Pulm Flashcards
What is the length for an acute vs chronic Bronchitis
Acute = less than 3 weeks
Chronic = longer than 3 months for 2 consecutive years
Characterization of GPA
Glomerulonephritis
Necrotizing granulomatis vasculitis
Small vessel vasculitis
GPA CXR and other physical exam findings
Nodular pulmonary infiltrates with cavitation
Tracheal stenosis ; strawberry tongue ; petechia/Purpura ; saddle nose deformity
Time frame for CAPNA
Less than 48 hours of hospital onset
4 bacteria responsible for CAPNA
Strep pneumo
Mycoplasma PNA
H. Influenza
Chlamydia
2 Vaccines good in elderly (over 65) for CAPNA
PCV 13
PPSV23
Physical exam findings and expected CBC for CPNA
PE: inspiratory crackles, bronchial breath sounds, egophony, whispering pectoriloquy, and dullness to
percussion
v Dx: CBC (leukocytosis + leftward shift)
Diagnostic tool for CPNA
CURB-65
1. Confusion (new onset)
- Urea ( > 20)
- Respirations ( > 30)
- BP (SBP < 90 and/or DBP < 60)
- 65 y/o
- Score: 1 = outpt, 2 = clinical decision, ≥ 3 = admit, 5 = ICU
Treatment for CPNA ; with no comorbidities ; no MRSA or Psuedomonas risk
Empiric
Amoxicillin or Doxy x5days or longer until 72 hours afebrile
CPNA for patients with comorbidities
-Resp Flouro x5days or longer until 72 hours afebrile
Augmentin OR cephalosporin plus a macrolide OR doxycyclin
3 common pathogens in HAPNA
Staph A. ; Psuedomonas ; gram neg rods
Fever ; Hemoptysis ; Wt. Loss ; Night Sweats ;; Think?
TB
Dx techniques if you suspect TB and TXM
Dx
1. PPD (cornerstone dx for latent TB)
2. Sputum for smear and culture
3. CXR: done w/ positive PPD or active clinical sxs
TXM = RIPE
Rifampin
Iosonizide
Pyrazinamine
Ethambutol
CXR findings in Coal Workers Dz
Diffuse 2-5mm opacities affecting the alveolar lung space ; UPPER LUNG FIELDS
Silicosis CXR ; and increased incidence of what?
Egg shell opacities in the hilar lymph nodes; rounded opacities
-TB ; if + get a skin test
Shipyard worker Asbestosis CXR
linear streaking at LOWER LUNG FIELDS
, opacities of various shapes/sizes, honeycombing
(advanced dz), and pleural calcifications
Best imaging for asbestosis ; shows what
CT ;
Parenchymal fibrosis
Pleural plaques
4 Characteristics of Asthma
Enhanced obstructive response of airway smooth muscle
Reversible flow limitation
Recurrent breathlessness and wheezing
FEV1:FVC less than 80
What is the significance of FEV1 ; FVC ; DLPCO ; FEV1:FVC ratio?
FEV1 = forced expiratory volume ; air exhaled in 1 second
FVC = amount of air exhaled after deep inhale ; total air exhaled
DLCO = diffusing capacity of air to the bloodstream ; ability to breathe oxygen to destination
FEV1:FVC = total amount of air that you can forcibly exhale!
Obstructive conditions mean it is harder to _____
Restrictive conditions mean its harder to ________
O= exhale
R= inhale
What FEV1/FVC ratio indicated COPD? What do you use to grade COPD severity
Less than 0.7
SEVERITY GRADING:
Mild = FEV1 greater 80%
Mod = FEV1 50-80%
Severe = FEV1 30-50%
VERY SEVERE = FEV1 less than 30% or less 50% w/ Chronic Respiratory F.
When is the use of SABA indicated in asthma
Relief of acute sxs
DOC for acute bronchospasms
Px for exercise induced
“albuterol”
When is the use of LABA indicated in asthma?
If you need to step up due to increased sxs/episodes and already on an ICS
“Salmeterol-Serevent”
“Formeterol-Foradil”
Inhaled CS TXM indicated for what in asthma?
