Pulm Flashcards
anti IgE monoclonal antibody
omalizumab
tx of asthma steps 1-6
1 - SABA
2- SABA + low dose ICS
3 - SABA + ICS + LABA
4 - SABA + max dose ICS + LABA + tiotropium
5 - SABA + ICS + LABA + tio + omalizumab (high IgE)
6 - add oral corticosteroid
severity of asthma and tx
intermittent - day sxs = 2/week, night sxs = 2/mo; tx: step 1
mild persistent - day sxs > 2/week but not daily, night sxs 3-4/mo; tx: step 2
moderate persistent - daily sxs, night sxs weekly; tx: step 3
severe persistent - sxs throughout day, almost nightly sxs; tx: step 4-5
tx of exercise-induced bronchoconstriction
administer SABA 10-20 mins before exercise
leukotriene inhibitor used as alternative long term control (versus ICS) in patients with asthma and atopy; hepatotoxic and asso with Churg-Strauss syndrome
zafirlukast
what can you use in acute, severe asthma exacerbation not response to several rounds of albuterol, while waiting for steroids to take effect?
magnesium - helps relieve bronchospasm
ECG findings in COPD
RA hypertrophy and RV hypertrophy
A fib and multifocal atrial tachycardia (MAT)
measures that improve mortality in COPD patients
smoking cessation, oxygen therapy (directly proportional to the number of hours that the O2 is used), and flu/pneumococcal vaccines
criteria for oxygen use in COPD
pO2 below 55 or O2sat below 88%
OR
if there are signs of right HF / strain:
pO2 below 60 or O2sat below 90%
supplemental O2 improves hypoxia but can cause CO2 retention by the following mechanisms
- loss of compensation vasoconstriction in areas of ineffective gas exchange
- Haldane effect: increase in oxyHb recudes uptake of CO2 from tissues
- loss of respiratory drive and lower RR –> lower MV (MV = RR x Tv)
hypercapnia does what to brain vessels
cerebral vasodilation –> can induce seizures
hypersensitive of the lungs to fungal antigens that colonize the bronchial tree; occurs almost exclusively in patients with asthma and hx of atopic disorders
allergic bronchopulmonary aspergillosis (ABPA)
asthmatic patient with recurrent episodes of brown-flecked sputum and infiltrates on CXR
ABPA - tx w steroids, recurrent episodes with itraconazole
CF inheritance
autosomal recessive
CF and endocrine/exocrine function of the pancreas
affects transport across apical surface of epithelial cells in exocrine glands (pancreatic insufficiency –> steatorrhea with vitamin A, D, E, and K malabsorption) but islets are spared - beta cell function (endocrine) is normal until much later in life
dx of CF: which test is most accurate?
sweat test (induce with pilocarpine) > genotyping
PFTs in CF
show mixed obstructive and restrictive pattern
ivacaftor
increases activity of CFTR in 5% of CF patients who have a specific mutation
common pathogens in CAP and their associations COPD - recent viral infection - alcoholism and DM - poor dentition and aspiration - young, health - hoarseness - contaminated water sources, ACs - birds - animals giving birth -
common pathogens in CAP and their associations
COPD - Haemophilus
recent viral infection - Staph
alcoholism and DM - Klebsiella
poor dentition and aspiration - anaerobes
young, health - Mycoplasma (asso with bullous myringitis)
hoarseness - Chlamydia pneumoniae
contaminated water sources, ACs - Legionella
birds - Chlamydia psittaci
animals giving birth - Coxiella burnetti
infections asso with dry cough
Mycoplasma, viruses, Coxiella, PCP, Chlamydia - these infection preferentially involve the interstitial space (–> bilateral interstitial infiltrates on CXR) and more often leave the space of the alveoli empty –> less sputum production –> dry cough
atypical PNA
organism that is not visible on Gram stain or cultural on standard blood agar
empyema labs
LDH > 60% of serum level, protein >50% of serum level; WBC >1000 or ph <7.2
infected pleural effusion or empyema will respond most rapidly to
drainage by CT or thoracostomy
CURB65
confusion, uremia (BUN >20), RR >30, BP low, >/= 65 yo
Definition and tx of HAP
= PNA developing >48 h after admission or <90 after discharge
Tx:
- antipseudomonal cephalosporin (CEFEPIME or CEFTAZIDIME)
OR
- antipseudomonal penicillin (PIPERACILLIN/TAZOBACTAM)
OR
- CARBAPENEM*
*note IMIPENEM can cause seizures, esp if its kidney excretion is impaired
Tx of VAP
combine 3 different drugs
1st) 1 drug from those used in the tx of HAP
2nd) a second antipseudomonal
- an aminoglycoside* (GENTAMICIN, TOBRAMYCIN, AMIKACIN)
OR
- a fluoroquinolone (CIPRO, LEVO)
3rd) MRSA agent (VANC, LINEZOLID)
*DAPTOMYCIN should never be used for lungs - it is inactivated by surfactant
Tx of CAP
healthy patient with no abx in the last 3 months - MACROLIDE or DOXY
