Lung 1 Flashcards
invasive aspergilosis - special biomarkers
positive cell wall biomarkers: galactomannan, beta D glucam.
an example of increased and decreased tactile fermitus
increased: consolidation
decreased: pleural effusion
ACE - when is the cough
within 1 week of initiation of increasing of dosage
approach to patient with suspected PE
stabilize patient with O2 and IV fluids –> evaluate for absolut contraindications to anticoagulation:
- yes: obstain diagnostic test for PE: (+) –> consider IVC filter, (-) –> no further
- no –> Wells criteria –>
- likely: consider anticoagulation esp if patient has no contraindications, moderate to severe distress –> diagnostic test
- unlikely –> diagnostic test
infl + pneumonoccoccal vaccination in COPD –> mortality
not decrease
goodpasture disease - systemic symptoms
uncommon
Invasive aspergiolsis - risk factors
immune
invasive aspergillosis - findings
- triad of fever, chest pain, hemoptysis
- pulm nodules with halo
- positive cultures
- positive cell wall biomarkers (galactomannan, betal D glucam
invasive aspergillosis -management
voriconazole +/- caspofungin
chronic pulmonary aspergilosis - risk factors
lung disease/damage (cavitary TB)
chronic pulm aspergilosis - findings
- more than 3 months: weight loss, hemoptysis, fatique
- cavitary lesion +/- funfus ball
- positive aspergillus IgG seology)
Chronic pulm aspergilosis - management
resect aspergilloma (if possible)
- azole (vorizonazole)
- embolization (if severe hemoptysis)
tumors of the mediastinum - location
anterior: thymoma, thyroid, teratoma, lymphoma
middle: bronchogenic cysts
posterior: neurogenic, esoph leiomyomas
hospitalized vs ventilator acquired pneumonia - definition
hosptial: 48 or more hours after admission
ventilator: 48 or more hours after intubation
Acute exacerbation of COPD - management
- O2 (target 88-92)
- inhaled bronchodilators
- systemic glucocrticoids (β2 or anticholinerg)
- antibiotics if at least 2 of dyspnea, more frequent cough, change in colore or volume of sputum)
- oselramivir if evidence of flu
- noninvasive (+) pressure ventilation
- intubation
acute exacerbation of COPD - steroids - route of administration
IV
pulm nodule sorrounded by ground glass
invasive aspergilosis (halo sign)
causes of obstructive pattern (and their DLCO)
asthma: normal/increaed
emphysema: decreasd
chronic bronchitis: normal
causes of increased DLCO
- asthma
- morbit obesity
- polycythemia
- pulm hemorrhage
increased PCWP is an indicator of
LA pressure
lung problems - PCWP?
not affected
asbesotis exposure - when develop disease
after 20 years of initial exposure
aspiration syndromes - types and mechanism
pneumonia: parenchyma infection, anaerobes microves
pnemonitis: parenchyma infl, aspiration of gastric acid
aspiration syndrome - types and clinical features
- pnemonia: daus after aspiration, fever, cough, sputum. CXR infiltrates, can progress to abscess
- pneumonitis: hours after event, from asymptomatic to resp distress, CXR infiltrates (1 or both lower lobes)
aspiration syndrome - types and management
pneumonia: clindamycin or b lactam + lactamase inh
pneumonitis: supportive (no antibiotics)
negative pressure pulm edema
when a patient has upper airway obstruction that results in large negative intrathoracic pressure (due to inspiration against obstruction)
the 3 MCC of clubbing
- Lung ca
- Cystic fibrosis
- R –> L cardiac shunts
Clubbing in COPD
copd does not cause
if there is, search for ca
management of PE if more than 4 wells
first antigoagulant, and after diagnostic tests
classic ECG in PE
prominent S in lead I, Q in lead III, and inverted T in head III (S1Q3T3)
management after Wells criteria
- PE likley –> CT pulm angiography –> if (-) is excluded, if (+) is confirmed
- PE unlikely –> D dimers –>: if more more than 500 –> CT pulm angiography, if less excluded
Modified Wells criteria
- 3 points: Clinical signs of DVT, alternate diagnosis is less likley
- 1.5 points: previous PE or DVT, herat rate more than 100, Recent surgery or immobilazation
- 1 point: hemoptyisis, cancer
MORE THAN 4 –> LIKELY
4 OR LESS –> UNLIKELY
fat embolism - time after event
12-78h
pulm contusion - symptoms can be worsen by
fluid overvolume
COPD indications for O2 at home
- resting PaO2 55 or lower
- SaO2: 88 or less
- Those with RHF or HCT higher than 55 should be started if Pao2 lower than 60 or Sao2 lower than 90
the 3 MCC of chronic cough are
- upper airway cough syndrome (postnasal drip_
- asthma
- GERD
POSTNASAL SYNDROME
caused by rhinosinus conditions including allergic, perennial nonallergic and vasomotor rhinitis –> mechanical stimulation of cough reflex
treatment: chlorpheniramine
COPD exacerbation - when to give antibiotics
if 2/3 of:
- increaed dyspnea
- increased cough (more frequent o sever
- sputum production (change in color or volume)
anaphylaxis - IV vs IM epinephrine?
