Pulm Flashcards
FEV1 definition
Forced expiratory volume in 1 second (volume of air forcibly expired from maximum inspiration in the first second)
FVC definition
Forced vital capacity (total air that can be forcefully expired after max inspiration)
Acute bronchitis definition, MCC, sx, dx, tx
▪︎lower respiratory tract infection (LRTI) characterized
by inflammation of the bronchi
MCC ⇢ viral (>90%)
Cardinal symptom: cough (+/- sputum), persists 1-3wks
+/- wheezing or mild dyspnea
▪︎prolonged cough ⇢ chest wall/substernal MSK pain
URI (e.g., common cold) symptoms before/during:
▪︎HA, congestion, sore throat, malaise
PE: +/- wheezing, rhonchi
DX: clinical ⇢ acute onset but persistent cough w/o clinical findings suggestive of pneumonia (e.g., fever, tachypnea, rales)
CXR ⇢ used only to r/o pneumonia
▪︎often normal/nonspecific (e.g., peribronchial thickening)
tx: Self-limiting ⇢ supportive tx
Bronchiectasis definition, sx, dx, tx
Bronchiectasis: irreversible & abnormal dilation of bronchial tree that produces chronic respiratory symptoms
Acute Exacerbation: a deterioration in symptoms that require a change in regular treatment (e.g., adding antibiotics, ⇡ airway clearance techniques)
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
Asthma definition
Asthma: chronic inflammatory disease characterized by bronchial hyperresponsiveness, episodic exacerbations, & reversible airflow obstruction
Allergic vs nonallergic asthma and patho
Allergic Asthma (MC): begins w/ intermittent symptoms
in childhood & usually associated w/ atopy
▪︎IgE-mediated type 1 hypersensitivity to an allergen
▪︎mast cell degranulation & histamine release
Risk Factors: ATOPY**
▪︎family hx, tobacco smoke
▪︎obesity, pollution, male
Nonallergic Asthma (uncommon): onset >40yo, not related to atopy, poor response to standard treatment
Patho
➀ airway hyperreactivity
➁ inflammation
➂ bronchoconstriction
Atopic Triad
Asthma
Allergic Rhinitis
Eczema
Samter’s Triad
Nasal polyps
Aspirin
Asthma
Asthma sx
4 classic sx
wheezing
cough
SOB
chest tightness
PE: widespread, high-pitched, musical wheezes
▪︎MC w/ expiration, characteristic of asthma
▪︎usually absent between exacerbations
Other possible findings:
▪︎prolonged expiratory phase
▪︎hyperinflation, hyperresonance to percussion
Severe (exacerbation/status asthmaticus):
▪︎tachypnea >30, tachycardia >120bpm
▪︎accessory muscle use, tripod, diaphoresis
▪︎poor air movement ⇢ “silent chest”
▪︎pulsus paradoxus (SBP ⇣ >12mmHg w/ inspiration)
Asthma dx
DX: asthma S/SXS + reversible airflow obstruction
Pulmonary function tests (PFTs):
➀ Spirometry ⇢ obstructive pattern
⇣ FEV1/FVC ratio, ⇣ FEV1, FVC ~normal
>70% = mild
50-70 = moderate
35-50 = severe
➁ Bronchodilator response ⇢ reversible obstruction
⊕reversibility = ⇡ FEV1 ≥12% after SABA
➂ Bronchoprovocation ⇢ airway hyperresponsiveness
▪︎provocative stimulus (e.g., inhaled methacholine,
inhaled mannitol, exercise)
⊕hyperresponsiveness = ≥20% ⇣ FEV1 after stimulus
Nitric Oxide: fraction exhaled NO ⇢ FENO
⊕ = ⇡ FENO (≥40-50ppb) *normal level does not exclude asthma
DX: asthma exacerbation ⇢ ABG
▪︎initial: respiratory alkalosis, +/- hypoxemia
▪︎late/severe: respiratory acidosis, PaO2 <60mmHg, PaCO2 >40-45mmHg
Asthma tx
All patients get SABA/SAMA rescue inhaler
mild: ICS LABA prn
