Pulmonary 1 (Asthma) - Jaynstein Final

Question 1

What are examples of Obstructive Diseases?

Answer 1

• Asthma
• COPD (Chronic Bronchitis and Emphysema)
• Bronchiectasis

Question 2

What are examples of Restrictive Diseases/ Interstitial Lung Diseases

Answer 2

• Pulmonary fibrosis
• Idiopathic Interstitial Pneumonia (IIP)
• Pneumoconiosis
• Sarcoidosis

Question 3

What is a disorder of pulmonary circulation?

Answer 3

Pulmonary HTN

Question 4

Obstructive lung diseases are caused by the inability to ____ ____ due to airway obstruction (inflammation or collapsed airways)

Answer 4

Obstructive lung diseases are caused by the inability to fully exhale due to airway obstruction (inflammation or collapsed airways)

Question 5

Obstructive lung diseases are:

A. Diseases of the lung parenchyma

B. Diseases of the airways

C. Described as the inability to get air out of the lungs

D. Described as the inability to get air into the lungs

E. B and C

Answer 5

E. B and C

B. Disease of the airways

C. Described as the inability to get air out of the lungs

Question 6

Restrictive lung diseases are caused by restriction or limitation of the lungs to expand and therefore ____ ____

Answer 6

fully inhale

Question 7

Restrictive diseases are disease of the?

Answer 7

lung parenchyma

Question 8

Pulmonary function tests (PFTs) are a group of tests that measure what?

Answer 8

• How well the lungs take in and release air
• How well they move gases from the atmosphere into the body’s circulation

Question 9

The most common type of PFT is?

Answer 9

Spirometry

Question 10

Forced Vital Capacity (FVC)

Answer 10

The maximum volume of air one can exhale

Question 11

What is Forced Vital Capacity determined by?

Answer 11

The volume of air after full inspiration (Total Lung Capacity TLC) and the volume of air remaining in the lungs after exhalation (Residual Volume RV)

FVC = TLC - RV

Question 12

What does Forced Vital Capacity help evaluate?

Answer 12

Issues of inhalation (Restrictive Disease)

Question 13

Forced Expiratory Volume (FEV1)

Answer 13

The amount of air exhaled in one second

Question 14

Forced Expiratory Volume FEV1 measures?

Answer 14

• The velocity of flow of exhalation
• Obstructive lung process evaluation

Question 15

What do you use to calculate PFTs for restrictive disease?

Answer 15

Measured FVC / Predicted FVC

If > 80% of predictive = normal

If < 80% of predictive = restrictive process

Question 16

What do you use to calculate PFTs for Obstructive disease?

Answer 16

Measured FEV1 / Measured FVC

If > 70% = normal

If < 70% = obstructive process

Question 17

What are peak flow meters and what do they help measure?

Answer 17

They are used at home by patiens for monitoring (obstructive processes)

Used for daily and acute monitoring (PRN symptoms, response to acute tx) - should be obtained when pt is well

Pt has known “best”

100-80% of best = green

79-50% of best = yellow

< 49% of best = red

Question 18

PFTs are for ____ and long-term ____

Answer 18

PFTs are for diagnosing and long-term monitoring

• At dx
• 3-6 post dx
• Q 1-2 yrs thereafter

Question 19

Asthma is characterized by chronic inflammation of the ___ ___, bronchial hyperactivity, and ___ airway obstruction

Answer 19

Asthma is characterized by chronic inflammation of the small airways, bronchial hyperactivity, and reversible airway obstruction

*remember asthma by definition is reversible aka pradoxical (ie intermittent)

Question 20

What is the atopic triad of asthma?

Answer 20

1. Eczema
2. Allergic rhinitis
3. Asthma (hypersensitivity response)

Question 21

T/F: Symptoms of asthma can be cured

Answer 21

False - symptoms can be managed but not cured

Question 22

What are the 3 pathological features of asthma?

Answer 22

1. Spasm/constriction of smooth muscle
2. Wall edema (stimulated by histamine)
3. Increased mucus produciton

Question 23

What are the 3 main types of asthma?

