Exam 2 Flashcards
What is the initial study used for respiratory sxs and which view is preferred?
CXR, PA view preferred
If you note a Hampton hump on CXR, what should you be concerned about?
Pulmonary infarct
What is a c/i to CXR?
Pregnancy
What systematic approach should be used when reading a CXR?
A- airway B- bones C- cardiac silhouette & costophrenic angle D- diaphragms (free air) E- edges F- fields (infiltrates, nodules)
CT is equivalent to how many XRays with respect to radiation?
80
Which form of pulmonary dx imaging is used to clarify abnormal cxr, characterize pulm nodules, eval lung mets/ suspected masses?
CT
CT’s place beds at increased risk of what due to higher sensitivity?
Leukemia/ brain tumors
In utero exposure of radiation with CT’s of pregnant women is linked to what?
Peds CA mortality
Low dose CT’s are used for what?
Screening
What are the indications for iodine contrast w/ CT?
Vessels, malignancy chest trauma
Patients should be pretreated with what due to possibility of iodine allergic rxn w/ CT?
Prednisone and diphenhydramine (Benadryl)
When does CIN occur/ peak?
Occurs @ 24-48 hrs post exposure
Peaks @ 3-5 days
If you note an increased serum creatinine >/= 0.5 mg/dL or >/= 25% from baseline following an iodine contrast CT, what should you be concerned about?
Contrast induced nephropathy (CIN)
When should you check kidney fxn prior to an iodine contrast CT due to concerns of CIN?
> 60 yo, hx of renal disease/ HTN/ DM, taking Metformin
What is the dx imaging of choice for pulmonary vasculature?
CT pulmonary angiography (CTPA)
What is the gold standard for PE eval?
Catheter directed pulmonary angiography (“direct”)
What pulmonary imaging is useful if V/Q scan or CTPA is inconclusive, but there is a high clinical suspicion for PE?
Catheter directed pulmonary angiography
What pulmonary imaging has the following associated risks?
Bleeding @ insertion site, arrhythmia, allergic rxn to contrast, CIN
Catheter directed pulmonary angiography
What pulmonary imaging is best if there is a normal CXR and high suspicion for PE?
V/Q scan
What is the pulmonary imaging test of choice for dx in pregnant women?
V/Q scan
What pulmonary imaging is used to detect cancer?
PET scan
What pulmonary imaging involves detection of radiation from fluorodeoxyglucose (FDG)?
PET scan
A PET scan is better than CT for mediastinal imaging due to the fact that you can ID a tumor in what?
Normal sized lymph nodes
When should an MRI/ MRA be avoided, due to use of Gadolinium contrast dye, and why?
Avoid if GFR < 30 mL/min, possibility of nephrotic systemic fibrosis
What are the specific risks associated with taking a bx with bronchoscopy?
Bleeding, bronchial perforation, pneumothorax
Should airflow spirometry be performed sitting or standing?
Sitting (prevents syncope)
Is FEV-1 most useful for obstruction or restriction?
Obstruction
What value defines the severity of obstruction and assists in differentiating between obstructive and restrictive diseases?
FEV-1: FVC ratio (< 0.7 = obstructive)
What value measures the airflow during the middle 1/2 of forced expiration?
FEF-25-75%
What value is non-specific for airway obstruction but may be an early indicator of disease?
FEF-25-75%
What is considered + on a reversibility testing for bronchodilation?
FEV-1 increases by 12% and 200mL
In which test do you give a dilute bronchoconstrictor at increased concentrations via a nebulizer at 30 and 90 seconds and test FEV1?
Bronchoprovocation (methacholine challenge)
Med = dilute methacholine
What is considered a + on the bronchoprovocation (methacholine challenge) test?
FEV1 decreases by 20%
In obstructive diseases, do you have normal inspiration or expiration?
Inspiration N (but decreased expiration)
In restrictive diseases, do you have normal inspiration or expiration?
Expiration N (but difficulty expanding lungs during inhalation)
What value measures the ability of the lungs to transfer gas and saturate Hgb, and when can it be misleading?
Diffusion capacity of lungs for CO (DLCO)
Misleading if anemic due to false reduction
If lungs are healthy, what will a DLCO show?
Little CO collected during exhalation
If lungs are diseased, what will a DLCO show?
Less CO diffused into lungs = higher levels measured in exhaled gas
What will the following values show for an obstructive lung disease?
