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CRRAB II- Week 5 > Johns: Chronic Cough and Hemoptysis > Flashcards

Johns: Chronic Cough and Hemoptysis Flashcards

1
Q

What is a chronic cough?

A

One that persists for 3 weeks or longer

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2
Q

What happens to intrathoracic pressures and expiratory velocity during the chronic cough?

A

Intrathoracic pressures may reach 300 mmHg.

Expiratory velocities approach 500 mph.

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3
Q

What is the complex reflex arc associated w/ the chronic cough?

A

Receptors in the nose, sinus, posterior pharynx, ear canals and diaphragm>
Medullary cough center>
Expiratory muscles, diaphragm, larynx

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4
Q

What is the MCC of the chronic cough?

A

Postnasal drip
asthma
GI reflux

Chronic URI

**most pts have more than 1 cause

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5
Q

What else should you consider in a pt w/ chronic cough?

A

ACE inhibitors

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6
Q

What percent of smokers have a chronic cough?

A

25%

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7
Q

What is the MCC of of chronic cough?

A

Post nasal drip

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8
Q

What causes postnasl drip?

A

Allergic
Vasomotor rhinitis
Sinusitis

(Silent drip)

**no definitive criteria for diagnosis

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9
Q

How do you treat post nasal drip?

A

Ipratropium nasal spray
Nasal corticosteroids
Antibiotics (if sinusitis present)

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10
Q

How is asthma associated with a cough?

A

Usually associated w/ wheezing but there is a cough variant type (cough w/ few other symptoms)

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11
Q

What is the best way to confirm an asthma related chronic cough?

A

Demonstrate improvement w/ one week of inhaled beta-agonist therapy

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12
Q

How do you treat an asthma related cough?

A

Inhaled bronchodilators/ inhaled corticosteroids.

Short course of prednisone.

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13
Q

How does gastroesophageal reflux cause a chronic cough?

A

Receptors stimulated in larynx, lower RT and distal esophagus–> chronic cough

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14
Q

How do you work up GERD?

A

24 hr esophageal pH monitoring

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15
Q

How do you treat GERD? How long do you usually treat GERD?

A

Empirically!

dietary changes (smaller meals, no evening snacks)

elevation of head of bed

Proton pump inhibitor

**6-12 mos of Rx

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16
Q

Besides post nasal drip, what is another very common cause of chronic cough?

A

GERD

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17
Q

What are less likely causes of a chronic cough?

A

Lung cancer
Bronchiectasis
Eosinophilic bronchitis

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18
Q

What are centrally acting cough medications and when are they used?

A

Short acting:
Codeine
Dextromethorphan

Both are superior to placebo

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19
Q

What would be your overall treatment plan for a pt w/ a chronic cough?

A

Establish etiology

If no cause found then try dextromethorphan and inhaled ipratropium or inhaled corticosteroid.

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20
Q

What are the top three MCC of cough?

A

Asthma, GERD, post-nasal drip

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21
Q

What is hemoptysis?

A

Can be pure blood or mixed w/ sputum

Rarely massive

22
Q

What is the origin of hemoptysis?

A

Vascular!

Bronchial arteries (supply airways, hilar LNs, visceral pleura)>
Are at systemic pressure unlike the pulmonary arteries>
can cause MASSIVE bleeding

23
Q

How do you evaluate a pt w/ hemoptysis?

A

H and P
Chest Xray!
CBC, UA, creatinine, coags (plts, INR, PTT)
Bronchoscopy

24
Q

When do you pursue a bronchoscopy in a pt w/ chronic cough?

A

In pts w/ normal CXR you will find a tumor in less than 5%, so generally, it won’t be very helpful to do a bronchoscopy in an individual w/ a normal CXRAY.

25
Q

What are RFs for a tumor that would indicate that a bronchoscopy is necessary in a pt w/ chronic cough?

A

Male sex
older than age 40
smoking hx w/ over 40 ppy
Hemoptysis greater than one week

26
Q

What is the source of most PEs? Other sources?

A

Iliofemoral thrombi

Also consider pelvic veins as source

Less likely- right heart, renal veins, upper extremities

27
Q

Do calf vein thrombi commonly embolize?

A

No, but we DO treat them, mostly to prevent chronic damage to the veins which could cause venous insufficiency down the line.

28
Q

What are RF for PE?

A 
Immobilization
Surgery w/in three months
Stroke
Hx of thromboembolism
Malignancy
Air travel over 3000 miles
29
Q

What are RF for PE in women?

A 
Obesity
heavy smoking
HTN
BCP
pregnancy
30
Q

What can cause PE w/out RFs?

A

Factor V leiden mutation in up to 40% of cases

High concentrations of factor VIII

31
Q

Why might you worry about an occult malignancy as a cause of PE w/ out RFs?

A

Occult malignancy can occur in up to 17% of people

pancreatic and prostate

32
Q

A pt presents w/ dyspnea, pleuritic pain, cough and hemoptysis. What do they have?

A

PE

33
Q

What are signs of a PE?

A 
Tachypnea
Crackles
Tachycardia
LOUD P2
Fever
34
Q

What is a loud P2 associated w/ a PE?

A

Pulmonary artery pressures increase d/t the emboli. An increase in pulmonary artery pressure causes a louder closure sound.

35
Q

What does a loud P2 mean?

A

Pulmonary HTN

36
Q

What is the wells criteria?

A 
Clinical sxs of DVT
Other diagnosis less likely
HR
Immopbilization or surgery in previous 4 wks
Previous DVT/PE
Hemoptysis
Malignancy

**calculate points to determine risk

37
Q

How do you work up a PE?

A

ABG
ECG- insensitive
CXR- may show atelectasis or pleural effusion, many are normal
D-Dimer

38
Q

What is usually seen on an ABG

A

Decreased p02, pCO2 and respiratory alkalosis.

Can be normal.

39
Q

Describe the sensitivity, specificity and PV of a D Dimer.

A

Low specificity
High sensitivity
NPV is HIGH in pts w/ a low pretest probability of PE

40
Q

What is pre and post test probability?

A

Determine pre-test probability based on RFs–> shows you post-test probability

Curves indicate likelihood ratios which can be positive or negative.

41
Q

How does a D dimer relate to post test probability?

A

A D dimer is very good for a NEGATIVE LIKELIHOOD TEST and can decrease the likelihood significantly. It is good at ruling OUT but not ruling IN.

42
Q

What is the specificity and sensitivity of a lung CT?

A

Sensitivity 70-87%
Specificity 90%

Can’t detect small emboli beyond normal segmental arteries

**too many are ordered

43
Q

If you have a pt with a low pretest probability and a normal D dimer do you need to anticoagulate?

A

No

44
Q

What do you do if you have a pt with a moderate or high pretest probability?

A

Proceed w/ a CT

45
Q

What do you do if you have a pt with a normal CT and a high pretest probability?

A

Consider angiography

46
Q

How do you treat a PE?

A

Heparin (unfractionated vs. LMW)

5 days of heparin overlapping w/ warfarin.

Continue w/ warfarin for 6 mos

47
Q

What are the advantages of LMW?

A

Once daily
fixed dose
no lab monitoring needed
less likely to cause decreased platelets

48
Q

When are thrombolytics used?

A

Massive PEs w/ hypotension

49
Q

When is an IVC filter used?

A

In pts w/ PE and contraindication for anti-coagulation or recurrent PE despite anti-coaulation

50
Q

What is the MC source of PE?

A

Ileo-femoral veins

CRRAB II- Week 5 (3 decks)

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