CHAPTER 20
Obstructive Lung Disease
Sputum Power
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Remember, a huge chunk of your clin...
6. About 15% of all smokers experience a more rapid decline of lung function than nonsmokers.
P. 471
7. Elastin is protect...
18. Controlled studies show a lessening of dyspnea. There is little additional bronchodilation.
Serum theophylline levels ...
31. The antigen cross-links to specific IgE molecules on the surface of mast cells in the bronchial
mucosa. Degranulation ...
D. PEFR—>80% predicted, less than 20% diurnal variation
41. P. 481 Table 20-2
Zone PEFR % predicted Treatment/Action
A. Gr...
54. P. 486
A. EIA—Asthma triggered by exercise, especially in cold air. The causes are poorly
understood.
B. Prophylaxis
1...
70. Collect a sample for gram stain, culture and sensitivity. (See Chapter 19)
71. Oxygen therapy.
P. 476
72. Inhaled bron...
Upcoming SlideShare
Loading in …5
×

Chapter 20

424 views
341 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
424
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Chapter 20

  1. 1. CHAPTER 20 Obstructive Lung Disease Sputum Power CHRONIC OBSTRUCTIVE PULMONARY DISEASE Remember, a huge chunk of your clinical simulation examinations covers COPD. Chapter 20 is an invaluable tool! Overview 1. P. 470 A. Gastroesophageal reflux B. Asthma C. Postnasal drip 2. Chronic bronchitis—14 million, Emphysema—2 million P. 470 3. COPD is fourth leading cause of death, so heart attack and stroke are more common. But, death rate from COPD is rising, where that of heart disease is not. P. 471 4. 24 billion dollars per year in U.S. P. 471 Risk Factors and Pathophysiology 5. Box 20-1 P. 471 A. Alpha1 antitrypsin deficiency B. Intravenous Ritalin abuse (also HIV, Marfan, Ehlers-Danlos) Copyright © 2004 Mosby, Inc. All rights reserved.
  2. 2. 6. About 15% of all smokers experience a more rapid decline of lung function than nonsmokers. P. 471 7. Elastin is protected by the protein alpha1 antitrypsin from neutrophil elastase, which is attracted to the lung by inflammation or infection. Decreased levels of alpha1 antitrypsin result in digestion of elastase. Cigarettes create inflammation and inhibit lung defenses. P. 472 Figure 20-3 8. P. 472 A. Inflammation and obstruction of small airways B. Loss of elasticity C. Bronchospasm Clinical Signs 9. P. 472 Also Table 20-1 A. Cough B. Phlegm production C. Wheezing D. Shortness of breath, especially on exertion 10. Dyspnea is usually seen in late 60s, early 70s with COPD, in 40s with -1 antitrypsin deficiency. P. 473 Table 20-1 11. Barrel chest (increased AP diameter and outward movement of ribs). Hoover’s sign. P. 472 12. P. 472 A. Use of accessory muscles of ventilation B. Edema from cor pulmonale C. Mental changes secondary to hypoxia and hypercapnia 13. P. 473 Table 20-1 Features Chronic Bronchitis Emphysema -1 A. Age of onset 60-70 60-70 40-50 B. Family Hx not necessarily not necessarily common C. Smoker often heavy often heavy not necessarily D. Lung volume normal increase increase E. DLCO normal decrease decrease F. FEV1/FVC decrease decrease decrease G. X-ray “dirty lungs” hyperinflation hyperinflation esp. at apex esp. at base Management—Optimizing lung function 14. Treatment is different. P. 473 15. 12% and a 200 ml rise in FEV1. P. 474. Note that this differs from the 15% value often found on the board exams. This represents the more recent standard. You should remember both. 16. P. 475 A. Why—Up to two thirds of COPD’ers have a reversible component B. What drugs—Anticholinergic and sympathomimetic bronchodilators C. Outcome—No real change in outcome 17. Systemic steroids have been shown to help up to 29% of patients. Studies are being conducted on inhaled steroids. P. 475 Copyright © 2004 Mosby, Inc. All rights reserved. 2
