Clin Med Exam 2 Flashcards
1
Q
Coin Lesion
A
<3 cm SMALL well defined bordered lung lesion- completely surrounded by pulmonary parenchyma
2
Q
Coin lesion
A
<3 cm
not assoc w/ infiltrate, atelectasis, or adenopathy
Most BENIGN
smooth edges
dense central calfification
3
Q
Coin Lesion (SPN)
A
<3 cm
most common are infectious granulomas
4
Q
Mass
A
> 3 cm
more likely Cancerous
5
Q
After what age, chance of an SPN being malignant increases to 50%?
A
60 or older!!
6
Q
Risk factors for SPN being malignant
A
Obvious ones: tobacco, family hx, previous CA, asbestos
ALSO:
Female> Male, emphysema
7
Q
SPNs in AZ
A
good chance it is Cocci 60% are
8
Q
1st step approach to SPN
A
Review old films
Malignant nodules usually double in 1-13 months
9
Q
Minimal growth of SPN
A
minimal in 2 years suggests BENIGN lesion
10
Q
Calcification of SPN
A
usually benign
11
Q
No calcification of SPN
A
bad sign
Increase risk of Malignancy
12
Q
Size of lesions
A
<3cm is considered Small Pulm Nodule (SPN)
IF 5 cm or greater = 90% CA
13
Q
Preferred imaging for SPN
A
Helical CT WITHOUT contrast with low dose radiation
14
Q
Helical CT without contrast details:
A
thin 1 mm sections
Most reliable for: nodule size, growth, lobar location, density and borders
15
Q
Solid nodule > 8mm and Low probability, what next?
A
CT at 3 months
no growth: another CT at 9-12 and 18-24
growth: pathologic eval
16
Q
Solid nodule > 8mm and Intermediate probability, what next?
A
FDG PET/CT and or Biopsy
CT again at 3, 9-12, and 18-24 months
17
Q
Solid nodule >8mm and High probability, what next?
A
Biopsy or excision!!! not only CT in this case- need to do more
Staging with PET/CT may be helpful
18
Q
Solid nodule 6-8 mm
A
Follow w CT at 6-12 months, repeat as indicated
19
Q
Solid nodule < 6mm
A
does not require f/u
CT at 12 months is optional (pt dependent)
20
Q
Indications for Referral
A
New/enlarging lesion
Lesion is, unstable, not calcified, irregular shape, >3cm
Lesions are are indeterminate
21
Q
Small cell CA is associated with
A
SIADH, Cushings syndrome, Eaton Lambert Synd, and Mets to BRAIN
22
Q
Staging of Small Cell
A
Limited (to ipsilateral hemithorax) vs Extensive (extends beyond hemithorax, includes pleural effusions)
23
Q
Staging of Non Small Cell
A
“T-N-M”
T: primary tumor
N: nodal involvement
M: distant Mets
24
Q
Performance status
A
0: fully active
1: strenous PE restricted, but able to carry out light work
2: capable of all self care, but unable to carry out work activities, about 50% of waking hours
3: capable of only light, limited self care
confined to bed >50% of waking hours
4: completely disabled, cannot carry out any self care
25
If FEV1 is <60% and Lung CA
<60 is the strongest indicator of post-op complications
26
What is used in PET scans
FDG
| Fluorodeoxyglucose
27
Downfall of PET scan
does not detect all CA (i.e. bronchoalveolar CA)
28
Air is
Black on X Ray
29
Bone is
White on X Ray
30
Fluid is
Grey on X Ray
31
PA (posterior anterior view)
Good for X Ray bc it doesn't falsely enlarge the heart
32
Systematic approach for reading CXR
```
A-airway (trachea midline?)
B- bones (fracture)
C- cardiac outline
D- diaphragm (free air?)
E- edges (pleural plaques, effusion?
F- fields (infiltrates, nodules?)
```
33
PA and Lateral view of CXR allow us to see
structures behind the heart and diaphgram
34
PA and Lateral decubitis CXR
good to evaluate for PNA vs effusion
| with effusion (Fluid) will lay out when person lies down
35
Pulmonary infarct
"Hamptons hump" on CXR
36
CT
a bunch of cross sectional slices thru body
a bunch of X ray slices
37
Indications for CT
```
Clarify abnormal CXR
Characterize pulm nodules
Assist in dx of clinical sx
Detect and Stage CA
Evaluate suspected mediastinal or hilar mass
```
38
Conventional CT scan
10 mm slice
Step and shoot
25-30 min
39
Helical (spiral) CT
Faster
Continuous
<5 minutes
40
HRCT
1mm slice
| best detail
41
Low dose CT
| LDCT
Used for Screening
| less detail
42
CT angiography
CTPA
43
Special populations to consider with CT scans
Peds- more radiosensitive than adults, inc risk of leukemia and brain tumors, radiation risk compounded d/t lifespan
Pregnant- in utero exposure linked to pediatric CA mortality
44
CT WITH contras
Iodine
45
When is contrast needed with a CT?