moderate: low dose ICS LABA maintenance
severe: moderate/high dose ICS LABA maintenance
Intermittent vs persistent asthma
intermittent
sx: 2 days/wk
nighttime awakenings: 2 times a month
persistent
mild: greater than 2 sx per/wk, nighttime awakenings 3-4 times per month
Moderate: sx daily, nighttime awakenings greater than 1 time per week but not nightly
severe: sx throughout the day, nighttime awakenings 7 times a week
SABA meds and MOA
Albuterol
Levalbuterol
MOA: binding at beta-2 receptors causes relaxation of bronchiole smooth muscle/bronchodilation
Indications: ALL PATIENTS W/ ASTHMA, used PRN for acute symptoms (quickly reverses bronchospasm)
SAMA meds and MOA
Ipratropium
MOA: block constricting action of acetylcholine at M3 receptors in bronchial smooth muscle resulting in bronchodilation; also ⇣ mucus secretion
Indications: may be used in combination w/ SABAs during exacerbations
Inhaled Corticosteroids (ICS) meds and MOA
Fluticasone
Budesonide DPI
Mometasone
Ciclesonide
MOA: block late-phase reaction to allergen, reduce airway hyperresponsiveness, potent & effective anti-inflammatory medications; ⇣ symptoms, ⇡ lung function, improve QOL, & reduce risk of exacerbations
Indications: FIRST LINE for long-term maintenance therapy, initiated in step 2
PO lukast meds and MOA
Montelukast
Zafirlukast
Zileuton
MOA: inhibit leukotriene mediators of airway inflammation; help ⇣ airway edema, constriction, & inflammation
COPD (emphysema vs bronchitis) definition, MCC, patho
*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
Emphysema vs Chronic Bronchitis sx
Cardinal SXS: dyspnea, chronic cough, sputum production
Emphysema: permanent enlargement and destruction of airspaces distal to the terminal bronchioles
pink puffer
dyspnea
accessory muscle use, tachypnea
hyper resonance, decrease breath sounds
cachectic
barrel chest
pursed lip breathing
tripod positioning
Chronic bronchitis: productive cough greater than 3 months for 2 consecutive years (blue bloater)
rales
peripheral edema
JVD
hepatomegaly
hypoxemia
hypercapnia
COPD dx
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
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)
ABG: hypoxemia (⇣ PaO2) & hypercapnia (⇡ PaCO2), +/- respiratory acidosis
▪︎PaO2 ≤55mmHg is an indication for continuous supplemental O2
CBC: polycythemia (⇡ H/H, ⇡ RBC)
➀ Spirometry confirmed diagnosis (postbronchodilator FEV1/FEV <0.7)
➁ Assessment of airflow limitation (% of predicted FEV1 ⇢ GOLD)
➂ Symptoms/exacerbation history (mMRC dyspnea scale, CAT score)
COPD tx
Group A: fewer symptoms, low risk
▪︎short-acting or long-acting bronchodilator (i.e., SABA,
SAMA, LABA, or LAMA)
typically SABA/SAMA
Group B: more symptoms, low risk
▪︎long-acting bronchodilator (i.e., LABA or LAMA)
Give LABA/LAMA
Group C: fewer symptoms, high risk
▪︎LABA/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
Acute Exacerbation of COPD sx, dx, tx
▪︎acute worsening of respiratory symptoms necessitating additional therapy
RF: advanced age, productive cough, longer duration of COPD, history of ABX therapy, COPD hospitalization within past year, chronic mucous hypersecretion, eosinophil count >340cells/µL, ⊕comorbidities (e.g., IHD, HF, DM)
Triggers: viral respiratory infections (e.g., rhinovirus) MC (~70%), environmental pollution, PE
