Restrictive and Obstructive lung diseases Flashcards Preview

Gen Med Unit 6 > Restrictive and Obstructive lung diseases > Flashcards

Flashcards in Restrictive and Obstructive lung diseases Deck (101):

What are the intrinsic restrictive lung diseases?

1. Pneumoconiosis
A. Asbestosis
2. Radiation Fibrosis
3. RA
5. Hypersensitivity Pneumonitis
6. Pulmonary Fibrosis
A. Sarcoidosis
B. Idiopathic
C. Eosinophilic Pneumonia
7. Drugs
A. Methotrexate
B. Amiodarone
C. Bleomycin


What are the extrinsic restrictive lung diseases?

1. Asthma
2. Dz restricting lower thorax/abd volume
A. Obesity
B. Diaphragmatic hernia
C. Ascites
3. Chest wall deformities
A. Pectus Excavatum
B. Kyphosis


What are examples of obstructive lung diseases?

Chronic obstructive pulmonary disease (COPD)
Cystic Fibrosis


What is the FEV1/FVC ratio in obstructive lung diseases?

FEV1/FVC ratio < 0.7
Inability to exhale 70% of their breath within one second


Define asthma

Chronic inflammatory disorder of the airways


What are the characteristics of asthma?

Variable and recurring sx’s
Airflow obstruction
Hyperactive (hyper-responsive) airways


What is the epidemiology of asthma?

1. Diagnosed by age 7 in 75% of cases
2. Childhood asthma: males > females
3. By age 40: female adults > male adults
4. Blacks > whites
5. Death rates highest among black males ages 15-24 yr


What is the pathophys of asthma?

Inflammatory cell infiltration with eosinophils, neutrophils, and T lymphocytes

Plugging of small airways with thick mucus
Collagen deposits beneath basement membrane
Hypertrophy of bronchial smooth muscle
Airway edema
Mast cell activation


What happens to the sensitivity/reactivity in asthma?

Leads to airway hyper-responsiveness (hyperactivity) and ↓ airflow


What are the exacerbating factors for asthma?

1. Atopy: atopic dermatitis, excema
2. Obesity
3. Exercise
4. URI
5. Gastroesophageal reflux disease (GERD): may have silent reflux, not responding to asthma tx, may respond to proton pump inhibitor and asthma meds
6. Changes in weather
7. Stress


What common allergens are asst. with asthma?

1. Environmental causes
A. Dust mites
B. Animal dander
C. Pollen


What are the sxs of asthma?

1. Episodic dyspnea
2. Chest tightness
3. Persistent cough (↑ am & hs)
4. Wheezing
5. Increased nasal secretions
6. Nasal polyps
7. Eczema


What dx studies are used to diagnose asthma?

1. Symptomatic adults and children > 5yo
A. Spirometry- useful to distinguish asthma from COPD
-Measurement of FEV in one sec (FEV1) and FVC
B. PFT’s
-↓ FEV1, normal FVC, decreased FEV1/FVC ratio
C. Peak Expiratory Flow Meter (PEF)


When do PFTs improve in asthma pts?

1. after trial of bronchodilator
A. Significant reversibility
≥ 12% and 200 ml in FEV1 OR
≥ 15% and 200 ml in FVC after inhaling short acting bronchodilator


What Peak expiratory flow results indicate poorly controlled asthma?

1. Comparison with one’s own baseline is most effective at predicting exacerbations
A. 20% change in PEF values from morning to afternoon or from day to day indicates poorly controlled asthma


What are the risk factors for asthma?

1. Personal Hx of atopic diseases
2. FH of atopy and/or asthma
3. Smoking
A. Active or 2nd-hand smoke
4. Occupational exposure
5. Home heating system


What is a positive methacholine challenge (bronchoprovocation testing) test? When is it indicated?

