RESP royal college Flashcards
(148 cards)
1
Q
what does the diagnosis of asthma require ?
A
- Variable sx ( cough, chest tightness, dyspnea) which vary overtime and intensity
- Variable exam : confirmed variable expiratory flow limitation
2
Q
what do you need diagnose asthma
A
need a spirometry
3
Q
which subtype of asthma requires higher ICS ?
A
adult onset
4
Q
which subtype of asthma is less responsive to ICS
A
non allergic type
5
Q
which subtype of asthma could have paucigranulocytic inflammation
A
non allergic
6
Q
which type of asthma is associated with little eosinophilic inflammation?
A
obesity
7
Q
which type o fasthma is assocxaited with eosinophilic inflammation
A
both allergic and non allergic
8
Q
how can variability be demonstrated via asthma testing ?
A
- BD reversibility ( FEV1>12% and 200 ml post BD)
- lung function w/ antiinflam x 4w ( FEV1>12% and 200 ml post BD)
- excessive FEV 1 variation in lung function between visits ( FEV1>12% and 200 ml post BD)
- peak flow variability ( average daily diurnal PEF variability >10% ; excessive variability in twice daily PEF over 2w)
- bronchial challenge test or exercise challenge test ( methacholine challenge)
9
Q
what if you have a normal spirometry ? does that rule out asthma
A
no
10
Q
what can you do if your spirometry test is normal
A
- test during sx
- methacholine/exercise tes
11
Q
what is a + methacholine test
A
basically if you have a drop in fev1 of 20% with 4 mg/ml of methacholine
12
Q
what is a (-) methacholine test
A
if you have a drop of fev1 >20% if require 20 mg/ml of methacholine
13
Q
what is a + exercise challenge
A
drop in fev1 >10% and >200ml from baselien
14
Q
what are the 9 criterias required for asthma control in terms of
1. Daily sx
2. Nighttime sx
3. physical activity
4. exacerbation
5. absence from work/school bcs exacerbation
6. need a reliever ( saba/ bud-form)
7. FEV1 or PEF
8. PEF diurnal variation
9. Sputum eosnophils
A
- <2
- <1
- Normal
- Mild ( no steroids, no ED) + infrequent
- none
- <2
- > 90% of personal best
- <10-15%
- <2-3%
15
Q
overuse of SABA is described as what ?
A
requiring use of 2 SABA inhalers ( bottles i guess) per year
16
Q
what is a risk for severe exacerbation
A
- hx of previous severe asthma exacerbation ( systemic steroids/ed/hospit) 2. poorly controlled per criterias
- overuse of SABA ( used 2 in last year)
- current smoker
17
Q
what is a severe asthma exacerbation vs mild
A
any asthma episode requiring
1. hospitalisation
2. ed visit
3. systemic steroids
mild= 0/3 criteria
18
Q
so based on cts management graphic how do you go stepwise
A
- confirm dx
- enviro control/education/written action plan
- PRN Saba or PRN bud-form
- ICS ( 2nd line LTRA)
5A. add LABA ( >12)
5B . increase ICS ( 6-11)
6A. add LTRA ( >12)
6b . add LABA /LTRA ( 6-11)
19
Q
Can use LABA in monotherapy? yes, no ? why
A
noooo
Increased risk of death
20
Q
what’s the main difference between CTS and GINA
A
well gina seems to like combining ICS-LABA, prescrisely ICS-formoterol and basically incrase in dose
- start with PRN in step 1 and step 2
- then move to low dose maintenance in step 3
- medium dose maintenance as step 4
- step 5 : erquest phenotype assessment , LAMA, add on +/- anti IGE , anti IL5, anti IL4 , anti TSLP. consider high dose ICS forometerol
21
Q
why do we love formeterol containing ICS compared to other LABAs?
A
bcs fast onset of action
22
Q
compared to SABA alone, why is PRN ICS formoterol better ?
A
- less exacerb
- less sx
- less hospit
23
Q
compared to ICS+SABA PRN, why is PRN ICS formoterol better ?
