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Clin Med Comprehensive > Pulm > Flashcards

Pulm Flashcards

1
Q

What is the MC infectious cause of death in the US?

A

Pneumonia

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2
Q

Pathophysiology of pneumonia

A

pathogen invades alveoli and neutrophils invade and phagocytize causing inflammation and neutrophilic exudate

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3
Q

What are the defense mechanisms of the respiratory tract?

A

cilla, saliva, mucus, immunoglobulins, neutrophils, cough reflex

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4
Q

How does tobacco smoking impair host defense?

A

disrupts mucocillary function and macrophage activity

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5
Q

How does aging impair host defense?

A

less effective mucocillary clearance and coughing and changes in cell mediated immunity

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6
Q

What are the RF of pneumonia?

A

> 65, underlying health problems, impaired immune response

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7
Q

What are typical PE finding with pneumonia?

A

dullness to percussion, rhonchi, bronchial breath sounds, reduced breath sounds, egophony, tachycardia and tachypnea

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8
Q

When would you perform bronchoscopy (BAL)?

A

immunosuppressed, suspected TB or pneumocystis, foreign body or not responding to Abx

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9
Q

What is atypical pneumonia?

A

less ill appearing, CXR appears different and need different Abx

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10
Q

What are complications of S. pneumoniae?

A

sinusitis, otitis media, endocardidis, meningitis, empyema

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11
Q

What is empyema?

A

pus collecting in pleural space
ph <7.2
high LDH
low glucose <60

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12
Q

When is the pneumococcal vaccine administered?

A

> 65 yo or current smokers with compromised immune system2 separate vaccines

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13
Q

What populations is associated with H. influenzae pneumonia?

A

COPD, alcoholics, older and immunosuppressed

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14
Q

What is Tularemia associated with?

A

rabbits

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15
Q

What is Pittacosis associated with?

A

birds

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16
Q

What are the sx of walking pneumonia?

A

chilld, non-productive cough, low grade fever, mild SOB

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17
Q

What is the MC cause of lower respiratory tract infection in young adults?

A

mycoplasma pneumoniae

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18
Q

What is the MC pneumonia in children?

A

RSV (viral pneumonia)

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19
Q

What is the MC pneumonia in military recruits?

A

Adenovirus

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20
Q

What area of the lung does aspiration pneumonia most commonly occur?

A

RLL or RML

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21
Q

What is CURB-65?

A 
confusion
urea >7 mmol
respiratory rate >30
low BP <90/<60
age >65
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22
Q

What curb score is high risk?

A

> 2

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23
Q

What are danger signs of pneumonia?

A

leukopenia, cavity infiltrates, alcohol abuse, chronic liver dx, asplenia, recent travel, pleural effusion

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24
Q

What is MC etiology of typical pneumonia?

A

S. pneumo, H. flu, M. catarrhalis

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25
Q

What is MC etiology of atypical pneumonia?

A

mycoplasma, chlamydia, coxiella burnettii, fungal

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26
Q

Whats is MC etiology of alcoholics with pneumonia?

A

Klebsiella, psdueomonas

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27
Q

Whats is MC etiology of COPD pts with pneumonia?

A

H. flu, pseudomonas, legionella

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28
Q

What is MC etiology of dementia pts with pneumonia?

A

anaerobes, enteric G ⊖

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29
Q

What is typical presentation of pneumonia?

A

Rhonchi, bronchial breath sounds, diminished breath sounds, ⊕ egophony, Fever, tachypnea, tachycardia

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30
Q

What is typical presentation of Streptococcus pneumonia?

A

Single shaking chill, Cough productive of rust color sputum
Fever
Pleurtic pain
Consolidation (diminished breahth sounds, dullnuss, egophony)

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31
Q

What is typical presentation of Haemophilus Influenza Pneumonia?

A

High fever, chills, cough, purulent sputum
Abdominal pain & diarrhea
Pleural effusion common
Appears toxic

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32
Q

What tests are diagnostic for H. flu pneumonia?

A

Urine Ag test
Sputum culture (G⊖rods)
PCR
Hyponatremia and ↑LDH

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33
Q

What age group typically gets atypical pneumo?

A

<40

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34
Q

What is etiology of atypical pneumo?

