IM PULM Flashcards
What is the typical presentation of a patient with acute bronchitis?(4)
Cough > 5 days
with or without sputum production, lasts 2-3 weeks
Chest discomfort
shortness of breath
+/- fever
What is the MCC of Acute bronchitis?
viruses (most common)
what is the recommended treatment of Acute bronchitis ?
Antibiotics not recommended—remember its mostly viral.
- treat symptoms with
1. NSAIDs, ASA, Tylenol, and/or ipratropium
2. Cough supressents (codeine containing cough meds
3. Bronchodilators (albuterol )
a 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes. this patient most likely has ___
Asthma
What is the Most common presentation for Asthma?
ost often young patients present with wheezing and dyspnea often associated with illness, exercise, and allergic triggers
What is the pathophysiology of Asthma?
Airway inflammation, HYPERROSPONSIVENESS AND REVERSIBLE AIRFLOW OBSTRUCTION
What instrument is used to diagnose asthma?
peak flow
what PFT finding is consistent with asthma?
decreased FEV1 and therefore a reduced FEV1 to FVC ratio
how wold you treat accute asthma ?
Oxygen, nebulized SABA short acting beta agonist (albuterol ,levalbuterol), ipratropium bromide, and oral corticosteroids
What is Samter’s Triad?
Asprin, Chronic Rhinosusitis with nasal polyps, Asprin (or NSAID) sensitivity
What spirometry / pulmonary function findings are consistent with obstructive pattern?
Low FEV1/FVC ratio
Give examples of LABA (long acting beta 2 agonist)
Formoterol, Salmeterol Used in maintenance to prevent symptoms
Describe Intermittment asthma/step 1
..
Daytime symptoms ≤2 days/week
Nocturnal awakenings ≤2/month
Normal FEV1
Exacerbations ≤1/year
SABA, as needed
Mild persistent asthma/step 2
..
what classifys asthma as Intermittent / step 1
and whats the treatment
Daytime symptoms ≤2 days/week
Nocturnal awakenings ≤2/month
Normal FEV1
Exacerbations ≤1/year
SABA, as needed
What classify asthma as Mild Persistent / Step 2
Daytime symptoms >2 but <7 days/week
Nocturnal awakenings 3 to 4 nights/month
Minor interference with activities
FEV1 within the normal range
Exacerbations ≥2/year
give
Low-dose ICS daily with SABA as neededor
Low-dose ICS plus SABA, concomitantly administered, as needed
what classifys asthma as moderate persistent/step 3 ?
Daily symptoms
Nocturnal awakening 8 or more time a month
treatment with ICS + LABA
hat classifys asthma as severe persistent/step 4
symptoms all day
nocturnal awakening nightly
treat with LABA (formoterol) + medium dose ICS
Medium to high-dose ICS-LABA plus LAMA daily and SABA as needed would be (preferred) for what step in the Asthma Guidelines?
Step 5
MC cause of pnemonia in adults is due to
flu
MC cause of pnemonia in peds is due to
RSV
what is the presentation of a patient with bacterial pneumonia ?
(6)
bacterial pneumonia presents as fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum
patchy, segmental lobar, multilobar consolidation;
get blood cultures x2, sputum gram stain
What is the treatment of choice for bacterial pneumonia inpatients
ceftriaxone + azithromycin/respiratory Floriquinalones (levo, moxfloxacin)
What is the treatment of choice for bacterial pneumonia outpatient?
Doxycycline or macrolides (mycin)
Fungal pneumonia is commonly seen in what type of patient?
immunocompromised patients ( AIDS, steroid use, organ transplant)
how do you test and treat fungal pneumonia?
Fungal inhalation in western states; test with EIA for IgM and IgG
Tx: fluconazole/itraconazole
fungal disease affecting the lungs and sometimes other organs of the body
Coccidiodomycosis (Valley Fever)
how do you treat Pulmonary aspergillosis (usually those with healthy immune systems
0
fluconazole/itraconazole
what is the treatment of choice for crypotocccus pneumonia?
found in soil; can disseminate and ⇒ meningitis
Lumbar puncture for meningitis
Tx: amphotericin B
What is bronchiectasis?
A condition in which the lungs’ airways become dilated and damaged, leading to inadequate clearance of mucus in airway\
Mucus builds up and breeds bacteria, causing frequent infections - crackles, wheezes, purulent sputum
What are the most common causes of bronchiectasis?
Cystic Fibrosis
CF, immune defects, recurrent pneumonia, aspiration, tumor
Give me signs and symptoms of bronchiectasis? (3)
ymptoms include a daily cough that occurs over months or years, production of copious foul-smelling sputum, and frequent respiratory infections
What is the gold standard diagnostic for bronchiecstatis
Ct chest
What is the treatment recommendation for for bronchiectasis(4)
ambulatory oxygen, aggressive antibiotics for acute exacerbations, CPT
(chest physiotherapy = bang on the back); eventual lung transplant
what CXR findings are consistent with bronchectasis
tram track lung markings, dilated and thickened airways
“plate- like” atelectasis
What is the typical presentation of a patient with carcinoid tumor(4)
Flushing, diarrhea, wheezing, low BP
43-year-old man who comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent “v” wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sounds
what is a carinoid tumor ?
