Pulm Flashcards
COPD: what decreases mortality
- stop smoking
- oxygen therapy: resting pO2
COPD: improves symptoms, but not mortality
- SABA
- Anticholinergic**
- Steroids
- LABA
- Pulm rehabilitation
COPD: Treatment for acute exacerbation
- ABX: macrolides, Cephalo, Amox/clav, Quinolones
- Bronchodilators
- Corticosteroids
COPD: tests to workup of acute exacerbation
- O2
- ABG: hypoxia, hypercapnea
- CXR: exclude PNA
- CBC: leukocytosis
- Chem8: electrolyte abn
- EKG exclude A-Fib
- Theophylline levels: can drop [macrolide]
ABPA: treatment
Allergic Bronchopulmonary Aspergillosis
- Oral steroids (inhaled steroids are NOT effective)
- Itraconazole orally for recurrent episodes
ABPA: Diagnostic tests
Allergic Bronchopulmonary Aspergillosis
- Peripheral eosinophilia
- Skin test re-activity to aspergillus antigens
- Precipitating Antibodies to aspergillus on blood test
- Elevated serum IgE levels
- Pulm infiltrates on CXR or CT
ABPA: Most likely patient has… PMH, S/S
Allergic Bronchopulmonary Aspergillosis
asthmatic pt recurrent episodes brown-flecked sputum transient infiltrates on CXR cough wheezing hemoptysis sometimes bronchiectasis
asthma: diagnostic tests
- ABG (best initial test)
- PEF (best initial test)
- CXR (normal, but r/o infection)
- PFT: FEV1/FVC (most accurate test)
Asthma: PFT findings
- decreased FEV1, FVC and ratio of FEV1/FVC
- albuterol –> increase FEV1 by 12%+ and 200mL
- methacholine –> decrease FEV1 by 20%+
- increase in DLCO
Asthma: treatment
1) SABA (intermittent, 2days/week, 3-4x night/mo)
3) LABA or increase in ICS dose (mod persistent, daily sx, >1 night/wk)
4) increase in ICS dose in addition to LABA and SABA
5) Omalizumab (if increased IgE level)
6) Oral CS prednisone taper
Acute Asthma Exacerbation: diagnostic tests
- PEF
- ABG with increased A-a gradient
- CXR: infection?
Acute Asthma Exacerbation: treatment
- oxygen
- albuterol
- steroids
CF: treatment
- ABX
- rhDNase
- albuterol
- vaccinations: PNA and flu
- lung transplant
- Invacaftor
PNA: infections with dry cough
- Mycoplasma
- Viruses
- Coxiella
- PCP
- Chlamydia
PNA: indication for hospital admission
CURB 65
- Confusion
- Uremia: BUN >20
- RR >30
- BP (hypotension)
exudate vs transudate
Exudate
- LDH >200
- LDH ratio of pleura/serum > 60%
- Protein ratio of pleura/serum >50%
Ventillator-Associated PNA: diagnostic tests
- tracheal aspirate
- BAL
- Protected brush specimen
- Video-assisted thoracoscopy (VAT)
- open lung biopsy
Ventillator-Associated PNA: treatment
- combine 3 different drugs
1) cephalosporin, PCN, or carbapenem (the C’s)
2) aminoglycoside or fluoroquinolone
3) MRSA: vanc or linezolid
PCP: diagnostic tests
-best initial: CXR or ABG
-most accurate: BAL
-sputum stain for PCP
positive= no further tests needed, reached Dx
negative= bronchoscopy is “best diagnostic test” –> look in there and see what’s going on
A normal LDH means PCP is NOT THE DIAGNOSIS. LDH is ALWAYS elevated in PCP
PCP: severe
pO2 below 70 or A-a >35
add steroids to TMP/SMX
if toxicity from TMP/SMX switch treatment to:
- Clinda and primaquine (can’t use primaquine in G6PD)
- OR pentamidine
RFs for TB
- Recent immigrant (past 5yrs)
- Prisoners
- HIV+
- Healthcare worker
- Close contact with someone with TB
- Steroid use
- Hematologic malignancy
- Alcoholic
- DM
TB: diagnosis and treatment
-CXR = best initial test
-Pleural biopsy = most accurate
-sputum stain
must be (-) x3 to r/o TB
positive –> 6mo therapy: 2 mo RIPE + 4mo RI
TB: treatment
-sputum stain
must be (-) x3 to r/o TB
positive –> 2 mo RIPE + 4mo RI
continue treatment >6mo if
- osteomyelitis
- miliary TB
- meningitis
- Pregnancy or any other time pyrazinamide not used
TB: S/E treatment meds
- Rifampin –> red pee –> benign
- Isoniazid –> peripheral neuropathy prevent w pyridoxine
- Pyrazinamide –> hyperuricemia –> no Rx unless symptoms
- Ethambutol –> optic neuritis/color vision–> decrease dose in renal failure
All meds cause hepatoxicity, do not stop until AST/ALT rise 3-5x ULN
TB: PPD reading >5mm positive in..
