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IPAP JUNIOR SEM. > Pulm Cards Culm > Flashcards

Pulm Cards Culm Flashcards

1
Q

What is the pulm dz that is associated with inhalation of mineral dust

A

Pneumoconioses

Chronic fibrotic lung dz 2ndary to occupation inhalation

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2
Q

Assoc Nitrofurantoin and Amiodernone with idiopathic Pulm Fibrosis

A
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3
Q

What are the S.s of ILD

A

Dyspnea, Cough, FINE crackles

CXR: septal thickening, bilateral infiltrates, and reticulondular changes

Additional:
Clubbing, Hemoptysis, wheezing, Rash

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4
Q

CXR: septal thickening, bilateral infiltrates, and reticulondular changes

Think

A

ILD ( MC Pulm fibrosis)

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5
Q

A Pt presents with fine, dry, bibasilar inspiratory crackles, with clubbing of the fingers..
think

A

Idiopathic ILD

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6
Q

A young African American presents with bilateral hilar lymphadenopathy

Is a classic classic finding of what condition

A

Sarcoidosis

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7
Q

What is the triad of lofgren syndrome

A

Erthyema nodosum, Bilateral Hilar LAD, polyarthralgias with fever

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8
Q

A pt presents with increased ACE levels on LABs,

Think

A

Sarcoidosis

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9
Q

Is sarcoidosis caseating or non ?

A

NON!

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10
Q

What is the treatment for Sarcoidosis

A

Is S/s present the oral steroids,

If nons/s then watch may go away in 1-2 years

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11
Q

A CXR presents with “photographic negative” pattern

Think

A

Chronic eosinophilic pneumonia

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12
Q

What is the triad of Granulmatosis with polyangitis

A

URI and LRI with Glomerulonephritis

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13
Q

What does a postive C-ANCA mean

A

Positive anitobidy that is assoc with pulm vasculitiis

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14
Q

RINGS and TRACS of CXR is a finding of

A

Brnachiectsasis

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15
Q

What is the triad of Eosinphilic granlomatous with polyangitis

A

Asthma, eosinophils, with chronic rhinitis

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16
Q

What are the two common treatments for eosinophilic and non-eosinophilic granulomatosis with polyarthalgias

A

Corticosteroids PLUS cyclophosphamide

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17
Q

What are the three effects of smoke inhalation

A

1) Impaired tissue oxygenation
2) Thermal injury to upper airway
3) Chemical injury to the lower airways and lung parenchyma

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18
Q

What is the 1st line tx for CO poisoning

A

Treatment is immediate high flow O2 followed if needed by hyperbaric oxygen and supportive care

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19
Q

A pt presents with dyspnea, AMS, HOTN, HA, and syncope
HPI: Inhalation of combustion from plastics and textiles

What is the Tx approach

A

Tx includes the use of the cyanide antidote kit (Cyanokit®) and supportive care

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20
Q

Where does Cyanide effect the electron transport chain

A

Inhibits oxidative phosphorylation
Inactivates cytochrome oxidase

Leading to anaerobic metabolism and lactate production

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21
Q

Supportive care for smoke inhalation

A

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

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22
Q

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

A

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

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23
Q

What is bronchilitis obliternas

A

Complication of smoke inhalation injury

One of several causes of damage to bronchioles
CT shows “ground glass” and bronchial wall thickening

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24
Q

What is E-VALI

A

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

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25
Q

What is the tx for Cyanide OX

A

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

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26
Q

At what percent of CO levels do non smokers become S/.s

A

10%

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27
Q

What is pneumoconioses

A

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

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28
Q

A coal miner presents with progressive fibrosis, with nodular opacities, with opacities in the upper lobes

What is the Tx approach

A

Supportive, usually asymptomatic incidental finding

Finding: Conglomeration of irregular masses >1cm & contraction in upper lung fields

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29
Q

On CXR you see Hilar lymph nodes “eggshell calcifications” with small rounded nodules in the lungs

Think

A

Silicosis

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30
Q

Pts with silicosis are at an increased risk of what Dz

A

TB

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31
Q

All pts with silicosis should get what screenings?

