Week 4 Respiratory/ENT Flashcards
What is presbycusis?
Age-related hearing loss, characterized by symmetrical progressive loss of hearing over many years. It usually affects high frequencies of hearing but can be variable.
What are the 3 anatomical areas of the ear?
Disorders of which of these areas can contribute to hearing loss?
External ear, middle ear, and inner ear.
Disorders of any of these areas can contribute to hearing loss.
Presbycusis affects more than half of adults by age 75 years, most adults over the age of 80, and nearly all adults who are 90 or older. It is more common in males than females, possibly related to higher levels of noise exposure seen in this population.
True or false?
True! As per UTD.
_______ ________ can be accompanied by tinnitus, vertigo, and disequilibrium, leading to _____________________.
Hearing loss can be accompanied by tinnitus, vertigo, and disequilibrium, leading to increased falls risk.
Hearing deficits are exacerbated in the presence of _________________, so people living with presbycusis will often do well one-on-one in a quiet room.
competing background noise
What should you be mindful of during your PE if assessing for presbycusis?
General PE is usually unremarkable.
It is common for older adults to have age-related benign opacification of the tympanic membrane and build-up of cerumen. If a moderate amount of cerumen is present, this should be removed to rule out impaction or obstruction as a potential cause of hearing loss.
Tuning forks may be used to discriminate between conductive and sensorineural hearing loss; however, their use is limited by patient cooperation and provider subjectivity.
Determining whether the pattern of hearing loss is sensorineural or conductive is an important first step in the diagnosis. This can be done by performing both the Weber and the Rinne test using a tuning fork.
Presbycusis is sensorineural in origin; therefore, the ______test should reveal that air conduction is heard longer than bone conduction in both ears. _________ test should localize toward the ear with better hearing, signifying a contralateral sensorineural loss. _______ test may vary and may result in a falsely normal result if hearing loss is symmetric.
Rinne
Weber’s
Weber’s
The treatment of choice for presbycusis is librolycra 2.5 mg daily to slow the progression of the disorder.
True of false?
False. I made that up.
The mainstay of treatment is hearing aids.
Cochlear implants may be an option for patients with severe bilateral hearing loss that is not responsive to hearing aids (there is specific criteria).
How is presbycusis diagnosed?
An audiogram: pure-tone testing. Presbycusis will appear as an overall down-sloping line that represents impaired hearing at higher frequency sounds.
What are some DDX for presbycusis?
Noise exposure
Infection
Ménière disease
Trauma
Autoimmune disease
Perilymph fistula
Genetically-inherited hearing loss
Otosclerosis
Tumor
Exposure to ototoxic agents
Metabolic dysfunction
If the pattern of hearing loss is conductive, then an alternative diagnosis to presbycusis should be considered. These include:
Cerumen impaction
Foreign body
Tumor obstruction
Infection
Perforation
Otosclerosis
Cholesteatoma
Cerumen impaction
Foreign body
Tumor obstruction
Infection
Perforation
Otosclerosis
Cholesteatoma (Non-cancerous abnormal growth of keratinizing squamous epithelium filled with air or fluid in the middle ear and temporal bone behind the ear drum. It may cause constant discharge, hearing loss, dizziness or headache.)
What is a red flag in a patient presenting with c/o hearing loss?
Sudden sensorineural hearing loss (SSNHL) is usually unilateral and onset it over 72 hours or less. Most is idiopathic and resolves spontaneously but the following must be evaluated for:
Recent head trauma
Barotrauma
Acute keratitis
Prior hx (assess for Meniere’s)
Focal neurologic s/s (diplopia, headache, vertigo, tinnitus)
Autoimmune disease or vasculitis
Recent exposure to Lyme disease
Acute infection (AOM, otitis externa, mastoiditis)
Exposure to ototoxic meds/drugs
Name some ototoxic medications/substances.
●Several antibiotics cause ototoxicity. All oral aminoglycosides are ototoxic.
●Other oral antibiotics that can cause ototoxicity include erythromycin and tetracycline. These drugs have a more pronounced ototoxic effect in patients with impaired kidney function.
●Many chemotherapeutic agents.
●High-dose aspirin (6 to 8 g/day) or other salicylates can cause hearing loss, but this is reversible with discontinuation of the drug.
●Acetaminophen, or nonsteroidal antiinflammatory drugs (NSAIDs; ≥2 times/week) was also associated with an increased risk of hearing loss, particularly in those less than 50 years old. Similar findings were found in women for acetaminophen and ibuprofen, but not aspirin [80].
●Phosphodiesterase 5 inhibitors.
●Antimalarial medications such as quinine and chloroquine may also cause sensorineural hearing loss and tinnitus but, similar to salicylates, these effects are usually reversible.
●Loop diuretics may cause temporary hearing loss and tinnitus.
●Cocaine, both intranasal and intravenous.
●Heavy metals, including lead, mercury, cadmium, and arsenic.
●Exposure to aromatic solvents, including toluene and styrene.
