Pulm Cards Culm Flashcards
What is the pulm dz that is associated with inhalation of mineral dust
Pneumoconioses
Chronic fibrotic lung dz 2ndary to occupation inhalation
Assoc Nitrofurantoin and Amiodernone with idiopathic Pulm Fibrosis
What are the S.s of ILD
Dyspnea, Cough, FINE crackles
CXR: septal thickening, bilateral infiltrates, and reticulondular changes
Additional:
Clubbing, Hemoptysis, wheezing, Rash
CXR: septal thickening, bilateral infiltrates, and reticulondular changes
Think
ILD ( MC Pulm fibrosis)
A Pt presents with fine, dry, bibasilar inspiratory crackles, with clubbing of the fingers..
think
Idiopathic ILD
A young African American presents with bilateral hilar lymphadenopathy
Is a classic classic finding of what condition
Sarcoidosis
What is the triad of lofgren syndrome
Erthyema nodosum, Bilateral Hilar LAD, polyarthralgias with fever
A pt presents with increased ACE levels on LABs,
Think
Sarcoidosis
Is sarcoidosis caseating or non ?
NON!
What is the treatment for Sarcoidosis
Is S/s present the oral steroids,
If nons/s then watch may go away in 1-2 years
A CXR presents with “photographic negative” pattern
Think
Chronic eosinophilic pneumonia
What is the triad of Granulmatosis with polyangitis
URI and LRI with Glomerulonephritis
What does a postive C-ANCA mean
Positive anitobidy that is assoc with pulm vasculitiis
RINGS and TRACS of CXR is a finding of
Brnachiectsasis
What is the triad of Eosinphilic granlomatous with polyangitis
Asthma, eosinophils, with chronic rhinitis
What are the two common treatments for eosinophilic and non-eosinophilic granulomatosis with polyarthalgias
Corticosteroids PLUS cyclophosphamide
What are the three effects of smoke inhalation
1) Impaired tissue oxygenation
2) Thermal injury to upper airway
3) Chemical injury to the lower airways and lung parenchyma
What is the 1st line tx for CO poisoning
Treatment is immediate high flow O2 followed if needed by hyperbaric oxygen and supportive care
A pt presents with dyspnea, AMS, HOTN, HA, and syncope
HPI: Inhalation of combustion from plastics and textiles
What is the Tx approach
Tx includes the use of the cyanide antidote kit (Cyanokit®) and supportive care
Where does Cyanide effect the electron transport chain
Inhibits oxidative phosphorylation
Inactivates cytochrome oxidase
Leading to anaerobic metabolism and lactate production
Supportive care for smoke inhalation
High humidity supplemental oxygen
Gentle suction of oral secretions
Elevate head 30 degrees
—Promotes clearing of secretions
Topical epinephrine
—Reduces edema of oropharynx
Monitor oxygenation status
—ABGs and/or pulse oximetry
Intubation may be necessary
—Especially w/ deep facial burns/oropharyngeal & laryngeal edema
-Tracheostomy if unable to intubate
A pt presents with bronchorrhea and bronchospasm, with dyspnea, tachypnea, and tachycardia
HPI is chemical inhalation of toxic gas/ combustion
Has diffuse wheezing and rhonchi
What is the Tx approach
Understand ARDS develops usually in 1-2 days
And Pneumonia in 5-7 days
However Routine corticosteroids & antibiotics are ineffective & not recommended
Tx:
Supplemental O2
Bronchodilators
Suction of secretions
Often: endotracheal intubation, chest physical therapy, humidified O2, mechanical ventilation
Positive end-expiratory pressure (PEEP) – for bronchiolar edema
Fluid management
Monitor for secondary bacterial infection
Daily sputum Gram stains
What is bronchilitis obliternas
Complication of smoke inhalation injury
One of several causes of damage to bronchioles
CT shows “ground glass” and bronchial wall thickening
What is E-VALI
Vaping-Associated Lung Disease
Aka E-VALI
—E-cigarette or vaping associated lung disease
Cough, fever, bilateral infiltrates
Cause: Vitamin E acetate – now removed
Reduced incidence of E-VALI
Treatment: supportive
What is the tx for Cyanide OX
Cyanide kit
Contains hydroxocobalamin
precursor to vitamin B-12
Binds to cyanide and neutralizes it
Eliminated harmlessly from the body through urination
Given IV and acts immediately
Side effects include temporary discoloration of the skin and urine
At what percent of CO levels do non smokers become S/.s
10%
What is pneumoconioses
A group of chronic fibrotic lung diseases caused by inhalation of inorganic dusts
—Coal dust
—Silica, asbestos, beryllium, etc.
Usually asymptomatic with diffuse nodular opacities on CXR
May be severe, symptomatic, life-shortening conditions
Treatment is mainly supportive
A coal miner presents with progressive fibrosis, with nodular opacities, with opacities in the upper lobes
What is the Tx approach
Supportive, usually asymptomatic incidental finding
Finding: Conglomeration of irregular masses >1cm & contraction in upper lung fields
On CXR you see Hilar lymph nodes “eggshell calcifications” with small rounded nodules in the lungs
Think
Silicosis
Pts with silicosis are at an increased risk of what Dz
TB
All pts with silicosis should get what screenings?
