Final: COPD/asthma

Question 1

what confirms diagnosis in asthma?

Answer 1

spirometry

• Tells us if there’s obstruction
• Asses for any reversibility after giving bronhodilator

Question 2

Asthma differentials

Answer 2

• upper airway dz
  
  • acute bronchiolitis, laryngotracheobronchitis
• allergic rhinitis
• sinusitis
• vocal cord dysfunction
• foreign body
• gerd
• copd
• CHF
• laryngeal and/or vocal cord dysufnction
• cystic fibrosis
• alpha 1 antitrypsin deficiency
• meds

Question 3

*asthma clinical hallmarks

Answer 3

• Bronchospasm is often reversible
  
  • episodic wheezing with or w/o hyper responsiveness
  • dyspnea
  • sputum production
  • Chest tightness
  • Cough

Question 4

well controlled/intermittent asthma vs poorly controlled/persistent asthma in children, have sx’s

Answer 4

• well controlled/intermittent asthma :
  
  • sx’s are < 2 days a week
  • should be using SABA < 2 times a week
  • night time awakenings < 2x/month
• poor/persistent asthma
  
  • mild: > 2 days/week
  • mod: daily
  • severe: throughout day
  • night time awakenings 3-4x/month

Question 5

*sx’s of more serious asthma exacerbation

Answer 5

• marked breathlessness
• RR > 30, HR > 120
• inability to speak more than short phrases
• use of accessory muscles
• drowsiness should result in initial treatment while immediately consulting with a clinician.

Question 6

initial treatment of asthma attack

Answer 6

• Inhaled SABA: up to 2 treatments 20 min apart of 2-6 puffs by MDI or nebulizer treatments.

Question 7

if initial treatment has a good response (no wheezing/dyspnea), peak est. flow > 80%:

Answer 7

May continue inhaled SABA every 3–4 h for 24–48 hr

Question 8

if initial treatment has an incomplete response (persistent wheezing/dyspnea/tachypnea), PEF 50-79%:

Answer 8

• add oral systemic corticosteroid
• continue inhaled SABA
• consult clinician for further action

Question 9

if initial treatment has a poor response (marked wheezing/dyspnea), PEF < 50%:

Answer 9

add oral systemic corticosteroids

repeat inhaled SABA ASAP

if distress severe and non responsive, call doc AND go to ED, consider 911

Question 10

asthma diagnosis

Answer 10

• (1) demonstration of episodic symptoms of airflow obstruction (e.g., wheeze, cough, shortness of breath),
• (2) evidence that airflow obstruction is at least partially reversible
• (3) exclusion of other conditions from the differential diagnosis.

Question 11

*diagnostic hallmark of asthma

Answer 11

reversal of obstruction after the giving a bronchodilator (improved spirometric values < 80% and improved post SABA)

Question 12

asthma diagnostics

Answer 12

• Pulse ox
• CBC if secondary infection
• Chest radiographs/sputum cx NOT recommended unless sus infectious illness
• Allergy evaluation
• Sweat test
• Pulmonary function tests
• Peak flow measurements
  
  • peak expiratory flow rate
  • maximal mid expiratory flow
  • FVC
    *

Question 13

daily controller meds of asthma are:

Answer 13

low dose ICS and long acting beta agonist bronchodilator combos (ICS/LABA)

add on controller meds include (long acting anticholinergic, Anti-IgE, Anti-IL 5 and systemic corticosteroids

Question 14

reliever asthma meds:

Answer 14

SABA (albuterol)

low dose ICS/formoterol

short acting anticholinergics

Question 15

how to monitor peak flow meter at home

Answer 15

for moderate/severe asthma

record at least once daily in early afternoon, after 2-3 weeks

Question 16

PEF > 80% measurement is what zone?

Answer 16

green

good asthma control; safe to proceed

Question 17

PEF 60-80% zone

Answer 17

yellow

sx’s that interfere with daily activities (cough, wheeze, chest tightness, SOB, nocturnal awakening)

need temporary increase in med dose or frequency (inc bronchodilator, add/inc ICS or oral steroids)

Question 18

PEF < 50%

Answer 18

red zone, danger, emergency treatment

inability to blow into the peak flow meter, accessory respiratory muscle use, difficulty walking or talking because of asthma, and cyanosis. Immediate use of inhaled rescue bronchodilator therapy and initiating or increasing oral corticosteroid therapy are necessary.

