M2 Pulmonary Week 2 - Key Facts Flashcards
Meta-Relative Risk - Interpretations (3) + Calculation
Interpretation
1 = No Difference Between Groups
> 1 = Event more likely to occur in the experimental group (e.g. drug causes risk increase)
< 1 = Event less likely to occur in the experimental group (e.g. drug causes risk reduction)
Key = What is the outcome measure - If you are looking at readmission you want it to be less in experimental
% of Events in Experiemental
/
% of Events in the Control
E.g. 5 of 100 have relapse in experimental vs. 10 of 100 in control
0.05 / 0.1 = Relative Risk Reduction of 50%
Absolute Risk Reduction
% Events in Experimental - % Events in Control
E.g. 5 of 100 have relapse in experimental vs. 10 of 100 in control
0.05 - 0.1 = Absolute Risk Reduction of 5%
Number Needed to Treat
Number needed to treat to help one person
1 / ARR
E.g. 5 of 100 have relapse in experimental vs. 10 of 100 in control
ARR = 5% ///// NNT = 20
Indoor Exposures Increasing Risk of Asthma Development - Causal (1) + Association (1)
Causal - Dust Mites
Association - Second Hand Smoke
Indoor Exposures Increasing Risk of Asthma Exacerbation - Causal (4) + Association (4)
Causal
1) Cat
2) Cockroach
3) Dust Mite
4) Second Hand Smoke
Association
1) Dog
2) Fungus
3) Rhinovirus
3) NO2
Ozone in Asthma
Ozone Increases Asthma
Dust Mite Management in Asthma - Key Points ()
Removal not found to be clinically significant but largely influenced by one large study that was to short and poorly controled
Forest Plot = Key
Funnel Plot - Definition + Example (2)
A funnel plot is a graph used designed to check for the existence of publication bias; funnel plots are commonly used in systematic reviews and meta-analyses. In the absence of publication bias, it assumes that the largest studies will be plotted near the average, and smaller studies will be spread evenly on both sides of the average, creating a roughly funnel-shaped distribution. Deviation from this shape can indicate publication bias.
Largest Study (Biggest y) should be closest to the middle (average) while smaller studies are more likely to be scattered Large Studies = Pyramid Tip
Big Bite in one Bottom Corner = Missing studies that show one effect - pushes the mean the other way
Missing Most of the Bottom = Low Methodological Quality of small studies = smaller bias vs. leaving studies out
Methods of Pneumonia Acquisition (4)
1) Inhalation
2) Aspiration
3) Hematogenous Spread
4) Spread from a contiguous Foci
Factors that Impair Respiratory Immune Defense (2) + Causes (5)
Impaired Cough Reflex
1) EtOH
2) Drugs
3) Neuro-Muscular Disease
Impaired Mucociliary Escalator
1) COPD
2) Influenza
3 Major Ways to Organize Pneumonia
1) Community (S. Pneumoniae) vs. Nosicomial (Gram Negative)
2) Rapid Onset (Bacterial) vs. Slow Onset (Fungi/TB/Anaerobic)
3) Lobar vs. Bronciolar (Scattered Patch Infiltrates Around Bronchioles) vs. Interstitial (Atypical/Walking)
Major Bronchopneumonia Pathogens (5)
1) S. Aureus
2) H. Influenzae
3) Pseudomnas Aeruginosa
4) Moraxella Calarrhalis
5) Legionella
Major Atypical Pneumonia Pathogens (6)
1) Mycoplasma Pneumoniae
2) Chlamydia Pneumoniae
3) RSV
4) CMV
5) Influenza
6) Coxiella burnetti
Consolidation Exam Findings (4) + Differential for Bronchial Breath Sounds + Crackles/Rales + Wheezing (1)
Consolidation
1) Dullness on Percusion
2) Egophany (E-A)
3) Bronchial Breath Sounds
4) Decreased Tactile Fremitous
DDx - Bronchial
1) Obstructive + Pleural Effusion + Pneumonia
DDx - Crackles/Rales
1) Pneumonia + CHF + Pulmonary Fibrosis
