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LMCC - Medicine > Respirology - Air Space Disease > Flashcards

Respirology - Air Space Disease Flashcards

1
Q

Discuss the pathophysiology of Asthma

A
  • variable airflow limitation and airway hyperresonsiveness represented by exaggerated contractile response of the airway to variety of stimuli
  • atopic march: eczema, food allergies, environmental allergies
    - strongest predictor for development
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2
Q

Discuss the symptoms and diagnosis of asthma

A

Signs and Symptoms
- Wheezing
- Cough
- Dyspnea
- Reduce air entry on auscultation
Diagnosis
- obstrutive pattern on spirometry
- Children 6-11 have FEV1/FVC <0.8 and increased FEV1 post-bronchodilator >=12%
- Adults have FEV1/FVC <0.75 and increase in FEV1 post-bronchodilator by >=12% and >=200mL
- scooped flow volume curve
- high residual volume RV/TLC >0.35
- methacholine challenge where have >20% drop in FEV1 with <4mg/mL of methacholine
- FEV1 drop of >10% at 80% of maximum HR

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3
Q

Discuss possible triggers for asthma exacerbation

A
  • Allergens exposure
  • Respiratory infection
  • Cigarettes
  • Animal dander
  • Dust mites
  • cold/dry air
  • exercise or emotional factors
  • B Blockers/ASA/NSAIDs
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4
Q

Discuss the management of asthma

A
  • Environmental control
  • Education
  • Action plan
    Medication
  • Short-Acting Bronchodilator on demand for very mild
  • Inhaled Corticosteroid for maintenance therapy for mild asthma (symptoms 3x per week)
    - leukotriene receptor antagonist second line
    - start at low dose and progress
  • Long acting bronchodilator used as third line add on
    - must be on ICS if using LABA
    - if less than 12 then increase ICS before
  • Third line to add LTRA
  • Fourth line prednisone
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5
Q

Discuss the characteristics of good asthma control

A
  • Daytime Symptoms <4x/week
  • Nighttime symptoms <1x/week
  • Normal physical activity
  • Infrequent and mild exacerbation
  • No absences due to asthma
  • Need for SABA <4dose/week
  • FEV1 >=90% best
  • sputum eosinophils <2-3%
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6
Q

Discuss the pathophysiology and symptoms of COPD

A

Pathophysiology
- airflow limitation caused by inflammatory response to inhaled toxins
Signs and Symptoms
- Productive cough
- Dyspnea
- Decreased breath sounds
- Wheezes
- Prolonged expiratory phase of breathing
Investigations
- PFT: FEV1/FVC <0.7 with no improvement with bronchodilator
- Spirometry increased FRC, RV and decreased VT
- CXR: hyperinflation of lung with flattended diaphragm

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7
Q

Discuss the Triggers and Signs of COPD exacerbation

A 
Triggers
- Respiratory infection
- Environmental pollution
- pulmonary embolism
- comorbid respiratory or cardiac condition
Signs
- Change in amount or color/purulence of sputum
- More short of breath
- change in mood
- Fatigue
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8
Q

Discuss the MRC dyspnea scale of symptoms and impairement of lung function

A

Normal
- MRC 1 dyspnea only with strenuous exercise
- Normal spirometry
Mild
- MRC 2 dyspnea when hurring on level ground or walking up hill
- FEV1 >80% predicted and FEV1/FVC <0.7
Moderate
- MRC 3 walk slower than people because of breathlessness or has to stop for breath
- MRC 4 stop for breath after walking 100m
- 50% <= FEV1 < 80% predicted
- FEV1/FVC <0.7
Severe
- MRC 5 too breathless to leave house or breathless with dressing
- 30%

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9
Q

Discuss the management of COPD

A 
Education
- inhaler
- action plan
Smoking Cessation
- most important intervention to slow lung decline
Exercise or Pulmonary Rehabilitation
- All patients should exercise
Vaccination
- influenza
- Pneumovax <65 or Prevnar >65
Pharmcotherapy
- Mild: SABA prn
- Moderate: SABA and LABA/LAAC prn
- Severe (>1 AECOPD/year): Long acting anticholinergic + ICS/LABA + SABA prn
Oxygen
- severe hypoxemia (PaO2 <55mmHg or SaO2 <88%)
- PaO2 <59mmHg or SpO2 <89% with evidence of right heart failure or cor pulmonale or erytrhocytosis (Hct >55%)
Surgery
- lung volume reduction surgery
Lung Transplant
- FEV1 <25%
- PaCO2 >55
- pulmonary hypertension
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10
Q

