Pulm Flashcards

Question

Bronchiectasis sx, dx, tx

Answer 1

Classic S/SXS: chronic productive cough w/ mucopurulent & tenacious sputum + HX of exacerbations ▪︎cough most days of the week for months to years ▪︎cough (98%), daily sputum production, dyspnea ▪︎rhinosinusitis, hemoptysis, recurrent pleurisy MC Exam Findings: crackles (MC, 75%), wheezing, digital clubbing (2%) dx: LABS: CBC, IgG, IgM, IgA, sweat chloride test for CF, sputum smear/culture for bacteria, mycobacteria, & fungi PFTs: obstructive impairment MC ▪︎normal/⇣ FVC, ⇣ FEV1, ⇣ FEV1/FVC CXR (nondiagnostic): linear atelectasis, dilated & thickened airways (tram or parallel lines, ring shadows on cross section), irregular peripheral opacities that may represent mucopurulent plugs Multidetector CT (MDCT) or HRCT: ▪︎lack of tapering of bronchi (tram track appearance) ▪︎signet-ring sign: dilated, air-filled bronchus & pulmonary artery ⇢ airway-to-arterial ratio ≥1.5 ▪︎airway visibility within 1cm of a costal pleural surface or touching the mediastinal pleura tx: ▪︎smoking cessation ▪︎regular chest physiotherapy to clear secretions ▪︎nebulized hypertonic saline Exacerbation prevention ⇢ ABX ▪︎indications: ≥3 exacerbations/year ▪︎duration: at least 3mo ⊖Pseudomonas ⇢ macrolide (azithromycin) *sputum stains/culture to r/o non-TB mycobacteria first ⊕Pseudomonas ⇢ inhaled ABX (tobramycin)

Answer 2

Community-Acquired Pneumonia (CAP) *outside hospital or within 48h of admission sx: CAP: acute onset fever, cough (+/- sputum), dyspnea dx: LABS: CBC, CMP, CPR, procalcitonin *leukocytosis w/ left shift *procalcitonin <0.25ng/dL suggests viral ≥0.25ng/dL suggests bacteria CXR: AP + lateral views *lobar consolidations *interstitial infiltrates *cavitations VIRAL: bilateral, multifocal, patchy or ground-glass opacities *dense consolidations, pleural effusion & abscess should be absent BACTERIAL: dense lobar or alveolar consolidations tx: CAP, outpatient: *Amoxicillin + macrolide (preferred) – Doxycycline is macrolide alternative ⊕heart, lung, liver, or kidney disease, diabetes, alcoholism, malignancy, asplenia, immunosuppression, or use of abx in last 3mo: *Augmentin + macrolide (preferred) – Doxycycline is macrolide alternative *FQ monotherapy (alternative) CAP, inpatient, non-ICU: *antipneumococcal beta lactam + macrolide *FQ monotherapy CAP, inpatient, ICU: *antipneumococcal beta lactam + Azithromycin *preferred *antipneumococcal beta lactam + FQ

Answer 3

– Hospital-Acquired Pneumonia (HAP) *acquired >48h after admission – Ventilator-Associated Pneumonia (VAP) *acquired >48h after endotracheal intubation

Answer 4

PCP: interstitial pneumonia caused by the yeast-like fungal organism Pneumocystis jirovecii Transmission: airborne *AIDS-DEFINING ILLNESS ⇢ CD4 <200/µL sx: S/SXS: gradual onset fever, dry cough, & dyspnea progressing over days to weeks ▪︎fatigue, chills, CP, weight loss ▪︎5-10% of patients are asymptomatic PE: tachypnea, crackles & rhonchi, ⇣ SpO2 (e.g., <90%) LABS: CD4 <200/µL, ⇡ LDH, ⇡ 1-3-beta-D-glucan dx: CXR: diffuse, bilateral perihilar infiltrates HRCT: bilateral patchy or nodular ground glass opacities DX ⇢ microbiologic identification via staining &/or PCR of a respiratory specimen ▪︎PCR preferred tx: TX: TMP-SMX x21d

Answer 5

PTX: a collection of air within the pleural space between the lung (visceral pleura) & the chest wall (parietal pleura) that can lead to parietal or complete pulmonary collapse PATHO: ⇡ intrapleural pressure ⇢ alveolar collapse ⇢ decreased V/Q ratio & ⇡ right-to-left shunting

