ABIM 2015 - Pulm Flashcards
Patients with DYSPNEA, those with KNOWN LUNG disease or to establish a BASELINE prior to a treatment or new job with potential LUNG injury, during PRE-OP period (thoracic surgery or LUNG resection), usually undergo what testing?
PULMONARY FUNCTION TESTS (PFT’s)
Most widely used pulmonary function test which measures the FORCED EXPIRATORY VOLUME (FORCED VITAL CAPACITY - FVC) over TIME after a patient has taken a DEEP INSPIRATION?
SPIROMETRY
After a patient takes a MAXIMAL (as much as they can), DEEP INSPIRATION, they are told to EXHALE FORCEFULLY, their ENTIRE BREATH, OVER 6-12 SECONDS. This is known as what component of SPIROMETRY?
FORCED VITAL CAPACITY (FVC)
What is FEV1 in spirometry?
The FORCED EXPIRATORY VOLUME (FVC) in ONE SECOND
The smaller the FEV1 is the smaller the FEV1/FVC will be, and if FEV1/FVC is
AIRWAY OBSTRUCTION
When a BRONCHODILATOR is given (to try and relieve an AIRWAY OBSTRUCTION that is caused by INFLAMMATION or IRRITATION of the AIRWAYS (bronchi), what is considered a “REVERSIBLE” airway obstruction?
An increase of FEV1/FVC ≥12% (or ≥200 mL)
What is best to review when performing SPIROMETRY testing in a patient in order to rule out poor test results such as due to a SLOW START, HESITATION or COUGH while a patient tries to perform the test?
FLOW-VOLUME CURVE (flow volume loop)
Conditions such as ASTHMA, ALLERGIES, VIRAL INFECTIONS, SMOKING, BRONCHITIS and CYSTIC FIBROSIS affect the airways in what way?
Make them HYPERRESPOSIVE
What test is performed to assess airway HYPERRESPONSIVENESS which is VERY SENSITIVE (rules OUT disease) for ASTHMA but NOT SPECIFIC (rules IN disease) - meaning if the test is negative, its NOT asthma, however if the test is positive, it CAN be asthma, but it can also be lots of other things like allergies, viral infections, the effects of smoking, bronchitis and cystic fibrosis)?
Bronchial Challenge Testing
In performing this test, SERIAL SPIROMETRY measurements are obtained while the patient is given INCREASING concentrations of an INHALED medication that causes BRONCHOCONSTRICTION - irritation of the airways (bronchi)?
Bronchial Challenge Testing
When is a Bronchial Challenge Test considered POSITIVE?
When the FEV1/FVC is DECREASED by ≥20% from BASELINE
What happens to the Bronchial Challenge Test if a patient with ASTHMA used their BRONCHODILATOR medication recently OR the test was IMPROPERLY PERFORMED OR the patient has SEASONAL/OCCUPATIONAL ASTHMA WITHOUT recent exposures?
FALSE NEGATIVE TEST
What is the ONLY USE for the Bronchial Challenge Test?
To RULE OUT or “exclude” (high SENSITIVITY) ASTHMA in patients with NORMAL SPIROMETRY and symptoms consistent with but not typical of ASTHMA
What are the agents METACHOLINE, HISTAMINE and MANNITOL used for?
These are DIRECT BRONCHIAL IRRITATING agents used in BRONCHIAL CHALLENGE TESTING (used to EXCLUDE ASTHMA)
HOW is MANNITOL a different and BETTER agent to use in BRONCHIAL CHALLENGE TESTING when attempting to EXCLUDE a diagnosis of ASTHMA?
Because it is an INDIRECT BRONCHOCONSTRICTING agent in that is causes the release of ENDOGENOUS mediators when inhaled, which cause airway (bronchial) smooth muscle constriction (more accurate in determining an underlying airway inflammation)
The volume of air contained in the lung after a FULL INHALATION? What is the normal volume?
TOTAL LUNG Capacity (TLC)
Normal volume is 6 L
The volume of air that can be INSPIRED AFTER a NORMAL INSPIRATION?
INSPIRATORY Capacity (IC)
The MAXIMAL volume of air that can be EXPELLED from the lungs AFTER a NORMAL EXPIRATION?
EXPIRATORY RESERVE Volume (ERV)
The volume of air LEFT in the lungs AFTER a FORCED EXHALATION (cannot be measured, only calculated)?
RESIDUAL Volume (RV)
The most amount of air a person can INHALE and EXHALE are called?
INSPIRED VITAL Capacity (IVC) and EXPIRED VITAL Capacity (EVC)
The TOTAL volume of air DISPLACED during a normal INSPIRATION and EXPIRATION WITHOUT any additional EFFOR is called? What is the normal volume for inspiration?
TIDAL Volume (TV) Normal is 500 mL or 7 mL/kg
When the Total Lung Capacity (TLC) is
CHEST RESTRICTION (parenchymal - pulmonary fibrosis or respiratory muscle weakness - neuromuscular disease)
What happens to ALL lung volumes in RESTRICTIVE lung disease (pulmonary fibrosis or neuromuscular disease)?
They are ALL reduced in parallel
Describe DLCO?
A patient has his nose pinched and is connected to a machine via his mouth. He is asked to take a deep breath (of carbon monoxide - CO), hold for one second, then exhale all of it out again. A computer measures HOW MUCH CO was INHALED and SUBTRACTS from this volume HOW MUCH CO was EXHALED. The resulting DIFFERENCE is HOW MUCH CO was DIFFUSED from the ALVEOLI into the BLOOD
In what TYPE of RESTRICTIVE LUNG DISEASE is the DLCO reduced?
In those that affect the PARENCHYMA of the lung (destruction of the alveolar-capillary bed)
What type of lung disease is suspected in a patient with REDUCED BOTH FVC and FEV1 with a NORMAL or HIGHER than NORMAL FEV1/FVC ratio?
RESTRICTIVE LUNG DISEASE
How is CHEST RESTRICTION confirmed, with what LUNG VOLUME test?
Total Lung Capacity (TLC)
In what diseases is there a LOSS of SURFACE for GAS EXCHANGE?
EMPHYSEMA, Pulmonary FIBROSIS, Pulmonary EDEMA and PNEUMONIA (infiltration)
When can the DLCO be LOW in the ABSENCE of LUNG DISEASE?
If there is something wrong with the VASCULATURE or BLOOD (ANEMIA, PULMONARY HTN)
When can the DLCO be HIGHER than NORMAL?
ASTHMA (increased blood volume and inflammation), Pulmonary HEMORRHAGE (faster uptake by RBC’s in the airspaces)
How much does the DLCO have to be REDUCED by in order to result in SYMPTOMS of DYSPNEA on EXERTION and potential need for supplemental OXYGEN?
DLCO
Why should PULSE OXIMETRY NOT be used in patients with FIRE/SMOKE or CO INHALATION?
BECAUSE the Pulse Oximeter CANNOT distinguish between OXYhemoglobin (O2-Hb complex) and CARBOXYhemoglobin (CO-Hb complex)
When a patient with suspected DECREASE in Partial Pressure of Oxygen (PO2) due to ALTITUDE SICKNESS or in a patient with HYPOventilation (increasing CO2), what MUST be done to get an ACCURATE measure of patient OXYGENATION (oxygen saturation)?
Arterial Blood Gas (ABG), CANNOT use Pulse Oximetry
An imaging test that is BEST for quickly assessing the DISTRIBUTION and PATTERN of PARENCHYMAL LUNG DISEASE as well as assessing short-term RESPONSE to TREATMENT (as in pneumonia, pneumothorax or CHF) is?
CXR
Where would the DISTRIBUTION of LUNG OPACITIES be demonstrated on a CXR in diseases such as SARCOIDOSIS, SILICOSIS, CYSTIC FIBROSIS, LANGERHANS CELL HISTIOCYTOSIS and REACTIVATION TB?
UPPER LUNG LOBES
Where would the DISTRIBUTION of LUNG OPACITIES be demonstrated on a CXR in diseases such as PULMONARY FIBROSIS, CRYPTOGENIC ORGANIZING PNEUMONIA, ASBESTOSIS and HEART FAILURE (CHF)?
