If any positive, then exudate. (2/3, 0.6, 0.5) 1. LDH <2/3 upper limit normal (200) 2. LDH (effusion/serum <0.6) 3. Total Protein (effusion/serum <0.5)

3 Pulmonary Flashcards by Marcus Wong

Asthma severity types: what are each daytime and noctural sxs?

Daytime sxs, noctural sxs:

intermittent: <2/wk, <2/mo
mild persistent: <1/day, >2 mo
mod persistent: >1/day, >1/week
severe persistent: >1/day, frequent
refractory

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Asthma severity types: what are their PFTs (FEV1)?

intermittent: >80%
mild persistent: >80%
mod persistent: 60-80%
severe persistent: <60%
refractory

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Asthma severity types: what are their txs?

All have SABA

intermittent: -
mild persistent: low dose ICS
mod persistent: LABA + low dose ICS
severe persistent: LABA + high dose ICS
refractory: PO Steroids

LABA can be replaced with LTA

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Asthma exacerbation in ED: What PEFR goes into which severity categories? (generalization)

PEFR>70% mild
50-70 mod
<50 severe

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Asthma exacerbation: the thing that saves lives is ____

steroids

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Paraneoplastic syndromes of lung cancers:

squamous
small cell
carcinoid

Squamous: PTH-rp (hyperCa)
Small cell: ADH (SIADH), ACTH (Cushing’s), Lambert-Eaton,
Carcinoid: serotonoin syndrome

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Carcinoid tumor: intestine vs lung, what similarities and differences?
-what lab test?

Same sxs: flushing, wheezing, diarrhea

intestine: liver mets, R sided heart valve dz
lung: serotoin starts in lung, so L sided heart valve fibrosis

5-HIAA urine

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Which lung ca often has pain, why?

Adenocarcinoma, b/c peripheral irritation of pleura

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Pleural effusion: how much fluid before visible on CXR?

about 250cc before blunting of costophrenic angle.

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Light’s criteria

If any positive, then exudate.
(2/3, 0.6, 0.5)

LDH <2/3 upper limit normal (200)
LDH (effusion/serum <0.6)
Total Protein (effusion/serum <0.5)

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Pleural effusion causes:
Transudate (3 main ones)
Exudate(3 big ones, and more)

transudate: CHF, Cirrhosis (low protein), Nephrotic syndrome (low protein)
USU BILATERAL

exudate: Infection, CA, TB. Also: PE, Hemothorax, chylothorax
USU UNILATERAL

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Pt with pleural effusion that is loculated. Do what and why?

Can’t do thoracentesis.
Do tube thoracostomy, to prevent empyema formation if parapneumonic effusion. If wait too long and empyema forms, must to thoracotomy.

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Pleural effusion thoracentesis sample: how many tubes and what tests to order?

Tube 1: CBC with diff (polys for PNA, Lymphs for TB/CA, RBC for hemothorax/CA)

2: cytology (looking for CA)
3. glu, pH, total prot, LDH (for light’s)
4. Gram stain, Cx, acid fast

Other tests possible

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Pleural effusion: what test for TB? Other than acid fast and lymphs

ADA (adenosine deaminase)

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Pt with PE. Also has met CA and short life expectancy. How to anticoag?

what is the exception to that rule?

Don’t use warfarin or NOAC.
Use LMWH for rest of life.

If brain mets, do IVC filter b/c risk of ICH

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PE pt. How to do Hep bridge to warfarin?

5 days Hep, or until INR 2-3, whichever is LONGER

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How to start Heparin for DVT anticoag

loading dose (80u/kg IV)
maintenance dose (18u/kg/hr)
check PTT in 6h to redose if necessary

target PT 46-70

HIT–hep induced thrombocytopenia:

when does it usu occur after starting Hep, first exposure vs repeat?
if suspected, do what?

