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Airway And Lung Diseases Flashcards

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1
Q

Dynamic evolution of asthma (3)

A

Brief Symptoms-Bronchoconstriction
Exacerbations AHR- Chronic airway inflammation
Fixes airway obstruction-Airway remodelling

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2
Q

Hallmarks of remodeling in asthma (3)

A

Thickening of basement membrane
Collagen deposition on submucosa
Hypertrophy of smooth muscle

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3
Q

Asthma- The clinical syndrome (9)

A 
Episodic symptoms and signs
Diurnal variability
Non-productive cough
Triggers
Associated atopy increase in IgE (rhinitis, conjunctivitis, eczema)
Blood eosinophilia >4%
Responsive to steroids or beta-agonists
Family history of asthma 
Wheezing due to turbulent airflow
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4
Q

Diagnosis of Asthma (5)

A

History and examination
Diurnal variation of peak flow rate
Reduced forced expiratory ratio (FEV1/FVC<75%)
Provocation testing to trigger bronchospasms (exercise, histamine, methacholine, mannitol)
Reversibility to inhalation of salbutamol (>15%)

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5
Q

Components of COPD (3)

A

Mucociliary dysfunction
Inflammation
Tissue damage

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6
Q

Causes of airflow limitation in COPD

A

Mucous hypersecretion
Disrupted alveolar attachments
Inflammatory instruction

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7
Q

Characteristics of Chronic bronchitis in COPD (6)

A 
Chronic neutrophilic inflammation
Mucus hypersecretion
Mucociliary dysfunction
Altered lung microbiome
Smooth muscle spasm and hypertrophy
Partially reversible
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8
Q

Characteristics of Emphysema in COPD

A

Alveolar Destruction
Impaired gas exchange
Loss of bronchial support
Irreversible

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9
Q

Assessment of COPD

A

Assess symptoms
Assess degree of airflow limitation using spirometry (FEV<50% indicates high risk)
Assess risk of exacerbations (2 or more withing past year indicates high risk)
Assess comorbidities (IHD/HF)

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10
Q

Clinical Syndrome COPD (8)

A 
Chronic symptoms-not episodic
Smoking
Non-atopic
Daily productive cough
Progressive breathlessness
Frequent infective exacerbations
Chronic bronchitis-wheezing 
Emphysema-reduced breath sounds
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11
Q

Causes of Thoracic Restriction outwith the lungs

A

Skeletal
Muscle weakness
Abdominal obesity/ascites

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12
Q

Skeletal causes of thoracic restriction

A

Vertebrae e.g. Thoracic kyphoscoliosis, Ankylosing spondylitis
Ribs e.g. Traumatic multiple rib injury

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13
Q

Muscle weakness causes of thoracic restriction

A

Intercostal or diaphragmatic e.g. myaesthenia gravis, guillan barre, motor neurone disease, poliomyelitis

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14
Q

Classification of DLPD (5)

A

Acute DLPD
Episodic DLPD (all of which may present acutely)
Chronic DLPD due to occupational or environmental hazards/drugs
Chronic DLPD with evidence of systemic disease
Chronic DLPD without evidence of systemic disease

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15
Q

Causes of fluid in alveolar air spaces

A 
Cardiac pulmonary oedema
Non-cardiac pulmonary oedema
Infective pneumonia
Infarction
Alveolitis
Dust-disease
Carcinomatosis
Eosinophilic
Other causes - rheumatoid disease, drugs, cryptogenic
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16
Q

Types of alveolitis in DLPD

A 
Extrinsic-Allergic-Alveolitis                                                    
Sarcoidosis
Drug induced alveolitis
Toxic gas/fumes
Pulmonary fibrosis
Autoimmune
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17
Q

Clinical syndrome of DLPD

A 
Breathless on exertion
Cough but no wheeze
Finger clubbing
Inspiratory Lung crackles
Central cyanosis (if hypoxaemic)
Pulmonary fibrosis
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18
Q

Types of drugs for airway obstruction (2)

A

Preventers (anti-inflammatory)

Relievers (bronchodilators)

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19
Q

Corticosteroids

A

Anti-inflammatory drugs used in asthma and COPD

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20
Q

Oral steroid

A

E.g. Prednisolone
Low therapeutic ratio
Only used for acute exacerbations not for maintenance

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21
Q

Inhaled steriod

A

E.g.Beclomethasone
High therapeutic ratio
Used for maintenance monotherapy in asthma
Used in ICS/ LABA combo in COPD not as monotherapy
Reduces exacerbations in eosinophilic COPD

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22
Q

What is the risk of using corticosteroids for COPD

A

May cause pneumonia in COPD due to local immune suppression & impaired mucociliary clearance
Especially with fluticasone due to prolonged lung retention

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23
Q

What size must particles be to enable them to travel down past the carina?