A

TB skin test and current CXRs

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32
Q

WHat are the CXR findings in asbestosis

A

CXR:
Linear streaking at lower lung fields

Opacities of various shapes/sizes

Honeycomb changes – advanced disease

PLEURAL CALCIFICATIONS may be best diagnostic clue

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33
Q

What is the best imaging test for asbestosis

A

High resolution CT (HRCT) – best imaging for asbestosis

Parenchymal fibrosis & coexisting pleural plaques

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34
Q

What is the Tx approach to Asbestosis

A

Smocking cessation

O2 for SOB
Resp physiotherapy for secretions

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35
Q

What is extrinsic allergic alveolitis

A

Hypersensitivity Penumonitis

An inflammatory disorder of the lung, involving alveolar walls and terminal airways

Organic causes

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36
Q

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?

A

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)

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37
Q

When does honeycombing set in on a pt with hypersensitivity pneumonitis

A

Chronic exposure

only tx at this point in lung biopsy

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38
Q

What is the HPI key to Dx occupational asthma

A

S/s at work

But symptomatic improvement away from work

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39
Q

What is the Tx approach to Occupational asthma

A

Treatment: avoidance

Bronchodilators

Symptoms may persist long after exposure terminated

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40
Q

What are the three keys to occupational asthma

A

S/s
Timing
Exposure

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41
Q

A cotton worker presents with dyspnea, cough, and chest tightness at work..
think

A

Byssinosis, Tx removal of agent

FIND A NEW JOB

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42
Q

Describe Silo fillers lung Dz

A

Acute, toxic pulmonary edema caused by inhalation of nitrogen dioxide from recently filled silos leading to bronchiloitis

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43
Q

Describe the radiography of bronchiolitis

A

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

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44
Q

Is silo fillers chemical or organic pneumonitis ?

A

Chemical!

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45
Q

Describe popcorn lung

A

Chronic inhalation of diacetyl (butter flavoring) linked to bronchiolitis obliterans

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46
Q

What is the most common cause of ARDS

A

Aspiration of Gastric Contents

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47
Q

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?

A

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

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48
Q

Look at toxic and radiation aspiration slide 67 on lecture 10 pulm

A
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49
Q

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?

A

Radiation pneumonitis/ fibrosis

Tx: prednisone

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50
Q

A cancer pt presents with CXR: tented diaphragms, obliteration of normal lung markings, reduced lung volumes, reticular and dense opacities

Think? Tx?

A

Pulm radiation fibrosis

TxL corticosteroids for 2-3 weeks followed by a slow taper

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51
Q

What happens with oxygen toxicity

A

Absorptive atelectasis (nitrogen keeps the alveoli open – if it’s all O2 and gets absorbed by the lung, then can collapse)

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52
Q

Describe TRALI

A

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

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53
Q

What is the tx approach to High Alt. D./o

A

Prevention: gradual ascent, acclimatization, meds (acetazolamide)

TX: immediate descent, O2/hyperbaric chamber,

If mild: sildenafil, acetazolamide, theophylline SR,
NSAIDS, Tylenol, aspirin
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54
Q

Describe histoplasmosis pneumonia

A

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

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55
Q

What is the Dx approach to histoplasmosis

What is the Tx

A

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

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56
Q

What two drugs increase the incidence of histoplasmosis

A

Remicaide/ Humira

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57
Q

What are the two manifestations of coccidiomycosis and where is it most common

A

Primary vs disseminated
(Due to spore inhalation)

Most common in southern USA, Mexico, and south/ Central America

Remember Coccidio cacti

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58
Q

Primary Coccidiomycosis commonly presents as ..

A

CAP

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59
Q

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

A

This dz is coccidiomycosis

S/s: Fever, myalgias, arthralgias (Knee and Ankles common)
Erthyema nodosum and multiforme

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60
Q

How does dissiminalted coccidiomycosis present and who does it affect most

A

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

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61
Q

What is the treatment approach to coccidiomycosis

A

No treatment necessary if mild

If severe then anti fungal ( fluconazole, itraconazole, Amphotericin)

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62
Q

What are the key features of Blastomycosis

A

Think Obama

From the Mid west, Middle Aged and shooting a shot gun (blast)
Effects men

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63
Q

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

A

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
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64
Q

Who does aspergillosis effect most

A

It’s a type I hypersensitivity reaction

So pts with asthma, bronchiecstasis, and/or cystic fibrosis

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65
Q

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

A

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.