  3. 3. 18. Controlled studies show a lessening of dyspnea. There is little additional bronchodilation. Serum theophylline levels should be maintained at 8-10 micrograms per ml. 19. P. 475, 476 A. Inhaled bronchodilators B. Intravenous steroids C. Oral antibiotics D. Supplemental oxygen 20. Maximized ability to perform activities of daily living. P. 476 21. Rehab improves exercise capacity, but has no effect on lung function or long-term survival. P. 476 22. P. 476 A. Instruction B. Group counseling C. Nicotine replacement therapy 23. Oxygen therapy. P. 477 24. Aggressive bronchodilator therapy will help up to one third of patients enough to avoid long- term supplemental oxygen. P. 477 25. P. 477 A. Influenza—annual B. Pneumonia (pneumococcal) 26. P. 477-478 A. Lung transplantation—COPD is the most common current indication. Patients must be <65 years old and have FEV1s of <20% of predicted. Single-lung transplant is usually performed with a 40% survival rate at 5 years. The surgery is associated with a significantly improved quality of life. B. Lung volume reduction surgery—Removes a portion of the diseased hyperinflated lung. FEV1, walking endurance, and oxygen are improved. Currently, studies are being conducted to clarify the indications and expected outcomes. ASTHMA HEY, I just took the national Certification Examination for Asthma Educators (AE-C) and I used the material in this chapter as one of my primary study tools. GUESS WHAT? I passed easily! The asthma info in Egan is super helpful. Overview 27. Older definitions emphasized airway reactivity and reversible obstruction. Current emphasis is placed on the inflammatory aspects of the disease. P. 478 28. A little over 5% of the population. P. 479 29. Asthma mortality is rising. Death rates have increased by 31% from 1980-1987. P. 479 Etiology and Pathogenesis 30. P. 479 A. Airway inflammation B. Bronchial hyperreactivity Copyright © 2004 Mosby, Inc. All rights reserved. 3
  4. 4. 31. The antigen cross-links to specific IgE molecules on the surface of mast cells in the bronchial mucosa. Degranulation occurs, and multiple mediators are released, resulting in airway inflammation and bronchospasm. P. 479 32. P. 480 Figure 20-9 A. EAR-Immediate hypersensitivity reaction that usually lasts about 30-60 minutes. B. LAR-Response that occurs in about 50% of asthmatics and lasts 3-8 hours. Characterized by increasing influx and activation of inflammatory cells such as eosinophils, mast cells, and lymphocytes. Clinical Signs 33. History P. 479 34. P. 479 A. Episodic wheezing B. Shortness of breath C. Chest tightness D. Cough 35. P. 480 A. Tumors B. Laryngospasm C. Aspiration of a foreign object D. Tracheal stenosis E. Vocal cord dysfunction 36. Pre and post bronchodilator measurement of FVC and FEV1. A 12% increase (at least 200 ml) or 15% increase of self-recorded peak flow rates. P. 480 37. P. 480 A. Drug—methacholine (cold air, exercise, hypertonic saline also used) B. Response—20% decrease in FEV1 38. ABGs are used in staging of an asthma attack. They may be normal in between attacks, and have no real diagnostic value. Mild asthma shows a normal PO2 with decreased CO2 and increased pH. PO2 declines in a moderate attack. In severe attacks, the PO2 is low, CO2 is normal or high, and pH is normal or decreased. See Mini Clini P. 485 Management 39. Table 20-2 P. 481 Severity Symptoms Long-term meds A. 1-intermittent <1x per week None B. 2-mild persistent >1x per week, <daily Steroids-MDI, cromolyn, long-acting dilator for noc. C. 3-moderate persistent Daily symptoms Steroids-MDI, long-acting dilator for noc. D. 4-severe persistent Continuous Same as above. Consider adding oral steroids. 40. P. 481 A. Symptoms—Minimal to no symptoms B. Beta2 agonists—Infrequent to no need C. Exercise—No exercise or activity limitations Copyright © 2004 Mosby, Inc. All rights reserved. 4
  5. 5. D. PEFR—>80% predicted, less than 20% diurnal variation 41. P. 481 Table 20-2 Zone PEFR % predicted Treatment/Action A. Green ≥ 80% Inhaled B2 agonist PRN B. Yellow >60 <80% Inhaled B2 agonist 3-4/day C. Red ≤60% B2 prn for symptoms 42. Inhaled corticosteroids are the most effective medication for treatment of the inflammatory response. They act locally on the airway to suppress the primary disease process. Bronchodilators are used to relieve the symptoms of airway spasm. P. 482 43. P. 482 A. Candidiasis B. Dysphonia C. Control/reduce—Use spacer, rinse mouth after treatment 44. P. 482 A. Indications 1. Adults—Prevent cough-variant and exercise-induced asthma 2. Children—Prevent atopic (allergic) asthma B. Acute attacks—Not useful 45. Similar to cromolyn but more potent. Used as an alternative to cromolyn. P. 482 46. Beta agonists. P. 484 47. Primary use is for treatment of nocturnal asthma. The role in chronic management is still evolving. P. 