Discuss the indications for hospitalization for AECOPD

A

Hospitalized if any of the following

  • inadequate response to outpatient emergency department management
  • marked increase in dyspnea
  • severe underlying COPD, FEV1 <50%
  • inability to eat or sleep
  • new cyanosis or worsening hypoxemia
  • Acute respiratory acidosis
  • Change in mental status
  • Insufficient home support
  • High risk comorbidities
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11
Q

Discuss the in-hospital management of AECOPD

A

Treatment
- target O2 >90%
- albuterol 2.5mg by nebulizer Q1-4H or 4-8 puffs with spacer
- Ipratropium 500mcg nebulizer Q4H or 2-4 puffs
- systemic steroids (prednisone 40mg PO for 5 days)
Non-Invasive Positive Pressure Ventilation
- respiratory distress: tachypnea >25 RR or use of accessory muscles
- respiratory acidosis: pH <7.35 or PaCo2 >45
Antibiotics
- uncomplicated (<65yo, FEV1 >50%, <3 exacerbations a year, no cardiac disease)
- Azithromycin 500mg POx1d then 250mg Q24H for 4d
- Cefuroxime 500mg PO Q12H
- Doxycycline 100mg PO Q12H x1d then 100mg Q24H
- Septra 1 tab PO Q12H
- Complicated (any of above risk factors)
- Levofloxacin 750mg Q24H
- Amox-Clav 875mg Q12H x1d then 100mg Q24H
- Pseudomonas then Cirpofloxacin
- Abx for 5d if mild-mod, 7d for severe

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12
Q

List the Common Asthma/COPD Inhalers and their side Effects

A 
SABA (blue)
- Salbutamol (ventolin)
- tachycardia
- arrhythmia
- irritability
- difficulty sleeping
- muscle cramps
LABA (orange)
- formoterol (oxeze)
- salmeterol (serevent)
- same as SABA
ICS (red)
- Fluticasone (flovent)
- Beclomethasone (ovar)
- hoarseness
- sore throat
- thrust
ICS + LABA
- Fluticasone + Salmeterol (Advair - purple)
- Pulmicort + Oxeze (Symbicort - red)
- shaky hands
- tachycardia
- thrush
- sore throat
- hoarse
Short-Acting Anticholinergic
- Ipratropium bromide (atrovent)
- dry mouth
- urinary retention
Long-Activing Anticholinergic
- Tiotropium (spiriva)
- same as SAAC
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13
Q

Discuss the presentation and consequences of OSA

A 
Symptoms
- snoring, apnea, choking
- morning headache
- GERD
- poor quality of sleep resulting in daytime sleepiness, impaired memory/concentration and depression
Long-term
- systemic hypertension
- increased risk of stroke or MI
- increased risk of AF or CHF
- increased risk of pulmonary hypertension as have vasopasm of pulmonary arteries from decreased desats
- increased risk of diabetes
- increased risk of depression
- daytime hypercapnia and hypoxemia
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14
Q

Discuss the management of OSA

A 
Indications
- symptomatic
- AHD >=15 as incrase cardiovascular risk
- occupation
- presence of comorbid condition
Non-Specific
- weight loss
- avoid substances
- positional therapy (side sleeping)
- avoid sleep deprivation
Nasal continuous Positive Airway Pressure (CPAP)
- 1st line
- continuous blowing of room air into airway splinting it open
- BiPAP for larger adults requiring greater pressure
Surgery
- for underlying anatomical problem
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15
Q

Discuss the diagnosis of OSA

A

Must have A or B and C
A: Excessive daytime sleepiness that cannot be explained
B: >=2
- recurrent choking or gasping in sleep
- recurrent awakening from sleep
- daytime fatigue
C: Apnea hypopnea index (apnea + hypopnea/hrs asleep) >5 (mild:6-15/hr, mod:16-30/hr, sev: .30/hr)
- hypopnea is decreased airflow by 50% with decreased O2 sat by >4% or EEG arousal

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16
Q

List the definition and risk factors for apnea

A

Apnea: cessation of airflow for >10 seconds or 2 breath cycles
- obstructive: cessation >10s despite respiratory efforts
- central: cessation for >10s with no respiratory effort
Risks for OSA
- male
- older age >45
- obesity, including pregnancy
- increased neck circumference (normal is 17.5 in men and 15.5 in women)
- substances (smoking, alcohol, sedative, opioid)
- medications
- any structural abnormality with airway
- increased mallampati score
- family history

17
Q

Discuss the dosing of inhaled corticosteroids

A 
Low Dose
- <12 <=200mcg/day
- >12 <=250mcg/day
Medium Dose
- <12 201-400 mcg/day
- >=12 251-500 mcg/day
High Dose
- <12 >400mcg/day
- >=12 >500mcg/day
18
Q