Answer 6

Primary Spontaneous PTX (PSP): occurs in patients w/o clinically apparent underlying lung disease ▪︎caused by ruptured subpleural apical blebs RF: smoking (90%) ⇢ up to 20-fold ⇡ in risk (risk ⇡ w/ ▪︎MC affects tall, thin males, ♂︎ > ♀︎ ~6:1 cumulative # of cigarettes smoked) ▪︎peak incidence 16-25yo ▪︎family hx, male, young, homocystinuria, tall/slim Secondary Spontaneous PTX (SSP): occurs as a complication of underlying lung disease ▪︎♂︎ > ♀︎ ~3:1, peak incidence 60-65yo ▪︎Marfan syndrome, malignancy ▪︎COPD (smoking): rupture of bullae in emphysema ▪︎infections: TB, PCP (alveolitis, rupture of a cavity) ▪︎Catamenial PTX ⇢ thoracic endometriosis (rare) ▪︎CF: bronchiectasis w/ obstructive emphysema & bleb

Answer 7

Traumatic PTX: a type of PTX caused by trauma (e.g., penetrating injury, iatrogenic trauma) ▪︎blunt trauma (e.g., MVC in which thorax hits steering wheel or rib fracture occurs) ▪︎penetrating injury (e.g., gunshot or stab wound) ▪︎Iatrogenic PTX ⇢ mechanical ventilation w/ high PEEP (barotrauma), thoracentesis, CVC placement, bronchoscopy, lung biopsy (usually closed PTX) PATHO: ▪︎Closed: air enters through a hole in the lung (e.g., d/t blunt trauma) ▪︎Open: air enters through a lesion in the chest wall (e.g., d/t penetrating trauma) Tension PTX (TPTX): a life-threatening variant of PTX characterized by progressively ⇡ pressure within the chest & cardiorespiratory compromise PATHO: ➀ disrupted visceral pleura, parietal pleura, or tracheobronchial tree ➁ 1-way valve mechanism ⇢ air enters the pleural space on inspiration but cannot exit ➂ progressive accumulation of air in pleural space & ⇡ ⊕pressure within the chest ➃ collapse of ipsilateral lung, compression of contralateral lung, trachea, heart, & SVC; angulation of IVC ➄ impaired respiratory function, ⇣ venous return to the heart ⇢ reduced CO ⇢ hypoxia & hemodynamic instability

Answer 8

S/SXS: sudden, severe &/or stabbing ipsilateral pleuritic CP & dyspnea PE: ⇣/absent breath sounds, hyperresonance to percussion, ⇣ fremitus on the ipsilateral side ⊕subcutaneous emphysema: infiltration of air under the dermal layers of the skin ▪︎distention/bloating of chest, neck, face ▪︎palpation ⇢ crackling sensation (crepitus)

Answer 9

Tension PTX: ▪︎severe acute respiratory distress: cyanosis, restlessness, diaphoresis ▪︎reduced chest expansion on the ipsilateral side, distended neck veins ▪︎hemodynamic instability (e.g., tachycardia, hypotension, pulsus paradoxus) ABG indications: tachypnea, accessory muscle use, SpO2 <92%, hx of hypercapnia ▪︎possible findings ⇢ hypoxemia & respiratory alkalosis

Answer 10

DX: CXR ▪︎ipsilateral pleural line + absence of bronchovascular markings past the pleural line ▪︎⊕deep sulcus sign: abnormally deepened costophrenic angle on ipsilateral side **SUPINE film Size assessment cut-off ⇢ cm between pleural line & chest wall at level of the apex ▪︎PSP: 3cm ▪︎SSP: 2cm Tension PTX: clinical DX based on S/SXS of tachycardia, hypotension, & severe dyspnea ▪︎supportive CXR findings: *tracheal shift to contralateral side