A tumor arising from neuroendocrine cells → leading to excess secretion of serotonin, histamine, and bradykinin
What are the common sites of carcinoid tumor ?(5)
GI tract, stomach, Liver, pancreas, ovaries
The most common site of a neuroendocrine (carcinoid) tumors to metatasize
the appendiceal cancer travels from the appendix then to the liver MC where it metastasizes to the lungs
What are the hallmark signs of Carcinoid syndrome?
Cutaneous flushing, diarrhea, wheezing itching
carcinoid tumors and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation.
What is the treartment of choice for carcinoid syndro
Surgical excise
why can Octreotide be used in carcinoid tumurs?
its a somatostatin analog that binds to the somatostatin receptors and decreases the secretion of serotonin by the tumor
What is the Most important risk factor for COPD ?
Cigarette smoking
What deficiency is commonly linked to COPD in patients < 40y/o (protects elastin in lungs from damage by WBCs)?
Alpha-1-antitrypsin deficiency
Describe the pathophysiology of emphysema
Exposure to irritants (e.g. cigarette smoke) → degrades elastin in alveoli, airways → lose elasticity → low pressure during expiration pulls walls of alveoli inward → collapse → air-trapping distal to collapse → septa breaks down → neighboring alveoli coalesce into larger air spaces → decreased surface area available for gas exchange
what physical exam findings are consistent with emphysema?
hyperresonance to percussion decreased/absent breath sounds, decreased fremitus, barrel chest (increased AP diameter), quiet chest, pursed-lip breathing
pink puffer vs blue bloater
COPD patients that are able to oxygenate blood (look pink) but they have to purse their lips to do so
pink puffers= emphysema patients
What chest x-ray findings are consistent with emphysema
loss of lung markings, hyperinflation, increased anterior-posterior diameter
tombstone lungss
What PFT findings are consistentr with emphysema ?
FVC decreased (esp. FEV1) + increased TLC (due to air trapping)
How long must a patient have a chronic cough to be classified as having chronic bronchitis
for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause
What is the pathophysiology of chronic bronchitis ?
hypertrophy/hyperplasia of bronchial mucous glands, goblet cells in bronchioles, cilia less mobile → increased mucus production, less movement → mucus plugs → obstruction in bronchioles → air-trapping → productive cough
what pulmonary function Test findings are consistent with chronic bronchitis
FEV1/FVC ratio of less than 0.7 Increased TLC (air trapping)
What lab and physical exam findings are consistent with chronic bronchitis
↑ HGB and HCT are common because of the chronic hypoxic state
Pulmonary HTN with RVH, distended neck veins, hepatomegaly
Rales (crackles), rhonchi, wheezing, signs of cor pulmonale (peripheral edema, cyanosis)
What will RV,TLC and functional residual capacity (FRC) look like in COPD patients?
INCREASED due to hyperinflation while FEV1, FVC,FEV1/FVC is DECREASED
What CXR findings are consisitent with emphysema?
hyperinflation flat diaphragm, increased AP diameter, decreased vascular markings; bullae
What CXR findings are consistent with chronic bronchitis?
increased AP diameter, increased vascular markings, enlarged right heart border
What is the single most important step in the treatment in COPD?
Smoking cessation
In a stable patient with COPD what medications are the treatment of choice for clincial therapy ?
β2 agonist + anticholinergic = greater response than used alone – tx of choice in stable COPD with resp. symptoms
+/- inhaled glucocorticoids: inhaled corticosteroids are not considered monotherapy
Oxygen
What are common side effects associated with anticholinergic agents
dry mouth, thirst, blurred vision, urinary retention, difficulty swallowing, mydriasis
Name two CI do impatropium
Glaucoma, BPH
Name SABA and LABA’s
(short acting ) Albuterol, Terbutaline
(Long acting) Salmeterol
preferred Short acting mujscarinic
ipratropium
Describe Mild COPD (stage 1)
FEV1 > 80%
treatment: SABA or SAMA PRN
What are indications for long term oxygen therapy in COPD patients?
chronic hypoxemia aka
PaO2 < 55 mmHg or SaO2 <89%
Describe Moderate COPD (stage 2)
FEV1 50-80%
treatment SABA or SAMA PRN + LAMA
describe severe COPD (stage 3)
FEV1 30-50%
treament : SABA or SAMA prn + LAMA + pulm rehab; inhaled steroids if increased exacerbations
describe very severe COPD (stage 4)
Cor pulmonale, right heart failure, resp failure, FEV1 <30%
SABA+SAMA prn + LAMA or LABA + pulm rehab and inahled steroids if increased exacerbations +o2 therapy
describe the typical presentation of a patient with Cor Pulmonale
65 y/o with 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate COPD. His PMH is relevant for a 40 pack-year smoking history, type II DM, hyperlipidemia, and coronary artery stenting 2 years ago. PE shows barrel-shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), his pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%
What is cor pulmonale ?