DDx - Wheezing (Expiratory)
1) Asthma
Viral Pneumonia - Keys (3)
Causes - Influenza (Main) + CMV (Immunocompromised)
Type - Atypical
Sympomts - Dry Cough + Dyspna + Unremarkable Exam
Streptococcus Pneumoniae - Bacteria + Key Features (2)
Gram + Diplocci - Lancet Shaped + Alpha Hemolytic
Most Common Cause of Pneumonia Stages (4) 1) Congesiton 2 Red Hepatization 3) Gray Hepatazation 4) Resolution
Streptococcus Pneumoniae - Signs/Symptoms (6) + Risk Factors (4)
Signs/Symptoms
1) Acute
2) High Fever
3) Pleuritic Chest Pain
4) Shacking Rigor
5) Rusty Color Sputum
6) Lobar Examination Findings
Risk Factors
1) Asplenia
2) Post-Influenza
3) Arthritis (Septic Joints)
4) Smoking/EtOH
Hemophilius Influenzae - Bacteria + Key Facts (2) + Risk Factors (2)
Gram (-) Coccobaccilus
Key Facts
1) Community Acquired
2) Hard to differentiate vs. chronic bronchitis - look for changes in cough/fever
Risk Factors
1) COPD
2) Infants
Staph Aureus - Bacteria + Key Facts (2) + Risk Factors (3)
Gram (+) Cocci in Clusters
Key Facts
1) Purulent yellow sputum
2) High risk of necrosis, cavitation and abscess
Risk Factors
1) Rare Community
2) High Nosocomial
3) High Post Influenza
Nosocomial/Rare Bacterial Pneumonia (3) + Key Facts (2-3-3)
Klebsiella - Gram Negative Rod
1) Lobar Aspiration in Alcoholoic + Diabetes
2) Currant Jam Sputum
Legionella - Gram Negative Rod with Silver Stain
1) Water sources
2) Hyponatremia from renal disease
3) Atypical
Pseudomonas Aeurginosa - Aerobic Gram (-) Rod
1) Most common CF
2) Coagulative Necrosis with vessel invasion
3) Green Sputum
Rhinopharyngitis - Definition + Causes
Common Cold - Communicable with Nasal Stuffiness
Causes
1) Rhinovirus
2) Coronavirus
3) Parainfluenza Virus
Rhinopharyngitis - Pathophysiology + Signs/Symptoms (3)
Patho - Inoculation - Epithelial cells infected + spreads to respiratory mucous - Submucosal Edema = Increased Risk for Bacterial Suprainfection
Signs
1) Nasal Discharge
2) Sore Throat
3) Worse in Infants
Tonsillophyaryngitis - Definition + Causes (5)
Inflammation of the mucous membranes of the throat without nasal signs/symptoms
Causes
1) Group A Beta Hemolytic Strep (Strep. Pyrogens)
2) Adenovirus
3) Parainfluenza
4) EBV
5) Enterovirus (Summer)
Tonsillophyaryngitis - Signs/Symptoms (6)
1) Petechia in Throat
2) Inflamed Uvula/Tonsils
3) Fever
4) Sore Throat
5) Abdominal Pain (Worse in Kids)
6) Tender Anterior Cervical Nodes
7) Can Cause Acute Rheumatic Fever + Scarlet Fever
Laryngotracheobronchitis - Definition + Causes (5) + Key Features
Croup - Uniquely Pediatric - Respiratory illness characterized by hoarse voice, dry barking cough, and inspiratory stridor
Causes - Parainfluenza Type 1 - Influenza + RSV + Adenovirus + Rhinovirus
Laryngotracheobronchitis - Pathophysiology
Diffuse tracheal inflammation with erythema + edema - Leads to narrowing + ciliary inhibition - Impaired vocal cords + steeple sign (narrow trachea on CXR)
Sinusitis - Description + Causes (2)
Purulent infection of the mucosal linings of the paranasal sinuses - Usually secondary to upper respiratory infection
Ca sues - Haemophilus (Not Type B) + Pneumococcus
Sinusitis - Signs/Symptoms (5) + High Risk Complications (3)
Signs
1) Fever
2) Cough
3) Facial Pain/Pressure
4) Potts Puff Tumor - Periostium erodes
5) Purulent Nasal Discharge
Complications
1) Meningitis
2) Abscess
3) Orbital Damage (Children)
Atypical Pneumonia (3) - Bacteria + Key Facts
Mycoplasma Pneumoniae - Not seen on gram stain - cold agglutinate
1) Walking Pneumonia (terrible X-Ray but feel okay)
2) Elder Patients
3) Dry Hacking Cough
