Test #1 Flashcards
Define Obstructive lung disease
airway blocked - air cannot get out of lung
Define Restrictive lung disease
lungs cannot fill with air - cant get air in
Obstructive disease examples
asthma
foreign object inhalation
bronchitis
invasive tumor
excessive mucous plugging
COPD
FEV1
forced expiratory volume in 1 sec
75% total FVC
FVC
forced vital capacity
Categories of Restrictive lung disorders
Neuromuscular, Intrinsic, Extrinsic
Neuromuscular restrictive lung disorder examples
weakness, diaphragm paralysis, MS, myasthenia gravis
Intrinsic restrictive lung disorder examples
sarcoidosis, TB, pneumonia, pneumonectomy
Extrinsic restrictive lung disorder examples
scoliosis, pleural effusion, pregnancy, obesity, ascites, tumor
Pts who CANNOT undergo bronchoprovocation challenge
unstable heart disease
heart attack or stroke within last 3 months
uncontrolled HTN
significant bronchspasms already present
pregnant or nursing mothers
FEV1% severity grading
Mild >70%
Moderate 60-69%
Moderately Severe 50-59%
Severe 35-49%
Very Severe <35%
DLCO uses
Diffusion Capacity
- differentiate chronic bronchitis from emphysema
- determining degree of emphysema
- differentiating interstitial and external restrictive disorders
- recurrent PEs
- pulmonary HTN
- disability measurement
Low DLCO with Obstruction
emphysema
cystic fibrosis in children
Low DLCO with Restriction
Pulmonary fibrosis
Hypersensitivity pneumonitis
Low DLCO with normal spirometry
Chronic PE
Anemia
Early interstitial lung dx
Increases carboxyhemoglobin levels
CHF
High DLCO
Asthma
Left-to-right intracardiac shunt
Polycythemia
Intrinsic Asthma
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
Extrinsic Asthma
Type-1 Hypersensitivity reaction
- Atopic: most common, elevated IgE & eosinophil count with family hx
- Occupational asthma
- Allergic bronchopulmonary aspergillosis
Exercise induced Asthma (EIA)
Vigorous physical activity triggers acute bronchospasms
Tx: SABA 10-15 minutes pre-activity, avoid activity in cold air
Asthma classic symptom triad
Persistent wheeze, end expiratory wheeze
Chronic episodic dyspnea
Chronic cough
Any and all symptoms may be worse or only present at night
Pulses paradoxus
Pulse rate decreases >10mmHg with inspiration
Asthma spirometry diagnosis
PFT: FEV1 12% & 200mL
Provocation test to support asthma Dx
Asthma Dx tests
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
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
Intermittent Asthma (Step 1)
SABA for rescue PRN - come in if use >2x/wk
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)
Mild Persistent Asthma (Step 2)
SABA for rescue PRN 1X/day
Low dose inhaled steroids or cromolyn/ nedocromil
2nd line: leukotriene inhibitors/theophylline
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
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
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
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!!
Status Asthmaticus presentation
Severe bronchospasms resistant to routine therapy
orthopnea, cant talk, accessory inspiration muscle use, AMS
Status Asthmaticus Treatment
Oxygen, Oximetry, ABGs,
Peak flows between SABA/anticholinergic/corticosteroid (Oral or IV) treatments
Status Asthmaticus Discharge list
SABA/LABA
Anticholinergics
Burst pack - Oral corticosteroids x 5 days
Have patient follow up in 5 days
Asthma Quick-relief medications
SABA - inhibit smooth muscle contraction
Asthma long-term control to prevent/reverse inflammation
Most effective approach
Anticholinergics
Corticosteroids
Mast cell-stabilizing agents
Leukotriene Modifiers
Methylxanthines
Asthma long-term control to inhibit smooth muscle contraction
LABA (long-acting beta-2 agonists)
MDI
metered dose inhaler releases specific amount of aerosolized particles frequently used with a spacer
Nebulizer
liquid “nebulized” medicine with moist continuous airflow ideal for pediatric patients or those unable to use MDI
Sympathomimetic Bronchodilators
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
SABA
Albuterol/Proventil/Ventolin - quick onset, last 4-6 hrs
Terbutaline - used to prevent uterine contractions
Bitolterol
Pirbuterol
Beta-2 agonist dosing
MDI: 2-4 puffs q4-6 hrs
>1 canister used/mo = inadequate asthma control
more frequent use = more SE
Beta-2 agonist SE
tachycardia, tremor, headache hypokalemia, hyperglycemia, increased lactic acid
LABA
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
Anticholinergic MOA
Block bronchial smooth muscle contraction and decrease parasympathetic mucous secretion.
