STEPUP Diseases of the Pulmonary System: Obstructive Lung Diseases

Question 1

What are two classic types of chronic obstructive pulmonary disease (COPD)?

Answer 1

1) Chronic bronchitis

2) Emphysema

Question 2

How is the diagnosis of chronic bronchitis made?

Answer 2

Chronic bronchitis is a clinical diagnosis: chronic cough productive of sputum for at least 3 months per year for at least 2 consecutive years

Question 3

How is the diagnosis of emphysema made?

Answer 3

Emphysema is a pathologic diagnosis: permanent enlargement of air spaces distal to terminal bronchioles due to destruction of alveolar walls

Question 4

Can a person have both chronic bronchitis and emphysema?

Answer 4

Yes. The two often coexist. Pure emphysema or pure chronic bronchitis is rare

Question 5

How common of a cause of death is COPD?

Answer 5

It is the fourth leading cause of death in the United States

Question 6

What are some risk factors and causes of COPD?

Answer 6

1) Tobacco smoke (indicated in almost 90% of COPD cases)
2) alpha1-Antitrypsin deficiency - risk is even worse in combination with smoking
3) Environmental factors (e.g., second-hand smoke)
4) Chronic asthma - speculated by some to be an independent risk factor

Question 7

What is the pathogenesis of chronic bronchitis?

Answer 7

1) Excess mucus production narrows the airways; patients often have a productive cough
2) Inflammation and scarring in airways, enlargement in mucous glands, and smooth muscle hyperplasia lead to obstruction

Question 8

What is the pathogenesis of emphysema?

Answer 8

1) Destruction of alveolar walls is due to relative excess in protease (elastase) activity, or relative deficiency of antiprotease (alpha1-antitrypsin) activity in the lung
2) Tobacco smoke increases the number of activated PMNs and macrophages, inhibits alpha1-antitrypsin, and increases oxidative stress on the lung by free radical production

Question 9

What are some common symptoms in COPD?

Answer 9

1) Any combination of cough, sputum production, and dyspnea (on exertion or at rest, depending on severity) may be present
2) Dyspnea is initially during exertion but eventually becomes progressively worse with less exertion and even at rest

Question 10

How do patients avoid the most common early symptom of COPD?

Answer 10

1) Some patients have very sedentary lifestyles but few complaints
2) They may avoid exertional dyspnea, which is the most common early symptom of COPD by limiting their activity

Question 11

In which patients is centrilobular emphysema seen in? What part of the lung is destroyed?

Answer 11

1) Most common type, seen in smokers (rarely in nonsmokers)
2) Destruction limited to respiratory bronchioles (proximal acini) with little change in distal acini
3) Predilection for upper lung zones

Question 12

In which patients is panlobular emphysema seen in? What part of the lung is destroyed?

Answer 12

1) Seen in patients with alpha1-antitrypsin deficiency
2) Destruction involves both proximal and distal acini
3) Predilection for lung bases

Question 13

In COPD, what is the FEV1/FVC ratio? What happens to FEV1? What happens to TLC? What happens to residual volume?

Answer 13

1) The FEV1/FVC ratio is

Question 14

What is the weight of a patient with predominant emphysema (“Pink Puffer”)? What do patients tend to do while seated? What does their chest look like?

Answer 14

1) Patients tend to be thin due to increased energy expenditure during breathing
2) When sitting, patients tend to lean forward
3) Patients have a barrel chest (increased AP diameter of chest)

Question 15

What is the breathing rate and pattern seen in emphysema? Is a patient with emphysema in respiratory distress?

Answer 15

1) Tachypnea with prolonged expiration through pursed lips is present
2) Patient is distressed and uses accessory muscles (especially strap muscles in neck)

Question 16

What is the weight of a patient with predominant chronic bronchitis (“Blue Bloater”)? What are typical symptoms? What may be present in severe or long-standing disease?

Answer 16

1) Patients tend to be overweight and cyanotic (secondary to chronic hypercapnia and hypoxemia)
2) Chronic cough and sputum production are characteristic
3) Signs of cor pulmonale may be present in severe or long-standing disease

Question 17

What is the respiratory rate in a patient with chronic bronchitis? Is the patient in respiratory distress?