LOWER LUNG LOBES
Diagnosis of Idiopathic Pulmonary Fibrosis, distinguishing between PULMONARY LN’s and Vessels (especially in hilar areas), evaluation of LIVER and ADRENAL GLANDS for METASTASES, identifying vascular abnormalities such as DISSECTION or THROMBOSIS and evaluating for suspected PE, is best made with this IMAGING MODALITY?
CT-scan (CT-angiography for PE)
Cancer cells have a HIGHER rate of glycolysis (however so are TB, FUNGAL diseases, Infections, Sarcoidosis and other Inflammatory conditions - FALSE POSITIVES) compared to non-neoplastic cells and can be detected EXCEPT for when they are
PET-CT
Although suggested on PET-CT scans, BEFORE deciding on SURGERY CANDIDACY for a LUNG or other CANCER, a POSSIBLE DISTANT METASTATIC FOCUS needs to be evaluated how?
BIOPSY
What IMAGING MODALITY is best for RIB Fractures, Pneumothorax, Pleural Effusion, HF, Pneumonia, Device/Line/Tube placement, Follow-Up or a recognized disorder?
CXR
What IMAGING MODALITY is best for Diffuse Parenchymal Lung Disease, Bronchiolitis, Bronchiectasis, Lung Masses, Lymphadenopathy, Lung Nodules, PE and Guidance for Fine Needle Aspiration Biopsy?
CT-scan
What IMAGING MODALITY is best for LUNG CANCER STAGING and DETAILED evaluation of a MASS/NODULE?
PET-CT
What is an effective method for sampling CENTRAL airway lesions, MEDIASTINAL LN’s and parenchymal MASSES?
Bronchoscopy
What Diagnostic Imaging modality can be used for lung cancer staging that is COMPARABLE to MEDIASTINOSCOPY?
Endobronchial Ultrasound (EBUS)
What does it mean when a BRONCHOALVEOLAR LAVAGE is performed and 95% of the cells are alveolar macrophages?
NORMAL LAVAGE
What does it mean when a BRONCHOALVEOLAR LAVAGE is performed and there is LEUKOCYTOSIS, NEUTROPHILIA or EOSINOPHILIA?
Infection (can further characterize by Bronchoscopy w/biopsy)
What are the THERAPEUTIC ROLES of Bronchoscopy?
Mucus PLUG Clearance, Foreign Body REMOVAL, DEBULKING central tumors, AIRWAY DILATION and STENT placement
Airway inflammation related to allergies, increased airway responsiveness with EPISODIC COUGH (productive of THICK SPUTUM), CHEST TIGHTNESS, SOB and WHEEZING?
ASTHMA
When patients with this disease are EXPOSED to an ALLERGEN, they develop an EARLY RESPONSE (15-30 minutes AFTER EXPOSURE) that resolves in 1-2 HOURS and 50% of these patients will also develop a LATE RESPONSE (3-8 HOURS AFTER EXPOSURE)?
ASTHMA
What can uncontrolled inflammation and repeat exacerbations in ASTHMA lead to?
AIRWAY REMODELING (structural airway changes)
The majority of ASTHMA patients have what underlying triggers for the disease?
Allergies (demonstrated by skin testing)
What occurs over time in the lung function of asthmatic patients?
It declines over time
Biopsy of an affected airway with this disease demonstrates eosinophils, mast cells, lymphocytes and neutrophils with sub-epithelial fibrosis, mucus gland hyperplasia and increased smooth muscle mass in the airways?
ASTHMA
Increased sub-epithelial fibrosis, increased smooth muscle mass and mucus gland hyperplasia are together signs of what?
Airway REMODELING in ASTHMA
A patient with EPISODIC cough, productive of thick sputum, without fever, usually late at night or in the early morning, triggered by viral URI’s, COLD air, STRESS and exercise besides allergies likely has?
ASTHMA
What can OSA, GERD, OBESITY, and Vocal Cord Dysfunction do to Asthma?
Worsen it
What does SPIROMETRY demonstrate in ASTHMA?
Airway Obstruction (LOW FEV1/FVC) with REVERSIBILITY (>12% improvement in FEV1 with bronchodilator)
If suspecting ASTHMA in a patient with NORMAL SPIROMETRY, what should be done NEXT?
Bronchial CHALLENGE test (HIGH SENSITIVITY)
How should you test an ASTHMA patient for allergies?
SKIN testing or if not available, RAST testing (IgE)
In a patient with ASTHMA, when during the day is their highest LUNG function and when is the lowest (diurnal)?
Highest lung function is in the mid-afternoon and lowest is in the MORNING
An occupational ASTHMA (cough, dyspnea, chest tightness) disorder that occurs MINUTES to HOURS after a SINGLE accidental EXPOSURE to high levels of irritant vapors, gases or fumes (chlorine gas, bleach, ammonia) leading to airway injury with PERSISTENT inflammation, dysfunction and hyperresponsiveness?
Reactive Airway Dysfunction Syndrome (RADS) - positive bronchial challenge test but may or may not have obstruction demonstrated on spirometry
Do patients with Reactive Airway Dysfunction Syndrome (RADS) have a history of ASTHMA or allergic sensitization to the offending irritant PRIOR to the accidental exposure?
NO!!
What can happen to ASTHMA control in a patient who gets a VIRAL URI (rhinovirus, RSV, influenza)?
Loss of control
What should a patient with ASTHMA with a MILD exacerbation due to a VIRAL URI?
Increase FREQUENCY of inhaled bronchodilator, START inhaled CORTICOSTEROIDS or ADDING a LONG-ACTING INHALED β-2 AGONIST BRONCHODILATOR
What should a patient with ASTHMA with a SEVERE exacerbation due to a VIRAL URI?
SYSTEMIC CORTICOSTEROIDS (5-7 DAYS)
After a VIRAL URI, how long does the exacerbated airway hyperresponsiveness last?
4-6 WEEKS
What is DIFFERENT about “COUGH-VARIANT” ASTHMA?
The cough is DRY
An older patient who smokes presents with COUGH and some asthma type symptoms, SPIROMETRY shows
Likely COPD
ABRUPT onset of MONOPHONIC WHEEZE, in younger patients?
Vocal Cord Dysfunction
A patient presents with DYSPNEA and a WHEEZE, CRACKLES on auscultation, LIMITED response to asthma therapy, CARDIOMEGALY, EDEMA, ELEVATED BNP (except for in OBSESE patients due to aromatase action), what do they have?
CHF
A cough productive of a LARGE amount of PURULENT sputum, RHONCHI and CRACKLES with WHEEZING and MAY HAVE CLUBBING?
BRONCHIECTASIS
RECURRENT infiltrates on CXR, EOSINOPHILIA, HIGH IgE levels and frequent need for CORTICOSTEROID TREATMENTS?
Allergic Bronchopulmonary Aspergillosis (ABPA)
A cough productive of a LARGE amount of PURULENT sputum, RHONCHI and CRACKLES and PROMINENT CLUBBING, MAY HAVE WHEEZING?
Cystic Fibrosis
LOCALIZED WHEEZING?
Mechanical Obstruction
When a patient has ASTHMA that is difficult to control and has typically more COUGH symptoms than other symptoms, what should be considered?
GERD
Would patients with GERD that is not symptomatic and ASTHMA benefit from GERD treatment as far as ASTHMA treatment is concerned?
NO!!
A patient who has difficulty ACHIEVING control of their ASTHMA with usual therapy or who has FREQUENT EXACERBATIONS requiring SYSTEMIC CORTICOSTEROIDS should be tested with a CXR for what?
Allergic Bronchopulmonary Aspergillosis - ABPA - (recurrent pulmonary infiltrates or bronchiectasis on CXR)
The UBIQUITOUS fungus that colonizes the ABNORMAL AIRWAYS in patients with ASTHMA or CYSTIC FIBROSIS with development of immune responses that cause pulmonary INFLAMMATION, BRONCHIECTASIS and FIBROSIS?