Vessels
Malignancy
Trauma
46
3 main risk of Iodine contrast with a CT scan
- Allergic rxn
- Contrast induced Nephropathy (kidney)
- Lactic acidosis (if taking glucophage/Metformin)
47
Allergic rxn to Radiocontrast
5-60 min after exposure
Risk factors: prior rxn, hx of Asthma or Atopy
Pre-tx with Prednisone and Diphenhydramine (benadryl)
48
CIN- Contrast Induced Nephropathy
Increased serum creatinine >/ -.5 or >/ 25 % from baseline
1-2 day after exposure, peaks at 3-5 days
Usually reversible
49
Caution using contrast in pts with impaired kidney fx
Creat > 1.5
GFR <60
Use alternative (CT without contrast, MRI without gadolinium, or US)
50
Check Renal fx prior to giving contrast IF
```
>60 YO
Renal dz
HTN on meds
Diabetes
Taking Glucophage
```
51
CTPA
replaced conventional catheter directed pulmonary angiography
less invasive, less $, and less time
52
CTPA
detect PE, Aortic dissection, SVC syndrome
53
Gold standard in evaluation of PE (even though it is invasive)
Catheter-directed Pulmonary Angiography
54
Catheter directed pulmonary angiography (invasive)
Needle/catheter is inserted into R femoral or internal jugular vein; into R side of heart and pulmonary arteries
Dye is injected and X rays taken
55
When is catheter directed pulmonary angiography especially useful?
When V/Q scan or CTPA is inconclusive BUT high clinical suspicion for PE
56
MRI has limited use in Pulmonary field, BUT use if
Hilar or mediastinal density
Sulcus tumor (pancoast)
Cyst/lesion of chest wall
HIGH QUALITY images of blood vessels
57
If person is allergic to Iodine (used in CT)
can do MRI with Gadolinium instead
58
MRI is less detailed for
Lung parenchyma (compared to CT chest)
59
No bone artifact seen on
MRI
AND no ionizing radiation
60
Limitations with MRI
Claustrophobia
| Nephrogenic Systemic Fibrosis- avoid use of Gadolinium if GFR <30
61
Possible contra to MRI
Implanted pacemaker/defib
Metal in eye
Aneursym clip in brain
Cochlear implant
62
V/Q
Evaluate PE and
| Pre-op assessment (before lung resection)
63
V/Q process
IV phase (perfusion): Tach 99 labeled to albumin
Inhalation (ventilation): radio labeled Xenon gas
64
Test of choice to dx PE in pregnant woman
V/Q scan
65
V/Q scan is best utilized in:
pts with normal CXR and high suspicion for PE
66
Absolute contra for V/Q?
NONE
67
PET
Standardized uptake value (SUV)
| >2.5 raises possibility of CA
68
Indications for Ultrasound in the Pulmonary field
Bedside detection of pleural fluid, hemothorax, or pneumothorax
Guide thoracocentesis
Place thoracostomy tubes
69
Normal lung on US
Positive motion lung beach "seashore sign"
70
Diseased lung with no chest wall motion (pneumothorax) on US
"Barcode/stratosphere sign"
71
Bronchoscopy
Diagnostic and therapeutic
72
Bronchoscopy Dx indications
Evaluate PNA, hemoptysis, cough
Dx tracheoesophogeal fistula/tracheobronchomalacia
Tissue sampling
73
Bronchoscopy Therapeutic
Remove excess mucus or FB
| ET tube placement
74
Contraindications to Bronchoscopy
```
Severe hypoxia
Bleeding risk
Pulm HTN
Severe cough/gag
Tracheal stenosis
```
75
How to perform spirometry
1. relax and breathe normally
2. deep Inhale
3. Forceful exhale
4. another deep Inhale
76
Forced vital capacity on Spirometry
Deep breath in, blow air out as fast as possible = total volume of air with max effort
77
FEV-1
most useful information for obstructive
78
FEV1/FVC ratio
Defines severity of obstruction
| Diff b/w Obstructive and Restrictive
79
Ratrio
<0.7 is RESTRICTVE
80
Bronchodilator reversibility testing
```
Nebulizer/inhaler
2-4 puffs
Hold inhaled med for 5-10 seconds
Spirometry test again 15 min after med provided
3-8 rounds of testing
```
81
Reversibility is positive IF
FEV1 increases by 12% and 200 ml with Bronchodilator testing
82
Bronchoprovocation
BUT BE CAREFUL
Dilute solution of Methacholine
Spirometry at 30 and 90 seconds
Positive if FEV1 decreases by 20%
83
Quality of curve must meet these parameters
curve plateaus
expiration >6 seconds
two best efforts w/in 0.2 L
volume loop free of Artifact
84
Obstructive
wide and scooped out
85
Restrictive pattern
Steep and overall less volume
86
DLCO
ability of lungs to txr gas and Saturate Hgb
misleading if person is anemic
87
DLCO technique
Pt inhales a single breath of gas with helium and Carbon Monoxide, expires, and measurement of exhalation is taken
Healthy lung: little CO collected (bc most of it was txr in persons lung)
Diseased lung: high levels measured in exhaled gas bc lung txr in persons body is not working well
88
Obstructive pattern
Can get air in, but cant get it out
High lung volumes
TLC: Increased
Ratio decreased
89
Restrictive pattern
Trouble getting air IN and OUT
Reduced lung volumed
EVERYTHING: decreased, except
Ratio: normal or increased
90
Most things we hear about often are Obstructive
```
Asthma
Bronchitis
COPD
Cystic Fibrosis
Emphysema
Obstruction
```
91
Examples of Restrictive
```
Pulm Fibrosis
Infectious lung dz
Thoracic deformity
Effusion
Tumor
Neuromusc dz
Obesity
```
92
FEV1 value is decreased by more than 15-20% of predicted
OBSTRUCTIVE
93
FEV1 <80% predicted
OBSTRUCTIVE
94
With obstructive
FEV1 decreased
| but TLC increased (bc person can get air in, trapped, cant get it out)
95
Ratio <70%
Obstructive
96
Ratio is normal or increased
Restrictive
97
How often to take Lung fx tests?
