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Pulmonology Flashcards

1
Q

FEV1 definition

A

volume of air exhaled forcefully in the first second of maximal expiration

Normal >=80%

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2
Q

FEV1 and FVC in asthma

A

FEV1 will increase >=12%
or
FVC will increase >=200 mL

after administration of SABA. This shows reversibility of asthma

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3
Q

FVC definition

A

maximum volume of air that can be exhaled after full inspiration

reported in liters and percentage predicted
i.e. adults can empty 80% air in <6 seconds

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4
Q

FEV1/FCV ratio

A

percentage of lung capacity able to be expelled in one second

normal is about 75-80%(varies) in adults

COPD: <70%

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5
Q

Asthma s/s

A

-Triggers: laughing, exercise, allergens, seasonal
-Onset <40 y/o
-Improve with bronchodilator

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6
Q

Asthma initial treatment

A

ICS-containing treatment essential

Do not give LABA or LAMA without ICS!

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7
Q

COPD s/s

A

-Persistent dyspnea on most days
->40 y/o
-cough/sputum
-with or without bronchodilator reversiblity

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8
Q

COPD initial treatment

A

Avoid high-dose ICS and maintenance steroids

Treat as COPD per GOLD guidelines

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9
Q

Intermittent asthma (frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.)

A

Frequency of symptoms: <=2 days/week
Nighttime awakenings: <=2times/mo
SABA use: <=2 days/week
No interference with daily activities
FEV1/FVC: normal to >85%
FEV1: normal
Exacerbations requiring oral steroids: 0-1/yr
Initial therapy: step 1

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10
Q

Step 1 Asthma therapy

A

SABA prn

If controlled: mild asthma

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11
Q

Step 2 Asthma therapy

A

Maintenance: Low dose ICS OR low-dose ICS + SABA prn

Rescue: low-dose ICS + SABA prn
Alt: SABA prn

Conditionally recommend SC immunotherapy if controlled

If controlled: mild asthma

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12
Q

Step 3 Asthma therapy

A

low-dose ICS+formoterol

Rescue: low-dose ICS + formoterol PRN
Alt: SABA prn

Conditionally recommend adjunct SC immunotherapy if controlled

If controlled: moderate asthma

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13
Q

Step 4 Asthma therapy

A

Medium-dose ICS + formoterol

Rescue: Medium-dose ICS-formoterol PRN
Alt: SABA prn

Conditionally recommend adjust SC immunotherapy if controlled

If controlled or remains uncontrolled: severe

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14
Q

Step 5 Asthma therapy

A

Medium/high-dose ICS-LABA + LAMA

Rescue: SABA prn

Consider asthma biologic

If controlled or remains uncontrolled: severe

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15
Q

Step 6 Asthma therapy

A

High-dose ICS-LABA + OCS

Rescue: SABA prn

Consider asthma biologic

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16
Q

Well-controlled asthma

A

NO
-daytime asthma symptoms
-night waking
-SABA need
-activity limitation

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17
Q

Partly controlled asthma

A

1 or 2 present:
-daytime asthma symptoms >2x/wk
-Night waking
-SABA need >2x/wk
-Activity limitation

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18
Q

Uncontrolled asthma

A

3 or 4 present:
-daytime asthma symptoms >2x/wk
-Night waking
-SABA need >2x/wk
-Activity limitation

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19
Q

Mild persistent asthma ((frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.))

A

Frequency: >2 days/week (not daily)
Nighttime awakening: 3-4x/mo (1-2x if 0-4)
SABA use >2days/wk (not daily)
Minor limitation with normal activity
FEV/FVC normal
Exacerbations req. steroids: >=2/yr (if 0-4y/o then >=2 in 6 mo)

Initial treatment: step 2

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20
Q

Moderate persistant asthma (frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.)

A

Frequency: daily
Nighttime awakening: >1x/wk, not nightly
SABA use: daily
Some limitations
FEV/FVC: reduced 5%
FEV >60 <80%
Exac req. steroids: >=2/yr (if 0-4 y/o then >=2/6mo)

Initial treatment step 3. Consider short course of PO steroids

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21
Q

Severe persistent asthma (frequency, awakenings, SABA use, daily activity interference, FEV/FVC, FEV, exac, treatment rec.)

