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Clin Med II Unit II > 3 Pulmonary Function Tests And Asthma > Flashcards

3 Pulmonary Function Tests And Asthma Flashcards

1
Q

What are the three basic PFTs?

A

Airflow spirometry

Lung volumes

Diffusion Capacity of the Lungs for Carbon Monoxide (DLCO)

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2
Q

Preferred patient position during spirometry

A

Sitting (because less likelihood of syncope)

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3
Q

How do you perform spirometry?

A

Patient sits

Tight seal over mouthpiece must be maintained

Visualization may be provided for motivation (ie candles)

Coaching is encouragaed (pt ed is key - useless if they don’t do it right)

Repeat testing at least 3X

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4
Q

How do you determine Forced Vital Capacity (FVC)

A

Deep breath in (full inspiration)

Blow out air as fast as possible (forced expiration)

FVC = total volume of air with maximal effort

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5
Q

Why do we use Forced Expiratory Volume in first second (FEV1)

A

Most useful information for obstruction

The FEV1/FVC ratio defines severity of obstruction - assists in differentiating obstruction and restrictive disease

<0.7 = obstructive pattern (<5th percentile LLN)

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6
Q

What does FEF 25-75% mean?

A

Airflow measurement during middle half of forced expiration

No specific for small airway obstruction but may be an early indicator of disease

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7
Q

Why do we do bronchodilator testing with spirometry?

A

Reversibility testing - if FEV1 increases by 12% and 200 ml after bronchodilator

If positive - aids in diagnosis, provides Tx options, improves compliance

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8
Q

How is reversibility testing performed?

A

Nebulizer or inhaler

Technique needs to be monitored - 2-4 puffs (preferably with chamber), and hold inhaled meds in lungs for 5-10 sec

Spirometry completed 15 min after meds provided

3-8 rounds of testing and possibly repeated during flare

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9
Q

What is bronchoprovocation and how is it performed?

A

Methacholine Challenge Test

  1. Dilute solution of methacholine given via nebulizer
  2. Spirometry conducted at 30 and 90 seconds
  3. Concentration increases

Positive test: FEV1 decreases by 20% (may have false positive)

RISK - must be closely monitored

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10
Q

Volume of air within the lung after maximal inhalation

A

Total Lung Capacity (TLC)

TLC = VC + RV

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11
Q

Volume of air we breathe out following maximal inhalation

A

Vital Capacity (VC)

TLC = VC + RV

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12
Q

Volume of air remaining in the lungs following maximal exhalation

A

Residual Volume (RV)

TLC = VC + RV

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13
Q

Measurement of the ability of the lungs to transfer gas and saturate the hemoglobin (alveolar-capillary membrane)

A

Diffusion Capacity (DLCO)

Can be misleading if a person is anemic (false reduction) and must be adjusted for hemoglobin level

CO is used as a surrogate for oxygen transfer

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14
Q

Technique for measuring DLCO

A

Patient inhales a single breath of gas consisting of helium/CO, then expires, and measurement of exhalation is taken

When lungs are healthy, little CO is collected during exhalation

When lungs are diseased, less CO diffuses into lungs, higher levels are measured in exhaled gas

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15
Q

Obstructive disease is characterized by …

A

Airway narrowing —> limits airflow with EXPIRATION

Reduced airflow with HIGH lung volumes (air trapping)

Inspiration likely normal

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16
Q

PFT results with obstructive disease

TLC: \_\_\_\_\_\_\_
FVC: \_\_\_\_\_\_\_
RV: \_\_\_\_\_\_\_\_\_
FEV1: \_\_\_\_\_\_\_
FEV1/FVC: \_\_\_\_\_\_\_\_
A 
TLC: Increased 
FVC: Normal
RV: Increased
FEV1: Decreased
FEV1/FVC: Decreased
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17
Q

Restrictive disease is characterized by…

A

Reduction in lung volume and reduced lung expansion

INSPIRATION & EXPIRATION will overall look normal but flow and volume are significantly reduced

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18
Q

PFT results for restrictive disease

TLC: \_\_\_\_\_\_\_
FVC: \_\_\_\_\_\_\_
RV: \_\_\_\_\_\_\_\_\_
FEV1: \_\_\_\_\_\_\_
FEV1/FVC: \_\_\_\_\_\_\_\_
A

Everything decreased except the ratio

TLC: Decreased

FVC: Decreased

RV: Decreased

FEV1: Decreased

FEV1/FVC: Normal or increased

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19
Q

Examples of obstructive lung disease

A 
Asthma
Asthmatic bronchitis
Bronchitis
COPD
CF 
Emphysema
Upper Airway Obstruction
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20
Q

Examples of Restrictive lung disease

A 
Pulmonary fibrosis
Infectious Lung Disease
Thoracic deformities
Pleural effusion
Tumors
Neuromuscular diseases
Obesity
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21
Q

5 steps to approaching PFT interpretation

A
  1. Examine the flow-volume curve
  2. Examine the FEV1 value
  3. Examine the FEV1/FVC ratio
  4. Examine the response to bronchodilator
  5. Examine the DLCO
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22
Q

What are we looking for when we examine the flow-volume curve?

