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533 > Week 7 COPD/Asthma > Flashcards

Week 7 COPD/Asthma Flashcards

1
Q

what confirms diagnosis in asthma?

A

spirometry

  • Tells us if there’s obstruction
  • Asses for any reversibility after giving bronhodilator
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2
Q

Asthma differentials

A
  • upper airway dz
    • acute bronchiolitis, laryngotracheobronchitis
  • allergic rhinitis
  • sinusitis
  • vocal cord dysfunction
  • foreign body
  • gerd
  • copd
  • CHF
  • laryngeal and/or vocal cord dysufnction
  • cystic fibrosis
  • alpha 1 antitrypsin deficiency
  • meds
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3
Q

*asthma clinical hallmarks

A
  • Bronchospasm is often reversible
    • episodic wheezing with or w/o hyper responsiveness
    • dyspnea
    • sputum production
    • Chest tightness
    • Cough
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4
Q

well controlled/intermittent asthma vs poorly controlled/persistent asthma in children, have sx’s

A
  • well controlled/intermittent asthma :
    • sx’s are < 2 days a week
    • should be using SABA < 2 times a week
    • night time awakenings < 2x/month
  • poor/persistent asthma
    • mild: > 2 days/week
    • mod: daily
    • severe: throughout day
    • night time awakenings 3-4x/month
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5
Q

*sx’s of more serious asthma exacerbation

A
  • marked breathlessness
  • RR > 30, HR > 120
  • inability to speak more than short phrases
  • use of accessory muscles
  • drowsiness should result in initial treatment while immediately consulting with a clinician.
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6
Q

initial treatment of asthma attack

A
  • Inhaled SABA: up to 2 treatments 20 min apart of 2-6 puffs by MDI or nebulizer treatments.
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7
Q

if initial treatment has a good response (no wheezing/dyspnea), peak est. flow > 80%:

A

May continue inhaled SABA every 3–4 h for 24–48 hr

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8
Q

if initial treatment has an incomplete response (persistent wheezing/dyspnea/tachypnea), PEF 50-79%:

A
  • add oral systemic corticosteroid
  • continue inhaled SABA
  • consult clinician for further action
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9
Q

if initial treatment has a poor response (marked wheezing/dyspnea), PEF < 50%:

A

add oral systemic corticosteroids

repeat inhaled SABA ASAP

if distress severe and non responsive, call doc AND go to ED, consider 911

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10
Q

asthma diagnosis

A
  • (1) demonstration of episodic symptoms of airflow obstruction (e.g., wheeze, cough, shortness of breath),
  • (2) evidence that airflow obstruction is at least partially reversible
  • (3) exclusion of other conditions from the differential diagnosis.
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11
Q

*diagnostic hallmark of asthma

A

reversal of obstruction after the giving a bronchodilator (improved spirometric values < 80% and improved post SABA)

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12
Q

asthma diagnostics

A
  • Pulse ox
  • CBC if secondary infection
  • Chest radiographs/sputum cx NOT recommended unless sus infectious illness
  • Allergy evaluation
  • Sweat test
  • Pulmonary function tests
  • Peak flow measurements
    • peak expiratory flow rate
    • maximal mid expiratory flow
    • FVC
      *
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13
Q

daily controller meds of asthma are:

A

low dose ICS and long acting beta agonist bronchodilator combos (ICS/LABA)

add on controller meds include (long acting anticholinergic, Anti-IgE, Anti-IL 5 and systemic corticosteroids

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14
Q

reliever asthma meds:

A

SABA (albuterol)

low dose ICS/formoterol

short acting anticholinergics

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15
Q

how to monitor peak flow meter at home

A

for moderate/severe asthma

record at least once daily in early afternoon, after 2-3 weeks

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16
Q

PEF > 80% measurement is what zone?

A

green

good asthma control; safe to proceed

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17
Q

PEF 60-80% zone

A

yellow

sx’s that interfere with daily activities (cough, wheeze, chest tightness, SOB, nocturnal awakening)

need temporary increase in med dose or frequency (inc bronchodilator, add/inc ICS or oral steroids)

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18
Q

PEF < 50%

A

red zone, danger, emergency treatment

inability to blow into the peak flow meter, accessory respiratory muscle use, difficulty walking or talking because of asthma, and cyanosis. Immediate use of inhaled rescue bronchodilator therapy and initiating or increasing oral corticosteroid therapy are necessary.

