Obstructive Lung Disease - Clin Med 5

What does this refer to

• A 5-year-old is brought to his pediatrician’s office by his parents because he cannot keep up with his friends while playing outside because he is short of breath.

• His parents report that they notice him occasionally coughing at night but he is otherwise healthy.

• On physical exam, respiratory rate is within normal limits and slight end expiratory wheezing is appreciated diffusely.

Asthma

What does this refer to

• Chronic respiratory condition marked by spasms in the bronchi of the lungs

• Reversible, intermittent and obstructive disease of the small airways

• Usually results from an allergic reaction or other forms of hypersensitivity

Asthma

What does this refer to

• Affects 5-10% of the population

• 75% dx before age 7

• MC chronic pediatric disease

• MC males in childhood

  • Males more likely to have decrease in sx by late adolescence

• Higher prevalence in females after puberty

Epidemiology of Asthma

What does this refer to

• Atopy is greatest risk factor → genetic etiology

  • Strongest identifiable factor

  • Atopic dermatitis (eczema)

  • Food allergies

  • Allergic rhinitis

• Eosinophilia

• Factors that contribute to airway hypersensitivity  asthma

  • Exposure to allergens/triggers

  • Exercise

  • GERD

  • Aspirin

  • Emotional factors or stress

  • Beta blockers

  • Obesity

EtiologyAsthma

What does this refer to

• Airway hyperreactivity + bronchoconstriction + inflammation

• Elevated level of IgE binds to mast cells (Eosinophilic asthma)

Asthma Pathophysiology

What does this refer to

• Atopy

  • Strongest identifiable factor

  • Atopic dermatitis

  • Food allergies

  • Allergic rhinitis

• Samter’s Triad

  • Asthma + Chronic rhinosinusitis with nasal polyps + ASA sensitivity

• Atopic Triad

  • Asthma + Atopic Dermatitis + Allergic Rhinitis

Risk factors for asthma

If your patient has asthma what medication do you NOT give (as it can exacerbate asthma)

Beta blockers

What kind of asthma has an aspirin sensitivity

Samster’s Triad (AERD?)

What does this refer to

• Non-allergic (Intrinsic)

• Allergic (Extrinsic) → IgE ↑

• Medications

TriggersAsthma

What does this refer to

• (Intermittent) dyspnea +

• Cough (typically NOT productive) +

• Wheezing

  • Expiratory usually more pronounced

• Chest tightness

Clinical historyAsthma

What does this refer to

• Acute Exacerbation

  • Pulmonary exam/auscultation

    • High pitched, musical wheezes

    • Pitch may be variable in different stages of the respiratory cycle

• Accessory muscle use

• Prolonged expiratory phase

• Tachypnea

• Hyperresonance

• Extrapulmonary findings

  • Pale, swollen membranes of the nasal cavities

  • Cobblestone appearance to the posterior pharyngeal wall

  • Nasal polyps

  • Atopic dermatitis

Physical exam asthma

What does this refer to

• Characteristically come and go

• Time course of hours to days,

• Typically spontaneous resolution

  • Removal from the triggering stimulus or medications

• Characteristic triggers

  • Exercise

  • Cold air

  • Exposure to inhaled allergens (aeroallergens)

Episodic presentation of asthma

What does this refer to

Differential Diagnosis for Asthma

What does this refer to

Workup for Asthma

What does this refer to

CXR in Asthma

When do asthma symptoms commonly occur

At night or early hours of morning

What does this refer to

Asthma classification

What does this refer to

What Asthma Looks Like on PFT

Your patient has pale nasal membranes what is the dx?

Asthma

What does this refer to

• ________ is measured using a simple and inexpensive device (approximately $20)

• Not a diagnostic tool

• Great for monitoring in a patient diagnosed with asthma

• Assess the role of a particular occupational exposure or trigger, rather than as a tool for the primary diagnosis of asthma

Peak Expiratory Flow Meters

What does this refer to

• Vaccinations

• Avoid triggers

• Medication compliance

Clinical Interventions of Asthma

What does this refer to

• Cromolyn (Mast cell stabilizer)

  • Exercise prophylaxis

• Montelukast (Singulair)

