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Pulmonology > Test #1 > Flashcards

Test #1 Flashcards

1
Q

Define Obstructive lung disease

A

airway blocked - air cannot get out of lung

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2
Q

Define Restrictive lung disease

A

lungs cannot fill with air - cant get air in

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3
Q

Obstructive disease examples

A

asthma

foreign object inhalation

bronchitis

invasive tumor

excessive mucous plugging

COPD

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4
Q

FEV1

A

forced expiratory volume in 1 sec

75% total FVC

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5
Q

FVC

A

forced vital capacity

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6
Q

Categories of Restrictive lung disorders

A

Neuromuscular, Intrinsic, Extrinsic

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7
Q

Neuromuscular restrictive lung disorder examples

A

weakness, diaphragm paralysis, MS, myasthenia gravis

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8
Q

Intrinsic restrictive lung disorder examples

A

sarcoidosis, TB, pneumonia, pneumonectomy

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9
Q

Extrinsic restrictive lung disorder examples

A

scoliosis, pleural effusion, pregnancy, obesity, ascites, tumor

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10
Q

Pts who CANNOT undergo bronchoprovocation challenge

A

unstable heart disease

heart attack or stroke within last 3 months

uncontrolled HTN

significant bronchspasms already present

pregnant or nursing mothers

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11
Q

FEV1% severity grading

A

Mild >70%

Moderate 60-69%

Moderately Severe 50-59%

Severe 35-49%

Very Severe <35%

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12
Q

DLCO uses

A

Diffusion Capacity

  1. differentiate chronic bronchitis from emphysema
  2. determining degree of emphysema
  3. differentiating interstitial and external restrictive disorders
  4. recurrent PEs
  5. pulmonary HTN
  6. disability measurement
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13
Q

Low DLCO with Obstruction

A

emphysema

cystic fibrosis in children

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14
Q

Low DLCO with Restriction

A

Pulmonary fibrosis

Hypersensitivity pneumonitis

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15
Q

Low DLCO with normal spirometry

A

Chronic PE

Anemia

Early interstitial lung dx

Increases carboxyhemoglobin levels

CHF

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16
Q

High DLCO

A

Asthma

Left-to-right intracardiac shunt

Polycythemia

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17
Q

Intrinsic Asthma

A

non-immune, IgE levels normal develops later in life, rare family hx

Sampler’s triad: ASA allergy, nasal polyps, asthma

Triggered by viral infections, stress, GERD, cold

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18
Q

Extrinsic Asthma

A

Type-1 Hypersensitivity reaction

  • Atopic: most common, elevated IgE & eosinophil count with family hx
  • Occupational asthma
  • Allergic bronchopulmonary aspergillosis
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19
Q

Exercise induced Asthma (EIA)

A

Vigorous physical activity triggers acute bronchospasms

Tx: SABA 10-15 minutes pre-activity, avoid activity in cold air

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20
Q

Asthma classic symptom triad

A

Persistent wheeze, end expiratory wheeze

Chronic episodic dyspnea

Chronic cough

Any and all symptoms may be worse or only present at night

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21
Q

Pulses paradoxus

A

Pulse rate decreases >10mmHg with inspiration

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22
Q

Asthma spirometry diagnosis

A

PFT: FEV1 12% & 200mL

Provocation test to support asthma Dx

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23
Q

Asthma Dx tests

A

CXR to r/o pneumonia, CHF, pneumothorax, lesions, FBO

GERD assessment to r/o - especially with lots of nighttime sx

Skin test for atopic

Blood tests (IgE & Eosinophils) for intrinsic dx - cannot r/o extrinsic

PFTs

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24
Q

Daytime sx 2 or less/wk

Two or less nocturnal awakenings/mo

SABA use <2x/wk

No activity interference

FEV1 w/in normal

FEV1/FVC normal

One or no exacerbations requiring oral glucocorticoids/yr

A

Intermittent Asthma (Step 1)

SABA for rescue PRN - come in if use >2x/wk

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25
Q

Sx >2x/wk but not daily

3-4 awakenings/mo

SABA use >2x/wk but not daily

minor normal activity interference

FEV1 w/in normal

FEV1/FVC w/in normal

2 or more exacerbations needing oral glucocoticoids/yr (seasonal allergies, viral infection)

