Pulm: Block 1 Flashcards
What is the pathophysiology of COPD
How does it present and what is seen on PE?
Abnormal and permanent enlargement of airspace due to wall destruction
Older PT w/ smoking Hx w/ Dyspnea
Dec sounds
Hyperresonance
What will be seen on diagnostic studies of COPD?
What are two complications that can arise from emphysema?
Dec FEV, Inc TLC
Pneumothorax from bullae
Weight loss due to breathing efforts
What mechanism allows us to breathe?
TP: 4mmHg, inflate
TTP: -4mmHg, deflate
TRP: air flow to/from atmosphere and to/from lungs
-4mmHg in interstitial space pulls lungs during inspiration
What is the criteria to receive the term ‘blue bloater’?
What will be seen/heard on exam and PFT?
Productive cough x3mon for two consecutive years
Inc resonance Dec sounds Accessory muscle use FEv/FVC ratio <0.7 FEV <80%
What are the two causes of the Cor Pulmonale showing in Blue Bloaters?
What is the most common and four less common causes of bronchiolitis?
RV failure
PHTN
MC= RSV LC= Parainfluenza, Rhino, Influenza, Metapneumo
How is bronchiolitis Dx and Tx
What are three potential complications?
What is the most common cause of Acute Bronchitis and how does it present?
Child under 2yrs w/polyphonic wheezes and ralesafter 1-3 day URI; Tx w/ Support
Dehydration, Apnea, Aspiration pneumo
Viruses- productive cough <1wk
Tx: support, dilators
How does acute bronchitis present?
What are the 6 viruses that can cause acute bronchitis?
What 3 bacteria could cause acute bronchitis?
Cough x 5days or more
Non/purulent sputum
URI prodrome
RPM RIC
Rhino Parainfluenza Metap
RSV Influenza Corona
Bordatella pertussis
Mycoplasma pneumo
Chlamydia pneumo
How does bronchiectasis present?
What will be seen on imaging of bronchiectasis
How is the Dx confirmed?
Large amount of sputum
Crackles and wheezing
Tram tracks- dilated and thickened airway
CT: Signet ring sign (wall thickening and plugs_ and
Tree-in-bud (trapped debris)
What is the most common cause of bronchiectasis
How is it Tx?
CF
Therapy Hydrate ABD Dilator
Define Bronchiectasis
What type of airway dz is it?
What vaccine has significantly reduced the prevalence of epiglottitis?
Dilation w/ decreased airway clearance causing mucus pooling
Obstructive
HIB
What are the top three the most common causes of URIs?
How do these PTs present?
How is it Tx?
Strep Pneumo- MC, in carriers
HIB- unvaccinated Peds PT
Moraxella- smokers
Rapid onset fever/dysphagia
Stridor, Tripod, drooling
Thumb sign on x-ray
ABX (Cephtriaxone, Vanc)- safe for young, old, pregnant
What is the full term of Croup
Croup is most commonly caused by ? and in ? age PT
How is Croup Tx?
Laryngotracheitis
Parainfluenza virus, 6mon-3yrs
Cool temps
Dexameth, Racemic Epi
What respiratory sound is made in Croup PTs and what Sx is rarely seen?
What hallmark image is seen on x-ray for these PTs?
What is the difference between this fever and epiglottitis fever?
Inspiratory stridor
Rare= hypoxia
Steeple sign on PA view
Croup: low, non toxic PT
Epiglottitis: high, toxic PT
Who and how does Bacterial Tracheitis present?
How is this one different?
What meds are used to Tx Bacterial Tracheitis
What is different about these PTs Tx process?
3-5y/o w/ high fever (+102), barky cough, stridor
Toxic appearing
Pseudomembrane development
IV Ceftriaxone/Vanc
IV fluids
Sedate, Intubate, Bronchoscope
How does influenza appear in clinic?
How is Influenza Dx
How are they Tx and what med can be given to high risk PTs if Dx is made within 48hrs
HA Myalgia Fevers Sudden onset fever Non-productive cough
Reverse PCR, rarely culture
Support- PO fluids
Oseltamivir- don’t use w/ statin due to liver damage
What is the most common cause of viral pneumonia in adults?
What are the differences between the three types of this microbe
How is this microbe spread?
Influenza
A: pandemic (PT more sick)
B: epidemic
C: sporadic
Respiratory droplet
What microbe causes Whooping Cough?
How does this present?
Bordetella Pertussis
Hx of nasal congestion, Cough
Low fever
Repetitive cough, whoop, post-cough emesis
What med is used to Tx Pertussis?
What are the three stages of pertussis?
Azith. preferred <1mon
Alt: TMP/SMX if macrolide c/i
Catarrhal- 1-2wks; fever, non-productive cough, rhinorrhea
Paroxysma- 2-6wks; whooping, stridor
Convalescent- 1-2wks; reduced Sxs
What microbe is the most common cause of bacterial pneumonia?
What can be seen on PE to ID this?
Strep Pneumo
Rust colored sputum, Gram Pos
What microbe is the most common cause of pneumonia in alcoholics?
What is the most common cause of pneumonia in drug users?
Klebsiella- currant jelly sputum, bulging fissures
Staph A: gram pos cocci in clusters seen post influenza, most dangerous
What is the most common cause of pneumonia in CF, nursing homes and cyanosis?
What microbe is most common cause in COPD PTs and is usually post-URI?
Pseudomonas
H Infleunza, gram NEG pleomorphic rods
What are the two microbes most likely to cause health care associated pneumonia?
How are pneumonias Tx?
Pseudomonas
MRSA
Outpatient, healthy: Macrolide or Doxy*- few s/e, no QTc lengthening
OutPT w/ comorbidity/Inpatient: respiratory flouroquinolone
ICU: Ceftriaxone/Cefotaxime and Azith or Respiratory fluoroquinolone
What comorbidities in a pneumonia PT change the Tx protocol?
“Walking Pneumonia” can be from what six microbes?
DM, HTN, Obese, Apnea
CCC FML Chlamydia Pneumo(mild) Chlamydia Psitt. Cox Burnetti F. Tularemia Mycoplasma pneumo (young PTs) Legionella Pneumo
Most common cause of Typical CAP, follows URI/influenza and has acute onset
May follow influenza, cavitary and possible MRSA
Present in DM, ImmComp, long term care facilities and aspiration pneumonia
Chronic lung Dz PTs or PTs on mechanical vents
Strep Pneumo- rust color sputum
Staph A
Klebsiella
Pseudomonas
What are the five atypical organisms that can cause
atypical pneumonia?