Also inhibit Ach-stimulated mast cell histamine release
Anticholinergics
Bronchodilator
Ipratropium bromide (Atrovent) - slow acting (60-90 min) used in combination with beta-agonist
Tiotropium (Spiriva) - longer acting (24 hrs)
Methylxanthines
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
Methylxanthines dosing
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
Methylxanthine side effects
insomnia, nervousness, N/V, anorexia, HA, tachycardia
plasma levels >30g/mL -> seizures and cardiac arrhythmias
Corticosteroids MOA
anti-inflammatory, can be used acutely or chronically
Inhaled have less SE, reduce airway reactivity or to wean off oral steroids
Corticosteroid SE
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
Inhaled Corticosteroids
Fluticasone (Flovent)
Budesonide (Pulmicort)
Beclomethasone (Vancecril, Beclovent, QVAR)
Triamicinolone (Azmacort)
Flunisolide (Aerobid, Aerobid-M)
PO Corticosteroids - Acute
Methylprednisolone - 40-60 mg IV q6hrs
Prednisone - 60 mg PO q6hr
reduce dose by 1/2 every 3-5 days to prevent adrenal shutdown
PO Corticosteroids - Chronic dosing
Alternate-day schedule to minimize SE
Don’t use long-acting preparations (Dexamethasone) - prolonged pituitary-adrenal axis suppression
Advair Diskus
combo product - dry powder for inhalation
fluticasone + salmeterol (cortico + LABA)
Combivent MDI
combo product - duoneb for nebulizer
Ipratropium + Albuterol (Anticholinergic + SABA)
Mast Cell Stabilizers
Antiinflammatory
Cromoly, Nedocromil
no influence on airway tone, only inhibit mast cell degranulation
Mast Cell Stabilizer dosage
best for seasonal dx - start 4-6 wks prior 2 puffs qid
prophylaxis 15-20 min precontact
Leukotriene inhibitors and MOA
Montelukast - 5mg qd
Zafirlukast - 20-40 mg qd
Zileuton - 600 mg qid
MOA: suppress cysteinyl leukotrine action (proinflammatory)
Leukotriene Inhibitor uses
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
Leukotriene Inhibitor SE
LFT abnormalities, HA
Anti-IgE Monoclonal Antibodies
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
Pulmonary Hypertension Vasodilators
be careful - systemic and may cause syncope
1st line - PO Ca+ Channel Blockers
PO Phosphodiasterase inhibitors or endothelin receptor antagonists
Continuous IV prostacyclin agents
Transdermal nicotine patch
OTC, long-acting 16 & 24 hr patches - continuous nicotine delivery
Transdermal nicotine patch dosing
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
Transdermal nicotine patch SE
Skin irritation, dizziness, nausea, HA , Sleep problems/unusual dreams, muscle aches and stiffness
If patch is too strong: tachycardia, nausea, over-stimulated
Short-acting Nicotine Replacement Therapies (NRT)
use in combo with patch to help control cravings and withdrawl
gum, lozenge, nasal spray (Rx), and inhaler (Rx)
Nicotine gum
OTC, most common
acidic beverages reduce nicotine absorption
Nicotine gum dosing
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
Nicotine gum SE
N/V
Abdominal pain
Constipation
Nicotine lozenge
OTC, dissolves in mouth over 30 mins
Nicotine lozenge dosing
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
Nicotine lozenge SE
Mouth irritation
Hiccups
N/V
NRT Nasal Spray
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
NRT Nasal Spray SE
Nasal irritation
Runny nose
Watery eyes
NRT Oral inhaler
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
NRT Oral inhaler SE
Coughing
Mouth/throat irritaition
Upset stomach
Tobacco Cessation Medical Therapy
Varenicline (Chantix)
Bupropion (Wellbutrin, Zyban)
Varenicline MOA
blocks alpha-4 beta-2 nicotine acetylcholine receptors =reduced pleasure reward
binding of A4B2 receptor provides partial stimulation = reduced withdrawl
Varenicline SE
Nausea - titrate up slowly to prevent
Constipation
Sleep distrubances
Unusual dreams
Increase risk of MI/stroke
BBW: Suicide risk CV SE
Varenicline dosing
