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IM RCPSC 2024 > Respirology > Flashcards

Respirology Flashcards

1
Q

Samter’s triad of ASA exacerbated respiratory disease

A

Asthma
Nasal polyps
ASA/NSAID sensitivity

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2
Q

Asthma Diagnosis requires these 2 features

A
  1. History of variable respiratory symptoms that vary over time and intensity
  2. Confirmed variable expiratory airflow limitation:
    NEED SPIROMETRY TO HAVE DIAGNOSIS OF ASTHMA
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3
Q

spirometry variability criteria for asthma diagnosis

A
  1. > 12% AND 200ml change in FEV1 with bronchodilator
  2. > 12% AND 200ml change in FEV1 after 4 weeks of treatment with anti inflammatory
  3. Excessive FEV1 variation in lung function between visits (>12% and 200 cc variation)
  4. Peak Flow Variability – Average daily diurnal PEF variability >10%
    – Excessive variability in twice daily PEF over 2 weeks
  5. Positive Bronchial Challenge Test or Exercise challenge test
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4
Q

Positive methacholine challenge for asthma

A

Methacholine Challenge – look for drop in FEV1 by 20%
– PC20 <4mg/mL = POSITIVE
– PC20 4-16 = borderline
– PC20 >16 = negative

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5
Q

Positive exercise challenge for asthma

A

Fall in FEV1 of >10% and >200mL from baseline

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6
Q

Assessing Asthma Control based on CTS 2021 guidelines

A

Daytime symptoms ≤ 2 d/week
Nighttime symptoms < 1d/ week and mild
Physical activity Normal
Exacerbations Mild (not requiring systemic steroids or ED visit) and infrequent
Absence from work/school due to exacerbation None
Need for a reliever (SABA or bud/fom) ≤ 2 doses per week
FEV1 or PEF ≥ 90% of personal best
PEF diurnal variation <10-15%
Sputum eosinophils <2-3%

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7
Q

Risk factors for severe asthma

A

any 1 of:
* Any history of a previous severe asthma
exacerbation (any of: requiring systemic
steroids, ED visit or hospitalization)
* Poorly controlled asthma per CTS criteria
* Overuse of SABA (=use of more than 2 SABA
inhalers per year)
* Current smoker

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8
Q

Severe asthma Exacerbation criteria as per CTS 2021

A

any 1 of
- Requiring systemic steroids
- Requiring ED visit
- Requiring hospital admission
Mild exacerbation = 0/3 above criteria

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9
Q

Asthma Treatment Step 1 and 2
(CTS 2021)

A

Low dose ICS and fometerol (LABA)
examples:
Symbicort
Zenhale
Fostair

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10
Q

Asthma treatment Step 3
(CTS 2021)

A

Low dose
maintenance ICS-formoterol
+ PRN

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11
Q

Asthma treatment Step 4
(CTS 2021)

A

Medium dose
maintenance ICS-formoterol
+ PRN Lose Dose ICS Formoterol

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12
Q

Asthma Treatment step 5
(CTS 2021)

A

Refer for phenotypic assessment,
+/- LAMA add on,
AntinIgE, Anti IL5, Anti IL4, Anti-TSLP.
Consider high dose ICS Formoterol.
PRN lose dose ICS formoterol

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13
Q

Non pharmacological management of Asthma

A

Educate + Written Asthma Action Plan
Weight loss, exercise training
Allergen / trigger avoidance / allergen
immunotherapy
Smoking cessation
Vaccinations
Avoid NSAIDs (and maybe beta blockers)
Comorbidities management (GERD, PND, Obesity)

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14
Q

indications for Leukotriene receptor agonist

A

Those intolerant of ICS
aspirin-exacerbated asthma,
exercise-induced symptoms,
allergic rhinitis
*Less effective than ICS at preventing exacerbations

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15
Q

Black box warning for leukotriene receptor agonists

A

Increased suicidality

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16
Q

LANCET AMAZES Trial 2017
Standpoint of Macrolides in severe Asthma

A

“In individuals >18 w severe asthma there is limited evidence that chronic use of macrolides may
decrease frequency of exacerbations

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17
Q

Indications for Anti-IgE (Omalizumab) in Asthma

A

allergic asthma IgE 30 – 700,
sensitive to at least 1 perennial allergen, severe despite high dose ICS and one other
controller
(CTS 2017)

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18
Q

Indications for IL-5 (mepolizumab, resilzumab, benralizumab) in asthma

A

severe eosinophilic asthma (generally >300) and
recurrent exacerbation despite high dose ICS and one other controller
(CTS 2017)

19
Q

Indications for IL-4/IL-13 (Dupilumab) in asthma

A

add-on option for severe eosinophilic asthma or
those with nasal polyposis or
moderate-severe atopic dermatitis

20
Q

how to make diagnosis of COPD

A

Spirometry is required to make the diagnosis, with a post-bronchodilator FEV1/FVC<0.70

21
Q

criteria for Mild Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Mild: FEV1 > 80% predicted

22
Q

criteria for Moderate Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Moderate: 50% < FEV1 < 80% predicted

23
Q

criteria for Severe Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Severe30% < FEV1 < 50% predicted