A
- exacerbation is similar
- less er visit
- less hospit
24
Q
meds to avoid in asthma
A
- nsaid
- bb
25
in what scenario is LTRA great in asthma
- Aspirin induced
- allergic rhinitis
- exercise induced
26
LTRA vs ICS, in what way is LTRA less effective
less effective in preventing exacerbations
27
blackbox LTRA warning
increased suicidality
28
if you have samter's triad, what should you try
LTRA
29
what's samter's triad again
ASA allergy
nasal polyp
asthma
30
when to consider AI investigation in asthma management
- maintenance oral cortico
- high dose ICS-LABA
31
if periph eo >0.3, what else should you do
consider non asthma dx, ie strongyloides, esp before corticosteroids systemic
32
if periph eo >1.5, what should consider
dx such as egpa
33
now , if have severe severe ashtma, what are the option considered in CTS 2017 ( and GINA 2024)
1. tiotropium mist inhaler
2. oral corticosteorid
3. macrolides
4. bronchial thermoplasty
5. biologics
34
biological option if allergic asthma w/ high IgE
omalizumab ( anti IgE)
35
bio option if eo allergic asthma
all others
- IL5 ( i..e mepolizumab)
- IL4-IL13 (i.e. Dupilumab )
36
which ICS has most evidence in pregnancy
budesonide
37
asthma associated with what in pregnancy
- preterm
- preeclampsia
- low birth weght
- perinatal mortality
38
ABPA
- major criteria
- minor criteria
major :
- predispo condition : athnma, cf, copd, bronchiectasis
- serum ige >500 or a fumigatus specific ige >0.35
minor ( 2/3)
- periph eo >500
- + IgG against a fumigatus
- fleeting opactiies on CXR
39
tx of ABPA
pred +/- itraconazole
40
differentiate rads ( reactive airway dysfunction) from vocal cord dysfunctionm?
rads will have abN methacholine test
41
asthma exacerbation tx primary care
salbutamol , systemic corticosteroids, o2 supplementation
42
asthma exacerbation in ed/ er tx
saba,atrovent, o2, steroids
+/- mg
-/- high dose ICS ( methylprednisolone 125 mg IV)
43
when would lung volume reduction surgery might potentially be useful in COPD ?
1. if fev1 <45% and significant gas trapping
44
Smoking cessation in COPD : how beneficial is it ?
increased survival for all , decreased rate of decline in fev 1
44
long term o2 therapy : survival benefit in who ?
those with severe resting hypoxemia
45
what does severe hypoxemia mean in terms of offering o2
1. PaO2 <55
2. PaO2 <60 w/ bilateral ankle edema , cor pulmonale or hct >56%
46
what does the NOTT trial 1980 say ? reduces what ???
those with copd and severe hypoxemia : continuous o2 reduces mortality compared to nocturnal o2 alone !!!!
47
what about giving LTOT in exercise ? what does the NEJM LOTT trial say ?
if stable copd and resting 89-93% or exercise induced desat --> LTOT did not result in longer time to death or first hospit comparefd to no LTOT
48
pulmo rehab : when does it decrease exacerbation ? what else does it increase ?
if started following recent <4 weeks AECOPD
Increased survival
49
other pharrm and non pharm tx with survival benefits since 2024
1. NIV
2. LAMA/LABA/ICS
50
what mrc dyspnea level is this : stops for breath after walking about 100 m or after a few min on the level
mmrc 3
51
what mmrc level is this : SOB breath when hurrying on level or walking up straight hill
1
52
what mmrc level is this : walks slower than people of same age on level b/c of breathlessness or has to stop for breath when walking at own pace on the level
2
53
what's mild copd . what's the tx
cat <10, mmrc 1
fev 1 >80
tx : lama or laba
54
whats the mod-severe tx if low aecopd risk ?
laba/lama --> laba/lama/ics
55
whats the mod-severe tx if high aercopd risk
laba/lama/ics --> + macrolide, pde4 inhb, mucolytic agents
56
high risk aecopd defined as what.
>2 exacerbation or >1 requiring hospit
57
low risk of aecopd means what
<1 exacerbation, no ed/hospit
58
what does cts recommend downstepping back to lama-laba once start lama-laba-ics in a mod-severe high risk aecopd ?
bcs withdrawing ics could lower health status and lung function
59
what's the benefit of adding macrolid to severe risk aecopd
decrease aecopd
60
risk of macrolide (3)
- hearing impairment
- qt prolongation
- atb resistanced
61
when do you consider adding roflumilat or n acetyl cystein ?
chronic bronchitis phenotype
62
can theophylline help in preventing acute exacerbation in copd ? what about asthma ?
