Pulmonary - MTB

Question 1

Asthma

Answer 1

abnormal bronchoconstriction of the airways

- reversible obstructive lung disease

Question 2

Causes of acute exacerbation of symptoms include:

Answer 2

• allergens
• infection and cold air
• emotional stress or exercise
• catamenial (related to menstrual cycle)
• aspirin, NSAIDS, B-blockers, histamine
• GERD

Question 3

Asthma: Presentation

Answer 3

• clear presence of WHEEZING w/ acute onset of SOB, cough, and chest tightness
• increased sputum though not fever

Question 4

Asthma: Clinical Symptoms

Answer 4

• symptoms worse at night
• NASAL POLYPS and sensitivity to aspirin
• eczema or atopic dermatitis on PE
• INCREASED LENGTH OF EXPIRATORY PHASE of respiration
• increased use of accessory respiratory muscles (e.g. intercostals)

Question 5

Asthma: Diagnostic

Answer 5

• CXR (normal in asthma)
  
  • exclude pneumonia
  • exclude pneumothorax or CHF
• Peak expiratory flow (PEF) or arterial blood gas (ABG)
• Pulmonary function testing

Question 6

Best initial test in acute exacerbation

Answer 6

Peak expiratory flow (PEF)

Arterial Blood Gas (ABG)

Question 7

Most accurate diagnostic test in acute exacerbation

Answer 7

Pulmonary Function Tests (PFTs)

• spirometry shows decrease in FEV1 / FVC
• FEV1 decreases more than FVC

Question 8

15 y/o boy comes to the office b/c of occasional shortness of breath every few weeks. Currently he feels well. He uses no meds and denies other medical problems. Physical exam reveals pulse of 70 and RR of 12 breaths per minutes. Normal chest exam Most accurate diagnostic test at this time?

Answer 8

> 20 % decrease in FEV1 with use methacholine`

Question 9

Pulmonary Function Testing in Asthma

Answer 9

• decreased FEV1 and decreased FVC w/ decreased ration of FEV1/FVC
• increased in FEV1 of more than 12% and 200mL w/ use of albuterol
• decrease in FEV1 of more than 20% w/ use of methacholine or histamine
• increase in diffusion capacity of lung for CO

Question 10

Acetylcholine and histamine

Answer 10

• provoke bronchoconriction and increase in bronchial secretions
• metacholine (artificial form of acetylcholine)

Question 11

Testing options for asthma

Answer 11

• CBC shows increased eosinophils
• Skin testing to ID specific allergens
• Increased IgE levels suggest allergic etiology

Question 12

Asthma: Treatment

Answer 12

1. Inhaled short-acting B-agonist (ALBUTEROL, pirbuterol)
2. Low dose inhaled corticosteroids (e.g. triamcinolone, fluticasone)
3. . Alternative long-term control agents (e.g. cromylyn, monteleukast, zileuton)
4. Add long acting B-agonist (e.g. salmeterol)
5. Oral corticosteroids (e.g. prednisone)

Question 13

Inhaled steroids (e.g. fluticasone, triamcinolone): adverse effects

Answer 13

• dysphonia

- oral candidiasis

Question 14

Systemic Corticosteroids: Adverse Effects

Answer 14

• Osteoporosis
• Cataracts
• Adrenal Suppression and Fat Redistribution
• Hyperlipidemia, hyperglycemia, acne, hirsutism
• Thinning of skin, striae, and easy bruising

Question 15

Anticholinergics

Answer 15

• examples: ipratropium and tiotroprium
• dilate bronchi and decrease secretions
• very effective in COPD

Question 16

47 y/o man w/ hx of asthma comes to ED w/ several days of increasing SOB, cough, and sputum production. On PE his RR is 34 per minute. He has diffuse expiratory wheezing and prolonged expiratory phase. Which of the following would you use at the best indication of the severity of the asthma?

Answer 16

Respiratory rate

- can indicate shortness of breasths

Question 17

Severity of asthma exacerbation can be quantified by:

Answer 17

• Decreased peak expiratory flow (PEF)
• ABG w/ an increased A-a gradient
• CXR r/o infeciton leading to exacerbation

**PEF is approximation of FVC, based on height and age

Question 18

Severe acute asthma exacerbation: treatment

Answer 18

• Oxygen
• Albuterol
• Steroids

Question 19

Best initial therapy of acute asthma exacerbation

Answer 19

Oxygen w/ inhaled short acting B-agonists (e.g. albuterol) and bolus of steroids
- epinepherine no more effective than albuterol and has potential for adverse effects

Question 20

Indication for Mg in acute asthma exacerbation

Answer 20

• Helps relieve bronchospasm

- used when in severe asthma exacerbation not responsive to several rounds of albuterol while waiting steroids

Question 21

If pt in acute asthma exacerbation and not responsive to oxygen, albuterol, and steroids (or develops respiratory acidosis), what’s next step?

Answer 21

Endotracheal intubation for mechanical ventilation

- should be paced in ICU

Question 22

Chronic Obstructive Pulmonary Disease (COPD)

Answer 22

• presence of shortness of breath from lung destruction decreasing elastic recoil of the lungs
• most of the ability to exhale is from elastin fibers in lungs passively allowing exhalation
• decrease in FEV1 and FVC and increase in TLC

Question 23

COPD: Etiology

Answer 23

Tobacco smoking leads to almost all COPD

- tobacco destroys elastin fibers

Question 24

COPD: Presentation

Answer 24

• Shortness of breath worsened by exertion
• Intermittent exacerbations w/ increased cough, sputum, and SOB
• “Barrel chest” from increased air trapping
• Muscle wasting and cachexia

Question 25

COPD: Diagnostic Tests

Answer 25

- CXR | - Pulmonary Function Tests

Question 26

Best initial test for COPD

Answer 26

CXR - increased anterior-posterior (AP) diameter - air trapping and flattened diaphragm

Question 27

Most accurate diagnostic for COPD

Answer 27

Pulmonary Function Tests - decreased FEV1, decreased FVC, decreased FEV1/FVC (< 70%) - Increased TLC b/c an increase in residual volume - Decreased DLCO (emphysema, not chronic bronchitis) - Incomplete improvement w/ albuterol - Little or no worsening w/ metacholine

Question 28

COPD and reversibility w/ bronchodilators

Answer 28

Have a range of reversibility: no reversibility to complete reversibility

Question 29

Ful reversibility

Answer 29

- greater than 12% increase and 200 mL increased in FEV1