A

<5 microns

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24
Q

What size must particles be to get past the 7th generation of bronchial tree?

A

<2microns

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25
Actions of a spacer device (6)
Avoids coordination problems with pMDI Reduces oropharyngeal and laryngeal side effects Reduces systemic absorption from swallowed fraction Acts a holding chamber for aerosol Reduces particle size and velocity Improves lung deposition
26
Cromones
Only used in asthma (eg Cromoglycate) Mast cell stabiliser - weak anti-inflammatory cf steroids Cromoglycate effective in atopic children (EIB) Inhaled route only Not used much due to poor efficacy
27
Leukotriene receptor agonists
Anti-inflammatory used in asthma E.g. Montelukast - oral route, once daily, high therapeutic ratio Less potent anti-inflammatory than inhaled steroid 2nd line: complimentary non steroidal anti-inflammatory additive to inhaled steroid Effective in EIB Also effective in allergic rhinitis ( with anti-histamine )
28
Anti-IgE monoclonal antibody
E.g. Omalizumab (Xolair) Inhibits the binding to the high-affinity IgE receptor Inhibits TH2 response and assoc mediator release from basophils/mast cells Injection every 2-4 weeks for asthma only For patients with severe persistent allergic asthma (raised IgE) despite max therapy. Very expensive Little effect on pulmonary function but reduces exacerbations and oral steroid sparing effect
29
Anti-IL5
Mepolizumab (Nucala )/Reslizumab (Cinquero) Blocks the effects of the TH2 cytokine IL-5 which is responsible for eosinophilic inflammation in asthma Injection every 4 weeks –for asthma only For patients with severe refractory eosinophilic asthma (raised blood eosinophils >4%) – despite max therapy Very expensive Little effect on pulmonary function or symptoms but reduces exacerbations and oral steroid sparing effect
30
B2-agonists
Stimulate bronchial smooth muscle B2-receptors Bronchodilators Short-acting - salbutamol Long-acting – bid :salmeterol/formoterol Used in asthma [as ICS/LABA dual ] Used in COPD [as ICS/LABA dual or LAMA/LABA dual or ICS/LABA/LAMA triple ] High therapeutic ratio when given by inhaled route Systemic B2 effects when given systemically or at high inhaled doses
31
Combination inhalers
Beclometasone/formeterol | Single Maintenance And Reliever Therapy
32
Muscarinic antagonists (anticholinergics)
Muscarinic antagonists (aka Anticholinergics) Block post junctional end plate M3 receptors Short acting: Ipratropium Long acting: Tiotropium,Glycopyrronium, Umeclidinium, Aclidinium Inhaled route only - high therapeutic ratio Used mostly in COPD to reduce exacerbations Also used in asthma as triple therapy at step 4 (only tiotropium) as ICS/LABA/LAMA High nebulised doses of ipratropium used in acute COPD and in acute asthma
33
Methylxanthines
Anti-inflammatory/ Bronchodilator | Used in asthma and COPD
34
Oral Methylxanthine
Theophylline for maintenance therapy Sustained release formulation useful for nocturnal dips Used as add to inhaled steroid as complimentary non steroidal anti-inflammatory
35
IV methylxanthine
Aminophylline for acute attacks Non selective phosphodiesterase inhibitor Also act as adenosine antagonist Low therapeutic ratio -metabolised by P450 in liver
36
PDE4 inhibitors
Roflumilast oral tablet Indicated for COPD only Minimal effect on FEV1 –anti-inflammatory action Reduces exacerbations –additive to LABA or LAMA Adverse effects : Nausea/Diarrhoea/Headache/Weight loss
37
Mucolytics
Oral carbocisteine , erdosteine To reduce sputum viscosity and aide sputum expectoration [and reduce exacerbations ] in COPD Rarely used –only as add on to other treatments
38
Aims in treatment of chronic asthma (7)
``` Abolish symptoms, Minimise B2-use, Normalise FEV1, Reduce PEF variability, Reduce exacerbations, Prevent long term airway remodeling Avoid triggers ```
39
Treatment of chronic asthma
Suppress inflammatory cascade with inhalatory steroid +/- Non steroid anti-inflammatory therapy –eg theophylline ,anti-leukotriene,cromoglycate +/- Stabilise smooth muscle with LABA/LAMA
40
Treatment of acute asthma
``` Oral prednisolone (or iv hydrocortisone ) Nebulised high dose salbutamol, ± Neb ipratropium, ± iv aminophylline/magnesium At least 60% O2 ITU Assisted mechanical intubated ventilation if falling PaO2 and rising PaCO2 ```
41
Aims of treatment of COPD
Reduce exacerbations Improve pulmonary function Improve QOL Prevent pulmonary heart disease
