Pulm Flashcards
Diagnosis of Asthma
spirometry
-> decrease FEV1/FVC ratio <80%
Bronchodilator response
-> greater than 12% increase in FEV1 after SABA
Bronchoprovocation
->hyperresponsiveness = >20% decrease in FEV1 after methacholine challenge
night time cough + hyperresonance to percussion + eosinophil containing suptum should make you think of?
Asthma, IgE mediated type hypersensitive.
Hyper-resonance to percussion occurs because there is air trapping.
Atopic triad
1)asthma
2) allergic rhinitis
3) eczema
Samter’s triad
asthma, nasal polyps, ASA sensitivity.
how does the methacholine challenge test work?
Methacholine is a muscarinic agonist that causes bronchoconstriction in the lungs. Should a greater than >20 decrease in FEV1
Why is SAMA (short-acting muscarinic antagonist) contraindicated in myasthenia gravis?
Because in Myasthenia gravis the immune system attacks the acetylcholine receptors at the neuromuscular junction.
What can be used in life threatening exacerbation or severe excerbation asthma with no improvement 1 hour after intensive bronchodilator therapy.
IV magnesium
What is a common side-effect of short-acting beta-agonists?
Tachycardia because it is systemically absorbed and acts on the beta 1 receptors in the heart.
What is SAMA (short-acting muscarinic antagonist)
Ipratropium is a SAMA it blocks the constricting action of acetylcholine at the muscarinic receptor = bronchodilator and decrease mucus secretion. Can be added to SABA to treat severe asthma excerbations.
T/F: LABA (long-acting beta agonist) such as salmeterol and formoterol can be used as monotherapy to treat asthma.
False. LABA should always be used with a ICS to address both the inflammation and bronchoconstriction of the airway . If LABA is used alone can lead to asthma related death.
Name some Inhaled corticosteriods
Fluticasone
budesonide
Beclomethasone
Note: high dose can cause adrenal supression & oral candidiaisis
What is the best medication to use for exercise-induced asthma & aspirin induced asthma?
Leukotriene receptos antagonist such as montelukast or Zafirlukast
associated with increased aggression, hallucinations and depression
Which medication can be used to treat high levels of IgE medicated bronchospasms
Anti-IgE monoclonoal antibody (omalizumab)
associated with anaphylaxis
What is the step-wise treatment for asthma?
step 1: SABA
Step 2: add low dose ICS
Step 3: add moderate dose ICS OR low dose ICS + LABA
Step 4: Moderate dose ICS + LABA
Step 5: high dose ICS + LABA
Step 6: add oral steriod + HIGH dose ICs + LABA
What are the risk factors for COPD?
Smoking MCC
Alpha-1 antitrypsin deficiency ( alpha 1 antitrypsin protects the elastin in the lungs. deficiency = break down of elastin = damage).
Smoking increase the production of elastase = break down of elastin.
The Ghon complex of tuberculosis is a combination of hilar lymphadenopathy and a______ on chest X-ray.
ghon focus
Mycobacterium tuberculosis is transmitted via _______________ from the respiratory tract.
airbrone droplets
__________Mycobacterium tuberculosis infection affects the middle to lower lung segments.
Primary Mycobacterium tuberculosis infection affects the middle to lower lung segments.
A hilar lymphadenopathy with a peripheral granulomatous lesion in the middle or lower lung lobes which can calcify is diagnosti
primary tuberculosis
____________is a second-line anti-tuberculous drug that can cause ototoxicity and nephrotoxicity.
Streptomycin
The interferon-γ release assay for tuberculosis is usually (positive/negative) if a patient has had previous immunization.
The interferon-γ release assay for tuberculosis is usually (positive/negative) negative if a patient has had previous immunization.
_________is an anti-tuberculous drug that can sometimes cause optic neuropathy
Ethambutol
The anti-tuberculous drug ___________________ can cause a benign red-orange discoloration of body fluids like tears and urine.
rifampin
A fibrocaseous cavitary lesion on chest X-ray is seen in (primary/secondary) tuberculosis.
