CAM Pulm Exam

What is asthma?

chronic pulmonary disorder characterized by episodic (intermittent) and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying airway inflammation

What are the three components to asthma pathophysiology?

1. airway inflammation

2. airway hyperactivity (IgE ab attack antigens --> mucus production --> deposition of collagen that may impair SM relaxation)

3. bronchoconstriciton (SM contraction and hypertrophy)

What does airway obstruction in asthma cuase?

- wheezing

- air trapping (hyperinflation, hypercapnia)

What are extrinsic triggers of asthma?

increased IgE

- Animal allergens (dogs, cats, cockroaches, mice)

- Outdoor pollen allergens (trees, grass)

- Mold

- Dust mites

What are intrinsic triggers of asthma?

- Exercise, physical activity

- Cold/dry air

- Air pollutants (tobacco and cannabis smoke)

- Respiratory infections

- Medications: Aspirin, NSAIDs, beta blockers

What are risk factors of asthma?

- Atopy (genetic disposition)

- Air pollution / occupational exposure

- Tobacco smoke exposure

- Family history

- Obesity

- Respiratory infections

In what population is asthma most common in?

- children

- males

- urban living

What are the three things that cause asthma?

•genetic susceptibility

•environmental exposure

•developmental risk factors

what are the 3 types of asthma?

- allergic (atopic)

- nonallergic

- eosinophillic

what is the most common type of asthma? what is it associated with?

- allergic (atopic)

- Associated with food allergies & atopic triad (asthma, eczema, allergic rhinitis)

How does airway remodeling in uncontrolled asthma change over time?

become stiff, thick bronchi

What are symptoms of asthma?

- symptoms worse at night or early morning

- Episodic wheezing

- Shortness of breath

- Chest tightness / mucous production

- Cough

What are physical exam findings for an asthma exacerbation?

- Wheezing

- Tachypnea, accessory muscle use, "tripoding"

- Tachycardia

- +/- silent chest

What are physical exam findings of chronic asthma or "between attacks"

- Often normal

- Can have mild wheezing

- Findings of allergic rhinitis (nasal mucosal swelling, increased secretions, polyps)

- Findings of eczema

How do you diagnose asthma?

history or presence of respiratory symptoms consistent with asthma, combined with the demonstration of variable expiratory airflow obstruction

What labs and imaging are needed to workup asthma?

- labs not needed

- imagine not needed but can do CXR +/- hyperinflation

What is the standard test for asthma diagnoses?

spirometry

What are pulmonary function tests?

- spirometry

- bronchoprovocation testing

- peak expiratory flow

What is the purpose of spirometry?

help differentiate between obstructive vs restrictive lung disease

What is FEV1?

maximum volume of air exhaled in the first second of exhalation

What is forced vital capacity (FVC)?

total amount of air exhaled

What is a normal FEV1/FVC?

80%

What is FEV1/FVC in restrictive disease? problem with inspiration or exhalation?

- FEV1/FVC ratio is normal (80%) or increased

- inspiration

What is FEV1/FVC in obstructive disease? problem with inspiration or exhalation?

- FEV1/FVC < 70%

- exhalation

If FEV1 or PVC increased by > 10% with a bronchodilator test, what is the diagnoses?

asthma

If FEV1 or PVC increased by < 10% with a bronchodilator test, what is the diagnoses?

COPD

What is a bronchoprovocation test?

spirometry test using bronchiconstrictor (histamine or methacholine) to provoke them into a temporary, mild asthma exacerbation

What is a bronchoprovacation test contraindicated?

patients with baseline FEV1 < 65% predicted

If FEV1 drops by > 20% in a bronchoprovocation test, what is the diagnoses?

asthma

What does a peak flow meter measure? why is this helpful?

- Measures peak expiratory flow

- Involve adherent patients in their own asthma management

What percent change on a peak flow meter would indicate inadequately controlled asthma?

20%

Give a general explanation of different asthma steps (sx not tx)

1 - infrequent symptoms, < 2 times/week

2 - symptoms > 2 times but not 7 days/week

3 - daily symptoms, >1 night time awakening/week

4- daily symptoms, nightly nocturnal awakenings

What are examples of SABAs?

albuterol, levalbuterol

What are examples of LABAs?