At diagnosis
3-6 months after starting tx (FEV1)
Every 1-2 yrs (more for high risk and children)
98
Asthma
Chronic inflammation
Intermittent and REVERSIBLE obstruction
Bronchial hyper-responsiveness
99
Often develop sx before age 5, but misdx
Cough (nocturnal)
| Wheezing*- hallmark sx
100
Wheezing in asthma can be heard with Ins and Exp but usually heard with
EXP due to obstructive pattern
101
Look for signs of Severe obstruction
```
Tripod position
Tachycardic
tachypneic
Access muscle use
Pulsus paradoxus
```
102
ASA Triad/ Samter's triad
Sinus dz with: Nasal polyps, ASA sensitivity, severe asthma
103
Atopic triad
Atopic dermatitis --> (food allergy) --> allergic rhinitis --> asthma
104
Gold standard ratio of COPD for Ratio
<70%
105
Reversibility bronchodilator test
>12% adults
| >8% in young children
106
Intermittent Asthma
Sx 2 or less days/wk
No PM awakenings for younger, 2 or less/month for older
FEV> 80%
Ratio: normal
2 or less SABA use
107
Mild Persistent Asthma
Sx >2 days wk
PM awakenings 1-2/mo for younger, 3-4/mo for older
FEV >80% still
Ratio: normal
>2 days/wk SABA use
108
Moderate Persistent Asthma
Daily sx
PM awakenings 3-4/mo for younger, once a week for older
FEV 60-80% !!!!
Ratio: reduced!!
Daily SABA use
109
Severe Persistent Asthma
Sx throughout day
PM awakenings once/mo for younger, nightly for older
FEV1 <60%
Ratio reduced
Extremely limited activity
SABA use several times daily
110
Stage 1 asthma
| "Intermittent"
SABA prn
111
Stage 2 asthma
| "Mild persistent"
Low dose ICS daily
OR
LTRA or Cromolyn
112
Stage 3 asthma
"Moderate persistent"
consider specialist
Medium dose ICS
OR
(Low dose ICS + LABA)
113
Any time LABA is seen, if you are <5 YO,
replace with LTRA
114
Stage 4 asthma
"Severe persistent"
definitely refer to specialist
Medium dose ICS and LABA
OR
(Medium dose ICS + LTRA)
115
Poorly controlled Step 5 asthma
High dose ICS and LABA
116
Poorly controlled Step 6 asthma
High dose ICS and LABA and Oral steroids
117
Step 5 and 6 poorly controlled Asthma
Consider adding Omalizumab (Xolair) for ages 12 or greater with allergies
118
PEFT: Peak Expiratory Flow Rate
>80% green: good control
50-80% yellow: SABA and med
<50%: Medical alert!!!! ED
119
Tx for Exacerbation
```
Oxygen
SABA
Systemic corticosteroids
Abx prn
Respiratory monitoring if in ED/inpatient
Severe: C-PAP, BiPAP, intubation
```
120
How soon to f/u after an Acute Exacerbation of Asthma?
within 1 week!!
121
Small airway dz vs. Parenchymal destruction
Small airway- inflammation and remodeling
Parenchymal destruction- loss of alveolar attachments and elastic recoil
122
COPD former terms
Emphysema and Chronic Bronchitis
123
Emphysema
destruction of alveoli
124
Chronic Bronchitis
Cough and sputum >3 months in each of past 2 consecutive years
125
Small airway dz
Inflammation bronchial wall, infiltration of submucosal layer by NEUTROPHILs, bacterial colonization, airway hyper-reactive
Mucous glands enlarge, hypersecretion, loss of ciliary transport, bronchial squamous metaplasia
126
Parenchymal dz
Destruction of alveolar walls, extensive ELASTASE or ANTITRYPSIN deficiency, reduced alveolar exchange
127
Parenchymal dz structural change
Decreased elastic recoil
| Enlargement of air spaces DISTAL to terminal bronchioles
128
Systemic effects of COPD
```
Cor pulmonale
Cyanosis
Wt gain or loss
Resp Acidosis
Hypoxemia, Hypercapnia
```
129
Sx of COPD (3)
Chronic cough, dyspnea, Sputum production
130
Sx of CODP
5th or 6th decade
| most common early sx: DOE
131
Elastase and relation to COPD
Degenerative changes in elastin and alveolar structures
| Release of cytoxic oxygen radicals from WBC in lung tissue
132
A-1 Antitrypsin Deficiency
Hereditary
causes premature emphysema
AAT is an inhibitor of Elastase
If not present, elastase does its thing too much
133
Main sx of COPD
Dyspnea
Cough
Sputum production
134
PE findings of COPD
```
Tripod
Access muscle usage
Pursed lip
Cyanosis
Tobacco staining
S3 gallop or RV lift
Muscle wasting
Peripheral edema
Barrel chest
Prolonged expiration
Dec breath sounds
Wheezing or Rhonchi
```
135
Pursed lip breathing
Keeps intrabronchial pressure high during exhalation, keeping bronchi open and allowing more air to be expelled
136
Most common cause of Cor Pulmonale
COPD
137
What is required to establish a COPD dx?