Answer 23

1. Extrinsic (allergen triggered)

• IgE mediated
• Allergic factors

2. Intrinsic

• Irritant mediated
• Environment

3. Mixed intrinsic and extrinsic

Question 24

When obtaining a PMH for a patient with asthma what are important things to ask/determine?

Answer 24

1. What medications the patient has been on for their asthma
2. Any recent medication changes
3. Compliant?
4. Known trigger?
5. Ever been hospitalized
6. Ever been intubated

Question 25

What are some clinical presentations of asthma?

Answer 25

* Cough (often dry) * Symptoms usually worse at night * Hx of seasonal allergies * Episodic **wheezing** (expiratory sound) * Chest tightening

Question 26

What would you find during the PE of an asthma patient?

Answer 26

1. Samter's Triad * asthma * nasal polyps * NSAID sensitivity 2. Expiratory wheeze

Question 27

What would you expect the PFTs to show for an asthma patient? What other work up would you want to do?

Answer 27

PFTs = obstructive pattern **Decreased FEV1/FVC ratio (\<0.7)** If PFTs are normal --\> perform provoking tests * Methacholine Challenge * Aspirin Challenge CXR = would be normal or show hyperinflation VBG/ABG

Question 28

Treatment for asthma?

Answer 28

1. **Minimize symptoms** that interfere with daily activity 2. Prevent recurrent exacerbations 3. Decrease ER visits and hospitalizations 4. Maintain near normal pulmonary function

Question 29

What are the medication classes used to treat asthma and what do each do?

Answer 29

1. Bronchodilators - ALL get this * relax smooth muscle and dilate bronchiole walls 2. Coricosteroids, Leukotriene modifiers, Mast Cell Stabilizers * decrease inflammation/wall edema 3. Anticolinergics * decrease mucus production

Question 30

What are specific bronchodilators prescribed? Which ones are for rescue purposes?

Answer 30

Beta2 Agonists * Short acting (SABA) = Ventolin, ProAir (Albuterol) * for rescue purposes * Long acting (LABA) = Salmeterol (Serevent) Theophylline * narrow therapeutic window - high toxicity * rarely initiated

Question 31

What are specific corticoidsteroids that could be prescribed?

Answer 31

1. Inhaled Corticosteroids (ICS) * Beclomethason (QVAR), Fluticasone (Flovent), Budesonide (Pulmicort) * **Maximize steroid dose before adding other agents (such as a LABA)** 2. Systemic (PO or IV) - use precaution and limit! * Methylprednisolone, Prednisone 3. Leukotriene modifiers * Montelukast (Singular) 4. Mast Cell Stabilizers * Cromolyn Sodium and Nedocromil

Question 32

What are specific anticolinergics that could be prescribed?

Answer 32

1. Ipratropium Bromide (Atrovent) 2 .Tiotropium (Spiriva)

Question 33

What are some combination therapies for asthma?

Answer 33

LABA + ICS 1. Flucticasone/Salmeterol --\> Advair 2. Budesonide/Formoterol --\> Symbicort

Question 34

What is the progression of asthma medication prescribed?

Answer 34

1. All patients get an Albuterol INH 2. Add on ICS (start low dose) 3. Increase ICS dose OR add a LABA (but increase ICS first!)

Question 35

What are some medications that may precipitate asthma?

Answer 35

* Beta blockers * NSAIDs, ASA * Histamine * Acetylcystine (used for acetaminophen overdose)

Question 36

What are the 4 classifications of asthma?

Answer 36

1. Intermittent - exercise or cold induced (symptoms _\<_ 2x/wk) 2. Mild (symptoms _\>_ 2x/wk, not daily) 3. Moderate persistent (daily symptoms) 4. Severe persistent (symptoms throughout the day)

Question 37

What would you expect to see for the VGB/ABG for a patient with asthma?

Answer 37

Mild = normal or **resp alkalosis,** hyperventilation (blow off CO2) Mod/Severe = **resp acidosis** - muscle fatigue, CO2 retained