1. Useful when asthma is suspected but PFT’s are non-diagnostic
2. Positive test
≥ 20% fall in FEV1 at exposure to concentration of 8 mg/ml or less


What are the steps in methacholine challenge test

1.) Perform PFT
2.) Inhale nebulized methacholine
3.) Repeat PFT
4.) Repeat using increasing doses until reaction
20% decrease in FEV1= bronchospasm
5.) Inhale nebulized albuterol to reverse effect


When is methacholine challenge contraindicated?

1. FEV1 < 65% of predicted
2. MI or CVA w/in last 3 mos.
3. Known aortic or cerebral aneurysm
4. Uncontrolled HTN SBP>200 or DBP>100
5. Pregnancy/nursing mothers


When are ABGs indicated in asthma?

1. Typically done if patient in distress
2. Normal early in asthma exacerbation
3. During severe exacerbations, patients may retain CO2  Respiratory Acidosis


What are the signs of impending respiratory failure?

1. Change in level of consciousness
2. Cyanosis
3. Pulsus paradoxus > 10 mm Hg
A. Abnormally large decrease in systolic BP and pulse wave amplitude during inspiration
B. Normal fall in pressure is less than 10 mmHg
4. O2 saturation < 90%
5. pCO2 > 45 mmHg


What factors impact the decision to hospitalize an asthma pt?

1. Duration & severity of sx’s
2. Severity of airway obstruction
3. Course & severity of prior exacerbations
4. Medication use at time of exacerbation
5. Access to medical care
6. Adequacy of social support


When is a cxr indicated for asthma?

Indicated when ruling out pneumonia or pneumothorax


When is skin testing indicated in asthma pts?

Identifies allergens that may be triggers for asthma


What are the complications asst. with asthma?

1. Exhaustion
2. Dehydration
3. Airway infection
4. Tussive syncope
A. Neurally mediated reflex vasodepressor-bradycardia response to cough
5. Severe asthma attack can be fatal if untreated


What are the 4 components of chronic asthma management?

1. Assessing & monitoring asthma severity and asthma control
2. Patient education
3. Control of environmental factors & co-morbid conditions
4. Pharmacologic agents


What are 2 ex of beta 2 agonists used in asthma?

1. Albuterol (Ventolin HFA, Proventil HFA, Pro-Air)
2. Levalbuterol (Xopenex)


What is the MOA of beta 2 agonists?

Short acting bronchodilator:
Relax airway smooth muscle  prompt increase in airflow (onset of action < 5 mins)


When should beta 2 agonists be used?

1. Can be used before exercise in EIB
2. PRN use (rescue inhaler)


What is an ex of a mast cell stabilizer?

Cromolyn (Intal MDI)


What is a mast cell stabilizers used for?

Short term asthma treatment


What are OTC asthma meds?

Ephedrine/guaifenesin (Bronkaid, Primatene Tabs)


What general class of meds are used in long term control of asthma and COPD?

Anti-inflammatory agents
Inhaled corticosteroids


What are examples of inhaled corticosteroids?

Flunisolide (AeroBid) MDI
Beclomethasone (Qvar) MDI
Ciclesonide (Asmanex) Twisthaler
Fluticasone (Flovent) Diskus or HFA
Budesonide (Pulmicort) (peds)


What is the first line treatment for long term control of asthma? How do they work?

1. Inhaled corticosteroids
A. Reduce swelling and inflammation


What are examples of systemic corticosteroids for short term control of asthma?

Prednisone/Prednisolone oral
Methylprednisolone (Solu-Medrol) IV


When are systemic corticosteroids indicated for short term control of asthma?

1. Effective for exacerbations and for patients with poorly controlled asthma
2. Reduce edema when inhaled corticosteroid not effective
3. Taper dose to minimum dose to control sx’s
4. Rapid discontinuation of long term steroids after long term use can lead to adrenal insufficiency


What are examples of long acting beta 2 agonist bronchodilators for asthma?

Salmeterol (Serevent) Diskus
Formoterol (Foradil) caps (Perforomist) sol.
Arformoterol (Brovana ) sol


What are the indications for long acting beta 2 agonist bronchodilators for asthma? How do they Work?