A

Is it normal appearing?

Is the curve scooped out, indicating an obstructive pattern?

Is the slope increased/peaked, indicating a restrictive process?

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23
Q

FEV1<80% suggests…

A

Suggestive of obstructive disease but NOT diagnostic

Could also examine FEF 25-75% as it is more sensitive for detecting early airway obstruction

If TLC available, correlate with this measurement. If it is also increased by 15-20% predicted, this favors obstructive disease

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24
Q

FEV1/FVC ratio of ________ indicates obstructive disease

A

≤ 70% LLN

If the ratio is normal or increased, possibly a restrictive disorder

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25
If FEV1 increases by 12% and 200 ml in response to a bronchodilator, it suggests...
Suggestive of hyper reactive, reversible airways
26
What is DLCO for?
Measures the ability of O2 to get to the blood and be transported
27
How often do we perform PFTs?
Assessment at diagnosis After 3-6 months of controller treatment (is FEV1 improved?) Periodic assessments at least every 1-2 years (may need to be more often if higher risk patients and in children)
28
How is Asthma defined?
Chronic airway inflammation Intermittent and Reversible Airway Obstruction (may test normally if not acute) Bronchial hyperresponsiveness
29
80% of asthma patients develop symptoms before....
Age 5 But often misdiagnosed
30
Symptoms of asthma
Coughing - NOCTURNAL, seasonal, response to specific exposures, duration longer than 3 weeks Wheezing - hallmark symptom (may be heard with inspiration AND expiration) Other Sx: CP, chest pressure, dyspnea, SOB
31
Important DDx for asthma
GERD - especially if patient experiences nighttime cough right after laying down
32
Asthma Sx are episodic and often associated with characteristic triggers, such as...
``` URI Exercise Weather Stress Irritant exposure (tobacco, pets, etc) Meds (BB, ASA, NSAIDs) ```
33
Risk factors for Asthma
``` Atopy Med intolerance (ASA/NSAID) Food allergies GERD (also a DDx) RSV (+) FMH Maternal smoking (prenatal and second hand exposure) Obesity ```
34
Physical exam findings in asthma
Increased AP diameter Wheezing with PROLONGED EXPIRATORY PHASE - wheezing most commonly heard during forced expiratory phase but may also be heard during inspiration Associated signs of rhinitis, sinusitis, conjuctivitis, URI, atopic dermatitis Signs of severe obstruction: tachypnea, tachycardia, tripod positioning, accessory muscle use, pulses paradoxus
35
Aspirin-exacerbated respiratory disease is characterized by what triad?
Samter’s Triad Sinus disease with nasal polyps ASA sensitivity Severe asthma
36
What should patients with ASA-exacerbated respiratory disease avoid?
NSAIDS | Alcohol (b/c 75% also have respiratory response to alcohol)
37
What is the atopic triad?
Atopic Dermatitis Allergic Rhinitis Asthma
38
Asthma DDx in infants and children
``` GERD**** Allergic rhinosinusitis URI CF Pertussis FB or mass RAD (reactive airway disease) CHD Laryngotracheomalacia Eosinophilic bronchitis ```
39
Asthma DDx in adolescents and adults
``` GERD COPD CHF PE Vocal Cord Dysfunction Obstructive sleep apnea Chronic upper airway syndrom (post nasal drip) Cough secondary to ACE inhibitor ```
40
Initial presentation of asthma
Hx, PE, and variable expiratory airflow limitation Spirometry helps confirm Dx of asthma if >5 years of age May need to be repeated on several occasions or during symptoms to confirm Dx FEV1<80% FEV1/FVC: Normal or decreased relative to predicted values (70-85%) (Note, it’s <70% for COPD) Reversibility >12% (>8% in young children) in FEV1 with bronchodilator
41
Name the Asthma Step: Sx ≤ 2 days/week Nighttime awakenings: Ages 0-4 - None Ages ≥ 5 - ≤ 2 nights/month
Intermittent Asthma (Step 1) Normal PFTs in between exacerbations FEV1 >80% FEV1/FVC normal (>85% ages 5-19) Normal activity ≤ 2 days/week SABA use