Aspergillus Fumigatus
Diagnosing this disease requires an elevated serum IgE (total and specific for this particular pathogen), POSITIVE SKIN test for the pathogen and EOSINOPHILIA?
Allergic Bronchopulmonary Aspergillosis (ABPA) - Aspergillus Fumigatus
CT scan shows MUCUS occlusion of the PROXIMAL airways with atelectasis?
BRONCHIECTASIS
How is Allergic Bronchopulmonary Aspergillosis treated?
SYSTEMIC corticosteroids + INHALED corticosteroids WITH bronchodilator RESCUE therapy with TAPER of SYSTEMIC corticosteroids once disease is under control
What can happen if Allergic Bronchopulmonary Aspergillosis is left untreated or POORLY controlled?
Progressive PULMONARY FIBROSIS (restrictive disease - with reduced DLCO) that leads to LOSS of lung function
A patient with ASTHMA breathing COLD, DRY air during INTENSE EXERCISE can cause what?
Exercise-Induced Bronchospasm (EIB) - bronchial obstruction that PEAKS 5-10 MINUTES after CESSATION of exercise and RESOLVES within 30 minutes
When are the SYMPTOMS of Exercise-Induced Bronchospasm (EIB) at their worst?
Immediately following CESSATION of EXERCISE
How are patients with Exercise-Induced Bronchospasm (EIB) prophylactically treated so that they CAN exercise without SYMPTOMS?
They are given a SHORT-ACTING INHALED β-2 AGONIST 15 MINUTES BEFORE exercise which lasts for ~3 HOURS
Gradual WARM-UP before INTENSE exercise, using a MASK over the NOSE & MOUTH during COLD weather and AVOIDING HIGH-INTENSITY INTERMITTENT exercise are non-pharmacological measures to prevent what?
Exercise-Induced Bronchospasm (EIB)
What should be suspected when a patient with ASTHMA presents with an ABRUPT-ONSET of an episode with LOUDER WHEEZING on INSPIRATION (stridor) and ABRUPT TERMINATION?
Vocal Cord Dysfunction (monophonic wheezing, loudest over the neck)
Monophonic wheezing, loudest over the neck?
Vocal Cord Dysfunction (VCD)
Polyphonic Wheezing, loudest over the chest?
ASTHMA
How can you diagnose vocal cord dysfunction?
Laryngoscopy (shows vocal cords coming TOGETHER - adduction - when the patient is trying to breath - they are SUPPOSED to move apart)
How is Vocal Cord Dysfunction treated?
Patient EDUCATION, BEHAVIOR modification and SPEECH therapy
How are ACUTE attacks of Vocal Cord Dysfunction treated?
Inhaled Helium-Oxygen mixture and/or CPAP (Continuous Positive Airway Pressure)
What is the SAMTER TRIAD in those patients who have ASPIRIN-SENSITIVE ASTHMA?
SEVERE asthma, ASPIRIN sensitivity and NASAL POLYPS
How OFTEN does a patient with “OPTIMAL” asthma control use their inhaler?
What types of ASTHMA medications are the following: INHALED SHORT-ACTING β-2 AGONISTS, SHORT-ACTING ANTICHOLINERGICS?
Asthma RELIEVERS (used INTERMITTENTLY as needed)
What types of ASTHMA medications are the following: INHALED CORTICOSTEROIDS, LEUKOTRIENE-modifying drugs, ANTI-IgE therapy (anti-inflammatories); INHALED LONG-ACTING β-2 AGONISTS, SUSTAINED-RELEASE THEOPHYLLINE (methylxanthine - a bronchodilator)?
Asthma CONTROLLERS (used on a REGULAR BASIS)
What are the TWO (2) main CLASSIFICATIONS of ASTHMA?
Intermittent and Persistent
What MODE of drug administration is preferred for ASTHMA to achieve the HIGHEST CONCENTRATION and MINIMIZE SYSTEMIC side effects?
INHALED (pressurized Metered Dose Inhalers - MDI’s OR Dry Powder Inhalers - DPI’s - require fast inhalation of drug)
What is the function of a SPACER when using Metered Dose Inhalers (MDI’s)?
Provides better coordination of inspiration and activation of the MDI (the device containing the aerosolized drug)
What should be evaluated BEFORE starting or ADJUSTING INHALED asthma medications?
Proper INHALER TECHNIQUE (whether MDI - metered dose inhaler with spacer or DPI - dry powder inhaler)
What MEDICATIONS should ALL ASTHMA patients have with them at ALL times?
INHALED SHORT-ACTING β-2 AGONISTS (most effective bronchodilators available - prevent exercise/cold-induced asthma and relieve bronchoconstriction caused by exposure to allergens)
If asthma symptoms are NOT adequately-controlled by allergen avoidance and OCCASIONAL use of INHALED SHORT-ACTING β-2 AGONISTS, what other medication is given?
INHALED LONG-ACTING β-2 AGONISTS (salmeterol/formoterol) are ADDED to INHALED CORTICOSTEROIDS - rapid onset, long duration (12-HOURS)
Is it proper to use INHALED LONG-ACTING β-2 AGONISTS as single-agent therapies in ASTHMA?
NO!! (because they have NO anti-INFLAMMATORY properties) - so they have to be ADDED AFTER inhaled corticosteroids achieve optimal control
What is IPRATROPIUM BROMIDE?
An INHALED, SHORT-ACTING ANTICHOLINERGIC drug (reliever) used in ASTHMA patients EITHER to ENHANCE the bronchodilator effect of INHALED SHORT-ACTING β-2 AGONISTS OR as a RESCUE INHALER in patients with EXCESSIVE SENSITIVITY to β-2 AGONISTS
What is TIOTROPIUM BROMIDE?
An INHALED LONG-ACTING ANTICHOLINERGIC DRUG (controller) that can be ADDED to INHALED CORTICOSTEROIDS INSTEAD of an INHALED LONG-ACTING β-2 AGONIST (salmeterol/formetorol)
What is ALBUTEROL?
An INHALED SHORT-ACTING β-2 AGONIST (reliever)
What are BECLOMETHASONE, FLUTICASONE, MOMETASONE, CICLESONIDE, BUDESONIDE, TRIAMCINOLONE?
INHALED CORTICOSTEROIDS (controllers) used in ASTHMA therapy
What are the MAINSTAY CONTROLLER therapy for ASTHMA?
INHALED CORTICOSTEROIDS
What are the TWO VERY important functions of INHALED CORTICOSTEROIDS?
BLUNT the LATE-PHASE inflammatory response to ALLERGENS in asthma and ENHANCE the EFFECTIVENESS of β-2 AGONISTS
REGULAR used of these medications REDUCE asthma exacerbations, hospitalizations and asthma-related mortality?
INHALED CORTICOSTEROIDS (controllers)
What are the side effects of INHALED CORTICOSTEROIDS?
Cough, Hoarseness and Oral THRUSH (reduced by using inhalational aids - MDI’s - rinsing mouth after each use and using the LOWEST effective dose)
What are side effects that can be seen PARTICULARLY in the ELDERLY with REGULAR use of HIGH-DOSE INHALED CORTICOSTEROIDS?
SYSTEMIC side-effects: weight gain, adrenal gland suppression, osteopenia, skin thinning, glaucoma and cataracts - need to evaluate periodically and STEP-DOWN therapy
These ASTHMA drugs are also controllers and are used PRIMARILY as ADD-ON or ALTERNATIVE therapy to CORTICOSTEROIDS or β-2 AGONISTS and most appropriate for patients with MILD, PERSISTENT asthma who are INTOLERANT of INHALED CORTICOSTEROIDS or have an ASPIRIN SENSITIVITY?
Leukotriene-Modifying DRUGS (montelukast, zafirlukast, zileuton)
What ASTHMA drugs have the side-effects of AGITATION, ANXIETY, HALLUCINATIONS, DEPRESSION, SUICIDAL IDEATIONS and LIVER TOXICITY?