Mycoplasma- young adult, NOT visible on x-ray
Legionella- hot tub, GI, Neuro, effusions
Chlamydia Pneumo- young adult after pharyngitis
Cox Burnetti- livestock, inc LFTs
Chlamydia psittaci- parrott exposure, temp/pulse dissociation
What microbe cause pneumonia after exposure to birds, NOT parrot?
Define Bullous Myringitis
Birds: Crypto Neoformans, H Capsulatum
Hemorrhagic bleb on TM during Mycoplasma Pneumonia
Tx w/ macrolide
What is the presenting cough Sx of atypical pneumonia?
How are Atypical Pneumonias Tx and what classes are avoided?
Non-productive cough
Rales
Interstitial infiltrate (CXR)
Tetracyclines- D/T
Macrolides- A/C
Fluoroquinolones
NO: B-Lactam/Sulfonamides
PT w/ Histoplasmosis probably has ? travel Hx and exposure?
How does this appear on CXR?
How is it Dx and Tx?
Fungal infection from Ohio-Mississippi valley, bird/bat droppings
Solitary pulmonary calcification
Hilar/mediastinal adenopathy
Sputum culture
Itraconazole/Amphotericin B
What causes Pneumocystitis Pneumonia
How do these PTs present?
What will be seen on lab work and imaging of PCP?
How is it Tx?
HIV Hx, most commonly from Pneumocystitis jirovecii
Gradual onset of non-productive cough
CD4 <200
Inc LDH
Bat wing pattern CXR
TMP-SMX
Steroids if PaO2 <70% or A-gradient >35
What will be seen on CXR of TB?
How are these Dx?
Primary/Latent: Ghon focus
Reactivation: cavitary in upper lobes
Primary/Latent: PPD
Reactivated: sputum smear for acid fast bacilli or, culture for AFB
What causes carcinoid syndrome?
How do these PTs?
How is Carcinoid Syndrome Dx?
Neuroendocrine tumor secreting histamine, , prostaglandins peptides catecholamine serotonin
Skin flush, wheezing, diarrhea
5-HIAA collection x 24hrs
What are non-pulmonary Sxs indicative of metastases?
What lab results will be seen in PTs w/ Carcinoid Syndrome?
What is this the leader of?
Hip/back pain
Horners (Pancoast)
Neuro Sxs
Tachy w/ HOTN
HyperCa
Cancer related death among men and women
What type of lung nodule is most likely benign and malignant?
Benign:
Fast/no growth on Q2yr images
Popcorn pattern,
Multiple nodules <5mm Lifelong non-smoker, <30y/o w/ no CaHx
Malignant: >2.5cm, Spiculated
Upper lobe
Multiple pulmonary nodules +1cm in diameter
PT >30y/o w/ smoking or CaHx
What is the most common cause of the two type of pleural diseases?
What will be seen on PE for these PTs?
How are these Dx?
Transudative: CHF
Exudative: infection (bacterial pneumonia)
Dec sounds
Dec tactile fremitus
Dull percussion
CXR w/ costophrenic and cardiophrenic angles, loss of diaphragm/apex silhouette
How are pleural Dzs Tx?
How are Transudative and Exudative differentiated?
Thoracentesis
```
Light’s Criteria-
Transudate:
Protein <0.5
Serum LDH <0.6
LDH <2/3 upper limit
HF PE Cirrhosis Nephrotic
~~~
What will be seen on PE of a Spot Pneumo?
What will be seen on CXR?
How are they Tx?
Dec sounds
Dec fremitus
Hyper resonance
Absence of lung markings
<20%= observation w/ O2 >20%= chest tube
What type of BP is seen in Tension Pneumos?
What is the most common chronic and acute cause of compromised pulmonary circulation
How doe they present?
How is it Tx?
HOTN w/ JVD
Chronic: COPD
Acute: PE
R side HF
Edema
Dyspnea
R heart cath
What is the most common presenting Sx and Sign of VTEs?
What would be seen on EKG?
Sx: dyspnea
S: tachypnea
Sinus tachy, S1Q3T3
What is Virchow’s Triad
What would be seen on CXR of VTE?
What is the TOC in mod/high probability cases?
Stasis, Trauma, Hypercoag
Hampton hump- pleural based wedge infarct
Westermak sign- vascular cutoff sign
CT pulmonary angiography
Alt Test= VQ if bad kidneys
What is Well’s Criteria
PE Risk Score
S/Sxs of DVT= 3 DDx less likely than DVT= 3 HR >100= 1.5 Imm/Surgery in 3 days/4wks= 1.5 DVT/PE Hx= 1.5 Hemoptysis= 1 Malignancy w/ Tx in past 6mon= 1
0-2= low 3-6= mod >6= high
How do restrictive pulmonary Dzs present?
How do Restrictive Pulmonary Dz appear on diagnostic studies?
How is it managed?
Male w/ Hx of smoking and chronic dry cough w/ dyspnea (smoking, dust exposure, GERD)
Dec FVC and FEV
Near normal FEV/FVC ratio
CXR w/ honey comb
O2, Pulm rehab
What two findings are seen in in PHTN?
What are the origins of each type of Pneumoconiosis: Beryillosis, Silcosis, Siderosis, Stannosis, Byssinosis
RVH, elevated Pulm Pressure +25mmHg
Asbestos: ship, roof, plumbing Bery: aerospace/fluorescent Sill: miner, sandblasting Side: arc welder, iron Stann: tin Byss: cotton
What is the key highlight for pneumoconiosis?
Which origins of pneumoconiosis affects the upper/lower lobes of the lungs?
How do pneumoconiosis PTs present
Dec lung volume
Up: Silica, Coal, Bery, Talc
Low: Cobalt/hard metals, asbestosis
Dyspnea
Non-productive cough
Chronic hypoxia
How does pneumoconiosis appear on Dx studies?
Define Lupus Pernio and where is it seen?