1st line anti-inflammatory for mild mod persistent asthma
To be used with SABA
fluticasone/budosenide/beclamethasone
In asthma exacerbation what is good management
Oral : Prednisone
IV : Methylprednisolone
Preferred controller / reliever of intermittent asthma would be? And how freq are they getting sxs
Less than 2 days a week ; nighttime awakenings = less than 2X monthly
PRN ICS-Formeterol = controller
prn SABA = reliever
Preferred controller / reliever of mild asthma would be? And how freq are they getting sxs
Greater than 2 days a week ; less than once daily ; nighttime awakenings = 3-4x monthly
Daily / PRN ICS/ ICS-Formeterol or LTRA = Montelukast = controller
prn SABA = reliever
Preferred controller / reliever of persistent moderate asthma would be? And how freq are they getting sxs
Daily with nighttime awakenings = greater than 1 weekly
Low Dose ICS-LABA or Medium Dose ICS or ICS-LTRA = controller ; consider = Oral Prednisone
prn ICS-Formeterol = reliever
Preferred controller / reliever of severe asthma would be? And how freq are they getting sxs
Sxs occur nightly and several times daily
Medium Dose ICS -LABA or High Dose ICS or +Tiotropium or +LTRA = controller ; consider oral prednisone
prn-ICS-Formeterol = reliever
Low Dose / Medium Dose / High Dose -ICS for fluticasone dipropionate and beclamethasone
Low Dose = F =[ 100-250] ; B=[100-200]
Medium Dose =F=[250-500] ; B=[200-400]
High Dose = F=[over500] ; B =[over400]
What is defined as improvement on bronchodilator therapy
improvement defined as : ↑ in FEV1 of > 12% after 2-4 puffs of SABA
Hallmark sxs of chronic bronchitis vs emphysema
CB = productive cough = WET ; blue bloater
E = DOE = DRY ; pink puffer
What genetic deficiency is linked to COPD
Alpha 1 Antitrypsin
Gold standard diagnostics for COPD
PFTs / Spirometry
W/ post bronchodilator FEV1 = non-reversible
ECG findings consistent with COPD
RVH
RAD
RAE
right sided HF
How do you assess COPD severity and TXM
mMRC score and Risk Factors =Hospitalizations
mMRC score 0-1 with 1 hospitalization in the last year vs 2 hospitalizations TXM
mMRC score 0-1 = SOB increasing pace on the level or going up slight hill
1 = SAMA or SABA
2 = LAMA
LAMA = Tiotropium SAMA = Iprotropium Bromide SABA = albuterol
mMRC score 2 or greater with 1 hospitalization in the last year vs 2 hospitalizations TXM
mMRC score 2 or greater = walking slower than others of same age; stopping at own pace on the level —> Too breathe less to leave the house or get dressed
1 = LABA or LAMA
2 = LAMA ; LAMA + LABA ; LAMA + LABA + ICS
LAMA = Tiotropium SAMA = Iprotropium Bromide SABA = albuterol
Caution SABA medications in what?
DM
Hyperthyroidism
Severe CAD
SAMA: short-acting muscarinic antagonist
Ipratropium Bromide
LAMA: long-acting muscarinic antagonist
Tiotropium
Are what drug class?
Anti Cholinergic Bronchodilators
Only med therapy that decreases mortality in COPD
Oxygen - AT HOME
Cor pulmonale with O2 less 88%
4 health Mx recommendations in COPD pts
i. Control triggers
ii. Smoking cessation
iii. Vaccinations: pneumococcal and influenza
iv. Azithromycin has anti-inflammatory properties in lung; option for pts on dual
or triple therapy w/ frequent exacerbations
Management uncomplicated vs complicated COPD exacerbation
Uncomplicated = less4 ; no Comorbids = AZITHROMYCIN or AUGMENTIN
Complicated = greater4 = AUGMENTIN or LEVOFLOXACIN or MOXIFLOXACIN
+CC / O2 / SABA
Hallmark PE finding of Interstial Lung Disease
Crackles
Get a Lung bx
Mc = Idiopathic ; Sarcoidosis
What syndrome is assoc with sarcoidosis
“ Lofgrens “
Triad = Sarcoidosis triad: bilateral hilar lymphadenopathy,
erythema nodosum,
migratory polyarthralgia
(95% specificity for Sarcoidosis)
TXM sarcoidosis
Tx sxs: NSAIDs, low-dose glucocorticoids, colchicine, and hydroxychloroquine
MC primary lung cancer
Adenocarcinoma
SCC Lung CXR findings
Assoc. w/ hilar adenopathy and mediastinal widening on CXR
Large Cell carcinoma of the lungs ; example and findings
Pancoast tumors and syndrome
a. Lung tumor of superior sulcus at extreme apex of lung
Small cell lung cancer is commonly assoc with what
SIADH / paraneoplastic syndrome
Prone to hematgenous spread ; high assoc with SMOKING
Carcinoid tumors arise from where?