Answer 17

1) Respiratory rate is normal or slightly increased

2) Patient is in no apparent distress, and there is no apparent use of accessory muscles

Question 18

What are signs to look for in COPD?

Answer 18

1) Prolonged expiratory time
2) During auscultation, end-expiratory wheezes on forced expiration, decreased breath sounds, and/or inspiratory crackles
3) Tachypnea, tachycardia
4) Cyanosis
5) Use of accessory respiratory muscles
6) Hyperresonance on percussion
7) Signs of cor pulmonale

Question 19

What is FEV1? What does a lower FEV1 cause?

Answer 19

1) FEV1 is the amount of air that can be forced out of the lungs in 1 second
2) The lower the FEV1, the more difficulty one has breathing

Question 20

What is necessary to diagnose diagnose airway obstruction?

Answer 20

To diagnose airway obstruction, one must have a normal or increased TLC with a decreased FEV1

Question 21

What is the definitive diagnostic test of COPD? What happens to FEV1 and FEV1/FVC ratio in COPD? What is the GOLD staging based on? What three values are increased in COPD? What happens to vital capacity?

Answer 21

1) Pulmonary function testing (spirometry)
2) Obstruction is evident based on the following:
a) Decreased FEV1 and decreased FEV1/FVC ratio - GOLD staging is based on FEV1. FEV1 >=80% of predicted value is mild disease, 50% to 80% is moderate disease, 30% to 50% is severe disease, and <30% is very severe disease
b) Increased total lung capacity (TLC), residual volume, and functional reserve capacity (FRC) (indicating air trapping). Although COPD increases TLC, the air in the lung is not useful because it all becomes residual volume and does not participate in gas exchange
c) Decreased vital capacity

Question 22

What are key points in taking history of COPD patients in general? What about pulmonary symptoms?

Answer 22

1) a) History of cardiopulmonary diseases
b) Smoking history (duration, intensity, current smoker)
c) Family history - COPD, heart disease, asthma
d) Occupation - industrial dusts, fumes
e) Overall health
f) History of respiratory infections - frequency, severity
g) Pulmonary medications
2) a) Dyspnea - quantitate severity
b) Cough
c) Sputum production - quantity, quality, duration, hemoptysis
d) Wheezing

Question 23

What is a good screening test for COPD?

Answer 23

One can measure the peak expiratory flow rate using a peak flow meter. If <350 L/min, one should perform pulmonary function testing, because this is a good screening test for obstruction

Question 24

What kind of acid/base disorder does COPD lead to?

Answer 24

COPD leads to chronic respiratory acidosis with metabolic alkalosis as compensation

Question 25

What does clinical monitoring of COPD patients entail?

Answer 25

1) Serial FEV1 measurements - this has the highest predictive value
2) Pulse oximetry
3) Exercise tolerance

Question 26

What tests are used to diagnose COPD?

Answer 26

1) Pulmonary function testing (Spirometry)
2) Chest radiograph (CXR)
3) Measure alpha1-antitrypsin levels in patients with a personal or family history of premature emphysema (<=50 years old)
4) Arterial blood gas (ABG) - chronic PCO2 retention, decreased PO2

Question 27

Is a CXR a good test for diagnosing COPD? When is a CXR useful for COPD?

Answer 27

1) Low sensitivity for diagnosing COPD; only severe, advanced emphysema will show the typical changes, which include: Hyperinflation, flattened diaphragm, enlarged retrosternal space, diminished vascular markings
2) Useful in acute exacerbation to rule out complications such as pneumonia or pneumothorax

Question 28

Are the following values low, normal, or high in obstructive lung disease? restrictive lung disease? FEV1, FEV1/FVC, peak expiratory flow rate, residual volume, total lung capacity, and vital capacity

Answer 28

1) Obstructive: Low, low, low, high, high, low

2) Restrictive: Normal or slightly low; normal or high; normal; low, normal, or high; low; low

Question 29

What can be used for treatment of COPD?