A

Mycoplasna pneumonia (YA)

Chylamydia pneumoniae (school age kids)

Legionella pneumonphilia (older)
Psittacosis (birds)
Tularemia (rabbits)

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35
Q

What is clinical presentation of atypical pneumo?

A

Gradual onset
Low grade fever, chills
Non-productive cough
Mild SOB

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36
Q

What does CXR show for atypical pneumo?

A

Diffuse or patchy infiltrate on CXR little or no pleural effusion

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37
Q

What does CXR show for mycoplasma pneumo?

A

CXR worse than clinical findings

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38
Q

What is clinical presentation of mycoplasma pneumoniae?

A 
<40 yo
Gradual onset
Bullus myringitis on TM
Sore throat
Non-productive cough
HA
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39
Q

What environmental exposure is known for Histoplasmosis?

A

Planting new grass, yardwork

Bats/chicken contact

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40
Q

Pathophys of fungal pneumo

A

Spore inhaaled enters lungs and causes hilar adenopathy

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41
Q

Define acute bronchitis

A

inflammatory condition of tracheobronchial tree associated with respiratory infection

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42
Q

What is the etiology of acute bronchitis?

A

Common cold viruses: influenza, adenocirus

Non-viral: M. pneumoniae, C. pneumoniae, B. pertussis

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43
Q

Clinical presentation of acute bronchitis

A

Cough, preceded by nasal and pharyngeal complaints
Purulent sputum
Fever
Substernal chest pain if tracheal involvement

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44
Q

What is incubation period for influenza?

A

1-4 days

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45
Q

Clinical presentation of influenza

A

Sx for 5-10 days
Abrupt onset, myalgias, pounding HA, fatigue, dry cough, sore throat (sometimes)
High fever, tachycardia, no nasal congestion or rhinorrhea

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46
Q

Pathyphsy of TB

A

aerosol droplet gets into lungs and incubates for 2-12 wks when the infection is either cleared, suppressed to latent or infects host

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47
Q

What is PPD size to dx TB?

A

> 5 if HIV, immunocompromised or close contact
10 if high prevalence country
15 mm everyone else

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48
Q

Clinical presentation of active TB

A

cough, weight loss, anorexia, fever, night sweats, hemoptysis, chest pain and fatigue

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49
Q

How do you dx TB?

A

CXR shows coin lesions or cavitations

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50
Q

How does Coccidioidomycosis present?

A

Asymptomatic typically

CXR shows dense infiltrate in upper lobe

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51
Q

Where is Coccidioidomycosis MC?

A

Desert areas of SW

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52
Q

Where are Histoplasmosis and Blastomycosis MC?

A

Mississipi-Ohio River

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53
Q

Define hypoxia

A

poor O2 delivery/oxygenation of tissues

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54
Q

Define hypoxemia

A

low arterial O2

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55
Q

Define hypocapnea

A

low arterial CO2

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56
Q

Define orthopnea

A

dyspnea when lying flat

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57
Q

Define apnea

A

cessation of breathing > 10 sec

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58
Q

Define hypopnea

A

decrease in airflow with accompanied by decrease in arterial O2 saturation >4%

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59
Q

What is apnea-hypopnea index (AHI)?

A

severity of sleep apnea based on number of apnea and hyopnea events per hour of sleep

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60
Q

What are categories of AHI?

A

Normal 0-4
Mild 5-14
Moderate 15-29
Severe 30 or more

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61
Q

What is Ondine’s Curse?

A

central sleep apnea stop breathing for 10 or more seconds when asleep

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62
Q

What are the medullary centers?

A

dorsal and ventral respiratory group

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63
Q

What is Dorsal respiratory group (DRG)?

A

Controls inspiratory movements and their timing

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64
Q

What is ventral respiratory group (VRG)?

A

Controls voluntary forced exhalation and acts to increase the force of inspiration. Inactive during quiet breathing

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65
Q

What are pontine center?

A

pneumotaxic center and apneustic center

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66
Q

What does pneumotaxic center do?

A

Coordinates speed of inhalation and exhalation Sends inhibitory impulses to the DRG
Involved in fine tuning of respiration rate

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67
Q

What does apneustic center do?

A

Promotes inspiration and controls depth of breathing . Signals to the DRG in the medulla.

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68
Q

What is Cheyne-Stokes Breathing and when is it seen?

