Pulm Flashcards
Name all 6 steps of asthma treatment
1) inhaled SABA (albuterol)
2) Add a long term control agent (ICS > Cromolyn/Nedocromil, Theophylline, LTE modifiers)
3) Add a LABA (Salmeterol) or increase the ICS dose
4) Max dose ICS + add a LABA
5) Add omalizumab if there is an increased IgE level
6) Add an oral steroid (prednisone)
What are the side effects of ICS?
Concern with Zafirlukast?
Dysphonia + oral candidiasis
Hepatoxic + churg Strauss association
What is the best indication of asthma severity?
How do you quantify the severity of an attack? (2 tests)
How do you treat?
RR
Decreased PEF + ABG with increased Aa gradient
O2 + albuterol + steroid bolus –> intubate if no response
What is the cause of COPD in a young non smoker?
What is the best initial test for COPD?
Most accurate test?
A1ATD
CXR
PFT
What COPD treatments improve mortality?
What COPD treatments improve Sx?
What do you give COPD pts who do not respond to albuterol?
Quit smoking + O2 + flu/pneumo vaccines
SABA, Anticholinergics (Tiotropium), steroids, LABA, rehab
Anticholinergics –> ICS
What is the most effective agent for COPD?
What is the COPD treatment when medals therapy fails?
Anticholinergics
Refer for transplant
How do you treat acute exacerbation of chronic bronchitis?
What are first line agents?
What are second line?
Abx Against Spneumo/Hflu/Moraxella
Macrolides/cephalosporins/Augmentin/Quinolones
Doxy/Bactrim
What is bronchiectasis? What is the most common cause? What is the classic Sx? What is the initial test? Accurate test?
Permanent chronic dilation of large bronchi CF Buckets of sputum CXR High res CT
Who gets ABPA?
How does it present?
How do you treat acutely?
How do you treat chronically?
Almost always asthmatics or atopic disorder patients
Brown flecked sputum
Oral steroids if severe
Itraconazole
What is the most common cause of death in CF?
What are the affected and unaffected parts of the pancreas?
What is the most accurate test to diagnose?
How do you treat?
Lung disease
Islets spared, beta cell decline later in life
Increased sweat chloride test
Abx + inhaled rhDNase + inhaled bronchodilators
What is the most common infectious cause of death in the US?
What is the most common organism?
What are 3 ways to distinguish this from bronchitis?
What 5 organisms cause nonproductive cough?
What is the best initial tests?
Pneumonia S pneumo Dyspnea + high fever + abnormal CXR Mycoplasma/virus/coxiella/pneumocystis/chlamydia CXR + sputum gram stain/culture
What are som specific diagnostic tests for Mycoplasma? Chlamydophila pneumonia? Legionella? Chlamydia psittaci? Coxiella? PCP?
PCR/cold agglutins/serology Rising serologic titers Urine antigen/Charcoal yeast culture Rising titers Rising titers Bronchoalveolar lavage
What drives initial therapy for pneumonia?
How is outpatient treatment done?
Severity of disease
Macrolide or doxy –> Levo or Moxifloxacin if sick or Abx in past 3 months
When would you hospitalize for pneumonia?
What is the inpatient treatment?
How do you treat an infected pleural effusion or empyema?
CURB65: confused/uremia/RR/BP low/age>65
Levo/moxie or Ceftriaxone + azythromycin
Chest tube for suction
What is the best initial test for acute exacerbation of asthma?
What is the most accurate test?
What is the most accurate if the patient is asymptomatic?
How much does FEV1 increase with albuterol/decrease with Methacholine or His?
How is the diffusion capacity for CO affected?
PEF or ABG PFTs Methacholine challenge test 12% and 200mL --> 20% Increase
When do you receive the pneumococcal vaccines?
What are weird reasons to get it early?
What do you do for those who got it early?