Answer 29

1) Smoking cessation - the most important intervention
2) Inhaled anticholinergic drugs (e.g., ipratropium bromide): bronchodilators
3) Inhaled beta2-agonists (e.g., albuterol): bronchodilators
4) Combination of beta-agonist albuterol with ipratropium bromide
5) Inhaled corticosteroids (e.g., budesonide, fluticasone): anti-inflammatory
6) Theophylline (oral) - role is controversial
7) Oxygen therapy
8) Pulmonary rehabilitation
9) Vaccination
10) Antibiotics are given for acute exacerbations
11) Surgery - may be beneficial in selected patients

Question 30

Why does smoking cessation help in treatment of COPD? What happens to the rate of FEV1 decrease around age 35? How does quitting smoking help? Does smoking cessation return your survival rate to normal? When do respiratory symptoms improve after quitting?

Answer 30

1) Disease progression is accelerated by continued smoking and can be greatly slowed by its cessation
2) At around age 35, FEV1 decreases approximately 25 to 30 mL/yr
3) In smokers, the rate of decline is faster (threefold to fourfold). If a smoker quits, the rate of decline of FEV1 slows to that of someone of the same age who has never smoked. However, quitting does not result in complete reversal
4) Smoking cessation prolongs the survival rate but does not reduce it to the level of someone who has never smoked
5) Respiratory symptoms improve within 1 year of quitting

Question 31

What is total lung capacity (TLC)? What is functional residual capacity (FRC)? What is residual volume (RV)? What is tidal volume (TV)? What is vital capacity (VC)?

Answer 31

1) Volume of air in the lungs after maximum inspiration
2) Volume of air in the lungs after a normal expiration
3) Volume of air in the lungs at maximal expiration
4) Volume of air breathed in and out of the lungs during quiet breathing
5) Volume of air expelled from the lungs during a maximum expiration

Question 32

What are the only interventions shown to lower mortality in COPD patients?

Answer 32

1) Smoking cessation

2) Home oxygen therapy

Question 33

How do inhaled anticholinergic drugs differ from beta-agonists?

Answer 33

Slower onset of action than the beta-agonists, but last longer

Question 34

How do inhaled beta2-agonists help in COPD? When should you use a long-acting beta2-agonist in COPD patients?

Answer 34

1) Provide symptomatic relief

2) Use long-acting (e.g., salmeterol) for patients requiring frequent use

Question 35

What are two advantages of the combination of beta-agonist albuterol with ipratroprium bromide inhaler?

Answer 35

1) More efficacious than either agent alone in bronchodilation
2) Also helps with adherence to therapy (both medications in one inhaler)

Question 36

How may inhaled corticosteroids help in COPD? Do they have any benefit in pulmonary function? What are they typically used in combination with and for which patients?

Answer 36

1) May minimally slow down the decrease in FEV1 over time
2) However, many studies have failed to show any benefit in pulmonary function
3) Typically used in combination with a long-acting bronchodilator for patients with significant symptoms or repeated exacerbations

Question 37

How should you treat COPD? What about for acute exacerbations?

Answer 37

1) Treat COPD with bronchodilators (anticholinergics, beta2-agonists, or both)
2) Give steroids and antibiotics for acute exacerbations

Question 38

What drug class is generally contraindicated in acute COPD or asthma exacerbations?

Answer 38

Beta-blockers

Question 39

How may theophylline help in COPD? What is important to monitor with theophylline use? How effective is it and when can it be used?

Answer 39

1) May improve mucociliary clearance and central respiratory drive
2) Narrow therapeutic index, so serum levels must be monitored
3) Only modestly effective and has more side effects than other bronchodilators. Occasionally used for patients with refractory COPD

Question 40

What has oxygen therapy in COPD been shown to improve? How do you determine the need for oxygen? What may long-standing hypoxemia lead to? How do you reduce mortality from this complication?

Answer 40

1) Shown to improve survival and quality of life in patients with COPD and chronic hypoxemia
2) Some patients need continuous oxygen, whereas others only require it during exertion or sleep. Get an ABG to determine need for oxygen
3) Long-standing hypoxemia may lead to pulmonary HTN and ultimately cor pulmonale. Continuous oxygen therapy for >=18 hr/day has been shown to reduce mortality in patients with these complications by controlling pulmonary HTN

Question 41

What is pulmonary rehabilitation and how does it help in COPD?