Answer 11

TX: assess stability ⇢ requires ALL of the following to be considered stable: ➀ RR <24 breath/min ➁ SpO2 >90% on RA ➂ HR 60-120bpm ➃ normal BP ➄ able to speak in whole sentences Primary Spontaneous PTX (PSP): ▪︎stable, small (≤3cm) PSP ⇢ usually resolves spontaneously within ~10d ▪︎observation +/- supplemental O2 (6L/min x6h to target SpO2 >96%) ▪︎repeat CXR after 3-6h » stable or improving ⇢ DC home w/ outpatient f/u CXR in 24h » enlarging ⇢ chest tube ▪︎stable, large (>3cm) PSP ⇢ chest tube preferred over needle/catheter aspiration Secondary Spontaneous PTX (SSP): ▪︎stable, small (<2cm) SSP ⇢ admit + chest tube (⇡ risk of developing TPTX d/t underlying lung disease) ▪︎if asymptomatic, observation &/or needle aspiration can be considered ▪︎stable, large (≥2cm) SSP ⇢ admit + chest tube Traumatic/tension PTX, bilateral PTX, or unstable: ▪︎emergency chest tube thoracostomy ⇢ admit ▪︎if chest tube is delayed, perform needle decompression Chest tube placement: superior rib margin, anterior to midaxillary line in 5th ICS (nipple line) Needle/catheter aspiration: superior rib margin in 2nd ICS, midclavicular line Definitive TX: surgical pleurodesis ⇢ VATS (preferred), medical thoracoscopy ▪︎indications: prolonged air leak >5d, recurrent PTX, bilateral PTX, high-risk of recurrence

Answer 12

PE: luminal obstruction of ≥1 pulmonary arteries, typically d/t blood thrombi from DVT MCC ⇢ DVT Non-thrombotic: fat, air, bacterial PATHO: thrombus formation ⇢ DVT (MC iliac vein) ⇢ embolize to pulmonary arteries via IVC ⇢ partial/complete obstruction Saddle Thrombus: blood clot that lodges at the bifurcation of the pulmonary trunk as it splits into the R/L pulmonary arteries ▪︎can obstruct flow through the pulmonary arteries & lead to R heart strain, hemodynamic instability, &/or death S/SXS: acute onset dyspnea (MC), pleuritic CP, cough +/- features of DVT (e.g., unilateral leg swelling) ▪︎hemoptysis is unusual presenting symptom (13%) PE: tachypnea, rales, tachycardia, ⇣ breath sounds MASSIVE: arrythmias (e.g., AFIB), presyncope, ▪︎accentuated pulmonic component of S2 syncope, hemodynamic collapse (<10%)

Answer 13

+3: sx of DVT +3: PE dx likely +1.5: tachycardia +1.5: surgery/immobilization +1.5: hx of DVT/PE +1: hemoptysis +1: malignancy

Answer 14

CBC/CMP: +/- leukocytosis, ⇡ ESR, ⇡ serum lactate, ⇡ LDH, ⇡ AST ABG: +/- hypoxemia, ⇡ A-a O2 gradient, respiratory alkalosis, hypocapnia EKG ⇢ nonspecific: tachycardia, nonspecific ST/T changes CXR ⇢ nonspecific abnormalities common: atelectasis, effusion The following signs are rare, but should raise suspicion for PE: ▪︎Hampton’s hump: shallow, hump-shaped opacity in the periphery of the lung w/ its base against the pleural surface ▪︎Westermark’s sign: sharp cutoff of pulmonary vessels w/ distal hypoperfusion ▪︎Palla’s sign: enlarged descending pulmonary artery w/ a “sausage” appearance PE suspected ⇢ calculate PTP using Wells score ➀ Wells <2: low PTP ⇢ PERC to determine if D-dimer indicated ▪︎all 8 criteria fulfilled = no further testing indicated ▪︎all 8 criteria not fulfilled ⇢ D-dimer ➁ Wells 2-6: intermediate PTP ⇢ D-dimer ➂ Wells >6: high PTP ⇢ CT pulmonary angiography (CTPA) ▪︎D-dimer not needed D-dimer ⇢ <500ng/mL = ⊖/normal ≥500ng/mL = ⊕ ⇢ get CTPA ▪︎for patients >50yo, age-adjusted cutoff value (ng/mL) = age x 10 » ex. 65yo patient ⇢ <650ng/mL as cutoff value for ⊖D-dimer CTPA w/ contrast: intraluminal filling defects of pulmonary arteries V/Q scanning ⇢ alternative if CTPA contraindicated