TB skin test and current CXRs
WHat are the CXR findings in asbestosis
CXR:
Linear streaking at lower lung fields
Opacities of various shapes/sizes
Honeycomb changes – advanced disease
PLEURAL CALCIFICATIONS may be best diagnostic clue
What is the best imaging test for asbestosis
High resolution CT (HRCT) – best imaging for asbestosis
Parenchymal fibrosis & coexisting pleural plaques
What is the Tx approach to Asbestosis
Smocking cessation
O2 for SOB
Resp physiotherapy for secretions
What is extrinsic allergic alveolitis
Hypersensitivity Penumonitis
An inflammatory disorder of the lung, involving alveolar walls and terminal airways
Organic causes
A pt presents with suden malaise, chills, fever, cough, and Dyspnea within 4-8 hours after leaving work
With bibasilar crackles, Tachypnea, and tachycardia
+cyanosis
On CXR there are small nodular densities, NOT in the apices or bases
Labs: increased WBC with neutrophils, Elevated ESR and CRP
PFTs: restrictive with reduced DLCO
What is this condition and Tx approach?
Hypersensitivity Pneumonitis (work related)
Treatment of hypersensitivity pneumonitis:
Identification of offending agent & avoidance of further exposure
—Farmer’s lung; maple bark stripper’s lung; cheese washer’s lung; thatcher’s lung; mushroom worker’s lung; and metal-working fluid hypersensitivity pneumonitis
Symptoms onset within 4-8 hours AFTER exposure (Delayed response)
Acute illness: Pts usually recover without corticosteroids
Severe/protracted cases: oral corticosteroids in long (4-6 week) followed by long taper (3 months)
When does honeycombing set in on a pt with hypersensitivity pneumonitis
Chronic exposure
only tx at this point in lung biopsy
What is the HPI key to Dx occupational asthma
S/s at work
But symptomatic improvement away from work
What is the Tx approach to Occupational asthma
Treatment: avoidance
Bronchodilators
Symptoms may persist long after exposure terminated
What are the three keys to occupational asthma
S/s
Timing
Exposure
A cotton worker presents with dyspnea, cough, and chest tightness at work..
think
Byssinosis, Tx removal of agent
FIND A NEW JOB
Describe Silo fillers lung Dz
Acute, toxic pulmonary edema caused by inhalation of nitrogen dioxide from recently filled silos leading to bronchiloitis
Describe the radiography of bronchiolitis
Ground glass opacity (ground glass nodules)
Refers to hazy area of increased attenuation in the lung
Ground glass nodules- a circumscribed area of increased pulmonary attenuation
Non-specific sign with a wide etiology to include infection (usually opportunistic), interstitial disease, acute alveolar diseases
Is silo fillers chemical or organic pneumonitis ?
Chemical!
Describe popcorn lung
Chronic inhalation of diacetyl (butter flavoring) linked to bronchiolitis obliterans
What is the most common cause of ARDS
Aspiration of Gastric Contents
A pt presents with CXR: patchy alveolar opacities in dependent lung fields (w/in a few hours) after aspiration
Signs/symptoms: abrupt onset of respiratory distress
Cough, wheezing, fever, tachypnea
Crackles at bases
Fever, even in absence of infection
Think >? Tx?
Acute Aspiration of Gastric Contents
Treatment
-Supplemental O2
-Maintain airway
-Treatment of acute respiratory failure
-Endotracheal intubation & mechanical ventilation
Secondary infection occurs in ¼ of -patients
-2-3 days after aspiration
-No evidence to support use of prophylactic antibiotics or corticosteroids
-Hypotension management with IV fluids
Look at toxic and radiation aspiration slide 67 on lecture 10 pulm
2-3 months after chemo rads, a pt presents with insidious onset of dyspnea, intractable dry cough, chest fullness/pain, weakness, fever
PFTs – reduced lung volume/lung compliance, diffusing capacity
CXR – alveolar or nodular opacities limited to irradiated area
Think? Tx?
Radiation pneumonitis/ fibrosis
Tx: prednisone
A cancer pt presents with CXR: tented diaphragms, obliteration of normal lung markings, reduced lung volumes, reticular and dense opacities
Think? Tx?
Pulm radiation fibrosis
TxL corticosteroids for 2-3 weeks followed by a slow taper
What happens with oxygen toxicity
Absorptive atelectasis (nitrogen keeps the alveoli open – if it’s all O2 and gets absorbed by the lung, then can collapse)
Describe TRALI
Transfusion Related Acute Lung Injury
Rapid onset of respiratory distress
Minutes to hours after transfusion (blood products)
Initially indistinguishable from ARDS
CXR: bilateral patchy infiltrates
5% mortality Overall rare (300/25 Million transfusions in USA)
Tx: Stop the transfusion
Supportive care (O2, fluids, pressure support)
Likely recovery in 2-5 days
What is the tx approach to High Alt. D./o
Prevention: gradual ascent, acclimatization, meds (acetazolamide)
TX: immediate descent, O2/hyperbaric chamber,
If mild: sildenafil, acetazolamide, theophylline SR, NSAIDS, Tylenol, aspirin
Describe histoplasmosis pneumonia
Histo-HISTORY (OLD caves, buildings, bats)
Histoplasma capsulatum, a dimorphic fungus endemic to Midwestern states
Ohio and Mississippi river valleys!!