Leukotriene-Modifying DRUGS
Use of this OLD asthma drug requires STRICT DRUG LEVEL monitoring, PREVENTION of drug-drug interactions (with fluoroquinolones) and TOXICITY (TREMOR, HA, NAUSEA, PALPITATIONS, CARDIAC ARRHYTHMIAS, SEIZURES)?
Theophylline (methylxanthine - a bronchodilator)
This ASTHMA drug is used as a SECOND LINE alternative to INHALED CORTICOSTEROIDS for chronic asthma management and should NOT be used in ACUTE asthma exacerbations?
Theophylline (methylxanthine - a bronchodilator)
In patients with SEVERE asthma who have EVIDENCE of ALLERGIES, have ELEVATED IgE levels and remain SYMPTOMATIC in spite of treatment with INHALED corticosteroids and long-acting β-2 agonists, can be treated with what?
OMAlizumab (an IgE blocker)
What is the MOST serious risk with the use of the IgE-blocking asthma drug OMALIZUMAB?
Anaphylactoid Reactions
An asthma patient receiving this anti-IgE DRUG must be monitored for at LEAST 2 HOURS for their first 3 doses and for 1 HOUR after subsequent doses?
OMAlizumab
WHEN is the ONLY time INHALED, LONG-ACTING β-2 AGONISTS be added to asthma therapy?
ONLY AFTER INHALED-CORTICOSTEROID therapy has been optimized
What CLASS/SEVERITY of ASTHMA does a patient have if they have SYMPTOMS ≤2 days/week, awaken at night with symptoms ≤2 x/month, use SHORT-ACTING β-2 AGONIST for SYMPTOM CONTROL (not Exercise-Induced Bronchospasm prevention) ≤2 days/week, have NO interference with normal activity and have a NORMAL FEV1 between exacerbations, NORMAL FEV1/FVC and an FEV1 >80% of predicted and have EXACERBATIONS 0-1/YEAR?
INTERMITTENT (not PERSISTENT - which is further subdivided into mild/moderate/severe))
What CLASS/SEVERITY of ASTHMA does a patient have if they have SYMPTOMS ≥2 days/week but NOT DAILY, awaken with symptoms at night 3-4 x/month, use SHORT-ACTING β-2 AGONIST for SYMPTOM CONTROL (not Exercise-Induced Bronchospasm prevention) >2 days/week but NOT >1 x/day, have MINOR limitations to normal activity, NORMAL FEV1/FVC and an FEV1 >80% of predicted and have EXACERBATIONS >2/YEAR?
PERSISTENT/MILD
What CLASS/SEVERITY of ASTHMA does a patient have if they have SYMPTOMS DAILY, awaken with symptoms at night >1 x/week but NOT NIGHTLY, use SHORT-ACTING β-2 AGONIST for SYMPTOM CONTROL (not Exercise-Induced Bronchospasm prevention) DAILY, have SOME limitations to normal activity, FEV1/FVC REDUCED by 5% and an FEV1 >60% BUT 2/YEAR?
PERSISTENT/MODERATE
What CLASS/SEVERITY of ASTHMA does a patient have if they have SYMPTOMS THROUGHOUT THE DAY, awaken with symptoms at night NIGHTLY, use SHORT-ACTING β-2 AGONIST for SYMPTOM CONTROL (not Exercise-Induced Bronchospasm prevention) SEVERAL TIMES/DAY, have EXTREME limitations to normal activity, FEV1/FVC REDUCED by >5% and an FEV1 2/YEAR?
PERSISTENT/SEVERE
What should be considered in ALL patients with PERSISTENT ALLERGIC asthma?
Subcutaneous ALLERGEN IMMUNOTHERAPY
BEFORE initiating ANY therapy for a patient with ANY CLASS/SEVERITY of ASTHMA, what should be ADDRESSED FIRST?
Education, Environmental control, Management of co-morbidities
What is the preferred treatment for patients who have INTERMITTENT ASTHMA?
SHORT-ACTING β-2 AGONISTS PRN
What is the preferred INITIAL treatment for patients who have PERSISTENT asthma?
LOW-DOSE INHALED CORTICOSTEROIDS (if need more control, ONLY THEN sequentially add LONG-ACTING β-2 AGONISTS or MEDIUM-DOSE INHALED CORTICOSTEROIDS, or HIGH-DOSE INHALED CORTICOSTEROIDS or ORAL CORTICOSTEROIDS, etc.
What are the ALTERNATIVES for INHALED CORTICOSTEROIDS?
Cromolyn (anti-inflammatory, mast-cell destabilizer and anti-histamine), LEUKOTRIENE RECEPTOR ANTAGONISTS (zafirlukast, montelukast), Theophylline (methylxanthine - a bronchodilator)
Can LONG-ACTING β-2 AGONISTS be used as ALTERNATIVES to INHALED CORTICOSTEROIDS?
NO!!! (Cannot be used as single-agents)
What is the STRONGEST REGIMEN for SEVERE ASTHMA CONTROL as an OUTPATIENT?
HIGH-DOSE INHALED CORTICOSTEROIDS + LONG-ACTING β-2 AGONISTS + ORAL (systemic) CORTICOSTEROIDS + OMALIZUMAB
What should be done for ALL PERSISTENT asthma patients who begin to require more and more medications for control?
CONSULTATION by ASTHMA specialist
How many SHORT-ACTING β-2 AGONIST treatments should be given prior to considering a course of ORAL corticosteroids?
3 TREATMENTS, 20-MINUTES APART
In a patient with ASTHMA, what indicates INADEQUATE CONTROL and need for STEPPING UP treatment?
USE of SHORT-ACTING β-2 AGONISTS >2 days/week for SYMPTOM relief NOT prevention of Exercise-Induced Bronchospasm
What would you advise a patient who called and complained of an acute ASTHMA exacerbation?
Increase SHORT-ACTING β-2 AGONISTS and possibly a short-course of SYSTEMIC CORTICOSTEROIDS
If SPIROMETRY is not available, what other test can be done in a clinical setting for an ACUTE asthma exacerbation?
Peak Expiratory Flow Rate (PEFR)
What should be the OUTPATIENT treatment for a patient who scores 40%-69% (moderate exacerbation) or
SHORT-ACTING β-2 AGONISTS and ORAL (SYSTEMIC) CORTICOSTEROIDS (can add inhaled IPRATROPIUM - short-acting anticholinergic drug used to enhance bronchodilator effect or as a rescue med)
How should CORTICOSTEROIDS be administered in SEVERE ASTHMA ATTACKS?
IV
When can a patient with a MILD or SEVERE asthma exacerbation be discharged from the hospital rather than be admitted?
IF Peak Expiratory Flow Rate (PEFR) is >70% 1 HOUR POST treatment and SUSTAINED for AN HOUR (checked again)
Patients with asthma that DO NOT ADHERE to inhaled medications, continue SMOKING, have co-morbidities and severe allergies or chronic sinusitis usually require what type of ASTHMA therapy?
CHRONIC ORAL (SYSTEMIC) CORTCOSTEROID therapy (needs to be addressed with education, close follow-up and an asthma specialist)
What is the ONLY testing MODALITY approved for diagnosing ASTHMA in PREGNANCY?
SPIROMETRY
Low birth WEIGHT, PREMATURE labor, PREECLAMPSIA and increased INFANT MORTALITY can all be seen if this respiratory disease is not well CONTROLLED during pregnancy?
ASTHMA
As INHALED corticosteroids are the MAINSTAY medications for ASTHMA therapy, which is the SAFEST to use during PREGNANCY?
BUDESONIDE (HOWEVER, if a pregnant patient is ALREADY on another inhaled corticosteroid, they can REMAIN on that as NO studies show adverse effects)
What rescue INHALERS should be used by PREGNANT patients for ASTHMA?
SHORT-ACTING β-2 AGONISTS
What is the RECOMMENDED second-line therapy for pregnant patients with ASTHMA ALREADY on INHALED CORTICOSTEROIDS?
LONG-ACTING β-2 AGONISTS
How is an ACUTE, SEVERE ASTHMA attack treated in ANY patient whether PREGNANT or NOT?
