FunMed Pulmonary Flashcards
Adult ICU CAP treatment
- ICU: B-lactam + macrolide OR B-lactam + fluoroquinolone
- broaden antibiotics with Pseudomonas coverage, i.e., B-lactam
- Consider further testing if not improving (eg CT of chest); thoracentesis if pleural fluid is present
- Outpatient: macrolide +/- B-lactam; doxycycline
- Inpatient: B-lactam + macrolide OR a respiratory fluoroquinolone
- Supportive care
- Limit the number of paroxysms
- Observe the severity of cough and provide assistance when necessary; Elevate head
- Maximize nutrition, rest, and recovery
- Azithromycin is the treatment of choice for all patients.
- Trimethoprim-sulfamethoxazole if a hypersensitivity to macrolides
- Prophylaxis for exposed/susceptible persons is also azithromycin for 5 days
Treatment of Pertussis
- paramyxovirus
- annual outbreaks, winter, mid-October - January
- A leading cause of hospitalization in US children
- Can also cause upper and lower respiratory tract infection in adults
- increasingly recognized severity in those with comorbid conditions
Respiratory Syncytial Virus (RSV)
Use these for diagnosis of what?
- Radiographically presents with nodular, irregular, pleural thickening, poss pleural effusion, and pleural plaquing
- CXR
- CT
- Thoracentesis
- Surgical biopsy
- Usually necessary for diagnosis
- Difficult to diagnose
- PET
- Helpful in ?malignancy; staging; poss surgical candidate
Mesothelioma
•2-5mm radio-opaque nodules on CXR
Dust particles in the alveoli are ingested by macrophages which then become “coal macules”
- HIV testing
- Interferon-gamma release assay (IGRA)
- Acid-fast bacilli (AFB) smear and culture with drug susceptibility
Using sputum from the patient collected in the early morning on how many consecutive days?
Diagnostic Tests for TB
3 consecutive days
- Complications include
- Respiratory failure for a minority of patients
- Malignancy
- Bronchogenic adenocarcinoma
- Malignant Mesothelioma (cancer arising from the mesothelial surface of the pleural cavity)
- Concomitant tobacco use increases risk of malignancy even more
- Treatment is supportive and preventative
Pneumoconiosis – Asbestosis
PCR assay is faster and more sensitive, but Nasopharyngeal swab is criterion standard for diagnosis
CBC will show leukocytosis with absolute lymphocytosis
Positive tests must be reported to state and local public health authorities
Diagnosis of Pertussis
•Alveolar ventilation (⩒A) ultimately determines the
PaCO2
- Recurrent, alveolar hemorrhage
- Children or young adults
- Iron deficiency
- Celiac disease.
- Treatment of acute episodes of hemorrhage with corticosteroids. Recurrent episodes of pulmonary hemorrhage may result in interstitial fibrosis and pulmonary failure.
Alveolar Hemorrhage Syndrome: Idiopathic pulmonary hemosiderosis:
Renal involvement and anti-glomerular basement membrane antibodies are absent, in contrast to Goodpasture Syndrome
- Symptoms last 5-7 days
- Edema and obstruction of these upper airways.
- Viral infection of the larynx, trachea, and the upper bronchial tree
- Most common between 7 and 36 months of age
- Lungs are typically clear to auscultation
Acute Laryngotracheitis / Croup
- Slowly progressive constitutional symptoms
- Malaise
- Anorexia
- Weight loss
- Fever
- Night sweats
- Chronic cough, productive with blood streaked sputum
Presentation of TB
- Patients typically present decades after relevant exposure with:
- Wait for it…
- Slowly progressive dyspnea, dry cough, and inspiratory crackles on exam…
Restrictive Lung Diseases Interstitial Lung Disease/Diffuse Parenchymal Lung Disease
Occupational Lung Diseases
Pneumoconiosis – Asbestosis
Pediatric Pneumonia, drug of choice for each age group?
- <4 weeks:
- 4-12 weeks:
- 3mo-5 yrs:
- >5yrs:
- <4 weeks: ampicillin and gentamicin or cefotaxime
- 4-12 weeks: IV ampicillin
- 3mo-5yrs: oral amoxicillin (if outpatient)
- >5 yrs: oral amoxicillin +/- a macrolide if an atypical organism is likely
Virchow triad?