CXR shows interstitial fibrosis
Dec volume
Raised plaques and nodules on face, pathognomonic for Sarcoidosis
What is seen on lab work and CXR of PTs w/ Sarcoidosis
How are these PTs managed?
HyperCa
Elevated serum ACE
CXR= hilar adenopathy
Mediastinal node biopsy= noncaseating granuloma is Dx
Steroids
What are S/Sxs that can be seen in Sarcoidosis?
What can obstructive sleep apnea lead to?
How are these PTs managed?
LUB pH
Lupus Uveitis Bells Polyarthritis Hemoptysis
PHTN, Cor Pulmonale (RVH)
CPAP, Life style changes
What is the pathphysiology of ARDS?
What is the most common cause of ARDS?
How do PTs present during PE?
Aveolar damage increasing permeability causing pulmonary edema
Sepsis
Hypoxemia refractory to O2
What is seen on Dx studies of ARDS PTs?
What can cause ARDS?
How is ARDS managed?
Bilateral infiltrates
PA wedge pressure <18
PaO2 <300mmHg
Inc A-gradient
Neurogenic pulm edema Transfusion injury High altitude Opioid OD PE Eclampsia
Ventilation w/ PEEP
Neonatal/Infant Respiratory Distress Dz is AKA ?
What causes Hyaline Membrane Dz
How does this look on CXR?
How is it Tx?
Hyaline Membrane Dz
Surfactant deficiency in premature as respiratory difficulty hrs after birth
Dec lung volume, Ground glass
Intubate, O2, CPAP, Surfactant
What is used for Step 1-6 of Asthma Tx?
1: SABA
2: Low dose CCS
3: Low dose CCS + LABA or Medium dose CCS
4: Med dose + LABA
5: High dose + LABA (Allergies= +Omalizumab)
6: High dose + LABA + PO CCS (Allergies= +Omalizumab)
How do PTs w/ HyperK present?
How does it look on EKG?
Brady, HOTN, dysrhythmia
Lethargy, paralysis
Peaked T
Prolonged PR
Wide QRS
How is hyperkalemia Tx?
If a PT is acidic, they are ?
Ca gluconate to stabilize cell membrane
Insulin/albuteral/BiCarb to redistribute K
HyperK
How do HypoK PTs present?
What will be seen on EKG?
Weak, Hyporeflexia, Cramps
U waves
Flat T
QT prolongation
ST depression
What will happen if HypoNa is Tx too fast?
What is the most common cause of HyperCa
Central Pontine Myelinolysis
Malignancy, Squamous Cell CA (inpatient) Primary hyperparathyroidism (outpatient)
Finding cervical/supraclavicular adenopathy can be the first PE finding indicating what two issues?
What issue can cause vessel engorgement of the head and neck?
Thoracic malignancy
Mycobacterial infection
Superior vena cava syndrome
What is the initial test for any PT presenting w/ hemoptysis?
Oxygen content in arterial blood depends on what two things and tissue perfusion needs what 3rd factor?
CXR
PO2
Hg level
CO
Ventilation is affected by what 3 factors?
What factor increases or decreases alveolar surface tension?
Airway resistance
Alveolar surface tension
Lung compliance
Water/fluid- inc
Surfactant- dec
What causes a left shift/increased affinity?
What causes a right shift/decreased affinity?
Inc pH (alkaline)
Dec PCO2
Dec temp
Dec pH (acid)
Inc PC02
Inc temp
Define DLCO
What med can be used to stimulate someone to hyperventilate?
Orthopnea is most commonly caused by ? but also could be from ?
Diffusing capacity of lungs for carbon monoxide
Epi
CHF
Secretions (pulonary dz)
Diaphragm weakness
Since there are no pain fibers in the lungs, PTs w/ pulmonary chest pain is indicative of an issue where?
What types of pain are indicative of CA?
Pleura Diaphragm Mediastinum
Diaphragm pain referring to shoulder
Pleural pain localized to chest wall
Both inc pain w/ inspiration
Define Tachypnea
Define Kussmaul breaths
Breathing due to dec tidal volume
>20/min
Rapid, large volume breaths due to metabolic acidosis
Define Cheyne Stokes
What breathing pattern is a precursor to respiratory failure?
Rhythmic waxing/waning tidal volume w/ apenic periods (high altitude, LV failure, Neuro dz)
Rapid, shallow breaths
Where and why do we palpate during a pulmonary PE?
What findings on percussion mean ?
Trachea- mediastinal shift
Posterior wall- fremitus, egophony
Anterior wall- cardiac impulse
Dull= consolidation, effusion (pneumonia) Hyper= emphysema, pneumothorax
Central bronchial lung sounds normally have what 4 characteristics?
What do wheezes sound like and what are they associated w/?
Louder High pitch, Hollow, Louder on expiration
High pitched, musical, whistling
Bronchospasm, edema/secretions
What do rhonchi sound like and what are they associated w/?
What do crackles sound like and what are they associated w/?
Low pitch, gurgling
Origin of large airway, cleared w/ cough; due to secretion, collapse
Brief, popping
Fine= Fibrosis, early pulmonary edema
Course= pneumonia, obstructive dz, CHF
What are four groups of PTs that can have clubbing?
What are two populations clubbing is not common in?
Chronic infections
AV malformation
Malignancy
Interstitial dz
Asthma COPD
PHTN is mPAP +_ and measured via ?
+25mmHg
R heart cath
Severe= +35 or
+25 w/ high RA pressure Cardiac index is <2L/min
What are the five classification s of PHTN?
What contrast is used in perfusion/ventilation scans when looking for PEs?
1: pulmonary arterial HTN
2: left side Heart Dz
3: chronic lung dz/hypoxemia (Cor Pulmonale)
4: chronic thromboembolic dz
5: unidentified mechanisms
Radioactive albumin- perfusion
Radioactive gas- ventilation
What are PET scans used for?
What Dzs are located in the basal lung?
ID and staging of CA
SAID PAB Scleroderma Aspiration Intersitial fibrosis Drug reaction Panlobar emphysema Asbestosis Bronchiectasis
What is the imaging modality of choice for assessing lung cancer or malignant mesothelioma?
When are VQ scans preferred?
MRI
RF PE Pregnancy
What are two ways lung function is evaluated?
What is the “sixth” VS?
What 3 pieces of info are required for pulmonary function tests?
What two pieces are sometimes used?