TLC, FVC, RV, FEV1, FEV1/ FVC
TLC- inc FVC- N RV- inc FEV1- dec FEV1/ FVC- dec
What will the following values show for an restrictive lung disease?
TLC, FVC, RV, FEV1, FEV1/ FVC
TLC- dec FVC- dec RV- dec FEV1- dec FEV1/ FVC- N/ inc
What are the 5 steps of PFT interpretation?
Examine:
- flow-volume curve
- FEV-1 value
- FEV-1/ FVC ratio
- response to bronchodilator
- DLCO
Will the flow-volume curve be scooped out or peaked with an obstructive lung disease?
Scooped out
What two guidelines classify asthma?
NAEPP and GINA
What are the primary sxs of asthma?
Coughing (nocturnal), > 3 weeks
Wheezing (hallmark)
What disease is characterized by tripod positioning, accessory muscle use, pulsus paradoxus, and tachypnea/cardia?
Asthma
What will the diagnostic values of FEV1, FEV1/FVC and reversibility be for asthma?
FEV1: < 80%
FEV1/FVC: N (70-85%)
Reversibility: > 12% w/ FEV1 bronchodilator
What makes up ASA triad/ Samter’s triad?
- sinus disease w/ nasal polyps
- ASA sensitivity
- severe asthma
What is made up of atopic derm, allergic rhinitis, and asthma?
Atopic triad
What is made up of atopic derm, food allergy, allergic rhinitis, and asthma?
Atopic march
What test is used to confirm a dx of asthma?
Spirometry
In regards to asthma classification, which steps are considered intermittent?
Step 1
In regards to asthma classification, which steps are considered persistent?
Steps 2-4
If a patient presents with hx of asthma sxs ≤ 2 days/ week and nighttime awakenings ≤ 2 nights/ month (≥ 5 yo) which step of asthma classification would they be?
Step 1
If a patient presents with hx of asthma sxs > 2 days/ week and nighttime awakenings 1-2x/ month (0-4 yo)/ 3-4x/ month (≥ 5 yo), which step of asthma classification would they be?
Step 2
If a patient presents with hx of asthma sxs daily and nighttime awakenings 3-4x/ month (0-4 yo)/ >1x/ week (≥ 5 yo), which step of asthma classification would they be?
Step 3
If a patient presents with hx of asthma sxs throughout the day and nighttime awakenings >1x/ week (0-4 yo)/ nightly (≥ 5 yo), which step of asthma classification would they be?
Step 4
What will the FEV1 value be for steps 1-4 of asthma?
Step 1: > 80%
Step 2: > 80%
Step 3: 60-80%
Step 4: < 60%
For which steps of asthma classification will the FEV1/ FVC ratio be decreased by 5%?
Steps 3-4
What is the treatment for Step 1 asthma?
SABA prn
What is the treatment for Step 2 (mild) asthma?
Low dose daily ICS
OR
LTRA/ Cromlyn (kids that don’t want steroid)
What is the treatment for Step 3 (moderate) asthma?
- Consider specialist referral
- Medium dose ICS (0-4 to)
OR - Low dose ICS + LABA (≥ 5yo) or LTRA
What is the treatment for Step 4 (severe) asthma?
- Refer to specialist
- Medium dose ICS & LABA (or LTRA 0-4 yo)
OR - Medium dose ICS + LTRA
What is the treatment for Step 5 asthma?
High dose ICS/ LABA (or LTRA if 0-4 yo)
What is the treatment for Step 6 asthma?
High dose ICS/ LABA (or LTRA if 0-4 yo) + oral steroids
When should you consider adding Omalizumab (Xolair) with steps 5-6 asthma?
If ≥ 12 yo with allergies
When would Theophyline with use of ICS be used in the treatment of asthma steps 5-6, and why is this a less attractive alternative?
> 5 yo
Serum levels must be monitored closely
What is the rule of 2’s and what disease does it pertain to?
Asthma
- Sx ≥ 2x/ week
- Awaken w/ asthma sx ≥ 2x/month
- Refill SABA ≥ 2x/ yr
- Peak flow meter measures 20% from baseline ≤2x
If results of a peak flow meter show green, what does this indicate?
> 80%, good control
If results of a peak flow meter show yellow, what does this indicate?
50-80%, caution- SABA + med change
If results of a peak flow meter show red, what does this indicate?
