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respiratory Flashcards

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1
Q

obstructive lung dis.

A

obstruction air flow–>air trapping
airways close premat. at high lung vols–>inc. RV and dec. FVC
v. low FEV1 and low FVC–>dec. FEV1/FVC ratio (

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2
Q

air flow directly prop to…

indirectly prop to…

A

dir. prop to driving pressure

inv. prop to resistance

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3
Q

obstructive lung disease

A

airway narrowing w/ inc. airway resistance +/- dec. elastic recoil w/ dec. driving pressure (emphysema)

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4
Q

*pathophys: what defines asthma?

A 
airway inflammation (current med tx)
*mucosal edema*
inc. mucus production
airway narrowing
hypersensitivity/hyperreactivity
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5
Q

asthma

A

hyper reactivity of lungs causes mucosal edema, airway inflammation
why we don’t just give B2s, but steroids–>target inflammation not just dilation

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6
Q

B2 receptors, smooth muscl

A

adr: dilates
chol: constricts

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7
Q

work of breathing is inc. as air-trapping occurs:

A

diaphragm flattened

inspiratory musc. fibers shortened, so little opportun. for further contraction

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8
Q

asthma

A 
industrialized country disease (pollution) 3-5%
chronic airway inflammation maj. mech
hyperreactiv. to triggers
sm. musc hypertrophy (extra work)
can be fatal
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9
Q

asthma: rev or irrev airway narrowing?

A

reversible airway narrowing, bronchospasm, bronchoconstr. (type 1 hypersens. rxn of airways)
COPD is not reversible!!

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10
Q

asthma incidence: increasing?

A

YES: inc. mold, roaches (poop), and pollution

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11
Q

dec. asthma risk with

A

breastfeeding

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12
Q

Curshcmann’s spirals

A

spiral shaped mucus plugs in sputum
desquamated/shed epithelium forms whorled MUCUS PLUGS (see pic)
think asthma

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13
Q

Charccot-Leyden crystals

A

asthma
eosinophilic (allergy related), hexagonal, double pointed needle-like crystals
formed by breakdown of eosinophils in sputum

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14
Q

asthma triggers

A

infections** (URI, pneumonia)
stress
environ.: insects, pollen, mold, pollution, weather changes, air temp/humid.**
allergens (roach droppings, allergies)
subsets of asthma pts: hypersensitivity to Aspirin, NSAIDS (inc. react. w/ motrin, naprocen, etc.) aspirin as well

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15
Q

symptoms of asthma

A

persistent wheeze (may be audible (pretty bad) or with auscultation)
need to be able to tell if asthma pt. is sick or not sick!!
chronic episodic dyspnea
cough
CP, tightness, inc. sputum prod, tachypnea, hypoxemia, dec. I/E ratio, pulsus paradoxus, mucus plugging

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16
Q

pulsus paradoxus

A

systolic will drop during inspiration by =>10mmHg

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17
Q

timeline of wheezing

A

expiratory wheezes –> add inspiratory when more severe (entire phase is wheezing)

  • *end expiratory wheezing** is beginning of asthma
    dec. expiratory phase (3-4 sec–>2-3 sec)
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18
Q

asthma: if no wheezing??

A

usually there is NO air movement

VERY SEVERE

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19
Q

asthma dx

A

Pulm. Func tests: dec. FEV1 which IMPROVES w. bronchodilator
inc. serum IgE and eosins
allergy testing

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20
Q

asthma: CXR

A

hyperinflation (hyperexpansion) w/ flat diaphragms

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21
Q

asthma dx studies

A

measu. of airway reactivity after graded challenge w. inhaled METHACHOLINE or HISTAMINE
bronchoconstriction occurs at LOWER doses in asthma

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22
Q

findings in sev. asthma

A

-speech difficulty
diaphoresis: implies they are sick!!**
-**fatigue: worrisome when become conversationally dyspnic (“are you feeling ok?”)-check in
-hypoxia: attempt to rip off mask; ominous during breathing tx
orthopnea: can’t lay down, diff. to intubate
agitation, somnolence, confusion

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23
Q

acid/base imbalance with asthma

A

respiratory acidosis from not blowing off CO2

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24
Q

accessory muscle use in asthma

A

“belly breathing”, retractions (gut sucks in, ribs stick out)
take shirt off!
tracheal tugging: ant. portion of neck pulls in and out (type of retraction, suprasternal notch)
nasal flaring