PFTs ABGs
Pulse Ox
Height Age Gender
Race Weight
What are the c/i to conducting a pulmonary function test?
What is the most available and useful PFT?
Severe asthma Hemoptysis Angina Active TB Respiratory distress Pneumothorax
Spirometry- measures volume exhaled in time
What does the Flow-Volume Loop do for testing?
What are the two parts?
Graphs max inspiratory and exhalation efforts
Flow vs volume
FEV1- effort dependent
Latter- effort independent and accurately reflect properties of lungs and resistance to flow
What does Forced Vital Capacity indicate?
What does it measure and indicate?
Degree of expansion
Measures total amount of air blow, out as fast as possible after inhaling as deeply as possible.
Good indicator of effort
Measures volume
What does an FEV1 measurement indicate?
What does this measurement indicate and measure?
Effort dependent
Patency of large airways
Indicates large and small airway function
Measures volume
What is the FEV1/FVC ratio
What does a low or high ratio indicate?
% of FVC in 1st second of effort based on Height/Age
Low: Obstruction
High: Restriction
FEF 25-75 is AKA and indicates ?
What does it measure?
MMEF rate
Patency of small airways, more sensitive for early obstruction
Measures FLOW of forced expiration
What part of the pFT is the least effort dependent?
What does this part of the test measure?
FEF25-75
Flow
What are the 4 things that can cause a “scoop” pattern on a spirometry test?
What are 4 things that can show a restrictive pattern?
Asthma
Bronchiectasis
COPD/CF
SAID OK
Scoliosis ALS Interstitial Dystrophy Obese Kyphosis
Obstruction and Restriction category %s
O- Mild: >80% Mod: 50-80% Sev: 30-50% VSev:<30%
R- M: 65-80% Mod: 50-65% Sev: 30-50% VSev: <30%
Lung volume measurements are useful when ?
What test is the gold standard for assessing PTs w/ obstructive sleep apnea?
Define Diffusing Capacity and when is it useful
Spirometry shows dec FVC but not normal ordered PFT
Body Plethysmography using Boyle’s Law
Measures rate of alveolar/capillary gas transfer
Infiltrative dz, Emphysema
Diffusing capacity is useful in differentiating between ?
These test results are dependent on what two factors?
Emphysema (Low) vs Chronic Bronchitis
Alveolar surface area
Pulmonary blood flow
Measure HgB first if PT is anemic
What can cause the Diffusing Capacity to be elevated?
What would cause it to be decreased?
When would these results be seen as normal?
Pulmonary hemorrhage
Acute HF
Asthma
Emphysema
Interstitial lung dz
Pulmonary vascular dz
Asthma
Chronic bronchitis
What is deemed as one of the most clinically valuable tests of lung function?
SpO2 measurements take what 3 physiological factors into assumption?
Transfer Factor for Carbon Monoxide (TLCO)
pH, PCO2, Hgb
SpO2 is useful for what two things?
What is the 40-50-60 SpO2 assumption rule?
Today Britanie taught something cool- Minus 30 rule
Tracking trends
Detecting Hgb saturation changes
SpO2 / PaO2
70%/40mmHg
80%/50mmHg
90%/60mmHg
What are the 3 categories of cough?
What is the MC cause of an acute cough?
Acute: <3wks
Subacute: 3-8wks
Chronic: > 8wks
Viral respiratory tract infection (acute bronchitis)
Others: Pneumonia, PE
When is a CXR needed in a PT w/ a cough?
Elderly PTs may not present w/ S/Sxs of pneumonia, what VS need to be assessed?
Pulse >100
Resp >24
Temp >100.4
Crackles/consolidation
Mental status
Respiration
SpO2
What is the most common cause of sub-acute coughs?
What are the most common causes of chronic coughs?
Post-infectious
Post nasal drainage- AKA Upper Airway Cough Syndrome
Asthma
GERD
What is the most common cause of chronic cough in non-smokers?
What are other causes?
Post Nasal Drainage
Non/Allergic rhinitis
Vasomotor rhinitis (hot to cold)
Chronic sinusitis
What etiology of chronic cough usually presents w/ more severe S/Sxs?
What part of the PE findings are irrelevant for this issue
Sinusitis
Color of sputum
When are ABX given to a chronic cough?
What meds are given to chronic cough (PND) PTs?
PND w/ proven sinusitis on imaging, can be clinically silent
Intranasal CCS
PO Montelukasts Antihistamines Decongestants
What is the second most common cause of chronic cough?
What is the work up process for chronic cough due to asthma?
Asthma- cough variant asthma- wheeze, tight chest, exertional dyspnea
Methacholine/Histamine challenge w/ response
Spirometry shows reversible obstruction
What meds are used for Chronic Cough from asthma?
What meds are given to PTs w/ Chronic Cough due to GERD?
What is the last resort/last Tx option for Chronic Cough due to GERD?
ICS w/ SABA
PO montelukast if ICS isn’t available
PPIs- Ome/Lansoprazle
Should improve in 3mon
Nissen Fundoplication
What will be seen on PE/CXR of chronic bronchitis
What imaging is used if CXR is not Dx?
Base crackles
Tracks/Rings in dilated mucus filled bronchi
CT- TOC
What is the imaging definition of Bronchiectasis?
What meds are used for this Dz?
Bronchus larger than adjacent pulmonary artery and bronchi visible w/in 1cm of pleura
ABX for exacerbation
Respiratory physical therapy
Inhaled bronchodilators
NO antitussives
What are the most common sites CF mucus plugs up and blocks?
CF lung issues will cause what sound to be audible on PE?
Exocrine ducts leading to inflammation: Lung, Pancreas, Testes
Crackles at apex
What will be seen on ABGs of a CF PT?
What will be seen on a PFT?
Hypoxemia
Compensated resp acidosis in advanced Dz
Obstructive > Restrictive
Dec FVC, FEV1, TLC, DLCO
Inc RV:TLC
What is the name of the sweat test needed to Dx CF?
What med can be used for these PTs?
Pilocarpine Ionotophoresis
2 tests on different days
rhDNAse- dec sputum viscosity and improves FEV1
Inhaled hypertonic saline
SABA
What is the only definitive Tx of CF
What med is given to CF PTs due to the gene mutation?