Spirometry
138
What is normal ratio?
70-80% of predicted OR
| greater than Lower limit normal which is >5th percentile
139
Ratio of what confirms obstructive?
<0.7 %
140
Mild COPD
FEV1 >/ 80%
141
Moderate COPD
FEV1 50-80%
142
Severe COPD
FEV1 30-50%
143
Very severe COPD
FEV1 <30%
144
As COPD progresses, what is common?
Respiratory acidosis
not able to breathe off CO2
145
When is Arterial Blood Gas indicated?
FEV1 <50
SPO2 <92
Depressed LOC
Acute exac of COPD
146
Why do we get BNP
Evaluate suspected Heart Failure
147
When to get AAT (Alpha-1 Antitrypsin) lab?
sx in a young pt <45
Non smoker
Family hx emphysema
148
What might you see on CXR of someone with COPD?
Increased AP diameter
Hyperinflation and hyperlucency
Flattened diaphragm
149
Blebs/ Bullae are pathognomic for on CXR
Emphysema
150
Perivascular/peribronchial markings on CXR
Chronic Bronchitis
151
Chest CT, obtain if sx of COPD suggest
Complication
Alternative dx
Considering lung volume reduction surgery (order HRCT)
152
ABCD assessment tool
mMRC and CAT questionarre
153
Best predictor of having frequent COPD exacerbations (2 or more per year)
is a hx of earlier treated events
154
Exacerbation history in the past year:
0-1 exacerbations: low risk
| 2 or more OR 1 hospitalization: High risk
155
GOLD standard based on
FEV1
156
How to classify COPD:
GOLD (based on FEV1), exacerbation hx, and Sx questionarre
157
Vaccines imp to get for COPD pts
Influenza
Pneumococcal
-13 AND 23 for all pts 65 or older
-at least 23 for those younger than that
158
When to give supplemental oxygen?
SpO2 <88
| PaO2 <55
159
Target oxygen sat
88-92%
160
Initiation of meds of COPD is based on
GOLD ABCD and risk of exacerbation
161
F/u management of COPD is based on
questionaries and exacerbation frequency
162
Grade A COPD
SABA, SAMA or combo
163
Grade B COPD
LAMA or LABA
164
Grade C COPD
LAMA
165
Grade D COPD
LAMA, or if severe SOB: LABA-LAMA
166
Bronchodilators- B2 agonists
SABA- albuterol
| LABA- salmeterol, formeterol
167
Bronchodilators- Anticholinergics
Short acting- Ipratroprium
| Long acting- Tiotropin, Umeclidirium
168
Corticosteroids
Inhaled form alone
Inhaled form + LABA
Inhaled form + LABA-LAMA
169
Antiprotease therapy
those w AAT deficiency
weekly infusions
expensive
170
Acute exac of COPD triggers
```
Respiratory illness (70% of time)
Viral often leading to bacterial
```
171
Most common bacterial pathogens
```
H. inf
S. PNA
M. Cat
Mycoplasma PNA
Pseudamonas
```
172
Outpt management of COPD Exacerbations
Increase SABA with or without SAMA
Oral steroids- 40 mg daily x 5 days
Abx x 5-7 days
173
Consider hospitalization for Acute Exacerbation of COPD IF:
```
Severe sx
FEV1 <50%
Significant comorbid
Onset of new sx
Failure to respond to meds
Older age
Insufficient home conditions
```
174
Acute bronchitis
cough >5 days
| usually 1-3 wks
175
Chronic bronchitis
Cough and sputum > 3 months for 2 consecutive years
176
Acute Bronchitis
Self limited inflamm of bronchi d/t URI
| USUALLY VIRAL
177
Acute Bronchitis is viral
90% of time
178
If Acute Bronchitis is bacterial, only tx with Abx if the causative pathogen is:
Bordetella Pertussis!!!
179
Acute Bronchitis sx
cough
chest wall tenderness
wheezing
180
Acute Bronchitis PE
Wheezing
Bronchospasm
Rhoncih- often clears with coughing
181
What will you see in physical for Acute bronchitis?
Rhonchi but NO RALES or CRACKLES
that would be signs of consolidation
182
Bronchitis is rhoncy
will see RALES- that often clear with coughing
183
PNA is unlikely if all of these are absent:
Tachycardic
Tachypneic
Fever
Consolidation on exam (crackles, fremitus, egophony)
184
If pt presents with Acute Bronchitis like sx and has any of the 4 PNA warning sx, OR cough >3 wks
get CXR
185
Tx for Acute Bronchitis
```
NSAIDs
Intranasal Ipratropium (Atrovent)
Antitussive (dextro..)