Answer 41

1) Education, exercise, and physiotherapy
2) A major goal is to improve exercise tolerance
3) Pulmonary rehabilitation improves functional status and quality of life

Question 42

What vaccinations should be given to patients with COPD?

Answer 42

1) Influenza vaccination annually for all patients
2) Vaccination against Streptococcus pneumoniae every 5 to 6 years - should be offered to patients with COPD over 65 years old, or under 65 who have severe disease

Question 43

When are antibiotics given to patients with COPD?

Answer 43

Antibiotics are given for acute exacerbations - increased sputum production in volume or change in character or worsening shortness of breath

Question 44

When is surgery beneficial for COPD? What are two options?

Answer 44

1) Surgery may be beneficial in selected patients; carefully weight potential benefits with risks
2) Options include lung resection and lung transplantation

Question 45

For mild to moderate COPD, what treatment should you begin with? What other medication can be used? What else can considered if these medications do not adequately control the symptoms?

Answer 45

1) Begin with a bronchodilator in a metered-dose inhaler (MDI) formulation (with spacer to improve deliver). Antichoinergic drugs and/or beta-agonists are first-line agents
2) Inhaled glucocorticoids may be used as well. Use the lowest dose possible
3) Theophylline may be considered if the above do not adequately control symptoms

Question 46

For severe COPD, what treatment should you begin with?

Answer 46

1) Begin with a bronchodilator in a metered-dose inhaler (MDI) formulation (with spacer to improve deliver). Antichoinergic drugs and/or beta-agonists are first-line agents
2) Inhaled glucocorticoids may be used as well. Use the lowest dose possible
3) Theophylline may be considered if the above do not adequately control symptoms
4) Continuous oxygen therapy (if patient is hypoxemic)
5) Pulmonary rehabilitation
6) Triple inhaler therapy (long-acting beta-agonst plus a long-acting anticholinergic plus an inhaled glucocorticoid) is an option for severe disease

Question 47

What is an acute COPD exacerbation? What can acute COPD exacerbation lead to?

Answer 47

1) Definition: Increased dyspnea, sputum production, and/or cough
2) Acute COPD exacerbation can lead to acute respiratory failure requiring hospitalization, and possibly mechanical ventilation; potentially fatal

Question 48

What treatments are used for COPD exacerbation?

Answer 48

1) Bronchodilators
2) Systemic corticosteroids
3) Antibiotics
4) Supplemental oxygen
5) Noninvasive positive pressure ventilation (NPPV)
6) Intubation and mechanical ventilation may be required

Question 49

What is the first-line therapy for an acute COPD exacerbation? What treatment is used for patients requiring hospitalization?

Answer 49

1) Bronchodilators (beta2-agonist) alone or in combination with anticholinergics are first-line therapy
2) Systemic corticosteroids are used for patients requiring hospitalization (IV methylprednisolone is a common choice). Taper with oral prednisone on clinical improvement. Do not use inhaled corticosteroids in acute exacerbations

Question 50

Which antibiotics are used in acute COPD exacerbation? What have studies shown for which antibiotics to use?

Answer 50

1) Azithromycin, levofloxacin, doxycycline, etc.; no antibiotic superior to another
2) Studies have shown that patients who receive broad-spectrum antibiotics do slightly better than a placebo group

Question 51

Supplemental oxygen is used in acute COPD exacerbation to keep O2 sat at what level? How should the oxygen be given? What if the SaO2 is above 93%?

Answer 51

1) Supplemental oxygen is used to keep O2 saturation 90% to 93%
2) Start with a nasal cannula; a face mask may need to be used
3) If SaO2 is >93%, the patient is at risk of CO2 retention from worsening V/Q mismatch, loss of hypoxemic respiratory drive, and the Haldane effect

Question 52

What type of ventilation is used in acute COPD exacerbation? How may it help these patients?

Answer 52

1) Noninvasive positive pressure ventilation (NPPV) (bilevel positive airway pressure [BIPAP] or CPAP): Studies have shown a benefit in acute exacerbations
2) It may decrease the likelihood of respiratory failure requiring invasive mechanical ventilation

Question 53

When are intubation and mechanical ventilation necessary in acute COPD exacerbation?

