Pulm Flashcards
Order of asthma management
Start with inhaled SABA
Next add low-dose inhaled corticosteroid, alternates include cromolyn, LK modifiers: montelukast
Next add LABA to the SABA and ICS or increase the dose of ICS
Then increase the dose of the ICS to maximum in addition to the LABA and SABA
May add Omalizumab if increased IgE
Finally, oral corticosteroids when all others have failed
The severity of an asthma exacerbation is quantified by?
Decreased peak expiratory flow – an approximation of the FVC
Also ABG with an increased A-a gradient
Treatment of an asthma exacerbation
Oxygen, albuterol, steroids, iPratropium may help, magnesium only an acute, severe asthma not responsive to several rounds of albuterol
COPD diagnosis
best initial: CXR
most accurate: PFT (will have decreased FEV1/FVC less than 70% decreased DLCO) (not reversible -i.e. less than 12% / 200 mL improvement in FEV1)
ABG in acute exacerbations will have increased pCO2 and hypoxia, elevated bicarb to compensate
what improves mortality in COPDers?
smoking cessation
O2 if pO2 less than 55 or sat lass than 88% (or 60, 90% if RHF or elevated HCT or pulm HTN)
influenza/pneumo vaccines
effective meds in COPD
anticholinergics are most effective**
SABAs, steroids, LABAs, pulm rehab
in contrast to asthmatics, COPD not controlled with albuterol>anticholinergic>ICS
management of AECB
bronchodilators, steroids, antibiotics: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line
high volume purulent sputum, +/- hemoptysis, wheezing, dyspnea, crackles, dilated, thickened bronchi (“tram-tracks”) on CXR, think? best diagnostic tool?
bronchiectasis
most accurate test is high-resolution CT (get CXR first)
sputum culture to determine specific bacteria
bronchiectasis tx
“cup and clap” - physiotherapy (associated with CF)
tx infection, rotate abx
sx resection
brown sputum, ^IgE, eospinophilia, think?
ABPA
sinus pain and polyps are common in ?
CF
biliary cirrhosis, intestinal obstruction, pancreatitis (islets are spared)
best diagnostic test for CF
what bugs on sputum cx
sweat chloride (above 60) after pilocarpine tx (^Ach>^Cl-) genotyping not accurate, too many diff genes H. flu (nontype), pseudomonas, S. aureus, Burkholderia
CF tx
abx: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line
inhaled rhDNase, inhaled bronchodilators (albuterol), pneumo/influenza vaccination, lung transplant if refractory
Ivacaftor ^CFTR activity
main ways to distinguish pneumonia from bronchitis
abnormal CXR, high fevers, dyspnea?
CAP orgs not visible on gram stain
Mycoplasma, Chlamydia, Legionella, Coxiella, viruses
sputum gram stain is adequate if ?
more than 25 WBCs and fewer than 10 epithelial cells
pleural effusion with:
WBC above 1000, pH less than 7.2?
LDH above 60% and protein above 50% of serum level?
infection
empyema
bronchoscopy in pneumonia?
rarely needed, only when stain/cx do not yield org and need for ICU placement
exception: PCP
other uses: foreign bodies, cytology for lung masses
Outpatient treatment of pneumonia
If previously healthy: macrolide or doxycycline
If comorbidities or antibiotics in the past three months: floor quinolones – not Cipro
Inpatient treatment of pneumonia
Flora quinolone – not Cipro or ceftriaxone and azithromycin
Reasons to hospitalize people with pneumonia
Hypotension, respiratory rate above 30 or PO to lesson 60, pH below 7.35, B1 above 30, sodium lesson 130, glucose about 250, possible of 125, confusion, temperature above 104, 65 or older or comorbidities such as cancer COPD CHF renal failure liver disease
Curb 65 criteria for pneumonia and mission
Confusion, uremia, respiratory distress, BP low, age over 65
With 0 to 1.: Home
If 2+ points: admission
How to manage infected profusion or empyema in addition to antibiotics?
