pulm Flashcards
3 types of lung cancers
small cell, squamous cell, adenocarcimoma
two lungs cancers associated with smoking
small cell and squamous cell
two centrally located lung cancers
small cell and squamous cell
two lung cancers with paraneoplastic syndromes
small cell and sqaumous cell
what do small cell and squamous cell lung cancer have in common?
smoking, centrally located, and paraneoplastic syndromes
small cell paraneoplastic syndrome
ACTH (cushing syndrome) and ADH (SIADH)
cancer with PTH-rp paraneoplastic syndrome
squamous cell
which cancer do you typically treat with resection?
adenocarcinoma, other two = chemo and radiation
what causes transudative pleural effusion
fluid leaking out of capillaries - CHF, nephrosis, cirrhosis
do oncotic and hydrostatic pressures lead to transudative pleural effusions?
yep
causes of exudative pleural effusions
malignancy, pneumonia, TB
what to do for pleural effusion in pt with CHF
diuresis - if fails, thoracentesis
Lights criteria
tells you if transudative pleural effusive
*** Lights criteria to be Transudative (T for Tiny, values must be LESS than in order to be Transudative)
LDH <200
LDH eff/serum <0.6
Protein eff/serou <0.5
*** white cells + lymphocytes in effusion
TB
do you tap in pt who has CHF, effusion < 1cm or effusion is loculated?
NO
*** what to do with effusion that has septations, lobes, is loculated
thoracostomy
Virchow’s triad
RISK OF COAGULATION - venous stasis, endothelial injury, hypercoagulable state (OCP, Factor V Leiden, malignancy)
*** OCP, Factor V leiden, malignancy = examples of
hypercoagulable state
> 2cm diameter between calves
suspect DVT = anti-coagulate
can a PE lead to pHTN?
YES, which would result in R heart strain
is pulmonary artery wedge pressure reflective of left atrial pressure?
YES
*** if PAWP is elevated, what can be cause?
something with left heart - left ventricular failure, MR, AR, MS, AS
*** PAWP > ? suggests HF
> 18 = CHF; when > 20 would expect to see resultant pulmonary edeuma
*** ABG of PE
hypoxemia, hypochloremia, met alkalosis
do you get a d-dimer when pre-test probability is high?
NO
definitive diagnosis of PE
CT scan with IV contrast, VQ scan
is VQ scan safe for bad kidneys?
YES, no contrast used
gold standard for PE diagnosis BUT is invasive, requires contrast
pulmonary angiogram
pt comes in with SOB, found to have discrepancy of calf diameter > 2cm - how to dx and tx?
with high clinical suspicion for PE, start anticoagulation; can firmly dx with CTA or VQ scan
how long to bridge warfarin for PE anticoagulation?
5 days or once INR is 2-3
types of anticoagulation for PE
Warfarin with heparin bridge OR NOAC
*** 4 progressive steps of COPD treatment?
SABA (albuterol)
LAMA (tiotropium, ipratropium)
LABA (salmeterol)
ICS (prednisone, methylprednisolone)
when O2 for COPD
sat < 88% or PaO2 < 55
goal O2 for COPD?
92-95
vaccines for COPD
Flu and pneumovac
COPD pt comes in with worsened SOB and increased sputum - what to do?
Abx treatment (macrolides), bronchodilators (ipratropium and albuterol) and steroids (PO prednisone or IV methylprednisolone)
if COPD pt is on salmeterol, what else are they likely on?
SABA (albuterol), LAMA (ipra/tio tropium)
*** eggshelll calcifications
silicosis, must get yearly Tb screens
what does silicosis predispose you to?
TB, get yearly ppd
reticulonodular process in lower lobes with pleural plaques
asbestosis
*** patchy lower lobe infiltrates
hypersensitivity pneumonitis
erythema nodosum, hilar LAD
sarcoidosis
why hypercalcemia in sarcoid?
macrophages make vitamin D
why optho referral in sarcoid?
uveitis
*** how dx and treat sarcoid?
dx with biopsy and tx with steroids
hypertrophic osteroarthropathy
acute new clubbing of fingers in patient with COPD, suspect malignancy and get CXR
*** role of FEV1 in COPD
prognostic indicator
adenocarcinoma metastasis
liver, bone, brain, adrenal glands
*** low PO4 and high Ca in pt with lung cancer
squamous cell carcinoma with parathyroid hormone paraneoplastic syndrome
shoulder pain, ptosis, constricted pupil and facial edema
superior sulcus syndrome from small cell carcinoma
sx from IgE mediated disease
urticaria, pruritus, angioedema, anaphylaxis
why SIADH in HIV?