B2 agonist- Alubterol
OTC lozenge
```
AVOID CODEINE
186
1st phase of Pertussis
Catarrhal
URI sx and fever
1-2 wks
187
2nd phase of Pertussis
Paroxysmal
"whooping" and post tussive emesis
2-6 wks
188
3rd phase of Pertussis
Convalescent
cough resolves
wks-months
189
Gold standard for Pertussis dx
Bacterial culture
190
Timing overlap for Pertussis dx
0-2 wks: bacterial culture
0-4 wks: PCR
2-8 wks: Serology
Culture, PCR, then Serology
191
Pertussis tx: start Empiric therapy while waiting for results to come back
Abx decreases spread but might not make pt feel much better
192
Tx for Pertussis (adults)
| MACROLIDES
Azithro 500 followed by 250x 4 days
Clarithro 500 BID x7days
Erythro 500 QID x14 days
193
Alternative tx for Pertussis for Adults if they can't take Macrolides
Bactrim BID x14 days
194
Children tx for pertussis
69% of children <6 mo need admission
sx control
MACROLIDES
195
Vaccinate for Pertussis
T dap booster recommended as teen
196
Abx prophylaxis for Pertussis
Recommended for:
- close contact exposure
- home,work,school,daycare
197
High risk populations for INFLUENZA
```
<2 YO
65 or older
Underlying chronic dz
Immunosupp
Pregnant
Morbidly obese
Nursing home
```
198
Influenza presentation
ABRUBT onset
fever, HA, myalgia, malaise
Chest exam usually negative unless PNA
199
Influenza dx
RIDT (rapid influenza diagnostic test)
10-30 min
low-mod sensitivity
high specificy
can get FALSE NEGATIVE
200
Most sensitive and specific dx test for Influenza
RT-PCR 2-6 hours
201
Viral culture for Influenza
48-72 hours
| Confirmatory (public health surveillance) but not used for initial clinical mgmt
202
Influenza
generally improved 2-5 days
203
PNA
Acute INFLAMMATION of pulmonary PARENCHYMA
Inflammation and consolidation of lung tissue from infectious agent
204
PNA
inflammation and consolidation of parenchyma (consolidation is when normally compressible tissue becomes filled with fluid)
205
CAP epidemiology
M> F
| African american> caucasion
206
CAP transmission most common cause
Aspiration from oropharynx (right behind soft palate)
207
CAP pathophys
Alveolar macrophages can no longer handle the bacterial load coming into the alveoli
208
Macrophages response to being overload by bacteria in PNA
initiate an inflammatory response to recruit help
209
Most common bacterial cause of Typical PNA
Streptococcus. PNA
210
Most common cause of Atypical PNA
Mycoplasma PNA
211
Atypical PNA can be
Bacterial
Fungal
Viral
212
CAP risk factors
```
Asthma
Immunosupp
70 or older
Alcoholism
Instutionalism
```
213
Risks for Pneumococcal PNA specifically
```
Dementia
Seizure
HF
CVD
Alcoholism
Smoking
COPD
HIV
```
214
CAP typical presentation
what makes it different?
ACUTE onset
FEVER
```
cough
sputum
dyspnea
night sweats*
pleuritic CP
CP, chills, rigor*
```
215
CAP physical exam
Decreased or bronchial breath sounds
crackles/rales
Signs of CONSOLIDATION: dullness to percussion, increased fremitus, bronchopohony, egophony
216
CAP dx
Leukocytosis with left shift
| CXR: Infiltrate!
217
CAP dx Gold Standard
Infiltrate on plain CXR
218
May also see this in CAP on CXR
Lobar consolidation
Interstitial infiltrates
Cavitation
219
Urine antigen tests for CAP will only show two things
Legionella and S. PNA
220
Tests to help with choice and duration of Abx when treating CAP
Procalcitonin and CRP
(inflammatory markers)
can also help tell bacterial vs viral
221
Sputum cultures with PNA not entirely helpful bc
diff to produce
| can be from resp tract and not lungs/lower airway
222
CURB 65 to classify PNA
```
Confusion
Urea >7, BUN >20
RR 30 or more
BP systolic <90, diastolic 60 or less
65 or older age
1 point for each
```
223
CURB 65 score (1 pt for each)
0-1 outpatient
2 ADMIT
3-5 possible ICU
224
CAP tx
AT LEAST 5 days
225
Sx resolution with CAP
fever: 3 days
cough/fatigue: 14 days
at least 1 sx left: 38 days
226
RETURN TO WORK after CAP
6 days
227
F/u CXR for CAP?
only if >40 YO or
smoker
get one in 7-12 wks
228
Uncomplicated CAP
previously healthy and no abx use in previous 3 mo
Macrolide: Azithro 500 day 1 then 250 x 4 days
OR
Doxy 100 BID x7-10 days
229
Complicated CAP
B-lactam + Macrolide
Amoxicillin-clavulanate 500 BID + Azithro
OR
Fluoroguinolone: Levofloxacin 750 x5 days
230
If you are treated for CAP, must meet these parameters in order to be able to go home:
```
>5 days abx
Afebrile for 48-72 hrs
Supp O2 not needed
HR <100bpm
RR <24
Systolic at least 90
```
231
Who should get Pneuomcoccal vaccine?