(1) venous stasis
(2) activation of blood coagulation
(3) vein damage
- 2-5mm radio-opaque nodules on CXR
- Nodular opacities occur primarily in the upper lung fields in simple version
- May become more widespread and then confluent with progression to large opacities in complicated version with progressive massive fibrosis
Pneumoconiosis – Coal Worker’s Lung
simple coal workers pneumoconiosis
complicated coal workers pneumoconiosis
Which Alveolar Hemorrhage Syndrome?
- Idiopathic, recurrent alveolar hemorrhage
- Glomerulonephritis - rapidly progressive
- Occurs in men 30-40 yo
- Hemoptysis usual presenting symptom
- Dyspnea, cough, hypoxemia, diffuse bilateral alveolar infiltrates
- Iron deficiency anemia and microscopic hematuria (glomerulonephritis)
Goodpasture syndrome
- Abrupt onset (w/in 4-6 hrs) of fever, chills, malaise, nausea, cough, chest tightness, dyspnea.
- Exam: basilar crackles and tachypnea.
- CXR frequently normal
- Potentially confused with a viral or bacterial infection and given antibiotics
- Treatment: remove from environment
- Symptoms subside within 12hrs to several days.
Disease may recur with reexposure
ACUTE Hypersensitivity Pneumonitis
- Transmitted via respiratory droplets
- Attacks ciliated epithelium
- Produces toxins —> inflammation and necrosis —> airway plugs, bronchopneumonia, and hypoxemia.
Pertussis
- Nasopharyngeal swab for culture is the Criterion standard for diagnosis but Takes a long time to get results and Must be cultured during catarrhal or paroxysmal phases
- PCR assays and antigen detection has Rapid results and More sensitivity and Can use later in the disease course
- CBC will show leukocytosis with absolute lymphocytosis
- Positive tests must be reported to state and local public health authorities
Diagnosis of Pertussis
- Since cause is most often viral, antibiotics not necessary.
- Avoid cough suppressants (try not to mess with the mucociliary clearance!)
- Okay to use at night if patient needs sleep
Treatment of Acute Bronchitis
Adult CAP Treatment
•Always cover _______?
Generally cover________?
- Outpatient:
- Inpatient:
- ICU:
S. pneumoniae
Atypicals
macrolide +/- B-lactam OR doxycycline
B-lactam + macrolide OR a respiratory fluoroquinolone
B-lactam + macrolide OR B-lactam + fluoroquinolone
- Most cases caused by RSV
- Edema and cellular debris cause obstruction of small airways.
- most often in infants and young children.
- Most commonly in first 2 years of life.
- Peak age is 6 months.
- Leading cause of infant hospitalization.
Acute Bronchiolitis
OSA: treatment (children)
●Much more likely to be treated surgically
○Good outcomes data in otherwise healthy children with adenotonsillar hypertrophy
●Other surgeries can be done for children with craniofacial abnormalities; case-by-case evaluation
●CPAP if no surgical option, especially in obese children
○Need frequent re-evaluation of mask fit
●Other lifestyle interventions
○Healthy diet, exercise, weight management
○Management of allergy/nasal congestion if present
○Orthodontia if needed otherwise
Adult CAP: diagnostic testing:
- CBC with differential and chemistries to?
- WBC differential can (sometimes) assist with differentiating?
- Must be true sputum rather than saliva. Criteria per high powered field?
- Blood cultures for high-risk patients or those suspected of?
- Nasopharyngeal swab for?
- Urine antigen testing for?
- Help assess the severity of illness
- Viral from bacterial etiology
- >25 WBCs and <10 squamous epithelial cells per HPF
- Sepsis
- PCR looking for viral infection and some atypicals
- Legionella and S. pneumoniae.
no current or recent hospitalization or stay in a long-term care facility
no antibiotic therapy in the past 3 months
not on chronic dialysis or home infusion therapy
no home wound care
no household contact with a multi-drug resistant organism
community-acquired pneumonia
- Identification of _________ and ferruginous bodies on pathology aid diagnosis (though usually unnecessary)
- Respiratory failure for a minority of patients
- Bronchogenic adenocarcinoma
- Malignant _________?
