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pulm Flashcards

1
Q

Asthma MOA

A

Reversible bronchoconstriction of airways

Mucosal inflammation

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2
Q

ASA Induced Asthma

A 
ASA insensitivity
Nasal polyps
Starts w/perennial vasomotor rhinitis
asthma w/minimal ingestion
desensitization possible
Chronic over-secretion of LKE = activate mast cells
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3
Q

Findings in patients with Asthma

A
  • Sx’s worse at night
  • Nasal Polyps
  • Increased expiratory phase length
  • Eczema or atopic dermatitis
  • Use of accessory muscles
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4
Q

Best Initial Test - Asthma

What does CXR show?

A

ABG
Peak Expiratory Flow
CXR = Normal

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5
Q

Most Accurate Test - Asthma

A

Pulmonary Function Tests (PFTs)
Decrease ratio of FEV1/FEVC
FEV1 decreases MORE than FEV during exacerbation

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6
Q

PFTs in Asthma
Albuterol effect
Methacholine effect

A

Decrease ratio of FEV1/FVC (FEV1 decreases MORE than FVC during exacerbation)
Increase in DLCO
Increase in FEV1 >12% w/Albuterol
Decrease in FEV1 >20% w/Methacholine or histamine

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7
Q

What is DLCO?

A

measures the alveolar membrane permeability

measures gas exchange

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8
Q

When is DLCO decreased?

A 
Alveolar walls are destroyed and pulmonary capillaries obliterated 
- Emphysema = Obstructive
Alveolar-capillary membrane thickened
- Edema, Consolidation
- Fibrosis = Interstitial Lung Dz
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9
Q

Asthma Treatment

A
  1. Inhaled SABA
  2. Low does ICS
  3. Inhaled LABA
  4. Increase dose of ICS
  5. Omalizumab for increased IgE
  6. Oral Steroid - Prednisone
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10
Q

Budesonide

What is it?

A

Low dose inhaled corticosteroid (ICS)

Category B = Pregnancy

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11
Q

Cromolyn and Nedocromil
MOA
Use?

A

Inhibit mast cell mediator release and eosinophil recruitment
Used in Peds asthma, never in adults

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12
Q

Theophylline
MOA
AE’s

A

Methylxanthine

AEs: N/V, palpitations, tremulousness, death by cardiac arrythmia

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13
Q

Theophylline increased toxicity with what drugs?

A 
FQ's
Clarithromycin
H2 blockers (rantidine, cimetidine)
some Beta blockers
CCBs
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14
Q

Theophylline decreased toxicity with what drugs?

A

Rifampin
Phenobarbs
smoking

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15
Q

Zafirlukast: MOA
AE
Ass’d with?

A

LKE receptor antagonist
Hepatotoxic
Ass’d with Churg-Strauss

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16
Q

Adverse effects of inhaled steroids?

A

Dysphonia

Oral candidiasis

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17
Q

Adverse effects of systemic steroids?

A 
Osteoperosis
Cataracts
Adrenal suppression - fat redistribution
Hyperlipidemia, hyperglycemia, acne, hirsutism
Thinning of skin, striae, easy bruising
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18
Q

What vaccines given to all asthma patients?

A

Influenza

Pneumococcal

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19
Q

Best indication for severity of asthma?

A

Increased Respiratory Rate

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20
Q

Severity of asthma exacerbation measured by?

A

Decreased PEF

ABG with increased A-a gradient

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21
Q

Tx for Asthma Exacerbation

A

Oxygen
Albuterol
Steroids - need 4-6 hrs to work

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22
Q

Are epinephrines used for asthma exacerbation?

A

Rarely - steroids used instead b/c less AE’s and same efficacy

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23
Q

Magnesium in asthma exacerbation?

A

Acute, severe exacerbation unresponsive to several rounds of Albuterol when waiting for steroids to work

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24
Q

When to do endotracheal intubation in asthmatic?

A 
Unresponsive to Oxygen, Albuterol, and steroids OR
Respiratory Acidosis (increased pCO2)
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25
Q

What happens to elastic recoil in emphysema?

A

Decreases b/c of abnormal permanent dilatation of air spaces distal to terminal bronchioles w/destruction of air space walls

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26
Q

What is lost in COPD?

A

Ability to exhale from elastic fibers (tobacco destroys elastin fibers)

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27
Q

COPD presentation

A

SOB worse w/exertion
cough, sputum,
Barrel chest from air trapping
Muscle wasting/cachexia

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28
Q

When do we see alveolar Hypoventilation?

A

Obstructive Lung Dz
Obesity hypoventilation syndrome
These cause hypoxia secondary to alveolar hypoventilation

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29
Q

Best initial test for COPD?

