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Pulmonology USMLE Step 3 > Section 1: Asthma and COPD 1 > Flashcards

Section 1: Asthma and COPD 1 Flashcards

1
Q

Therapy for COPD exacerbation

A

Bronchodilators (inhaled) = nebulized albuterol

Ipratropium (inhaled)

Steroids = prednisone or methylprednisone

Antibiotics = ceftriaxone

Counseling

Influenza vaccine

Pneumococcal vaccine

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2
Q

List the most important features of a severe asthma exacerbation

A

Hyperventilation/ increased respiratory rate

Decrease in peak flow

Hypoxia

Respiratory acidosis

Possible absence of wheezing

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3
Q

Enumerate the minimum management for patients with SOB

A

Oxygen

Continuous oximeter

CXR

ABG

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4
Q

What is the best test to determine a diagnosis of reactive airway disease in an asymptomatic patient suspected of being asthmatic?

A

Methacholine stimulation testing

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5
Q

What class of drug is methacholine?

A

Synthetic acetylcholine

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6
Q

What happens when methacholine is administered to asthmatic?

A

Methacholine will decrease FEV1 if the patient has asthma.

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7
Q

Name the two most frequently used pulmonary function tests

A

FEV1 (forced expiratory volume in one second)

FVC

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8
Q

What is the normal adult FEV1/FVC ratio?

A

> 75%

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9
Q

Describe the obstructive pattern in PFT

A

An FEV 1/FVC ratio of 70%

Total lung capacity (TLC) will be increased in some obstructive processes, such as COPD, whereas it may be normal or increased in asthma.

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10
Q

Name some obstructive lung disease

A

COPD

Asthma

Chronic bronchitis

Bronchiectasis

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11
Q

What is the meaning of DLCO

A

Diffusing capacity of carbon monoxide

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12
Q

What does DLCO measure?

A

Measures the gas exchange capacity of the capilary-alveolar interface

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13
Q

Why is DLCO normal in asthma

A

Because the alveoli are not affected

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14
Q

What is the DLCO in COPD

A

The DLCO in COPD is decreased because some alveoli are destroyed and unavailable for gas exchange.

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15
Q

Describe the restrictive pattern in PFT

A

Low FEV1, low FVC, but with normal or increased FEV1/FVC

Decreased TLC

An FVC of 80% is suggestive of restriction when the FEV1/FVC ratio is normal.

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16
Q

Examples of diseases with restrictive pattern on PFT

A

Obesity

Interstitial lung disease

Inflammatory/fibrosing lung disease

Kyphosis

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17
Q

Define hypoxia (or hypoxemia)

A

Defined as a room-air O2 saturation of 88%

or a PaO2 of 55 mm Hg on ABG measurement

or evidence of cor pulmonale.

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18
Q

Diagnosis: Hypoxia not responding to supplemental oxygen

A

Shunt physiology

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19
Q

Examples of diseases with ventilation-perfusion (V/Q) mismatch

A

Asthma

COPD

Nonmassive pulmonary embolus (PE)

Pneumonia.

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20
Q

Features of ventilation-perfusion (V/Q) mismatch

A

Responds to oxygen

Increased arterial-alveolar oxygen (A-a) gradient

21
Q

What is the common cause of hypoventilation?

A

Oversedation from medications

22
Q

Features of hypoventilation

A

Responds to O2

Characterized by a normal A-a gradient

23
Q

Features of hypoxia due to decreased diffusion

A

Responds to O2

Characterized by an A-a gradient

Associated with a very low DLCO.

Le, Tao; Bhushan, Vikas; Herman Bagga (2010-09-21). First Aid for the USMLE Step 3, Third Edition (First Aid USMLE) (Kindle Locations 11153-11157). McGraw-Hill. Kindle Edition.

24
Q

Features of hypoxia due to high altitude

A

Responds to O2

Characterized by a normal A-a gradient

25
Q

Causes of SOB due to shunt physiology

A

Acute respiratory distress syndrome

Significant lobar pneumonia

Patent foramen ovale

Patent ductus arteriosus.

26
Q

Features of SOB due to shunt physiology

A

Typically does not respond to O2

Characterized by an increased A-a gradient

27
Q

Differential diagnosis of Asthma presenting as chronic cough

A

Allergic rhinitis

Postnasal drip

GERD

28
Q

Differential diagnosis of wheezing

A

Asthma

Foreign body aspiration

Laryngeal spasm or irritation

GERD

CHF

29
Q

In asthma management, can inhaled corticosteroids be used in pregnancy

A

Yes, they are safe

30
Q

What is the implication of a normal PaCO2 in during an episode of asthma exacerbation

A

A normal Pco2 suggests that the patient is tiring out and is about to crash

31
Q

Outline the management of acute asthma

A

Initiate short-acting β-agonist (albuterol) therapy (nebulizer or MDI)

Administer a systemic corticosteroid such as methylprednisolone or prednisone

Begin inhaled corticosteroids as well

Follow patients closely with peak flows, and tailor therapy to the response

Chronic antibiotics (without evidence of infection), anticholinergics, cromolyn, and leukotriene antagonists are generally not useful in this setting

33
Q

Rx for exercise induced asthma

A

Inhaled bronchodilator prior to exercise

34
Q

What is the management of acute shortness of breath in a patient with COPD?

