FINAL Flashcards
asthma
-hypertrophy of bronchial smooth muscle
-plugging of small airways
-genetics (IgE) and environment
-atopic/allergic/extrinsic- younger
-nonatopic/nonallergic/intrinsic- older -> stress, exercise, anxiety, air, sickness
-type 2 inflammation- atopic dermatitis, nasal polyps
asthma reseribility
-FEV1/FVC ratio reduced (<90%)
-reversibility- increase of ≥ 12% and 200 ml in FEV1
asthma medication
-IgE Mediated Asthma- Omalizumab (Xolair)
-Eosinophilic Mediated Asthma (IL-5):
-Benralizumab (Fasenra)
-Mepolizumab (Nucala)
-Reslizumab (Cinqair)
-Mixed Eosinophilic and Allergic:
-Dupilumab (IL-4,13)
-Tezepelumab (TSLP)
-Methylxanthines- Theophylline
-biologics
-LAMA- tiotropium- option for >6yo
peak expiratory flow (PEF) meters
->20% change in a day -> uncontrolled
-<200 value -> severe obstruction
-moderate to severe:
-every morning and night
-before meds
-after exacerbation
severe asthma attack
-<40% PEF or FEV1 -> severe attack
-beta agonist + anticholinergic every 20 mins or for 1 hour
-O2 therapy
-systemic corticosteroids
COPD
-sedentary- few symptoms
-chronic
-acute exacerbation
-distant heart sounds
-depressed diaphragm
-can lead to cor pulmonale
-FEV1/FVC < 70%
mMRC scale
COPD tx + exacerbation
-resting O2 <88% -> O2 therapy
-alpha 1 antritrypsin
-lung transplant
-bilateral resection
-endobronchial valve
-bullectomy
-exacerbation (50%):
-augmentin
-doxy
-bactrim
bronchiectasis
-cytokines -> mucociliary + cartilaginous -> decrease V
-impaired drainage, obstruction, immunodeficiency
-copious amounts of purulent smelly sputum
-hemoptysis
-dyspnea and wheezing/crackles
-pseudomonas/MRSA is common
-obstructive
bronchiectasis dx
-immunoglobulins
-sputum- pseudomonas
-alpha 1 deficiency
-sweat test- cystic fibrosis
-PFTs
-x-ray- dilated and thickened bronchi -> tram tracks
-honey combing- cystic bronchiectasis
-bronchoscopy to R/O hemoptysis, obstruction, removal of secretion
-DX- CT*
-ring shadows, tree in bud
-cysts - grapes
bronchiectasis tx
-according to sputum culture
-multiple prior exacerbation and no sputum culture -> fluoroquinolone
-recurrent (2-3/year)- macrolide
-bronchodilator
-glucocorticosteroid
-resection if remaining part of lung is good
bronchiectasis complications
-hemoptysis -> massive may require embolization of bronchial arteries or surgical resection
-cor pulmonale
-amyloidosis
-abscesses at distant sites
cystic fibrosis
-increase mucus viscosity
-pancreatitis, infertility, gall stones
-Hyperresonance to percussion
-Apical crackles
-Sinus tenderness, purulent nasal secretions, nasal polyps
-Mixed obstructive and restrictive pattern
cystic fibrosis dx
-1. Clinical symptoms consistent with CF in at least one organ system
-2. Evidence of CFTR dysfunction:
-Elevated sweat chloride >60 mmol/L
OR
-genetic testing- Presence of 2 disease-causing mutations in CFTR
-Abnormal nasal potential difference (used if sweat chloride neg)
-PFTs, ABGs
-sputum- MRSA, p. aeruginosa
-bronchiectasis
-interstitial markings
cystic fibrosis tx
-pancreatic enzymes replacement
-CFTR modulators
-VEST, PEP
-Inhaled recombinant human deoxyribonuclease (rhDNase) *cleaves extracellular DNA in sputum
-azithromycin with chronic
-lung transplant- def tx
pleural effusion labs
-hemothorax- Hct/SHct >.5
-exudate- protein/Sprotein >.5, LDL/SLDL >.6, OR LDL > 2/3rds of normal
-transudates- glucose=Sglucose, pH 7.4-7.55, <1000 WBC
pleural effusion tx
-pleurodesis
-thoracocentesis
-indwelling pleural catheter
parapneumonic pleural effusion
-exudate
-uncomplicated
-complicated- depends on provider -> if glu is <60 or pH < 7.3 -> drain
-empyema- gram+ or culture -> drained and antibiotics
