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Flashcards in respiratory Deck (82):
1

obstructive lung dis.

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** (

2

air flow directly prop to...
indirectly prop to...

dir. prop to driving pressure
inv. prop to resistance

3

obstructive lung disease

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

4

*pathophys: what defines asthma?

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

5

asthma

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

6

B2 receptors, smooth muscl

adr: dilates
chol: constricts

7

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

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

8

asthma

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

9

asthma: rev or irrev airway narrowing?

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

10

asthma incidence: increasing?

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

11

dec. asthma risk with

breastfeeding

12

Curshcmann's spirals

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

13

Charccot-Leyden crystals

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

14

asthma triggers

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

15

symptoms of asthma

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

16

pulsus paradoxus

systolic will drop during inspiration by =>10mmHg

17

timeline of wheezing

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)

18

asthma: if no wheezing??

usually there is NO air movement
VERY SEVERE

19

asthma dx

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

20

asthma: CXR

hyperinflation (hyperexpansion) w/ flat diaphragms

21

asthma dx studies

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

22

findings in sev. asthma

-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

23

acid/base imbalance with asthma

respiratory acidosis from not blowing off CO2

24

accessory muscle use in asthma

"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

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