42
Name the asthma step Sx >2 days/week (not daily) Nighttime awakening: Ages 0-4: 1-2 nights/month Ages ≥5: 3-4 nights/month
Mild Persistent Asthma (Step 2) FEV1 > 80% FEV1/FVC normal (>80% ages 5-19) Minor limitation in activity >2 days/week of SABA use to control Sx (not daily)
43
Name the asthma step: Daily Sx Nighttime awakenings: Ages 0-4: 3-4x/month Ages ≥5: >1x/week (not nightly)
Moderate Persistent Asthma (Step 3) FEV1 60-80% FEV1/FVC reduced by 5% Some activity limitations Daily use of SABA
44
Name the asthma step: Sx throughout the day Nighttime awakenings: Ages 0-4: >1x/week Ages ≥5: Nightly
Severe Persistent Asthma FEV1 <60% FEV1/FVC reduced by >5% Extremely limited physical activity SABA used to control Sx several times daily
45
Different meds used to manage asthma
``` SABA: inhaled short acting ß2 agonist LABA: long activity ß2 agonist ICS: Inhaled corticosteroid LTRA: Leukotriene receptor antagonist - Montelukast (used in ages 0-4) Monoclonal Antibodies (Omalizumab or Benralizumab) Methylxanthines (Theophyline) Mast Cell Stabilizers Anticholinergics ```
46
Step 1 asthma treatment
SABA prn
47
Step 2 asthma treatment
Low dose ICS daily (Or LTRA/Cromolyn in younger patients) SABA prn
48
Step 3 Asthma treatment
Medium dose ICS OR Low dose ICS + LABA (or LTRA if ≥ 5 years) SABA prn Refer to specialist
49
Step 4 asthma treatment
Medium dose ICS + LABA (or LTRA in 0-4 YO) SABA PRN
50
Step 5 asthma treatment
High dose ICS + LABA SABA PRN Consider adding Omalizumab (Xolair) for ages ≥ 12
51
Step 6 asthma treatment
High dose ICS + LABA + oral steroids SABA PRN Consider adding Omalizumab (Xolair) for ages ≥ 12
52
Rule of Twos for determining if asthma is under control
Asthma Sx > 2x/week Night Sx > 2x/month Refill SABA > 2x/year Peak flow meter measures less than 2 x 10 (20%) from baseline
53
How often do we follow up with asthma patients?
Initially 1-3 monthns then every 3-12 months depending on severity
54
Stats for well controlled asthma
Sx ≤ 2 days/week Nighttime awakenings ≤ 1x/month for ages 0-11, ≤ 2x/month for ages ≥ 12 FEV1 >80% FEV1/FVC >. 80%
55
Stats for not well controlled asthma
Sx ≥ 2 days/week Nighttime awakenings >1x/month for ages 0-4, ≥ 2x/month for ages 5-11, 1-3x/week for ages ≥12 FEV1 60-80% FEV1/FVC 75-80%
56
Stats for very poorly controlled asthma
Sx daily Nighttime awakenings >1x/week for ages 0-4, ≥2x/week for ages 5-11, ≥4x/week for ages ≥ 12 FEV1: < 60% FEV1/FVC < 75%
57
Signs of severe obstruction in asthma patients
``` Tachypnea Tachycardia Tripod positioning Accessory muscle use Pulses paradoxus ```
58
What are the different “zones” when using Peak Expiratory Flow Rate?
>80% = Green (good control) 50-80% = Yellow (Caution - SABA and Med increase) <50% = Red (Med alert - go to ED)
59
When should you go to the ER based on Peak Flow Meter?
If less than 50% (the red zone)
60
Other diagnostics considered in asthma
ABG - Respiratory alkalosis initially due to hyperventilation (if PaCO2 normal, consider patient getting tired/breathless) CXR - only if ruling out infection or obstruction (may show hyperinflation)
61
Treatment for Asthma Exacerbation
O2 SABA/SVN (Albuterol or Xopenex +/- Ipratropium Bromide) Systemic corticosteroids (Prenisolone 1mg/kg/day with max dosing based on weight) Other possibilities: • Abx PRN • Respiratory monitoring if in ED or inpatient • Severe may warrant C-PAP, BiPAP, or intubation
62
The main goal of asthma treatment?
Prevent persistent symptoms and asthma progression with appropriate medication management
63
Key patient ed points for asthma patients
Smoke free home Regular bedding washing No pets Remove triggers if possible Allergy testing and immunotherapy may be beneficial Write out care plan with specific meds and routine follow up Demonstrate appropriate technique for inhaled meds

Clin Med II Unit II (7 decks)

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