Salmeterol

Formoterol

What are examples of SAMAs?

Ipratropium

What are examples of LAMAs?

tiotropium

What are examples of systemic steroids for asthma?

- prednisone

- prednisolone

- methyprenisoline

What are examples of ICS?

Beclomethasone, Flunisolide

What are examples of ICS/SABAs?

albuterol/budesonide

What are examples of ICS/LABAs?

budesoinde/foroterol

What is the treatment for mild asthma (step 1+2)?

low dose ICS + formoterol or daily low dose ICS + SABA PRN

What is the treatment for moderate asthma (step 3)?

low dose ICS + formoterol daily + PRN ICS + formoterol

What is the treatment for severe asthma (step 4)?

medium dose ICS + formoterol daily + PRN ICS + formoterol

What is the treatment for severe asthma (step 5)?

medium or high dose ICS + LABA + LAMA + PRN ICS + formoterol

What do you need to assess prior to diagnosing severe asthma?

- inhaler technique

- Medication adherence

- Comorbidities

- Ongoing exposure to allergens

When do you refer a patient for asthma?

"Severe asthma" should be referred to a pulmonology or asthma specialist

What is the pathophys behind asthma exacerbations?

Bronchial smooth muscle contraction

What is the medication approach to acute asthma exacerbation?

1. O2

2. SABA or SABA/SAMA (Duoneb) +/- IV mag

3. systemic steroids

Explain the bpm and PEF/FEV1 in a mild acute asthma exacerbation

< 100 bpm, > 70%

Explain the bpm and PEF/FEV1 in a moderate acute asthma exacerbation

100-120, 40-69%

Explain the bpm and PEF/FEV1 in a severe acute asthma exacerbation

>120, <40%

Explain the bpm and PEF/FEV1 in a respiratory arrest

bradycardic, < 25%

What are symptoms of respiratory arrest?

- breathlessness, silent (no wheezing)

- drowsy/confused

What is a road test?

Walk around with an O2 monitor; typically needed before discharge

How often should you administer a duoneb?

every 20 minutes or continuously for 1 hour

When do you repeat assessment after inhaled SABA for acute asthma exacerbation?

- Repeat assessment after initial inhaled SABA and again after 3 doses of inhaled SABA

- 60-90 minutes after initial evaluation

When do you admit/transfer a patient with asthma exacerbation?

•Patient does not feel any better

•O2 sat <94% on RA

•PEF <60% of baseline or predicted

•Fails the "road test" - cannot ambulate comfortably or without desaturation

•borderline "OK" to go home, but no follow-up in place and poor social support

When do you discharge a patient for asthma exacerbation?

•Patient feels better

•O2 sat >94% on RA

•PEF >70% baseline or predicted

•Passes the "road test" - can ambulate comfortably without desaturation on room air

•close follow-up available with PCP and good social support

What is an asthma action plan?

written document with instructions regarding what medications to take and when, and when to seek help

What is the #1 risk factor for asthma exacerbation?

poor symptom control

What are risk factors for asthma exacerbation?

- >1 exacerbation in the previous year

- Inadequate ICS use

- Undertreatment

- Poor adherence

- Incorrect inhaler technique

What is apnea?

breath cessation for >10 seconds

What is sleep apnea?

Sleep disorder characterized by repeated episodes of pauses in breathing during sleep

What are the types of sleep apnea?

obstructive, central and mixed

How does OSA occur?

- Passive collapse of the pharynx during inspiration due to loss of normal pharyngeal muscle tone

- Upper airway obstruction during sleep

What is the demographic of OSA?

Middle aged men with obesity

What are precipitating/ predisposing factors of OSA?

- ↑ neck circumference -strongest correlation with OSA

- Anatomically narrowed airways (Obesity, tonsillar hypertrophy, macroglossia)

- Alcohol or sedatives

- Nasal obstruction (URI)

What are signs and symptoms of OSA?

- Excessive daytime somnolence

- Daytime fatigue

What are signs and symptoms you can ask a pt's partner about regarding sleep apnea?