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19
Q

*atopic triad

A
  1. skin disorders (eczema)
  2. allergies? allergic rhinitis
  3. inhaler use/asthma

all 3 causes inflammation

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20
Q

Samter’s triad

A

chronic condition in pt’s with asthma

aka Aspirin Exacerbated Respiratory Disease

  1. atopic dermatitis/eczema
  2. nasal polyps
  3. aspirin or NSAID sensitivity
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21
Q

Exercise induced asthma management

A

if exercise regularly, use ICS as controller med

use 2 puffs B2 agonist and/or cromolyn MDI 15-30 mins prior to exercise [don’t use as controller med bc it builds tolerance]

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22
Q

Chronic cough is most often due to

A
  • viral URI or nonviral cause (e.g., asthma, exposure to pollutants)
  • ⅔ usu cleared within 2 weeks
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23
Q

3 most common causes of cough with NORMAL chest radiography include:

A
  • Corticosteroid-responsive esoinsophicili ariway disease (asthma, cough variant asthma and eosinophilic bronchitis)
  • Upper airway cough syndrome (previously referred to as postnasal drip syndrome)
  • GERD
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24
Q

chronic cough management

A
  • Antitussive (prevent, control, or eliminate cough) or protussive (to make cough more effective, and productive)
  • Eliminate triggers (smoke, ace, allergens)
  • Demulscents, opiates, GERD trial (PPIs) if purulent exudates
  • Treat underlying cough
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25
Q

most common cause of COPD? and others?

A

1: smoking

occupational

alpha 1 antitrypsin deficiency

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26
Q

gold standard for dx for COPD

A

spirometry required! confirms irreversible obstruction if FEV < 80% and FEV/FVC < 70% after given bronchodilator and it’s not reversible

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27
Q

on exam for COPD, the presence of of a postbronchodilator FEV1/FVC of ___ and FEV1 of _____ confirms airway limitation that is not fully reversible.

A

FEV1/FVC of < 70% and FEV1 < 80% confirms it’s not reversible

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28
Q

acute vs subacute vs chronic cough

A

acute: < 3 weeks
subacute: 3-8 weeks
chronic: > 8 weeks

29
Q

a cough associated with constant throat clearing and thick mucus production, especially on rising from bed, is consistent with

A

upper airway cough and sinusitis

30
Q

cough a/s with rhinorrhea or sneezing may be

A

viral or common cold

if recurs annually same time of year, allergic rhinitis is possible

31
Q

Intermittent productive cough associated with wheezing

A

most likely asthma

32
Q

loud hacking cough during daytime, non productive, leads to exhaustion, is a/s with

A

emotional stress, psychogenic cough

33
Q

hemoptysis sputum

A

bronchogenic cancer, pulmonary embolus, tuberculosis

34
Q

• Yellow-green, purulent sputum:

A

bronchitis

35
Q

pink frothy sputum

A

pulmonary edema

36
Q

fetid/foul smelling, purulent sputum

A

anaerobic infections

37
Q

rust colored sputum

A

pneumococcal pneumonia

38
Q

foam, serous, mucopurluent layers sputum

A

bronchiectasis

39
Q

chronic bronchitis on spirometry reveals

A

airway obstruction that does not respond significantly to inhaled bronchodilators (or improvement in FEV1 of > 12%)

40
Q

common complaints of COPD

A

dyspnea, cough, and/or sputum production

(late in the dz; when irreversible changes occurred)

41
Q

PE for COPD

A
  • confirmed with spirometry
  • late stages:
    • hyperinflation
    • tobacco stained fingers
    • clubbing
    • increase in AP diameter
    • increase intercostal spaces
    • abnormal restriction of interspaces between inspiration (severe)
    • increased resonance on percussion
    • cor pulmonale (advanced)
42
Q

COPD workup/labs

A
  • forced expiratory time → determines of more testing is needed [take deep breath in & breathe out quickly and completely as possible with mouth open] while auscultation trachea
    • 6 seconds or more = obstructive disease
  • confirm with spirometry (FVC, FEV1, FEV1/FVC)
    • any ratio < 70% FEV1/FVC
  • pulse ox
  • labs:
    • CBC with diff
    • ABG
    • alpha 1 antitrypsin
  • Chest xray (hyperinflation supports dx)
43
Q

COPD: Chronic bronchitis

A
  • Mild alteration in lung tissue compliance than emphysema and less parenchymal damage
  • Obese
  • Frequent cough with more sputum production
  • Accessory muscles
  • Coarse bronchi
  • Wheezes
  • R sided heart failure/cor pulmonale
  • Edema, cyanosis
44
Q

COPD: Emphysema

A
  • Damage to alveolar wall, destruction of alveolar architecture, mismatch of ventilation and perfusion
  • Thin, barrel chest
  • Cough (not as much as bronchitis)
  • Pursed lip breathing
  • thin frame
  • Accessory muscles
  • Tripod position
  • Hyperresonance
  • Wheezing
  • Heart sounds distant
45
Q

medication for COPD for acute exacerbation

A
  • oral prednisone 40mg QD x 5 days +
    • increase frequency of bronchodilators (beta agonist and/or anticholinergics)
  • and oral antibiotics:
    • Group A mild exacerbation: B lactam, tetracycline, bactrim]
    • Group B: moderate: Augmentin
    • Group C: severe: fluoroquinolone
46
Q