Lung transplant- 3yr survival rate 55%
Ivacaftor
What vaccines can CF PTs get?
Bronchiolitis is a generic term for ?
Pneumococcal
Influenza
Inflammation of bronchioles <2mm, usually RSV in Peds
What is a constrictive type of bronchiolitis seen in adults?
What type os exposure hx makes PT susceptible to Bronchiolitis
Bronchiolitis Obliterans
Ammonia/Diacetyl- obliterans
Viral
Organ transplant- obliterans, proliferative
CT d/o- follicular type (RA, Sjogren)
How does bronchiolitis present?
What would be seen on a PFT?
Insidious onset w/ Tachy, Crackles, Wheezing
Irreversible obstructive
What is a better imaging modality for bronchiolitis and what is seen?
How is it definitively Dx?
Chest CT, trapped air similar to asthma
Lung biopsy
How is bronchiolitis Tx?
Epiglottitis forms a boundary wall of ?
PO CCS for proliferative
Inhaled dilators
Cough suppressant
O2 to maintain SPO2 >88
Back wall of vallecular space below base of tongue
What labs are ordered for epiglottitis?
What ABX are used for epiglottitis?
CBC w/ Diff
Blood culture
Intubated PT- epiglottis culture
3rd Gen (Ceftriax/Cefotax) and Vanc
What is the common triad of FBA?
How do Sxs change by location of obstruction?
Wheeze, Cough, Diminished breath sounds
Laryngotracheal: uncommon, most life threatening: stridor, wheeze, dyspnea
Large Bronchi: cough, wheeze
Lower Airway: little distress after initial choking episode
How are objects stuck in throats recommended to be removed?
What is the next step for suspected aspirations if there is a mod/high or low suspicion?
<1yr= back blows, chest compression
Heimlich, Intubate, O2
Mod/High: PE, Chest/Neck xray, rigid bronchoscopy
Low: PE w/ normal x-rays
What is the 4th leading cause of death in the US?
What is the two of effects smoking causes in airways?
COPD + Asthma
Hypertrophy/proliferated mucus glands
Cilia paralysis
What part of the airway is most effected by smoking?
What are the effects of smoking on the lung parenchyma?
Bronchioles
Destruction of CT in alveolar walls
Smoking on the airways lead to ? while effects on parenchyma lead to ?
What is the protector of the lungs that prevent enzymes of inflammatory cells?
Airway: bronchitis
Parenchyma: emphysema
a1-antitrypsin- lack of this allows elastin degredation
When does a1-antitrypsin deficiency COPD develop?
What PTs are screened for this deficiency?
30-40yrs
All w/ FamHx of COPD
Chronic bronchitis as a sole Dx indicated ?
What are the two types of emphysema?
Mild COPD
Panacinar: involvement of acinus, mostly in lower lung and most common in AAT deficiency
Centrilobular: proximal acinus/bronchiole; irregular destruction sparing areas
MC in smokers
What is considered a high PaCO2 measurement?
What is the issue in the lungs during emphysema?
What is the Triad of presenting Sxs for the first decade?
> 40
Stretched, less recoil and loss of exhalation drive
SoB, inc cough, sputum
What are late S/Sxs of COPD
What is the hallmark of this Dz?
Pneumonia
PHTN
Cor Pulmonale
Chronic resp failure
Periodic exacerbation precipitated by infection or environmental cause
What two microbes are most likely to cause pneumonia in COPD PTs?
What is the common cause of death in COPD PTs?
Strep Pneumo
Moraxella Catt.
Mulitple/yearly lung infections
What is the chief complaint of PTs w/ emphysema?
What Sx is rare in these PTs?
Dyspnea
No cough, barely any sputum due to destroyed cilia
What PFT results will be seen in early, mid and late staged COPD?
Early: FEV 25-75%
Mid: dec FEV1 and ratio
Late: dec FVC, inc TLC (especially in emphysema)
What lung dz is DLCO low?
What are the 4 GOLD guidelines?
Emphysema
1 Mild: FEV +80%
2 Mod: 50-79%
3 Sev: 30-49%
4 Very Sev: <30%
Although rarely obtained, what results would be expected from an ABG draw in a COPD PT?
What work up studies are done?
Compensated Resp Acid
Sputum analysis/culture
What 3 arrhythmias could be seen on EKG in a COPD PT?
Why is a CXR ordered if it’s not diagnostic?
MAT- never shock
A-Fib/Flutter
R/o alternatives or comorbidities
What are the expected CXR results for chronic bronchitis and emphysema?
What would be the benefit of ordering a CT for COPD work up?
CB: cardiomegaly
E: small cardiac silhouette
Extent of damage for TPs considered for lobectomy
What does it mean if COPD PT has clubbing?
What is the single most important intervention in COPD PTs?
CA
Normally seen in bronchiectasis w/ pneumonia and hemoptysis
Smoking cessation w/ Buproprion or Carenicline
When is O2 given to COPD PTs?
What is the only therapy w/ evidence of improving COPD progression?
Resting hypoxemia <90%
O2 via cannula x 15hrs/day @ 1-3L/min
No mortality benefit
COPD PTs that start therapeutic O2 see an improvement in ? Sxs?
PHTN Impaired cognitive funtion Erythrocytosis Cor Pulmonale Morning MA
Short acting dilators:
Ipratropium
Albuteral, metaproterenol
Preferred for longer duration and fewer s/e w/ daily use
SABAs
Rapid onset w/ more s/e
Combined w/ Ipratropium
Long acting dilators:
Tiotropium
Formoterol, Salmeterol
LAMA
More expensive but fewer exacerbations
Improved Sxs, no mortality benefit
LABA
Combined w/ ICS
Monotherapy has no mortality risk
CCS:
ICS
PD4 Inhibitors
Roflumilast
Mod/Sev COPD but no mortality benefit
LABA + ICS= fewer exacerbations, improved status, fewer admits
Dec inflammation and promotes dilation
What drug combo is given for acute COPD exacerbation?
Giving ABX to these PTs is most beneficial when ? 2 of 3 are present?
10-14 day PO steroids
Inc sputum (purulence/quantity) Dyspnea
ABX for COPD PTs is considered in what 4 circumstances?
> 65y/o
FEV1 <50%
3+ exacerbations/yr
Comorbidities present
What ABX are even options for COPD?
