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Clin Med > Pulm Exam > Flashcards

Pulm Exam Flashcards

1
Q

A low FEV1, or a low FEV1/FVC, indicates _____

A

Obstructive lung disease

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2
Q

A normal DLCO is ____%. Low indicates…

A

80-120

Low = severe restrictive

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3
Q

Can the pulmonary interstitium be seen on CXR? CT? What even is it?

A

No and no, not normally. It’s a tissue network for gas exchange that goes to both lungs, alveoli, basement membrane, and capillaries.

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4
Q

Harming the interstitium ==> ….

A

Less oxygen IN.

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5
Q

4 ways to Dx IPF + 1 way to confirm?

A

1) PFTs - Spirometry = low FVC; DCLO <80% if severe
2) HxPE - insidious dry cough, DOE, clubbing, rales
3) CT - honeycomb
4) CXR - reticular
Can confirm - biopsy

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6
Q

4 types of PFTs you can order covered in class?

A

1) lung volume
2) Spirometry
3) spirometry pre/post bronchodilator
4) DLCO

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7
Q

Someone seems to have a restrictive lung disease, but their DLCO is normal. Why?

A

It could be extrathoracic-caused or a mild restrictive case! DLCO wnl does not mean it’s r/o!

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8
Q

Lung volume PFTs test things like tidal volume (what’s that?), residual volume, and vital capacity. If you add those last two together, what do you get? What’s a normal value for it?

A

Tidal = without trying

Vital capacity + residual volume = total capacity (normal is 3-4L)

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9
Q

Spirometry is over what time period? What are the three most useful results?

A

6 seconds

FEV1, FVC, ratio

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10
Q

An FEV1/FVC equal to or under ____ is abnormal, and indicates…

A

70%

Obstructive lung disease

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11
Q

Your patient’s Spirometry was low. What do you order now, and what does it tell you?

A

Spirometry pre and post bronchodilator

“Positive” = it improved = probably asthma

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12
Q

What is an FVC? What is a low FVC, and what does it mean?

A

Maximum amount of air you can exhale after taking the deepest possible breath in.
Normal varies by age/gender etc
Low = restrictive lung disease

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13
Q

If you do spirometry with a forced inspiration also, that’s called a ____. Why would you order that?

A

Flow Volume Loop

Do it + normal spirometry if dyspnea or stridor.

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14
Q

Obstructive lung disease would show ____ on a flow loop; restrictive would show ___.

A 
Obstructive = coving
Restrictive = everything reduced
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15
Q

Good news! Cleveland/ATS PFT interpretation IS NOT on the test!

A

Oh no it’s nottt (: woot woot

It is on therapeutics though so…

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16
Q

Low total capacity indicates ___. What’s the opposite?

A 
<80 = restrictive
>120 = hyperinflation = probable COPD
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17
Q

In what obstructive lung disease could DLCO be low?

A

Emphysema

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18
Q

Restrictive lung disease means decreased ___, ___, and/or ___.

A

Expansion
Volume
Diffusion

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19
Q

Restrictive lung disease can be either intrinsic (at the ___), or extrinsic (at the ___). Give examples of each.

A 
Intrinsic = at the interstitium (sarcoidosis, IPF, pneumoconiosis)
Extrinsic = at the chest wall/respiratory muscles (ALS, MG, obesity)
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20
Q

What are some prescription drugs that can lead to restrictive lung disease?

A

MTX
Amiodarone
Nitrofurantoin

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21
Q

Most likely patient to get IPF?

A

50+yo male, who either smokes or has occupational exposure or GERD

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22
Q

What’s the real name for IPF?

A

Idiopathic fibrosing interstitial pneumonia

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23
Q

What causes IPF?

A

Gotcha- it’s idiopathic. Definitely NOT inflammation!

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24
Q

4 s/s of IPF

A

Insidious dry cough
DOE
Clubbing
Rales

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25
Q

How do you treat IPF?

A

You transplant that mofo

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26
Q

Okay, you can’t transplant your IPF patient’s lungs. How do you treat it?

A

Oxygen/vaxxes/pulm rehab
Nintedanib (an RTKi)
Pirfenidone (an antifibrotic)

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27
Q

Pneumoconiosis is d/t…

What are the three common types?