Answer 15

▪︎supplemental O2 to target SpO2 ≥90% ▪︎IV fluids for hypotensive patients Initial Anticoagulation (first 5-10d): ▪︎SQ LMWH or fondaparinux Long-term AC (minimum of 3mo): DOACs ▪︎thrombin inhibitor: dabigatran ▪︎factor Xa inhibitors: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban Indications for AC >3mo: ▪︎unprovoked PE w/ low/moderate bleeding risk ▪︎provoked PE secondary to chronic RF ▪︎active cancer w/ any bleeding risk Contraindications to AC: significant active bleed, recent high-risk bleed (e.g., ICH), recent major surgery, severe thrombocytopenia IVC filter: AC is contraindicated or risk of bleeding is unacceptably high Hemodynamically unstable ⇢ reperfusion ▪︎tPA (e.g., alteplase, reteplase, tenecteplase) ▪︎DC anticoagulation before tPA, resume after Alternatives: catheter-directed thrombolysis, embolectomy Absolute contraindications to thrombolysis: ▪︎active bleeding ▪︎prior ICH ▪︎ischemic stroke ≤3mo ago ▪︎structural intracranial disease (AVM, neoplasm) ▪︎bleeding diathesis

Answer 16

▪︎fluid between pleural layers impairs lung expansion ▪︎normal pleural fluid volume 10-20mL Transudative: ⇡ hydrostatic pressure + ⇣ plasma oncotic pressure ▪︎CHF (MCC): 81% bilateral ▪︎cirrhosis w/ ascites (hepatic hydrothorax): 70% right sided ▪︎nephrotic syndrome: usually bilateral, subpulmonic ▪︎hypoalbuminemia: uncommon, >90% bilateral ▪︎atelectasis: ⇡ intrapleural ⊖pressure Exudative: ⇡ capillary permeability ▪︎pneumonia ▪︎pulmonary embolism: ⊕effusion in 30%, exudative ~80% ▪︎cancer: lung, breast, or lymphoma MC ▪︎autoimmune (e.g., SLE, RA, sarcoidosis, vasculitis)

Answer 17

sx: S/SXS: dyspnea, pleuritic CP (retrosternal), dry cough ⇣ tactile fremitus, ⇣ breath sounds dx: CXR: blunting of costophrenic angle ⇢ meniscus sign ▪︎lateral XR, posterior CP∠ (A): » ~75mL fluid needed to blunt CP∠ ▪︎frontal XR, lateral CP∠ (B): » ~200mL fluid needed to blunt CP∠ definitive DX ⇢ thoracentesis Light’s criteria: 1+ of the 3 ⇢ exudative ➀ pleural fluid LDH >2/3 ULN serum LDH ➁ pleural fluid protein/serum protein >0.5 ➂ pleural fluid LDH/serum LDH >0.6 tx: therapeutic thoracentesis ▪︎treat underlying cause

Answer 18

Mycobacterium Tuberculosis (mTB) *bacilli (rod-shaped), strict aerobes, acid fast (won’t gram stain) Tuberculosis Disease: newer term for active TB *contagious Tuberculosis Infection: newer term for latent TB (LTBI) *not contagious

Answer 19

Primary TB: usually asymptomatic w/ no radiographic signs Progressive Primary TB: high fever d/t TB pneumonia, pleurisy w/ effusion, lymphadenitis LTBI: asymptomatic, PPD⊕ *not transmissible *Lifetime risk of reactivation is 10% w/ 5% within first 2yrs Active Pulmonary/Reactivation TB: cough ≥2wks (starts dry, becomes productive), hemoptysis, night sweats, fever, weight loss, LAD, pleuritic chest pain

Answer 20

CXR: *findings variable & nonspecific *Primary TB: hilar &/or mediastinal LAD, pleural effusion, segmental or lobar consolidation *LTBI: +/- Ghon/Ranke Complex (peripheral calcified nodule & hilar LAD) *Reactivation TB: fibrocavitary apical disease *AIDS, CD4+ <200: diffuse, miliary, hilar/mediastinal LAD Sputum: x3 samples, ≥8h apart, at least 1 early-morning specimen *AFB smear, mycobacterial culture, NAAT – ⊕NAAT w/ or w/o ⊕AFB smear is sufficient for DX in at-risk pts Definitive: ⊕sputum culture Extrapulmonary TB: *Vertebral TB (Pott): osteolytic lesions on plain film *TB Lymphadenitis (Scrofula): single swollen non-tender cervical LN *meningitis, ocular, renal, pericarditis, salpingitis, peritonitis, intestinal tx: First: RIPE x2mo *Rifampin (RIF) *Isoniazid (INH) *Pyrazinamide (PZA) *Ethambutol (EMB) Then: continuation x4mo *Rifampin + Isoniazid

