Pulmonology

Question 1

Bronchitis v Emphysema Pathophysiology

Answer 1

Bronchitis

• Prod cough 3 mo per yr for > 2 yrs
• Excess mucous prod narrows airways; enlargement of mucous glands; smooth muscle hyperplasia; inflammation and scarring
• “Blue Bloaters” - cyanotic w/ signs for pulmonale

Emphysema

• Permanent enlargement of air space distal to terminal bronchioles due to destruction of alveolar walls
• Excess proteases & dec anti-proteases (alpha 1- antitrypsin); elastase released from PMNs destroy lungs)
• “Pink Puffers” - thin from expenditure; barrel chest; maintain oxygenation but trap CO2

Question 2

PE Signs of COPD

Answer 2

• Prolonged expiratory time
• End expiratory wheezes
• Dec breath sounds
• Crackles
• Cyanosis
• Hyper-ressonance
• Use of accessory muscles

Question 3

Centrilobular v Panlobular Emphysema

Answer 3

• Centrilobular (smoking/ proximal bronchioles)

- Pan lobular (alpha 1- antitrypsin / distal bronchioles)

Question 4

3 Major Long Term COPD Complications

Answer 4

• Secondary polycythemia (HCT > 55% males and > 47% females)
• Cor pulmonale
• Pulmonary HTN

Question 5

COPD Dx

Answer 5

• PFTs
  
  • Dec FEV1 (used to stage disease)
    
    • > 80% mild
    • 50-80% moderate
    • 30-50% severe
    • < 30% very severe
  • FEV1 / FVC decreased (obstructive)
  • Normal or inc TLC (air trapping)
• CXR - Hyperinflation, flat diaphragm and diminished vascular markings
• Meas alpha 1 -antitrypsin if < 50 yo
• ABG - chronic CO2 retention, dec PO2

Question 6

When should supplemental O2 be used for COPD?

How much should be used?

Answer 6

• PaO2 55
• OR O2 sat < 88% at rest or w/ exercise
• OR PaO2 55-59 + evidence of polycythemia or cor pulmonale

> 18 hrs / day

Question 7

How do you treat a COPD exacerbation?

Answer 7

• do CXR
• give abx, inhaled bronchodilators, systemic corticosteroids (IV)
• supplemental O2
• may also need non-invasive pos pressure ventilation (CPAP or BiPAP)
• intubation if unstable
• Do not want to over-correct oxygen so keep O2 sat 90-93% to maintain respiratory drive

Question 8

Asthma Pathophysiology

Answer 8

airway inflammation, airway hyper-responsiveness and reversible airflow obstruction

Question 9

What sign points to ASA associated asthma?

Answer 9

Nasal polyps

Question 10

Asthma PFTs

Answer 10

• Dec FEV1, dec FVC and dec FEV1/FVC ratio

- Inc FEV1 or FVC by 12% w/ use of bronchodilator

Question 11

What is a quick assessment for asthma severity?

Answer 11

Peak expiratory flow

Question 12

Asthma Exacerbation

Answer 12

• Inhaled beta agonist nebulizer
• IV corticosteroids - taper to inhaled once improved
• If severe - IV magnesium
• Work Up - CXR (r/o pneumonia and pneumothorax), ABG, peak expiratory flow

Question 13

Clinical Features of OSA

Answer 13

• Snoring
• Daytime sleepiness
• Dec libido, intellectual function or personality
• Oxygen desaturation / hypoxemia –> systemic and pulmonary HTN and cardiac arrhythmias
• Morning headaches
• Secondary polycythemia

Question 14

How do you diagnose OSA?

Answer 14

PSG in sleep lab