-complicated and empyema -> loculation common -> fibrinolytics (steptokinase and urokinase)
pneumothorax
-spontaneous or traumatic
-spontaneous- primary (no disease); secondary (lung ds)
-traumatic- trauma
-EKG changes that mimic MI
-supine- deep sulcus
-complication- subcutaneous emphysema
respiratory alkalosis vs acidosis
-alkalosis- pneumothorax, PE, anxiety, pain, hypoxemia
-acidosis- sleep apnea, obesity, hypoventilation syndrome, COPD, asthma
pneumothorax tx
-can resolve on own if minor
-spontaneous primary- needle decompression with small catheter+small chest tube -> imaging every 24 hrs
-2ndary, large, tension, severe- needle decompression and large test tube
-thoracoscopy or open thoracotomy- recurrent, bilateral, bullectomy required, tx failure
PE and DVT risk facotrs
-venous stasis- low mobility, high central venous pressure, hyperviscosity
-injury to vessel- surgery, trauma, prior thrombus
-hypercoagulability- genetics, meds, disease
pulmonary embolism
-usually multiple in lower lobes
-infarction, abnormal gas exchange, right ventricular strain
-pleuritic pain
-hypotension is a bad sign
-EKG- 70%
-<500 d-dimer- sensitive
-westermarks sign- prominent central pulmonary artery with local oligemia
-hamptons hump- infarct
-angiography- intraluminal filling defect in more than 1 projection, abrupt arterial cutoff, asymmetry (especially segmental oligemia)
PE tx
-O2 sat > 90%
STABLE
-low risk, nonmassive- empiric anticoagulation
-high risk, nonmassive/anticoagulation contraindicated- IVC filter
-moderate risk, nonmassive- case by case
-moderate risk, submassive- anticoagulate and monitor for thrombolytics
UNSTABLE
-thrombolytics (streptokinase and urokinase) and anticoagulate
-embolectomy
-anticoagulation - LMW (fondaparinux) or oral factor Xa inhibitors or direct thrombin inhibitors- rivaroxaban/apixaban
-3 months for 1st reversible risk
-12 months for 1st idiopathic
-6/12 months-forever- for irreversible risk or recurrent
pulmonary HTN
-mild >25, moderate > 30, severe > 45
-chest pain, fatigue, dyspnea, syncope
-S2 splitting
-idiopathic/primary- RHF -> low CO
-secondary- presents as underlying ds
pulmonary HTN dx
-polycythemia
-EKG- right axis deviation, RV hypertrophy/strain, RA enlargement
-CT/CXR- R and L main and lobar pulmonary artery dilation and pulmonary outflow tract enlargement
-DEF DX- right heart cath
pulmonary HTN tx
-idiopathic/primary- anticoagulation, O2 therapy, diuretics
-secondary- O2, anticoagulation, polycythemia tx, cor pulmonale tx
-PAH- vasodilators:
-prostacyclines- epopros, treprost, iloprost
-PDE-5- sildenafil, tadalafil
-endothelial- bosentan, ambrisentan, macitentan
-CCB
cor pulmonale
-caused by hypoxemia, pulm HTN, COPD, pulmonary fibrosis
-same S&S as pulm HTN
-polycythemia, low O2
-EKG- RBBB, SVT, right axis deviation
-echo
-DEF DX- right heart cath
-tx- treat what caused it, O2, diuretic therapy, diet
sleep apnea
-upper airway is smaller than normal due to fat, bone structure, genetics
-inspiratory ds
-nocturia
-males > 17; females > 16 neck size
-rule out arrythmia
-proteinuria, polycythemia
-apnea hypopnea index (AHI)
-epworth sleepiness scale
-inspire tx- <32 BMI
epworth sleepiness scale
-0 = Would never doze
-1 = Slight chance of dozing
-2 = Moderate chance of dozing
-3 = High chance of dozing
-during the day:
-Sitting and reading
-Watching television
-Sitting inactive in a public place (theater, meeting)
-Lying down to rest in the afternoon when circumstances allow
-Sitting and talking to someone
-Sitting quietly after lunch without alcohol
-In a car, while stopped for a few minutes in traffic
obesity hypoventilation
->45 CO2, >30 BMI
-upper airway obstruction
-restrictive chest