A

rhythmic increase and decrease of respirations followed by 15-60 sec apnea seen in response to hypercapnia such as in central sleep apnea

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69
Q

What is Pickwickian syndrome?

A

obesity hypoventilation syndrome

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70
Q

What is hyperpnia?

A

increased depth and rate of breathing in response to either physiologic (exercise) or pathologic, of respiratory control mechanisms

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71
Q

What are indications for mechanical ventilation?

A

acute respiratory failure, acute on chronic respiratory failure, pulmonary edema, inability to protect airway, neuromuscular dysfunction (ALS) and stabilize chest wall after trauma

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72
Q

What is positive ventilation volume cycle?

A

Volume constant and pressure varies with pts lung compliance

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73
Q

What is positive ventilation pressured cycle?

A

Pressure is constant and volume will vary with patient’s lung compliance

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74
Q

What are problems associated with positive pressure ventilation?

A

Iatrogenic upper airway damage, pneumonia and Lung parenchymal damage

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75
Q

What is Expiratory asynchrony?

A

Patient tries to take a breath when expiring and ventilator doesn’t respond

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76
Q

Pathophys of central sleep apnea

A

Brain temporarily srops sending signals to muscles of respiration and theres lack of abdominal and thoracic mvt for 10 sec or longer during sleep

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77
Q

Define hypercarbic failure

A

failure to eliminate CO2

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78
Q

When do you give supplemental O2?

A

80% or lower at rest

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79
Q

What is a normal A-a gradient?

A

5-10 mmHg

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80
Q

What conditions mimic ARDS?

A

CHF, ILD, marijuana or cocaine, cancer

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81
Q

What is normal PEEP vs PEEP in ARDS?

A

5 cm H20 nrml

~20 cm H20 ARDS

82
Q

What are RF of ARDS?

A

age, direct lung injury, pneumonia, sepsis, aspiration

83
Q

What is best tidal volume to ventilate at?

A

low tidal volume ~6ml/kg

84
Q

Pathyphys of ARDS

A

Inflammatroy lung injury→diffuse alveolar damage→Inc permeability of alveolar capillary barrier→Pulmonary edema

85
Q

What is hallmark of ARDS?

A

severe refractory hypoxemia

86
Q

What is normal PaO2/FIO2 ratio?

A

500

87
Q

What are characteristics of diagnosis or ARDS?

A 
Protein RICH edema fluid
CXR: Bilat pulm infiltrates (ground glass)
NO cardiogenic pulm edema present
ABG not responsive to 100% O2
PaO2/FIO2 <300
PEEP >5
PCWP <18 mmHg
88
Q

What is the function of PEEP?

A

prevents airway collapse at end expiration, increases FRC and expands alveoli for increased diffusion

89
Q

What is strong RF of sleep apnea?

A

obesity

90
Q

Pathophys of PE

A

Thrombus forms in lower extremity vein →dislodges →travels to pulmonary artery where it gets lodged btwn the artery to capillaries → prevents blood from getting oxygenated distal to the lodged embolism

91
Q

What are the respiratory effects of PE?

A

inc alveolar dead space
hypoxemia
hyperventilation

92
Q

What is the classic triad of PE?

A

dyspnea, pleuritic chest pain and hemoptysis

93
Q

What are hemodynamic effects of PE?

A

Dec area of pulm vascular bed
Diffuse vasoconstriction
Inc pulm vascular resistance

94
Q

What is virchows triad?

A

hypercoaguality, venous status and vessel wall damage

95
Q

Clinical presentation of PE

A 
Dyspnea, sudden tachypnea, tachycardia
Cough
Chest pain 
Rales
Fever
Prominent S2
96
Q

PE risk factors

A

M>F mortality

Elderly, blacks, pregnant (post partum), smokers, OCP, ortho surgery at higher risk

97
Q

What is high risk wells score for PE? Moderate?

A

> 7 high

2-6 moderate

98
Q

What are PERC Criteria?

A

<50 yo
<100 bpm
O2 >95%
No hepoptysis, estrogen use, prior CVT or PE, unilateral leg swelling or recent surgery

99
Q

What is D-dimer test?

A

fibrin degradation product will be elevated in presence of thrombosis so if clot is present anywhere in the body it will be positive

100
Q

What is S1Q3T3?