Which ones are usually used on outpatient basis?
TAD CAC Docy TMP/SMT Cefpodoxime Azithromycin Cipro/Levo Amox/Clavulonic
Doxy/Azith
What is the DOC for HIV Pts w/ Pneumonia Jerivici
What is a SABA/ABX combo that can be used for COPD
TMP/SMT
Albuterol + Ipratropium
What 3 drugs are not given for COPD exacerbation?
O2 therapy for 24hrs per day is recommended when PTs have resting hypoxemia which is ?
Suppressants
Expectorants
Mucolytics
<88%
PaO2 <56mmHg
When are COPD PTs admitted?
Severe/worsening Sxs despite Tx Acute/worsening hypoxemia, hypercapnia, peripheral edema, change in mental status Poor home care Inability to sleep Inability to hydrate/nutrition High risk comorbid condition
How are COPD PTs managed on an inpatient status?
O2 @ 90-94% Iprotropium + SABA CCS Broad ABX Chest physiotherapy
How are COPD Pts w/ Cor Pulmonale managed inpatient?
O2 Bed rest Acidemia correction Na/Fluid restriciton Diuretics
65y/o male w/ PCO2 at 60 and breathing at 35 resp/min. What is the only way to correct the PCO2 and fix the respiratory acidosis?
What is the BODE index?
Intubate and Ventilate
Only option for high PCO2 (>50)
BMI- lower is worse
Obstruction: FEV1 after dilator
Dyspnea: based on exertion
Exercise: based on 6min walk
When are COPD PTs referred?
Any PT under 40y/o
>2 exacerbation/year on max therapy (LABA+ long anticholinergic +ICS)
Severe/rapid progression
Disproportionate Sxs
Long term O2 therapy
Onset of comorbidity (CHF, Bronchiectasis, CA)
What vaccine follows Prevnar 13/when is the next one given?
PT w/ COPD exacerbation and multiple comorbidities is started on ? ABX?
PPSV23 one year later
Levofloxocin
To a certain extent, all asthmatics have what five pathophysiological issues?
Edema, infiltrates in bronchial walls Epithelial damage Hypertrophy/plasia of smooth muscles Inc collagen beneath epithelium Hypertrophy of glands and goblet cells
Why do asthmatics have airway remodeling?
What is the name of the asthma precipitant that occurs during a menstrual cycle?
GF induced tissue changes
Catamenial
What is the sequence of events of allergen exposure induced asthma?
What drugs are used to stop the two end products?
Allergen IgE Mast cells Mediators Constriction/Permeability
Constriction= B agonist Inflammation= inhaled CCS
What are the four common precipitants to asthma?
Why can asthma PTs be sensitive to ASA?
Allergen exposure
Inhaled irritant- smoking
RTI- viral are most common
Exercise- loss of heat/moisture= rapid cooling
Leukotriene production from arachidonic acid
What causes the obstruction of asthma?
What would be an ominous late finding of an asthma attack?
Bronchoconstriction
Rising PCO2
What are the 3 red flag questions of an asthma attack?
Abnormal coughing during what part of the day is indicative of asthma?
Ever been hospitalized, intubated, or on PO steroids?
Night
What sound is hear on PE of asthma and what makes it worse?
What finding is bad?
Wheeze, inc w/ expiration
No wheeze= dec airflow
What four findings are indicative an asthma PT is having a severe attack?
What finding can they develop?
No wheezing
Hunched shoulders
Accessory muscle use
Unable to be recumbent
Pulsus paradoxus
What are S/Sxs of an impending arrest of an asthma PT?
Drowsy/confused Paradoxical abdomen motion No wheeze Bradycardia Absent Pulsus Paradoxus (often in sev cases)
What would be seen on ABG in a mild, severe or impending asthma failure attack?
What will be seen on PFT in asthma?
Mild: alkalosis
Sev: hypoxemia
Impending: acidosis
PEFR, FEV1, Max mid-expiration all decreased
What is a severe asthma FEV1 level
What test is done if asthma is suspected and spirometry is nondiagnostic?
<50%
Mod: 50-70
Mild: +70%
Bronchial provocation test: Inhaled histamine or Methacholine challenge
+= FEV dec >20%
What is the difference between neg/pos Bronchial provocation test?
When is peak expiratory flow highest and lowest?
Pos is not pos for asthma
Neg is neg for asthma
Low: upon waking
High: hrs before mid-day
What would be seen on CXR of asthma?
Chart on Slide42
Normal or hyperinflated
Of Asthma lecture
Asthma PTs can step down their Tx if they’re stable for ?
What drug class is a preferred 1st line therapy for persistent asthma?
3mon
Inhaled CCS
What can be added to PTs taking inhaled CCS or what needs to be monitored?
What are the long acting dilator B-agonists?
Ca, Vit D
DEXA
Salmeterol
Formoterol
Tiotropium
Theophylline
What mediator inhibitors are used for asthma?
When is Tiotropium added to asthma Tx?
Cromolyn, Nedocromil
Mild persistent/exercise induced prior to exposure
Uncontrolled asthma while on ICS and LABA, usually in COPD
When is Theophylline added on to asthma Tx?
What asthma med needs to have LFT monitoring?
Persistent nocturnal Sxs
Leukotrienes
What is the MOA of Omalizumab for asthma?
What is done for mild asthma exacerbation?
Recombinent Ab that binds to IgE w/o activating mast cells
> 80% peak flow w/ full response to SABA
If not on ICS, start
If on ICS, give 7 day PO steroid dose (don’t double dose)
What is done for moderate asthma exacerbation
O2 for hypoxemia Continuous SABA Systemic CCS Serial PFTs PT education
What is done for severe asthma exacerbation?
SpO2 >90% (asphyxia is common cause of death)
Systemic CCS
Continuous high dose SABA
Avoid anxiolytics, hyponitcs and mucolytics
How are asthma exacerbations managed in the ER?
What type of recovery findings are the only ones for discharging a PT?
Repeat assessments after Initial bronchodilator and
after 3 doses of inhaler
FEV >70%
Sustained for 60min
No distress
Normal exam
When do asthma PTs need to be referred?
Atypical presentation Complicated comorbidity Suboptimal response High dose ICS 2+ systemic steroids in 12mon Any life threatening hospitalization in 12mon Social/psych d/o
What ABX can be used for epiglottitis, is safe on Peds kidneys and safe in pregnancy?