1. Provides bronchodilation for up to 12 hrs
2. Relaxes airway smooth muscle
3. Indicated for long term prevention of asthma sx’s & nocturnal sx’s


What are examples of long acting combined beta 2 agonist and inhaled steroids bronchodilators for asthma?

1. Fluticasone/salmeterol (Advair)
2. Budesonide/formoterol (Symbicort)
3. Mometasone/formoterol (Dulera)


What is the efficacy of ong acting combined beta 2 agonist and inhaled steroids bronchodilators?

1. Very effective at managing asthma
2. Efficacy same as doubling dose of steroids with fewer side effects


What are the effects and side effects of OTC asthma meds?

1. Thins secretions
A. Caution-raises BP
Ephedrine/guaifenesin (Bronkaid, Primatene) Tab


What is an example of a Phosphodiesterase inhibitor used for asthma?

Theophylline oral/IV


What are the effects and side effects of Theophylline?

1. Provides mild bronchodilation, decreases inflammation, enhances mucus clearance and strengthens diaphragm contractility
2. Limited use due to S/E:
A. Tachycardia, nausea, vomiting, seizures
B. Blood level monitoring required
C. Use for hs exacerbations if all other meds fail


What are the effects and side effects of immunomodulators for asthma?

1. Inhibits IgE binding to mast cells & eosinophils
2. Decreases mediator release
3. Changes behavior of immune system
4. >12 yr
5. Risk of anaphylaxis


What is an example of an immunomodulator used for asthma?

Omalizumab (Xolair) SQ q 2wks


What is an example of a leukotriene inhibitor used for asthma?

Montelukast (Singulair)
Zileutin (Zyflo)
Zafirlukast (Accolate)


What are the effects and indications of leukotriene inhibitors for asthma?

1.Provide bronchodilation, decreases vascular permeability and mucus secretion and activate anti-inflammatory response
2. Alternative in patients who are not well controlled on inhaled corticosteroids


When is desensitized recommended for asthma pts?

Recommended for specific allergens that contribute to asthma sx’s


What vaccinations are indicated for asthma pts?

Flu vaccine
Pneumococcal vaccine (Pneumovax/Prevnar)


What side effect is asst. with inhaled corticosteroids?



Define mild and moderate exacerbations of asthma

1. Mild exacerbation
A. PEF > 80%
B. Minimal sx’s
2. Moderate exacerbation
A. PEF 40 – 79%
B. Chest tightness, wheezing, hypoxemia


Define severe asthma exacerbation

1. Life threatening
2. PEF < 50%
3. Severe sx’s
4. Use of accessory muscles
5. Cyanosis


What is the treatment of mild-moderate asthma?

1. Oxygen to achieve O2 sat > 90%
2. Inhaled SABA via nebulizer or MDI
A. Max 3 doses in first hour
3. Oral steroids


What is the treatment for severe asthma?

1. Oxygen to maintain SaO2 > 90% or pO2 > 60 mmHg
2. Frequent High dose delivery of SABA via nebulizer
A. Minimum 3 treatments in first hour
B. Can be combined with ipratropium bromide
3. Systemic steroids
4. Repeat assessment after initial breathing treatment and frequently afterwards
A. May require intubation & mechanical ventilation


Define COPD

1. Characterized by presence of airflow obstruction due to chronic bronchitis or emphysema
A. Chronic Bronchitis - chronic prod cough on most days for 3 months of year for 2 or more years without known cause
B. Emphysema - air spaces enlarged due to loss of alveoli elasticity


What are the causes of COPD? What is the number 1 cause?

1. Smoking
A. # 1 Cause
2. Environmental pollutants
A. Occupational dusts & chemicals
B. Outdoor air pollution
3. Allergic component
4. Alpha-1-Antitrypsin deficiency


What is Alpha-1-Antitrypsin deficiency?