Concomitant tobacco use increases risk of malignancy even more
asbestos fibers
Pneumoconiosis – Asbestosis
Mesothelioma
(cancer arising from the mesothelial surface of the pleural cavity)
An Immunologic reaction to an inhaled organic antigen
Hypersensitivity Pneumonitis
- Reticular and small nodular opacities bilaterally in the lower lung fields
- Calcified pleural plaques, also typically in the lower lungs
- Pleural effusions
Pneumoconiosis – Asbestosis
- Most patients recover in 3 days
- Malaise may persist for weeks
Rapid Diagnostic Testing takes about 15 minutes for results.
RT-PCR assay testing can take 4 to 8 hours; Some tests can differentiate between A&B, some can specify the strain of A; complex lab test and $$$
Viral Culture takes 10-14 days.
Influenza
- Chronic
- Simple version:
- Appears as innumerable, small, rounded opacities (<10mm) in the dorsal, upper lung fields.
- HRCT is helpful in evaluation
Pneumoconiosis – Silicosis
- It is VERY important to establish clearing of?
- A common presentation of lung tumor is post-obstructive?
- A follow-up CXR should always be done in ______ to document return to normalcy
- After hospitalization, follow up within ______ prevents re-admission
pneumonia
pneumonia
6-8 weeks
5 days
Dyspnea- tachypnea- chest pain may be your only clues for?
PE
A normal A-a gradient is less than?
Patient’s age divided by 4 + 4
- Characteristic linear IgG deposits detected by immunofluorescence in glomeruli or alveoli is diagnostic
- Combinations of immunosuppressive drugs and plasmapheresis work well for treatment
Diagnosis and treatment for the Alveolar Hemorrhage Syndrome, Goodpasture syndrome
What disease?
A representative anteroposterior chest x-ray in the exudative phase of ARDS
•Pressure-volume relationship in the lungs of a patient with acute respiratory distress syndrome (ARDS)
- Low grade malignant neoplasms
- Most common in GI tract
- Well-differentiated neuroendocrine tumors
- Central vs. peripheral pulmonary
Carcinoid/Bronchial gland tumors, aka: bronchial adenomas
★A leading cause of hospitalization in young children
★Nasopharyngeal swab for RSV rapid viral antigen test
★Treat with oxygenation, hydration, bronchodilators, suctioning
★Bronchiolitis/RSV
A chronic, immunologically mediated, granulomatous disease
•Inhalation causes lung pathology. However, skin contact can cause cutaneous nodules as well
Pneumoconiosis – Berylliosis
- Occurs most commonly in children <2 or 9 - 15 yrs
- Cough may or may not be productive
Labs and Chest X-ray are usually not necessary unless patient appears to be more acutely ill or fever is very high.
Physical Exam shows:
- Wheezing
- Rhonchi
- Fever
Acute Bronchitis
- Symptoms: Gradual/insidious onset of: productive cough, dyspnea, fatigue, anorexia and weight loss.
- Exam: tachypnea, diffuse crackles.
- PFTs: restrictive, decreased DLCO.
- CXR: normal to micronodular or reticular opacities.
- HRCT: diffuse micronodules
- BAL: marked lymphocytosis
- Tissue pathology: noncaseating granulomas
- Treatment: remove exposure. glucocorticoids may be required. Improvement in symptoms and function takes longer than with acute HP, weeks to months.
SUBACUTE Hypersensitivity Pneumonitis
•CURB-65:
for what?
- Confusion
- Urea (BUN) >19
- Respiratory rate >30
- Blood pressure: systolic <90, diastolic <60
- 65 years of age or older
Adult CAP
The most common cause of death from ARDS is?
severe irreversible hypoxemia accounts for only?
multi-organ failure secondary to sepsis
9% to 19% of deaths
- Typical lesion is a granuloma with central caseation necrosis.
- Bacilli proliferate locally and spread through the lymphatics to a hilar node, forming the Ghon complex.