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25
questions to ask every pt having an asthma attack
*ever been intubated?* red flag-high risk how many times? last ED visit? how often? last attack? for you, is this a mild, mod, sev. attack compared to previous? -det. baseline trigger? document
26
obstructive lung diseases
``` asthma bronchiectasis emphysema chronic bronchitis bronchiolitis CF ```
27
albuterol inhaler
``` rescue inhaler! acute tx why use? to quickly bronchodilate, NOT a maintenance program, should not be used every day B2 agonist, relaxes bronch sm. musc SE: tachycardia, tremors inhaler or nebulizing tx ```
28
chronic asthma tx
peak flow monitoring: >500 is GOOD (200s is worrisome) - inhaled corticosteroids: aerobid, azmacort, flovent pulmicort, advair - B2 agonist-Albuterol - antichol-Atrovent - Leukotriene inhib.-singulair - mast cell stabilizer-cromolyn
29
salmeterol (serevent), formoterol
B2 agonist LONG ACTING PPX agent, not for acute SE: tremor, arrhythmia inhaled, inc. in deaths in asthmatics???
30
Methylxanthines
older drug, Marshall dislikes theophylline: : bronchodilator, narrow therapeutic index: SE: cario and neuro tox: arrhythmias, seizures blocks adenosine* metab. by P450 inhib. phosphodiesterase-->lowers cAMP hydrolysis-->inc. cAMP
31
Muscarinic antagonist
*atrovent-(ipratropium)* anticholinergic, comp. block competitive block of musc rec, prev. bronchoconstr. often used simultaneously w. albuterol *DUONEB*
32
Tiotropium
long-acting musc. antagonist
33
Cromolyn sodium
prev. rel. of mediators from mast cells (mast cell stabilizer, prev. mast cell degranulation) pox only, QID dosing?? dec. compliance largely repl. by leukotriene rec. antagonist
34
corticosteroids
fluticasone, budesonide, prednisone* (today give out like candy) can give IV: Solumedrol, about 6 hours to work
35
corticosteroid action
inhib. syn. of virtually all cytokines * FIRST LINE THERAPY* for chronic asthma - txs inflammation, reduces narrowing, most important - takes about 6 hrs to work
36
what really helps people
*inhaled corticosteroid:* prevents asthma attacks | take 1-2x day
37
antileukotrienes
Zafirlukast, montelukast -v. expensive, blocks leuk rec, v. good for aspirin-ind. asthma Zileuton -v. expensive, liver toxic SE, 5-LOX pathway inhibitor, blocks conversion of arachidonic acid to leukotrienes *prevent attack, do not tx symptoms*
38
cure for asthma?
NO | if using albuterol inhaler few times a week: uncontrolled
39
Omalizumab
MoAb anti IgE Ab binds mostly unbound serum IgE used in allergic asthma resistant to inhaled steroids and long acting B2 agonists
40
real life management
albuterol +/- atrovent neb: all pts | -if using often, need inh. corticosteroid
41
asthma pt presents to ER
DUONEB: albuterol + atrovent: all pts prednisone PO or Solumedrol IV: all pts (95% pts) Mag 2 gs IV over 20 min (mod-->sev. pts) -sm. musc relaxer terbutaline (bronchodil.-B2) SQ, or EPI SQ (v. severe pts) (Marshall dislikes cardiac effects of EPI) *last ditch effort!* O2: all pts Bipap: sev. and worse pts Intubation worst cases: difficult, *will desat. very fast!* Heliox: combo of helium and oxygen: makes air thinner, into airways w/ less resistance
42
Bipap
``` like Cpap: used for sleep apnea control inspiratory and expiratory pressures lets O2 in, sucks CO2 out be careful about barotrauma pts. need to be cooperative! ```
43
dx test to consider
consider CXR, ABG (Marshall already knows results) ensure no pneumonia, no dropped lung, etc -if following pts, consulting pulmonology
44
peak flow
how bad is asthma? improving? can take home, know what zone they are in
45
COPD
emyphsema chronic bronchitis will usually co-exist in same pt!** same: PE (lung sounds), etiology, tx, phys. tx and imaging
46
COPD etiology
SMOKING (if stop: 0% of damage done will be reversed :( ) slowly progressive, pts. blow off bc they get used to sym -dec. abs response to bronchodilators -inc. prevalence with age *4th leading cause of death in US!*
47
COPD: rev. or irreversible obstruction?
IRREVERSIBLE obstruction
48
first sign of COPD
DOE: dyspnea on exertion
49
COPD is how serious
4th leading COD in US!
50
COPD signs
``` pulmonary HTN inc. AP diameter of chest (cough, SOB, wheezing) access. musc use dec. breath sounds prolonged expiratory phase inc. A-P diameter cyanosis (ends up on home O2) ```
51
COPD causes
a1-antitrypsin deficiency smoking accounts for up to 90% (a lot of times called asthma) air pollution airway hyperresponsiveness (Dutch hypothesis) : unclear mechanism
52