A

wide deep S in lead I, both an isolated Q and T wave inversion in lead III

101
Q

Diagnostic signs of PE

A 
Wells prediction rule
Positive D-dimmer (if ⊖ r/o PE)
VQ scan (if CT contraind)
CT is go to if high likelihood 
Pulm angiogram 
CXR: normal but w/ hypoxiaavascular markings distal to the area of embolus ⊕westmarks sign or ⊕Hampton's hump
ECG: sinus tachy, S1Q3T3
ABG: ↑A-a gradient
102
Q

What is westmark’s sign

A

avascular markings distal to area of embolus

103
Q

What is Hamptom’s hump?

A

wedge shaped infiltrate (represents infarction)

104
Q

What is the go to study for high likelihood PE patients?

A

CT scan

105
Q

What patients should you use caution with for a CT scan?

A

young females, kidney failure pts

106
Q

What is the gold standard diagnosis for PE and why?

A

angiogram because you can diagnose and take it out at the same time if high suspicion

107
Q

What is the finding for venous ultrasonography that makes DVT very unlikely?

A

fully compressible veins

108
Q

What is mean pulm arterial pressure for Pulmonary HTN?

A

> 25 mmHg at rest or >30 mmHg during exercise

109
Q

Clinical presentation of pulmonary HTN

A

Dyspnea on exertion, fatigue, syncope, cyanosis, edema

Loud P2, systolic ejection click, ↑JVP

110
Q

Gold standard for diagnosing pulmonary HTN

A

R sided heart cath which shows that the mean pulmonary artery pressure is >25 mmHg

111
Q

Diagnostic features of pulmonary HTN

A

CXR: usually normal, may have enlarged heart or pulm arteries
ECG: P pulmonale, RAD, RBBB
Echo: ↑ size of RV
R heart cath shows mean pulm pressure >25

112
Q

Clinical signs of Cor pulmonale

A

Fatigue, tachypnea, dyspnea on exerttion, peripheral edema, angina
Early ejection click, split S2 with loud P2

113
Q

Diagnostic signs of cor pulmonale

A

ECG: P pulmonale
Echo: ↑size or R ventricle, regurgitate flow
R heart cath: ↑ PA pressure

114
Q

What is cor pulmonale?

A

abnormal enlargement of the R side of the heart as a result of disease of the lungs or the pulmonary blood vessels causing R sided heart failure

115
Q

What is the major limitation to gas movement in the body?

A

thickness and surface area

116
Q

When equilibrium is reached what is limiting exchange of gas at respiratory membrane?

A

perfusion

to get more O2 you need to inc blood flow

117
Q

When equilibrium is not reached what is limiting gas exchange?

A

diffusion

need to inc pressure gradient to increase O2

118
Q

What patients have limited diffusion capacity?

A

thickened respiratory membrane decreased surface area such as alveolar edema, pulmonary fibrosis and emphysema

119
Q

What is the net driving pressure for air movement into the lungs?

A

force of muscle contraction, lung compliance and airway resistance

120
Q

What is normal total lung capacity?

A

6 L

121
Q

When are elastic recoils of the lung equal but opposite?

A

FRC

122
Q

What is the function of surfactant?

A

reduce surface thension and increase compliance

123
Q

What is the major determinant of airway resistance?

A

radius

124
Q

What is the effect of stimulation of mAChR on bronchial smooth muscle?

A

bronchoconstriction and increased resistance

125
Q

What is the effect of stimulation of B2AR on bronchial smooth muscle?

A

bronchodilation and decreased resistance

126
Q

How do we estimate physiologic dead space?

A

Use concentration of CO2 in expired air and the concentration of CO2 in arterial blood

127
Q

What happens to PAO2 when PACO2 increases?

A

PAO2 decreases

128
Q

Why is PaO2 slighltly less than PAO2?

A

bronchial perfusion and thebesian channels

129
Q

What is the effect of sympathetic and parasympathetic regulation on pulmonary vascular resistance?

A

Sympathetic–>NE –> vasoconstriction

Parasympathetic–>M3–>vasodilation

130
Q

What is dead space

A

ventilated but not perfused

131
Q

What is a shunt

A

perfused but not ventilated

132
Q

What is the function of the medulla in control of respiration?

A

rhythm generator

133
Q

What is the function of the pons in control of respiration?

A

regulates medulla

134
Q

What is the function of the cortex in control of respiration?

A

conscious and emotional response

135
Q

What are J receptors?