Answer 53

1) May be required if the above treatment do not stabilize the patient
2) Intubate if increasing RR, increasing PaCO2, and worsening acidosis

Question 54

What is one of the main treatment goals for COPD patients?

Answer 54

To reduce the number and severity of exacerbations they experience each year

Question 55

What is one of the main precipitants of a COPD exacerbation?

Answer 55

Pulmonary infection

Question 56

What are the most common organisms in pulmonary infections that precipitate a COPD exacerbation?

Answer 56

S. pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Moraxella catarrhalis, and viruses

Question 57

If a patient presents with COPD exacerbation, what steps should you take to diagnosing them and treating them?

Answer 57

1) CXR
2) Beta2-agonist and anticholinergic inhalers
3) Systemic corticosteroids
4) Antibiotics
5) Supplemental oxygen
6) NPPV if needed

Question 58

What are three complications of COPD?

Answer 58

1) Acute exacerbations - most common causes are infection, noncompliance with therapy, and cardiac disease
2) Secondary polycythemia (Hct > 55% in men or >47% in women) - compensatory response to chronic hypoxemia
3) Pulmonary HTN and cor pulmonale - may occur in patients with severe, long-standing COPD who have chronic hypoxemia

Question 59

What triad is asthma characteristically defined by?

Answer 59

1) Airway inflammation
2) Airway hyperresponsiveness
3) Reversible airflow obstruction

Question 60

At what age can asthma being?

Answer 60

At any age

Question 61

What is extrinsic asthma? At what age do patients develop extrinsic asthma? What is intrinsic asthma related to?

Answer 61

1) Patients are atopic, that is, produce immunoglobulin E (IgE) to environmental antigens. May be associated with eczema and hay fever
2) Patients become asthmatic at a young age
3) Intrinsic asthma - not related to atopy or environmental triggers

Question 62

What are triggers of asthma?

Answer 62

Pollens, house dust, molds, cockroaches, cats, dogs, cold air, viral infections, tobacco smoke, medications (beta-blockers, aspirin), and exercise

Question 63

What are signs of acute severe asthma attacks? What is a sign of impending respiratory failure in an acute severe asthma attack?

Answer 63

1) Tachypnea, diaphoresis, wheezing, speaking in incomplete sentences, and use of accessory muscles of respiration
2) Paradoxic movement of the abdomen and diaphragm on inspiration is a sign of impending respiratory failure

Question 64

What are clinical features of asthma? How severe are the symptoms and are they present simultaneously? When do symptoms usually occur?

Answer 64

1) Intermittent symptoms of SOB, wheezing, chest tightness, and cough
2) Symptoms have variable severity and may not be present simultaneously
3) Usually occur within 30 minutes of exposure to triggers

Question 65

At what time of the day are asthma symptoms typically worse?

Answer 65

At night

Question 66

When should systemic glucocorticoids be used for COPD?

Answer 66

Only for acute exacerbations and should not be used for long-term treatment, even for patients with severe COPD

Question 67

What are criteria for continuous or intermittent long-term oxygen therapy in COPD?

Answer 67

1) PaO2 55 mm Hg OR
2) O2 saturation <=88% (pulse oximetry) either at rest or during exercise OR
3) PaO2 55 to 59 mm Hg plus polycythemia or evidence of cor pulmonale
Note that the above must be consistent findings despite optimal medical therapy

Question 68

What is the most common cause of wheezing? Can other conditions cause wheezing? Which ones and how?

Answer 68

1) Asthma
2) Any condition that mimics large-airway bronchospasm can cause wheezing
3) a) CHF - due to edema of airways and congestion of bronchial mucosa
b) COPD - inflamed airways may be narrowed, or bronchospasm may be present
c) Cardiomyopathies, pericardial diseases can lead to edema around the bronchi
d) Lung cancer - due to obstruction of airways (central tumor or mediastinal invasion)

Question 69

What is the most common finding on physical examination in a patient with asthma and when does it occur in respiration?

Answer 69

Wheezing (during both inspiration and expiration)

Question 70

What test is required for diagnosis of asthma? What do these tests show?