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66
Q

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

A

Treatment – Invasive
Long courses of antifungals
High mortality!

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67
Q

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?

A

Aspergillosis (aspergilloma)

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68
Q

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

A

Pneumocystitis Pneumonia
(Pneumonitis Jerevecii)

Treatment Trimethoprim sulfamethoxazole

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69
Q

What is the pathophys of Pneumonia

A

Pathogen gains entry (inhalation, aspiration, colonization, hematogenous spread)

Microorganisms replicate

Inflammation, cytokine release

Accumulation of WBCs in alveoli

Damaged cilia

Desquamation

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70
Q

A kid presents with fever, chills, cough, and sputum production

What is the KEY Dx to say its pneumonia

A

RADs finding with pulmonary opacities

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71
Q

What is the common viral infection to pneumonia

A

Rhinovirus

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72
Q

What are the 2 major and minor pathways of pneumonia infection

A

Major Inhalation, aspiration

And Minor Blood borne
Staph, Iv drugs

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73
Q

What are the most common causes of CAP

A

bacterial pneumonia

Most common is S. Pneumonia

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74
Q

If a pt gets a pneumonia within 48 hours of admission

What type of pneumonia is it

A

CAP

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75
Q

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

A

CXR!

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76
Q

What is the treatment approach to aspergillosis

A

Steroid with a antfungal (best answer is dual therapy)

Steroids is single best answer

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77
Q

When should cultures be ordered for a pneumonia pt

A

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

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78
Q

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..

A

Pneumonia

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79
Q

How long does it take for pneumonia to clear up on CXR

A

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).

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80
Q

When should you do a bronchoscopy in pneumonia pts

A

For sampling secretions, especially if P. jirovecii or M. tuberculosis is suspected

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81
Q

What is the Gold Standard for influenza testing

A

PCR

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82
Q

What assay can detect legionella

A

Urine antigen testing

83
Q

What assay can test for strep Pneumo

A

Urine antigen testing

84
Q

You just confirmed the Pt has CAP

What is the tx approach

A

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

85
Q

What is the ABX duration for CAP

A

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

86
Q

If a pt has had no ABX in the past o-days and has CAP

What ABX can be used

A

If no abx in past 90d:
Macrolide (clarithromycin or azithromycin) OR
Doxycycline

87
Q

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

A

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)
88
Q

In regions where there is high macrolide resistance

What ABX should be used for tx of pneumonia

A 
In region of macrolide resistance:
Respiratory FQ 
(moxi/gemi/levofloxacin) 
 OR
Macrolide PLUS beta-lactam (amox-clavulanate)
89
Q

If you are truly suspecting legionella (water exposure, smoker, elderly)

What is the ABX approach

A 
Augmentin and added Azithromycin 
Or fluoroquinolones (Levó, Moxifloxacin, genta)
90
Q

What is the ABX approach to Inpt

A

Ceftriaxone and a Macrolide (Azithromycin)

Or

Quinolones

If Influenza:
Oseltamivir
With possible added Ceftriaxone

91
Q

What is the ICU ABX txs

A

Respiratory FQ
OR
Azithromycin PLUS cefotaxime or ceftriaxone or ampicillin (antipseudomonal beta-lactams)

92
Q

What is CURB 65

A 
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

93
Q

Define HAP and VAP

A

HAP: hospital acquired pneumonia
Acquired >48hrs after admission without appearance of infection at admission

VAP: ventilator associated pneumonia
Develops >48hrs after intubation

94
Q

What are the common pathogens in Nosocomial Pneumonia

A 
S. aureus (methicillin resistant & susceptible)
Pseudomonas aeruginosa
Gram neg rods
-Enterobacter
-Klebsiella
-E coli
95
Q

How does aspiration pneumonia present

A

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

96
Q

How do you treat aspiration pneumonia

A

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

97
Q

What is the progression of TB

A

Primary to Latent to Reactivation

98
Q

What is the Dx criteria for TB

A

3 cultures of sputum on consecutive days

Acid fast

99
Q

What are the three progressions of TB

A

Primary: CXR shows patchy opacities
Latent : rediographically negative
And Reactivation: Common in HIV/ AIDs./ immunucomp

100
Q

What is the criteria for 5, 15 and 15 mm of TB skin test

A

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!

