Obstructive diseases: Asthma versus COPD

Question 1

What is the definition of asthma

Answer 1

Reactive airway disease where you have abnormal bronchoconstriction but it is REVERSIBLE (distinguish from COPD which is not)

Question 2

How would a patient with asthma present

Answer 2

Wheezing with acute onset of SOB and chest tightness with increased length of expiratory phase of breathing (because obstructive, takes longer for air to get out)

Hints on the exam: Symptoms more at night, nasal polyps, eczema or atopic dermatitis, use of intercostals

Question 3

Someone with history of asthma presents with an acute exacerbation. What is the best initial diagnostic study and the most accurate test

Answer 3

Initial study: Arterial blood gases (increased A-a gradient) or peak expiratory flow (PEF) decreased - do if patient experiencing ACUTE exacerbation

Best test: Pulmonary function testing (PFT) - explained in later flash card

CXR: usually normal in asthma and only used if need to exclude other diseases

Question 4

What is the role of pulmonary function testing in asthma

Answer 4

1. ) Decreased FEV1 and FVC and decreased FEV1/FVC ratio due to more decreased FEV1
2. ) FEV1 increased 12% with albuterol - useful if symptomatic
3. ) FEV1 decreased 20% with methacholine - BEST test if ASYMPTOMATIC
4. ) Decrease in carbon monoxide diffuse capacity

Question 5

What two diseases do you expect to see IgE risen in

Answer 5

1. ) Asthma of allergic etiology

2. ) Allergic bronchopulmonary aspergillosis

Question 6

What are the steps for asthma medications in order of severity

Answer 6

1. ) Inhaled short acting beta agonist
2. ) Low dose inhaled corticosteroid for long term
3. ) Increased corticosteroid dose or add long acting beta agonist
4. ) Add omalizumab if increased IgE levels present
5. ) Oral corticosteroids (i.e. prednisone) if too severe

Question 7

What are the side effects of inhaled corticosteroids and oral steroids

Answer 7

Inhaled: Dysphonia and oral candidiasis

Systemic: Osteoporosis, cataracts, acne, and hirsutism, and adrenal suppression: high lipids and glucose, and then thinning of skin and striae (think that these are all symptoms of adrenal suppression I think)

Question 8

What are alternative long term control agents for asthma control aside from low dose inhaled corticosteroids

Answer 8

1. ) Cromylin and nedocromil: Mast cell mediator release inhibitor
2. ) Theophyline
3. ) Luekotriene modifiers

Question 9

What is the side effect of one of the leukotriene modifiers used as long term control, zafirleukast

Answer 9

Hepatotoxic and associated with Churg-Strauss syndrome

Question 10

What is the role of anticholinergics for asthma

Answer 10

Although theoretically should help, role is not clear and this is more for COPD - remember this

Question 11

What is the best indicator of an acute asthma exacerbation

Answer 11

Respiratory rate

Question 12

In acute asthma exacerbation, the way to diagnose as seen earlier is a decreased PEF or ABG with increased A-a gradient. What is a PEF

Answer 12

Peak expiratory flow (PEF) that estimates FVC and based on height and age, not on weight, compared to the patient’s normal PEF

This time, do CXR because you can see if infection is leading to exacerbation

Question 13

What is the treatment for acute asthma exacerbation

Answer 13

Oxygen combined with albuterol and a bolus of steroids (steroids need 4 to 6 hours to work)

Epinephrine and magnesium use is limited, but use magnesium if several rounds of albuterol don’t work and can open up bronchospasm.

Anything else is ineffective

If refractory to all of this, then do endotracheal intubation

Question 14

What is the definition of COPD

Answer 14

Destruction of lung parenchyma resulting in loss of elastic fibers that are needed for exhalation, resulting in reduced FEV1 and FVC and increased total lung capacity

Results in shortness of breath

Almost always caused by tobacco smoking which destroys elastin

Question 15

How does someone with COPD present in the clinic

Answer 15

Shortness of breath that is worsened by exertion with intermittent exacerbations with increased cough, sputum, or SOB from infections

Barrel chest from increased air trapping, with muscle wasting

Question 16

Like asthma, COPD has a best initial and most accurate test. What are they

Answer 16

Best initial test: Chest X-ray - Will show increased anterior-posterior diameter, air trapping, and flattened diaphragm (was not useful for asthma)

Most accurate test: PFT showing decreased FEV1 and FVC (like asthma) with ratio less than 70%, increased TLC, decreased carbon monoxide diffusion, and no changes with albuterol or methacholine

Question 17

What will ABG show in an acute COPD exacerbation

Answer 17

Increased PCO2 and hypoxia associated with respiratory acidosis

Bicarbonate may rise to do metabolic compensation

Question 18

What is the response of the heart to COPD

Answer 18

Right atrial and ventricular hypertrophy with possible pulmonary hypertension and multifocal atrial tachycardia

Diagnose with echo or EKG

Question 19

What is the most effective treatment for COPD

Answer 19

Inhaled anticholinergic agents: Tiotropium, ipratropium (improves symptoms but not decrease disease progression)

Question 20

Aside from inhaled anticholinergics, what are some other treatments necessary or useful for COPD

Answer 20

1. ) Smoking cessation, oxygen therapy, influenza/pneumococcal vaccine all improve mortality and delays disease progression
2. ) All medications that can be used in asthma
3. ) Pulmonary rehabilitation

If refractory to everything, then refer for transplantation

Question 21

What is the best treatments for both asthma and COPD

Answer 21

1. ) Asthma: Inhaled steroid

2. ) COPD: Anticholinergic (tiotropium, ipratropium)

Question 22

What is the treatment of acute COPD exacerbations and compare to acute asthma exacerbation

Answer 22

Combination of bronchodilators and steroids (same as asthma) but this time give antibiotics too since infection is usually the cause

Question 23

What organisms should be covered in acute exacerbation and what antibiotics should be used

Answer 23

Strep pneumo, H influenzae, moxarella catarrhalis

1. ) Macrolides: Azithromycin, clarithromycin
2. ) Cephalosporins: Cefuroxime, cefixime
3. ) Augmentin
4. ) Quinolones

Question 24

What is the role of oxygen therapy in COPD acute exacerbation

Answer 24

Actually lowers mortality and so should always be used if pO2 is below 55, oxygen saturation below 88%

If hermatocrit risen or signs of right sided heart disease, that criteria increased to pO2 less than 60 or oxygen saturation less than 90%