Answer 70

1) Pulmonary function tests (PFTs) are required for diagnosis
2) They show an obstructive pattern: decrease in expiratory flow rates, decreased FEV1, and decreased FEV1/FVC ratio (<0.70)

Question 71

When should spirometry be done to confirm the diagnosis of asthma?

Answer 71

1) Spirometry before and after bronchodilators can confirm diagnosis by proving reversible airway obstruction
2) If inhalation of a bronchodilator (beta2-agonist) results in an increase in FEV1 or FVC by at least 12%, airflow obstruction is considered reversible

Question 72

When should patients use peak flow? When should peak flow be used for mild persistent asthma and what should the patient do if peak flow decreases? When should peak flow be used for moderate persistent asthma and what should the patient do if peak flow decreases? When should peak flow be used for severe persistent asthma and what should the patient do if peak flow decreases?

Answer 72

1) Peak flow (peak expiratory flow rate) is a useful measure of airflow obstruction. Patients should self-monitor their peak flow
2) Periodic monitoring is sufficient. Increase the dose of inhaled steroid if the peak flow decreases
3) Moderate persistent asthma: Daily monitoring is required. Increase the dose of inhaled steroid if the peak flow decreases
4) Severe persistent asthma: Daily monitoring is required. Initiate prednisone if the peak flow decreases

Question 73

When may the bronchoprovocation test be useful? What does it measure? How does it work?

Answer 73

1) May be useful when asthma is suspected but PFTs are nondiagnostic
2) Measures ease with which airways narrow in response to stimuli
3) Measures lung function before and after inhalation of increasing doses of methacholine (muscarinic agonist); hyperresponsive airways develop obstruction at lower doses

Question 74

What does a Chest X-ray show in asthma patients? When is it necessary to do a CXR and why?

Answer 74

1) Normal in mild cases; severe asthma reveals hyperinflation
2) Only necessary in severe asthma to exclude other conditions (e.g., pneumonia, pneumothorax, pneumomediastinum, foreign body)

Question 75

When should ABGs be considered for asthma? What may happen if the PaCO2 is normal or increased? Why is this so? What should you do for this patient?

Answer 75

1) ABGs should be considered if the patient is in significant respiratory distress. Hypocarbia is common. Hypoxemia may be present
2) If the PaCO2 is normal or increased, respiratory failure may ensure
3) Remember that patients with an asthma attack have an increased respiratory rate, which should cause the PaCO2 to decrease. Increased PaCO2 is a sign of respiratory muscle fatigue or severe airway obstruction
4) The patient should be hospitalized and mechanical ventilation considered

Question 76

What happens to the PFTs FEV1, FVC, and FEV1/FEC ratio in asthma? What happens to the FEV1 if albuterol is given to an asthmatic patient? What happens to the FEV1 with methacholine or histamine?

Answer 76

1) Decreased for all three
2) Increase in FEV1 > 12% with albuterol
3) Decrease in FEV1 > 20% with methacholine or histamine

Question 77

What is the quickest method of diagnosis of asthma when patient is SOB?

Answer 77

Although asthma can be diagnosed with PFTs and spirometry, in an acute setting (ED) when patient is SOB, peak flow measurement is quickest method of diagnosis

Question 78

During asthma exacerbations, what happens to the patient’s respiratory rate and what does this lead to? If the patient is no longer doing this, what could this be a sign of?

Answer 78

1) During asthma exacerbations, the patient hyperventilates, leading to low PaCO2 levels
2) If the patient is no longer hyperventilating (CO2 level is normal or high), this could be a sign that the patient is decompensating (due to fatigue) and that intubation may be required

Question 79

What medication should you avoid in asthmatics?

Answer 79

Beta-blockers

Question 80

What are treatment options for asthmatics?

Answer 80

1) Inhaled beta2-agonists
2) Inhaled corticosteroids for moderate to severe asthma
3) Montelukast - leukotriene modifiers
4) Cromolyn sodium/nedocromil sodium

Question 81

When are short-acting beta2-agonists (e.g., albuterol) used? How long does it take to work and how long does it last for? What are long-acting versions (e.g., salmeterol) especially useful for?