• Exercise prophylaxis or aspirin-induced asthma

• Prior to exposure to triggers

• Lifestyle modifications & allergy avoidance

Other management strategiesAsthma

What does this refer to

• _________ who do not reach optimal control following standard guidelines

• Mepolizumab (Nucala) SC injection (monthly)

  • Add-on

  • Adults and pediatric patients > or equal to 6 yo —> severe eosinophilic asthma

Clinical PharmacotherapeuticsEosinophilic Asthma

What does this refer to

• Freedom from frequent or troublesome symptoms of asthma

• Few night-time awakenings (≤2 nights per month) due to asthma

• Minimal need (≤2 days per week) for medication for acute relief of asthma symptoms

• Optimized lung function

• Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise

• Satisfaction with asthma care on the part of patients and families

Optimizing control of sxAsthma

What does this refer to

Rule of Two

What does this refer to

• Acute reversibility of airflow obstruction

• Tested by administering 2 to 4 puffs of a quick-acting bronchodilator

• Repeat spirometry 10 to 15 minutes later

• Measurements can also be made before and after administration of nebulized bronchodilator

• Increase in FEV1 of > or equal to 12% + absolute increase in FEV1 of at least 200 mL, can be attributed to bronchodilator responsiveness with 95% certainty

Bronchodilator ResponseAsthma

What does this refer to

• Presence of a LARGE bronchodilator response

• Minimal bronchodilator responsiveness may also be seen with

  • COPD

  • Cystic fibrosis

  • Non-cystic fibrosis bronchiectasis

  • Bronchiolitis

Bronchodilator ResponseAsthma

What does this refer to

• Pulmonology and allergists/immunologists

• Difficulty confirming dx

• Hx life-threatening asthma exacerbation(s)

• Need for step 5 care or higher

• Poor control after 3-6 months of active (and compliant) asthma care

• Complicating co-morbidities

ReferralAsthma

What does this refer to

• Patients with poorly controlled asthma may develop long term changes in airway

• Sx are chronic and become less likely to be irreversible due to the airway remodeling

• Onset of disease at older age = greater likelihood to have chronic sx

• Higher mortality rate in patients > 40 yo who smoke

• Peak Expiratory Flow Rate to monitor at home

PrognosisAsthma

What does this refer to

yikes (just know it i guess)

What does this refer to

• Spirometry, in which a maximal inhalation is followed by a rapid and forceful complete exhalation into a spirometer, includes measurement of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC).

• The results of spirometry can be used to determine the following:

1. Determine whether baseline airflow limitation (obstruction) is present (reduced FEV1/FVC ratio)

2. Assess the reversibility of the obstructive abnormality by repeating spirometry after administration of a bronchodilator

3. Characterize the severity of airflow limitation (based on the FEV1 as a percentage of the normal predicted value)

4. For patients with normal airflow (normal FEV1/FVC ratio), identify a restrictive pattern as an alternate explanation for dyspnea (eg, FVC <80% predicted)

Pulmonary Function Tests

What does this refer to

Classification of Asthma

According to GINA, what is the 1st line of tx for asthma for intermittent treatment

One product with inhaled Corticosteroid (ISC) + SABA (air supra aka budesomide + albuterol)

What does this refer to

• A 68-year-old man presents to his primary care physician for a cough.

• He has been coughing for the past 2 months and is associated with mucopurulent and tenacious sputum production, which has progressively worsened.

• Medical history is significant for chronic obstructive pulmonary disease.

• He smokes 1 pack of cigarettes daily for the past 45 years.

• On physical exam, the patient has wheezes and crackles bilaterally to auscultation.

• A radiograph of the chest is unremarkable; however, a CT scan of the chest demonstrates stigmata of bronchial dilatation.

Bronchiectasis

Your patient has been prescribed Airsupra but symptoms persist, what is the next time of treatment

Formoterol + budesonide (symbicort)/ICS

What does this refer to

Bronchiectasis

What does this refer to

• Suppurative lung disease

• Permanent and irreversible dilation of the bronchial airways

Bronchiectasis

What does this refer to

• MC in patients with cystic fibrosis

• Increased risk of infections

  • Pseudomonas

  • Mycobacterium avium complex

  • Aspergillus

EpidemiologyBronchiectasis

• What does this refer to
  MC cause is cystic fibrosis (CF)

• Recurrent lung infections

  • Pseudomonas aeruginosa in CF pt

  • H. flu

  • A1AT deficiency

• Collagen vascular diseases

EtiologyBronchiectasis

What does this refer to

• Persistent productive cough

Clinical History of Bronchiectasis

What does this refer to

• Lung auscultation

  • Wheezes

  • Crackles

Clinical presentationBronchiectasis

What does this refer to

• Pneumonia

• Pneumonitis

• COPD

Differential diagnosisBronchiectasis

What does this refer to

Workup for bronchiectasis

What does this refer to

Bronchiectasis

What used to diagnose bronchiectasis?