IM –> if no response –> IV
NO IMMEDIATELY IV DUE TO SE (arrhythmia)
the most effective way to differentiate asthma from COPD
spirometry before and after administration of a bronchodilator (usually albuterol)
COPD - factors that decrease mortality
- smoking cessation
- Long term supplemental 02 decreases mortality if:
- SpO2 under 88%
- SpO2 under 89% + RHF or erythrocytosis (HCT more than 55)
solitary pulm nodule - definition
round opacity up to 2 cm in diameter within and surrounded by pulm parenchyma
by convention: no pleural effusion, adenopathym atelectasis
solitary pulm nodule - DDX
- 1ry lung Ca
- Metastatic ca
- Benigh infect granulomas (TB, histopl, other fungus)
- Benign neolasm (lipomas, hamartomas, fibroma)
- vascular (AV malformation)
Solitary pulm nodule on routine chest X-ray - management
previous chest x-ray:
- stable over 2-3 years –> no further testing
- No previous imaging or possible nodule growth –>
CT:
1. Benign features –> serial CT scans
2. High suspicious for malignancy –> surgery
3. indeterminate or suspicious for malignancy –> biopsy or PET
high risk vs low risk for solitary pulm nodule
low: smaller than 0.8 cm, younger than 40, never skomed or smoking cessation more than 15 years, smooth margins
high: larger than 2 cm, older than 60, current smoker or cessation less than 5 years before, corona radiata or spiculated margins
Causes of recurrent pneumonia
- involving same region: local airway obstruction, aspiration –> CT
- involving different regions of lung: immunoddef, sinopulm disease, noninfectious (Vasculitis, etc)
antitryps def - smoking
COPD 10 years earlier compare to nonsmoking
empiric treatment of CAP
- outpatient:macrolide or doxycycline (healthy)
resp quinolone or beta lactam + macrolide (comorbitities) - inpatients: quinolone (IV) or betal lactam + macrolide
- ICU: beta lactam + macrolide or quinolne + beta lactam
resp quinolones
levo-, moxifloxacin
CURB-65
Confusion Urea more than 20 Respiration more than 30 Blood pressure lessthan 90/60 Age 65 or more
CURB-65 interpretation
0: low mortality –> outpatient
1-2 intermediate –> likley inpatient
3-4 urgent inpatient –> possibly ICU if socre more than 4
initial drug in stable PE in patient with RF
unfractionated heparin (if severe: GFR lower than 30) (the others are contraindicated)
SIADH - treatment
Fluid restrition (best initial) +/- salt tablets
hypertonic (3%)saline for severe
- DEMECLOCYCLINE ONLY IF THE OTHERS FAIL
PE - Aa gradient
increased
anemia - Aa gradient
low
dead space ventilation?