COPD lab findings
polycythemia (chr. hypoxemia) (not for asthma) a1-antitrypsin level (when younger than 40 yo) sputum: S. pneumo, H. flu most common during exacerbation
53
ABG shows
hypoxemia, with or without hypercapnia
54
lung CT shows:
alveolar walls breakdown-->non-func airspace coalesce-->bullae LONG, DARK AIR COLUMNS : dark: not much long tissue left, air trapping, hyperinflation flattened diaphragm narrow hear shadow
55
COPD PFT's
essential to dx FEV1 forced expiratory volume in 1 sec; most common used index of airflow obstruction TLC, FRC, RV all increased
56
COPD walking distance
how far can you walk in 6 minutes? good predictor of mortality -desat/hypoxic, higher risk
57
emphysema
distinction does not matter as much clinically "Pink puffer" *air spaces enlarge as alveolar walls are destroyed* air pockets (non-functioning) loss of elastic recoil-can't exhale inc. air trapping inc. compliance due to loss of elastic fibers -lose natural recoil that helps you exhale
58
bullae in emphysema
alveoli can coalesce to form bullae that compress normal lung, can compress on normal, functioning lungs
59
emphysema: less alveoli cause
dec. diffusion capacity
60
inc. elastase activity-->loss of elastic fiber
increased compliance
61
centriacinar emphysema
smoking
62
panacinar emphysema
**think a1-antitrypsin def.** | more diffuse, involving entire acinus
63
chest shape in emphysema??
barrel shape
64
emphysema pts breath how
pursed lips : self-taught or learned | increases airway pressure and prevents airway collapse during respirations
65
why are emphysema pts slender?
takes more work to breathe, | also sit forward
66
a1-antitrypsin deficiency
principal endogenous antiprotease: protects from elastase: uncont. elastase-->lose elasticity of lungs -genetic, premature
67
emphysema CXR
- hyperinflated lung (may see bottom of heart)-low flattened diaphragm - "arterial deficiency": don't see many arteries - hyperinflation - bullous disease * may be mistaken for pneumothorax!* - ->if not sure, get a CT scan
68
emphysema lung
pockets of non-func space | -cigarrette tar: carbon deposits
69
Bullae
pocket of non-func. tissue | may need to be surg. removed
70
Chronic Bronchitis
"blue bloater" airway walls become *deformed* (not "eaten away* like emphysema) and structurally altered due to atrophy, inflammation, smooth muscle hypertrophy, mucus hypersecretion in airway lumen Productive cough for MORE THAN 3 MONTHS per year, for at least 2 YEARS—does not have to be consecutive -Small airway disease -Mucus gland enlargement, (*hypertrophy of mucus gland*) is histologic hallmark -Hyperplasia of mucus secreting glands in bronchi
71
Reid index
gland layer depth/total bronchial wall thickness: | >50% ind. COPD (need to be dead!!)
72
symptoms of bronchitis
``` Wheezing Crackles Cyanosis Early onset hypoxemia due to shunting Late onset dyspnea (not as quick as emphysema pts) CO2 retention polychythemia ```
73
COPD tx
``` education oral and inhaled meds (same as asthma..) stop smoking pulm. rehab BiPaP surg (vol. reduction, bullectomy, lung txp) O2 ```
74
COPD tx: bronchodilators
Beta 2 agonist (albuterol inhaler) Anticholinergics (atrovent/ipratropium inhaler) Long acting
75
COPD tx: anti-inflammation
Steroids (solumedrol, prednisone) | Inhaled corticosteroids
76
COPD tx: abx?
MAYBE; pot. to be inf-related
77
COPD O2 therapy
-for supplementation in acute disease, home O2 for chronic lung disease
78
COPD:chronic hypoxic pt: CAUTION**
***O2 can worsen hypercapnia ***dec. hypoxia resp. drive **("CO2 retainers")**-chronically elevated, small subset of COPD pop CO2: 50-60! (should be 30-40) lost ability to breathe due to high CO2 levels (no longer acts as trigger, chron. elevated)-->if goes higher, CO2 narcosis -need for O2 only stimulation to breathe *never withhold O2 for hypoxic pt* -if give O2: fall asleep slowly, hypoventilate-->resp. arrest
79
how can you tell if pt. is retaining CO2??
ABG: - non-CO2 retainer: if elevated CO2, IF ACUTE: low pH, bicarb will be normal (kidneys cannot respond/adapt that quickly! takes days) - if CO2 retainer: elevated CO2, NORMAL (typ.) pH, bicarb will be HIGH (chronically elevated to comp. for CO2) -corrected resp. acidosis
80
how to give O2 if CO2 retainer
titrated O2, can't handle too much, will hypoventilate | *BiPaP is awesome for this* takes CO2 out
81
other things about asthma
B blockers can worsen (also COPD) | consider GERD if adult onset asthma
82
restrictive lung disease
dec. TLC

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