-blunted central respiratory drive
-pulmonary HTN
-dx of exclusion
-respiratory acidosis with metabolic alkalosis compensation
-CPAP
ARDS
-sepsis, trauma, gastric aspiration
-must R/O heart failure -> <18 pressure with cath
-PaO2/FIO2 ratio <300
-bilateral widespread whiteout on x-ray -> no pleural effusion
-FROTHY RED/PINK SPUTUM
-DIFFUSE CRACKLES
-no response to O2
ARDs imaging
-CXR- progresses overtime
-bilateral white out
-diffuse or patchy
-spares the angles
-no pleural effusions
-air bronchograms- 80%
ARDs tx
-lowest PEEP
-keep above O2 55, SO2 88%
-tx underling cause
-get FIO2 under 60% -> 40% is safe
-minimal fluids -> can cause HF
pulmonary aspiration
-esophageal dysfunction, AMS
-Aspiration of Inert Material
-Aspiration of Toxic Material
-“Café Coronary”- food
-Retention of Aspirated FB- recurrent pneumonia, bronchiectasis, abscess, hyperinflation -> bronchoscopy for dx and tx
-Chronic Aspiration of Gastric Contents- zenker, ppi, H2, metaclopramide
-Acute Aspiration of Gastric contents- copious or very acidic -> chemical pneumonitis -> <2.5 -> ARDS
Aspiration of Toxic Material
-Clinically evident pneumonia
-Hydrocarbon pneumonitis: aspiration of ingested petroleum distillates:
-Gasoline, kerosene, furniture polish
-Lung injury: mainly from vomiting and aspiration
-Symptoms: vomiting, coughing, respiratory distress, cyanosis, fever
-CXR: may initially be normal or near-normal but may significantly progress over the next 12 hours.
-Patchy airspace consolidation, particularly in the lower lobes, especially the medial basal segments
-Therapy is supportive
-right side mc for aspiration
intermediate probability nodule
-bx- transthoracic needle aspiration or bronchoscopy
-PET scan
-sputum- squamous
-VATs
fleischner society risk scale
carcinoid tumors
-<60
-slow growing
-rarely metastasize
-in the bronchi
-hemoptysis, cough, wheeze
-central
-pedunculated or sessile
-carcinoid syndrome- flushing, diarrhea, hypotension, wheezing
-bronchoscopy- dx
-Octreotide scintigraphy, Dotatate PET/CT*
-neuroendocrine
bronchogenic: NSCLC
-squamous cell- central, bronchial hypercalcemia, hemoptysis, sputum
-MC- adenocarcinoma- BAC- peripheral - can look like pneumonia
-large cell carcinoma- peripheral or central, grow fast, can be resected and cleared if caught early
SCLC
-begins centrally
-mediastinal adenopathy
-submucosal
-neuroendocrine -> paraneoplastic syndromes:
-cushings, SIADH, peripheral neuropathy, myasthenia, cerebellar degeneration
-limited (contained within 1 lung) and extensive (outside 1 lung area)
lung cancer complications
-SVC- plethera, headache, AMS
-pancoasts- apical tumor pushing on brachial plexus and cervical sympathetic -> horners + shoulder pain -> unilateral anhidrosis, miosis, ptosis
lung cancer work up
-bx
-thoracentesis- fluid cytology
-FNA- outside nodes - tissue bx
-bronchoscopy
-transthoracic needle bx with CT
-VATs- high risk
-Tumor markers: PDL1, ALK gene, EGFR gene
-MRI of brain
-PET of abdomen
-radionuclide bone scan
-V/Q- assess for surgery
lung cancer tx
-immunotherapy- NSCLC- PD-1 (nivo and pemb) or PDL-1 (mezo and durv)
-SCLC:
-limited- resect if isolated and no metastasis/spread
-extensive- chemo -> if responding -> radiation
metastatic lung cancer
-via pulmonary artery usually
-kidney, colon, cervix, metastatic melanoma, breast
-multiple spherical bilateral
-symptoms uncommon- same-> usually primary tumor symptoms
-lower lung MC
-bx if cant find primary tumor
-tx primary tumor and lung symptoms
-resection if SOLITARY and primary tumor is controlled, low risk, no other metastasis
-resection contraindicated if metastatic melanoma or pleural involvement
blue bloater, pink puffer