First-line for daily COPD symptoms:

A

short acting anticholinergic: ipratropium bromide (Atrovent)

47
Q

med for stage 3 or 4 COPD with FEV < 60%

A

inhaled corticosteroids AND LABA therapy (Sameterol or formoterol)

48
Q

lung cancer screening

A
  • Age 50 to 80 with 20 pack year smoking history and curently smoke or have quit w/in the last 15 years
  • Screen with low dose CT scan
  • Stop screening if not smoked for 15 years or develops health problem that limits life expectancy or ability or willingness to have curative lung surgery
49
Q

side effects of controller meds:

A
  • ICS: decreased bone density, addrenal suppression, Ca and Vitamin D supplements
  • LABA: black box in increase asthma related pulmonary death
50
Q

inhaled corticosteroids recommended for long term use for pediatrics if:

A
  • 4 wheezing episodes in a year affecting sleep and lasting more than 1 day AND have a positive asthma risk profile
  • 2 or more exacerbations requiring oral corticosteroids in last 6 months
  • child requires more than 2 doses of short acting bronchodilators per week for more than 4 weeks
51
Q

positive asthma profile includes

A
  • 1 or more of:
    • atopic dermatitis
    • sensitization to aeroallergen (pollen/spores in air)
    • parental hx of asthma

OR

  • 2 or more of:
    • wheezing apart from colds
    • more than 4% blood eosinophilia
    • food sensitization
52
Q

controller med for young children

A

SE: growth suppression, delayed puberty, bone density

53
Q

nebulizer or metered dose inhaler for children?

A

nebulizers or spacer( 1 way valve) equally good for SABA for exacerbations

PROPER TECHNIQUE

54
Q

when does response to controller med happen?

A

4-5 weeks

if not by then, stop med and consider another dx

if have measurable response for 3 months, lower dose but children have high rates of remission

55
Q

persistent asthma

A
  • < 5 yrs old:
    • if > 2 exacerbation in 6 months
  • > 5 years old:
    • > 2 exacerbations in 1 year but does not have daytime or nighttime impairment

lung function is included in 5 - 11 yr old criteria but not young children

56
Q

mild intermittent / step 1 management

A
  • sx’s < 2 days/week
  • nighttime < 2 x/month
  • no daily medicine needed
  • normal FEV1 > 80%
  • Saba when needed
57
Q

mild persistent asthma / step 2 management

A
  • sx’s > 2 days/wk
  • night time awakenings 3-4x/month
  • SABA use > 2 days/wk
  • FEV > 80%
  • controller: low dose inhaled CS
    • or cromolyn, leukotriene modifier, or theophylline
  • reliever as needed SABA
58
Q

moderate persistent asthma / step 3 management

A
  • Daily sx’s
  • night time awakening more than once a week
  • SABA used daily
  • FEV 60-80%
  • reliever: as needed SABA or low dose ICS/formoterol
  • controller: low dose ICS and LABA
    • or medium dose ICS
    • alternaties: low dose ICS + LTRA, theophylline, or zileuton
59
Q

severe persistent asthma / step 4 management

A
  • Sx’s throughout day
  • night time awakening every night
  • FEV < 60%
  • reliever: as needed SABA or low dose ICS/formoterol
  • controller: med/high dose steroids and LABA
    • If needed, add oral steroids
60
Q

when and how would you need to step up the asthma medications?

A
  • waking up more than once a month and has limitations in activity
  • before upping med, check med technique and environmental control
61
Q

COPD Stage 1

A

Mild

FEV > 80%

chronic cough, sputum production

62
Q

COPD Stage 2

A

Moderate

FEV 50-79%

worsening, SOB w/ exertion

63
Q

COPD Stage 3

A

Severe

FEV 30-49%

increasing OSB with repeated exacerbation impacting QOL

64
Q

COPD Stage 4

A
  • very severe
  • FEV < 30% or FEV < 50% + chronic respiratory failure present
  • QOL very impaired, life threatening
65
Q

COPD screening

A
  • ONLY if have sx’s, use:
  • spirometry
  • chest xray to confirm hyperinflation/bullae
  • chest CT to r/o malignancy
  • alpha 1 antitrypsin deficiency
  • 6 min walk test
66
Q

COPD workup

A

CBC (polycythemia)

ABG

pulse ox

alpha 1 antitrypsin def

chest x ray (hyperinflation)

67
Q

cardinal sx’s of COPD exacerbation

A

increased dyspnea

increased sputum volume

increased sputum purulence

68
Q

Children >12 with moderate to severe asthma may benefit from? (2nd line)

A

omalizumab if ICS doesn’t help

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