A

CXR
Increased A-P diameter
Flattened diaphragm (increases work of breathing) and air trapping

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30
Q

Most accurate test for COPD?

A

PFT

  • Decreased FEV1/FVC < 70% (both values decreased)
  • Increased TLC - increased RV
  • Decreased DLCO
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31
Q

How do we differentiate emphysema from Chronic Bronchitis?

A 
Emphysema = decreased DLCO
CB = Normal DLCO
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32
Q

Does COPD reverse with bronchodilators?

A

Not always - broad range.

This differentiates it from Asthma, where there is always reversal

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33
Q

What can be seen on EKG for COPD?

A

Right Atrial Hypertrophy
Right Ventricular Hypertrophy
A Fib
Multifocal Atrial Tachycardia

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34
Q

What is seen on Echo for COPD?

A

RA and RV Hypertrophy

Pulmonary Hypertension

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35
Q

What is the treatment for COPD that improves mortality and delays progression?

A

Smoking Cessation - Bupropion has increased SI risk
Home Oxygen for pts with hypoxia
Influenza and Pneumococcal vaccines

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36
Q

When do COPD patients get oxygen?

A

Hypoxemia

- pO2 is < 90%

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37
Q

What is tx for COPD?

A

Inhaled anticholinergic - most effective in COPD: tiotropium, ipratropium
Short acting beta agonist
Inhaled steroids
Long acting beta agonists

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38
Q

When do we refer COPD for transplantation?

A

When all medical therapy is insufficient?

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39
Q

What are causes of acute bronchitis and presentation?

A

Viral - MC

Blood tinged sputum, lack of other serious si/sx’s

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40
Q

What is the tx for acute exacerbation of chronic bronchitis (ACEB)?

A 
ABx: 
First Line: 
Macrolides: Azithromycin 
Cephalosporins: Cefuroxime, Cefixime, Cefaclor, Ceftibuten
Amoxicillin/Clavulanic Acid
Quinolones: Levofloxacin, Moxifloxacin, Gemifloxacin
Second Line: 
Doxycycline
Trimethoprim/sulfamethaxazole
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41
Q

Macrolides: Use

A

URIs, Pneumonia
STDs - Gram + coci
Atypical Pneumonia - Mycoplasma, Legionella, Chlamydia, Neisseria

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42
Q

What ABx Prolongs QT?

A

Azithromycin

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43
Q

What is the best indicator of survival in COPD patient?

A

FEV1

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44
Q

What is the pathophysiology of bronchiecstasis?

A

Chronic dilatation of large bronchi

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45
Q

MCC of bronchiecstasis

A

MCC = Cystic Fibrosis

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46
Q

What Infxn gives poor prognosis in CF?

A

Burkholdoria cepacia Infxn: Can’t get lung transplant

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47
Q

What is the presentation of bronchiecstasis?

A

Recurrent episodes of high volume sputum

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48
Q

Best initial test for Bronchiecstasis?

A

CXR

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49
Q

Most Accurate test for Bronchiecstasis?

A

High - resolution CT

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50
Q

Preventive vaccinations for Bronchiecstasis?

A

Influenza

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51
Q

Treatment for Bronchiecstasis?

A

Chest physiotherapy and postural drainage

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52
Q

What is Allergic Bronchopulmonary Aspergillosis (ABPA)?

A

Hypersensitivity of lungs to fungal Ags that colonize bronchial tree

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53
Q

Asthmatic patient w/ recurrent episodes of brown-flecked sputum?

A

ABPA

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54
Q

Presentation of ABPA?

A

cough, wheezing, hemoptysis, bronchiecstasis

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55
Q

Testing for ABPA?

A

Peripheral eosinophilia

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56
Q

Tx for ABPA?

A

Oral steroids = Prednisone

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57
Q

What is the pathophys of Cystic Fibrosis?

A

AR; mutation for chloride transport; CFTR

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58
Q

What is the presentation of CF?

A

Young adult with chronic lung dz and recurrent infxn

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59
Q

GI involvement in infants w CF?

General?

A

Meconium ileus - infants w/abdominal distension

Chronic, frequent diarrhea

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60
Q

What cell is responsible for dumping DNA into airway secretions in CF?

A

Neutrophils

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61
Q

Which pancreatic cell is spared until later in life in CF?

A

Islet cells - beta cell function

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62
Q

What are GU sx’s in CF?

A

Infertility

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63
Q

Most accurate test for CF?

A

Increased Sweat chloride test

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64
Q

What does Pilocarpine do?