What are cold agglutants?
Ceftriaxone, Vancomycin
IgM Abs indicating where a Dz is in process, Mycoplasma
What microbe is most common in PTs w/ aspiration/poor dentition related pneumonia?
What microbe predominates infections of PTs that have traveled to SW US?
Staph
C. Imitis
What are the two major and one minor pathways for pneumonia?
MC cause of bacterial pneumonia?
Major: inhalation, aspiration
Minor: blood borne
Strep Pneumo- 2/3 of all CAP cases
When is Staph A pneumonia common?
What microbe is most likely to cause pneumonia in PTs in a nosocomial/recent ABX population?
After influenza through hematogenous spread
Pseudomonas
What is the most deadly infectious Dz in the US?
What are the RFs for CAP in order?
CAP
Inc age
ETOH
Tobacco
What pathological process allows a CAP infection to grow?
What 3 tests can be used to differentiate the microbes of CAP?
Normal defenses prevent lower respiration infections:
Cough reflex
Immunity
Mucociliary clearance
PCR, UA, Agglutinin
How do atypical microbe CAP appear differently than typical?
What is usually the microbe and what drug classes are used for T?
Gradual onset of dry cough, HA, malaise, N/V, low fever
Mycoplasma
Macrolide, Doxy
What does a CXR of a PT w/ atypical pneumonia show?
How is CAP Dx?
Worse than PT appearance
Culture
What microbe causes cavitation seen on CXR?
Staph
TB if in apex
Viral pneumonia is usually seen as ? on CXR
What education piece needs to go w/ CAP Tx?
Bilateral
Clearing CXR takes longer, f/u imaging not needed if clinical response is present
Re-image if high risk to r/o malignancy (Smokers >40, Geriatrics >65)
What is Procalcitonin’s response to a bacterial or viral CAP infection?
What two microbes can be detected through urine antigen testing?
Bacteria: released
Viral: inhibited
Legionella
Strep Pneumo
Since Macrolide(A/C)/Doxy are used for CAP outpatient Tx, what are used if PT has used ABX in past 90 days, is >65, ImmSupp or has child daycare exposure?
What ABX are used for CAP outpatient in areas w/ high macrolide resistance?
Respiratory Fluoroquinolone
Macrolide + B-Lactam (Amox/Clavu)
Same as above
What two ABX are used for atypical pneumo Tx?
What two ABX can be used for CAP in an admitted PT?
Azithromycin
Doxy
Ceftriaxone and Macrolide (A/C) or,
Quinolone (Levo, Moxi, Gatifloxacin)
If influenza is complicated by a secondary bacteria pneumo infection, what ABX are used?
What anti-pseudomonas B-Lactam is used for inpatient CAP PTs?
Oseltamivir and
Ceftriax/Ceftaroline and
Vanc/Ilnezolid
Piper/Tazo, Cefepime
CAP outpt microbes
CAP hospitalized microbes
ICU admitted microbes
Nosocomial pneumonia microbe
Strep Pneumo
Mycoplasma
Chlamydia
Strep Pneumo
Mycoplasma
Chlamydia
Strep Penumo
H influena
Legionella
Staph A
Pseudomonas
Gran Neg rods: Enterobacter, Klebsiella, E Coli
How are ICU PTs w/ CAP Tx?
What is the CURB-65 criteria
Respiratory fluoroquinolone or Azithromycin and
Cefota/Ceftria/Amp (anti-pseudomonal B-lactams)
Confused Urea >20mg Resp Rate 30 or higher BP systloic <90, 60 or less D 65 or older 0-1: low 2: mod, consider admit 3: high, admit 4-5: ICU admit
Define HAP
Define HCAP
Define VAP
> 48hrs after admit w/out infection at admit
Non-hopitalized PT w/ extensive healthcare contact
> 48hr after intubation development
What meds are used as a prophylactic for admitted PTs to prevent nosocomial pneumonia
What would be S/Sxs of nosocomial pneumonia?
PPI, H2 blocker, Antacid
Fever, Leukocytosis, Purulent sputum
Opacity on imaging
What labs are drawn on PTs w/ nosocomial pneumonia
Blood culture CBC w/ diff CMP ABG Thoracentesis (Staph)
What may be seen on imaging in PTs w/ anaerobic pneumonia?
How are these PTs Tx?
Abscess: + air/fluid level
Necrotizing pneumonia- +air/fluid level
Empyema- do not have air/fluid level
Amxo/Clavu
Amox or PCN and Metron
No more Clindamycin
What microbe causes lung abscesses and empyemas?
Outpt pneumo Tx
Inpatient pneumo Tx w/ DM
Staph
Macrolide/Doxy
Resp Fluoroquinolone
What is the 2nd most common infectious cause of death in adults?
How is TB spread
TB (1st was CAP)
Droplet, ingest by macrophage in alveoli
What does primary TB develop
What is the only S/Sx seen in PTs w/ latent TB?
Infection escapes alveoli, lymph/hematogenous spread, contained by granulomas-> latent
No containment= Progressive TB
Crackles in apex
+ PPD
What is different about Miliary TB compared to Primary/Latent
What are the constitutional Sxs of an active TB dz?
Miliary= hematogenous spread and is primary progressive or reactivated
Malaise, Anorexia, Weight loss, Fever, Night sweats
What is the MC Sxs of TB and what is a rare Sx?
Primary TB is usually ? and ? silent
Chronic cough, progression from dry to purulent w/ blood
Rarely: dyspnea
Clinically, Radiograph
How is TB ID’d w/ labs?
3 sputum specimens Q8hrs induced w/ hypertonic saline for Acid Fast Bacilli
Blood culture: rarely + unless CD4 is low
Pleura biopsy: 50% chance of + test
When is imaging of TB recommended?
What is seen on CXR of Primary, Reactivated and Miliary TB?
+ PPD
+ clinical Sxs
Primary: hilar adenopathy, atelectasis, pleural effusion, granuloma/Ghon complex
Reactive: Cavitation in posterior upper lobe/superior lower lobe
Milliary: small opaque nodules across chest
Reactivated TB in lower lobes may be confused as ?
PTs that received a BCG vaccine are protected from ? but not ?
