Obstructive Lung Disease

Question 1

What happens to the FVC in asthma?

Answer 1

It is unchanged - normal

Question 2

FEV1/FVC ratio in obstructive vs restrictive lung disease.

Answer 2

Obstructive = <75%

Restrictive = >75% (normal)

Question 3

What test can be done to differentiate asthma from COPD?

Answer 3

Bronchial challenge test:

Response of FEV1 to a Beta agonist; asthma sees a >15% increase whereas COPD has less than 15% increase.

Question 4

Transfer factors in Restrictive and obstructive disease:

Answer 4

TCLO/DCLO measures the diffusion capacity of the lungs by measuring the amount of carbon monoxide diffusion that occurs in a single breath.

Restrictive disease = reduced
Ephysema = reduced
Asthma = normal.

Question 5

2 classes of drugs that can precipitate asthma?

Answer 5

Beta blockers and NSAIDs

Question 6

What type of inflammation occurs in asthma?

Answer 6

Eosinophillic

Question 7

Important parts of history in asthma?

Answer 7

1) Preciptants
2) Diurnal variation
3) Atopy (hay fever eczema)
4) Disturbed sleep (woken up SOB or cough = this is marker of severity)
5) Home life: pets, smokers, any changes.
6) Occupation; any triggers?
7) Impact, exercise tolerance? Activities of daily living.

Question 8

Investigations for asthma (4)?

Answer 8

PEAK FLOW (reduced)
Spirometers (obstructive picture (normal FVC, Decreased FEV 1)
Bronchial challenge test. >15% increase with SABA
CXR shows hyperinflation (>6 anterior ribs)

Question 9

Asthma treatment protocol NICE guidelines:

Answer 9

1) SABA as reliever
2) ICS as maintenance
3) ICS + SABA + LTRA (oral montelukast)
4) ICS + SABA +/- LTRA + LABA
5) MART (ICS + fast acting LABA) [acts as maintenance and reliever] + low dose ICS
6) MART + moderate dose ICS
7) MART + high dose ICS and consider long acting muscarinic or theophylline.

Question 10

Moderate asthma attack criteria?

Answer 10

Increasing symptoms

PEFR 50-75% best or predicted

No features of severe acute

Question 11

Features of severe acute asthma attack?

Answer 11

RR >25, Pulse >110

PEFR 33-50% best or predicted.

Inability to complete sentences.

Question 12

Life threatening asthma attack

Answer 12

O2 less than 92%, Pao2 less than8

Normal CO2 (normal co2 is worrying as shows the patient is exhausted)

Any of the following:

• exhaustion
• altered level of consciousness
• Solent chest
• poor resp effort
• cyanosis
• arrhythmia

Question 13

Management of acute asthma if all else fails?

Answer 13

IV magnesium sulphate

Question 14

Management of COPD if all else fails ?

Answer 14

IV aminophyline

Question 15

Management of acute asthma (including doses)

Answer 15

ABCDE (sit upright and give high flow oxygen)

Nebulised salbutamol (5mg) + Ipratropium (500micrograms)

• Give salbutamol every 15 mins and monitor ECG/
• Give ipratropium every 4-6hours.
• Hydrocortisone 100mg IV.
  Ix: FBC, U&E, ABG, PEFR, CXR

Add in magnesium sulphate if not responding.

Question 16

What type of inflammation in COPD?

Answer 16

Neutrophillic

Question 17

ECG changes in cor pulmonale?

Answer 17

Peaked P waves and Right ventricular hypertrophy.

The hypoxia in COPD results in pulmonary hypertension which eventually leads to cor pulmonale.

• Typical features are cyanosis. Not breathless, prominent cough with lots of swelling, peripheral oedema, wheeze on auscultation (BLUE BLOATERS)

Question 18

“Honey combing on CT”

Answer 18

Idiopathic pulmonary fibrosis.

Question 19

What does the ABG show in as acute asthma attack?

Answer 19

Normally it shows an uncompensated respiratory alkalosis (blowing off CO2)

Question 20

What is bronchiectasis?

Answer 20

Dilatation of the airways due to destruction of the elastic and muscular components of the airway walls.

Presents with cough and sputum production.

Question 21

What sign is seen on CT scan for bronchiectasis?

Answer 21

Signet ring sign

Question 22

Investigations for bronchiectasis?

Answer 22

• Spirometry - shows an obstructive picture.
• High resolution CT is diagnostic investigation
• CXR (lateral and PA) ; used for monitoring

Question 23

Management of bronchiectasis?

Answer 23

1) Exercise and increased nutrition (pulmonary rehab)
2) Inhalers : salbutamol
3) Nebulised saline
4) Long term oral macro lines e.g. azithromycin 3x per week (helps to prevent infections)

Question 24

treatment pathway for chronic COPD:

Answer 24

Stop SMOKING

1) SABA or SAMA (salbutamol or ipratropium)

2) Depends on FEV1
- If FEV1 > 50% = LABA or LAMA (salmeterol or tiotropium)

• if FEV1 < 50% = LABA + ICS (fool eternal + beclomethasone) or LAMA
  3) LABA + ICS + LAMA