A

Increases Ach Levels = increases sweat production

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65
Q

Is genotyping in CF testing accurate?

A

No, not as accurate as sweat chloride

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66
Q

What are PFTs of CF?

A

Mixed restrictive and obstructive

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67
Q

What bugs seen in CF on sputum culture?

A

Nontypable Haemophilus influenzae

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68
Q

Tx for CF?

A 
Respiratory therapy
Bronchodilators
Steroids
DNA-ase
ABX
Pancreatic enzymes
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69
Q

Vaccines in CF?

A

Influenza

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70
Q

What is Community Acquired Pneumonia (CAP)?

A

Pneumonia before hospitalization

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71
Q

Presentation of CAP?

A

Fever, cough, dyspnea

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72
Q

When are bronchial breath sounds heard and egophony?

A

Consolidation of air spaces in CAP

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73
Q

What auscultory findings heard in CAP?

A

Rales - crackles, velcro being pulled apart

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74
Q

When is abdominal pain seen in CAP?

A

Infection of lower lobes that irritate intestines through diaphragm

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75
Q

When are chills or rigors seen?

A

Bacteremia

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76
Q

When is chest pain seen in CAP?

A

Inflammation of pleura causing pleuritic pain - changes w/respiration

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77
Q

Dyspnea, high fever, abnormal CXR Dx?

A

Pneumonia

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78
Q

CAP in COPD/smokers pathogen?

A

Haemophilus influenzae

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79
Q

CAP with hoarseness?

A

Chlamidophila pneumoniae

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80
Q

CAP with contaminated water sources, AC, Ventilation systems?

A

Legionella

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81
Q

CAP epidemic infx with older smokers, GI and CNS involvement?

A

Legionella

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82
Q

Dry cough, rarely severe, bullous myringitis Pathogen?

A

Mycoplasma pneumoniae

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83
Q

Which pneumonia is seen w Infxn of alveolar space?

A

Lobar pneumonia w/parapneumonic pleural effusion:

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84
Q

Which area of lung do Infxn w/dry cough or non-productive prefer?

A

Prefer interstitial space - leave alveolar air spaces empty

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85
Q

Best initial test for CAP?

A

CXR - best initial for ALL respiratory infxn

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86
Q

What is seen on CXR for Atypical Pneumonia?

A

Bilateral interstitial infiltrates

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87
Q

When do we do Thoracocentesis?

A

Tapping

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88
Q

How do we classify empyema?

A

LDH >60% serum level

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89
Q

When do we do bronchoscopy?

A
  • Severe dz when initial testing of sputum stain and culture don’t show pathogen
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90
Q

Test for Mycoplasma Pneumoiae?

91
Q

Test for Chlamidophilia pneumoniae?

A

Rising serologic titers

92
Q

Test for Legionella?

A

Urine Antigen

93
Q

Test for PCP CAP?

A

Bronchoalveolar Lavage (BAL)

94
Q

What is the inpatient Tx for CAP?

A

Respiratory Fluroquinolones (Levo, Moxi)

95
Q

What is the Tx for CAP in pts w/severe PCN allergy?

96
Q

When to hospitalize for CAP?

A

Hypotension (SBP <90mmHg)

97
Q

When to hospitalize for CAP mneumonic?

98
Q

When do we do thoracostomy?

A

Drainage by chest tube

99
Q

What is seen on CXR of pleural effusion?

A

Meniscus sign

100
Q

Who gets a pneumococcal vaccine?

A

Everyone above 65 - 23 polyvalent vaccine

101
Q

When to give a pneumococcal vaccine?

A

Healthy get single dose at 65

102
Q

Do healthcare workers need pneumococcal vaccine?

103
Q

What is Hospital Acquired Pneumonia (HAP)?

A

Pneumonia after 48 hrs of admission

104
Q

Causes of HAP?

105
Q

Tx for HAP?

A

Antipseudomonal Cephalsoprins: Cefepime or ceftazidime

106
Q

When is Ventilator Associated Pneumonia seen?

A

Seen in mechanical ventilation, like positive pressure - damages normal ability to clear colonization

107
Q

Fever +/- rising WBC count, new infiltrate on CXR, and purulent secretions from endotracheal tube?

108
Q

When is Aspiration Pneumonia seen?

A

Recurrence

109
Q

Which part of lung does Aspiration Pneumonia affect?

A

Same anatomic region repeatedly

110
Q

Risk factors for Aspiration Pneumonia?

A

Altered consciousness

111
Q

What is a BAL?

A

Bronchoscope placed deeper into lung where there are not supposed to be organisms

112
Q

Open lung Bx?