65 or older
| 19-64 if you are high risk (CVD, sickle cell, tobacco, splenectomy, liver dz)
232
CAP tx uncomplicated
Macrolide (azithro) or Doxy
233
CAP tx complicated
Beta lactam + Macrolide
OR
Resp Fluoroquinolone
234
HAP
48 hrs or more after admission and was not sick at time of admission
235
Highest risk for Hospital acquired PNA
ICU
| Pseudomonas has the worst prognosis
236
Ventilator assoc PNA
| VAP
48-72 hrs after endotracheal intubation
237
HAP/VAP pathophys
Altered upper respiratory tract flora
238
HAP/VAP dx
New or progressive INFILTRATE on lung imaging AND at least 2:
- Fever
- Purulent sputum
- Leukocytosis
239
Diagnosing HAP or VAP
Sputum gram stain and culture are indicated
| (expectorated or suctioned secretions
240
prevention of VAP (ventilator)
Avoid acid blocking meds PPIs
| + others
241
Pneumocystis Jirovecii PNA
PCP nickname used
now considered Fungi
ASSOC w HIV!!!
242
PJP/ PCP sx
Fever, cough, progressive dyspnea, extra-pulm lesions
243
PJP/PCP
| ASSOC W HIV
High LDH
Low CD4
CXR: Reticular, ground glass opacities
Sputum: may require broncheoalveolar lavage
244
Tx for PCP/PJP
Assoc W HIV
Bactrim!!
And do prophylaxis in HIV pts with:
hx of previous PCP
CD4 <200
Oropharyngeal thrush
245
Aspiration PNA
displacement of gastric contents into the lung
Microbio: Gram (-) and anaerobic
246
Risk factors for Aspiration PNA
```
Post-op
Neuro compromise (Parkinsons, CVA, ALS, sedation)
Anatomical defect or aberrancy
```
247
Aspiration PNA
often in RLL because R main bronchus is more straight
248
ILD also referred to as DPLD
commonly involves extensive distortion of airway and alveolar compartment, alone w interstitium
249
ILD
progressive scarring of lung tissue
250
ILD Pathophys
Process of fibrosis and aberrant healing
Sometimes inflammatory but NOT infectious
251
ILD sx
Progressive DOE
Dry cough
extrapulm sx: MSK pain, weakness, joint pain, fever, dry eyes
252
Physical Exam of ILD
Crackles at bases (velcro)
| Inspiratory squeaks
253
Physical Exam of ILD
Digital clubbing assoc w advanced dz only in certain types
254
Erythema Nodosum
Sarcoidosis
255
Gottron papule
Dermatomyositis
256
Highest yield for a NON-INVASIVE test in diagnosing ILD
HRCT
| High resolution CT
257
Gold standard for dx ILD
Tissue biopsy
258
Most common CXR finding associated with ILD
Reticular "netlike", nodular, or mixed pattern of opacities
259
Honeycombing
small cystic spaces
| POOR PROGNOSIS
260
Which type of ILD is most Steroid responsive?
NSIP
| Non specific Interstitial PNA
261
Which type of ILD is considered the worst pattern?
Usual interstitial PNA
262
To r/o Auto-immune dz when dealing with ILD, order:
ANA
RF- rheumatoid factor
CCP- Citrullinated peptide
263
To evaluate for Vasculiitis when dealing with ILD, order:
ANCA
Antiphospholipid
Antistreptococcal antibodies
264
Most ILD are consistent with
Restrictive pattern
265
Diffusing Capacity of Lungs for Carbon Monoxide
may be the only finding in some cases of ILD
| normal: 80% of predicted
266
Bronchoalveolar Lavage
Allows sampling from distal airways and alveoli
| -Cell counts, cultures, cytology
267
Gold standard for ILD
Lung biopsy
268
Indications to get lung biopsy
Inability to specify dx (age <50, fever, wt loss, hemoptysis, signs of vasculitis)
Atypical/ rapidly progressing HRCT findings
Progressive course of dz
Unexplained extra pulm sx
269
Types of Lung biopsy
Transbronchial- CENTRAL locations
| Surgical- Video assisted (small incisions, safer) vs Thoracotomy (5-6 cm incision)
270
Lung biopsy
Endobronchial US guided transbronchial needle aspiration
EBUS-TBNA
Special to evaluate Hilar and Mediastinal lymphnodes
Esp useful if SARCOID suspected!!
271
Idiopathic Pulm Fibrosis
```
>50 YO
Males
"Usual Interstitial PNA"
Most common ILD!!