<50%, medical alert/ emergency tx
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: ≤ 2x/ week
- Nighttime awakenings (0-11 yo): ≤ 1x/ month
- Nighttime awakenings (≥ 12 yo): ≤ 2x/ month
- FEV1: > 80%
- FEV1/ FVC: > 80%
Well controlled
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: ≥ 2 days/ week
- Nighttime awakenings (0-4 yo): 1x/ month
- Nighttime awakenings (0-11 yo): ≥ 2x/ month
- Nighttime awakenings (≥ 12 yo): 1-3x/ week
- FEV1: 60-80%
- FEV1/ FVC: 75-80% (5-11 yo)
Not well controlled
If a pt shows the following, how well controlled is their asthma?
- Sx frequency/ SABA use: daily
- Nighttime awakenings (0-4 yo): 1x/ week
- Nighttime awakenings (0-11 yo): ≥ 2x/ week
- Nighttime awakenings (≥ 12 yo): ≥ 4x/ week
- FEV1: < 60%
- FEV1/ FVC: < 75% (5-11 yo)
Very poorly controlled
What is the tx for exacerbation of asthma?
- O2
- SABA/ SVN- Albuterol or Xopenex +/- Ipratropium bromide → repeat PEF, SVN repeated or continuous
- Systemic corticosteroids- prednisolone ~ 1 mg/kg/day w/ max dose based on weight
What role should abx and resp monitoring be considered in the tx of asthma exacerbation?
Abx prn
Resp monitoring if in ED/ inpatient, severe = C-PAP, BiPAP, intubation
How soon should a pt with asthma exacerbation f/u?
Within 1 week
Small airway disease –> ?
Obstructive chronic bronchitis
Blue bloater (hypoxemia, cyanosis, cor polmonale, weight gain) are associated w/ what disease?
Obstructive chronic bronchitis
Infiltration of the submucosal layer by neutrophils is associated w/ what disease?
Obstructive chronic bronchitis
Presence of dry cough and sputum production for 3+ months in 2 consecutive years is what?
Obstructive chronic bronchitis
Pink puffer (hypercapnia, weight loss, muscle wasting)
Emphysema
Parenchyma disease –>
Emphysema
Destruction of alveolar walls and reduced alveolar surface area available for gas exchange is associated w/ what disease?
Emphysema
Most common early finding ing COPD?
Dyspnea on exertion
Last COPD presentation?
Dyspnea, chronic cough, sputum production present at rest
Host risk factor for COPD? (3)
- a1-antitrypsin deficiency (AATD)
- asthma
- childhood respiratory infections
Tripod positioning, accessory muscle use, and pursed lip breathing are associated w/ what disease?
COPD
AP diameter increases or decreases w/ COPD?
Increases
Irreversibly after bronchodilator use is consistent w/ what disease?
COPD
FEV1/FVC < 70% indicates restrictive or obstructive disease?
Obstructive
Gold classes for COPD?
I. ≥80%
II. 50-80%
III. 30-50%
IV. <30%
TX goals for COPD? (4)
- Prevent progression (smoking cessation)
- Relieve sx/improve exercise tolerance
- Manage/prevent acute exacerbations
- Reduce mortality
Supplemental O2 sat for long term COPD tx?
88-92%
TX for COPD exacerbation?
SABA +/- SAMA
Prednisone 40 mg QD x 5 days
Mod-severe = + ABX 5-7 days Sever = +/- hospitalization
TX for class A COPD?
SABA PRN
TX for class B COPD?
SABA + LAMA/LABA
TX for class C COPD?
SABA + LAMA
TX for class D COPD?
SABA + LAMA (or LABA/LAMA if severe)
S3 gallop, RVH, hepatomegaly, and peripheral edema are consistent w/ what disease?
Cor Pulmonale
Bleds/bullae are pathognomic for?
Emphysema
Is CT needed for routine COPD dx?
No
Acute changes in baseline dyspnea, cough, sputum that warrant a change is therapy is considered what?
Acute COPD exacerbation
SE of B2 bronchodilators?
Palpitations, tachycardia, insomnia, tremors
Albuterol is falls under what drug classification?
SABA (B2)
Salmeterol and Formoterol are what type of B2 agonists?
LABA
Dry mouth, metallic taste, HA and cough are SEs of what drug class?
Anticholinergics
Atrovent and Combivent are SABA or LABA anticholinergics?
SABA
Spirival and Incruse Ellipta are SABA or LABA anticholinergics?
LABA
Oral candidiasis and bruising are SEs of what meds?