Fungus isolated from soil contaminated with bird or bat droppings (caves, abandoned buildings)
Infection occurs by inhalation of the spore
Most commonly asymptomatic or mild influenza like illness
Often past infection found incidentally on CXR has pulmonary/splenic calcifications
Common in HIV low CD4
S/s Fever, dyspnea, cough, wt loss
Multi-organ system involvement:
Hepatosplenomegaly, adrenal enlargement but rarely leads to adrenal insufficiency, GI involvement may mimic IBD
Fatal (Septic shock) if not treated
What is the Dx approach to histoplasmosis
What is the Tx
Urine and serum antigen!!
Broncho-alveolar lavage
Blood or bone marrow cultures
Most infections are self-limited and requires no treatment
Progressive or moderate/severe cases:
—Mild Cases: Itraconazole (200 mg BID x 6-12 weeks) if sx>4 weeks
—Severe illness (meningitis, etc) IV amphotericin B
What two drugs increase the incidence of histoplasmosis
Remicaide/ Humira
What are the two manifestations of coccidiomycosis and where is it most common
Primary vs disseminated
(Due to spore inhalation)
Most common in southern USA, Mexico, and south/ Central America
Remember Coccidio cacti
Primary Coccidiomycosis commonly presents as ..
CAP
A pt presents with what looks like CAP, they were recently in Arizona working in the soil
What are the other key S/s that can Dx this Dz
This dz is coccidiomycosis
S/s: Fever, myalgias, arthralgias (Knee and Ankles common)
Erthyema nodosum and multiforme
How does dissiminalted coccidiomycosis present and who does it affect most
Disseminated S/S
Significantly more pronounced pulmonary sxs, systemic sxs (increased productive cough and mediastinal enlargement)
Lung abscesses, meningitis common
Skin abscesses, wart like lesions
Fungemia, diffuse miliary CXR to early death
Effects: Filipino, black and pregnant pts
What is the treatment approach to coccidiomycosis
No treatment necessary if mild
If severe then anti fungal ( fluconazole, itraconazole, Amphotericin)
What are the key features of Blastomycosis
Think Obama
From the Mid west, Middle Aged and shooting a shot gun (blast)
Effects men
A pt presents with lesions on the skin, bone, and prostate, complains of abNML epiditimitis, is from South Central USA (OKlahoma, Missouri)
Think of what Dz and approach
Blastomycosis
Order a CXR ( may have cavitary lesions, nodular or fibrotic)
Culture ( Calcoflour staining)
Treatment Mild Disease - Azole antifungals Itraconazole, ketaconazole, etc. Mod to severe Disease Amphotericin B
Who does aspergillosis effect most
It’s a type I hypersensitivity reaction
So pts with asthma, bronchiecstasis, and/or cystic fibrosis
A pt with a history of asthma/ bronchiecstasis Presents with coughing up browning mucus plugs, with bronchospasm, eosinophilia,
What is the Tx approach and Dz
Aspergillosis
Tx with Oral prednisone often controls clinical symptoms
Several weeks to months of txt may be necessary
Bronchodilators often benefit
Anti-fungals may also show benefit.
(Up-to-date) Dual therapy.
A pt with a history of immunocompromise presents with an aspergillosis infection (aspergilloma)
S/s are favor, cough, chest pain, and hemoptysis
What is the Tx approach to this specific presentation of Aspergillosis
Treatment – Invasive
Long courses of antifungals
High mortality!
You find a rounded mass in a preexisting pulm cavity,
The pt has cough, hemoptysis, dyspnea, and wt loss, fever, fatigue and chest pain
What is this?
Aspergillosis (aspergilloma)
An HIV pt presents with a CD4 less than 200, CXR may show cavities, nodules, consolidations, and/or pneumothorax
With this CD4 count what pneumonia are they at an increase risk for
What is the Dz and Tx
Pneumocystitis Pneumonia
(Pneumonitis Jerevecii)
Treatment Trimethoprim sulfamethoxazole
What is the pathophys of Pneumonia
Pathogen gains entry (inhalation, aspiration, colonization, hematogenous spread)
Microorganisms replicate
Inflammation, cytokine release
Accumulation of WBCs in alveoli
Damaged cilia
Desquamation
A kid presents with fever, chills, cough, and sputum production
What is the KEY Dx to say its pneumonia
RADs finding with pulmonary opacities
What is the common viral infection to pneumonia
Rhinovirus
What are the 2 major and minor pathways of pneumonia infection
Major Inhalation, aspiration
And Minor Blood borne
Staph, Iv drugs
What are the most common causes of CAP
bacterial pneumonia
Most common is S. Pneumonia
If a pt gets a pneumonia within 48 hours of admission
What type of pneumonia is it
CAP
A pt present to the ER with fever, cough, dyspnea, sweats, chills, rigors, and chest pain
How could you Dx Pnuemonia vs other resp d.o
CXR!