Answer 21

Rifampin SE: Thrombocytopenia, flu-like sxs, orange-colored secretions (tears, urine), GI upset, hypersensitivity, fever, hepatitis Isoniazid SE: Hepatitis (esp. >35yrs), peripheral neuropathy, drug-induced lupus, rash, abdominal pain, high anion gap acidosis, cytochrome P450 inhibition Pyrazinamide Hepatitis & hyperuricemia, GI sxs, arthritis, photosensitive dermatologic rash Ethambutol Optic neuritis 🡪 scotoma, color perception problems (red-green), visual changes, peripheral neuropathy, GI sxs, rash

Answer 22

*COPD is characterized by persistent respiratory symptoms & airflow limitation ▪︎caused by a mixture of small airway obstruction & parenchymal destruction *Formerly subdivided into chronic bronchitis & emphysema ▪︎Chronic Bronchitis: productive cough for ≥3mo/y for 2+ consecutive years ▪︎Emphysema: enlargement of airspaces distal to the terminal bronchioles accompanied by destruction of the airspace walls » Centrilobular (MC): respiratory bronchiole destruction *classically seen in smokers, usually affects the upper lobes Etiology: ▪︎SMOKING MCC* ▪︎air pollution, occupational hazard exposures ▪︎⍺1-antitrypsin deficiency, impaired lung maturation ▪︎early childhood infections, bronchiectasis Comorbidities: heart disease, OSA, metabolic syndrome, depression, osteoporosis PATHO: begins with chronic airway inflammation that progresses to emphysema, a condition characterized by irreversible bronchial narrowing & alveolar hyperinflation ⇢ loss of diffusion area leads to V/Q mismatch w/ resultant hypoxemia & hypercapnia

Answer 23

pink puffer: emphysema non cyanotic and thin dyspnea accessory msucle use, tachypnea prolonged expiration hyper resonance, decreased breath sounds cachectic barrel chest pursed lip breathing tripod position Blue bloater: chronic bronchitis cyanotic and obese rales peripheral edema JVD severe mismatch: hypoxemia and hypercapnia productive cough

Answer 24

Gold standard/confirmatory: spirometry ⇢ demonstrates airflow limitation that is irreversible/only partially reversible w/ SABA ▪︎postbronchodilator FEV1/FVC <0.7, FEV1 ⇣ ▪︎ΔFEV1 postbronchodilator <12% = irreversible bronchoconstriction % of predicted FEV1 determines severity of airflow limitation Additional spirometer findings not required for diagnosis: ▪︎⇡ lung volumes (TLC, FRC, RV) ▪︎⇣ DLCO: establishes presence of emphysema (normal in chronic bronchitis) CXR: findings only present & diagnostic in severe emphysema ⊕hyperinflation (e.g., enlarged lungs, flattened diaphragm, ⇡ AP diameter) ⊕loss of parenchyma (e.g., ⇣ lung markings, large bullae)

Answer 25

Group A: fewer symptoms, low risk ▪︎short-acting or long-acting bronchodilator (i.e., SABA, SAMA) Group B: more symptoms, low risk ▪︎long-acting bronchodilator (i.e., LABA or LAMA plus SAMA) Group E = C + D Group C: fewer symptoms, high risk ▪︎LAMA Group D: more symptoms, high risk ▪︎LAMA monotherapy OR combination therapy ▪︎LABA + LAMA if highly symptomatic (e.g., CAT >20) ▪︎ICS + LABA if eosinophils ≥300cell/µL *ICS should only be used in combo w/ LABA/LAMA Long-term oxygen therapy (LTOT)

Answer 26

S/SXS: acute Δ in 1/3 cardinal symptoms ▪︎worsening of dyspnea ▪︎increased severity/frequency of cough ▪︎increased volume/purulence of sputum PE: wheezing, tachypnea, use of accessory muscles, tachycardia Short-acting bronchodilators ⇢ SABA +/- SAMA ▪︎mild: standard dose ▪︎moderate/severe: high-dose Systemic steroids (PO/IV) x5d ▪︎prednisone 30-60mg QD ▪︎methylprednisolone 60-125mg 2-4x/d