A

Occupational dust

1) Coal Worker’s
2) Silicosis
3) Asbestosis

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28
Q

ALl types of pneumoconiosis share what three symptoms?

A

Cough
DOE
SOB

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29
Q

What additional symptom might Black Lung or silicosis have?

A

Fever

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30
Q

What additional s/s might asbestosis have?

A

Inspiratory crackles, clubbing

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31
Q

When do symptoms present for Black Lung? For asbestosis?

A

Coal - asymptomatic for 15yr

Asbestos - asx for 20-30yr

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32
Q

Other names for Coal Worker’s Pneumoconiosis include…

A

Black Lung

Anthracosis if mild

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33
Q

How do you diagnose and treat Black Lung?

A

CXR - small upper lung opacities, then fibrosis

No Tx, no transplant, they die.

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34
Q

How do you Dx silicosis?

A

HxPE
PFTs
DLCO low
CXR/CT - tons of tiny lil nodules if chronic; bilat ground glass if acute

Confirm with biopsy
R/O all else

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35
Q

Risks of advanced silicosis?

A

CKD
TB
Lung CA

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36
Q

How do you treat silicosis?

A

d/c working in toxic environment
Can try steroid, but they are eh
Can transplant, but rarely done

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37
Q

Who is eligible for a lung transplant?

A

<65yo
No substance abuse
BMI 20-29

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38
Q

How do you diagnose asbestosis?

A

HxPE
PFTs
CXR/CT - pleural plaques, coarse honeycombing, hazy ground glass

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39
Q

How do you treat asbestosis?

A

Call your lawyer
Quit smoking, or enjoy mesothelioma
Steroids are eh.

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40
Q

When I say sarcoidosis, you say

A

MULTISYSTEMNON-CASEATINGGRANULOMA

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41
Q

Sarcoidosis can occur anywhere, especially lungs and heart. What particular patient population did he highlight?

A

Young AAF

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42
Q

Symptoms of sarcoidosis? (3)

A

Dry cough
Progressive dyspnea
Atypical chest pain

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43
Q

How do you diagnose sarcoidosis?

A

CXR - bilateral hilar adenopathy
CT - Right paratracheal lymphadenopathy with bilateral diffuse reticular infiltrate; sarcoid galaxy sign
BIOPSY - r/o lymphoma.

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44
Q

Three types of biopsies for sarcoid?

A

EBUS
VATS
Cervical mediastinoscopy

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45
Q

What is the treatment for sarcoidosis?

A

Just observe if they’re ASx; steroid course otherwise

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46
Q

Pneumonia predominately affects the ___ part of the lung by what mechanism?

A

Alveoli

By microaspiration of a virulent organism which takes advantage of a immune system defect

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47
Q

Overall, the main cause of community acquired pneumonia is ___. When is that not the case?

A

Bacterial
Under 5yo - viral
Immunocompromised - parasitic (toxo), fungal (aspergillus, PCP, histo, crypto, cocciodes)

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48
Q

Getting pneumonia 48-72hrs post-intubation is called…

A

Ventilator acquired pneumonia

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49
Q

5 categories of pneumonia?

A 
CAP
HCAP
HAP
VAP
Aspiration
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50
Q

Criteria for HAP? What’s another name for it?

A

48hrs or more after getting hospitalized

Nosocomial

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51
Q

HCAP includes hospitals >48 hrs within ___days, ___, ___, ___, or extensive healthcare contact.

A

90d
Nursing homes
Hemodialysis
IV/chemo

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52
Q

1 cause of CAP is ___. #2 is ____. #3 is ___.

A

S. pneumoniae
Myco pneum.
Flu virus

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53
Q

Most Sx of CAP are nonspecific like fever/cough/aches; name two more specific symptoms.What about in lil kiddos?

A

Hemoptysis and pleuritic pain

Kids - restless and not eating

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54
Q

Physical exam findings of CAP include:
CARDIO: (3)
PULM: (4)

A

CARDIO: tachy, hypotn, hypoxemia
PULM: expiratory wheeze, crackles/rales, tachypnea, and dec/asymmetric breath sounds

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55
Q

Bullous myringitis (on the TM) or erythema multiforme are most often consistent with which etiology of pneumonia? What quality of sputum might also suggest this?