42
Treatment of COPD
``` Smoking cessation Immunisation Pharmacotherapy Pulmonary rehab Oxygen ```
43
Acute Treatment of COPD
Nebulised high dose salbutamol + ipratropium Oral prednisolone Antibiotic (amoxycillin/doxycycline) if infection 24-28% O2 titrated against PaO2/PaCO2 Physio to aide sputum expectoration Non invasive ventilation to allow higher FiO2 ITU Intubated assisted ventilation only if reversible component (eg pneumonia)
44
Effort dependent pulmonary function test
Forced expiratory volumes/flow rates
45
Effort independent pulmonary function test
``` Relaxed vital capacity -spirometry Helium/N2 washout static lung volumes Whole body plethysmography Impulse Oscillometry Exhaled breath nitric oxide ```
46
Gas diffusion tests
CO transfer factor Arterial blood gases (resting) SaO2 during exercise
47
Spirometry in patient with asthma
FEV1 reduced compared to normal patient | FEV same, just takes longer, so slope is reduced
48
Spirometry of COPD patient
Slope gradient more shallow compared to normal patient FVC and FEV1 reduced Ratio the same
49
Volume dependent expiratory airway closure
Asthma, chronic bronchitis
50
Pressure dependent expiratory airway closure
Emphysema
51
Bronchial challenge testing
Exercise Methacholine/Histamine/Mannitol Allergens/Chemicals
52
Exercise testing
FEV1 or PEF decrease post exercise - Asthma | Decreased SaO2 during exercise in interstitial lung disease
53
Transfer Factor (diffusing capacity)
CO diffusion across alveolar-capillary barrier Single breath diffusing capacity Measured as TLCO To monitor treatment response in lung disease
54
Indications of decreased TLCO
``` Anaemia Emphysema Int lung disease Pulmonary oedema Po emboli Bronchiectesis ```
55
Airway resistance
Measured by either whole body plethysmography or more commonly/easily with impulse oscillometry Useful in patients (eg kids) where easier to breathe at tidal volume than doing forced expiratory manoeuvre
56
Exhaled breath condensate
Exhaled breath nitric oxide measured at flow of 50ml/s Non invasive marker of eosinophilic airway inflammation in asthma Not useful in COPD as nitric oxide suppressed by smoking High levels of exhaled NO (> 35ppb) reflect uncontrolled asthmatic inflammation Used as an adjunct to bronchial challenge to assess asthmatic inflammation –especially when spirometry is normal
57
Haemoptysis
Coughing up blood | Can be a direct consequence of a primary tumour
58
Why is recurrent episodes of pneumonia considered a symptom of lung cancer?
A primary lung cancer can cause obstruction of bronchi
59
Stridor
A coarse, audible wheeze during inspiration
60
Symptoms arising from local invasion of the recurrent laryngeal nerve
Recurrent laryngeal nerve palsy
61
Symptoms arising from local invasion of the pericardium
Breathless Atrial fibrillation Pericardial effusion
62
Symptoms arising from local invasion of the oespohagus
Dysphagia
63
Symptoms arising from local invasion of the brachial plexus
Wasting of small muscles
64
Symptoms arising from local invasion of the pleural cavity
Pleural effusion
65
Symptoms arising from local invasion of the vena cava
Distended veins
66
Most common sites for metastases in lung cancer
``` Liver Brain Bone Adrenal Skin Lung ```
67
Paraneoplastic symptoms of lung cancer
``` Finger clubbing Hypertrophic pulmonary osteoarthropathy Weight loss Thrombophlebitis Hypercalcaemia Hyponatraemia Eaton Lambert syndrome ```
68
Thrombophlebitis
Blood clot | Can present as a red track
69
Hypercalcaemia
Stones (Renal/biliary calculi) Bones (Bone Pain) Groans (Abdominal pain, Constipation, N+V) Thrones (Polyuria) Psychiatric overtones (Depression, anxiety, reduced GCS, Coma) Cardiac Arrythmia
70
Hyponatraemia (Syndrome of inappropriate antidiuretic hormone SIADH)
``` Results in low sodium concentration Nausea/vomiting Myoclonus Lethargy/confusion Seizures/coma ```
71
Possible Investigations for Lung Cancer
``` Chest X-ray CT scan of thorax PET scan Bronchoscopy Endobronchial Ultrasound (EBUS) Full blood count Coagulation screen Na, K, Ca, Alk Phos Spirometry, FEV1 ```
72
Smoking associated types of lung tumour
Adenocarcinoma (35%) Squamous carcinoma (30%) Small cell carcinoma (25%) Large cell carcinoma (10%)
73
What do adenocarcinomas express?
TTF (thyroid transcription factor) 1
74
What does SCC express
Nuclear antigen p63 and high molecular wt. cytokeratins

Respiratory (19 decks)

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