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Internal Medicine: PGY-1 > Respirology > Flashcards

Respirology Flashcards

1
Q

Asthma diagnosis?

A

1) History of variable resp sx

2) Confirmed variable expiratory airflow limitation:
Expiratory airflow limitation:
- confirm reduced FEV1/FVC (below lower limit of normal)

Excessive variability in lung function
- Spirometry: reduced FEV1/FVC; improves FEV1 by >12% AND 200mL post-BD or after 4 weeks of anti-inflam tx
- Excessive variability in BID PEF over 2 weeks (>10%)
- Exercise challenge: FEV1 drop >10% + >200mL from baseline
- Methacholine challenge: look for FEV1 drop by 20% [PC20 < 4mg/ml = POSITIVE; PC20 4-16 = borderline; PC20 >16 = NEGATIVE]

3) Airflow limitation may not be present at time of initial assessment [normal Spiro, but still have asthma), repeat spiro at time of symptoms

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2
Q

Asthma symptoms cutoff?
- Daytime symptoms
- Nighttime symptoms
- Physical activity
- Exacerbations
- Absence from work/school d/t exacerbations
- Need for a reliever (SABA or bud/fom)
- FEV1 or PEF
- PEF diurnal variation
- Sputum eosinophils

A
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3
Q

Definition of asthma?

A
  1. Heterogenous disease characterized by chronic airway inflammation
  2. Sx: wheeze, SOB, chest tightness, cough, airway wall thickening, increased mucous, and variable expiratory airflow limitation
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4
Q

Asthma phenotypes? (5)

A
  1. Allergic: classic asthma, atopy, eosinophilic inflam, responds to ICS
  2. Non-allergic: neutrophilic, eosinophilic or paucigranulocytic inflam; less response to ICS
  3. Adult-onset: non-allergic, require higher ICS, r/o occupational asthma
  4. Associated with obesity: little eosinophilic inflam
  5. Associated with persistent airflow limitation: longstanding asthma causing fixed obstruction d/t airway remodelling
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5
Q

DDx - Asthma:
- Sneezing, itching, blocked nose, throat clearing
- Dyspnea, inspiratory wheezing
- Dizziness, paresthesia, sighing
- Productive cough, recurrent infections
- Excessive cough + mucus
- Cardiac murmurs
- SOB, FHx emphysema
- Sudden onset sx
- Chronic cough, hemoptysis, SOB, b-sx

A
  • Chronic upper airway cough syndrome
  • Inducible laryngeal obstruction
  • Hyperventilation, dysfunctional breathing
  • Bronchiectasis
  • CF
  • CHD
  • A1-AT deficiency
  • Inhaled FB, PE
  • TB, cancer
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6
Q

Asthma treatment?

A

As needed low-dose ICS-form –> low dose –> med dose –> add-on LAMA

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7
Q

Risks of SABA PRN as sole reliever?

A
  • Increased risk of exacerbation
  • Decreased lung function
  • Regular use increases airway inflammation
  • Over-use associated with increased severe exacerbations and asthma-related death
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8
Q

Benefits of PRN Bud-Form in Asthma?

A
  • Reduces symptoms, exacerbations
  • Reduces asthma-related hospitalizations vs. SABA alone
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9
Q

Before stepping up therapy in asthma - what should you do?

A

Confirm inhaler technique and adherence
All non-pharm:
- confirm dx, educate, written asthma action plan
- weight loss, exercise training
- allergen/trigger avoidance; allergen immunotherapy
- stop smoking
- vaccinations
- avoid NSAIDs +/- BB
- co-morbidities (GERD, PND, obesity)

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10
Q

If asthma patient unable to tolerate ICS, what can be done instead? But?

A

LTRA: less effective than ICS at preventing exacerbations

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11
Q

LTRA most effective in which cases of asthma?

A
  • Aspirin-exacerbated
  • Exercise-induced symptoms
  • Allergic rhinitis
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12
Q

LTRA has a ‘use’ warning - for what?

A

FDA black box: increased suicidality in teens/adults

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13
Q

What is considered severe vs. mild asthma exacerbation?

A

Severe: any 1 of
- requiring systemic steroids
- requiring ED visit
- requiring hospital admission

Mild: 0/3 above criteria

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14
Q

Patient with Sampter’s triad (ASA allergy, asthma, nasal polyps), whose asthma not well-controlled on low-dose ICS. What do you add?

A

LTRA given ASA-exacerbated asthma

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15
Q

Definitions - Asthma: uncontrolled vs. severe

A

Uncontrolled:
- poor sx control
- frequent exacerbations (>2/yr) requiring OCS
- >1/yr serious exacerbation requiring admission

Severe:
- asthma requiring high-dose ICS-LABA + 2nd controller
- OCS for >50% of year to maintain control
- asthma worsens when therapy decreased

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16
Q

If severe asthma, what further investigations should you consider sending?

