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Flashcards in Pulmonology Deck (85)
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What is acute bronchitis?

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


What is the etiology of acute bronchitis?

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


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


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)


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


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


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


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


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


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


What is acute treatment for asthma?

oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids


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


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


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


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


What is the tx for bronchiectasis?

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


What is a carcinoid tumor?

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


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


How is carcinoid tumor dx?

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


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


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


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


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)


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"


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


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


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


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

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


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

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


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

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