Drainage for a chest tube or thoracostomy, each of the chest can accommodate 2 to 3 L of fluid, a large effusion ask like an abscess and is hard to sterilize
Who gets the pneumococcal vaccine
Everyone at 65: first 13 then the 23
Once underlying condition is discovered in those with heart, liver, kidney, lung disease or immunocompromise or cancer
Second those should be given five years after the first dose
Difference with HAP
Higher incidence of Graham negatives: E. coli or Pseudomonas, macrolides are not acceptable
Need anti pseudomonal cephalosporins or antipseudomonal PCN, (Zosyn) or carbapenem
Diagnostic test for VAP from least accurate but easiest to most accurate but most dangerous
Trick your aspirin, BAL, protected brush specimen, VAT, open lung biopsy – thoracotomy
Therapy for VAP
Combine three different drugs:
Anti-pseudomonal beta-lactam: cephalosporin, penicillin, or carbapenem
PLUS SecondAnti-pseudomonal agent: aminoglycoside or floor quinolone
PLUS MRSA agent: vancomycin or linezolid no daptomycin! Inactivated by surfactant
Best for covering long abscesses
Penicillin or clindamycin
CXR is the best initial test, CT is more accurate, only a long biopsy can establish the etiology, sputum culture is wrong
Alternative to Bactrim in PCP
Atovaquone if mild, if that Jim toxicity switch to clindamycin and primaquine or pentamadine
Diagnosing TB
Best initial test: CXR
Sputum stayed in culture,
Most accurate test: plural biopsy
When to extend six-month treatment for TB
Osteomyelitis,military TV, meningitis, pregnancy or any other time pyrazinamide is not used
What to do and hepatotoxicity with TB medications
Only stop when LFTs rise 3 to 5 times upper limit of normal
Pregnant patients should not receive pyrazinamide or streptomycin
Steroids decrease the risk of constructive pericarditis and neurological complications
PPD positive if larger than 5 mm in what people
HIV, steroid users, close contacts of those with active TB, abnormal calcifications on CXR, organ transplant recipients
PPD positive pressure than 10 mm and what people
Recent immigrants, prisoners, healthcare workers, close contacts of someone with TV, blood cancers, alcoholics, diabetes
If the first PPD is negative and someone who’s never had a PPD before, what to do
Get a second PPD, the first test may be falsely negative
What to do after positive PPD
Get CXR to rule out active TB, if negative implies latent, get nine months of INH with vitamin B6
What do you do if one lesion has malignant features: patient older than 40, enlarging mass, smoker, greater than 2 cm, adenopathy, and normal pet scan
Remove the lesion, the following tissue not be done because a negative test is likely to be a false negative: sputum cytology, needle biopsy, PET scan
Most appropriate next step in patients with intermediate probability of malignancy
Bronchoscopy for central lesions and transthoracic needle biopsy for peripheral lesions
PET scan does what?
Tells whether the content of lesion is malignant without a biopsy, malignancy you will have increased uptake of glucose, 85 to 95% sensitive, more accurate with larger lesion is greater than 1 cm
Most sensitive and specific test for long lesions
Video assisted thoracic surgery – VATS
Can convert to open thoracoscopy and lobectomy if malignancies found
Causes of pulmonary fibrosis
Radiation, Drugs: bleomycin, both so fun, amiodarone, metal surgeon, Macrobid, cyclophosphamide
Pneumoconiosis: coal, silicosis, asbestosis s, berylliosis
All forms of pulmonary fibrosis present with?
What type has granulomas?
DOE, Find rails or crackles, loud P2, clubbing of the fingers
Granulomas in berylliosis, Responds best to steroids
Parotid gland enlargement, facial palsy, her block, restrictive cardiomyopathy, CNS involvement, Iritis/uveitis, erythema nodosum, lymphadenopathy, think?
Sarcoidosis, CXR is best initial test, lymph node biopsy is most accurate – granulomas are noncaseating
Labs in sarcoidosis
Elevated AC E, hypercalciuria, hypercalcemia – granulomas make vitamin D, restrictive long pattern on PFTs
BAL shows elevated helper cells
Treat with steroids
Unique presentation in PE
Fever can arise from any cause a clot/hematoma, extremely severe emboli will produce hypotension
PE diagnosis
Get CXR, EKG, ABG 1st
CXR most likely be normal, if abnormal will show atelectasis, ABG will show hypoxia and respiratory alkalosis
This patient presents with SOB an elevated heart rate, CXR is normal with hypoxia an ABG, increase it a gradient with EKG showing sinus tack, what to do next?
Do not need CTA as this is high probability, much more important to start therapy – enoxaparin
If I find a clot and LE Doppler, what to do?
No need to get CTA, as treatment is the same: heparin and six months of warfarin
Most accurate test for PE
Angiography, .5% mortality, Rarely done
PE treatment
Heparin to warfarin for an INR of 2 to 3 times normal, fondaparinux is alternative
Rivaroxaban and dabigatran our oral agents that can be used in alternative to warfarin, use with LMWH
When is TPA The right answer in PE
Hemodynamically unstable and, a Q RV dysfunction – also a reason for IVC filter
When our direct acting thrombin inhibitor’s the right answer in PE?he
In cases of HIT
Examples: argatroban, lepirudin or fonduparinux
ASA is never the answer
Pulmonary hypertension
Systolic greater than 25, diastolic greater than eight, any chronic lung disease leads to back pressure into the pulmonary artery, obstructing blood flow out of the right heart