A

Mild Persistent Asthma (Step 2)

SABA for rescue PRN 1X/day

Low dose inhaled steroids or cromolyn/ nedocromil

2nd line: leukotriene inhibitors/theophylline

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26
Q

Daily asthma sx

Nocturnal awakenings >1x/wk

Daily SABA use

Normal activity somewhat limited

FEV1 between 60-80% predicted

FEV1/FVC 95-99% normal

2 or more exacerbations needing oral glucocorticoids/yr

A

Moderate Persistent Asthma (Step 3)

SABA PRN

Inhaled medium dose steroid

OR Inhaled low-medium dose steroid + LABA/Theophylline

OR medium-high corticosteroid + LABA/theophylline

CONSIDER REFERRAL

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27
Q

Asthma sx thoughout day

Nightly nocturnal awakenings

SABA use several times per day

Extreme activity limitation

FEV1 <60%

FEV1/FVC <95%

Two or more exacerbations requiring oral glucocorticoids/yr

A

Severe Persistent Asthma (Step 4)

SABA PRN

High dose inhaled steroid + LABA/theophylline

OR LABA+oral steroids

Try to reduce systemic steroid and maintain control with high dose inhaled steroids

REFER!!

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28
Q

Status Asthmaticus presentation

A

Severe bronchospasms resistant to routine therapy

orthopnea, cant talk, accessory inspiration muscle use, AMS

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29
Q

Status Asthmaticus Treatment

A

Oxygen, Oximetry, ABGs,

Peak flows between SABA/anticholinergic/corticosteroid (Oral or IV) treatments

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30
Q

Status Asthmaticus Discharge list

A

SABA/LABA

Anticholinergics

Burst pack - Oral corticosteroids x 5 days

Have patient follow up in 5 days

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31
Q

Asthma Quick-relief medications

A

SABA - inhibit smooth muscle contraction

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32
Q

Asthma long-term control to prevent/reverse inflammation

A

Most effective approach

Anticholinergics

Corticosteroids

Mast cell-stabilizing agents

Leukotriene Modifiers

Methylxanthines

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33
Q

Asthma long-term control to inhibit smooth muscle contraction

A

LABA (long-acting beta-2 agonists)

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34
Q

MDI

A

metered dose inhaler releases specific amount of aerosolized particles frequently used with a spacer

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35
Q

Nebulizer

A

liquid “nebulized” medicine with moist continuous airflow ideal for pediatric patients or those unable to use MDI

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36
Q

Sympathomimetic Bronchodilators

A

Beta-2 agonists

provide airway dilation via beta-adrenergic receptors

activated -> G proteins activated -> cyclic AMP formed -> inflammatory mediator release is decrease and mucociliary transport improves

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37
Q

SABA

A

Albuterol/Proventil/Ventolin - quick onset, last 4-6 hrs

Terbutaline - used to prevent uterine contractions

Bitolterol

Pirbuterol

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38
Q

Beta-2 agonist dosing

A

MDI: 2-4 puffs q4-6 hrs

>1 canister used/mo = inadequate asthma control

more frequent use = more SE

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39
Q

Beta-2 agonist SE

A

tachycardia, tremor, headache hypokalemia, hyperglycemia, increased lactic acid

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40
Q

LABA

A

Salmeterol, Formoterol (Oral or inhaled) -slower onset (30 min), lasts 9-12 hrs -maintenance therapy

Levalbuterol - longer acting, more beta-2 selectivity than albuterol

Fenoterol - not yet available in US

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41
Q

Anticholinergic MOA

A

Block bronchial smooth muscle contraction and decrease parasympathetic mucous secretion.