Pathophysiology of TB
Symptoms: URI symptoms, Wheezing, Cough, Dyspnea, Irritability, Poor feeding, Low grade fever, Apnea
Exam Findings
Tachypnea (can be up to 60-80 breaths per minute!), Nasal flaring, Use of accessory muscles for respiration, Diffuse wheezing
•Fine rales, Tachycardia, Fever (but not always), Hypoxia
Presentation of Bronchiolitis
Carcinoid Syndrome
Rare (<10%)
Name four Symptoms?
- Flushing
- Diarrhea
- Wheezing Bronchospasm
- Hypotension
Avoid triggers
Treat allergic rhinitis causing PND, treat GERD
QUIT SMOKING!!!!!!!!!
Allergy Desensitization if indicated
Vaccination: Pneumococcal and influenza
Asthma - prevention/treatment
★Supportive care, cool mist humidifier, bronchodilators as needed
★Antibiotics are NOT needed! This is most likely a viral infection
★Most common in the first 2 years of life
★Bronchiolitis/RSV
Pediatric pneumonia
•Transmitted upper airway noise is difficult to differentiate from lower respiratory abnormalities
•Listen to the chest, then hold your stethoscope up to the cheek
The mechanisms of lung parenchyma damage and role of airway changes following smoke inhalation injury. This is looking at what happens when thermal injury and chemical injury occur.
Cast formation!
Names of the three types of Mesothelioma?
1st. Most common, >50%?
2nd. Worst prognosis and resistant?
3rd. ?
All progress rapidly and are painful.
1st. Epithelial
2nd. Sarcomatoid
3rd. Biphasic
What type of Non-Squamous Cell Carcinoma?
- Can grow anywhere in the lungs, ie.e, central or peripheral
- Is heterogeneous, i.e., undifferentiated
- Rapid doubling time
- Metastasize early
Large Cell
- Prognosis:
- Course is variable and if disease responds to glucocorticoids then may live with it chronically.
- If fail glucocorticoids then may try Methotrexate or other immunosuppressive agents but no clear evidence showing efficacy
- Some patients experience progressive deterioration of lung function and development of pulmonary fibrosis
- No increased risk of cancer
Pneumoconiosis – Berylliosis
the minimum age for flu vaccine?
6 months
Xray shows normal or hyper-inflation
More done to rule out pneumonia or
Other complications
Chest x-ray in Asthma
★A self-limiting cough lasting more than 5 days and up to 3-4 weeks
★Most commonly caused by a virus (Rhinovirus, adenovirus,…)
★Occurs most frequently in children
★Virus disrupts the mucociliary clearance in the airways
★Causes cough and wheezing
★Supportive care, cool mist humidifier, bronchodilators as needed
★Antibiotics are NOT needed! This is most likely a viral infection
★Acute Bronchitis Pearls
•reticular opacities are more often in the middle and upper lung fields as opposed to the bases. Also see hilar adenopathy.
Sarcoidosis
Pleurodesis (though rare)
to seal lung to pleura using talc
○OSA is diagnosed when
there are 5 events (apnea, hypopnea, desaturation) per hour in a patient with typical symptoms; or 15 events per hour regardless of symptoms
Presentation of Mesothelioma
Bi or unilateral?
chest pain pleuritic or non-pleuritic?
usually present with?
Unilateral - 60% right sided, 5% bilateral
Non-pleuritic chest pain
pleural effusion
Tracheobronchomalacia- uncommon disease of the central airways resulting from softening or damage of the cartilaginous structures of the airway
Tracheal Stenosis - narrowing of the trachea
Chronic cough
GERD
DD for Asthama
Complication of Influenza?
- Associated with aspirin use in the management of viral infections
- Occurs in young children
- Consists of rapidly progressive hepatic failure and encephalopathy
- 30% mortality rate.
Reye syndrome
- What disease?
CXR usually diagnostic with these common patterns:
- Patchy…?
- Lobar…?
- Diffuse…?
- Pleural…?
- Patterns can be suggestive of but not…?