Legionella - Gram Negative Rod with Silver Stain
1) Water sources
2) Hyponatremia from renal disease
3) Atypical
Chlamydia Pneumonia
1) Atypical
2) Young Adults + Military Recruits
3) High Risk of Reactive Arthritis
Acidemia - 2 Causes
Alkalosis - 2 Causes
Acidemia
High PCO2 or Low Bicarb
Alkalosis
Low PCO2 or High Bicarb
Anion Gap - Calculation + Use
Anion Gap = Na - (Cl + Bicarb)
Normal = 7-16
Use in Metabolic Acidosis to Help Determine Type
Delta - Delta - Calculation + Use
Change in AG (AG - 10 ) vs. Change in Bicarb (24 - Bicarb) - Should be approx 0
Ratio > 0 = AG Change is Greater Suggest AG Metabolic Acidosis + Metabolic Alkalosis
Ratio < 0 = Bicarb Change is Greater than Suggested = AG Metabolic Acidosis + Non-AG Metabolic Acidosis
Respiratory Compensation Equations (4)
Acute Resp. Acidosis - Up 1 for 10 (Bicarb up 1 for 10 CO2 Rise)
Chronic Resp. Acidosis - Up 4 for 10 (Bicarb up 4 for 10 CO2 Rise)
Acute Resp. Alkalosis - Down 2 for 10 (Bicarb down 2 for 10 CO2 Drop)
Chronic Resp Alkalosis - Down 5 for 10 (Bicarb down 5 for 10 CO2 Drop)
Primary Causes of Respiratory Acidosis - Acute (4) + Chronic (2)
Acute - Reduced Ventilation
1) Sedatives
2) Airway Obstruction
3) Mechanical Ventilation
4) Muskuloskeletal
Chronic - Obstructive Disease
1) COPD
2) Asthma
Primary Causes of Respiratory Alkalosis - Acute (4)
Hyperventilation
1) High Altitude
2) Pneumonia- V/Q Mismatch leads to poor oxygenation - Response = Hyperventilation
3) PE - V/Q Mismatch leads to poor oxygenation - Response = Hyperventilation
4) Panic Attack
Metabolic Compensation Equations - Acidosis + Alkalosis
Acidosis - PCO2 = 1.5 * Bicarb + 8 +/- 2
Met. Acidosis = Hyperventilation to blow off all the CO2 and try to get back to normal
Alkalosis - PCO2 = 0.7 * Bicarb + 20 +/- 5
Met Alkalosis = Hypoventilatlion to save all the acidic CO2 and try to get back to normal
Causes of Metabolic Acidosis - With AG (3) + Without AG (2)
With AG = Lactic Acidosis + Ketoacidosis + Intoxication (EtOH or Aspirin)
Without AG = Diarrhea or Renal Tubular Acidosis
Hypoventilation/Hyperventilation - Acid Base Impacts
Hypo = Not blowing off enough CO2 = Saving Acid = Causes acidosis (and responds to metabolic alkalosis)
Hyper = Blowing off to much CO2 = Wasting acid = Causes alkalosis (and responds to metabolic acidosis)
Causes of Metabolic Alkalosis (2)
Vomiting
Thiazide/Loop Diuretics
Causes of Lactic Acidosis (3)
1) Exercise
2) CHF = Hypoperfusion
3) MI = Hypoperfusion
Major Types of Pulmonary Embolism (3) + Signs and Symptoms
1) Fat Emboli - Long Bone Fractures
Latency Period –> Followed by ARDS picture - Supportive therapy = key
2) Amniotic Fluid Emboli - Premature rupture of the amniotic sac causes lipoprotein based pulmonary artery occlusion
Allergic Reaction to the amniotic fluid with CV collapse
3) PE == Most likely lower lobe + Infarction with a peripheral wedge
Pathophysiology of PE - 5 Changes + Associated Symptoms
1) Hypoxemia - V/Q Mismatch to the blocked region - Increased A-a Gradient with cyanosis
2) Atelectasis - Decreased surfactant due to Type II Pneumocyte death
S/Sx = Dyspnea + Rales
3) Increased Pulm. Arterial Pressure - Flow Back-UP
S/Sx = Increases the P2 Heart Sound (Wide Splitting)
4) Increased Alveolar Ventilation (in an effort to try and fix the hypoxemia via hyperventilation) - Increased Physiological Dead Space (ventilation)
S/Sx - Mismatch causes overcompensation + tachypnea + Resp. Alkalosis
5) Embolism without Infarction - Tachycardia due to increased Strain
5B) Embolism with Infarction - Pleuritc Pain + Breathlessness + Pleural Friction Rub