A
  • CBC, CRP, ESR, IgG, IgA, IgM, IgE, fungal precipitins (including aspergillus) +/- ANCA, BNP, TTE, CT sinuses
  • CXR, DLCO, DEXA scan, HRCTC
  • Allergy IgE testing for relevant allergens
  • Consider screening for adrenal insufficiency in patients on OCS of high-dose ICS
  • If blood eosinophils >300, look for non-asthma causes (parasites, strongyloides, blood, stool); if >1500, consider EGPA
  • Sputum eosinophils, FeNO (to look for type 2 airway inflam)
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17
Q

Treatment of severe asthma?

A

Should be on at least mod ICS/LABA before considering:
- LAMA, LM/LTRA
- Low-dose Azithro
- Biologics (must meet criteria)
- Low-dose OCS
- Bronchial thermoplasty

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18
Q

Criteria for biologics in Asthma?

A

1) Anti-IgE (omalizumab)
2) Anti-IL5 / Anti-IL5R (benralizumab, mepolizumab)
3) Anti-IL4R (dupilumab)
4) Anti-TSLP (tezepelumab)

  • If allergies + high IgE = think Omalizumab
  • If high eosinophils, think about all other biologics
  • TEZEPELUMAB = does NOT require any biomarkers to Rx so Resp excited about this!
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19
Q
  • What is ABPA?
  • Criteria?
  • Treatment?
A
  • Chronic exposure to Aspergillus causing S&S
  • Asthma, pulm. infiltrates, skin+serum precipitins to aspergillus, increased total IgE + aspergillus specific IgE >1000, increased eosinophils, central bronchiectasis
  • Prednisone +/- itraconazole
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20
Q

COPD Severity Criteria?
- FEV1
- Diagnosis must contain what?

A
  • Mild: >80%
  • Mod: 50-80%
  • Severe: 30-50%
  • Very Severe: <30%
  • Spirometry with post-bronchodilator FEV1/FVC <0.70
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21
Q

What is CAT/mMRC? Grading system?

A
  • Dyspnea scales
  • mMRC: 0-4 [4 being worst]
  • CAT: 0-40
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22
Q

COPD classification systems: GOLD, E, A, B

A

1) GOLD
- 1: >80%
- 2: 50-80%
- 3: 30-50%
- 4: <30%

2) E, A, B
- E: >2 mod COPDE or >1 leading to hospitalization
- A: 0-1 mod COPDE not leading to admission; mMRC 0-1
- B: 0-1 mod COPDE not leading to admission; mMRC >2

23
Q

Which test should always be done once when patient diagnosed with COPD?

A

Alpha-1-antitrypsin

24
Q

Non-Pharm Tx of COPD?