A

Myco pneum.

Watery sputum or lack of sputum

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56
Q

HypoNa+ and GI Sx are most often consistent with which etiology of pneumonia?

A

Legionella pneum.

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57
Q

What two special symptoms are most consistent with S. pneum?

A

Single rigor and rust-colored sputum

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58
Q

“Currant jelly sputum” is most often consistent with which etiology of pneumonia? Who does this type of pneumonia most often occur in?

A

Klebsiella - COPD and EtOHics

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59
Q

Diagnostic methods for pneumonia

A

HxPE, CXR PA/Lat (gold standard)

Can also CT s contrast if it’ll change Tx, and microbio stuff

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60
Q

CXR-ordering criteria for pneumonia

A

1+: Fever >100, tachycardic, tachypneic (>20)

OR 2+: Rales, dec breath sounds, no PMHx asthma

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61
Q

What is a lobar finding on CXR and what does it suggest?

A

Single lobe or segment/pattern. Often S. pneum.

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62
Q

What CXR findings would suggest viral pneumonia or PCP?

A

Interstitial or peribronchial

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63
Q

TB CXR finding?

A

Caseating granulomas!

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64
Q

For what etiologies might a CXR show necrotizing pneumonia?

A

Aspiration pneum, Group A Strep, S. pneum, staph

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65
Q

Sputum inductions are pretty lame, but when might they be indicated? What is a ‘good’ sample?

A

Good sample = <25 ep cells + neutros present

Get if they’re immunocomp, bad COPD, EtOHics, admitting to ICU, or have failed ABx

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66
Q

Do all pts get blood cx?

A

Nah, brah. Pretty much just ICU pts.

But also do it if it’s real severe, or EtOHics, bad liver, no spleen, pleural effusion, or +pneumUAT

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67
Q

What labs are good to get for probable INPATIENT pneumonia pts?

A

CBC c diff
BMP or CMP
CRP/Pro-calcitonin/Lactic acid/ESR

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68
Q

Macrolides, go

A

ACE - Azithro, clarithro (po only and DDIs out the wazoo), erythromycin
Cover HNM and atypicals so they are good for respiratory
Resistance is an issue tho

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69
Q

Tetracyclines, go

A

Tetra po, doxy IV/po, mino po
Cover atypicals and MSSA/MRSA real well; some GNR like H and M but resistance.
Also metal ion DDIs
Use for respiratory, and MRSA stuff.

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70
Q

Fluoroquinoloooooones

A

Cipro, levo, moxi all IV/po
Cover gram positives (except cipro), HNM, atypicals; moxi is the only one that doesn’t have the moxie for pseudomonas
Use for atypical like TB/legionella/chlamydia!
Don’t use cipro for respiratory.

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71
Q

If your pt was healthy before they got pneumonia, and they haven’t been on ABx in the last three months, what should you prescribe them?

A

5 days of a macrolide, or 5 days of bid doxy

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72
Q

Your pt is either immunosuppressed or has some crazy comorbidities. What empiric ABx should you prescribe?

A

5 days of moxi or levo, or 5 days of a beta-lactam + macrolide or doxy

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73
Q

Your pt was healthy before they got pneumonia, but they did use ABx within the last three months. What should you prescribe them?

A

5 days of moxi or levo, or 5 days of a beta-lactam + macrolide or doxy

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74
Q

You’re in an area where S. pneum resistance is ‘cray cray.’ What should you prescribe?

A

5 days of moxi or levo, or 5 days of a beta-lactam + macrolide or doxy

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75
Q

You’ve got an inpt pt who needs ABx for their pneumonia. Which ones are ya loadin’ them up with?

A

IV levo or moxi, OR IV ceftriaxone or Unasyn + IV macrolide or doxy
Above can be +/- glucocorticoid

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76
Q

Obviously go with your gut, but if you need some help deciding whether to admit a pneumonia pt/whether to ship ‘em off to ICU, use…

A

PSI, CURB/CRB, SMART-COP

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77
Q

What is the PSI good for? Why is it meh?

