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IM - OBSTRUCTIVE LUNG DISEASES

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tonystep1's version from 2017-08-30 21:27

CLINICAL FEATURES

Question Answer
Chronic Obstructive Pulmonary Disease (COPD) symptomsSymptoms
a. Any combination of cough, sputum production, and dyspnea (on exertion or at
rest, depending on severity) may be present.
Chronic Obstructive Pulmonary Disease (COPD) signsSigns-the following may be present:
a. Prolonged forced expiratory time. Timed full exhalation of vital capacity
2:6 seconds (evidence for obstruction with 75% sensitivity).
b. During auscultation, end-expiratory wheezes on forced expiration, decreased
breath sounds, and/or inspiratory crackles
c. Tachypnea, tachycardia
d. Cyanosis
e. Use of accessory respiratory muscles
f. Hyperresonance on percussion
g. Signs of cor pulmonale
Asthmal. Characterized by intermittent symptoms that include SOB, wheezing, chest tightness,
and cough. Symptoms have variable severity and may not be present simultaneously.
Usually occur within 30 minutes of exposure to triggers.
2. Symptoms are typically worse at night.
3. Wheezing (during both inspiration and expiration) is the most common finding
on physical examination.
Bronchiectasisl. Chronic cough with large amounts of mucopurulent, foul-smelling sputum
2. Dyspnea
3. Hemoptysis
4. Recurrent or persistent pneumonia
Cystic FibrosisTypically results in obstructive lung disease pattern with chronic pulmonary infections
(frequently Pseudomonas) , pancreatic insufficiency, and other GI complications
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Treatment

Question Answer
Chronic Obstructive Pulmonary Disease (COPD) first linea. Smoking cessation-the most important intervention
b. Inhaled {beta-agonists (e.g. , albuterol): bronchodilators
COPD tx reserved for patients whose symptoms are not controlled by bronchodilatorsInhaled corticosteroids (e.g. , budesonide, fluticasone): anti-inflammatory
COPD with chronic hypoxemia
• Pao2 55 mm Hg OR
• 02 saturation <88% (pulse
oximetry) either at rest or
during exercise OR
• Pao2 55 to 59 mm Hg plus polycythemia
or evidence of cor
pulmonale
add oxygen therapy to regimen
• Shown to improve survival and quality of life in patients with COPD and
chronic hypoxemia
• Some patients need continuous oxygen, whereas others only require it during
exertion or sleep. Get an ABG to determine need for oxygen
COPD vaccinations• Influenza vaccination annually
• Vaccination against Streptococcus pneumoniae every 5 to 6 years
Acute COPD exacerbation• CXR
• /32-agonist and anticholinergic
inhalers
• Systemic corticosteroids
• Antibiotics
• Supplemental oxygen
• Noninvasive positive-pressure
ventilation INPPV) if needed
Asthma attackShort-acting ,beta-agonists (e.g., albuterol) are used for acute attacks (rescue).
Onset is 2 to 5 minutes, duration is 4 to 6 hours.
Night time AsthmaLong-acting beta agonists(e.g. , salmeterol)
Exercise induced AsthmaLong-acting beta agonists(e.g. , salmeterol)
acute severe asthma exacerbationa. Inhaled /32-agonist (first-line therapy)
• Via nebulizer or MDI
• Mainstays of emergency treatment-have an onset of action of minutes
• Assess patient response to bronchodilators (clinically and with peak flows).
b. Corticosteroids
Traditionally given intravenously initially, but may also be given orally if given
in equivalent doses.
• Taper IV or oral corticosteroids, but only when clinical improvement is seen.
• Initiate inhaled corticosteroids at the beginning of the tapering schedule
mild intermittent asthma symptoms 2 or more times per weekalbuterol for symptom relief
moderate persistent asthma daily symptoms , frequentDaily inhaled corticosteroid (low dose) or cromolyn/nedocromil or methylxanthine or antileukotriene
severe persistent asthma (continual symptoms, frequent exacerbations, limited physical activity)Daily inhaled corticosteroid (high dose) and long acting inhaled beta agonist or methylxanthine and systemic corticosteroids
Bronchiectasis acute exacerbationsAntibiotics for acute exacerbations-superimposed infections are signaled by
change in quality/quantity of sputum, fever, chest pain, etc.
Amoxicillin.
Tetracycline.
Trimethoprim-sulfamethoxazole.
Bronchiectasis hygienic practicesBronchial hygiene is very important.
a. Hydration
b. Chest physiotherapy (postural drainage, chest percussion) to help remove the
mucus
c. Inhaled bronchodilators
Cystic FibrosisTreatment is pancreatic enzyme replacement, fat-soluble vitamin supplements, chest
physical therapy, annual influenza vaccine, and treatment of infections with antibiotics.
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Diagnosis

