Obstructive Disorders

Question 1

Affects large bronchi
Permanent dilation
Destruction bronchial walls
LOTS of SPUTUM - often green/yellow
Chronic cough, hemoptysis, clubbing

Answer 1

Bronchiectasis

Question 2

Etiology (Bronchiectasis)

Answer 2

Idiopathic - majority
Genetic:
1) CF (MC overall)
2) IgG deficiency (recurrent sinopulmonary infxn in childhood)
Acquired - recurrent PNA, bact infx (Staph, Kleb, Bordetella), AIDS, TB, IBD (UC>Crohns)

Question 3

Dx (Bronchiectasis)

Answer 3

CXR (honeycomb/popcorning)
Chest CT (dilated bronchi/thickened walls)

Question 4

Tx (Bronchiectasis)

Answer 4

Underlying cause
Abx for infx (macrolides)
Inhaled bronchodilators (ICS, SABA, LABA)
Chest PT

Question 5

Asthma
C
H
E
R
I

Answer 5

Chronic
Hyper-responsive
Episodic
Reversible
Inflammatory

Question 6

RF’s (Asthma)

Answer 6

URI
Exercise
Atopy
Occupation
Environment 
Drugs

Question 7

Atopy triad

Answer 7

ASA
Asthma
Polyps

Question 8

4 classifications (Asthma)

Answer 8

Intermittent
Mild persistent
Moderate persistent
Severe persistent

Question 9

Dx eval (Asthma)
Step 1 eval

Answer 9

Spirometer
Before & after SABA
Shows reduced FEV1/FVC ratio
Shows reversibility p SABA

Question 10

Dx eval (Asthma)
Step 2 eval

Answer 10

Bronchoprovocation (methacholine challenge)

If spirometry not diagnostic, but high clin susp

Question 11

Tx (Asthma)

Step 1: rescue med

Answer 11

Inhaled SABA (albuterol)

Special rescue: Inhaled Anticholinergics (ipratropium)
Systemic corticosteroids (pred, methylpred)

Question 12

Tx (Asthma)

Step 2: maintenance

Answer 12

Inhaled corticosteroid (ICS)
Takes 1 - 2 wks max effectiveness
Rinse & spit
Beclomethasone, budesonide, fluticasone, triamcinalone

Question 13

Tx (Asthma)

Step 3: Add-on maintenance

Answer 13

Inhaled LABA (black box warning alone)
     Salmeterol, formoterol
LABA + steroid
     Advair, Symbicort
Leukotriene modifiers (for allergen-related)
     Montelukast

Question 14

Tx (Asthma):

Last lines

Answer 14

Anti-IgE
Immunotherapy
Inhaled mast cell stimulators
     cromolyn - poor efficacy
Phosphodiesterase inhibitor
     theophylline - poor toxicity

Question 15

Combination of:
1) Chronic bronchitis: inc secretions & cough
2) Emphysema: destruction alveolar-capillary membrane (dec gas exchange)
progressive, gradual decline in FEV1
mucus plugging, airway narrowing

Answer 15

COPD

Question 16

Signs/Sxs:
Chronic bronchitis =
Emphysema =

Answer 16

= “Blue bloater”, chronic cough (smoker’s), purulent sputum, inc pulm infx, wheeze
= “Pink puffer”, DOE, ? cough, scant/clear sputum
hemoptysis, cyanosis, edema, crackles

Question 17

PE Findings (COPD):
Early =
Late =

Answer 17

= prolonged exp, wheeze on forced exp

= inc AP chest, dec tactile fremitus, hyper-resonance, dec BS

Question 18

Main Dx strategy (COPD)

Answer 18

Spirometry

FEV1/FVC ratio < 0.7 (doesn’t respond to tx)

Question 19

Other Dx (COPD)

Answer 19

CXR - RVH, CM

CT - Shows hyperinflation & parenchymal BULLAE & BLEBS

Question 20

COPD staging

Answer 20

Stage 1 - 4

Mild, mod, severe, very severe

Question 21

Stage 1 (mild COPD)

Answer 21

Chronic cough & sputum; some SOB

FEV1 > 80%

Question 22

Stage 2 (mod COPD)

Answer 22

Chronic cough & sputum; SOB may limit exertion

FEV1 50-80%

Question 23

Stage 3 (severe COPD)

Answer 23

Progressive airway limitation; signs / sxs worse c freq exacerbations
FEV1 30-50%

Question 24

Stage 4 (very severe COPD)

Answer 24

Hypercapnea, hypoxia c severe recurrent exacerbations req home O2; affect QOL
FEV1 < 30% or < 50% c chronic resp fail

Question 25

Tx COPD

Answer 25

Education: smoking cessation Vaccines: Pneumo & Flu Pulm rehab Meds

Question 26

Mainstay med tx (COPD)

Answer 26

Bronchodilators 1) Short-acting inhaled rescue: combo SABA + Anticholinergic (combivent = albut + ipratrop) 2) Long-acting inhaled maint: Anticholinergics (tiotropium/spiriva) or LABA (salmeterol) + ICS

Question 27

Special Tx reserved for Stage 3 & 4

Answer 27

Inhaled corticosteroids (ICS) ??? Theophylline (older, inc toxicity profile) New: Roflumilast

Question 28

Autosomal recessive, Caucasian Chloride transport dysfxn Multisystem - most exocrine glands produce abnml thick mucus secretions that obstructs glands/ ducts

Answer 28

Cystic Fibrosis (CF)

Question 29

Sinopulmonary manifestations (CF)

Answer 29

``` Sinusitis Nasal polyposis Mult recurring lung infx become chronic (Bronchitis, PNA, Bronchiectasis) ? Pseudomonas Wheezing, chronic cough ```

Question 30

Extrapulmonary manifestations (CF)

Answer 30

``` MECONIUM ILEUS Pancreatitis / insufficiency Steatorrhea - fatty stools Infertility (M > F); bilat absence vas deferens FTT, bone issues Clubbing Anemia, hypernatremia, hypoproteinemia ```

Question 31

Dx (CF)

Answer 31

Eval: Newborn screening (many false +) Screening: Sweat test (> 90% sens); nml doesn't r/o CF Confirmation: CFTR mutation analysis for nml or borderline sweat test

Question 32

Tx (CF)

Answer 32

Multidisciplinary Clear/reduce secretions, chest PT, tx infxn Nutrition, pancreatic enzyme replacement Genetic counseling...