What is the treatment approach to aspergillosis
Steroid with a antfungal (best answer is dual therapy)
Steroids is single best answer
When should cultures be ordered for a pneumonia pt
Blood culturesandsputum culturesare recommended for !hospitalized! patients with, or at risk for, severe disease and complications; cultures should be collected before the start of antibiotics
Diagnostic testing (culture):
Not indicated routinely since empiric treatment works
Consider if travel hx or other specific concern
Consider on admission to the hospital
Start ABX don’t wait for Cultures
Your preceptor hands you a CXR with patchy airspace, lobar consolidations, with bronchograms, with or without pleural effusions, and cavitations, if opacities
Asks you what does this indicate..
Pneumonia
How long does it take for pneumonia to clear up on CXR
6 or more weeks
Only consider follow up CXR in 7-10 weeks
Sometimes underlying/predisposing malignancy revealed post-treatment (post-obstructive pneumonia)
Smokers > 40
Geriatric >65
In adults with CAP whose symptoms have resolved within 5 to 7 days, we suggest not routinely obtaining follow-up chest imaging (conditional recommendation, low quality of evidence).
When should you do a bronchoscopy in pneumonia pts
For sampling secretions, especially if P. jirovecii or M. tuberculosis is suspected
What is the Gold Standard for influenza testing
PCR
What assay can detect legionella
Urine antigen testing
What assay can test for strep Pneumo
Urine antigen testing
You just confirmed the Pt has CAP
What is the tx approach
Treatment:
Goal: prompt initiation of medications (antibiotics and/or antivirals) to which pathogen is susceptible
Do not delay for sputum cx, etc.
Supportive therapy (fluids)
Beware septic shock
Oxygen (including possible mechanical ventilation)
Corticosteroids for severe CAP
What is the ABX duration for CAP
5-7 days
Usually does not require Admission
At least 5 to 7 days (staph aureus, legionella: 10 – 14 days)
Goal: afebrile x 48-72 hrs or more
If a pt has had no ABX in the past o-days and has CAP
What ABX can be used
If no abx in past 90d:
Macrolide (clarithromycin or azithromycin) OR
Doxycycline
A pt is over 65/ Immuncomp and has had ABX treatment in the past o-days
What ABX should be used for their Pneumonia Tx
If any abx in past 90d; age >65; comorbidity; immunosuppression or exposure to child in daycare:
Respiratory FQ (moxi/gemi/levofloxacin) OR Macrolide PLUS beta-lactam (amox-clavulanate)
In regions where there is high macrolide resistance
What ABX should be used for tx of pneumonia
In region of macrolide resistance: Respiratory FQ (moxi/gemi/levofloxacin) OR Macrolide PLUS beta-lactam (amox-clavulanate)
If you are truly suspecting legionella (water exposure, smoker, elderly)
What is the ABX approach
Augmentin and added Azithromycin Or fluoroquinolones (Levó, Moxifloxacin, genta)
What is the ABX approach to Inpt
Ceftriaxone and a Macrolide (Azithromycin)
Or
Quinolones
If Influenza:
Oseltamivir
With possible added Ceftriaxone
What is the ICU ABX txs
Respiratory FQ
OR
Azithromycin PLUS cefotaxime or ceftriaxone or ampicillin (antipseudomonal beta-lactams)
What is CURB 65
Confusion Uremia (>30) RR (>30) BP (SBP 90, DBP 60) Age (>65)
1 point each
0-1 low risk
>2 hospitalize
4-5 points ICU
Define HAP and VAP
HAP: hospital acquired pneumonia
Acquired >48hrs after admission without appearance of infection at admission
VAP: ventilator associated pneumonia
Develops >48hrs after intubation
What are the common pathogens in Nosocomial Pneumonia
S. aureus (methicillin resistant & susceptible) Pseudomonas aeruginosa Gram neg rods -Enterobacter -Klebsiella -E coli
How does aspiration pneumonia present
On chest radiography, aspiration pneumonia is most commonly seen as a parenchymal bronchopneumonia process in the superior segment of the right lower lobe and the posterior segment of the upper lobes, but aspiration can involve any part of the lung except the apices, depending on the patient’s position during aspiration
How do you treat aspiration pneumonia
Treatment options:
Amoxicillin-Clavulanate
Amoxicillin or PCN PLUS metronidazole
Elderly or bedridden pt’s may require IV ABX (piperacillin-tazobactam, meropenem, or imipenem) – risk for multi-drug resistance
Risk of MRSA add vancomycin
Empyema & abscess may require surgical drainage
What is the progression of TB
Primary to Latent to Reactivation
What is the Dx criteria for TB
3 cultures of sputum on consecutive days
Acid fast
What are the three progressions of TB
Primary: CXR shows patchy opacities
Latent : rediographically negative
And Reactivation: Common in HIV/ AIDs./ immunucomp
What is the criteria for 5, 15 and 15 mm of TB skin test
5: HIV positive
Recent contact with Active TB
CXR evidence of prior Active TB
Organ transplants
10: recent immigrant
HIV-negative IV drug users
Mycobacteria lab personnel
Residents/staff of: prisons/jails, healthcare facilities, homeless shelters,
Gastrectomy, DM, advanced renal disease, malignancy
Young children (< 5 yrs)
Low body weight <90% of ideal body weight
Infants, children, and adolescents exposed to high-risk adults
15:
Normal individual with no known risk factors!
