Week 7 Flashcards
What is the classic presentation for COPD? (3 parts)
dyspena, cough, excess sputum
Name 3 late stage symptoms of COPD
Tripoding, pursed lip breathing, Increased resonance, crackles, diminished lung sounds, Cor pulmonale, Increased expiratory phase (early onset is asymptomatic)
What value on spirometry is diagnostic of COPD? FEV1 _____+ FVC/FEV Ratio _____
FEV < 80% and FVC/FEV < 0.7 post SABA (in order to demonstrate IRREVERSIBLE inflammation)
A patient with COPD has a CAT score of <10 and was hospitalized for a COPD exacerbation last month. What group is this patient in? (A,B,C,D)
Group C
What medication regimen should a group D COPD patient be on?
Multiple options : LAMA or LAMA + LABA or ICS + LABA
What are the components of the asthmatic triad?
asthma, allergies, atopy
What is the hallmark diagnostic spirometry finding for a patient with asthma?
Improved peak flow metrics post SABA + FEV < 80%
You diagnose a patient with asthma and decide they are appropriate to begin treatment at step 2. You prescribe a low dose ICS and PRN SABA. When should the patient be seen back in the office?
2-4 weeks for NEW onset asthma
How often should a known asthmatic with moderate asthma check their spirometry? What time of day should this be done?
daily in the early afternoon
A known asthmatic patient presents to the clinic complaining of shortness of breath most days with occasional nocturnal dyspnea. Their FEV1 is 85% in the office today. What step is this patient on? What do you prescribe?
Step 3; low dose ICS + LABA or med dose ICS + prn SABA (would be step 4 if their FEV was 60-80%)
A patient is seen in clinic for an asthma exacerbation. The provider administers three
nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L
of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient?
a. Administer three more nebulizer treatments and reassess.
b. Admit to the hospital with specialist consultation.
c. Give epinephrine injections and monitor response.
d. Prescribe an oral corticosteroid medication.
B
Patients having an asthma exacerbation should be referred if they fail to improve after three
nebulizer treatments or three epinephrine injections, have a peak flow less than 70% and a
pulse oximetry reading less than 90% on room air. Giving more nebulizer treatments or
administering epinephrine is not indicated. The patient will most likely be given IV
corticosteroids; oral corticosteroids would be given if the patient is managed as an outpatient.
An adult develops chronic cough with episodes of wheezing and shortness of breath. The
provider performs chest radiography and other tests and rules out infection, upper respiratory,
and gastroesophageal causes. Which test will the provider order initially to evaluate the
possibility of asthma as the cause of these symptoms?
a. Allergy testing
b. Methacholine challenge test
c. Peak expiratory flow rate (PEFR)
d. Spirometry
D
Spirometry is recommended at the time of initial assessment to confirm the diagnosis of
asthma. Allergy testing is performed only if allergies are a possible trigger. The methacholine
challenge test is performed if spirometry is inconclusive. PEFR is generally used to monitor
asthma symptoms.
A patient diagnosed with asthma calls the provider to report having a peak flow measure of
75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have
not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid
medication twice daily. What will the provider recommend?
a. Administering two more doses of albuterol
b. Coming to the clinic for evaluation
c. Going to the emergency department (ED)
d. Taking an oral corticosteroid
A
The patient is experiencing an asthma exacerbation and should follow the asthma action plan
(AAP) which recommends three doses of albuterol before reassessing. The peak flow is above
70%, so ED admission is not indicated. The patient may be instructed to come to the clinic for
oxygen saturation and spirometry evaluation after administering the albuterol. An oral
corticosteroid may be prescribed if the patient will be treated as an outpatient after following
the AAP.
A patient recovering from a viral infection has a persistent cough 6 weeks after the infection.
What will the provider do?
a. Perform chest radiography to assess for secondary infection
b. Perform pulmonary function and asthma challenge testing
c. Prescribe a second round of azithromycin to treat the persistent infection
d. Reassure the patient that this is common after such an infection
ANS: D
Postinfection cough is common after a viral infection and may persist up to 8 weeks after the
infection; this type of cough generally needs no intervention. It is not necessary to perform
chest radiography unless secondary infection is suspected. Antibiotics are not indicated.
Unless the cough persists after 8 weeks, asthma testing is not indicated.
A nonsmoking adult with a history of cardiovascular disease reports having a chronic cough
without fever or upper airway symptoms. A chest radiograph is normal. What will the
provider consider initially as the cause of this patient’s cough?
a. ACE inhibitor medication use
b. Chronic obstructive pulmonary disease
c. Gastroesophageal reflux disease
d. Psychogenic cough
ANS: A
About 10% of patients taking ACE inhibitors will develop chronic cough. COPD, GERD, and
psychogenic causes are possible, but given this patient’s cardiovascular history, the possibility
of ACE inhibitor-induced cough should be investigated initially.
