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Flashcards in Pulmonary - MTB Deck (29):
1

Asthma

abnormal bronchoconstriction of the airways
- reversible obstructive lung disease

2

Causes of acute exacerbation of symptoms include:

- allergens
- infection and cold air
- emotional stress or exercise
- catamenial (related to menstrual cycle)
- aspirin, NSAIDS, B-blockers, histamine
- GERD

3

Asthma: Presentation

- clear presence of WHEEZING w/ acute onset of SOB, cough, and chest tightness
- increased sputum though not fever

4

Asthma: Clinical Symptoms

- symptoms worse at night
- NASAL POLYPS and sensitivity to aspirin
- eczema or atopic dermatitis on PE
- INCREASED LENGTH OF EXPIRATORY PHASE of respiration
- increased use of accessory respiratory muscles (e.g. intercostals)

5

Asthma: Diagnostic

- CXR (normal in asthma)
- exclude pneumonia
- exclude pneumothorax or CHF
- Peak expiratory flow (PEF) or arterial blood gas (ABG)
- Pulmonary function testing

6

Best initial test in acute exacerbation

Peak expiratory flow (PEF)
Arterial Blood Gas (ABG)

7

Most accurate diagnostic test in acute exacerbation

Pulmonary Function Tests (PFTs)
- spirometry shows decrease in FEV1 / FVC
- FEV1 decreases more than FVC

8

15 y/o boy comes to the office b/c of occasional shortness of breath every few weeks. Currently he feels well. He uses no meds and denies other medical problems. Physical exam reveals pulse of 70 and RR of 12 breaths per minutes. Normal chest exam Most accurate diagnostic test at this time?

> 20 % decrease in FEV1 with use methacholine`

9

Pulmonary Function Testing in Asthma

- decreased FEV1 and decreased FVC w/ decreased ration of FEV1/FVC
-increased in FEV1 of more than 12% and 200mL w/ use of albuterol
- decrease in FEV1 of more than 20% w/ use of methacholine or histamine
- increase in diffusion capacity of lung for CO

10

Acetylcholine and histamine

- provoke bronchoconriction and increase in bronchial secretions
- metacholine (artificial form of acetylcholine)

11

Testing options for asthma

- CBC shows increased eosinophils
- Skin testing to ID specific allergens
- Increased IgE levels suggest allergic etiology

12

Asthma: Treatment

1. Inhaled short-acting B-agonist (ALBUTEROL, pirbuterol)
2. Low dose inhaled corticosteroids (e.g. triamcinolone, fluticasone)
3.. Alternative long-term control agents (e.g. cromylyn, monteleukast, zileuton)
4. Add long acting B-agonist (e.g. salmeterol)
5. Oral corticosteroids (e.g. prednisone)

13

Inhaled steroids (e.g. fluticasone, triamcinolone): adverse effects

- dysphonia
- oral candidiasis

14

Systemic Corticosteroids: Adverse Effects

- Osteoporosis
- Cataracts
- Adrenal Suppression and Fat Redistribution
- Hyperlipidemia, hyperglycemia, acne, hirsutism
- Thinning of skin, striae, and easy bruising

15

Anticholinergics

- examples: ipratropium and tiotroprium
- dilate bronchi and decrease secretions
- very effective in COPD

16

47 y/o man w/ hx of asthma comes to ED w/ several days of increasing SOB, cough, and sputum production. On PE his RR is 34 per minute. He has diffuse expiratory wheezing and prolonged expiratory phase. Which of the following would you use at the best indication of the severity of the asthma?

Respiratory rate
- can indicate shortness of breasths

17

Severity of asthma exacerbation can be quantified by:

- Decreased peak expiratory flow (PEF)
- ABG w/ an increased A-a gradient
- CXR r/o infeciton leading to exacerbation

**PEF is approximation of FVC, based on height and age

18

Severe acute asthma exacerbation: treatment

- Oxygen
- Albuterol
- Steroids

19

Best initial therapy of acute asthma exacerbation

Oxygen w/ inhaled short acting B-agonists (e.g. albuterol) and bolus of steroids
- epinepherine no more effective than albuterol and has potential for adverse effects

20

Indication for Mg in acute asthma exacerbation

- Helps relieve bronchospasm
- used when in severe asthma exacerbation not responsive to several rounds of albuterol while waiting steroids

21

If pt in acute asthma exacerbation and not responsive to oxygen, albuterol, and steroids (or develops respiratory acidosis), what's next step?

Endotracheal intubation for mechanical ventilation
- should be paced in ICU

22

Chronic Obstructive Pulmonary Disease (COPD)

- presence of shortness of breath from lung destruction decreasing elastic recoil of the lungs
- most of the ability to exhale is from elastin fibers in lungs passively allowing exhalation
-decrease in FEV1 and FVC and increase in TLC

23

COPD: Etiology

Tobacco smoking leads to almost all COPD
- tobacco destroys elastin fibers

24

COPD: Presentation

- Shortness of breath worsened by exertion
- Intermittent exacerbations w/ increased cough, sputum, and SOB
- "Barrel chest" from increased air trapping
- Muscle wasting and cachexia

25

COPD: Diagnostic Tests

- CXR
- Pulmonary Function Tests

26

Best initial test for COPD

CXR
- increased anterior-posterior (AP) diameter
- air trapping and flattened diaphragm

27

Most accurate diagnostic for COPD

Pulmonary Function Tests
- decreased FEV1, decreased FVC, decreased FEV1/FVC (< 70%)
- Increased TLC b/c an increase in residual volume
- Decreased DLCO (emphysema, not chronic bronchitis)
- Incomplete improvement w/ albuterol
- Little or no worsening w/ metacholine

28

COPD and reversibility w/ bronchodilators

Have a range of reversibility: no reversibility to complete reversibility

29

Ful reversibility

- greater than 12% increase and 200 mL increased in FEV1