LABA + ICS
Advair and Symbicort are fall under waht drug class?
LABA + ICS
What deficiency requires tx w/ antiprotease therapy?
a-1 antitrypsin (serum level < 11 micromol/L)
ABCD assessment tool combines what tools? (4)
- GOLD
- Modified British Medical Research Council (mMRC)
- COPD assessment tool (CAT)
- Exacerbation hx
Prior hospitalization for COPD exacerbation is predictive of what? (2)
Poor prognosis, ↑ risk of death
Grad A associated w/ (sx, risk)?
↓ sx, ↓ risk
Grad B associated w/ (sx, risk)?
↑ sx, ↓ risk
Grad C associated w/ (sx, risk)?
↓ sx, ↑ risk
Grad D associated w/ (sx, risk)?
↑ sx, ↑ risk
Cough >5 days is consistent w/ what dx?
Acute bronchitis
Acute bronchitis more commonly due to viral or bacterial pathogens?
Viral (90%)
Bacterial agent that causes acute bronchitis?
Bordetella pertussis
Ronchi > w/ expiration is consistent w/ what dx?
Acute bronchitis
First line TX for acute bronchitis?
Reassurance and edu on expected course
When are ABX used to tx acute bronchitis?
Pertussis ONLY
Cough ≥ 3 months for 2 consecutive years is consistent w/ what dx?
Chronic bronchitis
Gold standard diagnostic for pertussis?
Bacterial culture nasopharyngea secretions
Catarrhal, paroxysmal and convalescent are 3 phases of what disease?
Bordetella pertussis
Whooping cough is consistent w/ what disease?
Bordetella pertussis
When is serology used to dx pertussis?
Later stage of disease (2-8 weeks from cough onset)
Abx tx for what disease will ↓ transmission but have little effect on sx?
Bordetella pertussis
Is Bordetella pertussis a reportable disease?
Yes
ABX Tx for Bordetella pertussis in adults?
Macrolide: Azithro, clarithro or erythro
Bactrim if macrolide not tolerated
Fever, HA, myalgia and malaise are consistent with what disease?
Influenza
Viral culture, RIDT or PT-PCR is confirmatory dx for influenza?
Viral culture
Timeline to give antiviral treatment for influenza?
onset-48 hrs
If negative RIDT, but high clinical suspicion can you make dx clinically?
Yes
Acute onset fever and cough w/ crackles is consistent w/ what disease?
CAP
Aspirations from oropharynx is most common form of transmission for CAP, HAP or VAP?
CAP
CXR shoes infiltrate on plane films. This gold standard dx for what?
CAP
CURB-65 is used in the dx of HAP, VAP, or CAP?
CAP
What is CURB-65?
Confusion Urea > 7 mmol/L & BUN ≥ 20 mg/dl RR ≥ 30 b/min BP <90/60 > 65 yrs
2 requirements to dx uncomplicated CAP?
- Previously healthy
2. No ABX use in last 3 months
TX for outpatient CAP? (3)
- ABX ≥ 5 days
- Reassurance (resolution of fever in 3 days and 14 days for cough/fatigue)
- CXR f/u 7-12 wks post tx only in pt >40yrs or smokers
TX for uncomplicated CAP?
Azithromycin 500 mg x 1 day, 250 mg x 4 days
OR
Doxycycline 100 mg BID x 7-10 days
2 requirements to dx complicated CAP?
- Recent ABX use
2. HX of COPD, CA, DM, drug abuse, IMC
Tx for complicated CAP?
Bactrim or Levofloxacin 750 mg QD x 5 days
Most common pathogen of sx based pneumonia?
S. pneumoniae
Rare cause of CAP, especially in IMC pts?
Fungal infection
Is sputum cx definitive dx for CAP?
No, no proof of etiologic agent (not recommend for outpatient)
TX for CURB 65 score of 2
Hospitalization
TX for CURB 65 score of 3-5?
ICU
TX for CURB 65 score of 0-1?
Outpatient
CAP prevention measures (2)?
- Smoking cessation
2. Vaccines
Pneumonia onset 48+ post admission is CAP, HAP, or VAP?
HAP
New or progressive infiltrate and 2+ (fever, purulent sputum, leukocytosis) is dx for what forms of pneumonia?
HAP/VAP
First line tx for HAP & VAP?
Prevention + ABX
Non-resolving pneumonia is concerning for what? (5)
Atypical infection, aspirations, CHF, CA, fibrosis