Poor prog: 2-5 year survival from time of dx
```
272
Sx special to Idiopathic Pulm Fibrosis
```
Velcro crackles (insp)
Digital Clubbing in 25-50%
```
273
Imaging findings of Idiopathic Pulm Fibrosis
bibasilar reticulonodular opacities
274
Echocardiogram results for Idiopathic Pulm Fibrosis
Pulm HTN present in 20-40%
275
Need HRCT if
UIP pattern
Probable UIP
Indetermined UIP
Alt dx
276
Surgical Lung Biopsy + Bronch Lavage indicated if
Probable UIP
Indetermined UIP
Alt dx
277
Pharm options for Idiopathic Pulm Fibrosis
Nintedanib (TKI)
| Pirfenidone
278
Ivan IPF
Male
60 ish
Common man
smoker
279
Sarcoidosis
Multisystem inflammatory
Non-caseating granulomas
Secrete ACE
280
Sarcoidosis
African American
Female
20-40 YO
281
Extra pulm findings assoc w Sarcoidosis
Erythema nodosum
Lupus pernio (face rash)
Granulomatous uveitis
Arthralgias
282
CXR of Sarcoidosis
Hilar adenopathy
283
Lab testing of Sarcoidosis
Elevated ACE
Elevated Calcium
Elevated Alk Phos
284
Biopsy usually required for Sarcoidosis
EBUS-TBLB
285
Tx for Sarcoidosis
Does not require tx unless stage 2
| most spontaneously resolve
286
Stages of Sarcoidosis
1: Hilar adenopathy
2: Hilar adenopathy + diffuse infiltrates
3: only diffuse parenchymal infiltrates
4: pulm fibrosis
287
Tx for Sarcoidosis
Treat if stage 2 and sx-atic
Inhaled corticosteroids, topical for cutaneous, ocular dz
HIGH DOSE STEROIDS
-taper within 6 months to 10 mg/day
288
With steroid tx of Sarcoidis
put pt on PJP prophylaxis
289
Stage 4 Sarcoidosis
consider Lung transplant
290
Sally sarcoidosis
Female African American
30s
Non-smoker
She's an ACE with Hilar adenopathy
291
Pneumoconiosis
general term for 3 subtypes of lung dz caused by INHALATION and deposition of mineral dust
292
Silicosis
Fibronodular lung dz
Inhale silica dust
Mining
Smoking increases risk
293
Silicosis
Acute and Chronic
Acute is rare: would be d/t massive/rapid exposure (sandblasters)
"Crazy paving" pattern on HRCT
294
Coal workers Pneumoconiosis- CWP
Black lung
| inhaled coal dust
295
Silica and Coal workers
CXR, then HRCT
296
Chronic simple Silicosis & Coal workers
10-12 yrs exposure
May be A-sx
Stops progressing once exposure is eliminated
297
Chronic simple Silicosis & Coal
Hilar node calcification (egg shell)
| Small, round, nodular opacities on CXR
298
Chronic COMPLICATED Silicosis and Coal workers
>20 yrs exposure
Progressive even after exposure gone
Conglomerate masses- CAVITATION from ischemic necrosis or concomitant TB
Angel WING
HONECOMBING on HRCT
299
Not much to do tx wise for Silicosis or Coal workers
Steroids may help in ACUTE Silicosis only
300
Asbestos
no specific sign/sx
Insidous onset: nonspecific chest discomfort
End-inspiratory Rales
Digital clubbing
301
Asbestosis
Lower lung opacity
| PLEURAL PLAQUES
302
Hypersensitivity Pneumonitis
Fungi, mold, bird droppings, FARMS
| REVERSIBLE process
303
Hypersensitivity Pneumonitis
PE: diffuse bibasilar crackles, fever, tachypnea, muscle wasting, clubbing, weight loss
304
Tx for Hypsersensitivity Pneumonitis
Corticosteroids may speed recovery in severe dz
| Otherwise, remove triggers
305
Granulomatosis with Polyangiitis (GPA)
Immune mediated
Systemic vasculiits of sm-med vessels
ANCA
Necrotizing granulomas
306
GPA
35-55 YO
Relapse is common
Recurrent resp infections
```
Pulmonary infiltrates
Renal failure
RBC casts
Palpable purpura
Skin ulcers
```
307
Necrotic, blistering purpura
| Saddle nose deformity
GPA
| Granulomatosis with Poyangiitis
308
GPA- Granulomatosis with Polyangitis
CXR: highly variable
Chest CT: Stellate shaped periph pulm arteries "vasculitis sign"
diffuse alveolar hemorrhage
309
Labs for GPA
C-ANCA!!!
ESR/CRP elevated
310
GPA tx
Cyclophosphamide and Corticosteroids
311
Smoking related ILD
Respiratory Bronchiolitis Interstitial Lung dz
Desquamative interstitial pneumotis
pulm Langerhans cell histiocytosis
Most will have sig imp or even complete remittance when stopping smoking
312
Complications of ILD
Cor pulmonale/ Cardiovascular dz
313
Smoking accounts for how much Lung CA
90%
314
Once you hit this age, the % of a SPN being malignant increases up to 50%
60 YO or older
315
No calcification of SPN
increased risk
316
Malignant nodules usually double in
20-400 days
317
Preferred imaging for SPN
Helical CT without contrast with low dose
| easy on the person
318
Small Cell-
| Oat Cell CA
CENTRAL
| Large Hilar mass with bulky mediastinal adenopathy
319
Small cell-
| Oat Cell CA
Highly aggressive-70% w METS
| Sx present: cough, SOB, wt loss, debility
320
Small Cell-
| Oat Cell classifications
Limited (ipsilateral and regional nodes)
vs
Extensive (70% of time)
distant METs
321
Non Small cell-
| Adenocarcinoma (most common)
Arises frm mucous glands or any epithelial cell distal to terminal bronchioles
