Clinical Part 1 Asthma and COPD (Miller)

Question 1

Asthma is characterized by a limitation of airflow on which clinical tests?

Answer 1

• PFT

or

• Positive bronch-provocation challenge (i.e., methacholine challenge)

Question 2

What are the walls of the airway like in an asthmatic and what occurs to the airway during an asthmatic attack?

Answer 2

• Walls = inflammed and thickened
• During attack = tightened smooth ms.

Question 3

What is the strongest predisposing factor to asthma?

Answer 3

Atopy

Question 4

What is the pathophysiology of Asthma?

Answer 4

Type 2 inflammation

Sensitized by allergens (dust, pet, pollen, etc)

Eosinophilic infiltrate

Defective resoltuion!!

Long term: Airway remodeling secondary to chronic inflammation

Question 5

Dx criteria for Asthma

Answer 5

FEV1 <80%

Age adjusted FEV1/FVC <75%

Reversibilty of airway obstruction via bronchodialation (12% of improvement in FEV1 and a TLC increase of 200ml +)

Normal spriometry does not exclude asthma!!!

Question 6

What is difference in terms of airflow limitation reversibility in asthma vs. COPD?

Answer 6

• Asthma = reversible
• COPD = partially reversible; may be irreversible w/ significant disease

Question 7

What time of the day do sx’s of asthma typically worsen?

Answer 7

Occur/worsen at night (often awaken pt)

Question 8

Which RR and HR is a sign of imminent respiratory arrest?

Answer 8

• RR = >30/minute
• HR = bradycardia

Question 9

What are 2 classes of drugs which are great for long-term control of asthma?

Answer 9

• Inhaled corticosteroids
• Leukotriene modifiers (i.e., montelukast, zafirlukast, zileuton)

Question 10

What are the criteria for days per week w/ sx’s, nighttime awakenings, use of SABA for sx control, and interference with normal activity for asthma to be classfied as intermittent?

Answer 10

Sx: ≤2 days/week

Nighttime awakenings: ≤2x/month

Use of SABA for sx’s: ≤2 days/week

NO interference w/ normal activity

Exacerbations: 0-1/yr

Question 11

Moving from the intermittent category of asthma to the persistent category is an indication for the use of what?

Answer 11

Long-term preventative medicine such as ICS

Question 12

How many exacerbations of a pt’s asthma requiring oral systemic corticosteroids per year places them in the intermittent vs. persistent classification?

Answer 12

0-1/year for intermittent

≥2/year for persistent

Question 13

What are the criteria for days per week w/ sx’s, nighttime awakenings, use of SABA for sx control, and interference with normal activity for asthma to be classfied as persistent MODERATE?

Answer 13

Sx: daily

Nighttime awakenings: 3-4/month, or more than 1x/week, but not nightly

Use of SABA for sx’s: daily

SOME interference w/ normal activity

Exacerbations: more than 2x/yr

Question 14

Pts who had ≥2 exacerbations requiring oral systemic glucocorticoids in the past year may be considered the same as patients who have what classification of asthma; even in the absence of what?

Answer 14

Persistent asthma.. even in the absence of impairment levels consistent with persistent asthma

Question 15

What 4 things should you educate a patient on after starting them on medication for asthma?

Answer 15

Treatment goals

Inhaler technique

Elimination of triggers

Asthma action plan

Question 16

What is the initial at home tx for an asthma attack?

Answer 16

Inhaled SABA (i.e., albuterol) as needed for intermittent asthma

Question 17

If pt has sx’s >2 days per week, but not daily, which classification of asthma do they have?

What is the tx?

Answer 17

Persistent - MILD

Preferred: low dose ICS

Alternative: LTRA

Question 18

What is the progression of asthma treatment as severity increases?