- Adult CAP
- patchy airspace opacities
- lobar consolidation with air bronchograms
- diffuse alveolar or interstitial opacities
- pleural effusion
- diagnostic for specific etiologies
fever, fatigue and productive cough between 5 days and 3-4 weeks
- 90% viral
- inflammation of trachea, bronchi, and bronchioles.
- self-limiting
Acute Bronchitis
Prevention of what disease?
- DTaP vaccine: Recommended at the ages of ________ and __ - __ months and at age __ - __ years; it is not recommended for children aged 7 years or older
- Tdap vaccine: Recommended for children aged __ -__ years who are not fully vaccinated; as a single dose for adolescents 11-18 years of age; for any adult 19 years of age or older; and for pregnant woman regardless of vaccination history, including repeat vaccinations in subsequent pregnancies
Prevention of Pertussis
2, 4, 6, and 15-18 months
4-6 years
7-10
A multisystem granulomatous disorder of unknown etiology
Sarcoidosis
These are risks for?
- Age <3 months
- Low birth weight
- Gestational age of <29 weeks
- Low socioeconomic group
- Crowded living conditions
- Parental smoking
- Chronic lung diseases
- Neurologic diseases
- Congenital Heart disease with pulmonary hypertension
- Immunodeficiencies
- Airway anomalies
Acute Bronchiolitis
Adult Inpatient CAP
•Inpatients can be converted to oral antibiotics when:
1.
2.
3.
- Hemodynamically stable
- Able to ingest and absorb oral medications
- Clinically improving
Respiratory Failure
- Type I =
- Type II =
- Type III =
- Type IV =
hypoxemia
hypercapnia
Perioperative (atelectasis)
Shock (Hypoperfusion)
recurrent episodes of apnea lasting at least 10 seconds, associated with oxygen desaturation in the blood; or hypopnea, defined as decreased airflow and drop in saturation of at least 4%
Obstructive sleep apnea: definition
A 6-month-old boy presents to the ER with his parents with acute onset of rhinorrhea, cough, and wheezing. The symptoms have quickly progressed and the patient now has dyspnea and irritability. The mother states that her child was born at 34 weeks gestation with a small patent foramen ovale that they are hoping will close with age. On examination, the child’s temperature is 38oC or 100.4oF. There are rhonchi heard in all lung lobes. His respiratory rate is 50 breaths per minute, and he exhibits flaring of nares and use of accessory muscles of respiration resulting in intercostal and supraclavicular retractions. Widespread fine rales are heard at the end of inspiration and in early expiration. The expiratory phase is prolonged and wheezing is audible throughout the lung fields.
What is the most likely diagnosis?
What test or tests should be performed? Chest X-ray (?),
Treatment in this child will include what?
Is there a vaccine that this child missed?
Would this child have qualified for Synagis?
Acute Bronchiolitis
RSV rapid viral antigen nasal swab
Hospitalization, Humidified oxygen, nebulized bronchodilators, nebulized ribavirin, IV hydration, nasopharyngeal suctioning.
No vaccine for RSV.
Yes, premature and small congenital heart defect. Should have been started on Synagis at the beginning of the RSV season.
Adult CAP Treatment
- Traditional duration of treatment is ________, but when using a respiratory fluoroquinolone________ is sufficient IF uncomplicated
- Patient should be improving and afebrile ________ to stop ABx
10-14 days
5 days
48-72 h
- May have Fatigue, Malaise, Fever or Weight Loss
- Skin lesions
- Cervical Lymphadenopathy
- Visual changes, dry eyes
- Dry mouth, parotid swelling
- Palpitations, syncope
- Joint pain or swelling
- Muscle weakness
- Hepatomegaly and tenderness
Sarcoidosis: Extrapulmonary findings
Symptoms include: Malaise, Fever, Night Sweats, Weight loss, Productive cough, Blood-streaked sputum;
Exam: Cervical lymphadenopathy and apical rales.
Tuberculosis
★Virus disrupts the mucociliary clearance in the airways.
What disease?
