/difficulty breathing/wheeze)
    - Preferred: documented by physician
    - Alternative: convincing parental report of wheezing
  2. Documentation of reversibility of airflow obstructions
    - Preferred: physician observed improvement in signs of airflow obstruction to SABA +/- oral corticosteroid
    Mild symptoms, 4 puffs salbutamol, reassess 30 min
    Mod symptoms, 4 puffs salbutamol, reassess 60 min (may need 2-3 doses of 4 puffs within 60 min)
    OR mod symptoms oral steroid (dexamethasone 0.15-0.6 mg/kg max 50 mg) 1 dose, reassess in 3-4 hours
    - Alternative: convincing parental report of symptomatic response to 3 month trial medium dose ICS with PRN SABA, expect 50% decrease in # off exacerbations (should document daytime/nighttime symptoms, SABA use, exacerbations)
  3. No clinical evidence of an alternative diagnosis
31
Q

Diagnosis asthma 6+ years old

A
  • Patient and family history
  • MUST have spirometry and in its absence, a positive methacholine or exercise challenge test or sufficient peak expiratory flow variability
  • If refractory to treatment, exclude other pathology
  • Assess for atopy which predicts persistent asthma
  • Any signs/symptoms of variable lower airway obstruction + response to therapy suggests asthma diagnosis but definitive diagnosis needed

DO NOT order full pulmonary function testing or CXR to confirm asthma unless questioning a diagnosis other than asthma

For accuracy, discontinue ICS+/- LABA 24 hr prior to spirometry

Spirometry (preferred) 
- Children >6 
Decreased FEV1/FVC <0.8-0.9 
Increased FEV1 12% with bronchodilator 
- Adults 
Decreased FEV1/FVC <0.75-0.8 
Increased FEV1 12% with bronchodilator 
PEF (alternative) 
- Children >6 
Increased min 20% with bronchodilator 
- Adults
Increased 60L/min (min 20%) with bronchodilator 
Diurnal variation >8% if measured BID

Methacholine
PC20 <4 mg/mL (4-16 borderline, >16 negative)

Exercise
Decreased FEV1 minimum 10% post exercise

32
Q

Asthma control

A 
Daytime symptoms <4 days/week 
Need for Ventolin < 4 dose/week 
Night-time symptoms <1 night/week 
FEV 1 or PEF 90%+ personal best 
PEF diurnal variation <15% 
Sputum eosinophils (mod to severe asthma) <3% 
Physical activity normal 
Exacerbation mild, infrequent 
Absence from work/school secondary to asthma none
33
Q

Asthma nonpharmacologic management

A

Encourage aerobic exercise

Strongly encourage smoking cessation

Consider avoiding NSAIDs (10-20% are sensitive to NSAIDs/aspirin and non-cardioselective BB)

Avoiding all allergens and environmental triggers is unrealistic

If risk of anaphylaxis, ensure auto-renewable prescription of epi-pen

Consider annual influenza vaccination

34
Q

SABA drugs, doses, routes

A

Short acting beta 2 agonist (SABA)

  • Ventolin (Salbutamol) 100 mcg 2 puffs q4-6 hours
  • Bricanyl Turbuhaler (Terbutaline) 2.5 mg 1-2 puffs q6h
35
Q

Inhaled corticosteroid adverse effects

A

Delay growth velocity

Oral thrush

Dysphonia

36
Q

Risk of LABA monotherapy

A

Associated with increase asthma morbidity

37
Q

Role of SAAC in asthma

A

less effective than SABA

38
Q

ICS drugs, doses, routes

A

Inhaled corticosteroid

  • Flovent (fluticasone) 50, 125, 250 mcg 1 puff BID
  • Pulmicort (Budesonide) 100, 200, 400 mcg 1 puff BID
39
Q

ICS + LABA drugs, doses, routes

A

ICS + long acting beta 2 agonist (LABA) ** NO LABA MONOTHERAPY

  • Symbicort budesonide/formoterol 100/6, 200/6 2 buffs BID
  • Advair fluticasone/salmeterol 100/50, 250/50, 500/50 1 puff BID
40
Q

LTRA drugs, doses, routes

A

Leukotriene receptor antagonists (LTRA)

- Singulair (montelukast) 4 mg granules, 4 mg tablets chewable, 5 mg tablets chewable, 10 mg tablets - 1 tab PO Qpm

41
Q

6-11 years old asthma medication ladder

A

SABA (Ventolin) prn

  1. ICS (Flovent 50 ug BID)
  2. Increase ICS dose (Flovent 100 ug BID)
  3. ICS + LABA (Advair 100/50 BID) REFER
    or
    ICS + LTRA (Flovent 125 BID + Singulair) REFER
  4. Increase ICS + LABA (Advair 250/50 ug BID)
42
Q

12 Years old and older asthma medication ladder

A

SABA (Ventolin) prn

  1. ICS (Flovent 50-125 ug BID)
  2. ICS + LABA (Symbicort 100/6 or Advair 100/50 BID)
    * Symbicort can be used as a controller and reliever in 12+ yo
  3. Increase ICS + LABA (Symbicort 200/6 BID or Advair 250/50 BID) REFER
    OR
    ICS/LABA + LTRA (Advair/Symbicort + SIngulair) REFER
  4. Increase ICS/LABA +LTRA (high dose Advair or Symbicort + Singulair)
43
Q

