Obstructive Lung Dz Flashcards by Jacqueline Dinh

Indications for bronchial thermoplasty and contraindications

Stable severe asthma on optimal medical therapy (at least ICS-LABA) with poor control.
No trials in those with >3 exacerbations/year, FEV1 <60% pred, or chronic sinus disease.

Contraindications:
1. Active implantable electronic device
2. Acute myocardial infarction <6 weeks ago
3. Prior BT
4. Coagulopathy
5. Allergies to anesthestics for BT

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Indications for antibiotics in COPD exacerbation

increased dyspnea, sputum volume and sputum purulence

Also if severe exacerbation needing invasive or noninvasive MV

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Dynamic extrathoracic obstruction on flow volume loop

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Dynamic intrathoracic obstruction on flow volume loop

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Fixed upper air way obstruction on flow volume loop

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Indication for O2 therapy in COPD

PaO2 </=55 or SaO2 </=88%
OR
PaO2 </= 59 or SaO2 </=89% AND
- EKG with signs of cor pulmonale
- HCT >55
- Evidence of RH failure
OR
Exercise desat to </=88% and documented improvement with O2

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Indication for NIV for COPD

GOLD Stage 4 w/ PaCO2 ≥52mmHg and pH>7.35 a few weeks (2-4) after hospital discharge.

In RCTs, NIV settings were titrated to achieve at least 20% reduction in PCO2, typically EPAP 4 to 5 cm H2O and IPAP 22 to 26 cm H2O and backup RR 14 to 16/min (ie, high-intensity NIV).

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Goal of NIV for COPD

decrease PaCO2 by >= 20% from baseline or <48

Improved 1 year mortality

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Who has survival benefit from lung volume reduction surgery?

Upper lobe predominant emphysema and low baseline exercise capacity

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Most common risk of endobronchial valve insertion

Pneumothorax 20-30%

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ICS/LAMA/LABA benefit

In pt with hx frequent or severe exacerbations
improves lung function, symptoms, health status, reduces exacerbation, all cause mortality

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How to best predict COPD related hospitalizations and mortality on PFTs?

FEV1/FVC <0.7 more accurate than LLN

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treatment of hereditary angioedema

Icatibant (bradykinin receptor antagonist)
Replacement of plasma-derived C1 inhibitor
Ecallantide (inactivation of plasma kallikrein)

ppx with plasma derived C1 inhibitor, lanadelumab, plasma kallikrein

Steroids not effective

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Most common cause of nonCF bronchiectasis

Post infectious
Idiopathic

Immunodeficiency
ABPA
PCD
CTD/RA
Chronic aspiration
yellow nail syndrome

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When is allergen immunotherapy not recommended for pt with asthma?

if asthma is uncontrolled - risk of bronchospasm
Pregnancy
Unstable CV disease
concurrent treatment with beta blocker

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Effect of allergen immunotherapy for asthma

very minimal benefit for asthma outcomes

If mild to mod asthma controlled on ICS then can reduce asthma symptoms

No known effect on exacerbations

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Definition of bronchial atresia

focal obliteration of lobar, segmental or subsegmental bronchus complicated by mucous impaction and/or air trapping distal to atretic bronchus

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Which segment is frequently affected by bronchial atresia

left upper lobe

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DDx for Perihilar tubular lesion and hyperinflation

Congenital lobar emphysema
AVM
intralobar pulm sequestration
Bronchogenic cyst
mucoid impaction

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Imaging findings for AVM

tubular lesion that enhances with contrast
No bronchial obs, hyperluciency or hyperinflation

Gene that determines azithromycin resistance in M. abscessus complex?

erm(41) gene

rpoB gene mutation can lead to what resistance?

rifampin

rrs gene mutation leads to which resistance

Aminoglycosides

Only in those w/ lots of exposure to amikacin or other AG

embB leads to what kind of drug resistance in M abscessus?

ethambutol

Effect of flu vaccine for pts with COPD?

reduces # exac and flu hospitalization frequency

Goal VO2 max for lobectomy?

VO2>20

When to prescribe O2 for flying?

- resting SpO2 <92% -->2L - SpO2 <84% 6MWT --> get HAST or empiric 2L - If <4L O2 baseline then increase 1-2L for flight - If on >4L at rest at baseline then dont fly

When to get 6MWT prior to a pt flying if suspicious for hypoxia?

if SpO2 >95% RA and a mMRC 3 or greater

What can cause the PRISm pattern on PFTs

1. Air trapping w or w/o hyperinflation (pseudoresriction) 2. simple restriction (FVC

What are the associated issues with PRISm?

increased risk resp symptoms reduced exercise tolerance respiratory related hospitalizations increased mortality

What is a nonspecific pattern on PFTs?

VC<80%, TLC nl can be airway hyperresponsiveness, chronic lung dz, obesity , Neuromsk impairment, chest wall restriction, poor testing

Initial inhaler for pts with COPD?

LAMA/LABA

Best treatment for pt with CF and F508del mutation

elexacaftor plus tezacaftor plus ivacaftor

Placental transmogrification of the lung treatment

bronchodilators, ICS, smoking cessation and vaccines. If that fails then bullectomy

Congenital causes of unilateral cystic or bullous lesions

- bronchogenic cysts - Congenital lobar emphysema - placental transmogrification of the lung - Swyer-James-MacLeod syndrome (reduced pulmonary vasculature and alveolar hyperdistention +/- bronchiectasis)

CT scan findings of RML and lingular bronchectais in older pt w/o history of pulmonary disease

nontuberculous mycobacteria

how long can people continue to benefit from long term maintenance PR?

24 months

CT findings of bronchopulmonary sequestration

focal areas of lucency or irregular cystic spaces w or w/o fluid CT angio can identify the arterial blood supply

Most common form of bronchopulmonary sequestration

Intralobar sequestrations Located in posterior basal segment of lower lobe 60% Presentation: recurrent pneumonia

What is the prevalence of undiagnosed COPD in pts >40yo with >10pkyrhx

70-78%

Effect of deesclation of triple inhaler therapy to LAMA/LABA in non-frequent exac pts with FEV1 40-80% and no asthma

Reduction in lung function No increased AECOPD and no change in QoL or mortality

When to continue patient on triple inhaler therapy despite being GOLD B?

Blood eos >300 - higher risk of AECOPD - Greater lung function loss off of ICS

When to NOT use ICS in COPD?

Recurrent PNA Eos <100 hx mycobacterial infection

Prior to starting augmentation therapy for AAT def what lab?

IgA

What are some of the adverse effects and contraindications of roflumilast?

- Weight loss - Nausea, vomiting, diarrhea - Contraindicated moderate-to-severe hepatic impairment (Child-Pugh class B or C) - Drug interactions with inducers and inhibitors of CYP 3A4 (inducers: rifampicin and carbamazepine; inhibitors: erythromycin, cimetidine, and protease inhibitors)

What are the direct and indirect agents for bronchoprovocation testing and the thresholds for a positive test in each respective category?

Cystic fibrosis patients with a new pseudomonas aeruginosa should receive what treatment?

Inhaled tobramycin solution for 28 days (Grade A recommendation - CF Foundation Guidelines)

Indications for O2 prescription:

1) Resting room air Pao2 ≤55 mm Hg or Spo2 ≤88% 2) Resting room air Pao2 56 to 59 mm Hg or Spo2 ≤89% if there is evidence of dependent edema, or cor pulmonale or pulmonary hypertension, or erythrocythemia >56% 3) Exercise desaturation to Spo2 ≤88% and documented improvement of hypoxemia during exercise with oxygen.