Question Answer
Chronic Obstructive Pulmonary Disease (COPD) FEV1/FVC ratioDecreased FEV1 and decreased FEV/FVC ratio-If FEV1 is reduced to 70%
of predicted value, mild disease is suggested. If FEV 1 is reduced to 50% or
less of predicted value, severe disease is present. Values in between indicate
moderate disease
Chronic Obstructive Pulmonary Disease (COPD) total lung capacity (TLC), residual volume, and functional reserve capacity (FRC)Increased total lung capacity (TLC), residual volume, and functional reserve
capacity (FRC) (indicating air trapping)
Chronic Obstructive Pulmonary Disease (COPD) vital capacityDecreased vital capacity
Chronic Obstructive Pulmonary Disease (COPD) CXRa. Low sensitivity for diagnosing COPD; only severe, advanced emphysema will
show the typical changes, which include:
• Hyperinflation, flattened diaphragm, enlarged retrosternal space (see
Figure 2-3)
• Diminished vascular markings
b. Useful in an acute exacerbation to rule out complications such as pneumonia
or pneumothorax
Asthma Pulmonary function tests (PFTs)Pulmonary function tests (PFTs) are required for diagnosis. They show an obstructive pattern: decrease in expiratory flow rates, decreased FEV 1 and decreased FEV/FVC ratio ( <0.75) .
Asthma Spirometry before and after bronchodilators what is the increase in FEV1 post bronchodilator?Spirometry before and after bronchodilators can confirm diagnosis by proving
reversible airway obstruction. If inhalation of a bronchodilator (,82-agonist) results
in an increase in FEV1or FVC by at least 12%, airflow obstruction is considered
reversible.
Asthma Peak flow (peak expiratory flow rate) Mild diseaseMild: >300
Asthma Peak flow (peak expiratory flow rate) Moderate to severeModerate to severe: 100 to 300
Asthma Peak flow (peak expiratory flow rate) SevereSevere: < 100
Asthma Peak flow (peak expiratory flow rate) Normal• Normal: 450 to 650 Vmin (men), 350 to 500 Vmin (women)
Asthma Bronchoprovocation testa. May be useful when asthma is suspected but PFTs are nondiagnostic
b. Measures ease with which airways narrow in response to stimuli
c. Measures lung function before and after inhalation of increasing doses of
methacholine; hyperresponsive airways develop obstruction at lower doses
Asthma CXR severesevere asthma reveals hyperinflation
Asthma ABGs with increased PaCO2 indicate?Increased Paco2 is a sign of
respiratory muscle fatigue or severe airway obstruction
The patient should be hospitalized and mechanical ventilation considered
Bronchiectasis study of choiceHigh-resolution CT scan is the diagnostic study of choice.
Bronchiectasis PFTsPFTs reveal an obstructive pattern.
Bronchiectasis CXRCXR is abnormal in most cases, but findings are nonspecific
Cystic FibrosisA genetic test showing that a person inherited one or two defective cystic fibrosis transmembrane regulator (CFTR) genes. This testing can be done using blood or a sample from the mother's womb before birth (chorionic villus sampling or amniocentesis).
Two positive sweat tests on different dates. Sweat tests measure the level of salt in sweat. People with cystic fibrosis have more than the normal amount of salt in their sweat. If a genetic test detects two defective CFTR genes, then just one sweat test result may be all that is needed to confirm a diagnosis.
An abnormal nasal potential difference test. This test uses electrodes on the lining of the nose to see how well salts flow into and out of cells.
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Complications

Question Answer
Chronic Obstructive Pulmonary Disease (COPD)l. Acute exacerbations-most common causes are infection, noncompliance with
therapy, and cardiac disease
2. Secondary polycythemia (Hct >55% in men or >47% in women)-compensatory
response to chronic hypoxemia
3. Pulmonary HTN and cor pulmonale-may occur in patients with severe, longstanding
COPD who have chronic hypoxemia
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