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
Initial Evaluation:
▪︎vitals, pulse oximetry
▪︎CXR: exclude pneumonia, PTX, pulmonary edema, pleural effusion
▪︎CBC, electrolytes, glucose, ABG
Additional DX: mainly used to exclude differentials
▪︎EKG/troponins, BNP, D-dimer
▪︎sputum gram stain/culture, influenza rapid antigen, respiratory biofire
tx
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
ABX: indicated if 2+ cardinal symptom changes
▪︎macrolides, FQs, cephalosporins, Zosyn
O2 therapy: target SpO2 88-92%
▪︎HFNC O2 therapy, NIPPV, intubation & mechanical ventilation
Hypoventilation Syndrome
Alveolar Hypoventilation: ⇡ PaCO2 >45mmHg
Obesity Hypoventilation Syndrome ⇢ sleep-related hypoventilation disorder defined by a BMI ≥30, diurnal
S/SXS: sluggish/sleepy during day, headaches
dx
▪︎serum bicarbonate ≥27mEq/L
*d/t compensation for hypercapnia
ABG:
▪︎PaCO2 >45mmHg that cannot be explained by another condition
▪︎hypoxemia, respiratory acidosis
Polysomnography: hypoventilation during sleep +/- obstructive apnea events
TX: weight loss
▪︎ideally 25-30% of body weight
Ventilation support:
▪︎CPAP: preferred if associated OSA
Pulmonary HTN sx, dx, tx
S/SXS: progressive DOE, easy fatigability MC
▪︎mean pulmonary artery pressure (mPAP) 10-14mmHg
▪︎CP, exertional faintness, presyncope, cyanosis
▪︎pulmonary capillary wedge pressure (PCWP) ≤15mmHg ▪︎hemoptysis & hoarseness (rare)
▪︎pulmonary vascular resistance (PVR) 0.25-1.6 Wood units (WU) PE: right ventricular heave, wide split S2, systolic ejection click, accentuation P2 of S2, JVD, peripheral edema, hepatojugular reflux
dx
CXR: enlarged hilar vessels w/ pruning (⇣ number & size of vessels in periphery), right heart hypertrophy (prominent right heart border)
EKG: RAD, R > S in lead V1, RBBB, peaked P wave in lead II (P pulmonale) d/t right atrial enlargement
TTE: tricuspid regurgitation velocity (TVR) ≥2.8m/s, ePASP >35mmHg, RVH
Confirmatory ⇢ RHC: mPAP >20mmHg
tx
Group ➀ PH: ⊕vasoreactivity ⇢ CCBs
▪︎alternatives (⊖vasoreactivity):
» endothelin receptor antagonists
– bosentan, ambrisentan, macitentan
» PDE-5 inhibitors – sildenafil, tadalafil
» prostacyclin analogs
– iloprost, treprostinil, epoprostenol
Group ➁ PH: CHF treatment
▪︎diuretics, sodium restriction, AFIB TX
▪︎valve repair/replacement
Group ➂ PH: long-term O2 therapy
Group ➃ PH:
▪︎pulmonary thromboendarterectomy*
▪︎balloon angioplasty as alternative
Group ➄ PH: treat underlying cause
Pulmonary HTN 5 groups
➀ Pulmonary arterial HTN
➁ Left heart disease
➂ Lung disease (COPD)
➃ Pulmonary artery obstruction
➄ Miscellaneous
Cor Pulmonale definition, sx, dx, tx
▪︎altered structure (i.e., hypertrophy, dilation) or impaired function of RV d/t pulmonary HTN resulting from a disorder of the
respiratory or pulmonary artery system
ACUTE: sudden ⇡ in RV afterload results in RV dilation & dysfunction
S/SXS: acute onset ⇢ CP, SOB, hypotension, tachycardia, syncope
CHRONIC: ⇡ RV afterload leads to progressive RVH that over time
results in RV dilation & dysfunction
S/SXS: peripheral edema, JVD, right ventricular heave, loud S2
dx
ECHO: RV dilation, RVH, RV dysfunction
Gold standard ⇢ RHC
TX: heart failure medications, ASA, anticoagulation, O2
Idiopathic Pulmonary Fibrosis (IPF) definition, sx, dx, tx