1. Genetic disorder w/ decreased levels of above protease inhibitor A1AT
2. A1AT protects lungs from enzyme that disrupts connective tissue
3. Deficiency of A1AT leads to lysis of elastin  decreased elasticity & increased compliance  Emphysema (Cirrhosis)


Describe the pathophys of COPD

1. Abnormal inflammatory response of lungs caused by noxious particles/gases
A. Leads to increased airway resistance & expiratory flow limitation

2. Inflammation, narrowing, remodeling, increased mucus secretion and vascular changes leads to hypoxia and later pulmonary HTN


What cells cause the Excessive lysis of elastin and other structural proteins in lung tissue seen on COPD?

elastase from neutrophils and macrophages


What are the general sxs of COPD?

1. Excessive cough
2. Excessive sputum production
3. Shortness of breath
4. Resonance in lung fields
5. Dec breath sounds
6. Prolonged expiration
7. +/- wheezing


What condition is asst with the term pink puffers?



What condition is asst with the term blue bloaters?

Chronic bronchitis


What are the sxs seen with COPD pts who predominately have emphysema?

1. Exertional dyspnea
2. Rare cough with scant sputum
3. Quiet lungs
4. Thin, weight loss
5. Barrel chest
6. Flattened diaphragms
7. Hyperinflation of lungs


What are the sxs seen with COPD pts who predominately have chronic bronchitis?

1. Mild dyspnea
2. Chronic productive cough
3. Noisy lungs with rhonchi and wheezing
4. Overweight and cyanotic
5. Pursed lip breathing
6. Normal diaphragms
7. Parenchymal bullae & blebs


What the PFT results seen in COPD?



What are the CBC results in COPD?

Polycythemia due to chronic hypoxia


What are the ABG results seen in COPD?

1. If hypoxic or in distress
2. Hypercapnia, hypoxia and respiratory acidosis are signs of impending respiratory failure


What complications can occur from COPD?

1. Acute bronchitis with COPD exacerbation
2. Pneumonia
3. PE


What are the complications in severe COPD?

1. Pulmonary HTN
2. Cor pulmonale
A. Right sided heart failure secondary to pulmonary HTN
3. Chronic respiratory failure
A. ↓ SaO2, ↑ pCO2


What are the smoking cessation options for pts with COPD?

1. Nicotine replacement
A. Transdermal patch, gum, lozenge, inhaler
2. Varenicline (Chantix)
A. Partial agonist at nicotinic AcH receptors
B. Produces less euphoria than nicotine
3. Bupropion (Wellbutrin)
A. Weak dopamine & NE reuptake inhibitor
B. Reduces cravings for nicotine


What is the MOA of anticholingeric bronchodilators?

Bronchodilation & dries secretions
Improves sx’s & exercise tolerance


What is the first line treatment for COPD?

Anticholinergic bronchodilators


What are examples of Anticholinergic bronchodilators
used in COPD?

1. Ipratropium bromide (Atrovent) MDI or sol’t
2. Tiotropium (Spiriva) HandiHaler
3. Aclidinium (Tudorza) Pressair
4. Ipratropium/albuterol (Duoneb sol., Combivent MDI)


What are the short acting beta 2 agonists used in COPD?

Albuterol (Proventil,Ventolin, ProAir)
Levalbuterol (Xopenex)


What are the side effects of short acting beta 2 agonists used in COPD?

Adverse side effects: tachycardia, tremor, nervousness


What are the long acting beta 2 agonist used in COPD?

Salmeterol (Serevent) Diskus
Formoterol (Foradil) Aerolizer, (Perforomist) sol
Arformoterol (Brovana) sol


What are side effects of he long acting beta 2 agonist used in COPD?

tachycardia, tremor, hypokalemia


What are the effects and indications of inhaled corticosteroids in COPD?

1. Reduces frequency of COPD exacerbations
2. Improves self reported functional status
3. Not solo therapy in COPD
4. Combination therapy with LA β2 agonist


What are examples of inhaled corticosteroids in COPD?

