Internal Medicine > 5) Pulmonary (Part 1) > Flashcards

5) Pulmonary (Part 1) Flashcards

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1
Q

3 most important measures in Spirometry

A
  • FVC
  • FEV1
  • FEV1/FVC ratio
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2
Q

Spirometry normal values vs. COPD

A
  • Normal is 80%

- The diagnosis of COPD is an FEV1/FVC ratio less than 70%

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3
Q

The greatest value of the flow-volume loop is to assess for

A
  • Upper airway obstruction (for example, a laryngeal cancer)
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4
Q

DLCO

A
  • Measure of the ability of the lungs to transfer gas
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5
Q

Diffusion in the lungs is most efficient when

A
  • Surface area for gas transfer is high and the blood is readily & able to accept the gas being transferred
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6
Q

Decreased DLCO seen in

A
  • COPD
  • Infiltrative lung disease
  • Pulmonary HTN
  • PE
  • Sarcoidosis
  • Scleroderma
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7
Q

Normal DLCO seen in

A
  • Asthma
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8
Q

Examples of obstructive pulmonary diseases

A
  • Asthma
  • COPD
  • Cystic fibrosis
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9
Q

Examples of restrictive pulmonary diseases

A
  • Idiopathic pulmonary fibrosis
  • Pneumoconiosis
  • Coal worker’s pneumoconiosis
  • Silicosis
  • Asbestosis
  • Sarcoidosis
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10
Q

Asthma

A
  • Reversible airway obstruction, airway inflammation, and increased airway responsiveness to various stimuli
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11
Q

Asthma symptoms

A
  • Wheezing
  • Chest tightness
  • Dyspnea
  • Cough (range from mild to severe)
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12
Q

Asthma physical exam findings

A
  • Tachypnea

- Wheezing

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13
Q

Asthmatic spirometry findings

A
  • Decreased FEV1/FVC ratio
  • Obstruction will typically improve with a bronchodilator (significant bronchodilator response)
  • Normal DLCO
  • If FEV1/FVC ratio is normal, order a methacholine challenge test/ bronchoprovocation test
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14
Q

Asthma medication classes

A
  • Short acting inhaled beta agonists (SABA)
  • Inhaled corticosteroids (ICS)
  • Long acting inhaled beta agonists (LABA)
  • Combination inhaled corticosteroids and long term beta agonists
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15
Q

Short acting inhaled beta agonists (SABA)

A
  • Albuterol

- levalbuterol (Xopenex)

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16
Q

Inhaled corticosteroids (ICS)

A
  • flunisolide (Aerospan)
  • ciclesonide (Alvesco)
  • fluticasone furoate (Arnuity Ellipta)
  • mometasone furoate (Asmanex)
  • fluticasone propionate (Flovent)
  • budesonide (Pulmicort)
  • beclomethasone dipropionate (Qvar)
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17
Q

Long acting inhaled beta agonists (LABA)

A
  • formoterol (Foradil)

- salmeterol (Serevent)

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18
Q

Combination inhaled corticosteroids and long term beta agonists

A
  • fluticasone propionate
  • salmeterol (Advair)
  • mometasone furoate
  • formoterol fumarate (Dulera)
  • budesonide
  • formoterol fumarate dihydrate (Symbicort)
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19
Q

Never prescribe a long-acting beta agonist without an inhaled corticosteroid

A
  • Has been associated with increased mortality
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20
Q

Most important cause of COPD

A
  • Smoking
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21
Q

COPD symptoms

A
  • Progressive shortness of breath with exertion
  • Chronic cough
  • Sputum prodction
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22
Q

COPD physical exam findings

A
  • Increased AP diameter

- Scattered wheezes

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23
Q

COPD CXR findings

A
  • Flattened diaphragms
  • Hyperinflated lungs
  • Increased AP diameter (on lateral CXR)
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24
Q