A

Most accurate test for VAP, BUT greater morbidity

113
Q

TX for VAP?

114
Q

AE of Imipenem

A

Causes seizures

115
Q

Causes of large volume aspiration

A

Stroke with loss of gag reflex

116
Q

When do pts get Aspiration pneumonia? What part of lung affected?

A

Lying flat

117
Q

When does lung abscess occur?

A

Pt with large volume aspiration of oral/pharyngeal contents

118
Q

Foul smelling sputum and weight loss?

A

Lung Abscess

119
Q

Best initial test for Lung Abscess

120
Q

What test to determine tx for Lung Abscess?

121
Q

Tx for Lung Abscess

A

Clindamycin

122
Q

Best initial test for PCP?

123
Q

Most Accurate test for PCP?

124
Q

What is elevated in PCP?

125
Q

Tx for PCP?

A

Trimethoprim-sulfmethoxole

126
Q

AE’s of Trimethoprim-sulfmethaxole?

127
Q

PCP PPX?

A
  1. Trimethoprim-sulfmethaxole
128
Q

What drugs are CI in G6PD?

129
Q

Risk factors for TB

A

Immigrant (past 5 yrs)

130
Q

Best initial test for TB?

131
Q

Most accurate test for TB?

A

Pleural Bx

132
Q

Sputum stain req’s for TB?

A

3 times for acid-fast to exclude TB

133
Q

Tx for TB?

A

Positive smear:

134
Q

When to tx TB for 9 mo’s?

A

Osteomyelitis

135
Q

Which TB drugs CI in pregnancy?

A

Pyranzinamide

136
Q

When to tx TB for 12 mo’s?

A

Meningitis

137
Q

Which TB drugs are hepatotoxic?

A

All of them

138
Q

TB drug with hyperuricemia?

A

Pyranzinamide

139
Q

What AE does Ethambutol cause?

A

Optic neuritis/color vision

140
Q

When do we decrease dose of ethambutol?

A

In renal failure

141
Q

When do we use steroids in TB?

A

Meningitis, Pericarditis

142
Q

Who is screened for TB?

A

Those with risk factors

143
Q

What is a positive PPD test?

A

Induration > 5mm

144
Q

Who gets a CXR in TB testing?

A

Everyone with reactive PPD

145
Q

If first test is +, do we do second in 2-stage test?

146
Q

Tx for positive PPD

A
  1. CXR to r/o active TB
147
Q

Actinomyces

A

Gram + filamentous

148
Q

Nocardiosis

A

Gram + partially acid fast filamentous

149
Q

What is the Tx for Nocardiosis?

150
Q

What is the Tx for Actinomyces?

151
Q

Best initial step in lung lesions?

A

Compare size with old CXR

152
Q

Most common adverse effect of transthoracic Bx?

A

Pneumothorax

153
Q

What is a PET scan done and when is it done?

A

To assess content of lesion - malignant v benign - w/out bx.

154
Q

What is the next step in an enlarging lung lesion?

155
Q

What is pathophys of pulmonary fibrosis?

A

Thickening of interstitial septum of lung b/t arteriolar space and alveolus

156
Q

What is the A-a gradient of pulmonary fibrosis?

157
Q

Drugs that cause pulmonary fibrosis?

158
Q

Pneumoconiosis ass’d with sandblasting, rock mining and tunneling?

159
Q

Pneumoconiosis ass’d with shipyard workers, pipe fitting, insulation?

A

Asbestosis

160
Q

Pneumoconiosis ass’d with cotton?

A

Byssinosis

161
Q

Pneumoconiosis ass’d with electronic manufacture and ceramic alloys?

A

Berylliosis

162
Q

Pneumoconiosis ass’d with moldy sugar cane?

A

Bagassosis

163
Q

What lung dz is increased in asbestosis exposure?

A

Bronchogenic cancer

164
Q

Bronchogenic cancer presentation

A

Progressive dyspnea

165
Q

Bronchogenic cancer CXR?

A

Bibasilar Reticulonodular infiltrates

166
Q

Presentation of pulmonary fibrosis?

A

Dyspnea, worse on exertion

167
Q

Best initial test pulmonary fibrosis?

168
Q

Most accurate test pulmonary fibrosis?

169
Q

Echo findings on pulmonary fibrosis?

A

Pulmonary HTN

170
Q

PFT’s in Pulmonary fibrosis?

A

Restrictive lung dz findings: decreased everything in proportion

171
Q

Tx of pulmonary fibrosis

A

If Bx shows WBCs or inflammation ->Prednisone

172
Q

Sarcoidosis Presentation

A

African American

173
Q

Skin finding in Sarcoidosis

A

Erythema nodosum - inflammation of fat cells under the skin

174
Q

CXR/CT with hilar adenopathy in healthy African American female?