1. Fluticasone/salmeterol (Advair)
2. Budesonide/formoterol (Symbicort)
3. Mometasone/formoterol (Dulera)
4. Fluticasone/vilanterol (Breo)


When are antibiotics indicated in COPD?

1. Treat acute exacerbations
A. Acute dyspnea and change in character of sputum
2. Treat acute bronchitis
3. Prevent acute exacerbations of chronic bronchitis (prophylaxis)


What are the antibiotics indicated in COPD?

1. Macrolides (azithromycin / Z-pack)
2. Fluoroquinolones (Levofloxacin / Levaquin)
3. Beta lactam inhibitor (amoxicillin clavulanate / Augmentin)


What are the goals of oxygen therapy in COPD?

1. Maintain pO2 > 55% and SaO2 > 88%
2. Flow rate 1-3 l/min


What is the only drug therapy documented to improve sx’s of COPD in pts with resting hypoxia?



What is the purpose of Roflumilast/Daliresp
in treating COPD?

Reduces exacerbation frequency


What is pulmonary rehab for COPD?

1. Prevents deterioration of physical condition
2. Improves exercise capacity, decreases hospitalizations, enhances quality of life
3. Improve pt’s ability to carry out daily activities
A. Pursed lip breathing
B. Abdominal breathing exercises to reduce fatigue of accessory muscles of breathing


What are the other treatment measures used in COPD?

1. Expectorant-mucolytic therapy helpful in chronic bronchitis
2. Replace A1AT weekly in pts who have deficiency
3. Pneumatic vest provides high-frequency chest-wall oscillation (HFCWO) is a promising therapy for chronic mucus hypersecretion in COPD


When is inpt COPD management indicated?

1. Patients with significant co-morbidities
2. Failed outpatient treatment
3. Worsening gas exchange
4. Unable to manage at home


What are the indications for ICU admission for COPD pts?

1. Worsening respiratory function (hypoxia, hypercapnia)
2. Severe respiratory acidosis
3. Hemodynamic instability
4. Mechanical ventilation


What are the inpt COPD treatment options?

1. Supplemental O2
2. Inhaled ipratropium bromide plus albuterol
A. Duoneb (Combivent) remember albuterol + ipatropium
3. Antibiotics (Broad spectrum)
4. Corticosteroids
5. If progressive resp failure:
A. Endotracheal intubation and mechanical ventilation


What do COPD pts need to be educated about?

1. Smoking cessation
2. Flu vaccine
3. Pneumonia vaccine (Pneumovax/Prevnar)
4. Annual or more frequent measurement of lung function
5. Regular follow-up


What is the prognosis for COPD?

1. Outlook for patients with clinically significant COPD is poor

2. Dyspnea at end of life can be difficult for patient and family alike

3. As patient near end of life, meticulous attention to palliative care is essential


What is the staging for COPD?

GOLD is short for the Global Initiative for Chronic Obstructive Lung Disease, a collaboration between the National Institutes of Health and the World Health Organization.


What is mild COPD?

1. FEV1/FVC 80% predicted


What is moderate COPD?

1. FEV1/FVC < FEV1 < 80% predicted


What is severe COPD?

1. FEV1/FVC < FEV1 < 50% predicted


What is very severe COPD?

1. FEV1/FVC < 30% predicted or FEV1 <50% predicted plus chronic respiratory failure


What is the treatment for mild COPD?

1. Reduce risk factors
2. SA bronchodilators prn


What is the treatment for moderate COPD?

1. Reduce risk factors
2. SA bronchodilators prn
3. Long acting bronchodilators prn
4. Pulmonary rehab


What is the treatment for severe COPD?

1. Reduce risk factors
2. SA bronchodilators prn
3. Long acting bronchodilators prn
4. Pulmonary rehab
5. Inhaled glucocorticosteroids


What is the treatment for very severe COPD?

1. Reduce risk factors
2. SA bronchodilators prn
3. Long acting bronchodilators prn
4. Pulmonary rehab
5. Inhaled glucocorticosteroids
6. Long term oxygen if chronic respiratory failure
7. Consider surgical treatment