A

Frequency: throughout the day
Nighttime awakening: often nightly
SABA use: several times/day
Extremely limited normal activity
FEV/FVC reduced >5%
FEV <60%
Exac req. steroids: >=2/yr (if 0-4, >=2/6 mo)

Initial treatment, all consider short course of oral steroids:
>=12: Step 4 or 5
5-11: Step 3 or 4
0-4: Step 3

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22
Q

low dose ICS

A

> 12 y/o only

beclomethasone: 100-200mcg/day
budesonide: 200-400mcg/day
ciclesonide: 80-160mcg/day
fluticasone propionate: 100-250mcg/day
fluticasone furoate: 100mcg/day
mometasone: 100-220mcg/day (twisthaler) or 200-400 mcg/day (HFA)

Use for Step 2-3

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23
Q

Medium dose ICS

A

> 12y/o only

beclomethasone: >200-400mcg/day
budesonide: >400-800mcg/day
ciclesonide: >160-320mcg/day
fluticasone propionate: >250-500mcg/day
fluticasone furoate: N/A
mometasone: >220-440mcg/day (twisthaler)

Use for step 4 or 5

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24
Q

High dose ICS

A

> 12 y/o only

beclomethasone: >400mcg/day
budesonide: >800mcg/day
ciclesonide: >320mcg/day
fluticasone propionate: >500mcg/day
fluticasone furoate: 200mcg/day
mometasone: >440mcg/day (twisthaler) or >400 mcg/day (HFA)