★Acute Bronchitis Pearls
Airway Edema + Accumulation of cellular debris in small airways —-> obstruction —-> V/Q mismatch = wasted perfusion, a right-to-left shunt, and hypoxemia early in the course of the disease
Pathophysiology of Acute Bronchiolitis
Sarcoidosis
Chronic, immunologically mediated, granulomatous disease
Pneumoconiosis – Berylliosis
REMEMBER IT THIS WAY:
Eosinophils, think
Granuloma, think
Angiitis, think
asthma
nodules in lungs
vasculitis of arteries
- pO2 < 60 mmHg and/or
- pCO2 > 50 mmHg
Respiratory Failure
Pleural effusion
- Transudative =
- Exudative =
- If moderate or greater, should be_________?
(clear) fluid is an inflammatory reaction
(purulent) fluid = empyema
tapped and evaluated
moderate to severe acute exacerbation of COPD
2 or more of the following get what?
increased sputm, dyspnea or sputum purulence
ABs
- Symptoms:
- # 1 Weight loss/anorexia/asthenia
- # 2 A cough
- Dyspnea
- Chest pain
- Symptoms more likely if prior COPD dx
- Exam:
- Lymphadenopathy
- Hepatomegaly
- Clubbing fingers
NSCLC
CT of Non-Small Cell Squamous Cell Carcinoma
Pathologic condition in which alveoli are perfused with blood, but not ventilated.
Pulmonary Shunting
ECG is typically normal except in advanced disease, where right ventricular hypertrophy (right axis deviation, incomplete right bundle branch block) and right atrial enlargement (peaked P wave in the inferior and right-sided leads)
Pulmonary Hypertension
People with AIDS are 20-40 times more likely than immunocompetent persons to develop
- HIV infection
- Intravenous drug abuse
- Incareration
- Household contacts with TB
- Homelessness/Shelter living
- Travel to an endemic area
- Alcoholism
- Diabetes mellitus
- Silicosis
- Immunosuppressive therapy
- Tumor necrosis factor–alpha antagonists
- Cancer of the head and neck
- Hematologic malignancies
- End-stage renal disease
- Intestinal bypass surgery or gastrectomy
- Chronic malabsorption syndromes
- Low body weight
- Smoking - Smokers who develop TB should be encouraged to stop smoking to decrease the risk of relapse
- Age below 5 years
Risk Factors for TB
TB is the leading cause of death in HIV positive people.
This treatment for which neoplastic lung disease?
- Surgery (Only Stage I), Mediastinal Staging always indicated preop, Always followed by chemo
- Smoking Cessation
- Systemic Chemotherapy +/- radiation
- Good initial response but often recurrence
- Pain management
- Palliative care referral usually indicated
Small Cell
Inpatient treatment:
- Oxygen
- Racemic epinephrine via NEB
- Corticosteroids
- Intubation/ventilation
Most patients can be treated at home:
- Cool, humidified air
- Corticosteroids
- Single dose dexamethasone
- Single dose racemic epi
Treatment for Croup
Exam Findings
- Fever
- Tachycardia
- Flushed face
- Conjunctival erythema
- Pharyngeal injection
Influenza
Board buzz words for?
Egophony
Pleural friction rub
Dullness to percussion
Other symptoms to expect?
pleural effusion
- Dyspnea
- Cough
- Chest pain
- Absent or diminished breath sounds over the effusion
- Bronchial breath sounds
- Tracheal shift (large effusion)
- Imaging:
- CXR:
- Basilar predominance of Reticular opacities indicative of Idiopathic Pulmonary Fibrosis
- Imaging shows
- Reticular and small nodular opacities bilaterally in the lower lung fields
- Calcified pleural plaques, also typically in the lower lungs
- Pleural effusions
Pneumoconiosis – Asbestosis
Chest X-ray: may show hyperinflation with scattered consolidation or lobar consolidation from a secondary infection
Acute Bronchiolitis
- Chest X-ray or CT scan
- Caseating granuloma in the apical lung
- Miliary granulomas
- Hilar and paratracheal lymphadenopathy
- Calcified granuloma + associated lymph node = Ghon Complex
- Segmental atelectasis
- Pleural effusion
Radiograph shows right apical thick-walled cavity and surrounding lung consolidation
Diagnostic Tests for TB
The radiograph shows a classic posterior segment right upper lobe density consistent with active tuberculosis.