SHORT-COURSE of ORAL (SYSTEMIC) CORTICOSTEROIDS
A SLOWLY-PROGRESSIVE INFLAMMATORY disease of the AIRWAYS and LUNG PARENCHYMA characterized by a gradual LOSS of LUNG FUNCTION and increasing OBSTRUCTION to EXPIRATORY airflow?
Chronic Obstructive Pulmonary Disease (COPD)
INFLAMMATORY NARROWING of the small airways (BRONCHOLITIS) with eventual FIBROSIS and proteolytic digestion of supportive lung tissue adjacent to these airways (EMPHYSEMA) causing loss of elasticity which keeps the airways open are seen in lung disease?
COPD
What types of HYPERINFLATION of the lungs are seen in EMPHYSEMA (COPD)?
STATIC (more air STAYS in the lungs after exhalation due to decreased elasticity of the lung) and DYNAMIC (a NEWly inhaled breath begins BEFORE a full EXHALATION has been completed therefore TRAPPING air in the lung with EACH breath)
When is HYPERINFLATION of the lung worsened in a patient with EMPHYSEMA (COPD)?
During COPD EXACERBATION or EXERTION
The VOLUME of GAS INHALED or EXHALED from a person’s LUNGS per MINUTE is known as?
MINUTE ventilation
In this LUNG disease, during a disease exacerbation or during exertion, the Tidal Volume and Respiratory Rate INCREASE, the available time for EXHALATION becomes INSUFFICIENT beginning a vicious CYCLE of AIR TRAPPING and HYPERINFLATION?
EMPHYSEMA (COPD)
This PROCESS FLATTENS and REDUCES the EFFECTIVENESS of the DIAPHRAGM making the use of the ACCESSORY MUSCLES of BREATHING more crucial while also MARKEDLY INCREASING the WORK of BREATHING as CHEST WALL COMPLIANCE DECREASES?
HYPERINFLATION of the lungs (COPD - EMPHYSEMA)
What happens to the DLCO in EMPHYSEMA?
It DECREASES and correlates with the degree of disease
EXPOSURE to ANY TOBACCO smoke, DUSTS and CHEMICALS, POLLUTION as well as GENETIC factors (α-1 anti-trypsin deficiency) are all RISK factors for this LUNG disease?
COPD
Pulmonary HTN, Cor Pulmonale, PNA, PTX, Bronchiectasis, Atelectasis, Lung Cancer are all complications of this LUNG disease?
COPD
What LUNG VOLUME is increased in patients with COPD due to HYPERINFLATION and air trapping?
Residual Volume (RV)
SMOKING, h/o TB, h/o CHRONIC ASTHMA, AIR POLLUTION (burning of wood, charcoal, coal, particulate matter, NO2, CO), OCCUPATIONAL EXPOSURES (crop farming dusts - grain dust, animal farming dusts - organic, ammonia and hydrogen sulfide dusts, mining, concrete manufacturing, construction, iron and steel, plastics, textile, rubber and leather industries, automotive and automotive repair) are RISK factors associated with what LUNG disease?
COPD
How are SMOKING and COPD related?
DOSE related
How are smoking PACK-YEARS calculated?
PACKS smoked/day X YEARS smoked (where one pack is 20 cigarettes and 10 cigarettes is 1/2 pack, etc. ROUNDED UP)
What is the SINGLE most EFFECTIVE way to PREVENT COPD, SLOW PROGRESSION of established disease and IMPROVE SURVIVAL?
SMOKING CESSATION
How are ASTHMA and COPD related?
CHRONIC, POORLY-CONTROLLED ASTHMA ca cause a degree of FIXED airflow OBSTRUCTION similar to COPD
How are TB and COPD related?
TB can cause a degree of LUNG destruction and therefore EXPIRATORY airflow OBSTRUCTION similar to that seen in COPD
PROLONGED inhalation of SMOKE caused by BIOMASS FUELS (wood, charcoal, vegetable matter, animal dung) can cause what LUNG disease?
COPD
The DEFICIENCY of this circulating INHIBITOR of SERINE PROTEASE can cause COPD in patients ≤45, in NON-SMOKERS and in patients with OTHER underlying chronic lung or LIVER disease?
α-1 anti-trypsin deficiency
WEIGHT LOSS, MUSCLE WASTING, WEAKNESS as a result of deconditioning and malnutrition, are EXTRAPULMONARY manifestations of this LUNG disease?
COPD (result in decreased functional status and survival)
What is the FEV1/FVC value that is DIAGNOSTIC for airway OBSTRUCTION (such as seen in asthma and COPD)?
What should EARLY INTERVENTIONS focus on in the TREATMENT of COPD?
PREVENTING and AGGRESSIVELY treating co-morbidities and complications of COPD
What should be suspected in a patient that presents with dyspnea, chronic productive (sputum) cough, intermittent wheezing, DECREASED EXERCISE TOLERANCE, h/o SIGNIFICANT SMOKING or other INHALATIONAL EXPOSURES?
COPD (dyspnea, chronic productive cough, intermittent wheezing - are also seen in patients with ASTHMA)
Hyperresonance and Distant breath sounds are noted in more ADVANCED stages of this LUNG disease?
COPD
How should DIAGNOSTIC SPIROMETRY testing be performed for a patient SUSPECTED of having COPD?
AFTER the administration of an INHALED BRONCHODILATOR because it will IMPROVE the ACCURACY of the study results
How CLOSE measurements made are to a “TRUE” (previously established and recognized) VALUE is called what?
ACCURACY (how close to the BULL’s eye on a target you are)
How CLOSE measurements made are to EACH OTHER is called what?
PRECISION (your grouping on a target)
Post-bronchodilator FEV1/FVC (GOLD - scale of 1 to 4), Dyspnea scale measuring clinical symptoms and frequency of exacerbations (MMRC) and Factors such as BMI (the lower the worst as in ≤21), Obstruction, Dyspnea and Exercise (BODE index) are used for what?
Classification of COPD severity (risk for hospitalization, long-term prognosis and assessment for interventions such as surgery or transplantation)
What is the 4-year survival prediction for a patient with COPD and a BODE index score of ≥7 (BMI, Obstruction, Dyspnea, Exercise)?
≤20% (0-10)
Flattening of the diaphragm on CXR indicates what about a patient with COPD?
CHRONIC and worsening disease
What can a CT of the chest demonstrate about a patient with COPD - EMPHYSEMA?
Destruction of the pulmonary parenchyma
- An FEV1 ≥80% of predicted is a GOLD scale of COPD severity of what?
- An FEV1
- GOLD-1 (mild)
- GOLD-2 (moderate)
- GOLD-3 (severe)
- GOLD-4 (very severe)
What TYPE of medications are the MAINSTAY of COPD management?
INHALED
What should always be evaluated BEFORE considering an adjustment of therapy in a patient with COPD?
INHALER technique used by patient
What should be done for patients diagnosed with COPD that are
Refer to a PULMONARY SPECIALIST
What medication has been shown to reduce the progressive decline in LUNG function in COPD?
NONE
For MILD COPD (FEV1/FVC ≥60% of predicted), for “breakthrough symptoms” and for exacerbations, what is the FIRST-LINE treatment?
SHORT-ACTING β-2 AGONISTS or ANTICHOLINERGIC meds (IPRATROPIUM) either alone or in combination, used on a PRN basis
In patients with COPD, WHEN should a DAILY BRONCHODILATOR treatment be used?
When they are SYMPTOMATIC AND their FEV1/FVC
What medications CAN be used for MONOTHERAPY when treating COPD in a symptomatic patient with FEV1/FVC
EITHER a LONG-ACTING β-2 AGONIST (cannot be used as monotherapy in asthma and must be used as co-therapy with inhaled corticosteroids) or a LONG-ACTING ANTICHOLINERGIC
Salmeterol, Folmoterol, Bambuterol, Indacaterol? Adverse effects?
LONG-ACTING β-2 AGONISTS
Tremors, Tachycardia, Overdose: FATAL
Tiotropium?
LONG-ACTING ANTICHOLINERGIC
After switching classes of MONOTHRAPY drugs used for the treatment of COPD (LONG-ACTING β-2 AGONISTS or ANTICHOLINERGICS) and pt still remains symptomatic or not adequately controlled, what is the NEXT STEP?
