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Flashcards in Pulmonology Deck (85)
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1

What is acute bronchitis?

cough > 5 days with or without sputum production, lasts 2-3 weeks
-chest discomfort
-shortness of breath
-+/- fever

2

What is the etiology of acute bronchitis?

viruses (most common)
-cannot distinguish acute bronchitis from URTI in the first few days

3

What are the labs for acute bronchitis?

labs not indicated, unless pneumonia suspected (HR>100, RR >24, T>38, rales, hypoxemia, mental confusion, or systemic illness) - CXR

4

What is the tx for acute bronchitis?

antibiotic not recommended - mostly viral
-symptomatic-based treatment NSAIDs, ASA, Tylenol, and/or ipratropium
-cough suppressants - codeine-containing cough meds
-bronchodilators (albuterol)

5

What is the presentation of asthma?

most often young patients present with wheezing and dyspnea often associated with illness, exercise and allergic triggers
-airway inflammation, hyperresponsiveness, and reversible airflow obstruction

6

How do you diagnosis with asthma?

diagnosis and monitor with peak flow
-PFT's: greater than 12% increase in FEV1 after bronchodilator therapy
-FEV1 to FVC ratio <80% (you would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
-in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio

7

What is the tx for mild intermittent asthma?

less than 2 times per week or 3-night symptoms per month
-step 1: short acting beta2 agonist (SABA) prn

8

What is the tx for mild persistent asthma?

more than 2 times per week or 3-4 night symptoms per month
-step 2: low-dose inhaled corticosteroids (ICS) daily

9

What is the tx for moderate persistent asthma?

daily symptoms or more than 1 nightly episode per week
-step 3: low dose ICS + long acting beta2 agonist (LABA) daily
-step 4: medium-dose ICS + LABA daily

10

What is the tx for severe persistent asthma?

symptoms several times per day and nightly
-step 5: high-dose ICS + LABA daily
-step 6: high-dose ICS + LABA + oral steroids daily

11

What is acute treatment for asthma?

oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids

12

What is forced vital capacity?

-forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath
-the amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath
-forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
-you would expect the amount of air exhaled during the first second to be the greatest amount
-in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a decreased FEV1 to FVC ratio

13

What is bronchiectasis?

a condition in which the lungs' airways become dilated and damaged, leading to inadequate clearance of mucus in airways
-mucus builds up and breeds bacteria, causing frequent infections
-a common endpoint of disorders that cause chronic airway inflammation (CF, immune defects, recurrent pneumonia, aspiration, tumor)
-1/2 of cases are due to cystic fibrosis

14

What are the symptoms of bronchiectasis?

include a daily cough that occurs over months or years and production of copious foul-smelling sputum, frequent respiratory infections

15

How is bronchiectasis dx?

CXR=linear "tram track" lung markings, dilated and thickened airways - "plate-like" atelectasis; CT chest = gold standard
-crackles, wheezes, purulent sputum

16

What is the tx for bronchiectasis?

ambulatory oxygen, aggressive antibiotics for acute exacerbations, CPT (chest physiotherapy = bang on the back); eventual lung transplant

17

What is a carcinoid tumor?

a tumor arising from neuroendocrine cells = leading to excess secretions of serotonin, histamine, and bradykinin

18

What are the characteristics of carcinoid tumor?

-common primary sites include GI (small and large intestines, stomach, pancreas, liver), lungs, ovaries, and thymus
-carcinoid syndrome (the hallmark sign) is actually quite rare and occurs in approximately 5% of carcinoid tumors and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation
-carcinoid syndrome = diarrhea, shortness of breath, flushing, itching

19

How is carcinoid tumor dx?

octreotide scan, urine for 5-hydroxyindoleacetic acid (5-HIAA), serum niacin, CT scan to locate tumor

20

What is the tx for carcinoid tumor?

is by surgical excision and carries a good prognosis
-the lesions are resistant to radiation therapy and chemotherapy
-octreotide - a somatostatin analog which binds the somatostatin receptors and decreases the secretion of serotonin by the tumor
-niacin supplementation

21

What is chronic obstructive pulmonary disease?

a chronic inflammatory lung disease that causes obstructed airflow from the lungs due to loss of elastic recoil and increasing airways resistance

22

What are the characteristics of chronic obstructive pulmonary disease?

-includes emphysema and chronic bronchitis = both usually coexist with one being more dominant
-damage to the lungs from COPD can't be reversed
-30 pack-year history = low dose chest CT

23

What are the risk factors of chronic obstructive pulmonary disease?

-cigarette smoking/exposure is the most important risk
-alpha 1 antitrypsin deficiency = genetic and linked to COPD in patients <40 y/o (protects elastin in lungs from damage by WBCs)

24

What is emphysema?