65 PCV13 –> 6-12 months later PSV23
Asplenia/heme CA/CSF leak or cochlear implant/immunosuppressed
2nd dose given 5 years after 1st dose
What is the concerning pathogen in HAP?
What is not acceptable HAP treatment?
What are 3 treatments?
Gram negatives
Macrolides
Cefepime/Cefatadime or Pip/Tazo or Carbapenems
What are 5 tests for VAP?
What is the treatment?
Tracheal aspirate > BAL > protected brunch specimen > VAT > open lung biopsy
3 drug combo: antipseudomonal beta lactam + 2nd antipseudomonal (aminogylcocide or quinolone) + MRSA agent (Vanc or linezolid)
What pseudomonas drug can cause seizures?
Imipenem
What is the best initial test for lung abscess?
What is more accurate?
What is most accurate?
CXR
CT
Lung biopsy
What is the best initial test for PCP? What is the most accurate test? What is also very specific? What lab test makes PCP unlikely? How is PCP treated? What do you add if it is severe? What if the 1st line becomes toxic?
CXR or ABG BAL Sputum stain Normal LDH TMP/SMX Steroids (pO2 35) Clinda + primaquine or Pentamidine
What is the first line PCP prophylaxis?
What if there is a reaction?
What are the 2 main reactions?
TMP/SMX
Atovaquone or dapsone
Rash or neutropenia
What do you do if you have a negative sputum stain for TB?
What is the most accurate test?
What is never the right test if the patient is symptomatic?
Do it again! 3 times total
Pleural biopsy
PPD
What are the 4 TB treatments?
How long are they used?
What are their side effects?
Rifampin - 6 months - red color secretions
INH - 6 months - peripheral neuropathy (prevent with B6)
Pyrazinamide - 2 months - hyperuricemia (no tx unless Sx)
Ethambutol - 2 months (or not at all if sensitive to other 3) - optic neuritis/color vision/renal failure
What are glucocorticoids used for with regards to TB?
Decrease risk of constrictive pericarditis
Decrease risk of neuro complications if meningitis
What does 2 stage testing mean with TB?
What do you do to treat positive PPD and negative CXR?
For the first PPD, you need a 2nd 1-2 weeks later
INH + B6 for 9 months (yearly screening CXR if in healthcare)
If you have an intermediate probability lesion, what is the most appropriate next step?
What is a side effect of those?
Bronchoscope (central )or TT needle biopsy (peripheral)
Pneumothorax
What are 4 features of pulmonary fibrosis?
What is the initial test?
More accurate?
Most accurate?
Which pneumoconiosis responds to steroids?
Dyspnea on exertion/rales/loud P2/finger clubbing CXR High res CT Lung biopsy Berylliosis
What condition is present in 95% of sarcoidosis?
What is most accurate for sarcoidosis?
What is the treatment?
Hilar adenopathy
Lymph node biopsy
Prednisone
What is the best initial tests for PE (3)?
What is the next step?
What is the most common EKG finding?
What is the suggestive ABG finding?
What is the next step when findings suggest PE?
What is the best confirmation test in pregnancy?
CXR + EKG + ABG CTA (spiral CT) Sinus tach with nonspecific ST-T changes Hypoxia + RespAlk Start therapy V/Q
What is the reason to use an IVC filter for PE?
When do you use thrombolytics?
When do you use direct thrombin inhibitors?
When do you use ASA?
Contraindications to anticoagulants/recurrent emboli/RV dysfunction
HypoTN/acute RV dysfunction
HIT
Never!
What is the initial test for pulm HTN?
What is the accurate test?
What are 3 in initial medication options?
What is a cure?
CXR/CT
Swan Ganz/Right heart catheter
PGI analogues (epoprostenol, iloprost, beraprost)/endothelin antagonists (bosentan, ambrisentan)/PGE inhibitors (sidenafil)
Lung transplant
What is the definition of ARDS?
What is the treatment?
pO2/FIO2 ratio