COMBINATION therapy (β-2 AGONIST + ANTICHOLINERGIC or INHALED CORTICOSTEROID with EITHER a β-2 AGONIST or ANTICHOLINERGIC or ALL THREE COMBINED if advanced, poorly-controlled disease)
Which INHALED DRUG DELIVERY DEVICES are easiest to use in the elderly with COPD?
NEBULIZERS
Albuterol, Fenoterol, Levabuterol, Metaprotenerol, Pirbuterol, Terbutaline? Adverse effects?
INHALED, SHORT-ACTING β-2 AGONISTS
Tremors, Tachycardia
Ipratropium? Adverse effects?
INHALED, SHORT-ACTING ANTICHOLINERGIC
Dry mouth, Mydriasis (dilation of pupil), tremors, tachycardia, acute narrow-angle glaucoma
Tiotropium, Aclidinium? Adverse effects?
INHALED, LONG-ACTING ANTICHOLINERGIC
Dry mouth, Mydriasis (dilation of pupil), tremors, tachycardia, acute narrow-angle glaucoma
What is the MOST serious SIDE EFFECT of LONG-ACTING β-2 AGONISTS?
DEATH (can be fatal in an OVERDOSE)
Theophylline, Aminophylline? Adverse effects?
Both LONG and SHORT-ACTING METHYLXANTHINE BRONCHODILATORS
Tachycardia, N/V, Sleep disturbance, Narrow therapeutic index (can be TOXIC - FATAL with seizures and anemia)
What is the MOST serious SIDE EFFECT of SHORT or LONG-ACTING METHYLXANTHINE BRONCHODILATORS?
DEATH (can be fatal with anemia and seizures in an overdose due to its NARROW therapeutic index) - Theophylline, Aminophylline
Roflumilast? Adverse effects?
Oral Phosphodiesterase-4 Inhibitor
Diarrhea, Nausea, Backache, Dizziness, Decreased appetite
This medication is an ORAL agent used to REDUCE the RISK of EXACERBATIONS in patients with SEVERE COPD with CHRONIC BRONCHITIS and h/o exacerbations and SHOULD NOT BE USED with METHYLXANTHINES (Theophylline, Aminophylline) due to potential toxicity?
Roflumilast
These medications act by RELAXING the smooth MUSCLES of the airways resulting in WIDENING of the airways which IMPROVES EMPTYING of the LUNGS during EXHALATION and reduces DYNAMIC HYPERINFLATION?
Bronchodilators (PREFERRED: β-2 AGONISTS, ANTICHOLINERGICS) METHYLXANTHINES can also be used
What is the strongest and longest-lasting RESCUE therapy for ASTHMA or COPD?
COMBINATION of a SHORT-ACTING β-2 AGONIST + IPRATROPIUM - a short-acting anticholinergic)
What is the duration of a typical SHORT-ACTING β-2 AGONIST? SHORT-ACTING ANTICHOLINERGIC?
SHORT-ACTING β-2 AGONIST: 3-6 HOURS
SHORT-ACTING ANTICHOLINERGIC: 4-5 HOURS - slower onset of action
What is the duration of a typical LONG-ACTING β-2 AGONIST? LONG-ACTING ANTICHOLINERGIC?
LONG-ACTING β-2 AGONIST: 12 HOURS
LONG-ACTING ANTICHOLINERGIC: 24 HOURS
Are INHALED CORTICOSTEROIDS preferred MONOTHERAPY for COPD?
NO!! (for asthma, yes)
Is COMBINATION treatment with INHALED CORTICOSTEROIDS recommended for COPD patients?
NO!! (for asthma, yes) - in COPD, this can result in PNA, especially in oder patients - however, sometimes TRIPLE combined therapy with inhaled corticosteroids is used
In patients with SEVERE EXACERBATIONS of COPD warranting HOSPITALIZATION, what medication is used?
IV CORTICOSTEROIDS (unlike oral corticosteroids used for acute exacerbations not requiring hospitalization)
What two medication types are RESERVED for COPD patients that continue to do poorly EVEN after combined therapy with long-acting bronchodilators ± inhaled corticosteroids?
Methylxanthines (theophylline, aminophylline) or phosphodiesterase-4 inhibitor (roflumiLAST)
What is the duration of METHYLXANTHINES (Theophylline, Aminophylline)?
24-HOURS (used only as a last resort)
This COPD drug is to be used ONLY as an ADD-ON in SEVERE COPD associated with CHRONIC BRONCHITIS patients with FREQUENT exacerbations and a h/o exacerbations. It is NOT to be used for EMPHYSEMA-COPD or as a rescue medication?
Phosphodiesterase-4 Inhibitor roflumiLAST (NOT to be used in patients with liver impairment or in combination with STRONG cytochrome P-450 inducers (rifampin, carbamazepine, phenytoin, phenobarbital)
How is α-1 anti-trypsin deficiency - related disease (COPD-emphysema) treated?
With α-1 anti-trypsin REPLACEMENT therapy
What is the recommendation for the use of antitussive agents and pulmonary vasodilators (phosphodiesterase-5 inhibitors - sildenafil) in COPD patients?
NOT RECOMMENDED - no benefit (cough serves a very important protective role)
When a patient with COPD presents with increased DYSPNEA associated with increased SPUTUM VOLUME and sputum PURULENCE, what should be suspected and treated?
INFECTION (bacterial OR viral - because thought to be colonized with bacteria anyway)
When should ANTIBIOTICS be used to treat a patient with a COPD exacerbation?
When INFECTION is suspected AND when they require MECHANICAL VENTILATION (invasive or not)
What are the most common pathogens responsible for INFECTION-related COPD EXACERBATIONS? What is the recommended antibiotic treatment?
H. influenzae, S. pneumoniae, Moraxella catarrhalis
FLUOROQUINOLONES (levofloxacin) OR 3rd gen cephalosporin + macrolide (CEFTRIAXONE + AZITRHOMYCIN)
What vaccinations are recommended in ALL COPD patients?
INFLUENZA and PNEUMOCOCCAL vaccines
What are the ONLY two interventions known to REDUCE COPD risk and POSITIVELY affect DECLINE in pulmonary FUNCTION?
SMOKING CESSATION and OXYGEN THERAPY
What should be considered for ALL SYMPTOMATIC patients with an FEV1
Pulmonary Rehabilitation (education, nutritional counseling, exercise - ≥30 min 3x/week for 6-8 weeks, assessment and follow-up to reinforce behaviors and techniques)
What is considered RESTING HYPOXEMIA and how is it treated?
PO2 ≤55 mm Hg OR an arterial O2 saturation ≤88%, treated with OXYGEN THERAPY (at rest, while sleeping and during exercise)
How long should patients with RESTING HYPOXEMIA be treated with OXYGEN THERAPY throughout the day?
≥15 HOURS/day (IMPROVES SURVIVAL)
In hospitalized patients with COPD, receiving OXYGEN therapy to raise their PO2 levels ≥60 mm Hg and OXYGEN SATURATION ≥90%, what should be MONITORED every 30-60 minutes throughout the therapy and WHY?
To check for CO2 RETENTION and PREVENTION of acidosis
What can be used in a HOSPITALIZED patient with an ACUTE EXACERBATION or INFECTION with SEVERE COPD that is spontaneously breathing to improve their breathing PATTERN, reduce DYSPNEA, improve OXYGENATION and AVOID INTUBATION?
Non-invasive Positive Pressure Ventilation - NPAP - (BiPAP or CPAP), especially while sleeping
In a patient presenting with VERY SEVERE PULMONARY DISEASE and/or LIFE-THREATENING HYPOXIA, PROGRESSIVE HYPERCAPNIA, SOMNOLENCE or SIGNIFICANTLY AMS, what should be done?
Endotracheal Intubation
Resecting up to 30% of diseased or non-functioning lung parenchyma to reduce hyperinflation and allow remaining lung to function more efficiently is called?