-exposure to irritants (eg cigarette smoke) - degrades elastin in alveoli, airways - lose elasticity - low pressure during expiration pulls walls of alveoli inward - collapse - air-trapping distal to collapse - septa breaks down - neighboring alveoli coalesce into larger air spaces - decreased surface area available for gas exchange
-loss of elastin - lungs more compliant (lungs expand, hold air)
-alveolar air sacs permanently enlarge, lose elasticity - exhaling is difficult
-DOE = hallmark symptom
-hyperinflation of lungs + hyperresonance to percussion, decreased/absent breath sounds, decreased fremitus, barrel chest (increased AP diameter), quiet chest, pursed-lip breathing
-individuals are able to oxygenate blood (pink) but they have to purse their lips to do so (puffers) = Pink Puffers
-pursing lip increases pressure in airway - keeps the airway from collapsing - weight loss
-barrel chest due to air trapping and hyperinflation of lungs
-CXR reveals loss of lung markings, hyperinflation, increased anterior-posterior diameter
-PETs show FVC decreases (esp. FEV1) + increased TLC (due to air trapping)
-ABG/labs: respiratory alkalosis, mild hypoxemia, normal CO2
-cachectic with pursed-lip breathing - "pink puffers"

25

What is chronic bronchitis?

defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause
-exposure to irritants (e.g cigarette smoke) - hypertrophy/hyperplasia of bronchial mucous glands, goblet cells in bronchioles, cilia less mobile - increased mucus production, less movement - mucus plugs - obstruction in bronchioles - air trapping - productive cough
-rales (crackles), rhonchi, wheezing, signs of cor pulmonale (peripheral edema, cyanosis)
-ABGs: respiratory acidosis (arterial PCO2>45 mmHg, bicarbonate >30 mEq/L)
-PET's: FEV1/FVC ratio less than 0.7
-increased TLC (air trapping)
-chest radiography: peribronchial and perivascular markings
-increased HGB and HCT are common because of the chronic hypoxic state
-pulmonary HTN with RVH, distended neck veins, hepatomegaly
-obese and cyanotic = blue bloaters

26

What are the diagnostic studies for chronic obstructive pulmonary disease?

-PFTs/spirometry = gold standard diagnosis COPD
-FEV1 = important factor of prognosis and mortality (<1 L = increased mortality)
-obstruction: decreased FEV1, decreased FVC, decreased FEV1/FVC
-hyperinflation: increased lung volumes: increased RV, TLC, RV/TLC, increased FRC (functional residual capacity)
-CXR/CT scan
-emphysema: hyperinflation: flat diaphragm, increased AP diameter, increased vascular markings, enlarged right heart border
-ECG: cor pulmonale: RVH, RAE, RAD, r-sided heart failure (due to longstanding pulmonary hypertension), MAT, hypertension

27

What are the clinical therapeutics for chronic obstructive pulmonary disease?

-smoking cessation = single most important step
-bronchodilators: combo therapy (Beta2 agonist + anticholinergic = greater response than used alone - tx of choice in stable COPD with resp. symptoms
-short acting (SAMA) or long-acting (LAMA) muscarinic agent (also known as an anticholinergic agent): tiotropium (spiriva) inhaled long-acting; ipratropium (atrovent)
-ipratropium preferred over short-acting B2 agonist in COPD
s/e: dry mouth, thirst, blurred vision, urinary retention, difficulty swallowing, mydriasis
-contraindications: glaucoma, BPH
-short acting (SABA) or long-acting (LABA) beta 2 agonist: albuterol, terbutaline, salmeterol (long-acting)
-s/e: B1 cross-reactivity, tachycardia/arrhythmias, muscle tremor, CNS stimulation
-contraindications: severe CAD; caution in pt. with DM (hyperglycemia), hyperthyroid)
-theophylline: only used in refractory cases bc narrow therapautic index - monitor serum levels to prevent nausea, palpitations, arrhythmias, seizures from toxic levels; higher doses needed in smokers and coffee drinkers - don't initiate in acute exacerbation
-+/- inhaled glucocorticoids: inhaled corticosteroids not considered monotherapy
-s/e: osteoporosis, thrush
-oxygen: only medical therapy proven to decrease mortality (decreases pulmonary hypertension/cor pulmonale by decreasing hypoxia-mediated pulmonary vasoconstriction)
-long-term oxygen therapy in all patients with COPD who have chronic hypoxemia defined as resting PaO2 <55 mmHg or SaO2 <89

28

What is the tx for stage I for chronic obstructive pulmonary disease?

mild
-FEV1 >80%
-bronchodilators prn short-acting/decrease risk factors

29

What is the tx for stage 2 for chronic obstructive pulmonary disease?

moderate
-FEV1 50-80%
-above + long-acting dilator

30

What is the tx for stage 3 for chronic obstructive pulmonary disease?

severe
-FEV1 30-50%
-above + pulm rehab; inhaled steroids if increased exacerbations