Question 19

*atopic triad

Answer 19

1. skin disorders (eczema)
2. allergies? allergic rhinitis
3. inhaler use/asthma

all 3 causes inflammation

Question 20

Samter’s triad

Answer 20

chronic condition in pt’s with asthma

aka Aspirin Exacerbated Respiratory Disease

1. atopic dermatitis/eczema
2. nasal polyps
3. aspirin or NSAID sensitivity

Question 21

Exercise induced asthma management

Answer 21

if exercise regularly, use ICS as controller med

use 2 puffs B2 agonist and/or cromolyn MDI 15-30 mins prior to exercise [don’t use as controller med bc it builds tolerance]

Question 22

most common cause of COPD? and others?

Answer 22

1: smoking

occupational

alpha 1 antitrypsin deficiency

Question 23

gold standard for dx for COPD

Answer 23

spirometry required! confirms irreversible obstruction if FEV < 80% and FEV/FVC < 70% after given bronchodilator and it’s not reversible

Question 24

on exam for COPD, the presence of of a postbronchodilator FEV1/FVC of ___ and FEV1 of _____ confirms airway limitation that is not fully reversible.

Answer 24

FEV1/FVC of < 70% and FEV1 < 80% confirms it’s not reversible

Question 25

common complaints of COPD

Answer 25

dyspnea, cough, and/or sputum production (late in the dz; when irreversible changes occurred)

Question 26

PE for COPD

Answer 26

* confirmed with spirometry * late stages: * hyperinflation * tobacco stained fingers * clubbing * increase in AP diameter * increase intercostal spaces * abnormal restriction of interspaces between inspiration (severe) * increased resonance on percussion * cor pulmonale (advanced)

Question 27

COPD workup/labs

Answer 27

* forced expiratory time → determines of more testing is needed [take deep breath in & breathe out quickly and completely as possible with mouth open] while auscultation trachea * 6 seconds or more = obstructive disease * confirm with spirometry (FVC, FEV1, FEV1/FVC) * any ratio \< 70% FEV1/FVC * pulse ox * labs: * CBC with diff * ABG * alpha 1 antitrypsin * Chest xray (hyperinflation supports dx)

Question 29

COPD: Chronic bronchitis

Answer 29

* **Mild** alteration in lung tissue compliance than emphysema and less parenchymal damage * Obese * Frequent cough with more sputum production * Accessory muscles * Coarse bronchi * Wheezes * R sided heart failure/cor pulmonale * Edema, cyanosis

Question 30

COPD: Emphysema

Answer 30

* Damage to alveolar wall, destruction of alveolar architecture, mismatch of ventilation and perfusion * Thin, barrel chest * Cough (not as much as bronchitis) * Pursed lip breathing * thin frame * Accessory muscles * Tripod position * Hyperresonance * Wheezing * Heart sounds distant

Question 31

medication for COPD for acute exacerbation

Answer 31

* **oral prednisone 40mg QD x 5 days +** * + increase frequency of bronchodilators (beta agonist and/or anticholinergics) * and oral antibiotics: * Group A mild exacerbation: B lactam, tetracycline, bactrim] * Group B: moderate: Augmentin * Group C: severe: fluoroquinolone

Question 32

First-line for daily COPD symptoms:

Answer 32

short acting anticholinergic: ipratropium bromide (Atrovent)

Question 33

med for stage 3 or 4 COPD with FEV \< 60%

Answer 33

inhaled corticosteroids **AND** LABA therapy (Sameterol or formoterol)

Question 34

lung cancer screening

Answer 34

* Age 50 to 80 with 20 pack year smoking history and curently smoke or have quit w/in the last 15 years * Screen with low dose CT scan * Stop screening if *not* smoked for 15 years or develops health problem that limits life expectancy or ability or willingness to have curative lung surgery

Question 35

side effects of controller meds:

Answer 35

* ICS: decreased bone density, addrenal suppression, Ca and Vitamin D supplements * LABA: black box in increase asthma related pulmonary death

Question 36

inhaled corticosteroids recommended for long term use for pediatrics if:

Answer 36

* 4 wheezing episodes in a year affecting sleep and lasting more than 1 day **AND** have a positive asthma risk profile * 2 or more exacerbations requiring oral corticosteroids in last 6 months * child requires more than 2 doses of short acting bronchodilators per week for more than 4 weeks

Question 37

**positive** asthma profile includes

Answer 37

* 1 or more of: * atopic dermatitis * sensitization to aeroallergen (pollen/spores in air) * parental hx of asthma OR * 2 or more of: * wheezing apart from colds * more than 4% blood eosinophilia * food sensitization

Question 38

controller med for young children

Answer 38

* budesonide for children \< 4 yrs old * fluticasone * [beclomethasone](https://accessmedicine-mhmedical-com.ezproxy.simmons.edu/drugs.aspx?GbosID=130854) SE: growth suppression, delayed puberty, bone density

Question 39

nebulizer or metered dose inhaler for children?

Answer 39

nebulizers or spacer( 1 way valve) equally good for SABA for exacerbations PROPER TECHNIQUE

Question 40

when does response to controller med happen?

Answer 40

4-5 weeks if not by then, stop med and consider another dx if have measurable response for 3 months, lower dose but children have high rates of remission

Question 41

persistent asthma

Answer 41

* \< 5 yrs old: * if \> 2 exacerbation in 6 months * \> 5 years old: * \> 2 exacerbations in 1 year but does not have daytime or nighttime impairment lung function is included in 5 - 11 yr old criteria but not young children

Question 42

mild intermittent / step 1 management

Answer 42

* sx's _\<_ 2 days/week * nighttime _\<_ 2 x/month * no daily medicine needed * normal FEV1 \> 80% * Saba when needed

Question 43

mild persistent asthma / step 2 management

Answer 43

* sx's \> 2 days/wk * night time awakenings 3-4x/month * SABA use \> 2 days/wk * FEV \> 80% * controller: low dose inhaled CS * or cromolyn, leukotriene modifier, or theophylline * reliever as needed SABA

Question 44

moderate persistent asthma / step 3 management

Answer 44

* **Daily sx's** * **night time awakening more than once a week** * SABA used daily * FEV 60-80% * reliever: as needed SABA or low dose ICS/formoterol * controller: low dose ICS **and** LABA * or medium dose ICS

Question 45

severe persistent asthma / step 4 management

Answer 45

* Sx's throughout day * night time awakening every night * FEV \< 60% * reliever: as needed SABA or low dose ICS/formoterol * controller: med/high dose steroids **and** LABA * If needed, add oral steroids

Question 46

when and how would you need to step up the asthma medications?

Answer 46

* when it is poorly controlled * Symptoms \>2 days/week

Question 47

COPD Stage 1

Answer 47

Mild FEV _\>_ 80% chronic cough, sputum production

Question 48

COPD Stage 2

Answer 48

Moderate FEV 50-79% worsening, SOB w/ exertion

Question 49

COPD Stage 3

Answer 49

Severe FEV 30-49% increasing OSB with repeated exacerbation impacting QOL

Question 50

COPD Stage 4

Answer 50

* very severe * FEV \< 30% or FEV \< 50% + chronic respiratory failure present * QOL very impaired, life threatening

Question 51

COPD screening

Answer 51

* ONLY if have sx's, use: * spirometry * chest xray to confirm hyperinflation/bullae * chest CT to r/o malignancy * alpha 1 antitrypsin deficiency * 6 min walk test

Question 52

COPD workup

Answer 52

CBC (polycythemia) ABG pulse ox alpha 1 antitrypsin def chest x ray (hyperinflation)

Question 53

cardinal sx's of COPD exacerbation

Answer 53

increased dyspnea increased sputum volume increased sputum purulence

Question 54

Children \>12 with moderate to severe asthma may benefit from? (2nd line)

Answer 54

omalizumab if ICS doesn't help