A fibrocaseous cavitary lesion on chest X-ray is seen in secondary tuberculosis.
rifampin, _____________ , pyrazinamide, and ethambutol are the four antimycobacterial drugs used to treat tuberculosis.
isoniazid
___________ is an agent that is co-administered with isoniazid to decrease the chance of a peripheral neuropathy or sideroblastic anemia developing
Pyridoxine (B6)
______ is the name given to tuberculous arthritis and osteomyelitis of the spine.
Pott Disease
Mycobacterium tuberculosis is a mycobacterial species that thrives in high oxygen environments, flourishes in the apex of the lung during_
Reactivation
_________is an anti-tuberculous drug that can cause hyperuricemia and thus increase the chance for gout in susceptible patients.
Pyrazinamide
Which drug is used to treat latent TB?
Isoniazide + pyridoxine (B6)
What is used to treat active or primary TB?
RIPE for 2 months
Rifampin
Isoniazide
Pyrazinamide
Ethambutol
Then
Rifampin + Isoniazide for an additional 4 months.
Extrapulmonary tuberculosis sites
Kidneys are the most common site
Meningitis
Vertebral Tuberculosis
Peri-carditis
TB diagonsis
pulmonary sputum or bronchoalveolar lavage get acid-fast culture.
Target SpO2 for COPD
88-92%
3 cardinal symptoms of acute excerbation of COPD
1) worsening dyspnea
2) increase severity/frequency of cough
3) increased volume purulence of sputum
Emphysema what is
Permanent enlargement & destruction of terminal airspace making it hard to get air out
Emphysema presentation
Dyspnea is the most common CC
prolonged expiration
use of accessory muscles
decreased tactile fremitus (decreased vibration due to increased air in the lungs)
hyper-resonance
Chrontic bronchitis what is it?
productive cough >/=3months for 2+ consecutive years
Severe v/q mismatch in chronic bronchitis can stimulate
severe V/Q mismatch results in hypoxemia & hypercapnia leading to erythopoieses
Chronic productive cough is the most common presentation of
Chronic bronchitis
FEV1/FVC ratio of <70% indicates?
obstruction commonly seen in COPD
What is FVC & FEV1
FVC (forced vital capacity) is the max amount of air forcibly exhales from lungs after max inhalation
FEV1: the volume of air exhaled during the 1st second of the forced exhalation.
In treating COPD groups B & E what medications should be given?
Group B: LABA (salmeterol) + LAMA (Tiotropium)
Group E: LABA (salmeterol) + LAMA (Tiotropium) +/- ICS if blood eos >/= 300
What is used to treat patient that falls into Group A of COPD
bronchodilators such as SAMA (Ipratropium) Or SABA (albuterol)
How should an acute COPD excarbation be managed ?
1) SABA +/- SAMA
2) systemic glucocorticoid steroids (prednisone)
3) Abx (macrolide, FQ) if 2+ cardinal sxs changed.
4) Oxygen therapy target SpO2 88-92%
People with COPD should get what vaccines yearly?
Influenza & pneumococcal vaccine
COPD is associated with
1) MAT
2) Cor pulmonale
What is acute bronchitis
Inflammation of the upper bronchi and trachea following and upper respiratory tract infection
What is the most common cause of acute bronchitis?
adenovirus
Most common presentation of acute bronchitis
persistent cough (+/-) sputum 1-3 weeks
What is community acquired pneumonia?
infection of one or both of the lungs outside the hospital or within 48 hours of hospital admission
Hospital aqcuired pneumonia
infection acquired>48 hours after admission.
Often caused by Pseudomonas aeruginosa or MRSA
Typical Community acquire pnemonia is caused by which pathogens
1) strep pneumoniae (mcc)
2) Haemophilus influenzae
3) Moraxella catarrhalis
4) Klebsiella pneumoniae
5) Staphylococcus aureus
Atypical CAP (walking pneumonia) is caused by which pathogens?
Mycoplasma penumoniae (MCC)
Chlamydophila pneumoniae
Legionella spp.