Use for step 5 or 6

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25
ICS Class side effects
Oral candidiasis (rinse mouth after use) Hoarseness May slow bone growth in children (but similar adult height) Arnuity (fluticasone furoate) is contraindicated with severe hypersensitivity to milk protein
26
ICS onset of improvement
5-7 days
27
SAMA class side effects
Headache skin flushing blurred vision tachycardia palpitations
28
Spiriva Respimat unique indication
Only LAMA indicated for long term maintenance asthma treatment >=12 y/o
29
Albuterol side effects
tremor tachycardia (less w/ levalbuterol) hypokalemia hypomagnesemia hyperglycemia tachyphylaxis
30
SABA/SAMA combination primary use
used primarily in COPD
31
LAMA/LABA combination use
maintenance of COPD glycopyrrolate/formoterol (Bevespi) tiotropium/olodaterol (stiolto) umeclidinium/vilanterol (anoro) aclidinium/formoterol (duaklir)
32
Single Maintenance and Reliever Therapy (SMART)
budesonide/formoterol (symbicort) 5-11: 1-2 puffs prn up to total daily maintenance and reliever dose of 8 puffs/day >=12: 1-2 puffs prn up to a total daily maintenance and reliever dose of 12 puffs/day
33
ICS + LABA dosing frequency
All are 2 puffs BID. Exceptions: -fluticasone/salmeterol DPI (advair diskus) = 1 puff BID -Fluticasone furoate/vilanterol (breo) = 1 inh once daily
34
Leukotriene Receptor Antagonists
Montelukast, Zafirlukast, Zileuton ADR: HA, GI upset, heptatoxicity (Zs only) BBW (montelukast only): neuropsychiatric events Montelukast can be used as young as >=1y/o. Zileuton can only be used in >12 y/o. Inx with warfarn, theophylline (Zs only) Used as alternative therapy in Steps 2-5 Step 4 & 5 must also include ICS
35
Omalizumab (Xolair)
IgE-binding inhibitor MAB given every 2-4 weeks as >= 6 y/o Second line therapy for severe persistent allergy-related asthma Increased risk of CV and cerebrovascular ADRs (MI, TIA, PE/DVT, unstable angina, pulmonary HTN) Can be self-injected
36
Dupilumab (dupixent)
IL-4 antagonist SC every other week >=6/yo Add-on therapy with eosinophilic asthma or OCS-dependent Do not give live vaccines
37
IL-5 antagonists
mepolizumab (nucala) - SC q4w >=6y/o reslizumab (cinqair) - IV q4w >=18 y/o benralizumab (fasenra)- SC q4w x3 doses then q8w >=12 y/o Must try for 4 months to determine efficacy Add on maintenance therapy for severe asthma with eosinophilic phenotype
38
Tezepelumab (Tezspire)
Thymic stromal lymphopoietin (TSLP) blocker Given SC q4w We never have on hand Add on maintenance for >=12 y/o At least 4 months needed to determine efficacy
39
Breathing technique for inhalers
Slow & Deep: HFAs Ellipta (anoro, breo, arnuity, incruse) Respimat (combivent, spiriva, striverdi, stiolto) Steady & deep, not too forceful: Spiriva handihaler Quick, forceful, deep: Multidose DPIs (pressair, twisthaler, flexhaler, diskus) Respiclick Digihaler
40
Exercised-induced bronchospasm
Diagnosis: Exercise challenge. FEV1 decreases by 15%, or peak expiratory flow occurs before and after exercise, measured at 5 min intervals for 20-30 min Treatment: can initiate or step up, especially if frequent/severe Pretreatment with SABA or low-dose ICS-formoterol and prn for symptom relief is recommended Can use LTRAs but onset is hours after administration
41
When to assess with spirometry
Baseline After treatment started and symptoms stable (3-6 mo) If prolonged or progressive loss of asthma control Then at least every 2 years Only >=5 y/o
42
Asthma Action Plan - Green
No/minimal symptoms of coughing, wheezing, dyspnea Continue maintenance, reliever inhaler, avoid triggers
43
Asthma Action Plan - Yellow
Increased frequency of symptoms, nighttime awakenings. Decreased ability to do normal activities peak expiratory flow rate (PEFR) 50-79% Plan: 1) Increase reliever to max of 72mcg formoterol/day or SABA 2-4 puffs, repeat in 20 min 2) Wait 1 hour. ---Complete response: contact physician, consider steroid burst ---Incomplete response: repeat SABA. Add steroid burst. ---Poor response: repeat SABA immediately. Add steroid burst. Contact physician immediately or go to ER. 3) Continue SAVA q3-4 hours regularly for 24-48 hours
44
Steroid burst for asthma exacerbation using asthma action plan
prednisone Adults: 40-60mg/day for 5-7 days Children: 1-2mg/kg/day x3-5 days
45
Asthma Action Plan - Red
Medical alert- inability to speak more than short phrases. Use of accessory respiratory muscles. drowsy. PEFR <50% best Plan: 1) Contact physician immediately 2) Increase reliever. Max formoterol 72mcg/day. SABA 2-6 puffs 3) If incomplete/poor response, repeat SABA immediately, go to ER if severe distress 4) If lips/fingernails blue or gray, trouble walking or talking b/c of SOB: go to ER Continue SABA q3-4h for 24-48h
46
Mild or moderate asthma exacerbation
S/S: -Talk in phrases -Sitting > lying -RR, HR increased; O2 on RA 90-95% PEF >50% of personal best Treatment: -Treat at home or office visit -Oxygen if needed -SABA +/- oral steroids
47
Severe asthma exacerbation
S/S: -dypsnea at rest -Interferes with conversation -sits hunched forward -HR >120, RR >30, accessory muscles, O2 RA <90% PEF<=50% best Treatment: -ED visit, hospitalization -Oxygen -PO steroids -High dose SABA + ipratropium
48
Life-threatening asthma exacerbation
S/S: -Too dyspneic to speak -Perspiring -Confused, drowsy PEF <25% best Treatment: -ER, possible ICU -Little or no relief from SABAs -IV steroids
49