A pt is a recent immigrant and HIV negative, but is a drug user, who is currently in jail,
What measurement would show a positve TB skin test
10+
A child (4 years old) presents with IDBW less than 90% and has been exposed to a high risk TB adult IS a recent immigrant from Asia
What measurement of TB skin test is positive
10+
A pt is HIV postive, has recently gotten a organ transplant, with a CXR that shows prior evicedce of active TB
What measurement is a positive TB skin test
5+
When do we use the interferon gold test for TB
Blood test for TB, Fewer false positives w/ BCG hx
Single pt contact
What are the Tx approaches to Active TB
RIPE x 6-9 months
Or (NEW CDC)
Rifampentine+ Moxifloxacin x 4 months
What drug is Isoniaziad combined with to reduce its ADE profile
Add Pyridoxine to reduce peripheral neuropathy
What is the Major ADE or rifampin
Orange tinged body fluids
What are the Major ADE of Ethambutol
Red green color changes, and visual acuity
What are the major ADE of streptomycin in TB tx
Cranial 8 nerve damage
Nephrotoxic
Monitor Audiogram and BUN/Cr
What is the tx appraoch to latent TB
INH plus Pyridoxine x 9 months
What is the most common cause of lower tract infection in children younger than 1 year
RSV
Dx with PCR nasal swab
A pt presents less than 12 months with a lower resp dz, during the winter, with known circulation of RSV
What is the tx
Supportive,
Reassurance and close follow up
What are the three phases of Whooping cough
Catarrhal phase: Characterized by nonspecific symptoms. Ex. generalized malaise, rhinorrhea, and mild cough. Lacrimation and injections
Paroxysmal phase: Characterized by paroxysmal cough (series of severe, vigorous coughs that occur during a single expiration).
Convalescent phase: characterized by a gradual reduction in the frequency and severity of cough. It usually lasts one to two weeks but may be prolonged.
How do you Dx pertussis
A cough illness lasting at least TWO weeks without clear cause and one of the following symptoms:
- paroxysms of coughing
- inspiratory whoop
- post-tussive emesis.
In the setting of an outbreak or known close contact to a confirmed case of pertussis, the presence of a cough lasting ≥2 weeks is sufficient for clinical diagnosis (even in the absence of other symptoms).
What is the gold standard for Pertussis Dx
Gold standard: culture; PCR more sensitive, but more false positives – more PCR in clinical practice
What are the Tx approaches to Pertussis
Azithromycin
or TMP/SMX ( Bactrim
If contra to Azithromycin an older than 2 months)
When should post exposure prophylaxis for pertussis be initiated
Close contacts, same households, or face to face in 3 feet more than 1 hour within 21 days of exposure
Or high risk pts:
Immuno comp
New baby
Pregnant
Use Azithromycin
What is the major ADE of Azithromycin in kids
Pyloric stenosis and can lead to vomiting , regurgitation
Projectile
What is the cause of croup
What are the S/s
What is the classic finding?
parainfluenza type 1
S/s inspiratory stridor, barking cough, and hoarseness
Classic: barking cough and steeple sign
What is the tx for Croup
Mild: single dose dexamethasone or oral prednisone
Mod-severe- plus neb Epi
What are the pts most at risk of Inluenza
Age older than 65 and HIV pts
A 66 yr old pt presents with Abrupt onset of fever, headache, myalgia, and malaise after an incubation period of one to four days (average two days).
S/s consitent with pnuemonia
Think
Influenza
What pts get antivirals for Influenza
Hospitalized Pregnant Asthma Diabetes Heart Disease Immunocompromised
What is the most common Pneumo in HIV pts
P. jirovecci Pneumo
Tx with High Does Bactrim
A pt presents with Localized, sharp, fleeting pain made worse by cough, sneezing, deep breath or movement
Radiation to ipsilateral shoulder, plus a friction rub on auscultation (lungs)
Think?
Tx?
Pluertis
Treat the underlying condition -Analgesics & anti-inflammatory drugs are helpful for pain relief -Indomethacin 25mg PO 2-3x/day -Codeine 30-60mg q 8 hrs. (Pain relief — – Poor evidence for cough suppression)
Other opioids, NSAIDs, acetaminophen
Intercostal nerve blocks sometimes used (RARE)
What are the 4 types of pleural effusions
Transudates: increased production of fluid in the setting of normal capillaries due to increased hydrostatic or decreased oncotic pressure
Exudates: increased production of fluid due to abnormal capillary permeability or decreased lymphatic clearance of fluid
Empyema: infection in pleural space
Hemothorax: bleeding in pleural space
A pt presents with dyspnea, cough and respirophasic pain
With dullness to percussion and diminished lung sounds (focal)
Think
Tx?