Classic PE Presentation (4)
1) Dyspnea (Rapid Onset)
2) Pleuritc Chest Pain
3) Tachycardia
4) Hemoptysis
Steps in DVT Evaluation (3)
1) Clinical/Lab Evaluation
2) Apply Well’s Score
3) Diagnostic Radiology
Venous Duplex - Findings (2)
1) No DVT = Compressible
2) DVT = Non-compressible
Pulmonary Arterial HTN - Definition + Classic Presentation
Definition = Pulm Pressure > 25 mmHg Classic = Exertional Dyspnea + Right HF
Secondary Causes of Pulmonary HTN (4)
1) Left HF (#1 Cause)
2) Lung Disease/Hypoxemia (V/Q Mismatch)
3) Embolic Disease
4) Disease - Pneumonia Sarcoidosis
Primary Pulmonary HTN - Key Points (3)
1) Idiopathic (Must Rule Out Secondary)
2) BMPR2 Gene - Inactivated = Increased Pulmonary Smooth Muscle Hypertrophy
3) Most Common Equal Female 20-40 Years of Age
Lung Disease Causing Pulm. HTN (3) + Pathophysiology
1) Obstructive Sleep Apnea
2) COPD
3) Tissue DIseae
Destruction of the lung parenchyma increases pulmonary resistance and hypoxic vasoconstriction - pathological over use of normal physiological shunting
Risk Factors for Obstructive Sleep Apnea (7)
1) Male Gender
2) Age
3) Race
4) EtOH/Smoking
5) Neck Circumference
6) BMI > 30
7) Menopausal Women
Night Time OSA Symptoms (6)
1) Snoring
2) Excessive Sweating
3) Twisting/Turning
4) Heartburn
5) Enuresis (Kids)
6) Nocturia (Kids)
Daytime OSA Symptoms (6)
1) Excessive Somnolence
2) Decreased Libido
3) Morning Headaches (High CO2 On Waking)
4) Hyperactivity (Kids)
5) Depression
General Management of OSA (4)
1) Avoid EtOH
2) Sedatives
3) Weight Loss
4) Exercise
Advanced OSA Treatment (4)
1) Nasal CPAP = Low Compliance
2) Oral Appliance = Mild/Moderate Only
3) Surgery = Uvulopalatopharyngoplasty
4) Tracheostomy = Most Serious
Major Physiologic Impacts of OSA (3)
1) Increased Endothelian 1
2) Endothylial Dysfunction
3) Increased Symp. Activity
All Cause HTN
Major OSA Disease Links (5)
1) HTN
2) Pulm. HTN
3) CHF
4) Stroke
5) Arrhythmia
Major Pathophysiology Behind Dyspnea (6) - 1 Example Each
1) Structural/Mechanical - Airway obstruction
2) Flow Obstruction - Asthma
3) Restriction of Chest Wall Expansion - Intrinsic (Lung Parenchyma) = ARDS
4) Restriction of Chest Wall Expansion - Extrinsic (Blocked) - Obesity
5) Increased Dead Space Ventilation - PE
6) Increased Respiratory Drive - Hypoxmia/Acidosis
Dyspnea with Coughing
Think Obstructive
Dyspnea with Sputum Production
Pulm. Edema
Dyspnea with PND and Orthopnea
CHF
Dyspnea Causes - Extrinsic Restrictive (4)
1) Obesity
2) Ascites
3) Pregnancy
4) Kyphposcholiosis
Dyspnea Causes - Increased Respiratory Drive (4)
1) Hypoxemia
2) Acidosis
3) Exercise
4) Reduced CO/Hb
Pulmonary Causes of Dyspnea (3)
Airflow Obstruction (Restrictive or Obstructive)
2) Mismatch between neuro ventilatory output and achieved ventilation
3) Lung Over-Inflattion
Non Cardio-Pulm. Causes of Dyspnea (5)
1) DKA
2) Metabolic Anemia
3) Neuromuscular
4) Hypothyroid
5) Psych (Panic Attack)
Three Major Classes of Pleural Fluid + Findings on Analysis
Exudate = Thick/Protein + Cloudy
+ If Pleural Protein/Serum Protein > 0.5
+ If Pleural LDH/Serum LDH > 0.6
Low pH
2) Transudate = Clear
Ruled out Exudate
High pH
3) Chylotorax - Milky Triglycerides
TAG > 110
Exudate - Findings + Common Causes (5)
1) Exudate = Thick/Protein + Cloudy
+ If Pleural Protein/Serum Protein > 0.5
+ If Pleural LDH/Serum LDH > 0.6
Low pH
Causes - Microvascular Damage
1) Pulmonary Infarction (PE)
2) Infection (TB, Pneumonia)
3) Malignancy
4) Connective Tissue Disease (SLE/Rheumatoid)
5) Trauma
Transudate - Findings + Common Causes (4)