Lung Volume Reduction Surgery (LVRS)
In patients with ADVANCED COPD, FEV1 >20% of predicted, DLCO >20% of predicted with B/L UPPER LOBE EMPHYSEMA who remain symptomatic despite MAXIMAL therapy should be considered for what?
Lung Volume Reduction Surgery (LVRS)
A hospitalized patient with MODERATE-to-SEVERE dyspnea, with use of ACCESSORY muscles and paradoxical abdominal motion OR MODERATE-to-SEVERE acidosis (pH 45 mm Hg) OR RR >25/min should be treated with what?
Non-invasive Positive Airway Pressure (NPAP)
SEVERE ACIDOSIS (pH 60 mm Hg) or RR >35 breaths/min (despite aggressive medical treatment) are an indication for what?
Immediate Endotracheal Intubation
Which procedure, Lung Volume Reduction Surgery or Lung Transplantation (single or double) has been shown to confer an overall survival benefit?
NEITHER (they only improve functional capacity and quality of life)
What is Obliterative Bronchiolitis?
Chronic Lung Allograft Rejection in lung transplant patients
- B/L upper lobe EMPHYSEMA, post-bronchodilator TLC >150% and RV >100% of predicted with MAX FEV1 >20% but ≤45% of predicted, PCO2 ≤60 mm Hg & PO2 ≥45 mm Hg, what’s the next step?
- H/o ACUTE HYPERCAPNIA (PCO2 >50% mm Hg), pulmonary HTN, Cor Pulmonale, FEV1
- Consideration for Lung Volume Reduction Surgery
2. Consideration for Lung TRANSPLANT
Continued smoking, substance addiction (alcohol, tobacco, narcotics - current or active over the past 6 MONTHS), malignancy in the last 2 years, significant chest wall/spinal deformity, poor social support system, untreated psychiatric issues, untreated advanced dysfunction of another organ system are ABSOLUTE contraindications for what?
Lung TRANSPLANT
PO2 ≤55 mm Hg, Oxygen Saturation ≤88%?
HYPOXEMIA (requires OXYGEN therapy)
What is the GREATEST predictor of future COPD exacerbations in a particular patient?
≥2 exacerbations in the PAST YEAR OR an FEV1
Cardiovascular Instability (hypotension, arrhythmia, MI), AMS/uncooperative patient, Viscous or Copious secretions, Recent Facial or Gastro/Esophageal surgery, Craniofacial trauma or burns or Fixed Nasopharyngeal abnormalities are all contraindications to this method of preventing Endotracheal Intubation?
Non-invasive Positive Airway Pressure (NPAP) - BiPAP/CPAP
What medication should be started prophylactically for OLDER patients who have COPD?
PPI’s to prevent GERD-related exacerbations common in this group
How is a CHF exacerbation differentiated from a COPD exacerbation?
BNP (except in morbidly obese pts), CXR, Physical Exam, ECHO
When should an ORAL corticosteroid be added to a patient’s COPD management?
When FEV1 ≤50% of predicted
What is the risk of DEATH correlated in a patient with a COPD exacerbation?
Development of RESPIRATORY ACIDOSIS, co-morbidities and requirement for VENTILATORY support
What should be done when a hospitalized patient with an ACUTE COPD exacerbation no longer needs their SHORT-ACTING β-2 AGONIST more frequently than Q4 HOURS, are clinically stable AND their ABG has been stable for 12-24 HOURS?
Can be DISCHARGED with a FOLLOW-UP visit in 2-4 weeks
Why is EALRY follow-up post discharge from hospital for a COPD exacerbation IMPORTANT?
To REDUCE hospital RE-ADMISSION rates
PO2 60 mHg, pH
IMMEDIATE ICU ADMISSION with ENDOTRACHEAL INTUBATION
DISEASES that affect the TISSUE and SPACE around the ALVEOLI are known as?
Diffuse Parenchymal Lung Disease (DPLD) or Interstitial Lung Disease (ILD)
NON-INFECTIOUS diseases that affect the lung parenchyma (airways, vasculature, pleura, tissue and space around the alveoli) AND that appear DIFFUSE on IMGING studies with main presentation of EXERTIONAL DYSPNEA & FATIGUE and do NOT INCLUDE copd or pulmonary HTN are called?
Diffuse Parenchymal Lung Disease (DPLD) or Interstitial Lung Disease (ILD)
EXERTIONAL DYSPNEA & FATIGUE that eventually leads to symptoms of RIGHT HEART FAILURE - RV hypetrophy (exertional chest pain or syncope and congestion including peripheral edema, ascites, and pleural effusion) and INABILITY to INCREASE CARDIAC OUTPUT (CO) during EXERCISE is caused by what?
Pulmonary HTN (PH)
Why can Pulmonary HTN (PH) present with HOARSENESS?
Because hoarseness is caused by compression of the left recurrent laryngeal nerve by a dilated main pulmonary artery
How does Diffuse Parenchymal Lung Disease (ILD) present?
Progressive, with gradually-worsening cough and SOB ≥3 MONTHS with FAILURE to respond to antibiotic or diuretic therapy (for presumed infectious or cardiogenic edema)
Occupational exposures, Medications, Viral illnesses, Radiation therapy, Family history are all possible risks for this rare, progressive lung disease?
Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)”
Inspiratory Crackles, Wheezing (suggestive of airflow obstruction), cardiac features of Pulmonary HTN and RIGHT heart failure with digital CLUBBING, presence of RA or Systemic Sclerosis are present in this rare, progressive lung disease?
Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)”
Can Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)” occur ACUTELY?
YES!! (Interstitial PNA, Eosinophilic PNA, Hypersensitivity Pneumonitis - hot tub, birds, farmers - Drugs - amiodarone, nitrofurantoin, chemo - Bronchiolitis Obliterans Organizing Pneumonia, Diffuse Alveolar Hemorrhage and Vasculitis, otherwise check for infectious/cardiogenic cause)
What is the GOLD standard IMAGING test for LUNG PARENCHYMA?
High-Resolution CT (especially in symptomatic patients with a NORMAL CXR)
If a High-Resolution CT scan cannot make the diagnosis of Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)” what should be done next?
Open-LUNG Biopsy
Connective Tissue Diseases (RA, polymyositis, systemic sclerosis), Hypersensitivity Pneumonitis (farmer’s lung, hot tub lung, Bird Fancier’s lung), Pneumoconioses (asbesosis, silicosis, coal workers), Drugs (chemo, amiodarone, nitrofurantoin), Smoking (Langerhans cell histiocytosis, bronchiolitis, desquamative interstitial pneumonia), Acute Eosinophilic Pneumonia, Radiation and Toxic Inhalation (cocaine, zinc chloride - “smoke bombs,” ammonia) can all cause this progressive lung disease?
Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)”
CT demonstrating a PATTERN of SEPTAL, RETICULAR, NODULAR, RETICULONODULAR or GROUND-GLASS, the most likely diagnosis also based on DISTRIBUTION of disease is?
Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)”
What imaging “window” on high-resolution CT can further narrow the differential of Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)”?
SOFT-TISSUE window (can better visualize the pleura and mediastinum for lymphadenopathy, effusions, etc.)
What are the IDEAL biopsy sites for LUNG biopsies?
Upper and Lower lobes as well as Normal and Abnormal-appearing areas
What kind of disease is Idiopathic Pulmonary Fibrosis?
An Idiopathic Interstitial Pneumonia
On CT, a pneumonia with PERIPHERAL or BASAL predominant distribution in an older patient with progressive pulmonary symptoms (inspiratory crackles at the bases), biopsy revealing SUB-PLEURAL COLLAGEN deposition and FIBROBLASTIC foci in between NORMAL lung as well as CYSTIC areas forming a HONEYCOMB pattern and Pulmonary HTN late in the disease?
Idiopathic Pulmonary Fibrosis
CT: RETICULAR opacities and HONEYCOMBING with a PERIPHERAL or BASILAR predominance and MINIMAL GROUND-GLASS opacification?
Idiopathic Pulmonary Fibrosis
What is the treatment for Idiopathic Pulmonary Fibrosis?