CA, Pneumonia
Protected: TB meningitis, Disseminated TB
Not: Primary, Latent
What is the Gold Standard for testing for TB?
Quantiferon Gold/T-spot- blood test measuring reaction w/ M Tuberculosis Ag
What test is ordered to confirm a TB Dx if TST is pos but there’s a low likelihood of TB infection?
What test is ordered in place of, not in addition to, a TST?
Quantiferon Gold
Interferon Gamma Release Assay
S/e, monitoring and comments on INH
Peripheral neuropathy, Hepatitis, Rash
AST/ALT, Neuro
Pyridoxine as prophylaxis
S/e, monitoring and comments on Rifampin
Hepatitis, Fever, GI, Bleeding, Renal failure
CBC, PLT, AST/ALT
Fluids turn orange
S/e, monitoring and comments on Pyrazinamide
Hyper uricemia, Hepatotoxic
Uric acid, AST/ALT
-cidal to intracellular organisms
S/e, monitoring and comments on Ethambutol
Optic neuritis, rash
Red/green discrimination
-static, inhibits resistance
S/e, monitoring and comments on Streptomycin
CN8 damage, nephrotoxicity
Audiogram, BUN/Creatinine
What baseline labs are ordered when starting TB Tx?
What is done each month as monitoring?
CBC, CMP, Visual acuity, Audiogram, Serum uric acid, HcG
Sputum culture until negative
What med combo is used for latent TB Tx?
How is RSV Dx?
INH w/ pyridoxine x 9mon
Nasal wash for PCR
Nasopharyngeal/throat swab
How is Pertussis Dx?
Culture and PCR
If more than 4wks, serology
Exposure to Pertussis can get prophylaxis when?
What causes Croup?
Within 21 days of onset of cough
Parainfluenza Type 1
Mild, Mod and Sev Croup Txs
Mild: no stridor at rest, no respiratory distress= Dexameth or non-pharm Tx
Mod: Stridor at rest, retractions
Sev: stridor at rest w/ marked retractions and distress
Mod/Sev= Nebulized Epi and Dexameth
How much of an PFT improvement needs to be seen for the Dx of asthma to be given?
What is heard on PE of pneumonia?
12%, 200mL
Crackles
Bronchial breath sound
Dull percussion
Egophony= lobar effusion
PHTN work up can include ? test
What type of CA causes hypercalcemia?
TTE
Squamous cell lung carcinoma
What microbe is most likely to cause lobar pneumonia?
What is the most important drug agent for mod-persistant asthma?
Strep Pneumo- encapsulated, Gram Pos, Tx w/ Azith/Doxy
Inhaled fluticansone
PTs w/ mod/sev asthma must be on ? drug?
Fungal causes of epiglottitis
Viral causes
Inhaled CCS
Candidia
PHIVE
Parainflu HSV Influ VZoster EBV
What type of non-cell CA is the most common worldwide and leading cause of CA death?
What is the most common risk factor for this type of CA?
Bronchiogenic carcionoma
Smoking
Non-small cell CA includes ? 4 types?
What CA are central?
SLAB
Squamous Large Adeno Bronchoalveolar/Adeno in situ
Small cell carcinoma
Squamous cell
Large Cell
Small Cell Carcinoma
Central
Hilar/Mediastinal on imaging
Associated w/ SIAD, Paraneoplastic Syndrome
Early hematogenous spread, common, poor prognosis
Adenocarcinoma
Peripheral in women/non-smoker
Grows from mucus gland
MC Primary Lung CA
Squamous Cell CA
Central from bronchial epithelium- 2/3 bronchus
More likely to show w/ hemoptysis
Dx w/ Sputum Cytology
Local spread
Hilar adenopathy and widened mediastinum, caviation
Large Cell CA
Hetergenous of undifferentiated Central or Peripheral (MC) Rapid double time Cavitary lesion w/ air/fluid level Rarer than Adenocarcinoma
What type of CA is a slow spreader?
CA in liver equates to ? BUN
Non-Small Cell CA
Low or none
Pancoast tumor
Superior sulcus of lung apex Shoulder*/arm pain following ulnar C8/T1 Horner's Weak/atrophy hand Progression to SVC Syndrome if on R side
What type of CA can cause SIADH
What type can cause HyperCA?
SIADH w/ Small Cell- water retention, HypoNA, concentrated urine
HyperCA w/ Squamous
? form of pneumonia will trigger a positive Cold Agglutin Test?
What causes exercise induced asthma?
Mycoplasma- Tx w/ Azith
Bronchospasm
What version of paraneoplastic syndrome is seen in Myasthenia Gravis PTs?
How is Myasthenia Gravis Dx?
Thymoma
Acetylcholine receptor AB test
All suspected lung CA PTs get w/ Labs
How are each types of tumors Dx
CBC CMP
FNA if palpable (cervicle/supraclavicular)
Bronchoscopy biopsy if central
Transthoracic aspiration for peripheral
When is surgery the TOC for CA?
Prior to surgery all PTs have ? test
Early non-small cell Stages 1 and 2
PFTs
When is Chemo/Radiation the TOC for CA
Difference between node and mass?
Small cell CA
Adv non-small stage 3-4
Nodule= <3cm Mass= >3cm
Most common cause of benign solitary pulmonary nodules?
Most common cause of malignant nodules?
Infectious granulomas
Adenocarcinoma
What is the most common type of benign tumor?
Hemoptysis + CKDz= ?
Hamartomas
Granulomatosis w/ polyangitis (Wegners)
Features of a nodule making the likelihood of malignancy greater
<30y/o Smokers CAHx Larger size at discovery Eccentric calcification Spiculated Corona Radiata margin
Features of a nodule making it more likely to be benign
<30y/o Smooth/defined borders Dense central/diffuse calcification Small and stable on repeat image <8mm
4 buzz words for benign patterns
2 buzz words for malignant patterns
Dense Laminated Popcorn Diffuse
Stippled Ecentric
What is the image TOC for monitoring nodules?
What is the f/u schedule for nodule size for low/high risk PTs
Chest CT
4mm or less- none/CT Q12mon
>4-6mm- CT Q12mon/CT Q 6-12 and 18-24mon
>6-8mm: CT Q6-12mon/CT Q3-6mon, 9-12 and 24mon