SABA dose during mild-severe exacerbation
Albuterol 4-10 puffs q20 minutes up to 4 hours, then every 1-4 hours as needed OR nebulizer* q20 min for 3 doses then q1-4hours prn *should include ipratropium for severe
50
Steroid burst for mild-severe asthma exacerbation requiring treatment
prednisone adults: 40-50mg 1-2x daily peds: 1-2mg/kg in two divided doses (max 40mg/day) Give until peak expiratory flow >70%
51
Adjunctive therapies for severe-life-threatening asthma exacerbation
IV magnesium IV ketamine Heliox Consider if patient unresponsive
52
Respiratory arrest plan from asthma exacerbation
Mechanical ventilation w/ oxygen 100% Nebulized SABA + ipratropium IV steroids IV Magnesium or heliox if unresponsive to therapy
53
Gold standard diagnosis for COPD
Spirometry FEV1/FVC <70%
54
GOLD 1
Mild FEV >=80%
55
GOLD 2
Moderate FEV 50-79%
56
GOLD 3
Severe FEV 30-49%
57
Gold 4
FEV <30%
58
COPD Group A
CAT <10, mMRC 0-1 No hospitalizations <=1 exac in past year Initial: Bronchodilator (short or long-acting)
59
COPD Group B
CAT >=10, mMRC >=2 No hospitalizations <=1 exac in past year Initial: LABA + LAMA
60
COPD Group E
Few or many symptoms >=1 COPD-related hospitalization OR >=2 exac in past year LABA + LAMA or LABA + LAMA + ICs (esp. if eosinophils >300)
61
COPD Therapy Modification if on LABA or LAMA, with predominant dyspnea
Change to LABA + LAMA May also need to change inhaler device May need to investigate other causes dyspnea
62
COPD Therapy Modification if on LABA + LAMA, with predominant dyspnea
Change inhaler device Escalate nonpharm treatment Treat other causes of dyspnea
63
COPD Therapy Management if on LABA or LAMA, with predominant exacerbation
LABA + LAMA or LABA + LAMA + ICS (eosinophils >300)
64
COPD Therapy Management if on LABA + LAMA, with predominant exacerbation
LABA + LAMA + ICS (if eosinophils >300) or If eosinophils <100, add roflumilast (also FEV <50% and chronic bronchitis) AND/OR azithromycin daily (if former smoker)
65
COPD Therapy Modification if on LABA + LAMA + ICS, with predominant exacerbation
De-escalate ICS and change to LABA + LAMA or Add roflumilast if FEV <50% and chronic bronchitis AND/OR azithromycin daily (if former smoker)
66
Roflumilast (Daliresp)
PDE-4 inhibitor Indication: daily treatment to reduce risk of COPD exacerbations. Inhibits breakdown of cAMP -- no direct bronchodilator activity Must have FEV <50%, chronic bronchitis, history of frequent exac despite being on LABA + LAMA + ICS, especially if eosinophils <100 Contraindicated in liver impairment and breastfeeding
67
Azithromycin in COPD
Anti-inflammatory and antibacterial properties Add-on therapy for LABA + LAMA +/- ICS if eosinphil <100 and former smoker 250mg daily or 500mg 3x/w
68
Home oxygen therapy
Recommend if Pao2 <55mmHg or Sao2 <88% with or without hypercapnia, confirmed twice during 3-week period *Improved survival* with long term use
69
BB in COPD
Not recommended for COPD, but do not withhold in patients with heart disease Possible benefit due to upregulation of B2 receptors on lungs, thus making bronchodilators more efficient
70
Statins in COPD
Possible benefit in reducing exacerbations and COPD mortality Not recommended to initiate in COPD if no other cardiac risk factors
71
Preferred treatment of COPD exacerbation
SABA w or without ipratropium
72
Steroids in COPDe
-Effective -Shorten recovery time -Improve FEV1 -Improve/shorten hospital stays Use in most exacerbations (not needed in mild) Outpatient: prednisone 40mg daily x5 days (noninferior to 14 days)
73
Most common pathogens for COPDe
S. pneumoniae H. influenzae M. catarrhalis Pseudomonas if GOLD 3-4
74
Cardinal symptoms of COPDe
Increased dyspnea Increased sputum volume Increased sputum purulence
75
Antibiotics for COPDe
Give if all 3 cardinal symptoms present OR 2/3 present with 1 being increased purulence OR if requiring intubation Empiric: Augmentin, Azithromycin, Doxycycline ABX in past 3 months: Use alternative class Consider Augmentin or levo/moxi if complicated COPD w/ risk factors (comorbid dx, FEV <50%, >3 exac/year, ABX in past 3 mo) GOLD 3-4: levo 750 or cipro + sputum culture 5-7 days
76
Adult with previous PPSV23 vaccine
Give PCV20 or PCV15 (at least 1 yr after PPSV23), no need for additional PPSV23 after PCV15.
77
Adult with previous PCV13, have not completed PPSV23
PCV20 one year after PCV13 or complete PPSV23 series
78
RSV Vaccine for pregnancy
Abrysvo 32-36w
79
Flu vaccine without egg
Recombinant influenza vaccine (RIV) cell culture based inactivated vaccine (ccIIV4)
80
Tdap if patient has recent Td
Tdap recommended as one-time replacement for Td, including 65 and older
81
LAMA benefits in COPD
-delays first exacerbation -reduces overall # COPDe & hospitalizations -Improves symptoms, health status -Improves pulmonary rehabilitation No significant FEV1 improvement
82
LABA vs LAMA COPD
Tiotropium > Salmeterol in time to first exac & annaul # of exac TIoptropium > LABA at preventing exac but NOT in overall hospitalization/mortality LABA/LAMA > LABA/ICS in preventing copd exac
82
LABA benefits COPD
-improve health status -improve QOL & FEV1 -Decreased COPD exac rate No effect on mortality or rate of lung function decline Salmeterol significant reduces hospitalization rate & treatment of exac
83
ICS monotherapy in COPD
AVOID Can increase mortality compared to combination therapy

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