IPF: MC type of ILD, characterized by irreversible pulmonary fibrosis & impaired pulmonary function
▪︎MC affects men >40yo, smokers
S/SXS: gradual onset DOE & dry cough over several months
PE: bibasilar inspiratory crackles, digital clubbing
PFTs ⇢ restrictive pattern: ⇣ FVC, normal FEV1/FVC, ⇣ DLCO
dx
CXR: ⇡ reticular markings
HRCT: peripheral, basilar-predominant opacities associated w/ honeycombing & traction bronchiectasis-bronchiolectasis
BX: honeycombing & traction bronchiectasis
TX: supportive
▪︎smoking cessation, supplemental O2
▪︎influenza/pneumococcal vaccines
Antifibrotics: pirfenidone, nintedanib
▪︎may ⇣ mortality/acute exacerbations & slow
decline in FVC
Only cure ⇢ lung transplant
Asbestosis sx, dx, tx
▪︎airborne asbestos fibers
Risk Factors: shipping yards, demolition, insulation, mining, brakes
S/SXS: exertional dyspnea MC
▪︎dry cough that transforms into productive
▪︎digital clubbing ▪︎bibasilar, fine end-expiratory rales
dx
CXR/HRCT ⇢ LOWER LOBES
▪︎pleural plaques, diffuse pleural thickening, effusion
▪︎reticular opacities +/- honeycombing
Histology ⇢ ferruginous bodies in alveolar septa
PFT: restrictive
tx
▪︎removal from exposure, smoking cessation
▪︎supplemental O2, flu/pneumococcal VAX
Complications: ⇡ risk of lung cancer
Silicosis sx, dx, tx
Acute: short-term exposure to a large amount, symptom onset weeks to years
S/SXS: rapid onset ⇢ dyspnea, cough, weight loss, fatigue, +/- pleuritic CP & fever
Chronic: long-term exposure, remain asymptomatic or symptom onset after decades
S/SXS: cough (often productive), DOE
dx
CXR/HRCT ⇢ UPPER LOBES
▪︎multiple small (<1cm), solitary, rounded opacities
▪︎hilar/mediastinal LN enlargement ⇢ eggshell calcifications
▪︎bilateral diffuse ground-glass opacities
BX ⇢ silicotic nodules: spiral appearance w/ hyalinized central zone composed of concentrically arranged collagen fibers
tx
▪︎removal from exposure, smoking cessation
▪︎supplemental O2, flu/pneumococcal VAX
Complications: ⇡ risk of TB
▪︎annual PPD recommended
Coal Workers Pneumoconiosis sx, dx, tx
S/SXS: most commonly asymptomatic Caplan Syndrome: pneumoconiosis + RA
▪︎cough +/- black sputum ▪︎arthralgia, morning stiffness
▪︎shortness of breath, chest tightness
dx
CXR/HRCT ⇢ UPPER LOBES
▪︎small, rounded, nodular opacities <1cm in diameter
tx
▪︎removal from exposure, smoking cessation
▪︎supplemental O2, flu/pneumococcal VAX
Complications: progressive massive fibrosis
Berylliosis sx, dx, tx
Risk Factors: fluorescent light, dental, computer, & aerospace
S/SXS: dry cough, SOB
PE: cutaneous nodules, bibasilar crackles
dx
CXR/HRCT ⇢ UPPER LOBES
▪︎multiple small, rounded opacities that can calcify
▪︎upper lobe scarring w/ volume loss & bullae (late)
Beryllium lymphocyte proliferation test (BeLPT): ⇡ uptake
BX ⇢ noncaseating granulomas, mononuclear cell infiltrates
TX: supportive + chronic systemic steroids
Sarcoidosis definition and sx
▪︎multisystem inflammatory disorder characterized by noncaseating granulomas in 1+ organs/tissues, ♀︎ > ♂︎ 2:1
▪︎average onset 30-55yo, highest prevalence in Black Americans & northern Europeans, esp. Scandinavian
▪︎lungs MC affected organ (90%), lymph nodes MC extrapulmonary site (70-90%)