Also inhibit Ach-stimulated mast cell histamine release

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42
Q

Anticholinergics

A

Bronchodilator

Ipratropium bromide (Atrovent) - slow acting (60-90 min) used in combination with beta-agonist

Tiotropium (Spiriva) - longer acting (24 hrs)

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43
Q

Methylxanthines

A

Theophylline - bronchodilator

Aminophylline (IV) - loading dose + maintenance dose

rarely ever used - narrow therapeutic window (10-15 mcg/mL) hard to achieve and maintain

Immediate release - interchangable

Sustained release - not interchangable

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44
Q

Methylxanthines dosing

A

long-acting dose 1-2x/day - dose in evening to reduce nocturnal sx

monitor serum levels - q3 days till stable, q6-12 mo dose

requirements and clearance rates increase with children and concurrent smoking/pot/phenobarbital/phenytoin

dose requirements & clearance decreased in neonates, elderly, hepatic dysfunction, cor pulmonale, fever, macrolide/quinolone/propranolol use

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45
Q

Methylxanthine side effects

A

insomnia, nervousness, N/V, anorexia, HA, tachycardia

plasma levels >30g/mL -> seizures and cardiac arrhythmias

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46
Q

Corticosteroids MOA

A

anti-inflammatory, can be used acutely or chronically

Inhaled have less SE, reduce airway reactivity or to wean off oral steroids

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47
Q

Corticosteroid SE

A

Thrush (inhaled)

Dysphonia

adrenal suppression, insomnia, cataract formation, stunted growth, purpura, bone metabolism interference

Inhaled need 2-4 wks to work, supplement with oral glucocorticoids to cover

48
Q

Inhaled Corticosteroids

A

Fluticasone (Flovent)

Budesonide (Pulmicort)

Beclomethasone (Vancecril, Beclovent, QVAR)

Triamicinolone (Azmacort)

Flunisolide (Aerobid, Aerobid-M)

49
Q

PO Corticosteroids - Acute

A

Methylprednisolone - 40-60 mg IV q6hrs

Prednisone - 60 mg PO q6hr

reduce dose by 1/2 every 3-5 days to prevent adrenal shutdown

50
Q

PO Corticosteroids - Chronic dosing

A

Alternate-day schedule to minimize SE

Don’t use long-acting preparations (Dexamethasone) - prolonged pituitary-adrenal axis suppression

51
Q

Advair Diskus

A

combo product - dry powder for inhalation

fluticasone + salmeterol (cortico + LABA)

52
Q

Combivent MDI

A

combo product - duoneb for nebulizer

Ipratropium + Albuterol (Anticholinergic + SABA)

53
Q

Mast Cell Stabilizers

A

Antiinflammatory

Cromoly, Nedocromil

no influence on airway tone, only inhibit mast cell degranulation

54
Q

Mast Cell Stabilizer dosage

A

best for seasonal dx - start 4-6 wks prior 2 puffs qid

prophylaxis 15-20 min precontact

55
Q

Leukotriene inhibitors and MOA

A

Montelukast - 5mg qd

Zafirlukast - 20-40 mg qd

Zileuton - 600 mg qid

MOA: suppress cysteinyl leukotrine action (proinflammatory)

56
Q

Leukotriene Inhibitor uses

A

safe in kids 6-14 w/ minimal SE

use in combo with beta-agonist or corticosteroid

Suboptimal alternative to corticosteroid but can reduce needed corticosteroid dose

not for acute attack reveral - 1 hr onset

57
Q

Leukotriene Inhibitor SE

A

LFT abnormalities, HA

58
Q

Anti-IgE Monoclonal Antibodies

A

Omalizumab - new, inhibit IgE binding to Mast Cells

cannot stop degranulation if IgE bound

repeated IV/SQ injections lessen asthma severity and reduce corticosteroid requirements in asthma pts

59
Q

Pulmonary Hypertension Vasodilators

A

be careful - systemic and may cause syncope

1st line - PO Ca+ Channel Blockers

PO Phosphodiasterase inhibitors or endothelin receptor antagonists

Continuous IV prostacyclin agents

60
Q

Transdermal nicotine patch

A

OTC, long-acting 16 & 24 hr patches - continuous nicotine delivery

61
Q

Transdermal nicotine patch dosing

A

Light smoker (10cigs/day) start at 14mcg for 6 wks, 7 mcg for 2 wks

Heavy smoker (>10cigs/day) start at 21 mcg for 6 wks, 14 mcg for 2 wks, 7 mcg for 2 wks