- HIV+
- Glucocorticoid user
- Abn calcifications on CXR
- organ transplant
- Close contact with TB person
TB: PPD reading > 10mm positive in..
- recent immigrant (past 5yrs)
- prisoners
- healthcare workers
- close contact TB person
- hematologic malignancy, alcoholic, DM
TB: PPD reading > 15 mm positive in..
people with NO risk factors
TB: treatment for +PPD or +IGRA
exclude active TB with CXR
-9mo isoniazid (use B6 to prevent periph neuropathy)
Pulmonary fibrosis: causes
- idiopathic
- radiation
- drugs: bleomycin, busulfan, amiodarone, methylsergide, nitrofurantoin, cyclophosphamide
Pneumoconioses: cotton
byssinosis
Pneumoconioses: electronic manufacture
berylliosis
Most likely to respond to steroid treatment
Pneumoconioses: moldy sugar cane
bagassosis
Pneumoconioses: shipyard
asbestosis
Pneumoconioses: sandblasting, rock mining, tunneling
silicosis
PE: when do you use IVC filter?
- can’t use anticoagulants
- recurrent emboli while on heparin or warfarin (2-3)
- RV dysfunction with enlarged RV on Echo: next emboli might kill the person
PE: when to use thrombolytics
-hemodynamically unstable
PE: when to use direct-acting thrombin inhibitors (argatroban, lepirudin)
-Heparin-induced thrombocytopenia
A-a gradient formula
PAO2 = 150 - pCO2/0.8
PAO2 - PaO2 = (150 - pCO2/0.8) - PaO2 82 year
normal is
normal blood gas
7.4 pH/ 40 CO2/ 90 O2 / 100% sat
PE: initial tests
ABG: hypoxemia, increased A-a gradient, normal in healthy young patients
CXR: normal, effusion, Westermark sign, Hampton hump
EKG: sinus tachycadia, S1Q3T3
PE: specific tests
Spiral CT: may miss small peripheral PEs
V/Q Scan: perfusion defect, normal ventilation
Angiogram: gold standard
DVT: Doppler U/S, venogram, MRI
D-dimer: sensitive, rule out, ELISA
Fat embolism: triad
- Acute dyspnea
- Petechiae: neck and axilla
- Confusion
occurs 3-4days after long bone fractures
Rx = supportive, no anticoagulation
ARDS: definition
-pO2/FiO2 (mild 300-200, moderate 200-100, severe
Squamous CA: types
PTH-rP = PTH related peptide
Hypercalcemia
Small Cell CA: types
Para-neoplastic
- SIADH –> ADH –> save water
- Cushing syndrome –> ACTH
- Lambert-Eaton Syndrome –> antibody against pre-synaptic Ca2+ channels causing muscle weakness
CAP treatment
Outpatient
-healthy = macrolide or doxycycline
-comorbids = fluoroquinolone
beta-lactam + macrolide
Inpatient (non-ICU)
- Fluoroquinolone OR
- Beta-lactam + macrolide
Inpatient (ICU)
- Beta-lactam + macrolide (IV)
- Beta-lactam + fluoroquinolone
atypical PNA: organisms
Mycoplasma Chlamydophilia Legionella Coxiella Viruses
not visible on gram stain, not culturable on standard blood agar
Pulmonary embolism: symptoms
sudden onset pleuritic chest pain dyspnea tachypnea tachycardia hypoxemia
Causes of exudate
- Infection: TB
- Autoimmune: RA
- Neoplasm: sarcoidosis, lymphoma
all of these increase capillary permeability –> protein and LDH passes into pleural fluid
TMP/SMX S/E and alternative meds
S/E: rash, bone marrow suppression
alternate meds: atovaquone or dapsone (can’t use dapsone in G6PD)
When does a patient require oxygen?
-pO2 55%, OSA with hypoxia at night or cardiomyopathy –>
pO2
Hypertrophic Osteoarthropathy (HOA)
- digital clubbing
- sudden-onset arthropathy (wrist, hand joints)
- Hypertrophic pulmonary osteoarthropathy (HPOA) is a subset of HOA where clubbing/arthropathy 2/2 underlying lung dx: lung CA, TB, bronchiectasis, emphysema
Conditions associated with digital clubbing
- Intrathoracic neoplasms: bronchogenic CA, metastatic CA, malignant mesothelioma, lymphoma
- Intrathoracic suppurative Dx: lung abscess, empyema, bronchiectasis, CF, chronic cavitary lesions
- Lung Dx: idiopathic pulm fibrosis, asbestosis, pulm a-v malformations
- CV Dx: cyanotic congential heart dx
Modified Wells Criteria
Score 3pts
- Clinical signs DVT
- Alternate diagnosis less likely than PE
Score 1.5pts
- previous DVT/PE
- HR > 100
- Recent surgery (3days)
Score 1pts
- Hemoptysis
- Cancer
total Score
4 PE likely