PATHO: unknown antigen triggers cell-mediated immune response characterized by accumulation of T cells & macrophages, release of cytokines & chemokines, & organization of responding cells into granulomas
S/SXS: often asymptomatic in early stages Pulmonary: cough, dyspnea, CP + fatigue, malaise, fever, weight loss
Hepatic: LFT abnormalities, hypolucent lesions on CT Lymphadenopathy: hilar/paratracheal mediastinal adenopathy
Neuro: cranial neuropathy ⇢ facial nerve palsy (VII),
hearing loss (VIII) Cutaneous: papular, nodular, or plaque-like lesions
Cardio: heart block, arrhythmias, HF, infarction, ▪︎erythema nodosum ⇢ painful nodules on anterior LE
pericardial disease, sudden death
Sarcoidosis dx and tx
LABS: hypercalciuria, ⇡ ACE, hypergammaglobulinemia, ⇡ ESR
PFTs: typically restrictive pattern, ⇣ DLCO
CXR: bilateral hilar LAD (BHL) +/- pulmonary infiltrates (i.e., reticular &/or ground glass opacities)
IV ⇢ diffuse pulmonary fibrosis (irreversible ⇣ lung function)
▪︎often associated w/ fibrotic-appearing conglomerate
masses, traction bronchiectasis, & traction cysts
Confirmatory ⇢ BX: noncaseating granulomas
TX: glucocorticoids +/- DMARDs
Glucocorticoids: prednisone
Pneumonia social vs nosocomial
Community-Acquired Pneumonia (CAP)
*outside hospital or within 48h of admission
Viral Pathogens (“Atypical” Presentation):
*RSV, influenza, parainfluenza
*CMV, adenovirus, SARS-CoV-2
Nosocomial Pneumonia
– Hospital-Acquired Pneumonia (HAP)
*acquired >48h after admission
– Ventilator-Associated Pneumonia (VAP)
*acquired >48h after endotracheal intubation
Pathogens (Nosocomial):
*Pseudomonas aeruginosa (cystic fibrosis)
*Enterobacter spp.
*Acinetobacter spp.
*S. aureus (esp. MRSA)
RF: recent abx use, prolonged hospitalization (≥5d)
Pneumonia sx
CAP: acute onset fever, cough (+/- sputum), dyspnea
EXAM: tachycardia, tachypnea, crackles (rales), rhonchi
– tactile fremitus, egophony, dullness to percussion
*no clinical features reliably distinguish between different pathogens, but certain features can raise the index of suspicion for certain microbes
Legionella: GI (N/V/D), hyponatremia, elevated liver transaminases, CPR >100mg/L
Mycoplasma *MC in ambulatory setting
S/SXS: gradual onset HA, malaise, low-grade fever +/- sore throat
– cough (+/- sputum) follows, may have pleuritic CP/SOB
*chest soreness from persistent coughing common complaint
– ⊕URI SXS (rhinorrhea, otitis media, sinusitis, cervical LAD)
Non-Respiratory Associated Disease:
*autoimmune hemolysis (cold agglutinin disease), usually mild
*mucocutaneous disease
– erythema multiforme, SJS, other skin rashes, mucositis
*mild hepatic transaminase elevations
*arthralgias & myalgias
Nosocomial: new lung infiltrate + ≥2 clinical features of infection
S/SXS: new-onset fever, leukocytosis or leukopenia, purulent sputum, decline in oxygenation
Pneumonia 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
Microbiology (only need if inpatient)
*blood culture x2
*sputum gram stain + culture
*S. pneumoniae urine antigen
*PCR for Legionella
*PCR for pneumonia (BioFire PN)
CURB-65 Assessment
CURB-65 Assessment (1pt each)
C – confusion
U – BUN >19mg/dL (>7mmol/L urea)
R – respiratory rate ≥30
B – SBP <90mmHg or DBP ≤60mmHg
65 – age ≥65yo
0-1: outpatient
2: admission
≥3: assess for ICU care (esp. if 4-5)
Pneumonia 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