Answer 18

Step 1: SABA prn for intermittent

Step 2a: add low dose ICS or LTRA

Step 3: add LABA/LTRA or switch to medium dose ICS

Step 4: medium dose ICS + LABA/LTRA

Step 5: high dose ICS + LABA + immunotherapy

Step 6: ICS + LABA + oral corticoteroids + immuno

Question 19

What are the 3 treatments use in combo for pt having exacerbation of their asthma (aka asthma attack)?

Answer 19

SABA (i.e., albuterol)

Oxygen

Oral corticosteroids

Question 20

What are potential complications of asthma or non-compliance with asthma control tx?

Answer 20

Pneumonia

Pneumothorax

Exacerbation attacks

Respiratory failure

Remodelling –> COPD

Question 21

What are the major risk factors for COPD?

Answer 21

40+ pack-year smoking hx

45+ y/o

Hx of TB

Outdoor polution??

1% will have Alpha-1-antrirypsin deficiency

Question 22

All patients who have unexplained dyspnea and cough should be evaluated for what?

Answer 22

α₁-AT deficiency

Question 23

Cardiac exam of pt with COPD may show what?

Answer 23

Cor pulmonale

↑ intensity of the pulmonic sound, persistently split S2

Parasternal lift due to RVH

Other cardiac comorbidities include

CAD

Arrhythias

HTN

Question 24

Using the GOLD criteria for staging COPD what are the characteristics of stage I through stage IV?

Answer 24

I (mild) = FEV1 ≥80% of predicted

II (moderate) = 50% ≤FEV1 <80%

III (severe) = 30% ≤FEV1 <50%

IV (very severe) = FEV1 <30% of predicted or FEV1 <50% of predicted plus chronic respiratory failure

_*All have FEV1/FVC <70%_

_*Less than 12% reversibility_

Question 25

Using the GOLD criteria for staging COPD what are the characteristics of stage II - moderate?

Answer 25

In Pts with FEV1/FVC \<70%; **50% ≤ FEV1 \< 80%** of predicted

Question 26

Which postbronchodilator value of FEV1 and FEV1/FVC ratio confirms the presence of nonreversible obstruction?

Answer 26

- **FEV1 \<80%** of predicted - **FEV1/FVC** ratio **\<70%** In other words --\> failure to improve 12% + on FEV1 (or FVC) and 200ml + on TLC

Question 27

What is Hoover's sign?

Answer 27

**Inward** movement of the lower rib cage during **inspiration**, instead of outward as is normal Implies a flat, but functioning, diaphragm

Question 28

Basic tx considerations in COPD

Answer 28

ORAL CORTICOSTEROIDS is mainstay Oral antibiotics needed if purulent or increased mucus production is a concnern Use O2 if needed, or mechaninal ventillation if respiratory acidosis is present

Question 29

What are the 2 suffixes for inhaled corticosteroids?

Answer 29

- **-asone** (i.e., flutic**asone**) - **-ide** (i.e., budeson**ide**)

Question 30

For patient with GOLD I: mild COPD what is the standard tx?

Answer 30

**Either SABA** or **SAMA** prn; often ordered together as **Combivent**

Question 31

For patient with GOLD II: moderate COPD what is the standard tx?

Answer 31

**LABA** or **LAMA**

Question 32

For patient with GOLD IV: very severe COPD what is the standard tx?

Answer 32

ICS + LABA **or** ICS + LAMA **or** ICS + LAMA + LABA With or without **roflumilast** or **theophylline**

Question 33

For patient with GOLD III: severe COPD what is the standard tx?

Answer 33

ICS + LABA **or** ICS + LAMA (**NEVER** use ICS alone in COPD) With or without either **roflumiast** or **theophylline**

Question 34

Which drug used in tx of COPD is **NEVER** used alone in COPD?

Answer 34

ICS used for prevention of exacerbation!

Question 35

Treatment of COPD is stepwise and largely based on what?

Answer 35

PFT's

Question 36

What are the 3 most common bacteria responsible for pneumonia in COPD?

Answer 36

- *S. pneumoniae --\> **vaccinate!*** - *M. catarrhalis* - *H. influenzae --\> **vaccinate!***