A

within alveolar walls that are stimulated when capillaries are engorged with blood during pulmonary edema

136
Q

What is the effect of activation of central chemoreceptors?

A

hyperventilation in response to decreased pH and increased PaCO2

137
Q

What is the function of peripheral chemoreceptors?

A

when PaO2 decreases below 60 mmHg they increase ventilation

138
Q

What does it mean when A-a gradient is high?

A

O2 in alveolus is not getting into arterial blood efficiently

139
Q

What is pleural effusion?

A

fluid accumulates in pleural cavity and impairs breathing by limiting expansion of lung

140
Q

What are pink puffers?

A

emphysema hunches, barrel chest, weight loss, dyspnea non productive cough

141
Q

What are blue bloaters?

A

bronchitis, cough with mucus production, no barrel chest, cyanosis, obese

142
Q

What size particle can reach alveoli?

A

<4 micrometers with low water solubility

143
Q

What particles affect upper airway?

A

larger highly water soluble materials

144
Q

What are risk factors for silicosis?

A

mining, quary work, slate, granite, quartz, pottery sandblasting

145
Q

What are risk factors for berylliosis?

A

electronics, aerospace, ceramics, tool and dye manufacturing and fluorescent light bulb

146
Q

What are risk factors for byssinosis?

A

cotton exposure

147
Q

What are risk factors for silo filler disease?

A

nitrogen dioxide gas exposure

148
Q

What is the function of CFTR gene?

A

transport chloride ions across membrane

149
Q

What is the MC mutation in CFTR gene?

A

Delta F508

150
Q

What is the effect of a mutated CFTR gene?

A

reduces Cl concentration in the secretions drawing Na+ back into the cell and water follows so secretions become thick

151
Q

GI effects of CF

A

steatorrhea, pancreatitis, rectal prolapse, meconium ileus & plug

152
Q

Signs of acute exacerbation of CF

A

inc cough, sputum, dyspnea, RR, accessory muscle use, crackles or wheezes, decreased appetite and weight loss

153
Q

Pathophys of CF related diabetes

A

insulinopenia from B-cell apoptosis

154
Q

What is average life expectancy of CF patients?

A

about 40 years

155
Q

What is the MC cause of death in patients with CF?

A

respiratory failure

156
Q

Clinical presentation of CF

A

Failure to thrive, abnormal stools, nasal polyps, rectal prolapse, cough, wheezing, repeated infections, exercise intolerance, SOB, respiratory failure

157
Q

Epidemiology of CF

A

White> hispanic> AA
MC life threatening autosomal recessive Disease among whites

Men are infertile

158
Q

Clinical presentation of bronchiectasis

A

Chronic daily cough, mucopurulent sputum production, hemoptysis

159
Q

Pathophys of bronchiectasis

A

Airway insult causes inflam response and mucocillary destruction causing secretion stasis and bronchial obstruction and dilation

160
Q

RF of bronchiectasis

A

CF, HIV, toxic gas exposure, smoking, ciliary dyskinesia

161
Q

What are the hallmarks of acute bronchiectasis exacerbation?

A

Increasing cough, dyspnea, increase in sputum production of darker color and chest pain

162
Q

Epidemiology of bronchiolitis

A

Infants and young children

163
Q

Etiology of bronchiolitis

A

Respiratory syncytial virus (RSV)

164
Q

Clinical presentation of bronchiolitis

A

Starts with typical URI followed by nasal flaring, tachypnea, retractions, accessory muscle use, wheezing and hypoxia

165
Q

Diagnostic studies of bronchiolitis

A

CBC might be normal
Nasal swab for rsv
Chest X-ray shows air trapping (not recommended)

166
Q

Why is asthma worse at night?

A

decrease in catecholamines at night

167
Q

What causes symptoms associated with asthma?

A

bronchoconstriction, airway thickening and increased mucus

168
Q

Clinical presentation of asthma

A

Variable sx going on for >10 days and worse at night

Wheezing, SOB, chest tightness, cough

169
Q

What is hallmark of asthma?

A

hyperresponsiveness which is an exaggerated response to different stimuli

170
Q

What are triggers of asthma?

A

allergens, respiratory tract infections, airborne irritants, changes in weather, exercise, drugs

171
Q

What indicated poorly controlled asthma?