Bronchial mucosa or GI tract
Carcinoid tumors secrete what?
Vasoactive Material = serotonin ; histamine ; catecholamine ; prostaglandin ; peptides
4 sxs of carcinoid syndrome
Flush
Diarrhea
Wheeze
HYPOTENSION
4 associated complications of Pancoast Tumor
Shoulder or Neck pain OOP
Horner’s syndrome : anhydrosis Ipsilateral miosis ; ptosis
Weakness / Atrophy of hand
SVC syndrome = right side ; face neck swelling dyspnea chest pain
Squamous cell carcinoma is assoc with
Hypercalcemia
think paraneoplastic syndrome = extra manifestations of lung cancer
Examples of paraneoplastic syndromes ? 4
Cushings
Hypercalcemia
SIADH
SVC
Lab findings of SIADH
Hyponatremia with increased urine osmolality > 300
Describe Group 1 Pulm HTN
Due to : Vascular Remodeling / Connective Tissue DO / Drugs
Describe Group 2 Pulm HTN
Left sided heart F. Cause
Increased intra cardiac and venous pressures
Describe Group 3 Pulm HTN
Hypoxia due to lung disease; either obstructive/restrictive/ or developmental lung d/o
Describe Group 4 Pulm HTN
Obstructive due to emboli
-Sarcoidosis
-hematologic d/o
-NFT
Describe txm of Pulm HTN
Get a right heart catherization to confirm PAP greater 20 and rule out left sided intracrdiac pathology
TXM = vasodilators
Virchow Triad in VTE
Virchow’s Triad
- Vessel wall injury
a. Thrombosis, vessel inflammation, infxn, direct trauma or surgery - Venous stasis: immobility (bed rest, obesity, stroke), hyperviscosity (polycythemia), ↑ central
venous pressure (pregnancy, low CO states) - Hypercoagulability: inherited, deficiency or dysfxn of antithrombin III, protein C, protein S, or
prothrombin, antiphospholipid antibody syndrome, acquired (age, OCP, malignancy, surgery)
VTE Anticoag therapy :
- LMWH: enoxaparin
- Factor Xa inhibitor: Rivaroxaban, Apixaban, Edoxaban
MC DVT location to cause PE
Proximal vein thrombosis: involves popliteal, femoral, or iliac veins; MC to cause PE
TXM for all types of DVTs [nml; preg/cancer; renal dysfunction; contraindications/recurrent]
Tx
a. Factor Xa inhibitors
i. DOC for most DVT unless pregnant, cancer, renal dysfxn
b. LMWH: use w/ warfarin to provide tx until warfarin starts working, then take off LMWH
i. DOC for pregnant and cancer pts
c. Unfractionated heparin: first line in pts w/ renal dysfxn d. Warfarin: works well but effects take time to start, use w/ LMWH
e. IVC filter
i. If anticoag contraindications ii. Recurrent thromboembolism w/ anticoag
iii. Recurrent embolism w/ pulmonary HTN iv. Urgent surgery w/out time for anticoag
S/Sx: dyspnea, pain on inspiration, cough, hemoptysis, wheezing, tachypnea (only reliable
sign), tachycardia, crackles/S4, Homan’s sign, syncope
Think?