– Suspect MRSA: ⊕Vancomycin or Linezolid
– Suspect Pseudomonas:
*beta lactam + FQ
*both w/ antipseudomonal coverage
ABX REVIEW
Anti-MRSA: Vancomycin, Linezolid
Respiratory FQ
– Levofloxacin, Moxifloxacin, Gemifloxacin (PO)
Antipseudomonal FQ: Ciprofloxacin, Levofloxacin
Antipneumococcal Beta Lactam:
– Augmentin, Ampicillin-Sulbactam (Unasyn)
– Ceftriaxone, Cefotaxime, Ertapenem
Antipneumo + Antipseudomonal Beta Lactam:
– Piperacillin-Tazobactam (Zosyn), Imipenem
– Meropenem, Cefepime, Ceftazidime
Macrolides: Azithromycin, Clarithromycin
Nosocomial (Pseudomonas coverage):
*Zosyn or Cefepime
– Risk of MRSA: ⊕Vancomycin or Linezolid
PJP definition, sx, dx, tx
PCP: interstitial pneumonia caused by the yeast-like fungal organism Pneumocystis jirovecii
Transmission: airborne
*AIDS-DEFINING ILLNESS ⇢ CD4 <200/µL
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
▪︎hypoxemia: ⇡ A-a O2 gradient (ref. 5-10mmHg), ⇣ PaO2, ⇣ DLCO
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
▪︎direct fluorescent antibody (DFA) staining
» visualization of cystic or trophic forms
TX: TMP-SMX x21d
HIV⊕ w/ moderate/severe PCP ⇢ add prednisone
PCP prophylaxis ⇢ indicated for CD4 <200/µL
▪︎low-dose TMP-SMX
Solitary Pulmonary Nodule benign vs malignant
SPN: single, well-defined lesion ≤30mm in diameter completely located in the pulmonary parenchyma
BENIGN:
▪︎Infectious granuloma (MCC): TB, atypical
▪︎Benign neoplasms
▪︎Vascular
▪︎Developmental: bronchogenic cyst
▪︎Inflammatory: granulomatosis w/ polyangiitis
MALIGNANT:
▪︎Bronchogenic carcinoma: adenocarcinoma, SCC, ▪︎Metastatic lesions
▪︎Pulmonary carcinoid ▪︎Extranodal lymphoma
▪︎Miscellaneous: plasmacytoma, schwannoma
Solitary Pulmonary Nodule dx and tx
dx
Imaging: chest CT w/o contrast preferred modality ⇢ thin-section (1mm) volumetric scanning
FDG PET/CT: avidity measured by standardized uptake value (SUV)
Biopsy
tx
depends on if benign or malignant
Bronchogenic Carcinoma different types
MCC of cancer-related deaths in the US Types ⇢ ➀ Small Cell Lung Cancer (SCLC) – 15%
➁ Non-Small Cell Lung Cancer (NSCLC) – 85%
*Adenocarcinoma (MC)
S/SXS: cough, SOB, fever, weight loss, fatigue
*Bronchoalveolar Carcinoma (adeno in situ)
Small Cell Lung Cancer (SCLC):
*central, aggressive, often METS at presentation
*Paraneoplastic: Cushing’s, SIADH, SVC syndrome (face/neck swelling), Lambert-Eaton (proximal muscle
weakness, dry mouth, hyporeflexia)
Adenocarcinoma: *asbestos exposure Large Cell Carcinoma:
*peripheral, slow growing, MC seen in non-smokers *central or peripheral, rare
*Paraneoplastic: thrombophlebitis *large peripheral mass w/ prominent necrosis MC
*Paraneoplastic: gynecomastia
Squamous Cell Carcinoma:
*central, often associated w/ hemoptysis
*hypercalcemia, +/- elevated PTHrp
Pancoast syndrome: shooting arm pain/weakness, Horner’s (ipsilateral miosis, ptosis, anhidrosis)
Carcinoid Tumors ⇢ excess secretion of serotonin, histamine, bradykinin
*central, GI tract MC site, lung 2nd MC
S/SXS: hemoptysis, focal wheezing, recurrent pneumonia
*Carcinoid syndrome: flushing, diarrhea, hypotension
Bronchogenic Carcinoma dx and tx
dx
First ⇢ CXR Central: transbronchial biopsy
Then ⇢ CT w/ contrast
tx
NSCLC: surgical excision, radiation + chemo
SCLC: chemo + radiation, no surgery!