Answer 81

1) For acute attacks (rescue)
2) Onset is 2 to 5 minutes, duration is 4 to 6 hours
3) Nighttime asthma and exercise-induced asthma

Question 82

Why are inhaled corticosteroids preferred over oral steroids for moderate to severe asthma? What happens if you use inhaled corticosteroids on a regular basis?

Answer 82

1) Fewer systemic side effects (oral steroids are reserved for severe, persistent asthma)
2) Airway hyperresponsiveness decreases, and the number of asthma exacerbations decreases

Question 83

What long-term control medications are used for mild intermittent (symptoms two or fewer times per week) asthma? Mild persistent (symptoms two or more times per week but not everyday)? Moderate persistent (daily symptoms; frequent exacerbations)? Severe persistent (continual symptoms, frequent exacerbations, limited physical activity)?

Answer 83

1) None
2) Low dose inhaled corticosteroids
3) Daily inhaled corticosteroid (low dose) with long-acting inhaled beta-agonist, or daily inhaled corticosteroid (medium dose). Alternatives include adding a leukotriene modifier to theophylline to the daily inhaled corticosteroid (low dose)
4) Daily inhaled corticosteroid (medium or high dose) and long-acting inhaled beta2-agonists. Omalizumab (anti-IgE) may be considered additionally. If poor control, systemic corticosteroids should be considered

Question 84

When is montelukast useful? How can they help the dose of steroids and bronchodilators?

Answer 84

1) It is less efficacious than inhaled steroids but useful for prophylaxis of mild exercise-induced asthma and for control of mild to moderate persistent disease
2) They may allow reductions in steroid and bronchodilator requirements

Question 85

When is cromolyn sodium used? Is it used in adults?

Answer 85

1) Only for prophylaxis (e.g., before exercise)

2) Rarely used in adults

Question 86

What are side effects of inhaled corticosteroids due to and what are they? What should you do to reduce side effects?

Answer 86

1) Due to oropharyngeal deposition and include sore throat, oral candidiasis (thrush), and hoarseness
2) Using a spacer with MDIs and rinsing the mouth after use helps minimize these side effects

Question 87

What tests should be ordered in acute asthma exacerbation?

Answer 87

1) PEF - decreased
2) ABG - increased A-a gradient
3) Chest x-ray - rule out pneumonia, pneumothorax

Question 88

What treatments are used for acute severe asthma exacerbation (hospital admission)?

Answer 88

1) Inhaled beta2-agonist (first-line therapy)
2) Corticosteroids
3) Third-line agent includes IV magnesium
4) Supplemental oxygen (keep oxygen saturation >90%)
5) Antibiotics if severe exacerbation or suspicion of infection
6) Intubation for patients in respiratory failure or impending respiratory failure

Question 89

How are inhaled beta2-agonists given? What is their onset of action? What should you do after giving a bronchodilator?

Answer 89

1) Via nebulizer or MDI
2) Mainstays of emergency treatment - have an onset of action of minutes
3) Assess patient response to bronchodilators (clinically and with peak flows)

Question 90

How are corticosteroids administered in an acute severe asthma attack? When should you taper corticosteroids in this setting? What do you initiate when you begin the taper?

Answer 90

1) Traditionally given intravenously initially, but may also be given orally if given in equivalent doses
2) Taper IV or oral corticosteroids, but only when clinical improvement is seen
3) Initiate inhaled corticosteroids at the beginning of the tapering schedule

Question 91

What does IV magnesium help with in an acute asthma attack?

Answer 91

Not as effective as beta-agonists, magnesium helps with bronchospasm but only used in acute severe exacerbation that has not responded to above medications (albuterol, steroids, oxygen)

Question 92

What are complications of asthma?

Answer 92

1) Status asthmaticus - does not respond to standard medications
2) Acute respiratory failure (due to respiratory muscle fatigue)
3) Pneumothorax, atelectasis, pneumomediastinum

Question 93

When should aspirin-sensitive asthma be considered in a patient? What should be avoided in these patients?