When to step up asthma therapy

A
  1. Usually using first line medications if no risk factors for exacerbations AND 0-1 daytime symptoms per month
  2. Second line meds if risk factors for exacerbations OR 2-8 daytime symptoms/mo or awakenings at night. Can consider intermittent ICS
  3. Usually using 3rd line if daytime symptoms most days or awakening 4+ nights per month. REFER IF MODERATE DOSE ICS IS INSUFFICIENT IN A CHILD
  4. Respirology may consider high dose ICS/LABA, LAMAs (in adults), biologic therapy (Anti-IgE, Anti-IL5) or oral prednisone)

Consider step down therapy only if exacerbation risk is low and asthma is well-controlled for at least 3 months

44
Q

Classifying severity of asthma exacerbation in <6 y/o

A

PRAM score

SaO2
0- 95%+
1- 92-94%
2- 0-91%

Suprasternal retraction
0- absent
2- present

Scalene contraction
0-absent
2- present

Air entry 
0- normal 
1- decreased at the base 
2- decreased at the apex/base 
3- minimal or absent 
Wheeze 
0- absent 
1- expiratory 
2- inspiratory 
3- audible without stethoscope

0-3 mild
4-7 moderate
8+ severe

45
Q

Indications to transfer asthma case 6+ years old to acute care with O2, SABA, ipratropium + reliever

A

Severe or life threatening:

Posture - Hunched forward, not talking in sentences
Decreased consciousness

Quantitative findings 
RR >30 
P >120 
O2 0-89% 
Accessory muscle use 
Silent chest
46
Q

Acute asthma exacerbation action plan for 6-11 years old

A

If on SABA - consider starting regular ICS

If on ICS and SABA - Prednisone 1 mg/kg x 3-5 days (max 50 mg) OR dexamethasone 0.15-0.6 mg/kg/d (max 10 mg)

If on ICS/LABA and SABA - Prednisone 1 mg/kg x 3-5 days (max 50 mg) OR dexamethasone 0.15-0.6 mg/kg/d (max 10 mg)

Notes

  • Warn parents to seek medical attention if child exposed to varicella
  • In preschool children, dexamethasone can be given at 0.15-0.3 mg/kg/d as the first dose to subsequent 2-4 day course of prednisone or at 0.6 mg/kg/day as part of a 1-2 day course
  • CPS recommends prednisone or dexamethasone in children
  • 6 RCTs prednisone x 5d = dexamethasone 0.3-0.6 mg/kg/day x 1-2 days (less vomiting with dexamethasone)
47
Q

Acute asthma exacerbation action plan for 12+ years old

A

If on SABA - consider starting regular ICS

If on ICS and SABA -
increase ICS 4 fold x 7-14 days OR
Prednisone 30-50 mg 5+ days

If on Symbicort +/- SABA -
Increase Symbicort 4 puffs BID x 7-14 days OR
Prednisone 30-50 mg x 5+ days

If on Advair and SABA or Symbicort -
Increase ICS 4 fold x 7-14 days OR
Prednisone 30-50 mg 5+ days

Notes

  • Warn parents to seek medical attention if child exposed to varicella
  • CPS recommends prednisone or dexamethasone in children
  • 6 RCTs prednisone x 5d = dexamethasone 0.3-0.6 mg/kg/day x 1-2 days (less vomiting with dexamethasone)
48
Q

Asthma criteria for hospital admission

A

Unable to speak sentences

Tachypnea >25/min

Tachycardia >110/bradycardia

PEF <40% predicted

Silent chest

Cyanosis

Confusion

49
Q

Management of status asthmaticus

A

Oxygen

CXR, ABG, PEF

B2 agonists with spacer, anticholinergic therapy, corticosteroids

IV salbutamol prn

50
Q

Structured evaluation at scheduled asthma visits

A
  1. Document height and weight of children + adolescents (growth velocity and potential side effects of corticosteroid)
  2. Document signs and symptoms of adrenal suppression
  3. Review disease control, symptoms, activity level, triggers and comorbidities
  4. Review risks for exacerbations (hx exacerbations, hospitalizations, intubations, cormobidities, environmental irritants, FEV1 <60%, very high SABA use ex. >1 canister/month, nonadherence/no action plan)
  5. Review medication adherence and action plan (technique, barriers)
  6. F/u within 1-3 months of diagnosis + initiating treatment and then at least twice per year or as clinically needed. Serial FEV1 (spirometry) at 3-6 months after initiating tx and q1-2 years once control achieved or as clinically indicated
51
Q

Why can you use same dose of asthma medication regardless of age

A

auto-scaling

52
Q

When to refer asthma patients

A

Children 1-5 with 2+ exacerbations needing oral steroid or 8+ symptom days/month despite moderate ICS

Children 6-11 who fail control on medium dose ICS

Recurrent need of oral steroids or frequent symptoms 8+/month

Diagnostic uncertainty

Need for environmental allergy testing

Suspected occupational-related asthma

Considering immunotherapy/biologic therapy

Family Medicine Notes (3 decks)

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