Pleural effusion
Eval with a thoracocentesis
(Can also be therapeutic)
Determine if its complicated of uncomplicated
Uncomplicated: Sterile pleural fluid accumulation in the pleural space.
-Resolve with antibiotic treatment of the pneumonia
Complicated: Pleural fluid accumulation with bacterial invasion of pleural space which leads to acidosis (low pH), low glucose or loculations but negative Gram stain or culture
-Txt with antibiotic and tube thoracostomy if glucose <60 or PH <7.2
Empyema: Pleural fluid accumulation with bacterial invasion of pleural space: purulent appearance, low pH and positive Gram stain or culture
-Treatment is antibiotics and tube thoracostomy
What are the C/I of thoracentesis
Contraindications:
Uncooperative patient
Relative Contraindications: Bleeding diathesis Small volume of fluid Low benefit to risk ratio Chest wall infection
How many liters should be removed in a pleural effusion
30-50 mL to run tests
Can remove up to 1.5 L to alleviate symptoms
Do not remove > 1.5 L at one time as it can result in ‘re-expansion pulmonary edema’
What is lights criteria for Pleural effusion
Pleural effusion is an exudate if one of following criteria is met
- Protein greater than 0.5
- LDH greater than 0.6
- LDH greater than 2/3 ULN serum value
What defines a Chylothorax effusion
TriGs greater than 110
How will a TB effusion present
With elevated protein
How much fluid can be detected with CT in an effusion
As little as 10 ml
What level of fluid is required to do a blind centesis
1 cm in decubitus view
What findings are consistent with a complicated para pneumonic effusion
pH less tha 7.2
And gl less than 60
You find frank pus in the pleural space of centesis, and the gram stain is positive with refractory fevers
What is the Dz and tx
Empyema!
Requires prompt drainage(tube thoracostomy, pig tail catheter, intrapleura t-PA and DNase, video assisted thoracic surgery, etc.
What is primary vs secondary of spontaneous Pneumo
Primary: Occurs in the absence of underlying lung disease
Due to rupture of sub-pleural apical blebs
Tall thin men, aged 20-40.
Common hx of smoking or a familial
Increased frequency in Marfan’s
Often recurs repeatedly
Secondary: complication of pre-existing lung disease (COPD, asthma, cystic fibrosis, tuberculosis, pneumocystis pneumonia, interstitial lung disease)
What is the Tx appraoch to Spon PneumoTHX
If small, <3 cm of air between the lung and chest wall on the chest radiograph, and stable treat conservatively with observation in the ER or home for a few hrs. and oxygen. Repeat CXR (within 24 hours) and if no progression can be discharged.
If large and stable or symptomatic, treat with needle aspiration
If secondary or large pneumothorax or severe symptoms or on ventilation, place chest tube
- Needle Decompression first (needle thoracotomy)
- Chest tube is usually placed under water sealed drainage and suction applied until lung expands.
Pts respond well within 3 days.
What is the definition of Acute Resp Failure
Life-threatening, abnormal gas-exchange
Oxygenation and/or ventilation
Impairs function of vital organs
ABG criteria are not absolute ;
PaO2 under 60 mm Hg
(SaO2 of <90%) or
PaCo2 over 45 mm Hg
What are the common causes of Hypoxemic Acute Resp Failure
ARDS Pneumonia Acute Lobar Atelecasis Cardiogenic Pulm Edema Lung Contusion
What are common causes of Hypercapnic Acute Resp Failure
COPD
Asthma
Drugs that cause resp depression
NMR/MSK D/o
GBS
Acute MG
Electrolyte imbalances
OHS
What is the O2 goal in hypercapnic Resp failure
88-92
What is the max FiO2 with a NC
Standard nasal prongs: max FiO2: 22-50% with flow rate of 1-6 liters/min
What is the max FiO2 with a simple face mask
Simple face mask can deliver oxygen concentrations of 40% to 60% with flow rates from 6 to 10 L/min
What is the max FiO2 with a Venturi mask
Venturi principle masks 24% to 60% with flow rates from 4 to 12 L/min
What is the max FiO2 with a NRB
Non-rebreather mask with reservoir: FiO2: 50-100% with flow rates from 10 to 15 L/min
What is the max FiO2 with a High Flow NC
High-flow nasal cannula 21-100% fi02 atflowrates of up to 60 liters/min
What are the indications for Intubation
(1) Hypoxemia despite supplemental O2
(2) Upper airway obstruction (tumor, laryngeal edema)
(3) Impaired airway protection
(4) Inability to clear secretions
(5) Progressive general fatigue, tachypnea, use of accessory respiratory muscles, or mental status deterioration
(6) Apnea
(7) Severe hypoxemia
How do you prevent Ulcers in a vent pt
PPI
What two prevention measures that should be given to every vent pt
PPI and DVT/PE prevention
What are the characterist findings of ARDS
Respiratory Distress
Acute onset within 1 week of known clinical insult
Bilateral radiographic pulmonary infiltrates
Respiratory failure not fully explained by heart failure or volume overload
PaO2/FIO2 ratio < 300 mm Hg (according to the Berlin Definition)
Define ARDS
non-cardiogenic form of pulmonary edema that leads to acute hypoxemic respiratory failure
What is Mild/Mod/Severe ARDS
Mild :PaO2/FIO2 ratio of between 200 and 300 mm Hg
Moderate :PaO2/FIO2 ratio between 100 and 200 mm Hg
Severe :PaO2/FIO2 ratio less than 100 mm Hg