COPD Dx

A
  • Requires spirometry
  • Post-bronchodilator FEV1/forced vital capacity <0.7 (confirms the presence of airflow limitation that is not fully reversible)
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25
American Thoracic Society COPD staging
- Mild disease: FEV1/FVC <70%, FEV1 >80% predicted - Moderate disease: FEV1/FVC <70%, FEV1 50-80% predicted - Severe disease: FEV1/FVC <70%, FEV1 30 to 50% predicted - Very severe disease: FEV1/FVC <70%, FEV1 <30% predicted
26
COPD treatment
- Smoking cessation | - Long-term oxygen therapy improves survival, exercise, sleep and cognitive performance
27
COPD long term oxygen therapy indications
- PaO2 <55mgHg (per ABG) or cor pulmonale, Pulmonary HTN present. - Goal: to maintain O2 saturation >90% during rest, sleep and exertion
28
COPD medications
- Short Acting βeta 2 Adrenoceptor-Agonists (SABA) - Long Acting βeta 2 Adrenoceptor-Agonists (LABA) - Short Acting Muscarinic Antagonist (SAMA) - Long Acting Muscarinic Antagonist (LAMA) - Inhaled Corticosteroid (ICS)* - Combination SAMA + SABA - Combination LABA + LAMA - Combination ICS + LABA - Phosphodiesterase Inhibitors
29
Short Acting βeta 2 Adrenoceptor-Agonists (SABA)
- Albuterol - Metaproterenol - Terbutalin - Isoetharine - Levalbuterol - <6 h effect on lung function
30
Long Acting βeta 2 Adrenoceptor-Agonists (LABA) Salmeterol, formoterol, olodaterol, vilanterol, = long acting (>12 h) effect on lung Indaceteraol = ultra long acting
- Salmeterol - Formoterol - Olodaterol - Vilanterol - >12 h effect on lung - Indaceteraol = ultra long acting
31
Short Acting Muscarinic Antagonist (SAMA)
- Ipratropium (4x /day)
32
Long Acting Muscarinic Antagonist (LAMA)
- Tiotropium - Clidinium - Umeclidinium - Glycopyrronium
33
Inhaled Corticosteroid (ICS)
- Beclomethasone - Budesonide - Triamcinolone - Fluticasone - Flunisolide
34
Combination SAMA + SABA
- Albuterol/ipratropium
35
Combination LABA + LAMA
- Vilanterol/umeclidinium - Olodaterol/tiotropium - Idacaterol/glycopyrronium - Formoterol/glycopyrrolate - Formoterol/aclidinium
36
Combination ICS + LABA
- Fluticasone propionate/salmeterol - Mometasone furoate/formoterol fumarate - Budesonide/formoterol fumarate dihydrate - Fluticasone furoate/vilanterol
37
COPD medications for refractory disease
- Phosphodiesterase inhibitors | - Rofluminast
38
Cystic fibrosis (CF) prevalence
- Most common genetically inherited autosomal recessive disease in Caucasians
39
CF leads to
- Multi-system organ dysfunction | - Majority of morbidity and mortality related to respiratory and gastrointestinal (GI) systems
40
CF pathophysiology involving the lungs includes
- Vicious cycle of infection - Inflammation - Bronchiectasis
41
CF diagnosis/clinical course
- Diagnosed with a chloride sweat test | - Clinical course includes acute exacerbations and eventual respiratory failure
42
Idiopathic pulmonary fibrosis SXS/clinical manifestations
- Progressive dyspnea | - Chronic cough
43
IPF diagnostic studies
- CXR, PFTs (restrictive pattern), High Resolution CT | - Bronchoscopy: transbronchial biopsy, bronchoalveolar lavage
44
IPF Tx
- Corticosteroids - Azathioprine (Imuran) - Mycophenolate (CellCept) - O2 - Pulmonary Rehab
45
Pneumoconiosis
- Occupational lung disease | - Caused by the inhalation of dust
46
Types of pneumoconiosis
- Coalworker’s pneumoconiosis (aka “black lung”) – coal dust - Asbestosis – asbestos dust - Silicosis – silica dust - Berylliosis – beryllium dust
47
Pneumoconiosis SXS
- Progressive dyspnea | - Chronic cough
48
Pneumoconiosis Tx
- D/c offending agent - Corticosteroids - O2 - Pulmonary rehab
49
Pneumoconiosis diagnostic studies
- CXR, PFTs (restrictive pattern), High Resolution CT | - Bronchoscopy: transbronchial biopsy, bronchoalveolar lavage
50
Sarcoidosis clinical presentation case (50 y/o male example)
- Chronic fatigue, nonproductive cough, dyspnea, anorexia, weight loss, blurred vision, and arthralgias - Tells you his “liver tests” have been abnormal - Skin findings: reddish-purple, hard (indurated), painful nodules
51
Sarcoidosis CXR findings
- Bilateral hilar lymphadenopathy
52
Sarcoidosis significant lab findings
- AST/ALT, alkaline phosphatase mildly elevated - Calcium is elevated - PFTs reveal decreased DLCO and FVC - ACE level may be elevate
53
Sarcoidosis biopsy
- Diagnostic | - Non-caseating granulomas
54
Sarcoidosis Tx
- First line = corticosteroids
55
CXR in acute respiratory distress syndrome (ARDS) shows
- B/l pulmonary infiltrates
56
ARDS Tx
- Requires special expertise with mechanical ventilation and management of critical illness - Tx of underlying condition is essential - Supportive care: Appropriate ventilator and fluid management
57
Risk factors for Obstructive Sleep Apnea (OSA)
- Obesity - Increased neck diameter (>17cm in men >16cm in women) - Abnormal upper airway abnormalities
58
Abnormal upper airway abnormalities that increase risk for OSA
- Macroglossia - Long soft palate and uvula - Enlarged tonsils - Micrognathia - Narrow oropharynx
59
Clinical manifestations of OSA
- Morning headaches - Recurrent awakenings - Daytime somnolence affecting daily activities (including driving) - Sleeping partner reporting snoring, periods of apnea, gasping for air - HTN
60
Manifestations of extreme cases of OSA
- Hypoxemia and pulmonary vasoconstriction --> pulmonary hypertension and right ventricular failure
61
Sleep Apnea
- Diagnosis = sleep study (Polysomnography) | - Treatment = CPAP machine (most effective)
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