484 48. Sustained-release theophylline is useful for nocturnal asthma. IV or oral theophylline may be used in hospitalized patients. P. 484 49. Daily use has not been established. May be helpful for cough-variant asthma. Can also be used when first-line bronchodilators are ineffective. P. 484 50. P. 485 A. Symptoms B. PEFR C. ABGs 51. P. 485 A. PaO2—PaO2 >60 mm Hg B. PEFR—Patient’s best or >70% of predicted C. Symptoms—No nocturnal symptoms, return to preadmission state D. Discharge meds—12- to 24-hour stability on discharge meds 52. Immunotherapy is one potential method. Avoidance and standard pharmacotherapy are the usual recommended method. ? Leukotriene inhibitors? P. 485 53. P. 485-486 A. Outdoor 1. Ragweed 2. Grass 3. Pollen (and molds) B. Indoor 1. Pets 2. House-dust mites 3. Molds Copyright © 2004 Mosby, Inc. All rights reserved. 5
  6. 6. 54. P. 486 A. EIA—Asthma triggered by exercise, especially in cold air. The causes are poorly understood. B. Prophylaxis 1. Beta2 drugs 2. Cromolyn 3. Leukotriene inhibitors 55. Asthma caused by exposure to a specific sensitizing agent in the workplace. It is the most common form of occupational lung disease in industrialized nations. Toluene diisocyanate used in the plastics industry is the most common cause. P. 486 56. Total cessation of exposure. P. 486 57. Ipratropium P. 487 58. P. 487 A. Sustained-release theophylline B. Salmeterol C. Antacids 59. Use acetaminophen and avoid aspirin and NSAIDs. P. 487 60. One third get better control, one third worsen, one third stay the same. P. 487 Poor control of asthma increases perinatal mortality, prematurity, and low birth weight. 61. Theophylline, beta 2 agonists, inhaled steroids, and cromolyn are safe. P. 487 BRONCHIECTASIS 62. Chronic production of large amounts of purulent sputum. P. 487 63. “Fine-cut” CT scanning P. 488 64. P. 488 A. Local 1. Foreign body 2. Benign tumors B. Diffuse 1. Cystic fibrosis 2. Ciliary dyskinesia 3. Serious lung infections (also rheumatoid arthritis, alpha1-antitrypsin deficiency, aspergillosis, and hypogammaglobulinemia) 65. P. 488 A. Antibiotics B. Bronchopulmonary hygiene techniques CASE STUDIES Case 1 66. Emphysema P. 473 67. 100 pack-years (see workbook introduction) 68. Smoking cessation. P. 476 Case 2 69. Chronic bronchitis. P. 473 Copyright © 2004 Mosby, Inc. All rights reserved. 6
  7. 7. 70. Collect a sample for gram stain, culture and sensitivity. (See Chapter 19) 71. Oxygen therapy. P. 476 72. Inhaled bronchodilators—both beta agonist and ipratropium. Consider steroids. P. 475 Figure 20-5. Case 3 73. 1-antitrypsin deficiency. He is young, a nonsmoker, and has a familial history. He shows signs of emphysema-barrel chest, decreased breath sounds. The chest x-ray shows basilar hyperinflation. P. 473 74. Lung transplant therapy, administration of purified 1-antitrypsin. P. 478 Case 4 75. EIA. P. 486 76. Methacholine or other type of challenge. P. 480 WHAT DOES THE NBRC SAY? 77. B. Expiratory wheezing P. 479 78. A. Acute respiratory alkalosis 79. C. Nasal cannula at 2L. The hypoxemia is mild and cannulas are well tolerated by asthmatics. You could make an equally valid claim for the entrainment mask based on the abnormal breathing pattern, but a 50% produces a relatively low total flow rate. 80. B. 0.5 ml Proventil (albuterol) via SVN P. 483 81. C. Oxygenation 82. D. Intubation and mechanical ventilation The patient is now having a severe attack bordering on respiratory failure. Naturally there are other strategies that could be attempted to avoid intubation. P. 485 83. B. Air-entrainment mask at 28% You’ll need to check out “Medical Gas Therapy” 84. D. Bronchiectasis P. 459-60 85. A. Emphysema P. 473 86. B. II only P. 480 FOOD FOR THOUGHT 87. There is also an increased risk of lung cancer and cardiovascular disease. Second-hand smoke represents another hazard. 88. Purified alpha1-antitrypsin is available from donated human blood. The therapy must be taken weekly, and may improve PFT’s, improve survival, and slow the decline of lung function. It costs $25-50,000 per year and poses risks of blood-borne pathogens. 89. These drugs block or prevent the release of leukotrienes, which play an important role in the pathogenesis of inflammatory asthma. They are new drugs. Copyright © 2004 Mosby, Inc. All rights reserved. 7

×