air in non-perfused areas
subacute vs chronic cough
subacute: 3-8 wks
chronic: more than 8 wks
evaluation of subacute or chronic cough
evaluate and treat as indicated (stop ACEi, H1 for upper airway cough, OFT for asthma, PPI for GERD) –> if no improvement –> Cest X-ray
- parenchymal disease, purulent sputum, immune, no specific etiology –> chest x-ray
atelectasi - PCO2
low
upper airway obstruction - graph
decrease the airflow rate during insipration and expiration –> flattening both the top and bottom of the flow - volume loop
FRC in ankylosing spond
normal or increased due to fixation of a rib in the inspiratory position
pulsus paradoxus - seen in
- cardiac teponade 2. asthma 3. obstructive sleep apnea
4. pericarditis 5. croup
asthma - histology
- smooth muscle hypertrophy
- Curschmann spirals: shed epithelium forms whorled mucus plugs
- Charcot - Leyden crystals: eosinophilic, hexagonal, double-pointed, needle-like crystal from breakdown of eosinophils in sputum
asthma drugs
- β2 agonists (albuterol, salmeterol, formoterol)
- corticosteroids (fluticasone, budesonide)
- Muscarinic antagonists (ipratropium)
- Antileukotrienes (montelukast, zafirlukast, zileuton)
- omalizumab
- Methylxanthines (theophylline)
- Metacholine
role of corticosteroids (fluticosine, budesonide) in asthma therpay
asthma - albuterol used in
- 1st line therapy for chronic asthma
- during acute exacerbation
asthma - ipratropium vs tiotropium according to action
tiotropium is long acting
montelukast, zafirukast mechanism of action
block leukotriene receptor (CysLT1)
Zileuton mechanism of action / SE
5-lipoxygenase pathway inhibitor. Block conversion of arachnoid acid to leukotrienes
- hepatotoxic
adenosine receptor antagonists
- theophylline
2. caffeine
theophylline adverse effects
- cardiotoxicity
- neurotoxicity
narrow therapeutic index
think asthma as a diagnosis when
- Recurrent episodes of wheezing
- Cough at night
- Coughing or wheezing after exercise
- Cough, wheezing, chest tightness after exposure to allergens or pollutants
- Colds “go down to the chest” or take longer than 10 days
inspiratory reserve volume (IRV)
air that can still be breathed in after normal inspiration (3.3L)
Expiratory reserve volume (ERV)
air that can be breathed out after normal expiration (1L)
Inspiratory capacity (IC)
inspiratory reserve volume (IRV) + tidal volume (TV)
3.8L
Vital capacity (VC)
Maximum volume of gas that can be expired after a maximal inspiration (4.8L)
inspiratory reserve volume (IRV) + tidal volume (TV) + Expiratory reserve volume (ERV)
Functional residual capacity (FRC)
Volume of gas in lungs after normal expiration (2.2L) Residual volume (RV) + Expiratory reserve volume (ERV)
minute ventilation (Ve)
total volume of gas that entering lungs per minute
Ve = tidal volume x respiratory rate
Alveolar ventilation (Va)
volume of gas per unit time that REACHES ALVEOLI
Va = (tidal volume - physiological dead space) x respiratory rate
situations that alter FEV1/FVC
decreased: obstructive lung disease
increased: restrictive lung disease
IRV is used during
exercise
Causes of increased Vital capacity
acromegaly
physiologic dead space equation
tidal volume (Vt) x (arterial PCO2- expired PCO2)/ arterial PCO2
physiologic dead space definition
anatomic dead space of conducting airways plus alveolar dead space
Volume of inspired air that does not take part in gas exchange
alveolar dead space distribution
apex of healthy lung is largest contributor of dead space
Physiologic dead space (per breath) normal
150 ml/breath
pathologic dead space
when part of the respiratory zone becomes unable to perform gas exchange (ventilated but not perfused)
Lung cancer - complication
mnemonic: SPHERE + dysphagia + phrenic nerve paresis - heart or pericardial invasion +pleural invasion
1. Superior vena cava syndrome 2. Pancoast tumor
3. Horner syndrome 4. Endocrine (paraneoplastic)
5. Recurrent laryngeal nerve compression (hoarseness)
6. Effusions (pleural or pericardial)
Lung cancer - risk factors
- smoking 2. secondhand smoking 3. radon 4. asbestos 5. family history 6. Asbestosis 7. Silicosis
- Coal
primary lung cancer - types (small or non small?) / location
- small cell (oat cell) carcinoma - central
- adenocarcinoma (non-small) - peripheral
- Squamous cell carcinoma (non-small) - central
- Large cell carcinoma (non-small) - peripheral
- Bronchial carcinoid tumor (non-small) - central or peripheral
lung small cell (oat cell) carcinoma may cause/produce
- Cushing syndrome (ACTH) 2. SIADH
- antibodies against presynapitc Ca2+ channels (Lambert-Eaton myasthenic syndrome)
- or neurons (paraneoplastic myelitis/encephalitis, sabacute cerebellar degeneration)
lung small cell (oat cell) carcinoma - gene amplification
MYC
lung small cell (oat cell) carcinoma - histology