METs to distant organs
322
Non small cell-
| Adenocarcinoma
Peripheral nodules or masses
323
Non small cell-
| Squamous cell
CENTRAL/Main bronchus
Hemoptysis
METs to regional/close by lymphnodes
Can cavitate
324
Non small cell-
| Large cell
METs to distant organs
| Aggressive clinical course- RAPID FAST doubling times
325
Small Cell -
| Oat Cell
assoc with SVC syndrome, and paraneoplastic syndromes
326
Non small cell-
| Adenocarcinoma
Most common
Peripheral
Thrombophlebitis, clubbing
Most d/t smoking
327
Non small cell-
| Squamous cell
```
Central bronchi
Hemoptysis
PTH(hypercalcemia)
Hilum and Mediastinum
Slower growing
May cavitate
```
328
Non small cell-
| Large cell
FAST growing
| primary a dx of exclusion
329
Pancoast syndrome
superior sulcus tumor spread into shoulder causing Neuro sx frm compressing Brachial Plexus
330
Paraneoplastic syndrome
non metastatic systemic effects that accompany a malignancy
331
Cough
most freq occurs with Squamous cell and Small cell lung CA
332
SVC syndrome
mostly assoc with Non small cell CA
333
SVC syndrome dx
Superior vena cavogram = GOLD standard
334
Horner's syndrome
part of Pancoast syndrome
Facial involvement
injury of sympathetic nerves of face
Miosis, anhidrosis, ptosis
335
Most commonly assoc with Pancoast syndrome
Non small cell
336
Paraneoplastic syndrome
altered immune response to neoplasm
Hypercalcemia
Leukocytosis
Thrombocytosis
Hypercoag
337
Paraneoplastic syndrome
PTH-like substance
Hypercalcemia
Non-small cell (Squamous)
338
Paraneoplastic syndrome
Excess HCG production
Gynecomastia and nipple d/c
Non-small cell (Large cell)
LARGE breasts
339
Paraneoplastic syndrome
```
SIADH and Cushings (endocrine)
Eaton Lambert (neuro)
```
SMALL cell association (the only 3 that are small cell related)
340
SIADH
Hyponatremia
Small cell
Irritable, confused, personality
341
Cushing's syndrome
Small cell
| Muscle weakness, wt loss, HTN, Hirsuitism, Osteoporosis
342
Eaton Lambert syndrome
Small cell
Immune mediated
Antibodies at Neuromuscular junction
Muscle weakness and decreased DTRs
343
Brain METs from lung CA is mostly assoc with
Small cell
344
Performance with Lung CA, when FEV1 is <60%, this is
strongest indicator of post-op complications
345
Tx of Small cell
Chemo regardless of stage
| 80% response rate (Cisplatin + Etoposide)
346
Other tx options of Small cell
Radiation
Proph cranial radiation
Relapse common
Surgery only <5%
347
Tx of Non small cell
Surgical resection = tx of choice in localized dz!!
348
Stage 1-3a in Non small cell with adequate pulmonary function
can proceed to SURGERY
349
Stage 3b-4 in Non small cell
Palliative radiation or combo chemo
350
Who do we screen for regarding Lung CA?
HIGH RISK
Current smoker 55-74YO with 30 PPY hx
Quit w/in 15 yrs
20 PPY hx with 1 additional risk factor
351
Smoking Cessation
```
Zyban (wellbutrin, 5-7)
-seizures
Chantix (varenicline, 7)
-HTN, palp, GI
Rx Nicotine replacement
-HTN, palp, GI
OTC Nicotine
```
352
TB requires
prolonged exposure
353
Must have Active TB
to spread infection
354
Latent TB
most common form
| present in body WITHOUT SX
355
Latent TB can become active
when immune system unable to fight infection
356
Latent TB
Granuloma
| unable to transmit
357
TB
unintentional weight loss
358
Classic finding of TB
Posttussive crackles
359
Other PE findings of TB
dullness or decreased fremitus
| general area, diffuse
360
Dx TB
Mantoux tuberculin skin test (TST)
| Measure induration 48-72 hours later
361
Gold standard to confirm TB
Culture with sputum collection
362
1st line tx for TB
RIPE
| Rifampin, Isoniazid, Pyraz, Ethambutol
363
DOT
Direct observe tx for TB
| must watch pt take medicine
364
Drug tx for Latent TB
INH and Rifapentine
| 12 weeks
365
MDR - TB does not respond to
INH and RIFampin
366
XDR-TB
responds to even less drugs including Fluoroquinolones, and INH and Rifampin
367
Histoplasmosis
Bird and bat droppings
| Immunocomp-HIV most likely to get it
368
Presentation of Histoplasmosis
90% A-sxatic or mild flu like sx
most resolve in few weeks
369
Sx of Histo Acute sx pulm
Fever, fatigue, few resp sx
| 1 wk- 6 months
370
Progressive disseminated Histo
pt usually immunocomp
fever, MARKED fatigue, cough, SOB, wt loss
Multiple organ involvement
Fatal w/in 6 wks
371
Chronic pulm Histo
Older COPD pts
| Progressive lung changes
372
CXR
Hilar adenopath
| Patchy/nodular infiltrates in LOWER Lobes
373
Cocci
sports
| contaminated soil
374
Cocci valley fever
only 40sx have sx
| many let it go- resolves in wks-months
375
primary sx of Cocci
fever
cough
pleuritic CP
other: fatigue, HA, arthralgia (Desert Rheumatism), Rash- erythema nodosum
376
Disseminated Cocci valley fever sx
more pronounced lung findings (abscess)
bone lesions
lymphadenitis
meningitis