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
Bupropion MOA
unknown, may enhance CNS noradrenergic and dopaminergic release
May help with post-cessation weight gain
First line for pts with Schizophrenia
Bupropion SE & CI
Insomnia
Dry mouth
HA
CI for smokers with seizure disorder
Bupropion dosing
Start 1-2 wks prior to stop date
150 mg/day for 3 days, then 150 mg 2X daily for 12 wks
5 Stages of Change
Stage 1 - Pre-contemplation
Stage 2 - Contemplation
Stage 3 - Preparation
Stage 4 - Action
Stage 5 - Maintenance
5 A’s
Ask
Advise
Assess
Assist
Arrange
Bronchoscopy CI
Pts with cardiac problems or severe hypoxemia
Rigid - aneurysm, marked kyphosis
Chest CT Air Bronchogram DDx
Non-obstructive atelectasis
Pneumonia
Pulmonary Edema
Hemorrage
Bronchioloalveolar carcinoma
Lymphoma
Chest CT Bronchiectasis DDx
Infection
Bronchial obstruction
Cystic fibrosis
Primary ciliary dyskinesia
Immunodeficient state
Alpha-1 Antitrypsin deficiency
RA & Sjogrens
Pulmonary fibrosis
Chest CT Septal thickening
Pulmonary edema
Pulmonary hemorrhage
Lymphangitic cancer spread
Chest CT Ground Glass Opacities DDx
Alveolitis/interstitial pneumonitis
- Hypersensitivity pneumonitis
- IPF
- Sarcoidosis
Pulmonary Edema
Resolving pneumonia/hemorrhage
Chest CT Emphysema DDx
Smoker
Alpha-1 Antitrypsin deficiency
IV drugs
Immunodeficiency
Vasculitis
Connective tissue disorders
Chest CT Filling Defect DDx
Intersegmental nodes
Vascular tumor invasion
Flow artifact
V/Q scan CI
No absolute CI
Relative CI: Pulmonary HTN or R to L shunts (VSD)
Respiratory Stimulants
Medroxyprogesterone
Acetazolamide
Theophylline
Apnea
Breath cessation for at least 10 seconds with concurrent decrease in 02 saturation
Hypopnea
Decreased airflow with an 02 sat drop of at least 4%
Apnea-hypopnea index (ADI)
Average number of desats/hr during sleep
Needed to determine RDI
Respiratory Disturbance Index (RDI)
The number of apneas, hyponeas, and respiratory effort - related arousals per hour of sleep
Arousal includes movement from deeper to light sleep
Mild sleep apnea
5-14 RDIs/hr
Moderate sleep apnea
15-29 RDIs/hr
Severe sleep apnea
>= 30 RDIs/hr
Acidotic physiologic changes
Decreased cardiac contraction force
Decreased vascular response to catchecholamines
Decreased response to certain medications
Alkalotic physiologic changes
Normal tissue oxygenation interference
No change in neurological or muscular function
Normal pH range
7.35 - 7.45
Normal PaCO2 range
35 - 45
Normal PaO2 range
80 - 102
Normal HCO3 range
22 - 28
Normal Anion gap
6 - 12
Respiratory acidosis causes
CNS depression
Impaired respiratory muscle function
Pulmonary disorders (atelectasis, pneumonia)
Massive PE
Hypoventilation
Trauma
Respiratory alkalosis causes
Psychological response (anxiety, fear)
Pain
Increased metabolic demands (fever, sepsis, pregnancy)
Respiratory stimulants
CNS lesions
Metabolic acidosis causes
*Look for hypoxic tissue in body*
Renal failure
Diabetic ketoacidosis
Diarrhea
Anaerobic metabolism (tissue hypoxia)
Starvation
Salicylate intoxication
Metabolic alkalosis causes
Excess base (antacids, bicarb use, lactate from dialysis)
Acid loss (vomiting, excess diuretics, hypochloremia)
Hypoxemia
Insufficient oxygenation
Hypoxia
Low oxygen content in tissue
Asthma vs COPD
Asthma = CD4, Eosinophils - completely reversible
COPD = CD8, macrophages, neutrophils - is not reversible
Chronic Bronchitis
3 Cardinal Symptoms
- Dyspnea with early SOB w/ exertion
- Productive cough
- Mucous production
Pursed Lip Breathing “PEEP”
- Increases resistance to air outflow
- Prevent airway collapse by increasing airway pressure
COPD Acute Exacerbation ICU Admision Indications
Severe dyspnea
Mental status changes
Persistent, worsening hypoxemia
Hypercapnia
Respiratory Acidosis
COPD Acute Exacerbation Discharge List
Bronchodilator use less than every 4 hours
Clinical and ABG stable for 12-24 hours
Acceptable ability to eat, sleep, and ambulate