Answer 93

1) Patient with asthma and nasal polyps
2) Avoid aspirin or any nonsteroidal anti-inflammatory drugs in these patients because they may cause a severe systemic reaction

Question 94

Is an MDI with a spacer as effective as a nebulizer? What is a spacer? What does spacer use lead to?

Answer 94

1) An MDI with a spacer is just as effective as a nebulizer
2) A spacer is a holding chamber that obviates the need to coordinate inhalation and depression of the canister, and thus makes the use of an MDI easier
3) Its use leads to a greater bronchodilator effect because more of the drug is deposited in smaller airways and less accumulates in the oropharynx

Question 95

Is a nebulizer more effective than an MDI? When may it be preferred?

Answer 95

1) A nebulizer is no more effective than an MDI, but patients may report greater relief of symptoms simply because it provides more medication
2) It may be preferred by patients with very severe asthma unresponsive to MDIs

Question 96

What is bronchiectasis? Is it common?

Answer 96

1) There is permanent, abnormal dilation and destruction of bronchial walls with chronic inflammation, airway collapse, and ciliary loss/dysfunction leading to impaired clearance of secretions
2) Less common today because modern antibiotics are used for respiratory infections

Question 97

What are causes of bronchiectasis?

Answer 97

1) Recurrent infections (airway obstruction, immunodeficiency, allergic bronchopulmonary aspergillosis, mycobacterium)
2) Cystic fibrosis (CF) is most common cause of bronchiectasis (accounts for half of all cases)
3) Primary ciliary dyskinesia (e.g., Kartagener syndrome)
4) Autoimmune disease (rheumatoid arthritis, systemic lupus erythematosus, Crohn disease, etc.)
5) Humoral immunodeficiency (abnormal lung defense), airway obstruction

Question 98

What are clinical features of bronchiectasis?

Answer 98

1) Chronic cough with large amounts of mucopurulent, foul-smelling sputum
2) Dyspnea
3) Hemoptysis - due to rupture of blood vessels near bronchial wall surfaces; usually mild and self-limited, but sometimes can be brisk and present as an emergency
4) Recurrent or persistent pneumonia

Question 99

How do you diagnose bronchiectasis? What do PFTs show? CXR? Do you use bronchoscopy for diagnosis?

Answer 99

1) High-resolution CT scan is the diagnostic study of choice
2) PFTs reveal an obstructive pattern
3) CXR is abnormal in most cases, but findings are nonspecific
4) Bronchoscopy applies in certain cases

Question 100

What is the treatment of bronchiectasis?

Answer 100

1) Antibiotics for acute exacerbations - superimposed infections are signaled by change in quality/quantity of sputum, fever, chest pain, etc.
2) Bronchial hygiene is very important
a) Hydration
b) Chest physiotherapy (postural drainage, chest percussion) to help remove the mucus
c) Inhaled bronchodilators

Question 101

What is cystic fibrosis caused by genetically? What is the pathophysiology of cystic fibrosis? What type of lung disease does it result in and what other complications occur?

Answer 101

1) Autosomal recessive condition predominantly affecting Caucasians
2) Defect in chloride channel protein causes impaired chloride and water transport, which leads to excessively thick, viscous secretions in the respiratory tract, exocrine pancreas, sweat glands, intestines, and genitourinary tract
3) Typically results in obstructive lung disease pattern with chronic pulmonary infections (frequently Pseudomonas), pancreatic insufficiency, and other GI complications

Question 102

What is the treatment for cystic fibrosis?

Answer 102

Pancreatic enzyme replacement, fat-soluble vitamin supplements, chest physical therapy, vaccinations (influenza and pneumococcal), treatment of infections with antibiotics, inhaled recombinant human deoxyribonuclease (rhDNase), which breaks down the DNA in respiratory mucus that clogs the airways

Question 103

Why is cystic fibrosis a concern in adults?

Answer 103

Traditionally considered a pediatric topic; however, the prognosis has improved significantly, with the median age of death now over 30 years of age

Question 104

How do infections usually cause bronchiectasis?

Answer 104

A variety of infections can cause bronchiectasis by destroying and damaging the bronchial walls and interfering with ciliary action

Question 105

What is the main goal in treating bronchiectasis?

Answer 105

To prevent complications of pneumonia and hemoptysis