Transudate = Clear - Oncotic Disruption - High Hydrostatic or Low Oncotic Pressure
Ruled out Exudate
High pH
Causes
1) CHF (Left)
2) Pulmonary HTN
3) Nephritic Syndrome (Low Fluid Protein)
4) Hepatic Cirrohosis (Ascities + Low Albumin)
Chylothorax - Findings + Common Causes (3)
Chylotorax - Milky Triglycerides
TAG > 110
Causes
1) Thoracic Duct Trauma
2) Lymphoma
Special Cases for Pleural Effusion Diagnostics (4)
1) Frankly Purulent (Pus) Fluid = CLosed pus filled infection
2) Putrid Odor - Anaerobic Empyema
3) Low pH = More Severe
4) S/Sx after 300 ml (Normal = 10ml)
Pneumothorax Signs/Symptoms (6)
1) Unilteral Chest Pain
2) Dypsnea
3) Pleuritc Pain
4) Decreased Tactile Fremitous
5) Hyper-Resonance
6) Diminished Breath Sounds
Primary vs. Secondary vs. Tension Pneumonthorax
Primary = Spontaneous = Tall Thin Men + LAMB (Menstral) Secondary = Underlying Lung Pathology
Both = Same Side Trachea
Tension = Flap from Trauma = Opposite Side
Major Classes of Primary Lung Tumors (4) + Prevalence %
1) Small Cell (15%) vs. Non-Small Cell (80%)
Non Small Cell
1) Large Cell (10%)
2) Adenocarcinoma (50%)
3) Squamous Cell (30%)
Squamous Cell Carcinoma - Histology + Gross Examination
Histo - Keratin Pearls + Desomosmal Intracellular Bridges
Gross - Cavitation + Central
Small Cell Carcinoma - Histology + Gross Examination
Histo - Small undifferentiated blue cells (like lymphocytes) - Chromagramin (+)
Gross - Central + Hilar Lymp nodes without cavitation
Large Cell Carcinoma - Histology + Gross Examination
Histo - Poorly differentiad malignant cells with abundant cytoplasm (vs. none in small cell)
Gross - Peripheral + chance of cavitation
Adenocarcinoma - Histology + Gross Examination
Histo - Glands of mucin cells = key = no keratin pearls
Gross - Peripheral + Metastatic SPread - Pleural Involvement Likely
Bronchioalveolar Adenocarcinoma - Histology + Gross Examination
Histo - Well differentiated columnar cells (from clara cells)
Looks like Pneumonia but with cancer cells not neutrophils
Gross - Peripheral + Consolidation like a lobar pneumonia - Grows along the bronchioles
Carcinoid Tumor - Histology + Gross Examination
Histo - Cells in nests - Chromagramin (+)
Gross - Polyp like mass - Benign
Squamous Cell Carcinoma - Key Associations (5)
1) Hypercalcemia due to increased Parathyroid Hormone (Vit. D)
2) Cavitation
3) Pancost Tumor
4) Atelectiasis
5) Pneumonia
Pancost Tumor - Key Associations (6)
Apex of the Lung
1) Cervical Sympathetics (Horner’s)
2) Superior Vena Cava Syndrome
3) Brachial Plexus Inhibition
4) Hoarseness (Recurrent Laryngeal)
Adenocarcinoma - Key Associations (5)
1) Non-Smoking Women
2) Hypertrophic Oseoarthopathy (CLubbing)
3) Peripheral + Pleural Involvement
4) 3 Mutations - EGFR + ALK + KRAS
Large Cell Carcinoma - Key Associations (6)
1) Possible Cavitation
2) Early Metastasis
3) Associated with Gyncomastia (Man Boobs)
Bronchioalveolar Adenocarcinoma - Key Associations (
1) Subtype of Adenocarcinoma
2) Arises from Clara Cells
3) Multifocal can look like pneumonia
4) Around the bronchioles
5) Bronchorrea (cups of mucous)
Small Cell Carcinoma - Key Associations
1) Paraneoplastic - SIADH (Hyponatrermia) + Cushings + Eaton Lambert
2) CXR Show Hilar Mass
3) Poor Prognosis - No Surgery
Classic Features of Lung Cancer Presentation (5)
1) Weight Loss
2) Dyspnea
3) Cough
4) Hemoptysis (Streaks in Sputum)
5) Vocal Cord/Diaphragm Issues
Lung Cancer Diagnostic Tools + Uses
1) Fiberoptic Bronchoscopy - Only good for central cancer
2) Percutaneous Needle Biopsy - Good for peripheral but risk of pneumothorax