Discuss proper MDI use

A
  • Shake inhaler well
  • Remove cap
  • put inhaler into spacer
  • Breather out away from spacer
  • Bring spacer to mouth and close lips around
  • Press top of inhaler
  • Breathe in slowly (if not using spacer only press top once starting to breath in)
  • remove inhaler from mouth and hold breath for 10 seconds
  • wait 1 minute and shake in between
  • rinse mouth when finished to reduce risk of oral thrush
19
Q

Discuss the screening for COPD

A

Spirometry in patient’s over 40 who currently or previously smoked and have one of the following
- Cough regularly
- Productive cough regularly
- Short of breath with minimal exertion
- Wheeze with exertion or at night
- Frequent colds that persist long
Lung Cancer Screen in 55-74 with 20year smoking history

20
Q

Discuss the screening for lung cancer

A
  • Annual low dose CT for adults 55-74 with 30 pack year smoking history who currently smoke or quit within last 15 years
21
Q

Discuss the presentation and management of asthma in the ED

A 
Presentation
- previous ICU, intubation, hospital admission
- triggers
- SOB
- Chest tightness
- wheezing
- increased puffer use
Investigation
- FEV1 
- CXR
Managemnt
- supplemental O2 to target >92%
- SABA with 3 back-to-back treatments initially
      - mild-mod MDI 4-6 puffs Q20-40min
      - severe nebulizer 2.5-5mg Q20min
- SAAC (ipatropium bromide)
      - same as SABA
- Epinephrine IM if due to anaphylaxis
- if FEV1 <40% despite treatment then MgSO4 2g IV over 20 minutes
- Decrease inflammation with prednision 50mg, dexamethasone 16mg or hydrocortisone 100-200mg IV
22
Q

Discuss the disposition for asthma exacerbation

A 
Home
- Oxygen sat >90%
- no respiratory distress and normal exam for >1hr
- >=75% expected FEV1 >2hrs since treatment
- discharge with Salbutamol, prednisone 50mg for 4 days and inhaled corticosteroid
Admitted to Ward
- FEV1 40-75%
- Mild to moderate symptoms
- Risk factors or near-fatal attack
Admit to ICU
- FEV1 <40%
- PaCO2 <60
- PaCO2 >42
- Altered mental statu
23
Q

Discuss the modified Dyspnea scale for asthma exacerbation

A

Level of consciousness
- Severe have altered
Appearance
- Respiratory distress and cyanosis in severe
- some respiratory distress in moderate
Vital Signs
- Mild: tachypnea, normal BP and O2 sat
- Mod: Tachypnea, normal BP, decreased O2 sat
- Severe: severe tachypnea, low BP, very low O2 sat
Physical Exam
- Mild: wheezing with bilateral air entry
- Mod: Talking in 3-4words, indrawing, decreased air entry and wheezing
- Severe: talking in 1 word, paradoxical breathing, may have no wheezing
FEV1
- Mild: 50-70%
- Mod: 25-50%
- Severe: <25%

24
Q

Discuss the presentation and management of COPD in the ED

A 
Presentation
- SOB
- Exercise intolerance
- chest tightness
- Wheezing
- Increased use of puffer
- Infectious if >=2: increased sputum production, increased sputum purulence, increased dyspnea
Investigation
- CBC, electrolytes, creatinine, BUN
- VBG or ABG (if not responding to therapy)
      - increased pCO2, decreased pO2
- CXR
       - hyperinflated lungs
Management
- O2 support to target of 88-92 as can be CO2 retainers
    - can move to BiPAP
- SABA and SAAC same as asthma
- Systemic steroids
- Antibiotics if infectious cause
25
Q

Discuss disposition for COPD

A

Home

  • if O2 sat >90% at rest and with exertion
  • Salbutamol, Prednisone 50mg for 10-14d and inhaled corticosteroid
26
Q

Discuss when to switch from BiPAP to intubation in COPD

A
  • worsening hypoxemia
  • confusion or decreased LOC
  • worsening acidosis
  • worsening hypercapnia
  • pH <7.36 and PaCO2 >45
27
Q

Discuss the pathophysiology, presentation and management of bronchiectasis

A 
Pathophysiology
- irreversible dilatation of airways due to inflammatory destruction of airway walls resulting from persistently infected mucus
- Cystic fibrosis, H influenzae, Pseudomonas, M catarrhalis
Presentation
- Chronic cough with purulent sputum
- Dyspnea
- Hemoptysis
- Inspiratory and exporatory crackles
- Wheeze
Investigation
- PFT obstructive or normal
- CXR: linear atelectasis, tram tracking
- CT: signet ring with dilated bronchi with thickened walls where diameter bronchus >1.5x diameter of artery
Management
- vaccination
- Chest physio
- Abx: inhaled: tobramycin for pseudomonas
- Mucolytics

LMCC - Medicine (40 decks)

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