First exposure: 7 days
repeat: 3 days

Stop Hep, draw HIT panel, give Argatroban

Severity types of PE (4)

what’s the difference
what is tx for each

asx PE, incidental discovery–d/c from ED, to LMWH bridge to coumadin
sx PE: Stay overnight on floor. No R heart strain (no abnormality with BNP, Trops, or Echo.) d/c with LMWH bridge to coumadin
submassive PE: findings of R heart strain, but no hypotension. abnormality of these 3 tests: BNP, Trops, Echo. Transfer to ICU with Hep to Coumadin bridge. Stay in hospital until bridge complete.
Massive PE: Hypotensive. give TPA. ICU with pressors.

CTEPH: what is this

chronic thromboembolic pulmonary HTN

-outpt workup in pts with Pulm HTN. Do angiography and thrombectomy endovascularly

Well’s criteria (8)

3 each:

PE most likely dx
Signs/sxs DVT
5 each
HR>100
immobilization >3 days, or surgery w/i 4 weeks
hx DVT/PE

1 each:

hemoptysis
malignancy w/i 6 mo

<2: low prob
2-6: mod prob
>6 high

Bronchitis in COPD: definition

productive cough for more than 3 mo in 2 consecutive years

Pt in ED with SOB. Has pitting edema, JVD, and HSM.

What hx and signs to differentiate CHF from COPD blue bloater?

In CHF, hx of orthopnea and PND. Also, lung crackles and S3/4

Crackles can be present in COPD

Why hypercapnia in COPD? what is significance?

Pink puffers have barrel chests, with air trapping. CO2 is trapped.

Chronic CO2 retention means resp drive is from Low O2, NOT HIGH CO2 (body used to that). So, be careful in giving too high oxygenation, could eliminate hypoxic resp drive.

What's main diff between COPD and asthma in PFTs?

Asthma is reversible (with bronchodilators). Both obstructive process

COPD exacerbation tx

``` "COPD" Corticosteroids O2 Preventive (Abx) Dilators (Duonebs) ```

COPD: when to do chronic home O2?

Strict criteria, to make sure not to eliminate hypoxic drive. (from chronic hypercapnia) If pO2 <55 or spO2 <88%, chronic home O2 indicated with goal spO2 >90%

COPD pt in ICU. What target sats?

88-92%

COPD outpt meds, in increasing severity of dz?

- SABA - antichol (tiotropium, spiriva) - LABA (formoterol) - ICS (beclomethasone) - PDE4-i (oral) - steroids

COPD exac: which abx to use for ppx?

Doxy is best, if no signs of infection /PNA Could also use Azithro. Moxi try to avoid in elderly

COPD: what 2 things improve mortality?

1. smoking cessation | 2. home O2 if spO2<88% or paO2<55

ARDS: What PaO2 to FiO2 ratio

<200

ARDS pt in ICU: What happens if you give too much O2 (high FiO2)?

Superconcentrated O2 means free radicals. Can lead to pulmonary fibrosis. This looks similar to ARDS on CXR.

Pt intubate in ICU: When to do tracheostomy? Why?

Laryngeal stenosis concern if pt intubated for 14 days. Do trach soon if you suspect >14 days intubated, otherwise delay.

ILD, idiopathic. | what are the names and criteria for the acute and chronic versions?

acute: AIP--acute interstitial pneumonitis. <6 weeks chronic, >6mo insidious: IPF. Instertitial pulmonary fibrosis

ILD: drug causes? (2)

bleomycin, amio

Silicosis: what 2 things to know

1. CXR finding of upper lobe nodules, looks like TB | 2. Screen annually for TB b/c increased risk

Coal miner's lung: what to konw

-Caplan's syndrome: RA. A pt with bilateral symmetrical arthralgia and restrictive lung dz should be worked up for RA. (Rh factor, anti-CCP)

asbestosis: what on CXR? What on bx?

pleural plaques. barbell shaped asbestos bodies

Hypersensitivity pneumonitis: what is the vignette to know

Pt describes SOB sxs only during workweek. Resolves on weekends or long holidays. HP takes 24h to 'set in' and out. Remove exposure is tx. (pigeon feathers) noncaseating granulomas

Sarcoidosis: what extrapulm sxs to know? (4) also, levels of what may be elevated in blood?

- heart block - bells palsy - erythema nodosum - uveitis hypercalcemia from increased 1,25-vitD. Sarcoid can create this.