Right ventricular enlargement and eventually failure secondary to lung disorder that causes pulmonary artery HTN
MC caused by COPD , PE, Vasculitis, Asthma, ILD, Acute Respiratory Dress Syndrome
what is the gold standard diagnostic test in the diagnoses of cor pulmonale ?
right heart catheterization.
true or false.
Diuretics are not helpful! May be harmful in cor pulmonale
True
what is idiopathic pulmonary fibrosis?
a type of lung disease that results in scarring (fibrosis ) of the lungs for an unknown reason
What pulmonary function test are consistent with idiopathic pulmonary fibrosis?
restrictive (decreased lung volume, normal/increased FEV1/FVC ratio)
What CT scan findings are consistent with idiopathic pulmonary fibrosis ?
diffuse patchy fibrosis with pleural-based honeycombing
Hwat are the treatment recommendation for idiopathic pulmonary fibrosis
antifibrotic drugs
(pirfenidone or nintedanib),
oxygen therapy, and
definitive= lung transplant
what pneumoconiosis is associated withcoal mining and what CXR findings might this patient have?
Coal worker pneumoconiosis
what pneumoconiosis is associated with mining, sandblasting, stone, quarry work;
AND HAS increased risk TB and progression to massive fibrosis
SIlicosis
describe the CXR findings associated with Silicosis
small rounded opacities throughout the lung, hilar lymph nodes may be calcified - “eggshell” calcifications
What is one major complication of Asbestos pneumonconiosis ?
Mesothelioma
what occupuation is most commonly associated with berylliosis ?
Tech, aerospace, electrical plants foundries,
when the right heart cant pump againstr vascular resistance and right heart failure starts
Cor pulmonale
What is the most common cause of pulmonary HTN?
mitral stenosis
other causes include: constrictive pericaridits, LV failure
what is the gold standard in diagnosing pulmonary HTN?
right heart catheterization (gold standard)
What heart sound is specifically related to pulmonary HTN?
loud pulmonic P2
Other than pulmonary manifestations (MC) what other manifestations are associated with sarcoidosis ?
Skin Manifesations
Erythema Nodosum = tender red nodules usually on the lower legs
LUPUS PERNIO =chronic, violaceous, raised lesions on the face
what chest xray findings are consistent with sarcoidoisis ?
Bilateral hilar lymphadenopathy. Reticular infiltrates
what abnormal lab values are associated with sarcoidosis ?
↑ ACE levels + ↑ calcium levels + bilateral hilar adenopathy
what histological findings are associated with sarcoidosis?
non caseating granulomas
Name the treatment recomended for sarcoidosis
Steroids (90%) respond
Methotrexate
what is the difference in a pulmonary nodule vs pulmonary mass.
(hint: size related)
<3cm = nodule
>3 cm= mass
What is the best next step if a pulmonary nodule was visible on CXR?
If suspicious ⇒ biopsy (ill-defined lobular or spiculated suggests cancer)
Not suspicious ⇒ < 1 cm monitor at 3 mo, 6 mo, then yearly for 2 yr (calcification, smooth well-defined edges = benign)
Where does small cell lung cancer metastasize to?(5)
Bone, Bone marrow, liver, adrenals and brain
What is the typical presentation of a patient with Superior Vena Cava syndrome
Facial Swelling
Often worse in the morning or when bending over.
Can progress to include neck and upper extremities.
Neck and Upper Extremity Edema
Due to impaired venous return.
Dyspnea (shortness of breath)
Especially when lying flat (orthopnea) due to increased venous congestion.
Cough or Hoarseness
From compression of adjacent structures.
Dilated Chest Wall Veins
Collateral circulation may develop and become visible on the chest.
Head Fullness or Pressure
Patients may report a sensation of “head fullness” or headache.
Visual Disturbances or Dizziness
Due to increased intracranial pressure in severe cases.
Cyanosis or Plethora of the Face
Facial skin may appear flushed or bluish.
fore prophylaxis is administered. ____ is the preferred prophylactic regimen for prevention of Pneumocystis pneumonia in HIV-positive patients with CD4 cell counts under 200 cells/micro
Trimethoprim-sulfamethoxazole DS daily
Which antimicrobials should be prescribed prophylactically for in an AIDs patient with PJP in addition to antiretroviral medication? and what would you give if sulf allergic?
TMX/SMP , Dapsone
Which type of emphysema is associated with spontaneous pneumothorax and young adults?
Distal acinar emphysema