What stain?
IGRA •Interferon-gamma release assay with antigens specific for Mycobacterium tuberculosis (blood test) - more specificity
AFB •Acid-fast bacilli smear and culture with drug susceptibility - Use sputum from patient collected early morning on 3 consecutive days
•HIV testing
Ziehl-Neelsen stain
Diagnostic Tests for TB
Parainfluenza viruses are the most common agents, along with adenovirus, respiratory syncytial virus (RSV), and (rarely) Mycoplasma pneumoniae.
- 5% of children will have during their second year of life.
- Symptoms last for 5-7 days
- Inspiratory stridor
Chest X-ray shows “Steeple sign” =
Acute Laryngotracheitis / Croup
•A viral infection of the larynx, trachea, and the upper bronchial tree
subglottic narrowing in the neck; lungs usually appear normal
- Chronic
- Complicated version (Progressive Massive Fibrosis)
- The small nodules of Simple version progress and coalesce into larger nodules (>1cm) that evolve into conglomerate masses
- Looks similar to malignancies
Pneumoconiosis – Silicosis
- Supportive care
- Limit the number of paroxysms
- Observe the severity of cough and provide assistance when necessary; Elevate head
- Maximize nutrition, rest, and recovery
- Azithromycin is the treatment of choice for all patients.
- Trimethoprim-sulfamethoxazole if a hypersensitivity to macrolides
- Prophylaxis for exposed, susceptible persons is also azithromycin for 5 days
Treatment of Pertussis
If HIV negative: 6 to 9 mo regimen
2 months Isoniazid, Rifampin, Pyrazinamide, and Ethambutol.
If I-sensitive, stop E
•If I and R sensitive, drop P and continue I and R 4 months more
*Treatment must extend 3 months beyond documentation of negative sputum
Treatment of Active TB
Case Study
- 57 yo male with 30 pack/year history presents with new bothersome productive cough x 3 days with fever 101F. No other symptoms. No pertinent medical history. PE wnl
- What do you order???
- Diagnosis???
- Treatment???
CXR
Classic RML Pneumonia
- Outpatient: macrolide +/- B-lactam; doxycycline
- Inpatient: B-lactam + macrolide OR a respiratory fluoroquinolone
- ICU: B-lactam + macrolide OR B-lactam + fluoroquinolone
What disease?
Electrocardiogram demonstrating the changes of __________________ (long arrow) with strain in a patient with __________________. Right axis deviation (short arrow), increased P-wave amplitude in lead II (black arrowhead), and incomplete right bundle branch block (white arrowhead) are highly specific but lack sensitivity for the detection of right ventricular hypertrophy.
Electrocardiogram demonstrating the changes of right ventricular hypertrophy (long arrow) with strain in a patient with primary pulmonary hypertension. Right axis deviation (short arrow), increased P-wave amplitude in lead II (black arrowhead), and incomplete right bundle branch block (white arrowhead) are highly specific but lack sensitivity for the detection of right ventricular hypertrophy
What disease?
★Chest X-ray typically shows ____________; and Ghon complex, which is?
Tuberculosis
apical caseating granuloma in the lung
a calcified focus of infection and associated lymph node
Alveolar inflammation leads to?
recruitment of inflammatory cells
•Primary screening method for TB infection (active or latent)
A positive test cannot determine between active and latent infections.
•Mantoux tuberculin skin test with purified protein derivative (PPD)
- Dormant tubercle bacilli are reactivated
- Mycobacteria are released into the surrounding tissue and bloodstream causes a vigorous, nonspecific immune response
- Host becomes symptomatic and highly contagious
•Secondary Tuberculosis
COPD chest X-ray findings
•Historically was known as “Consumption”
85% of patients present with pulmonary complaints.
Tuberculosis (TB)
- Incubation period 1–4 days.
- Aerosol transmission may occur 1 day before onset of symptoms.
- Viral shedding continues for 5-10 days.
Influenza
Orthomyxovirus
single- or double-stranded RNA virus?
What are used to distinguish the 3 types?