What are the presentations of typical CAP?
acute fever, cough +/- sputum, dyspena
What are the physical exam findings of typical CAP?
evidence of consolidation: increased tactile fremitus, egophony, dullness to percussion
Crackles, tachypnea & tachycardia
What are the presentations of atypical CAP?
gradual onset of HA, malaise, low-grade fever +/- sore throat, dry non productive cough
URI sxs
physical exam normal
CXR finding for typical pneumonia
Lobar consolidations
CXR findings for atypical pneumonia
interstitial infiltrates
Strep pneumoniae CAP assoications
Most common cause of CAP
-> Gram-positive cocci
-> rust color/blood-tinged sputum
-> common in young adults, post influenza
Haemophillus influenza CAP assoications
2nd most common cause of CAP
common in COPD & Elderly
-> Gram negative rod
Kiebsiella pneumoniae CAP assoications
Common in alcoholics & diabetics, aspiration (affects upper lobe) & abscess formation
Gram neg rod
Current jelly sputum
Staphylococcus aureus CAP assoications
Most commonly develops after the flu (post influenza)
associated with elderly, IVDU, immunocompromised
Gram + in clusters
salmon colored sputum
Bilateral lobe pneumonia
Mycoplasma pneumoniae CAP assoications
Most common cause of atypical pneumoniae
associated with young health people living in close quarters such as college, military
Legionella CAP assoications
transmission via aerosolized contaminated water
Nausea vomiting
hyponatremia
elevated Liver enzymes
CURB 65
Confusion
U: BUN
Respiratory
B: SBP <90 or DBP<60
65: >/= age 65
Pneumocystis pneumonia is caused by
pneumocystis jirovecii, aids defining illness in patient with CD4 count <200
Pneumocystis pneumonia treatment
Bactrim
Treatment for CAP outpatient
Macrolide or doxy
CAP inpatient treatment
beta lactam (ceftrixaone) + macrolide
Hospital aquired pnuemonia treatment
antipseudomonal beta lactam: piperacillin-tazobactam (Zosyn), imipenem
vancoymcin or linezolid if MRSA
The most common type of lung cancer is
adenocarcinoma
associated with asbestos exposure. MC seen in non-smokers
Peripheral located
Non small cell carcinoma includes
adenocarcinoma
squamous cell carcinoma
Large cell carcinoma
Squamous cell carcinoma
centrally located
associated w
1) pancoast syndrome (arm/ shoulder pain)
2)honrner’s syndrome (miosis, ptosis & anhidrosis)
hypercalcemia
Large cell carcinoma
very aggressive
doubles in sie quickly
peripherally located
associated with gynecomastia
Carcinoids tumors
slow growing centrally located
secrete serotonin, histamine & bradykinin
most commonly affects the GI tract, lungs 2nd common site
Small cell lung cancer
Very aggressive
centrally location, Mets at presentation
Small cell lung cancer is associated with
Cushing syndrome
SIADH
Lambert-eaton (proximal muscle weakness that improves with continued use)
Small cell lung caner treatment
chemo +/- radiation
Non small cell lung cancer
surgery +/- chemo and radiation
What are the 2 types of sleep apnea?
Obstructive sleep apea: decreased air flow due to upper airway obstruction. Most common type.
Central sleep apnea: when the breathing repeatedly stop and start during sleep
What are the risk factors for obstructive sleep apnea?
obesity (neck circumference >40cm)
alcohol or drug use before bed can cause increased snoring but not sleep apnea.
What does STOP-BANG stands for?
it is used to diagnose sleep apnea
Snoring
Tired (daytime sleepiness
Observed pnea
Pressure (HTN)
BMI >35
Age >50
Neck >43
Gender: male
complication of of sleep apnea
pulmonary HTN/cor pulmonale
treatment for tobacco use
Chantix
wellbutrin (bupropion)
Lung cancer screening
annual screening, 50-80 years old with a hx of smoking (20 yr pack hx, currently smoking or quit within past 15 years) -> low dose computed tomography
AAA screening
abdominal ultrasound to screen for abdominal aortic aneurysm in men 65-75 years when they have any smoking history
Bone density scan
screen for osteoporosis in women at average risk starting at age 65 years
Fecal immunochemical test
colorectal cancer screening 50–75 years old annual for anyone who does not want to do a colonoscopy
Which smoking cessation medication is contraindiacted in patient with a history of seizure
bupropion lowers the seizure threshold and so is contraindicated in patients with a history of seizures
What is the most effection treation for smoking cessation
Varecniline
Recommened pneumococcal vaccine for all patient >65 yrs old and who have never received the vax in the past
PCV15 or PCV20
if PCV 15 is given, a dose of pneumococcal polysaccharide vaccine (PPSV23) should be administered 1 year later.
Which pneumococcal vaccine is used in ped population
PCV13