A
  • Smoking cessation
  • Vaccination
  • Pulmonary Rehab
  • Supplemental O2
  • Self-management/education
  • Review inhaler technique
  • EOL care (palliation, dyspnea mx)
25
Which non-pharm Tx aid with SURVIVAL benefit in COPD?
- Smoking cessation - Long-term O2 therapy (for severe hypoxiemia, PaO2 <55) - Pulm rehab
26
Treatment of COPD is based on what? (and not on what)
- Level of dyspnea + exacerbations - NOT: lung function
27
Overall, inhalers work to improve what?
- Reduce symptoms - Increased activity level - Increase health status
28
COPD treatment escalation?
1) mMRC 1: LAMA 2) mMRC >2: - Low risk: LAMA/LABA - High risk: LAMA/LABA/ICS Risk Level: - High: >2 COPDE in < 1yr or > 1 requiring hospitalization
29
Why is ICS not given as monotherapy?
Increased risk of PNA
30
Why are oral therapies (PDE-4i, PDE-5i, mycolytics, herbal remedies) are not part of COPD treatment guidelines?
No evidence for symptomatic benefit in stable COPD
31
If recurrent COPDE, what other therapies can be added? Non-pharm?
1) Pharm - Azithromycin: high-risk COPDE (QTc, hearing impairm., sputum cx for NTM) - Roflumilast: chronic bronchitis type (diarrhea, wt loss) - NAC: chronic bronchitis type 2) Non-Pharm - Flu vaccine, pneumococcal, TdAP, Covid-19, Shingrix - Smoking cessation - Pulm rehab - Education, inhaler technique
32
If starting COPDer on prophylactic Azithromycin, what test should you do at baseline? (2)
- ECG: QTc - Sputum culture: non-TB mycobacteria (NTM)
33
What therapies can be instored for dyspnea management in advanced COPD? Which are NOT?
Recommended: - Oral opioids - NM electrical muscle stimulation - Chest physio - Walking aids - Pursed-lip breathing - Continuous O2 NOT recommended: - Anxiolytics, antidepressants - Supplemental O2 in non-hypoxemic patients - Not enough evidence acupuncture, acupressure, distractive auditory stimuli, relaxation, handheld fans, psychotherapy, etc.
34
When to suspect Asthma/COPD overlap?
- COPD risk factors - COPD sx (sputum, dyspnea, cough, exercise limitation) - Hx of allergy, atopy, asthma (child, MD dx, wheeze, exacerbation, supportive physiology) - Pre/post bronchodilator spirometry
35
Asthma/COPD overlap diagnostic criteria?
Required - Dx of COPD given risk fx, hx, spirometry - history of asthma (PMHx, current sx, confirmed on spiro) - spirometry: post-broncho fixed FEV1/FVC <0.7 Supportive, but NOT required - documentation of broncho improvement FEV1 by 200ml or 12% - sputum eosinphils >3% - blood eosinophils >300 (current or prev)
36
What is the significance of asthma/COPD overlap?
- Worse prognosis/outcomes - More exacerbations - Decreased lung function - Poorer QoL - Increased mortality
37
Asthma/COPD overlap treatment? Caveat?
- 1st line: LABA/ICS - Refractory sx: add LAMA - Caveat: no RCT addressing this population (asthma trials exclude smokers, COPD trials exclude asthmatics)
38
Indications for O2 therapy in stable COPD?
- PaO2 <55 or sats <88% with or w/o hypercapnia - PaO2 55-60 with evidence of right-heart failure [pHTN, peripheral edema to suggest CHF, or polycythemia (hct above 55%)]
39
When should home O2 be reassessed?
60-90 days after initiation
40
Indications for NIV? (3)
1. Resp acidosis (CO2 >45 or <7.35) 2. Severe dyspnea (impending resp failure: resp fatigue, WOB) 3. Persistent hypoxemia despite supp. O2
41
What is the 1 year mortality rate after COPDE? How much mL of FEV1 is lost after AECOPD?
- ~30% vs. 23% with MI! - ~8mL/yr
42
Antibiotics in COPDE should be given when?
- 3 cardinal sx: dypnea, sputum volume + purulence - 2 of above **IF** purulence is one of them - If patient require invasive/NIV
43
What is bronchiectasis?
- Chronic resp disease - Characterized by clinical syndrome of cough, sputum production, bronchial infection AND imaging of permanent/abnormal dilatation of bronchi
44
Most common symptoms of bronchiectasis?
- cough - sputum production and/or hemoptysis - rhinosinusitis - thoracic pain
45
List few causes of bronchiectasis. What are the 2 most common ones which account for 50% of cases?
1. postinfectious (prior PNA, pertussis, NTM, TB) 2. idiopathic 3. Humoral immunodeficiency 4. CF 5. Autoimmune/CTD 6. IBD 7. ABPA 8. Aspiration 9. Congenital 10. PCD 11. Alpha-1-AT
46
List workup plan for bronchiectasis.
- Based on H&P [think of diff. causes of Dx] - All: CT chest, PFT - Serum Ig - Sputum cultures - CF (sweat test), Primary ciliary dyskinesia (nasal nitric oxide) - ABPA: blood count, total IgE, sensitization to aspergillus (IgE specific Ab or skin prick) - Consider: ANA, RF, anti-CCP, ANCA, A-1-AT, videofluoroscopic swallow, HIV
47
Mainstays of treatment for bronchiectasis? Advacned therapies?
Maintsay: - Airway clearence: breathing techniques - Mucoactive: hypertonic saline - Abx: inhaled colistin or gent (if PsA colonized), chronic Azithro (if recurrent exacerbations) - Puffers: unless CI'd; do **NOT** routinely offer ICS, oral steroids, PDE4-I - Pulm rehab: if mMRC >1 - Vaccines: flu, pneumococcal, TdAP, Covid) - Supp. O2 (same criteria as COPD) Advanced therapies: - Consider surgery, lung resection - Transplant: massive hemoptysis, severe PH, ICU admissions or resp failure (require NIV) - Consider NIV if resp failure with hypercapnia, esp if recurrent admissions
48
Bronchiectasis exacerbations: treatment?
- Sputum cultures - Empiric Abx, typically 14 days - If major hemoptysis, IV Abx, TXA +/- embolization
49
Typical UIP pattern on CT?
- reticular changes - subpleural, basal - honeycombing - absence of inconsistent features
50
What is Light's criteria?
Exudate if 1 or more met: - Protein fluid : serum >0.5 - LDH fluid : serum >0.6 - Pleural fluid LDH >2/3 ULN for serum LDH
51
Pleural effusion. Which cancer cannot be diagnosed from cytology?
Mesothelioma. Need pleural biopsy.
52
Indications for thoracentesis?
- Suspect exudate - Cause unclear - Paranpneumonic effusion: if less 1cm fluid on lateral decubitus in context of PNA, can forgo sampling and follow radiographically
53
Indications for chest drain/tube?
- drainage of pus/cloudy - positive gram stain/culture - pH <7.2 (if unavailable, use glucose <3.4) - >50% of hemithorax or loculations on imaging

Internal Medicine: PGY-1 (17 decks)

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