101
Q

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

A

10+

102
Q 
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

A

10+

103
Q

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

A

5+

104
Q

When do we use the interferon gold test for TB

A

Blood test for TB, Fewer false positives w/ BCG hx

Single pt contact

105
Q

What are the Tx approaches to Active TB

A

RIPE x 6-9 months

Or (NEW CDC)
Rifampentine+ Moxifloxacin x 4 months

106
Q

What drug is Isoniaziad combined with to reduce its ADE profile

A

Add Pyridoxine to reduce peripheral neuropathy

107
Q

What is the Major ADE or rifampin

A

Orange tinged body fluids

108
Q

What are the Major ADE of Ethambutol

A

Red green color changes, and visual acuity

109
Q

What are the major ADE of streptomycin in TB tx

A

Cranial 8 nerve damage

Nephrotoxic

Monitor Audiogram and BUN/Cr

110
Q

What is the tx appraoch to latent TB

A

INH plus Pyridoxine x 9 months

111
Q

What is the most common cause of lower tract infection in children younger than 1 year

A

RSV

Dx with PCR nasal swab

112
Q

A pt presents less than 12 months with a lower resp dz, during the winter, with known circulation of RSV

What is the tx

A

Supportive,

Reassurance and close follow up

113
Q

What are the three phases of Whooping cough

A

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.

114
Q

How do you Dx pertussis

A

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).

115
Q

What is the gold standard for Pertussis Dx

A

Gold standard: culture; PCR more sensitive, but more false positives – more PCR in clinical practice

116
Q

What are the Tx approaches to Pertussis

A

Azithromycin

or TMP/SMX ( Bactrim
If contra to Azithromycin an older than 2 months)

117
Q

When should post exposure prophylaxis for pertussis be initiated

A

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

118
Q

What is the major ADE of Azithromycin in kids

A

Pyloric stenosis and can lead to vomiting , regurgitation

Projectile

119
Q

What is the cause of croup

What are the S/s

What is the classic finding?

A

parainfluenza type 1

S/s inspiratory stridor, barking cough, and hoarseness

Classic: barking cough and steeple sign

120
Q

What is the tx for Croup

A

Mild: single dose dexamethasone or oral prednisone

Mod-severe- plus neb Epi

121
Q

What are the pts most at risk of Inluenza

A

Age older than 65 and HIV pts

122
Q

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

A

Influenza

123
Q

What pts get antivirals for Influenza

A 
Hospitalized
Pregnant
Asthma
Diabetes
Heart Disease
Immunocompromised
124
Q

What is the most common Pneumo in HIV pts

A

P. jirovecci Pneumo

Tx with High Does Bactrim

125
Q

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?

A

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)

126
Q

What are the 4 types of pleural effusions

A

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

127
Q

A pt presents with dyspnea, cough and respirophasic pain
With dullness to percussion and diminished lung sounds (focal)

Think

Tx?

A

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

128
Q

What are the C/I of thoracentesis

A

Contraindications:
Uncooperative patient

Relative Contraindications:
Bleeding diathesis
Small volume of fluid
Low benefit to risk ratio
Chest wall infection
129
Q

How many liters should be removed in a pleural effusion

A

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’

130
Q

What is lights criteria for Pleural effusion

A

Pleural effusion is an exudate if one of following criteria is met

  1. Protein greater than 0.5
  2. LDH greater than 0.6
  3. LDH greater than 2/3 ULN serum value
131
Q

What defines a Chylothorax effusion

A

TriGs greater than 110

132
Q

How will a TB effusion present

A

With elevated protein

133
Q

How much fluid can be detected with CT in an effusion

A

As little as 10 ml

134
Q

What level of fluid is required to do a blind centesis

A

1 cm in decubitus view

135
Q

What findings are consistent with a complicated para pneumonic effusion

A

pH less tha 7.2

And gl less than 60

136
Q

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

A

Empyema!