A

Sarcoidosis

175
Q

Best initial test for Sarcoidosis?

A

CXR - Hilar LA; parenchymal involvement common

176
Q

What is the most accurate test for Sarcoidosis?

A

Lymph Node Bx.

177
Q

Lab findings in Sarcoidosis?

A

Elevated ACE

178
Q

PFT’s in Sarcoidosis?

A

Restrictive lung dz

179
Q

Bronchoalveloar lavage findings in Sarcoidosis?

A

Elevated level of helper cells

180
Q

Tx for sarcoidosis?

A

Prednisone if symptomatic

181
Q

What happens if you tx asymptomatic sarcoid pt?

A

Increased remission

182
Q

Most common vessel in DVT?

A

Large vessels of legs (70%)

183
Q

Etiology of DVT?

A

Stasis from:

184
Q

Presentation of PE/DVT?

A

Sudden onset SOB

185
Q

Best initial test in PE

186
Q

Most accurate test in PE

A

Angiography

187
Q

Most common abnormality with PE

A

CXR - usually normal

188
Q

EKG findings in PE?

A

Sinus tachycardia

189
Q

ABG of PE?

190
Q

If hx and initial labs suggest PE, what is the most appropriate next step?

A

Start IV unfractionated heparin

191
Q

After CXR, EKG and ABG, what is the next best test?

A

Spiral CT = CTA = CT Angiogram

192
Q

When do we do V/Q scan for PE?

193
Q

What test is used to rule out PE?

194
Q

When is LE Doppler done?

A

If V/Q and Spiral CT do not give clear Dx.

195
Q

What are the adverse effects of angiography?

196
Q

What is the tx for PE?

A

Best initial = heparin. Start warfarin @ same time to get INR 2-3

197
Q

When is IVC filter answer in PE?

A

CI to anticoagulation - melena, CNS bleeds

198
Q

When do we use thrombolytics in PE?

A

Hemodynamically unstable pt

199
Q

When are direct acting thrombin inhibitors tx in PE?

200
Q

When is ASA answer in PE?

201
Q

Normal pulmonary pressure?

A

Systolic 25mmHg

202
Q

What causes Pulmonary HTN?

A

Chronic lung dz, fibrosis - elevate PA pressure

203
Q

Presentation of pulm HTN?

A

dyspnea/fatigue

204
Q

Best initial test Pulm HTN?

A

CXR - dilation of proximal PAs, narrowing of distal vessels

205
Q

What is the most accurate test in pulm HTN?

A

Right heart/Swan-Ganz catheter

206
Q

EKG/ECHO findings in pulm HTN?

A

EKG: Right Axis deviation, RA and RV Hypertrophy

207
Q

Curative tx for Pulm HTN?

A

Lung transplant

208
Q

Tx for Pulm HTN?

A

Prostacyclin analogues - PA vasodilators - “prosts”

209
Q

Sx’s of Obstructive Sleep Apnea

210
Q

When does OSA most commonly occur?

A

In REM = muscle atonia - loss of voluntary control of diaphragm, eyes, spinchter

211
Q

Most accurate test for OSA?

A

Polysomnography

212
Q

Tx for OSA?

A

Weight loss

213
Q

ARDS - pathophys?

A

Hypoxia -> Respiratory failure

214
Q

CXR in ARDS?

A

Congestive failure, normal cardiac hemodynamics

215
Q

Causes of ARDS?

A

Sepsis - MCC

216
Q

When does ARDS occur (time frame)

A

Within 5 days of inciting event

217
Q

Si’s/Sx’s of ARDS?

A

Dyspnea, Increased respiratory rate, diffuse rales and rhonchi

218
Q

What does CXR show of ARDS?

A

Bilateral infiltrates - white out/confluent

219
Q

pO2/FIO2 in ARDS?

A

pO2/FIO2 ratio < 200

220
Q

Tx for ARDS

A

Low tidal-volume mechanical ventilation

221
Q

Blastomycoces dermatitis

A

Midwest, Mississippi Valley

222
Q

Skin findings seen with Blastomycoces dermatitis

A

Heaped up, verrucuous, nodular lesions w/violet hue ->evolve into microabscess

223
Q

What is Pickwickian syndrome?

A

Obesity Hypoventilation Syndrome (OHS)

224
Q

Mediators in asthma?

A

Histamine
Bradykinin
Leukotrienes C, D, E
PGE2, F2, D2

Pulmonary (2 decks)

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