1. copd no
2. asthma no
63
what are the 3 required criteria for ACO
1. COPD dx ( hx, spirometry, risk factors)
2. Asthma hx ( past hx, dignoasis, sx consistent, physio confirmed with spirometry)
3. fixed post BD FEV1/FVC <0.7
64
how to treat ACO
Per GOLD - treat as asthma
1st line is LABA-ICS and can progress to adding LAMA if needed
65
NIV in stable copd with hypercapnea, imp0roves what per multiple trials ?
mortality benefit
66
paco2 level to initiate NIV even in stable COPD
52
67
in whom does lung volume reduction surgery increase survival ( type of copd) per nett trial ?
emphysema (severe) with upper lobe predominant disease and low post rehab exercise capacity
68
1 year mortalty after aecopd compared to MI ?
what's the FEV 1 loss that you get with it ?
30% vs 23%
8ml/year
69
aecopd tx
1. o2
2. SABD + LABD stat
3. steroids
4. atb
5.NIV
70
what does steroid reduce when given ina ecopd
recovery and hospit duration
71
what the atb duration in aecopd as outpatient ?
<5days as shown by meta analysis
72
per gold 2024, benefit of BIPAP/NIV
mortality benefit and reduced reintubation rate
73
when to BIPAP/NIV per GOLD 2024
1. paco2 >45 + ph <7.35
2. severe dyspnea (impeding resp failure)
3. hypoxemia despite supp o2
74
is hfnc recommended in aecopd
nope
75
what smoking cessation tx is superior to nicotine patch
varenicline
76
bronchiectasis definition
clinical syndrome with cough, sputum production and bronchial infection w/ radiological evidence of permanent + abN dilatation of bronchi
77
what pattern pfts expected with bronchiectasis ?
obstruction
78
most common cause of bronchiectasis ?
- postinfectious
- idiopathic
79
mournier kuhn, a congenital disease, can be associated with what ?
bronchiectasis
80
how can you test for primary ciliary dyskinesia ?
via nitric oxide
81
antimicrobial for bronchiectasis
1. colistin/gentamicin inhaled for psA colonbization
2. chronic azithro if recurrent exacerbations ( w/ or w/o PSA colonization)
82
what do you want to rule out prior to starting chronic azithro in bronchiectasis
NTM
83
what should not be offered routinely in bronchiectasis
1. ICS, PDE4i, oral steroids
84
tx bronchiectasis exacerbation and during of atb
- atb (IV ideally)
- if hemoptysis : atb, txa, embolization
atb for 14 days especially if PSA colonized. shorter course if mld bronchiectasis
85
what's the most common IIP
IPF
86
type of radiological pattern seen in IPF
it's UIP ( usual interstitial pneumonia pattern)
1. honeycombining
2. subpleural, basal predominal
3. reticular changes
4. No presense of anything suggestive of an alternate dx
-cysts
-predominant GGO
-nodules/centrolobular nodules
-profuse micronodules
-consolidation
- mosaic attenuation
- predominant distribution : peribronchovascular/perilymphatic/upper-midlung
87
antifibrinolytic meds? what do they reduce ?
1. Nintendanib
2. Pirfenidone
FVC decline by 50%
88
NIntendanib beneficial in what way
Per INPULSIS 1/2 trials
- reduced fvc decline
- trend to reduced mortality
89
Pirfenidone beneficial in what way
Per the Ascend/Capacity trials
- reduced FVC decline
- reduced 6MWTD decline
- improved survival
90
role for corticosteroids chronically or immunosup in IPF ?
NO ( PANTHER-IPF) , incrased mortality
91
role chronic atb in ipf
no ( Cleaup-IPF)
92
tx for acute exacerbation in IPF
- high dose steroids and empiric atb
93
in who should you consider immunosuppression in context of ILD
non IPF
94
how does hypersensitivity pneumonitis
- cause
- location
- tx
- cause : organic
- location : upper lobe
- tx : remove trigger, steroids, mmf/aza sometimes
95
pneumoniosis
- cause
- location
- tx
- inorganic ( i.e. silica)
- location ( variable, silica upper lobe)
- tx supportive care , transplant
96
CTD associated ILD
- tx
- steroids ( short term)
- MMF prefered
- ritux/aza
- toci for scleroderma
97
scleroderma ILD , what do you give as tx
tocilizumab
98
drugs that can cause ILD
- mtx
- amio
- bleo
- nitrofurantoine
- vap
99
how to traet drug induced ild
steroids
100
Per chest guideline - if have parapneumonic effusion, when can you forego sampling and follow radiographically ?
<1cm
101
what imaging for exudate nyd ?
ct chest
102
what are lights criteria ?
LDH >2/3
LDH >0.6 ( fluid : serum)
proten >0.5 ( fluid : serum)
103
#1 cause of chytlothorax
malignancy ( lymphoma)
104
causes of pleural fluid eosinophilia
asbestos, infection, pe, drugs ( nitrofurantoin) , EGPA
105
if you have low glucose in pleural fluid
- <1 : ?