Screening: USPSTF recommends ANNUAL low-dose CT screening for those 55-80 who have no sxs of lung cancer + a 30PPY smoking hx who currently smoke or have quit within 15yrs
Mesothelioma definition, sx, dx, tx
▪︎malignant tumor that develops from mesothelial cells
▪︎Pleural mesothelioma (MC, 80%) ▪︎MCC ⇢ asbestos exposure**
▪︎Peritoneal mesothelioma (rare)
▪︎Pericardial mesothelioma (very rare)
Pleural Mesothelioma:
▪︎3 histologic subtypes ⇢ epithelioid (MC), sarcomatoid, biphasic (mixed)
S/SXS: dyspnea, CP, cough, night sweats, weight loss, fatigue, pleural effusion
dx
CXR/CT w/ contrast: unilateral pleural thickening w/ pleural effusion
Thoracentesis: bloody, exudative
Confirm ⇢ biopsy + immunohistochemistry
TX: surgery + chemo + radiation therapy
Surgery: pleurectomy/decortication or radical extrapleural pneumonectomy
Chemo: cisplatin + pemetrexed
Coccidioidomycosis
“Valley Fever” definition, sx, dx, tx
Fungi: Coccidioides immitis, Coccidioides posadasii
Region: southwestern US ⇢ Arizona & California
Transmission: inhalation of airborne mycelial arthroconidia located in soil
RF: HIV, immunosuppressants, advanced age, 2nd half of pregnancy/PP
Primary pulmonary infection: onset 7-21d after exposure
➀ asymptomatic/minimally symptomatic disease (60%)
➁ focal pneumonia: chest pain, cough, fever
➂ diffuse reticulonodular pneumonia (less common):
▪︎dyspnea at rest or w/ minimal exertion, fever, night sweats
➃ systemic SXS: night sweats, HA, rash, weight loss, fatigue
➄ immunologic manifestations:
» cutaneous ⇢ erythema nodosum, erythema multiforme
» rheumatic (“desert rheumatism”) ⇢ symmetric arthralgias of
ankles, knees, & wrists
Disseminated ⇢ meningitis: hematogenous spread
S/SXS: onset weeks-months after 1° infection ⇢ persistent HA MC
dx
First: enzyme immunoassay (EIA) for IgM & IgG
▪︎IgM ⇡ within 2wks, disappears after 2mo
▪︎IgG ⇡ at 1-3mo
▪︎KOH/wet prep: spherules w/ endospores
CXR: unilateral dense infiltrate w/ hilar LAD
*MC in upper lobes
tx
Mild: no treatment
Moderate: fluconazole 400mg QD or itraconazole 200mg BID x6-12wks
Severe: amphotericin B + azole x12-24wks
Pleural Effusion transudative vs exudative
Transudative: ⇡ hydrostatic pressure + ⇣ plasma oncotic pressure
* Caused by a combination of ↑ hydrostatic
pressure in the vasculature and ↓ oncotic pressure in the plasma
* Fluid in the pleural space
Heart failure (HF)
* 90% of cases * Liver cirrhosis * Hypoalbuminemia * Nephrotic syndrome
Exudative: ⇡ capillary permeability
* Caused by inflammation and ↑ capillary
permeability
* Fluid rich in protein and LDH in the pleural space
Pneumonia
* Empyema
* Tuberculosis (TB)
* Malignancy (most commonly a
primary lung cancer) * Connective tissue diseases * Pancreatitis * Asbestos * Post-cardiac injury syndrome
➁ lymphedema
Chylothorax: milky white effusion high in TGs caused by trauma ➂ dystrophic yellow nails
or neoplastic (MC lymphomatous) damage to thoracic duct
▪︎small pleural effusion (<300mL) often asymptomatic
Hemothorax: bloody fluid (pleural Hct >50% peripheral Hct) d/t S/SXS: dyspnea, pleuritic CP (retrosternal), dry cough
trauma, spontaneous PTX, coagulopathy, etc.