A 65-year-old male is evaluated in a follow-up examination
for worsening dyspnea and chronic cough productive of
mucoid sputum for the past 6 months. He was diagnosed with (COPD) 3 years ago, and uses inhaled albuterol as needed.
Vital signs are normal and the
patient is not in any respiratory distress. Breath sounds
are decreased, but there is no edema or jugular venous
distention. Spirometry shows FEV1/forced vital capacity (FVC) ratio
of 65%. His COPD symptoms seem poorly controlled and
he has had one exacerbation in the past year. Chest x-ray shows mild hyperinflation.
Which of the following is the most appropriate therapy for
this patient?
a. Add inhaled corticosteroid to his current treatment
plan.
b. Add a long-acting inhaled bronchodilator.
c. Continue with inhaled albuterol every 4 hours.
d. Add theophylline and montelukast.
e. Treat the patient with an antibiotic
Answer is
b. Add a long-acting inhaled bronchodilator.
In uncontrolled COPD, that would be the next appropriate step.
He is not showing signs and symptoms of pneumonia.
What are some defining characteristics of COPD?
*Dyspnea-Progressive over time
Worse with exercise
Persistent-daily
People describe it as “increased effort to breathe”, heaviness, air hunger, gasping”.
Chronic cough
Sputum production
Key risk factors:
Tobacco smoke
Occupational dust and chemicals
Smoke from home cooking and heating fuel
Family hx/α-1 antitrypsin
deficiency
Provide examples of obstructive airways diseases
COPD (emphysema &/or bronchitis), asthma, bronchiectasis and cystic fibrosis.
Provide examples of restrictive lung diseases.
Interstitial lung disease (ILD), sarcoidosis, neuromuscular diseases (e.g. ALS), pulmonary fibrosis, asbestosis, silicosis.
In someone with obstructive lung disease, expect to see:
a) Increased pulmonary compliance, destructions of alveolar space, forced expiration volume is decreased.
b) Decreased pulmonary compliance, increased alveolar space, forced expiration volume is decreased.
c) Decreased pulmonary compliance, destruction of alveolar space, lung capacity is normal.
Answer is A
Expiration effect is decreased, alveolar space is destroyed, hard to exhale air, lung capacity is normal, vital capacity is normal, forced expiration volume is decreased.
In someone with restrictive lung disease, expect to see:
a) decreased pulmonary compliance, presence of bullae, vital capacity is reduced, lung capacity is decreased.
b) Increased pulmonary compliance, increase of alveolar space, reduced vital capacity
c) Forced expiration volume is normal, lung capacity is reduced, vital capacity is reduced.
Answer is C
Reduced effect of inspiration, increased alveolar space and destruction of elastic fibers, lung capacity is decreased, vital capacity is reduced, forced expiration volume is normal.
What are risk factors of obstructive lung disease?
Smoking: Primary risk factor for COPD
Occupational Exposures: Exposure to pollutants or occupational irritants.
Genetics: e.g. Alpha-1 antitrypsin deficiency is a risk factor for COPD. Asthma is a familial d/o.
Allergies: Allergies can trigger asthma symptoms, contributing to the development or exacerbation of obstructive lung diseases.
Pre-existing Conditions: such as bronchiectasis or cystic fibrosis, HIV, and Marfan syndrome.
History of Respiratory Issues in Childhood
Age
Family history of atopy
What are some risk factors of restrictive lung disease?
Environmental Exposure: Occupational or environmental exposure to substances such as asbestos, silica, or coal dust.
Connective Tissue Disorders: Conditions like rheumatoid arthritis, scleroderma, or lupus.
Radiation Therapy: Previous exposure to chest radiation.
Neuromuscular Disorders: , such as muscular dystrophy or amyotrophic lateral sclerosis (ALS)
Obesity - obesity hypoventilation syndrome.
Age (the elderly)
Smoking
What is the pathophysiology of restrictive lung disease?
Narrowing of the airways, often due to inflammation and mucus production.
Reduced Expiratory Flow Rates: Difficulty exhaling air efficiently.
Air Trapping: Incomplete emptying of the lungs, leading to hyperinflation.
Airway obstruction (decreased lung recoil and increased lung compliance) = Airflow reduction = alveoli expand but slowly or unable to deflate = increased lung volumes.
What is the pathophysiology of restrictive lung disease?
Stiffening of lung tissue, making it harder to expand.
Decreased Lung Volumes: Reduced total lung capacity and vital capacity.
Impaired Gas Exchange: Difficulty in oxygen and carbon dioxide exchange due to decreased lung surface area.
Reduced lung compliance = restricted lung expansion = more effort to expand the lung during inhalation (alveoli deflate, but it is unable to inflate properly) = reduced lung volumes and increased WOB.
Causes
-Intrinsic lung diseases - diseases that affect tissue and space around alveoli in the lungs e.g pulmonary fibrosis
-Extrinsic disorders - conditions that affect the chest wall, spine, or pleura e.g kyphosis, obesity hypoventilation
What would spirometry show in obstructive lung disease?