A

daytime asthma or reliever needed more than 2x a week, night time awakening, limitation

172
Q

How frequently should asthma be reviewed?

A

1-3 mo after start of treatment and then every 3-12 mo

1 wk after exacerbation

173
Q

What spirometry values indicate obstructive problem?

A

FEV1/FVC <70%

174
Q

What qualifies a patient as high risk for COPD exacerbations?

A

2 or more mild to mod or at least one severe exacerbation in past year

175
Q

Clinical presentation of emphysema

A 
Dyspnea
Minimal sputum production
Barrel chest but thin
Hyperresonance
↓ /abs breath sounds
↓fremitus
↑AP lat diameter
Pursed lip breathing and accessory muscle use
Tripoding
176
Q

Clinical presentation of chronic bronchitis

A 
Persistent productive cough with white/grey sputum
Crackles, rhonchi, wheeezing
Respiratory acidosis
Obese and cyanotic
Accessory muscle use
177
Q

What interstitial lung diseases have inflammatory neutrophilic profiles?

A

IPF, asbestos, silicosis

178
Q

What interstitial lung diseases have inflammatory lymphocytic profiles?

A

sarcoidosis, hypersensitivity pneumonitis

179
Q

What is the compliance of a normal human lung?

A

200 ml/cm H2O

180
Q

Clinical presentation of idiopathic pulmonary fibrosis (IPF)

A

Dry cough, progressive dyspnea on exertion , inspiratory crackles always heard
clubbing

181
Q

What is the survival rate of IPF?

A

<10 yr (50% to 5 yr)

182
Q

Clinical presentation of non-sepcific interstitial pneumonitis (NSIP)

A

Dyspnea, cough, fatigue, weight loss, basilar crackles, clubbing less common than in IPF

183
Q

Clinical presentation of respiratory bronchiolitis interstitial lung disease

A

Mild sx dyspnea, cough, smoking hx

184
Q

Clinical presentation of desquamative interstitial pneumonia

A

Insidious onset of dyspnea and dry cough and smoking hx

185
Q

Epidemiology of sarcoidosis

A

20-40 y AA females

186
Q

Pathophys of sarcoidosis

A

exaggerated T cell response to a variety of Ag causing granuloma formation

187
Q

Clinical presentation of sarcoidosis

A

low grade fever, fatigue, malaise, weight loss, occasionally night sweats, skin lesions, dyspnea, dry cough, vague chest pain

188
Q

Clinical presentation of hypersensitivity pneumonitis

A

Cough, SOB, fever, malaise, flu-like sx 4-8 hr after inhaling Ag lasting for 12-48 hr

189
Q

Define pneumoconiosis

A

accumulation of dust in lungs and tissue reactions to its presence (silicone, asbestos)

190
Q

What size nodule has a high probability of being malignant?

A

Strong concern for anything >5mm, high probability >20 mm

191
Q

What are benign patterns of nodules?

A

central, laminar and diffuse

192
Q

What are non-specific potentially malignant patterns of nodules?

A

popcorn, stippled, eccentric

193
Q

What are classifications of T3 tumor?

A

large (507 cm), invade something or have second tumor in same lobe

194
Q

Classifications of T4 tumor?

A

> 7 cm, invade something that cant be removed or get a second tumor in diff lobe or lung

195
Q

What is the N component of staging?

A

N0=no adenopathy
N1=intrapulm or hilar adenopathy
N2=ipsilateral mediastinal adenopathy
N3=contralateral or supraclavicular adenopathy

196
Q

What is M component of staging?

A

M=metastes
M1a=contralat involvement
M1b=single metastasis
M1c=multiple metastases

197
Q

What is low risk patient for surgical resection?

A

FEV1>2L
DLCO>60% predicted
Absence of heart disease

198
Q

What is high risk patient for surgical resection?

A 
PCO2>45
PO2 <50
FEV1<40% pred
DLCO<40% pred
>80 yo
poor exercise performance
199
Q

Define pancoast tumor

A

tumors in apex of lung that may invade contiguous structures (brachial plexus)
Show Horner’s syndrome with unilateral ptosis, meiosis and ipsilateral anhyrdosis

200
Q

What are the most common sites of metastasis?

A

lung, brest, colon and kidney

201
Q

What is horner’s syndrome

A

miosis, ptosis and anhydrosis

Clin Med Comprehensive (9 decks)

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