Requires prompt drainage(tube thoracostomy, pig tail catheter, intrapleura t-PA and DNase, video assisted thoracic surgery, etc.

137
Q

What is primary vs secondary of spontaneous Pneumo

A

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)

138
Q

What is the Tx appraoch to Spon PneumoTHX

A 
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

  1. Needle Decompression first (needle thoracotomy)
  2. Chest tube is usually placed under water sealed drainage and suction applied until lung expands.

Pts respond well within 3 days.

139
Q

What is the definition of Acute Resp Failure

A

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

140
Q

What are the common causes of Hypoxemic Acute Resp Failure

A 
ARDS 
Pneumonia 
Acute Lobar Atelecasis 
Cardiogenic Pulm Edema 
Lung Contusion
141
Q

What are common causes of Hypercapnic Acute Resp Failure

A

COPD
Asthma
Drugs that cause resp depression
NMR/MSK D/o

GBS

Acute MG

Electrolyte imbalances
OHS

142
Q

What is the O2 goal in hypercapnic Resp failure

A

88-92

143
Q

What is the max FiO2 with a NC

A

Standard nasal prongs: max FiO2: 22-50% with flow rate of 1-6 liters/min

144
Q

What is the max FiO2 with a simple face mask

A

Simple face mask can deliver oxygen concentrations of 40% to 60% with flow rates from 6 to 10 L/min

145
Q

What is the max FiO2 with a Venturi mask

A

Venturi principle masks 24% to 60% with flow rates from 4 to 12 L/min

146
Q

What is the max FiO2 with a NRB

A

Non-rebreather mask with reservoir: FiO2: 50-100% with flow rates from 10 to 15 L/min

147
Q

What is the max FiO2 with a High Flow NC

A

High-flow nasal cannula 21-100% fi02 atflowrates of up to 60 liters/min

148
Q

What are the indications for Intubation

A

(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

149
Q

How do you prevent Ulcers in a vent pt

A

PPI

150
Q

What two prevention measures that should be given to every vent pt

A

PPI and DVT/PE prevention

151
Q

What are the characterist findings of ARDS

A

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)

152
Q

Define ARDS

A

non-cardiogenic form of pulmonary edema that leads to acute hypoxemic respiratory failure

153
Q

What is Mild/Mod/Severe ARDS

A

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

154
Q

What are the MC causes of ARDS

A

Sepsis

Diffuse Pneumonia

Aspiration of Gastric Contents

Trauma (severe)

155
Q

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

A

ARDS

156
Q

What are the Hallmarck CSR in ARDS

A

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

157
Q

What is the Treatment for ARDS

A

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

158
Q

Describe neonatal resp distress syndrome

A

AKA Hyaline membrane dz

Most prevalent in preterm births

INSUFFICIENT SURFACTANT

159
Q

When does surfactant start coating the lung in gestation

A

In preparation for air breathing, surfactant is expressed in the lung starting around the 20th week of gestation .

160
Q

What is the role of surfactant

A

Surfactant reduces the alveolar surface tension, thereby facilitating alveolar expansion and reducing the likelihood of alveolar collapse atelectasis.

161
Q

In Neonatal distress what are the two outcomes of reduced surfactant and atelectasis

A

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.

162
Q

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?

A

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

163
Q

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

A

Antenatal corticosteroids

164
Q

What is the FiO2 requirement for a neonate in resp distress syndrome

A

Defined as requiring a fraction of inspired oxygen [FiO2] of 0.40 or higher to maintain oxygen saturation above 90 percent

165
Q

What is the most common malignant cancer among men

A

Lung Cancer/ Bronchogenic carcinoma

166
Q

What are the two major histológicas groups of Lung Cancer

A 
Small cell 
And non small cell 
—Adenocarcinoma 
—Squamous Cell 
—Large Cell
167
Q

What is the biggest risk Fx for Small cell cancer

A

Smoking

168
Q

Understand slide 8 in the neoplasm lecture

A
169
Q

What is the 1st step in evaluating a solitary neoplasm on CT

A

Compare with an old CXR or CT

170
Q

If the pt is low risk for malignancy and you want to do serial CTs what is the time intervals of scans

A

Q 3months

171
Q

If a pt has a high risk of malignancy on CT scan for neoplasm

What is the approach

A

Refer right away

Plus PET scan , bronchoscopy, and FNA biopsy

172
Q

What defines a high risk malignancy pt

A

Smoking Hx
Nodule size greater than 8mm

Occupational: asbestos, Hx of Rads, radon, metals, toxins inhalation

Age >30

173
Q

What is CAUTION W for cancer

A 
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!