⇣ tactile fremitus, ⇣ breath sounds, dullness to percussion
» pleural friction rub (uncommon)
Empyema: pus in the pleural space; can occur as complication
to pneumonia, abscess, etc.
Trapped Lung: encasement w/ fibrous peel ⇡ ⊖intrapleural pressure caused by empyema or tumor ⇢ transudation of fluid from parietal pleural capillaries; borderline between transudative/exudative
Pleural Effusion dx and tx
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∠
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
Additional PF markers: Exudative:
▪︎PF cholesterol >55mg/dL
▪︎PF LDH
>200U/L
▪︎PF protein
>3.0g/dL
▪︎PF glucose <60mg/dL
TX: therapeutic thoracentesis
▪︎treat underlying cause
Parapneumonic: ABX
Empyema:
▪︎ABX, chest tube drainage
▪︎VATS debridement
Hemothorax:
▪︎fluid resuscitation, PRBCs
▪︎chest tube +/- open thoracotomy
Malignant:
▪︎therapeutic thoracentesis
▪︎indwelling pleural catheter
▪︎chemical pleurodesis
Pulmonary Embolism definition, MCC, sx
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, syncope, hemodynamic collapse (<10%)
▪︎accentuated pulmonic component of S2
PE Wells score
DVT sx: 3
PE sx: 3
tachycardia: 1.5
surgery: 1.5
Previous PE/PVT: 1.5
hemoptysis: 1
Malignancy: 1
Pulmonary Embolism dx
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
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
» 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
PE tx
▪︎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
Hemodynamically unstable ⇢ reperfusion
▪︎tPA (e.g., alteplase, reteplase, tenecteplase)
▪︎DC anticoagulation before tPA, resume after
Alternatives: catheter-directed thrombolysis, embolectomy
Tuberculosis (TB) definition and causes
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
Transmission: airborne respiratory droplet inhalation
TB dx
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
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
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
TB tx
First: RIPE x2mo
*Rifampin (RIF)
*Isoniazid (INH)
*Pyrazinamide (PZA)
*Ethambutol (EMB)
Then: continuation x4mo
*Rifampin + Isoniazid
Latent TB Infection (3 options):
*3HP: Isoniazid + Rifapentine q1wk x3mo
*4R: Rifampin QD x4mo
*3HR: Isoniazid + Rifampin QD x3mo
Rifampin (RIF) ADR
Thrombocytopenia, flu-like sxs, orange-colored secretions (tears, urine), GI upset, hypersensitivity, fever, hepatitis
MOA: inhibits RNA synthesis
Isoniazid (INH) ADR and MOA
Hepatitis (esp. >35yrs), peripheral neuropathy, drug-induced lupus, rash, abdominal pain, high anion gap acidosis, cytochrome P450 inhibition
MOA: inhibits mycolic acid synthesis
Peripheral neuropathy prevented by pyridoxine (B6)
Baseline LFTs recommended
Pyrazinamide (PZA) ADR and MOA
Hepatitis & hyperuricemia, GI sxs, arthritis, photosensitive dermatologic rash
MOA: inhibits mycolic acid synthesis
Peripheral neuropathy prevented by pyridoxine (B6)
Baseline LFTs recommended
Ethambutol (EMB) ADR
Optic neuritis 🡪 scotoma, color perception problems (red-green), visual changes, peripheral neuropathy, GI sxs, rash
Pneumothorax definition, primary vs secondary
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
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 or cyst rupture
Recurrent PTX: a second episode of spontaneous PTX, either ipsilateral or unilateral
Pneumothorax: traumatic vs tension
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
Pneumothorax definition, primary vs secondary vs traumatic vs tension sx and dx
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)
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)
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
*rib splaying, flattening of the ipsilateral diaphragm
Pneumothorax definition, primary vs secondary vs traumatic vs tension tx
TX: assess stability ⇢ requires ALL of the following to be considered stable:
RR <24 breath/min
normal BP
SpO2 >90% on RA
able to speak in whole sentences
HR 60-120bpm
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