- 1-3
- RA & empyema
- SLE, TB, malignancy
106
high lymphoytosis in pleural fluid, what's you dx
tb vs lympohoma
107
chest tube insertion for parapneumotic effusion
PH <7.2
PH 7.2-7.4 w/ LDH >300
no pH but glucose < 3.3
108
other causes of low glucose in pleural fluid
tb
ra
109
how long tx parapneumotic efffusion
5-7D IV + long course
long course usually around 3 weeks ( BTS says about 2-6 weeks)
110
antibiotics for pleural infection
1. community |
2. hosp
1. 2/3 gen cephao + anaerobe : ctx+ mtx
2. gram neg + mra : tazo+vanco
111
risk factors for primary spont pneumothorax
1. smoker, marfan,thoracic endometriosis , fam hx
112
if symptomatic primary spont pneumothorax - what do you look for ?
what do you do ?
1. tension
2. bilat
3. hemopneumo
4. >50
5. smoker
6. significant hypoxia
admit and chest drain insertion
113
secondary spont pneumothorax. most common etiology?
COPD
114
chances of secondary spontaneous pneumothorax to spontaneously resolve ?
unlikely
115
follow up pneumothorax if conservative
2-4 days and then 2-4 weeks
116
sarcoid involvement
- 90% lungs
- about 30% extrapulmonary : cardiac, cns, eyes !!! ( and then rest liver, spleen, msk, kidney)
117
2 syndromes in sarcoid
1. lofgren
2. heerfordt
118
lofgren syndrome involves what
bilat hilar adnp
eryhthema nodosum
migratory polyarthralgia
fever
women >>>
spont remission often
119
heerford syndrome
anterior uveitis
parotid enlargement
fever (uveoparotid fever)
Facial palsy
120
pft w/ sarcoid looks like what?
anything !!!!!
normal, restriction, obstruction, or both (+/- reduced DLCO)
121
pulmo htn in sarcoid?
rarely
122
fibrosis s what state of sarcod ?
stage 4
123
another cutaneous sarcoidosis finding other than erythema nodosum ?
yes . lupus pernio
124
most common neuro finding of sarcoidosis ?
cranial nerve palsy
125
most common ocular sarcoidosis finding
anterior uveitis
126
how do you screen for abN in cardiac sarcoidosis
ekg for heart block +/- echo
cardiac mri
pet if concern
127
finding on cbc about sarcoidosis ?
lymphopenia
128
why ask alp in sarcoidosis ?
to screen for hep sarcoid
129
when steroid indicated in sarcoidosis ?
enhd organ failure from granulomatous inflammation
130
if skin disease refractory to steroids in sarcoid, what do you give ?
infliximab
131
if relapse on steroids while tx sarcoidosis, what other regimen to consider
mtx
132
fatigue in sarcoidosis, what to do ?
pulmo rehab
133
erythema nodosum in sarcoidosis, what to give ?
nsaids alone
134
definition of pulmonary htn ?
mean PAP >20 and PVR > 2WU
135
what on pft makes you sus about phtn
isolated low DLCO
136
tx of groupe 1 htn
endothelin r antagonist
prostanoid
pde5i
137
main cardiac dyhfct seen in groupe 2 pulmo htn
1. l heart dysfunction
2. diastolic dysfunction precisely
138
what is one widened A-a gradient condition which doesn't improve with 100% fio2
Shunts
139
if you have a young non smoker with hemoptysis and lung collapse, what are you suspecting and what should do for work up up
carcinoid ( endobronchial tumors)
TTE to rule out carcinoid heart ( TR)
140
single solid nodule . if <6 mm , but high risk, when to follow
ct in 12 months
141
single solid nodule. low risk. but 7 mm. when to follow ?
CT at 6-12 mos then consider 18-24mos
142
single solid high risk but 7.5 mm . when to follow?
CT at 6-12 mos, AND CT at 18-24 mos.
143
now single solid nodule , but >8mm. what to do ?
Consider CT at 3 mos, PET – CT or biopsy
144
multple solid nodules. 4 mm. what to do in low risk vs high riks
- low risk : nothing
- high risk : ct (optional) 12 months
145
now let's say >6mm multple solid nodules. they seem low risk. what to do.
CT at 3-6 mos, then consider CT at 18-24 mos*
146
let's say >6mm multple solid nodules. they seem high risk . what to do.
CT at 3-6 mos, and CT at 18-24 mos
147