___________ is most common type in humans and is genetically labile, with mutation rates as high as 300 times that of other microbes?
Influenza Virus
Single-stranded
Core nucleoproteins: A, B, and C.
Influenza A
CXR in Interstitial Lung Disease showing:
- Reticular and nodular opacities
- Pattern and distribution of opacities on CXR can help differentiate which form it is.
- Most common type of lung CA in US
- Most common histology in NON-SMOKERS
- Starts in the cells that line the alveoli of the lungs/peripheral
- Metastasizes to distant organs
- Often brain
- Common path of colon CA
Non-Squamous Cell Carcinoma: i.e., Adenocarcinoma
Clinical Course of?
ARDS
- The exudative phase is the acute, early phase
- A proliferative phase ensues within 7 days – prominent interstitial inflammation and early fibrotic changes
- Most patients recover approximately 21 days after the initial pulmonary injury; however, some enter the fibrotic phase (substantial fibrosis and bullae formation)
CXR for what disease shows “Steeple sign” and what is it?
Croup
= subglottic narrowing in the neck; lungs usually appear normal
Solitary Pulmonary Nodule
- Size?
- Etiology?
- Risk Factors/History?
- Symptoms?
- Imaging?
- Treatment?
- Biopsy?
- Risks?
- <3 cm (if >3cm, lesion is not called nodule anymore, it’s called a called mass)
- >2cm <3cm = 80 % malignancy rate
- Cancer/Malignancy, Granuloma, Fungal infection, TB, Benign Tumor, Foreign body (rare)
- Environmental, Occupational, Smoking, Infections, Cancers
- Almost always asymptomatic/incidental finding
- CXR, CT, PET, review old imaging
- PET detects increased glucose metabolism
- High sensitivity and specificity
- PET detects increased glucose metabolism
- what’s their risk?
- low - serial imaging every 3 for 12 then 6 till 24
- after 24, considered benign
- intermediate - PET scan, biopsy
- high - surgical referral for diagnosis/treatment
- low - serial imaging every 3 for 12 then 6 till 24
- •CT guided lung biopsy/transthoracic needle aspiration (TTNA)
- Biggest risk are bleeding and pneumothorax
Interstitial Lung Disease, general findings
- Imaging: HRCT - High Res CT
- Reticular pattern
- Honeycombing
- Traction bronchiectasis
- Radiologic findings in which disease?
- Focal lucencies scattered in lungs consistent with pathologic changes
- Often predominates in upper zones of each lobe.
- May reveal large bullae or blebs
- Loss of vasculature in affected areas
- Mostly ordered to assess for which form?
- and to rule out?
chest CT in COPD
emphysema
bronchiectasis
- A bacterial infection that affects airways lined with ciliated epithelium.
- Most common in the unimmunized.
- Highly contagious
- Half of all cases occur before 2.
- Adults and adolescents are reservoirs of infection.
Pertussis (Whooping Cough)
Four stages of what?
1) Cancer only in pleura, lateral, only one side
2) ipsilateral, spread within lung or LN on the same side
3) Spread to contralateral side, anywhere in chest wall, pericardium or ABD cavity
4) Widespread disease
Mesothelioma
- Usually unexpected/incidental
- Almost always asymptomatic/incidental finding
- Otherwise can have similar symptoms as will discuss in malignancy/compression symptoms if large
- “coin lesion”
- isolated
- <3 cm•>3cm —> MASS
Sarcoidosis
- A bacterial infection that affects airways lined with ciliated epithelium.
- Most common in unimmunized infants and adults.
- Highly contagious
- Adults and adolescents are reservoirs of infection.
Bordetella pertussis
aka
Whooping Cough
DTaP and Tdap vaccinations for what?
But?
Prevention of Pertussis
★Neither immunization nor disease confers lasting immunity
- Cough lasting > 5 days and up to 3-4 weeks
- Symptoms include: fever, fatigue, and a productive cough.
- 90% are viral in origin, and 10% are bacterial.
- Infection leads to inflammation of the trachea, bronchi, and bronchioles.
- Usually self-limiting and resolves over time.
Acute Bronchitis