- neoplasm of neuroendocrine Kulchitsky cells (small dark blue cells)
- chromogranin A positive
- undifferentiated (very aggressive)
- Neuron specific enolase positive
lung squamous cell carcinoma - may cause/produce / CXR
- cavitation
- hypercalcemia (produce PTHrP)
- CXR: Hillar mass arising from bronchus
bronchial carcinoid tumor - histology
nests of neuroendocrine cells
chromogranin A positive
chromogranin A positive lung tumors
- bronchial carcinoid tumor
2. lung small cell (oat cell) carcinoma
bronchial carcinoid tumor - presentation/symptoms
- symptoms due to mass effect
2. carcinoid syndrome (flashing, diarrhea, wheezing)
lung Large cell carcinoma - treatment / it can secrete …
- less responsive to chemotherapy
- remove surgically
- β-hCG
MC primary lung cancer
MC lung cancer in non smokers
adenocarcinoma
lung adenocarcinoma activating mutations / paraneoplastic
- KRAS 2. EGFR 3. ALK
- hypertrophic osteorarthropathy (clubbing)
adenocarcinoma in siitu
bronchioarveolar subtype (hazy infiltrates similar pneumonia)
bronchioarveolar subtype - smoking
Bronchial carcinoid tumor - smoking
both no relationship
mesothelioma - risk factors
asbestosis
smoking is not a risk factor
mesothelioma - histology / RF
- psammoma bodies
- calretinin and cytokeratin (+) in almost all mesotheliomas, ((-) in most carcinomas)
- RF: ASBESTOSIS (not smoking)
pancoast tumor (superior sulcus tumor) may cause
Compression of locoregional structures:
- Horner syndrome
- Superior vena cava syndrome
- hoarseness
- sensorimotor deficits
superior vena cava syndrome - medical emergency because
it can raise intracranial pressure (if obstruction is severe)
–> headaches, dizziness, increased risk of aneurysm/rupture of intracranial arteries
Lung Ca - MC symptom
Lung Ca - single most common area of metastasis
- cough (75%)
- brain
lobar pneumonia - typical organisms
- S pneumonia
- Legionella
- Klebsiella
Bronchopneumonia - typical organisms
- S. pneumonia
- S. aureus
- H. influenza
- Klebsiella
interstitial (atypical) pneumonia - typical organisms
- Viruses (influenza, CMV, RSV, adenovirus)
- Mycoplasma
- Legionella
- Chlamydia
organism that causes BOTH Lobar and Bronchopneumonia
Klebsiella
S. pneumonia
bronchopneumonia - distribution
patchy distribution involving >= 1 lobe
walking pneumonia
interstitial (atypical) pneumonia –> generally follows a more indolent course
interstitial atypical pneumonia - typical presentation
relatively mild URI symptoms
lung abscess - organisms
- anaerobes (bacteroids, peptostreptococcus, fusobacterium)
- S aureus
- Klebsiella
S. aureus - pneumonia type?
Bronchopneumonia (or lung abscess)
H. infl - pneumonia type?
bronchopneumonia
Lung abscess 2ry to aspiration is most often found in …. (location)
right lung:
upright –> basal segment of right lowr lobe
supine –> posterior segment of right upper lobe or superior segment of right lower lobe
structure perforating diaphragm (an where)
T8: IVC
T10: esophagus vagus
T12: aorta, thoracic duct, azygos vein
Screening test for fetal lung maturity
- lecithin/sphingomyelin ration in amniotic fluid –>
- if more than 2 –> healthy
- if less than 1.5 –> predictive of NRDAS - foam stability test
- surfactant/albumin ratio
Pulmonary surfactant synthesis by time
begins around week 26 of gestation, but mature levels are not achieved until around week 35
neonatal respiratory distress syndrome - persistently low O2 tension - risk of
- PDA
- metabolic acidosis
- necrotizing enterocolitis
neonatal respiratory distress syndrome - therapeutic supplemental of O2 can result in
- retinopathy of prematurity
- Intraventricular haemorrhage (brain)
- Bronchopulmonary dysplasia
hemoglobin (hb) - properties
- positive cooperativity
2. negative allostery
hemoglobin (hb) - positive cooperativity
tetrameric Hb molecule can bind 4 02 molecules and has higher affinity for each subsequent O2 molecule bound
methemoglobin vs normal hemoglobin - iron status
normal: resuced state Fe2+ (FERROUS)
methemoglobin: oxidized state Fe3+ (FERRIC)
methemoglobin properties
- it does not bind 02 as readily
- it has increased affinity for cyanide
methoglobinemia may present with
- cyanosis 2. chocolate-colored blood
methoglobinemia can can be treated with
- methylene blue
2. vitamin C
how to treat cyanide poisoning (and the mechanism)
nitrites followed by thiosulfate
nitrites: hemoglobin –> methoglobin which bind cyanide
thiosulfate: to bind cyanide, forming thiocyanate , which is renally excreted
substance that cause poisoning by oxidizing F2+ to F3+ (found in)
- nitrites (from dieaary intake or polluted/high altitude water)
- benzocaine
methylene blue is used to
treat methoglobinemia
how to improve oxygenation in incubation
increase PEEP of FiO2
if FiO2 already higher than 60, prefer PEEP
goals for oxygenation in ARDS
- 88-95
- 55-80