What are the MC causes of ARDS
Sepsis
Diffuse Pneumonia
Aspiration of Gastric Contents
Trauma (severe)
A pt presents with rapid onset of profound dyspnea After a day of being on the Vent,
Marked Hypoxemia,
Crackles and tachypnea with multiple organ failure
Think
ARDS
What are the Hallmarck CSR in ARDS
CXR: diffuse or patchy bilateral infiltrates that rapidly become confluent
Characteristically spares the costophrenic angles
Air bronchograms occur in about 80% of cases
Heart size is normal
Pleural effusions are small or nonexistent
What is the Treatment for ARDS
Identify & treat underlying illness/injury
Broad spectrum antibiotics for sepsis and/or infection
General supportive care
Tracheal intubation and mechanical ventilation
The lowest levels of PEEP (used to recruit atelectatic alveoli) with supplemental O2 (FiO2 <60%) to maintain SaO2 >88%
Low tidal volume (ideal weight based 6 ml/kg)
Prone positioning
Monitor cardiac & other organ functions
Describe neonatal resp distress syndrome
AKA Hyaline membrane dz
Most prevalent in preterm births
INSUFFICIENT SURFACTANT
When does surfactant start coating the lung in gestation
In preparation for air breathing, surfactant is expressed in the lung starting around the 20th week of gestation .
What is the role of surfactant
Surfactant reduces the alveolar surface tension, thereby facilitating alveolar expansion and reducing the likelihood of alveolar collapse atelectasis.
In Neonatal distress what are the two outcomes of reduced surfactant and atelectasis
Surfactant deficiency leads to rapid accumulation of neutrophils in the lung and subsequent pulmonary edema.
Atelectasis will also lead to a cytokine-mediated inflammatory response.
A preterm infant Presents with tachypnea, and labored RR, with cyanosis
+nasal flaring
+extra muscle use
Labs: hypoxemia
CXR” Low volume, and Ground glass appearance + bronchograms
Think/>?
Tx?
Neonatal Distress Syndrome
Tx:
Prevent premature birth
Administration of antenatal corticosteroids!
—All pregnant woman at 23-34 weeks who are at increased risk of preterm delivery (~7dys)
Pos Pressure Vent with exogenous surfactant
All pregnant woman at 23-34 weeks who are at increased risk of preterm delivery (~7dys) should get what Tx to prevent Neonatal Resp Distress Syndrome
Antenatal corticosteroids
What is the FiO2 requirement for a neonate in resp distress syndrome
Defined as requiring a fraction of inspired oxygen [FiO2] of 0.40 or higher to maintain oxygen saturation above 90 percent
What is the most common malignant cancer among men
Lung Cancer/ Bronchogenic carcinoma
What are the two major histológicas groups of Lung Cancer
Small cell And non small cell —Adenocarcinoma —Squamous Cell —Large Cell
What is the biggest risk Fx for Small cell cancer
Smoking
Understand slide 8 in the neoplasm lecture
What is the 1st step in evaluating a solitary neoplasm on CT
Compare with an old CXR or CT
If the pt is low risk for malignancy and you want to do serial CTs what is the time intervals of scans
Q 3months
If a pt has a high risk of malignancy on CT scan for neoplasm
What is the approach
Refer right away
Plus PET scan , bronchoscopy, and FNA biopsy
What defines a high risk malignancy pt
Smoking Hx
Nodule size greater than 8mm
Occupational: asbestos, Hx of Rads, radon, metals, toxins inhalation
Age >30
What is CAUTION W for cancer
Change in Bowl habits A wound doesnt heal Unexplained bleeding Tumor or Tissue growth Indigestion/ Dysphagia Obvious change in a mole or nodule Nagging or Coughing
WT loss!
A pt presents with cough, dyspnea, pain, and hemoptysis
With new unexplained wt loss, fatigue, and anemia
+fever
Think what DDX
CANCER CANCER CANCER
What does asthenia mean
Weakness
Which spreads faster, small or nonsmall cell
small cell
What two labs should all cancer suspected pts get
CBC and CMP (includeds LFTS and Electrolyts with Ca2+ )
What are the indications for screening with low dose helical CT scan
Adults 50-80
+ 20 pack/yr history of tobacco
+ Currently smokes or quit within the past 15 years
Life expectancy that would support ability and willingness to have curative lung cancer surgery
What defines a mass vs a nodule
> 3cm is considered a mass
<3cm is considered a nodule
Define solitary pulm nodule
Defined: < 3cm isolated, rounded opacity, outlined by normal lung tissue
Not associated w/ infiltrate, atelectasis or adenopathy
Look at slide 26 for solitary pulm nodules DDX Be familiar
What are the two patterns of BAD solitary pulm nodules
Stippled, speculated, and eccentric are more likely to be BAD
Diffuse/ Central/ popcorn/ laminated are all typically benign
What is TNM of Cancer staging
Tumor Size
Nodules
Metastasis
What is the most common artery for Metz in lung cancer
Pulm artery
What does Metz cancer look like on CXR
Multiple, spherical densities with sharp margins
Most are < 5cm
Bilateral
More common in the lower lung fields
Cavitations—suggests squamous cell
What are the 4 (S) of Small cell
Small, Spreads Fast, SIADH, Smokers
Define Adenocarcinoma
Non Small Cell
—Peripheral nodules or masses
Most common in women and nonsmokers
Arises from mucus glands
Most common primary
lung cancer!!