patient with comorbidities or abx in the last 3 months - FLUOROQUINOLONE
Inpatient (CURB65): IV FLURO or [CEFTRIAXONE + AZITHRO]
lung abscess abx’s
clindamycin or penicillin
PCP workup
CRX - bilateral interstitial infiltrates
ABGs - hypoxia, increased A-a gradient
Elevated LDH levels (a normal LDH means you should not answer PCP as the most likely dx)
Sputum stain, if negative –> bronchoalveolar lavage
tx of PCP
TMP/SMX, atovaquone, primaquine (C/I in G6PD def) or clinda, pentamidine
for ppx: TMP/SMX, atovaquone, dapsone (also C/I in G6PD def), pentamidine (least efficacious)
add steroids to decrease mortality if PCP is severe
Diagnostic test for TB
the best initial test if CXR. sputum and culture specifically for acid-fast bacilli - must be done 3x to fully exclude TB. pleural bx is the single most accurate test
tx of TB if positive smear
RIPE thx; you do not need ethambutol if the organism is sensitive to all the others; after RIPE for first 2 months, stop and ethambutol and pyrazinamide and continue rifampin and isoniazid for 4 months - total of 6 months
tx is extended to >6 months for osteomyelitis, miliary TB, meningitis, pregnancy (because you can’t use pyrazinamide)
use glucocorticoids to decrease the risk of constrictive pericarditis in those with pericardial involvement; they also decrease risk of neurologic complications
adverse effects of antiTB medications
Rifampin - red secretions
Isoniazid - peripheral neuropathy - give pyridoxine
Pyrazinamide - hyperuricemia
Ethabutol - optic neuritis, affects color vision - renally dose
which one has the highest sensitivity? PPD (purified protein derivative) or IGRA (interferon gamma release assay)?
equal sensitivity
IGRA has no cross reactivity with BCG, IGRA is preferred because only one visit is needed
if a patient never had PPD test before…
a second test is indicated within 1-2 weeks if the first test if negative
if patient test positive with PPD and has negative CXR…
receive 9 months of isoniazid with pyridoxine - reduces lifetime risk of TB from 10% (in those who test positive) to 1%
berylliosis
similar to sacoidosis, presence of granulomas, respond to steroids
agents to decrease progression of idiopathic pulmonary fibrosis
pifenidone and nintedanib (inhibit collagen synthesis and fibroblast activity, respectively)
sarcoidosis presents with
parotid gland enlargement, facial palsy, heart block and restrictive cardiomyopathy, CNS involvement, iritis and uveitis
modified Well’s criteria for pretest probability of PE
3 points
- clinical signs of DVT
- alternative dx less likely than PE
- 5 points
- previous PE/DVT
- HR >100
- recent surgery or immobilization
1 point
- hemoptysis
- cancer
> 4 - PE likely –> CT or V/Q scan if pregnant –> if negative, do LE doppler
= 4 - PE unlikely –> D dimer
imaging for PE
CT angiogram - same as spiral CT
use V/Q scan in pregnant patient
if negative, do LE doppler
Angiography is the most accurate test but has 0.5% mortality
tx of PE
LMWH (enoxaparin) followed by NOAC (xabans, dabigratran) or warfarin
NOACs have rapid onset (no need for bridging thx), no need for INR monitoring, less intracranial bleed than warfarin
if patient develops HIT –> fondaparinux
dabigatran can be reversed by idarucizumab
when is IVC filter the right answer?
- anticoagulant C/I
- recurrent emboli while on anticoagulant or therapeutic INR
- RV dysfunction - because the next embolus could be fatal
when are thrombolytics the right answer?
- HD unstable patient
- acute RV dysfunction
adenocarcinoma of the lung: incidence, location, associations
50%, peripheral, clubbing and hypertrophic osteoarthropathy (clubbing + sudden onset hand and wrist joint pain)
squamous cell carcinoma of the lung: incidence, location, associations
25%, central, necrosis and cavitation, hypercalcemia
small cell carcinoma of the lung: incidence, location, associations
15%, central, Cushing, SIADH, Lambert-Eaton
large cell carcinoma of the lung: incidence, location, associations
10%, peripheral, gynecomastia, galactorrhea
first step in the management of newborn with respiratory compromise
endotracheal intubation; bag-and-mask ventilation can exacerbate respiratory decline
tx of anaphylaxis
IM epinephrine - note additional doses may be required for refractory sxs
common lung manifestation of systemic sclerosis
pulmonary artery hyperTN –> RV enlargement and HF –> RV heave on physical exam
hypotension, JVD, and new onset RBBB in postop patient
massive PE
recurrent PNA with unchanging area of consolidation
must r/o lung malignancy causing localized airway obstruction
first line tx of SIADH
fluid restriction