- Loud cyclical snoring

- Breath cessation

- Restlessness

What is present of PE of a patient with OSA?

- may be normal

- "bull neck": short, thick neck

- May see narrowed oropharynx

- Nasal obstruction

What are severe complications of OSA?

- cardiac arrythmias

- HTN

- Pulmonary hypertension

What is the survey used for OSA?

STOP - BANG

What labs are needed for OSA? Why?

- CBC may show erythocytosis due to chronic hypoxia

- Thyroid function test to r/o hypothyroidism

Definitive dx for OSA?

1.Otorhinolaryngologic (ENT) examination

2.Polysomnography (sleep study)

What does a polysomnography look like with a person with OSA?

Demonstrates apneic episodes with hypoxemia

What is the treatment for OSA?

- weight loss

- avoidance of sedatives (alcohol, hypnotic meds)

- continuous positive airway pressure (CPAP)

- mandibular repositioning device (MRD)

What is obesity hypoventilation "Pickwickian" syndrome

Alveolar hypoventilation while awake in an obese individual which cannot be contributed to other conditions associated with hypoventilation

aka OSA with daytime dypnea

What causes obesity hypoventilation syndrome?

- obesity (BMI > 30)

- blunted respiratory drive

What are signs and symptoms are obesity hypoventilation syndrome?

- Excessive day time somnolence

- Day time fatigue

- daytime dyspnea

How do you diagnose obesity hypoventiation syndrome?

1.BMI > 30

2.Hypoventilation: Arterial partial pressure of CO2 > 45 mmHg

3.Sleep disordered breathing (Evidence of OSA)

4.Exclusion of other causes of alveolar hypoventilation

What is the treatment for obesity hypoventilation syndrome?

- Weight loss

- Treat OSA w/ CPAP

- Avoid sedatives: hypnotics, opioids, alcohol

- Severe cases - tracheostomy

What is COPD?

irreversible and progressive pulmonary disease characterized by persistent respiratory symptoms and airflow obstruction

What are risk factors of COPD?

- inhaled pollutants (cig smoking, biomass fuel)

- alpha 1 antitrypsin deficiency

What is the overall difference between chronic bronchitis and emphysema?

- bronchitis: mucus problem, blue bloaters

- emphysema: structural problem, pink puffers

Explain the patho behind chronic bronchitis

repeated exposure --> inflammation and irritation --> increased mucus gland size + ciliary damage --> bronchial endothelial thickening --> airway obstruction + chronic cough and phlegm

What are physiologic consequences of chronic bronchitis?

- airway obstruction --> air trapping

- damage of mucociliary defenses --> increased risk of pulm infections

Explain the pathophysiology of emphysema

chronic irritant exposure leads to increased protease production leads to destruction of the capillaries and alveolar wall with air space enlargement (dilation)

In what patients would you suspect alpha 1 antitrypsin deficiency?

young patients COPD symptoms

What are physiologic consequences of emphysema?

alveolar wall and capillary destruction

What is the clinical presentation of chronic COPD?

- excessive cough

- sputum production

- shortness of breath

What is the clinical presentation of a COPD exacerbation?

increased cough, sputum and dyspnea

What are the three diagnostic criteria for COPD?

- symptoms consistent with COPD

- persistent airflow limitation (FEV1/FVC < 70%, obstructive)

- no alternative explanation for symptoms and obstruction

What would you FEV1/FVC be for COPD?

< 70%

What are the four GOLD categories?

- gold 1: FEV1 > 80%

- gold 2: 50-80%

- gold 3: 30-50%

- gold 4: FEV1 < 30%

What assessment tool is used for COPD?

GOLD ABE

What may be abnormal on the CBC for COPD?

- polycythemia

- increased eosinophil count

What are CXR findings for COPD?

- hyperinflation

- flattening of the diaphragm

- hyperlucency of the lungs

- prominent pulmonary arteries

- +/- bullae

What is a bullae? What disorder is it common in?

thin walled air space in the lungs common in COPD

What rescue therapy do COPD patients get?

SABA+SAMA preferred but SABA okay

What is the most important non pharm treatment for COPD?

STOP SMOKING