24
Q

criteria for very severe Airflow Limitation in COPD

A

In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Very Severe: FEV1 < 30% predicted

25
Q

non pharmacological management of COPD

A

Smoking cessation
Self education management
Exercise therapy
Vaccinations (Flu, Clovid, Pneumovax)

26
Q

Non-Pharmacology Managent of COPD with SURVIVAL benefit

A

Smoking cessation -survival for ALL
Oxygen -survival for severe resting hypoxia
Pulmonary rehab -survival in patient <4 weeks post AECOPD

27
Q

Indications for long term oxygen therapy

A

PaO2<55mmHg
PaO2<60mmHg with bilateral pedal edema
PaO2 < 60mmHg with cor pulmonale HCT >56%

28
Q

Modified MRC dyspnea scale

A
  1. Not troubled by breathlessness except on strenuous exercise
    1 Shortness of breath when hurrying on level or walking up slight hill
    2 Walks slower than people of the same age on the level b/c of breathlessness or has to stop for breath when walking at own pace on the level
    3 Stops for breath after walking about 100m or after a few minutes on the level
    4 Too breathless to leave the house or breathless when dressing or undressing
29
Q

Initial pharmacological therapy of COPD

A

LAMA (e.g. Spiriva)
Prevents acute exacerbations compared to LABA

30
Q

COPD management for moderate COPD
CAT >10

A

LAMA+LABA combo
(e.g. Inspiolto)

31
Q

COPD for severe COPD
(already on LABA/LAMA)

A

LAMA+LABA+ICS
(E.G. Trelogy)

32
Q

treatments to AVOID in COPD

A

– ICS monotherapy : increases risk of pneumonia
– Oral therapies (PDE-4i, PDE-5i, mucolytics, herbal remedies) have no evidence for symptomatic benefit in stable COPD

33
Q

Recommended oral therapies if ongoing exacerbations of COPD despite triple therapy

A

– Azithromycin (care: QTc, hearing impairment, sputum culture for NTM)
– Roflumilast if chronic bronchitis phenotype (caution: diarrhea and weight loss)
– NAC 600 mg BID if chronic bronchitis phenotype
– Recommend AGAINST theophylline to prevent exacerbations!

34
Q

Proposed required criteria for Asthma COPD overlap

A
  1. Diagnosis of COPD given risk factors, history, spirometry
  2. History of asthma (past history/diagnosis, current symptoms consistent, or
    physiology confirmed /w spirometry)
  3. Spirometry: post-bronchodilator fixed FEV1/FVC <0.7
35
Q

Supportive but not required criteria for diagnosis of Asthma COPD overlap

A
  1. Documentation of a bronchodilator improvement of FEV1 by 200ml or 12%
  2. Sputum eosinophils >3%
  3. Blood eosinophils >300 cells/uL (current or prev documented)
36
Q

Indications for antibiotic therapy in COPD

A

Antibiotics should be given in COPD in the presence of three cardinal symptoms (or two of the following if increased purulence is one of them):
1. Increase in dyspnea
2. Increase in sputum volume
3. Increase in sputum purulence
Should also be given if requires NIV or Intubation

37
Q

indications for BiPAP in COPD
(GOLD 2022)

A

Recommended if any of:
* pH ≤7.35 with pC02 ≥ 45
* severe dyspnea (impending respiratory failure)
* persistent hypoxemia despite supp oxygen

38
Q

Diagnosis/characterization of Bronchiectasis

A

Bronchiectasis is a chronic respiratory disease characterized by a clinical syndrome of cough, sputum production and bronchial infection, and radiologically by abnormal and permanent dilatation of the bronchi.

39
Q

Absolute contraindications to Methacholine challenge

A
  1. Severe airflow limitation FEV1<50% or <1L
  2. Recent MI or Stroke in last 3m
  3. Uncontrolled HTN, SBP >200/100
  4. Known Aortic Aneurysm
40
Q

Relative contraindications to methacholine challenge

A
  1. Moderate airflow limitation FEV1<60% or <1.5L
  2. Pregnancy or nursing mothers (methacholine is category C)
  3. Use of cholinesterase inhibitor (myesthenia gravis)
41
Q

Contraindications for Pulmonary function tests

A
    1. Hemoptysis
    1. Pneumothorax
    1. Unstable cardiovascular status including recent MI
    1. Aneurysms – thoracic, abdominal or cerebral
    1. Recent eye surgery – eg. Cataracts
    1. Recent thoracic or abdominal surgery
    1. Presence of acute illness that may interfere with test performance
42
Q

Definition of obstructive sleep apnea

A

Symptoms (sleepiness, choking, awakenings etc) and
Objective testing (> 5 apnea/hypopnea events during sleep monitoring)
* Mild 5-15 (events/h) / Moderate 15-30 / Severe >30

43
Q

Treatment options for obstructive sleep apnea

A

– Weight loss (diet/exercise)
– CPAP
* All patients should be offered therapy, asymptomatic patients should be treated if have comorbidities (ie. HTN), AHI >30, critical occupation
– Oral appliances – for mild-moderate disease
– Surgery (rare) – Tonsillectomy if appropriate, uvulopalatopharyngoplasty in select patients

IM RCPSC 2024 (9 decks)

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