A young adult patient develops a cough persisting longer than 2 months. The provider
prescribes pulmonary function tests and a chest radiograph, which are normal. The patient
denies abdominal complaints. There are no signs of rhinitis or sinusitis and the patient does
not take any medications. What will the provider evaluate next to help determine the cause of
this cough?
a. 24-hour esophageal pH monitoring
b. Methacholine challenge test
c. Sputum culture
d. Tuberculosis testing
ANS: B
Chronic cough without other symptoms may indicate asthma. If PFTs are normal, a
methacholine challenge test may be performed. 24-hour esophageal pH monitoring is
sometimes performed to evaluate for GERD, but this patient does not have abdominal
symptoms and this test is usually not performed because it is inconvenient. Sputum culture is
not indicated. TB is less likely.
Which is characteristic of obstructive bronchitis and not emphysema?
a. Damage to the alveolar wall
b. Destruction of alveolar architecture
c. Mild alteration in lung tissue compliance
d. Mismatch of ventilation and perfusion
ANS: C
Obstructive bronchitis causes much less parenchymal damage than emphysema does, so there
is milder alteration in lung tissue compliance. The other symptoms are characteristic of
emphysema.
Which test is the most diagnostic for chronic obstructive pulmonary disease (COPD)?
a. COPD Assessment Test
b. Forced expiratory time maneuver
c. Lung radiograph
d. Spirometry for FVC and FEV1
ANS: D
Spirometry testing is the gold standard for diagnosis and assessment of COPD because it is
reproducible and objective. The forced expiratory time maneuver is easy to perform in a clinic
setting and is a good screening to indicate a need for confirmatory spirometry. Lung
radiographs are non-specific but may indicate hyperexpansion of lungs. The COPD
assessment test helps measure health status impairment in persons already diagnosed with
COPD.
A patient diagnosed with chronic obstructive pulmonary disease reports daily symptoms of
dyspnea and cough. Which medication will the primary health care provider prescribe?
a. Ipratropium bromide
b. Pirbuterol acetate
c. Salmeterol xinafoate
d. Theophylline
ANS: A
Ipratropium bromide is an anticholinergic medication and is used as first-line therapy in
patients with daily symptoms. Pirbuterol acetate and salmeterol xinafoate are both
beta2-adrenergics and are used to relieve bronchospasm; pirbuterol is a short-term medication
used for symptomatic relief and salmeterol is a long-term medication useful for reducing
nocturnal symptoms. Theophylline is a third-line agent.
excessive cough can lead to complications including
nausea, vomiting, anorexia, headache, throat pain, hemorrhages, fatigue, insomnia, myalgias, dypsnonia, persperation, hernia, anxiety, depression
acute cough is classified as
a cough lasting < 3 weeks
subacute cough is classified as
cough lasting 3-8 weeks
chronic cough
cough persisting beyond 8 weeks
subacute cough is caused by
bacterial sinusitis, asthma, upper respiratory infections
post infectious cough lasts
no more than 8 weeks
most common cause of cough
cigarette smoking
most common cause of a cough with normal chest xray is
asthma, eosinophilic bronchitis, post nasal drio, gerd,
chronic bronchitis is classified as
a cough that lasts 3 consecutive months for more than 3 consecutive years.
describe a cough caused by ace inhibitor
non productive cough more common in women, chinese and non smokers
ACE inhibitor cough usually resolved
1-4 weeks after cessation of ACE inhibitor
a normal chest xray excludes
malignancy, Tb, sarcoidosis, pneumonia, bronchiectasis
pulmonary function test and O2 saturation can help to diagnose
asthma, copd, restrictive lung disease.
cough variant asthma is characterized by
dry, nocturnal cough with a drop in early morning peak flows
what are the initial diagnostics of a chronic cough
chest xray, Ct , PFT, bronchosopy
biggest risk factor for chronic cough and COPD
smoking
an FEV1 less than ___ predicted value is strongly responsive to inhaled beta2 adrenergic bronchodilators
80%
bronchiectasis is
associated with an overproduction of secretions cobined with reduced clearance of secretions.
30ml os sputum, fever, hemoptysis, weight loss.
what is considered a positive result for methacholine test
a drop in 20% in FEV1 from baseline
organisms responsible for bronchiectasis
HIB, staph aureus, pseudomonas aeruginosa
most efficient dx tool for bronchiectasis is
high resolution CT scan
potentially serious causes for chronic cough
asthma, TB, carcionma, chronic aspiration, heart failure, COPD, interstitial lung disease