A

Oxygen and arterial blood gas (ABG)

Chest x-ray

Albuterol, inhaled

Ipratropium, inhaled

Bolus of steroids (e.g., methyl prednisolone)

Chest, heart, extremity, and neurological examination

If fever, sputum, and/ or a new infiltrate is present on chest x-ray, add ceftriaxone and azithromycin for community-acquired pneumonia.

35
Q

When to intubate patients with COPD?

A

Do not intubate patients with COPD for CO2 retention alone. These patients often have chronic CO2 retention. Only intubate if there is a worsening drop in pH indicative of a worse respiratory acidosis. Serum bicarbonate is often elevated due to metabolic alkalosis as compensation for chronic respiratory acidosis.

36
Q

List the typical physical findings in COPD

A

Barrel-shaped chest

Clubbing of fingers

Increased anterior-posterior diameter of the chest

Loud P2 heart sound (sign of pulmonary hypertension)

Edema as a sign of decreased right ventricular output (the blood is backing up due to the pulmonary hypertension)

37
Q

Laboratory findings in COPD

A

EKG: Right axis deviation, right ventricular hypertrophy, right atrial hypertrophy

Chest x-ray: Flattening of the diaphragm (due to hyperinflation of the lungs), elongated heart, and substernal air trapping

CBC: Increased hematocrit is a sign of chronic hypoxia. Reactive erythrocytosis from chronic hypoxia is often microcytic. An erythropoietin level is not necessary.

Chemistry: Increased serum bicarbonate is metabolic compensation for respiratory acidosis.

ABG: Should be done even in office-based cases to assess CO2 retention and the need for chronic home oxygen based on pO2 (you expect the pCO2 to rise and the pO2 to fall).

Pulmonary function testing (PFT): You should expect to find the following:

– Decrease in FEV1

– Decrease in FVC from loss of elastic recoil of the lung

– Decrease in the FEV1/ FVC ratio

– Increase in total lung capacity from air trapping

– Increase in residual volume

– Decrease in diffusion capacity lung carbon monoxide (DLCO) caused by destruction of lung interstitium

38
Q

Chronic medical therapy for COPD

A

Tiotropium or ipratropium inhaler

Albuterol inhaler

Pneumococcal vaccine: Heptavalent vaccine,

Pneumovax Influenza vaccine: Yearly

Smoking cessation

Long-term home oxygen if the pO2 < 55 or the oxygen saturation is < 88 percent

39
Q

Name two interventions that lower mortality in COPD

A

Smoking cessation

Home oxygen therapy (continuous)

40
Q

Spot Diagnosis: A case of COPD at an early age (< 40) in a nonsmoker who has bullae at the bases of the lungs.

A

Alpha-1 antitrypsin deficiency

41
Q

Rx for alpha-1 antotrypsin deficiency

A

Alpha-1 antitrypsin infusion

42
Q

What is the most accurate diagnostic test for bronchiectasis?

A

High-resolution CT scan of the chest.

45
Q

Diagnosis: Decreased TLC, Decreased RV, Decreased VC, Normal FEV1, Normal FEV1/FVC ratio, Normal DLCO

A

Extra-parenchymal (extra-thoracic) restriction

  • Kyphosis
  • Obesity
46
Q

Diagnosis: Increased TLC, Increased RV, Decreased FEV1, Decreased FVC, Decreased FEV1/FVC ratio, Decreased DLCO

47
Q

Diagnosis: Normal or Increased TLC, Normal or Increased RV, Decreased FEV1, Decreased FVC, Normal or Decreased FEV1/FVC ratio, Normal or Increased DLCO

48
Q

Diagnosis: Decreased TLC, Decreased RV, Decreased FEV1, Decreased FVC, Normal or Increased FEV1/FVC ratio, Decreased DLCO

A

Fibrotic (or Interstitial Lung) Disease

49
Q

List the minimum that should be done for all patients with shortness of breath (SOB)

A

Oxygen

Continuous oximeter

Chest X-ray

Arterial blood gas (ABG)

50
Q

Causes of low DLCO

A

Emphesema

Pneumonectomy

Interstitial lung disease

pulmonary embolism

Pulmonary HTN

51
Q

Arterial blood gases measurements

A

pH: 7.35 to 7.45

PCO2: 33-45mmHg

PO2: 75-105mmHg

52
Q

What is A-a gradient?

A

A-a gradient is alveolar-arterial gradient (PAO2-PaO2 gradient). It is a useful calculation for the assessment of oxygenation. A-a gradient increases with age and is only valid in room air. It is calculated as follows:

PA02-Pa02 gradient = 150 - 1.25 X PaCO2 - PaO2

i.e.,

A-a gradient = [150 - (1.25 X PaCO2) - PaO2]

This gradient is between 5 and 15 mmHg in normal young adults. It increases with all causes of hypoxemia except hypoventilation and high altitude

Pulmonology USMLE Step 3 (5 decks)

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