pulmonary pathology like PCP, leads to hyponatremia
*** how to improve oxygenation with ventilator settings?
increase FiO2 or PEEP
role of PEEP
prevents alveolar collapse and may reopen already collapsed alveoli; life-saving in ARDS
what is the risk of prolonged high FiO2
oxygen toxicity with formation of free radicals
what do you expect of RR and blood gas acid status in asthma exacerbation
hyperventilation with hypocarbia since blowing off
1st step of asthma tx
SABA
2nd step of asthma tx
low dose ICS
3rd step of asthma tx
medium-dose ICS
4th step of asthma tx
medium-dose ICS + LABA
5th step of asthma tx
high-dose ICS + LABA
when do you add oral corticosteroids to asthma tx?
Step 6 (high-dose ICS + LABA + oral corticosteroids)
SABA a couple times a week and nighttime awakenings a couple times a month
step 1 - SABA prn
SABA 3 times a week and 3-4 nightly awakenings per month
step 2 - SABA + low-dose ICS
SABA daily and night awakenings weekly
step 3 - SABA + medium-dose ICS
SABA multiple times a day and night awakenings most nights during a week
step 4 or 5 - SABA + medium/high-dose ICS + LABA
*** must you be on a ICS before you start a LABA with asthma tx?
YES
tachypnea, low-grade fever, tachycardia, chest pain worse with coughing
PE
irregular RR intervals, absent P waves, narrow QRS complexes
a fib
is a fib associated with PE
yes
are the manifestations of PE variable and non-specfici?
yes
what oxygen information do we get from ABG?
PaO2
*** how do you calculate PAO2 to determine A-a gradient?
PAO2 = 150 - (PaCO2/.8)
*** what is age appropriate A-a gradient?
(patient age/4) + 4
what to do for an asthmatic pt with impending resp failure (absent wheezing, retention of CO2, decreased mental status)
intubate
severe asthma exacerbation tx
SABA, ipratropium, systemic corticosteroids
upper and lower respiratory tract disease and glomerulonephritis
granulomatosis with polyangiitis, vasculitis of small and medium sized vessel
*** how do you diagnose granulomatosis with polyangiitis?
ANCA antibody test, then tissue biopsy (may need to rule out HIV as + can muck up ANCA results)
*** otitis, sinusitis, dyspnea, hemoptysis, weight loss, fatigue, mild anemia
granulomatosis with polyangiitis
*** young adult male with kidney and lung pathology
Goodpasture’s disease, Ab against protein of glomerular and alveolar basement membranes
*** how to dx Goodpasture’s disease?
renal biopsy demonstrating linear IgG deposition along membrane
HIV with CD4 < 200, dyspnea and non-productive cough
PCP
Osler’s nodes, Roth’s spots, Janeway lesions, splinter hemorrhages, new onset heart murmur
endocarditis
can people who had pulmonary TB develop a chronic pulmonary aspergillosis in the future?
YES
Aspergillus is a ______ and thus is treated with _____
Aspergillus is a fungus and treated with azoles!
how does pneumonia cause hypoxemia
right-to-left intrapulmonary shunting and V/Q mismatch
pulsus paradoxus
cardiac tamponade; > 20mg blood pressure change with inspiration
cancer and SOB
think PE!! cancer is part of Virchow’s triangle (hypercoagulability of malignancy)
low arterial perfusion (hypotension, syncope), acute dyspnea, pleuritic chest pain, tachycardia
massive PE - leads to RV dysfuction and resultant hypotension
*** a pt has a suspect effusion/mass in lung, what to do?
TAP, if negative but still suspect mass then do bronchoscopy BUT if + then proceed with further imaging etc to qualify but no need for bronchoscopy
you identify a coin lesion in the lungs by XR, but it is stable when compared to previous XR 2 years ago - malignant? workup?
benign if stable for 2-3 years, no work-up required
increased lung compliance, air-trapping, functional residenual and total lung capacities
COPD
*** immunocompromised + pulmonary nodules with surrounding ground-glass opacities + thick sputum
acute aspergillosis
pt has acute exacerbation of COPD, what to do?
SABA, ICS, antibiotics – and if doesn’t improve start non-invasive ventilatory support