PE
4 labs to get in PE ; SOC
D-dimer
Troponin
ABG
BNP
SOC = CTPA / V/Q Scan = preg
Wells Score Less than 4
Wells Score Greater than 4
Less = d-dimer
Greater = CTPA
Nocturnal and Daytime sxs of OSA
Nocturnal sxs: snoring, apneas, choking, nocturia, disrupted sleep
Daytime sxs: nonrestorative sleep, morning HA, excessive daytime sleepiness, cognitive deficits,
significant other reports sleep issues
STOP BANG Screening criteria
Snore loudly
Tired
Observed apnea
Pressure (HTN)
BMI > 35
Age > 50
Neck circumference > 40 cm
Gender male
3+ = Get Sleep Study
Labs = CBC/TSH/FT4
3 causes of central sleep apnea
a. Cessation of effort or inadequate ventilator drive
b. Narcotics
c. Idiopathic
Describe spontaneous PTX / PE findings / Risk Factors
Sudden onset of unilateral chest pain and dyspnea, often begins at rest or sleep
May present as life-threatening respiratory failure if underlying COPD or asthma is
present
PE
i. Small: mild tachycardia ii. Large: ↓ breath sounds, ↓ tactile fremitus, hyperresonance unilaterally
RF: tall, thin men, smokers, family hx, Marfan’s syndrome, previous episode
TXM Small (< 3 cm of air btwn lung and chest wall)
PTX ; STABLE
Stable: tx conservatively w/ observation in ER; repeat CXR w/in 24 hrs
and discharge if no change
TXM Large (> 3 cm of air between lung and chest wall)
PTX ; STABLE /
Severe on ventilation
Stable or symptomatic: needle aspiration
Severe or on ventilation: place chest tube
TPTX Sxs / Needle D instructions for Tension PTX
S/Sx: severe tachycardia, hypotension, mediastinal or tracheal shift
If suspected, large bore needle inserted immediately (needle-D):
i. Btwn 2nd and 3rd ICS at mid clavicular line
ii. Btwn 4th and 5th ICS mid axillary or anterior axillary line
iii. Tube thoracostomy for definitive care
Large effusion PE findings
large effusions = dullness to percussion, diminished/absent
breath sounds over effusion
SOC for Pleural Effusions
CT Chest
Lab findings EXUDATIVE vs TRANSUDATIVE
i. Exudative: protein > 0.5, LDH > 0.6, LDH > ⅔ upper limit of normal
ii. Transudative: if none of exudative values are met
TXM for TRANSUDATIVE / Malignant Effusion / Hemothorax
i. Can remove up to 1.5 L to alleviate sxs
ii. Transudative: tx underlying condition
iii. Malignant effusion: chemo/radiation, therapeutic thoracentesis if sx
iv. Hemothorax: large bore tube thoracostomy
Hemoglobin (oxygen affinity) is altered by what? (3)
a. pH (↑ = ↑ affinity for O2)
b. PCO2 (↓ = ↑ affinity for O2)
c. Temperature (↓ = ↑ affinity for O2)
Definition of respiratory f. By lab values
PaO2 < 60 (SaO2 of under 90%) and/or PaCO2 > 45
Decrease in what 2 electrolytes leads to hypoventilation
K
Phosphate
Complications of acute respiratory f. (3)
Complications: stress gastric/ulcer, DVT, PE
4 causes of ARDS (4)
Common causes: sepsis, diffuse pna, aspiration of gastric contents, trauma
ARDS will often lab values consistent with?
PaO2/FiO2 < 300 mmHg
The ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) is an indicator of pulmonary shunt fraction
What is PEEP? When is it used?
Positive end-expiratory pressure (PEEP) keeps the airways and small lung spaces open to allow for adequate oxygenation when a person cannot breathe on their own. If the lungs cannot oxygenate properly, the individual may need to be intubated and placed on mechanical ventilation to allow the lungs time to heal.
SaO2 goal on PEEP ventilation ; what position in ARDS
Over 88%
-Prone
Describe septic shock
Type of distributive shock: peripheral vasodilation seen d/t warm extremities and compensatory ↑
in cardiac output
S/Sx: fever, hypotension, tachycardia
SIRS Criteria
SIRS criteria (temp, pulse, RR, and WBC)
a. Fever > 38.3C or < 36C
b. Pulse > 90 bpm
c. RR > 20 d. Leukocytosis (WBC > 12,000) or leukopenia (WBC < 4,000)
TXM Sepsis
a. Assess ABCs and replenish circulating volume → 1-2 L bolus of NS or LR
b. No response to volume expansion = give vasopressor (Norepinephrine)
c. Give abx ASAP (w/in 1 hr of recognizing sepsis)
Describe Anaphylaxis Hypersensitivity
Arises from activation of mast cells and basophils by cross linking of IgE and aggregation of
high-affinity receptors for IgE
Ultimate shift of sxs in anaphylaxis
respiratory distress, ↓ LOC, circulatory collapse
TXM anaphylaxis
a. Airway, breathing, and circulation management
b. IV fluids, O2, cardiac rhythm monitoring
c. Epinephrine IM d. If pt is taking B-blockers, give glucagon (reversal agent)
e. If IM epi fails → start Epi IV f. 2nd line: corticosteroids, antihistamines, vasopressors, glucagon, B2 bronchodilator