VERY poor prognosis (3-5 years), treat CO-MORBIDITIES (OSA, GERD, Pulmonary HTN, Obesity, Emphysema) Supportive treatment with Pulmonary REHABILITATION and OXYGEN therapy (if oxygen saturation is
DO CORTICOSTEROIDS HELP in Idiopathic Pulmonary Fibrosis?
NO!!
What is the ONLY intervention shown to IMPROVE SURVIVAL for patients with Idiopathic Pulmonary Fibrosis?
Lung TRANSPLANTATION
CT showing a SEPTAL lung disease PATTERN (short lines extending to the pleura) is commonly seen in?
Lymphatic enlargement from pulmonary edema or cancer
CT showing a RETICULAR lung disease PATTERN (interlacing lines as in a mesh or lattice) is commonly seen in?
Diffuse Parenchymal Lung Disease (DPLD) or “Interstitial Lung Disease (ILD)”
CT showing a NODULAR lung disease PATTERN (spherical
Sarcoidosis
CT showing a RETICULONODULAR lung disease PATTERN (intersection of reticular lines or nodules) is commonly seen in?
Sarcoidosis, Langerhans Cell Histiocytosis and Lymphangitic carcinomatosis
CT showing GROUND-GLASS lung disease PATTERN (hazy opacities that DO NOT obscure underlying vascular markings) is commonly seen in?
Desquamative Interstitial Pneumonia (and in Idiopathic Pulmonary Fibrosis when MINIMAL)
CT showing HONEYCOMB lung disease PATTERN (septal lines adjacent to cystic areas in the periphery of the lung) is commonly seen in?
Idiopathic Pulmonary Fibrosis
What is the DISEASE DISTRIBUTION expected on a CT of a patient with Idiopathic Pulmonary Fibrosis?
BASILAR or PERIPHERAL
What is the DISEASE DISTRIBUTION expected on a CT of a patient with Hypersensitivity Pneumonitis?
UPPER-LOBE
What is the DISEASE DISTRIBUTION expected on a CT of a patient with Eosinophilic PNA and Cryptogenic Organizing PNA?
PERIPHERAL
What is the DISEASE DISTRIBUTION expected on a CT of a patient with Alveolar Proteinosis?
CENTRAL
What is the DISEASE DISTRIBUTION expected on a CT of a patient with Sarcoidosis?
UPPER LOBE & CENTRAL
How is Idiopathic Pulmonary Fibrosis palliated?
OPIOIDS
Connective tissue diseases (systemic sclerosis, RA, polymyositis) can present with what type of lung involvement?
Nonspecific Interstitial PNA
CT with BASILAR disease PATTERN and GROUND-GLASS predominance (not “minimal”) with associated connective tissue disease such as Systemic Sclerosis or RA or Polymyositis, is likely showing?
Nonspecific Interstitial PNA
What is necessary to make the diagnosis of Nonspecific Interstitial PNA?
Lung BIOPSY (a UNIFORM lymphoplasmacytic interstitial infiltration disrupting the normal lung architecture)
How is Nonspecific Interstitial PNA treated besides treating the underlying Connective Tissue Disease (systemic sclerosis, RA, polymyositis)?
Systemic CORTICOSTEROIDS
What are potential causes of Bronchiolitis Obliterans Organizing Pneumonia (BOOP)?
Infections, Collagen vascular diseases, Drugs
What is the IDIOPATHIC form of Bronchiolitis Obliterans Organizing Pneumonia (BOOP)?
Cryptogenic Organizing Pneumonia (COP)
If a patient presents with symptoms suggestive of a community-acquired pneumonia, undergo a couple of antibiotic regimens but 6-8 weeks later still have the disease, what is the diagnosis most likely?
Cryptogenic Organizing Pneumonia (COP)
How long does Cryptogenic Organizing Pneumonia (COP) persist for?
3-6 MONTHS
How is Cryptogenic Organizing Pneumonia (COP) diagnosed?
Lung BIOPSY
How is Cryptogenic Organizing Pneumonia (COP) treated?
Systemic CORTICOSTEROIDS
RAPID-ONSET PNEUMONIA over days-to-weeks with PROGRESSIVE, HYPOXEMIC RESPIRATORY FAILURE with BIOPSY demonstrating DIFFUSE ALVEOLAR DAMAGE with an appearance like ARDS (but without sepsis or inhalational injury)?
Acute Interstitial Pneumonia
How is Acute Interstitial Pneumonia treated?
Systemic CORTICOSTEROIDS and low Tidal Volume ventilation
A pulmonary disease with CT findings of Thin-Walled Cysts that are UPPER-LUNG predominant with NODULES, found in SMOKERS with cough and dyspnea and in more severe disease, Pulmonary Function Tests demonstrate an OBSTRUCTIVE (FEV1
Langerhans Cell Histiocytosis (smoking-related)
How is Langerhans Cell Histiocytosis treated?
SMOKING CESSATION and systemic CORTICOSTEROIDS
Langerhans Cell Histiocytosis, Respiratory Bronchiolitis and Desquamative Interstitial Pneumonia are all caused by what?
SMOKING (treatment is smoking cessation)
How is Connective-Tissue associated LUNG Disease treated?
By treating the UNDERLYING connective tissue disease (RA, Polymyositis, Systemic Sclerosis)
What is the leading cause of DEATH in patients with Systemic Sclerosis (scleroderma)? Treatment?
Progressive Diffuse Parenchymal Lung Disease (ILD)
Treated with CYCLOPHOSPHAMIDE (steroids don’t help)
In which TWO Diffuse Parenchymal Lung Diseases (DPLD) or “Interstitial Lung Diseases (ILD)” do systemic corticosteroids have no effect and thus NOT used for treatment?
Idiopathic Pulmonary Fibrosis and in Systemic Sclerosis (scleroderma) - associated lung disease
Repeated INHALATION of FUNGAL (actinomycets), BACTERIAL, PROTOZOAL, ANIMAL/INSECT PROTEINS (bird droppings) or CHEMICAL COMPOUNDS can cause this lung disease?
HYPERSENSITIVITY PNEUMONITIS
Pt that works around FUNGI or ANIMALS/INSECTS, CHEMICALS, that develops FLU-LIKE symptoms (fever, chills, malaise, anorexia, weight loss, HA, arthralgia/myalgia) 4-8 HOURS after INTENSE exposure with dyspnea, chest tightness and a dry cough with CT demonstrating B/L UPPER and MID-LING distributed hazy ground-glass opacities with resolution in 24-48 hours but RECUR with re-exposure most likely has?
HYPERSENSITIVITY PNEUMONITIS
How is HYPERSENSITIVITY PNEUMONITIS treated?
REMOVAL of the offending AGENT + systemic CORTICOSTEROIDS (if severe)
How can it be determined that a particular LUNG DISEASE is being caused by a DRUG or THERAPY?
There would be a TEMPORAL (time of onset from initiation of drug) relationship between drug and development of disease
Lung disease that usually presents within the FIRST YEAR of treatment with this DRUG?
AMIODARONE (HIGH-incidence of toxicity) - poor prognosis
What is the mainstay of treatment of DRUG-induced LUNG disease AFTER REMOVAL of offending DRUG?
Systemic CORTICOSTEROIDS
This drug can RARELY cause LUNG disease with peripheral EOSINOPHILIA and BIOPSY shows GRANULOMAS?
METHOTREXATE
Lung disease that occurs within DAYS of starting this DRUG with a CUTANEOUS RASH with peripheral EOSINOPHILS with imaging showing KERLEY B lines (faint, discrete bi-basilar markings) and pleural EFFUSIONS?
NITROFURANTOIN
Pneumonitis, Sub-pleural masses, Pulmonary Fibrosis, Pneumonia, Diffuse Alveolar Damage and Alveolar Hemorrhage are all seen in LUNG DISEASE associated with this DRUG?
AMIODARONE
6 weeks after this treatment, patients present with cough and dyspnea, CT shows hazy ground-glass opacities around the area of treatment and resolve in 6 MONTHS however may need CORTICOSTEROIDS if severe?
Radiation Therapy