174
Q

A pt presents with cough, dyspnea, pain, and hemoptysis
With new unexplained wt loss, fatigue, and anemia
+fever

Think what DDX

A

CANCER CANCER CANCER

175
Q

What does asthenia mean

A

Weakness

176
Q

Which spreads faster, small or nonsmall cell

A

small cell

177
Q

What two labs should all cancer suspected pts get

A

CBC and CMP (includeds LFTS and Electrolyts with Ca2+ )

178
Q

What are the indications for screening with low dose helical CT scan

A

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

179
Q

What defines a mass vs a nodule

A

> 3cm is considered a mass

<3cm is considered a nodule

180
Q

Define solitary pulm nodule

A

Defined: < 3cm isolated, rounded opacity, outlined by normal lung tissue

Not associated w/ infiltrate, atelectasis or adenopathy

181
Q

Look at slide 26 for solitary pulm nodules DDX Be familiar

A
182
Q

What are the two patterns of BAD solitary pulm nodules

A

Stippled, speculated, and eccentric are more likely to be BAD

Diffuse/ Central/ popcorn/ laminated are all typically benign

183
Q

What is TNM of Cancer staging

A

Tumor Size
Nodules
Metastasis

184
Q

What is the most common artery for Metz in lung cancer

A

Pulm artery

185
Q

What does Metz cancer look like on CXR

A

Multiple, spherical densities with sharp margins

Most are < 5cm

Bilateral

More common in the lower lung fields

Cavitations—suggests squamous cell

186
Q

What are the 4 (S) of Small cell

A

Small, Spreads Fast, SIADH, Smokers

187
Q

Define Adenocarcinoma

A

Non Small Cell

—Peripheral nodules or masses

Most common in women and nonsmokers

Arises from mucus glands

Most common primary
lung cancer!!

188
Q

Define Squamous Cell Carcinoma

A

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

189
Q

Define Large Cell Carcinoma

A

Heterogeneous group of undifferentiated cancers, dot fit into other categories

Can present as central or peripheral masses

Most commonly-peripheral masses

190
Q

Define Pancoast Tumors

A

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

191
Q

Define horners syndrome

A

Horner’s syndrome: Neurological syndrome due to lesion along sympathetic pathway that supplies head, eye, and neck.

Ptosis, miosis, and anhidrosis

192
Q

Define SVC syndrome

A

SVC Syndrome: Face/neck swelling, dyspnea, chest pain, neurological manifestations.

193
Q

What is the most common initial S/s of Pancoast Tumors

A

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

194
Q

An elevated calcium level without cause should prompt what work up

A

Cancer Workup for Squamous Cell

195
Q

What is the hallmark of Myasthenia Gravis

A

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.

196
Q

Define limited vs extensive staging of small cell carcinoma

A

Limited (about 30%) one side of lung and regional nodes

Extensive (about 70%) both lungs and/or distant spread

197
Q

What is the tx for small cell cancer

A

Chemo TOC

198
Q

what is carcinoid syndrome

A

Flushing, diarrhea, wheezing, hypotension

Think Lung Carcinoid

199
Q

24 hour 5- hydroxindoleactic acid is the Dx assay for…

A

Carcinoid syndrome

200
Q

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?

A

Mesothelioma

Tx Chemo

201
Q

What are the 3 compartments to classify and assist DDX on a CXR

A

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

202
Q

What are the common tumors to the anterior mediastinum

A

(“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

203
Q

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

A

This is Sarcoidosis (with Tb ruled out)

1st line : Prednisone
2nd line: Methotrexate if intolerant to Steroids
I.e; DM, Wt gain, osteoporosis, myopathy

IPAP JUNIOR SEM. (43 decks)

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