FEV1/FVC – reduced
TLC – elevated or normal
RV – elevated or normal
DLCO – Normal (asthma) or reduced
Decreased flow rates, hyperinflation and air trapping (increased TLC)
- FEV1/FVC ratio < 0.7
What would spirometry show in restrictive lung disease?
FEV1/FVC – normal or increased
TLC – reduced
RV – reduced, normal or increased
Reduced (intrinsic) or normal (extrinsic)
Decreased lung volumes and compliance
Normal or increased FEV1/FVC ratio (between 0.7 to 0.
If you suspect COPD, what testing would you order?
Spirometry:
Post bronchodilator FEV1/FVC ration <0.70.
Chest x-ray may show hyperinflation, but need spirometry to diagnose COPD.
Annie comes in because she feels that her COPD symptoms are not well managed with her current medication regime. What would you assess first?
First evaluate Annie’s inhaler compliance and technique before making any medication adjustments.
Up to 90% of patients use their device incorrectly! Arthritis, pain, and other factors are barriers to appropriate technique. Ensure that they are sitting upright.
What else should you assess when considering the next step in medication management in COPD?
Assess exertional dyspnea, functional status, history of exacerbations, complexity of medicines or devices, patient preference (e.g., cost and ability to adhere to treatment plan) and occurrence of adverse effects.
You are prescribing medication for John, who was just recently diagnosed with COPD. What would be the first step?
1-A SAMA or SABA
If symptoms are not well controlled, then proceed with
2-SAMA AND SABA
John returns 6 months later and you determine that you need to escalate medication management. He is already on SAMA and SABA. What would be your next step?
LABA or LAMA monotherapy.
Continue SABA as rescue
The next step after that is having him take LABA and LAMA together.
Note: LAMA and SAMA should not be used concurrently.
John has been having multiple AECOPD. What should you do now?
He is currently on LABA and LAMA combination.
Triple therapy of LAMA and LABA and ICS for those patients with FEV1 < 50% predicted and ≥ 2 exacerbations in the past 12 months.
With ICS, use lowest dose possible and avoid use as monotherapy.
What is AECOPD?
Sustained (e.g., 48 hours or more) worsening of shortness of breath and coughing, usually with increasing sputum volume.
The most common cause of AECOPD is a viral or bacterial infection; other causes-pleural effusion, heart failure, pulmonary embolism, and pneumothorax.
Most COPD action plans have which medications?
1) short-acting bronchodilator for initial treatment of acute exacerbations
Adequate doses of bronchodilator (e.g., salbutamol 400 to 800 mcg [4 to 8 puffs]) delivered via metered dose inhaler with a spacer is equivalent to 2.5 mg by nebulizer and is as effective. Administer salbutamol frequently (up to every couple of hours) and titrate to response
2) oral corticosteroids in most moderate to severe COPD patients.
A dose of 40 mg of prednisone per day for 5 days is an appropriate dose.17 However, a dose of 50 mg of prednisone per day is often used in Canada because of its availability in a single tablet. Lower doses may need to be used, especially in the presence of diabetes mellitus.
3) Antibiotic treatment
amoxicillin 1 g PO TID or
doxycycline 200 mg PO once, then 100 mg PO BID or
sulfamethoxazole-trimethoprim 1 DS (800-160 mg) tablet PO BID
Treat for 5-7 days.
For guidance check: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/copd_appendix_b.pdf
When would you refer a COPD patient to a specialist?
-the diagnosis is uncertain;
-a patient is < 40 years with COPD and limited smoking history, or has severe symptoms and disability which is disproportionate to their lung function
-there is evidence of an alpha-1 antitrypsin (A1AT) deficiency (e.g. early onset of emphysema or COPD, unexplained liver disease, family history)
-there are signs and symptoms of hypoxemic or hypercarbic respiratory failure
-there are severe or recurrent exacerbations and treatment failure;
-the patient has severe COPD and disability requiring more intensive interventions
-a more intensive comorbidity assessment and management is required
-a patient is frail and may benefit from multidisciplinary or comprehensive geriatric assessment
-difficulty in assessing home oxygen or sleep disorders.
Match the following:
a) salbutamol. 1) LAMA
b)spiriva. 2) combo
LABA
and LAMA
c)Ultibro breezhaler. 3) SABA
d) Symbicort turbuhaler 4) ICS
and LABA
combo
a/3
b/1
c/2
d/4
A patient comes in with dry eye (sicca). What would be your management plan for them?
Hot compresses, artificial tears, and nighttime lubricating ointments.
Avoid artificial tears with preservatives or OTC “antiredness” eye drops with naphazoline or pheniramine as they worsen symptoms.
Name some S&S of sicca.
- eye dryness
-visual disturbance - eye discomfort or FB sensation
- burning/stinging
- grittiness
- tearing
- ocular fatigue
Can be episodic or chronic
What are risk factors for sicca?
dry environment
medications
blepharitis
smoking
alcohol use
long-term contact lens use
LASIK surgery
pollution
activities with decreased blinking (computer use)
topical ocular medications
female sex,
Sjögren syndrome
increasing age