Define Squamous Cell Carcinoma
Arises centrally from bronchial epithelium
—Mainstem, secondary and tertiary bronchus (most commonly)
Intraluminal sessile or polypoid mass
More likely to present with hemoptysis!!
More frequently diagnosed by sputum cytology
Spreads locally
Associated w/ hilar adenopathy & mediastinal widening on CXR
Can form cavitation
Define Large Cell Carcinoma
Heterogeneous group of undifferentiated cancers, dot fit into other categories
Can present as central or peripheral masses
Most commonly-peripheral masses
Define Pancoast Tumors
Pancoast tumor –lung tumor of the superior sulcus at extreme apex of the lung
Usually NSCLC
Shoulder & arm pain
Horner’s syndrome: Neurological syndrome due to lesion along sympathetic pathway that supplies head, eye, and neck.
—Ptosis, miosis, and anhidrosis
Weakness & atrophy of hand
Can progress to SVC syndrome if tumor is on R side
Define horners syndrome
Horner’s syndrome: Neurological syndrome due to lesion along sympathetic pathway that supplies head, eye, and neck.
Ptosis, miosis, and anhidrosis
Define SVC syndrome
SVC Syndrome: Face/neck swelling, dyspnea, chest pain, neurological manifestations.
What is the most common initial S/s of Pancoast Tumors
Should pain
Severe unremitting pain
Invasion of brachial plexus, pleura, ribs or vertebral bodies
Radiates up head/neck, down scapula, axilla, chest or ipsilateral arm
Follows ulnar distribution (C8, T1 nerve roots)
Often misdiagnosed as cervical OA or bursitis
Progresses to weakness/atrophy of hand
An elevated calcium level without cause should prompt what work up
Cancer Workup for Squamous Cell
What is the hallmark of Myasthenia Gravis
Hallmark of myasthenia gravis is muscle weakness that worsens after periods of activity and improves after periods of rest.
Muscles such as those that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are often (but not always) involved in the disorder.
The muscles that control breathing and neck and limb movements may also be affected.
Define limited vs extensive staging of small cell carcinoma
Limited (about 30%) one side of lung and regional nodes
Extensive (about 70%) both lungs and/or distant spread
What is the tx for small cell cancer
Chemo TOC
what is carcinoid syndrome
Flushing, diarrhea, wheezing, hypotension
Think Lung Carcinoid
24 hour 5- hydroxindoleactic acid is the Dx assay for…
Carcinoid syndrome
A pt presents with pleural thickening, Insidious onset of SOB, unilateral non-pleuritic CP, wt loss
PE: Dullness to percussion, diminished breath sounds, digital clubbing
Pleural effusion or pleural thickening on CXR
Think? Tx?
Mesothelioma
Tx Chemo
What are the 3 compartments to classify and assist DDX on a CXR
Anterior mediastinal mass (“terrible T’s”)
Thymoma, teratoma, thyroid lesions, “terrible” lymphoma, mesenchymal tumors (lipoma, fibroma)
Thymic lesions are the most common tumor in the anterior mediastinum and are associated with various paraneoplastic syndromes, such as myasthenia
Middle mediastinal mass
—Lymphadenopathy, pulm artery enlargement, Aortic Aneurism, Developmental cyst
Posterior mediastinal mass
Hiatal hernia, neurogenic tumor, meningocele, esophageal tumor, thoracic spine lesions
What are the common tumors to the anterior mediastinum
(“terrible T’s”)
-Thymoma, teratoma, thyroid lesions, “terrible” lymphoma, mesenchymal tumors (lipoma, fibroma)
Thymic lesions are the most common tumor in the anterior mediastinum and are associated with various paraneoplastic syndromes, such as myasthenia gravis
A 45-year-old male presents to your office with a 2-month history of a nonproductive cough, mild shortness of breath, fatigue, and a 5-lb weight loss. On examination his lungs are clear.
A PPD skin test is negative. A chest radiograph shows bilateral hilar adenopathy and his angiotensin converting enzyme level is elevated. A biopsy of the lymph node shows a noncaseating granuloma.
What Dz best describes this pts ILD and what is the first line and second line Tx
This is Sarcoidosis (with Tb ruled out)
1st line : Prednisone
2nd line: Methotrexate if intolerant to Steroids
I.e; DM, Wt gain, osteoporosis, myopathy