62
Q

Transdermal nicotine patch SE

A

Skin irritation, dizziness, nausea, HA , Sleep problems/unusual dreams, muscle aches and stiffness

If patch is too strong: tachycardia, nausea, over-stimulated

63
Q

Short-acting Nicotine Replacement Therapies (NRT)

A

use in combo with patch to help control cravings and withdrawl

gum, lozenge, nasal spray (Rx), and inhaler (Rx)

64
Q

Nicotine gum

A

OTC, most common

acidic beverages reduce nicotine absorption

65
Q

Nicotine gum dosing

A

2 mg for light smokers, 4 mg for >25 cigs/day

“chew & park” 1 piece of gum q 1-2 hrs for 6 wks, gradually reduce for 6 wks

66
Q

Nicotine gum SE

A

N/V

Abdominal pain

Constipation

67
Q

Nicotine lozenge

A

OTC, dissolves in mouth over 30 mins

68
Q

Nicotine lozenge dosing

A

2 mg for most smokers, 4 mg if they smoke w/in 30 mins waking

1 lozenge q1-2 hrs for 6 wks, gradually reduce over next 6 wks

Max dose: 5 lozenges q6 hrs or 20 lozenges/day

69
Q

Nicotine lozenge SE

A

Mouth irritation

Hiccups

N/V

70
Q

NRT Nasal Spray

A

Rx, nicotine absorbed in nasal mucosa

1-2 sprays/hr for 3 mo

Max dose 80 sprays/day

Each spray = .5mg nicotine 2 sprays = 1 cig

71
Q

NRT Nasal Spray SE

A

Nasal irritation

Runny nose

Watery eyes

72
Q

NRT Oral inhaler

A

Rx, nicotine cartridge with thin plastic tube

Pt inhales on tube to produce nicotine vapor

6-16 cartridges/day for 6-12 wks, gradual decrease over 6 wks

Most expensive NRT

73
Q

NRT Oral inhaler SE

A

Coughing

Mouth/throat irritaition

Upset stomach

74
Q

Tobacco Cessation Medical Therapy

A

Varenicline (Chantix)

Bupropion (Wellbutrin, Zyban)

75
Q

Varenicline MOA

A

blocks alpha-4 beta-2 nicotine acetylcholine receptors =reduced pleasure reward

binding of A4B2 receptor provides partial stimulation = reduced withdrawl

76
Q

Varenicline SE

A

Nausea - titrate up slowly to prevent

Constipation

Sleep distrubances

Unusual dreams

Increase risk of MI/stroke

BBW: Suicide risk CV SE

77
Q

Varenicline dosing

A

can smoke for 1 wk after starting

0.5mg daily for 3 days, .5 mg 2X daily for 4 days, 1 mg 2X daily for rest of 12 wks