CT Chest IV Contrast

What does this refer to

• Airway clearance techniques

  • Improve secretion clearance/bronchial hygiene

    • Mucolytics

      • Guafenesin (Mucinex)

      • Carbocisteine

      • Dornase alfa (Pulmozyme)

• Bronchodilators

  • Beta-2 agonists

  • Anticholinergics

  • Theophylline

• Chest physiotherapy (postural drainage)

Clinical managementBronchiectasis

What does this refer to

• Morbidity

  • Antibiotic resistance

• Mortality

  • Recurrent lung infections

Prognosis Bronchiectasis

What does this refer to

• A 24-year-old woman with a past medical history of atopic dermatitis presents to an urgent care center for dyspnea on exertion.

• She reports that for the past few months, she has become increasingly short of breath with exertion, particularly during exercise.

• She denies any other symptoms and denies having ever smoked or been exposed chronically to second-hand smoke.

• Close examination into her pediatric records shows a documented history of hepatomegaly but no workup.

• Labs reveal significantly decreased alpha-1 antitrypsin and increased transaminitis.

• She is given nebulized ipratropium and albuterol, a course of steroids, and referred for regular treatments with alpha-1 antitrypsin.

Alpha-1 antitrypsin deficiency

What does this refer to

• ___________ is characterized early onset emphysema and cirrhosis

Alpha-1 Antitrypsin Deficiency

What does this refer to

• MC in young adults (often without a history of smoking)

  • + smoking hx exacerbates illness

• Family hx

  • Autosomal dominant

• Occurs as a result of decreased or dysfunctional alpha-1 antitrypsin

EtiologyAlpha-1 Antitrypsin Deficiency

What does this refer to

Clinical history of Alpha-1 Antitrypsin Deficiency

What does this refer to

• Asthma

  • Typically no associated liver disease

• Autoimmune hepatitis

  • Not associated with COPD or decreased A1A

Differential diagnosisAlpha-1 Antitrypsin Deficiency

What does this refer to

Workup for Alpha-1 Antitrypsin Deficiency

What confirms the diagnosis for Alpha-1 Antitrypsin Deficiency

Genetic testing

What does this refer to

Alpha-1 Antitrypsin Deficiency

What does this refer to

Alpha-1 Antitrypsin Deficiency CT w/ Contrast

What does this refer to

• Alpha-1 antitrypsin infusion

• Standard treatment of COPD

• Liver transplant

  • Decompensated cirrhosis

  • Hepatocellular CA

• Vaccinations

  • Influenza

  • Pneumonia

  • COVID

• Minimize EtOH

Clinical Management of Alpha-1 Antitrypsin Deficiency

What does this refer to

• A 69-year-old male presents with concerns about his declining health.

• His brother recently died of renal cell carcinoma and he is now concerned about his own health.

• The patient has a history of type II diabetes mellitus, HTN and a 50 pack-year smoking history.

• He asks you what he can do to improve his health.

Smoking cessation

What does this refer to

• Smoking is considered the most important modifiable risk factor in the US for cancer and cardiovascular and pulmonary disease

• Screen all adults regularly for tobacco use

• Discuss smoking cessation at EVERY clinical contact with those who smoke/vape

Smoking Cessation

What does this refer to

• Nicotine replacement

  • OTC

  • Forms include gum, lozenge, patches and sprays

• Bupropion (Zyban)

  • Rx

• Varenicline (Chantix)

  • Rx

  • Initiate 1 week prior to quit date (pt can continue to smoke in this time) THEN

  • No smoking

  • Continue tx x 4 months

• Cognitive behavioral therapy (CBT)

• Combination therapy (multiple treatments from above) are the most effective

Clinical pharmacotherapeuticsSmoking Cessation