78
Q

Bupropion MOA

A

unknown, may enhance CNS noradrenergic and dopaminergic release

May help with post-cessation weight gain

First line for pts with Schizophrenia

79
Q

Bupropion SE & CI

A

Insomnia

Dry mouth

HA

CI for smokers with seizure disorder

80
Q

Bupropion dosing

A

Start 1-2 wks prior to stop date

150 mg/day for 3 days, then 150 mg 2X daily for 12 wks

81
Q

5 Stages of Change

A

Stage 1 - Pre-contemplation

Stage 2 - Contemplation

Stage 3 - Preparation

Stage 4 - Action

Stage 5 - Maintenance

82
Q

5 A’s

A

Ask

Advise

Assess

Assist

Arrange

83
Q

Bronchoscopy CI

A

Pts with cardiac problems or severe hypoxemia

Rigid - aneurysm, marked kyphosis

84
Q

Chest CT Air Bronchogram DDx

A

Non-obstructive atelectasis

Pneumonia

Pulmonary Edema

Hemorrage

Bronchioloalveolar carcinoma

Lymphoma

85
Q

Chest CT Bronchiectasis DDx

A

Infection

Bronchial obstruction

Cystic fibrosis

Primary ciliary dyskinesia

Immunodeficient state

Alpha-1 Antitrypsin deficiency

RA & Sjogrens

Pulmonary fibrosis

86
Q

Chest CT Septal thickening

A

Pulmonary edema

Pulmonary hemorrhage

Lymphangitic cancer spread

87
Q

Chest CT Ground Glass Opacities DDx

A

Alveolitis/interstitial pneumonitis

  • Hypersensitivity pneumonitis
  • IPF
  • Sarcoidosis

Pulmonary Edema

Resolving pneumonia/hemorrhage

88
Q

Chest CT Emphysema DDx

A

Smoker

Alpha-1 Antitrypsin deficiency

IV drugs

Immunodeficiency

Vasculitis

Connective tissue disorders

89
Q

Chest CT Filling Defect DDx

A

Intersegmental nodes

Vascular tumor invasion

Flow artifact

90
Q

V/Q scan CI

A

No absolute CI

Relative CI: Pulmonary HTN or R to L shunts (VSD)

91
Q

Respiratory Stimulants

A

Medroxyprogesterone

Acetazolamide

Theophylline

92
Q

Apnea

A

Breath cessation for at least 10 seconds with concurrent decrease in 02 saturation

93
Q

Hypopnea

A

Decreased airflow with an 02 sat drop of at least 4%

94
Q

Apnea-hypopnea index (ADI)

A

Average number of desats/hr during sleep

Needed to determine RDI

95
Q

Respiratory Disturbance Index (RDI)

A

The number of apneas, hyponeas, and respiratory effort - related arousals per hour of sleep

Arousal includes movement from deeper to light sleep

96
Q

Mild sleep apnea

A

5-14 RDIs/hr

97
Q

Moderate sleep apnea

A

15-29 RDIs/hr

98
Q

Severe sleep apnea

A

>= 30 RDIs/hr

99
Q

Acidotic physiologic changes

A

Decreased cardiac contraction force

Decreased vascular response to catchecholamines

Decreased response to certain medications

100
Q

Alkalotic physiologic changes

A

Normal tissue oxygenation interference

No change in neurological or muscular function

101
Q

Normal pH range

A

7.35 - 7.45

102
Q

Normal PaCO2 range

A

35 - 45

103
Q

Normal PaO2 range

A

80 - 102

104
Q

Normal HCO3 range

A

22 - 28

105
Q

Normal Anion gap

A

6 - 12

106
Q

Respiratory acidosis causes

A

CNS depression

Impaired respiratory muscle function

Pulmonary disorders (atelectasis, pneumonia)

Massive PE

Hypoventilation

Trauma

107
Q

Respiratory alkalosis causes

A

Psychological response (anxiety, fear)

Pain

Increased metabolic demands (fever, sepsis, pregnancy)

Respiratory stimulants

CNS lesions

108
Q

Metabolic acidosis causes

A

*Look for hypoxic tissue in body*

Renal failure

Diabetic ketoacidosis

Diarrhea

Anaerobic metabolism (tissue hypoxia)

Starvation

Salicylate intoxication

109
Q

Metabolic alkalosis causes

A

Excess base (antacids, bicarb use, lactate from dialysis)

Acid loss (vomiting, excess diuretics, hypochloremia)

110
Q

Hypoxemia

A

Insufficient oxygenation

111
Q

Hypoxia

A

Low oxygen content in tissue

112
Q

Asthma vs COPD

A

Asthma = CD4, Eosinophils - completely reversible

COPD = CD8, macrophages, neutrophils - is not reversible

113
Q

Chronic Bronchitis

3 Cardinal Symptoms

A
  1. Dyspnea with early SOB w/ exertion
  2. Productive cough
  3. Mucous production
114
Q

Pursed Lip Breathing “PEEP”

A
  1. Increases resistance to air outflow
  2. Prevent airway collapse by increasing airway pressure
115
Q

COPD Acute Exacerbation ICU Admision Indications

A

Severe dyspnea

Mental status changes

Persistent, worsening hypoxemia

Hypercapnia

Respiratory Acidosis

116
Q

COPD Acute Exacerbation Discharge List

A

Bronchodilator use less than every 4 hours

Clinical and ABG stable for 12-24 hours

Acceptable ability to eat, sleep, and ambulate

Pulmonology (2 decks)

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