A

CAP decisions. It’s got 5 classes of scores, and anything III and up is probably an admission.
You need an ABG and it’s legit insane to try to memorize

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78
Q

What is the CURB score criteria? What’s its main con?

A 
Confusion
Urea >19
RR >30
BP <90mmHg systolic 
and >65yo
Not so great on the comorbidities.
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79
Q

How is the CURB scored? What about the CRB?

A

ICU if 3+, inpt if 2, outpt if 0 or 1.

CRB - admit anything 1 or more

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80
Q

What’s the SMART-COP for?

A 
Figuring out which pts need ventilation or vasopression,  if they're >50yo.
0-2 low risk
3-4 moderate risk
5-6 high risk
7+ very high risk
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81
Q

For microbio testing, what’s the UAT good for?

A

S. pneum and legionella

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82
Q

For microbio testing, what’s the Multiplex PCR good for?

A

Myco pneum
Pertussis
Chlamydia pneum
RSV/flu/all them viruses

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83
Q

What’s the “standard for diagnosis” for microbio testing? I put it in quotes because it sucks. What can it pick up on?

A

Serology - Myco pneum, chlamydia pneum, and legionella, past or present

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84
Q

When and how would you transition someone off IV ABx?

A

If they’re afebrile and improved after 48hr.

Transition to similar class, total of 5-7d.

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85
Q

If you’re treating CAP outpt, what should you tell the pt?

A

Fever should be gone within 72hr
Call us in the next 48-72hr to f/u or if not improving
Let ‘em know Sx can last even after Tx finished
Super unlikely, but might have to do a f/u CXR in like 12wks

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86
Q

Who gets the pneum vax?

A

> 65 yo or smoker/comorbidities (repeat in 6yr if under 65yo)

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87
Q

If HAP or VAP is less than 5d, what caused it?

A

S. pneum, H. flu, MSSA, GNR

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88
Q

If HAP or VAP is more than 5d, what caused it?

A

S. pneum, H. flu, MSSA/MRSA, GNR, Pseudomonas, Acinetobacter

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89
Q

How do you Tx HAP/VAP <5d old?

A

IV Rocephin, IV/po levo, IV Unasyn, or po bid Augmentin

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90
Q

How do you Tx HAP/VAP >5d old?

A

IV Cefepime or Ceftazadime, IV meropenem, IV Zosyn, or IV levo…PLUS IV Vanco or po Linezolid!

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91
Q

If your pt is CTD and has HAP/VAP >5d old, how do you Tx it?

A

IV Cefepime or Ceftazadime or meropenem,
+ IV levo or aminoglycoside,
+ IV Vanco

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92
Q

There are 4 big red flags for concern of MDR pneumonia. What are they?

A

1) it’s goin’ round in town
2) HCAP.
3) they’ve been hospitalized for more than 5d.
4) they’ve been poppin’ ABx within the last 90d.

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93
Q

Aspiration pneum is usually d/t…How do you Tx it?

A

Anaerobes, or just stomach content/fluids (nonbacterial)
Tx nonbacterial by IVF, +/- steroid, +/- ventilator
Tx bacterial by IV clinda, or Flagyl+Amoxicillin for 7-10d

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94
Q

Sx of nonbacterial aspiration pneumonia?

A

ABRUPT-onset hypoxemia

Diffuse crackles/rales/other pulm edema signs

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95
Q

Sx of bacterial aspiration pneumonia?

A

SLOW-onset hypoxemia

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96
Q

A CD4+ under 50 puts the pt at risk for __ and __.

A

MAC and CMV

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97
Q

A CD4+ under 100 puts the pt at risk for __ and __.

A

Toxo and Kaposi sarcoma

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98
Q

A CD4+ under 200 puts the pt at risk for __.

A

PCP

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99
Q

PCP Sx are gradual and nonspecific; what signs can clue you into it?

A

Thrush, hypoxemia, rhonchi/crackles, tachypnea, fever

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100
Q

If you suspect PCP, what labs should you order?

A

CD4, ABG, LDH, 1,3-b-d-g, sputum with gram stain

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101
Q

If you suspect PCP, what imaging/diagnostic tests should you order? What would you find if they did have it?

A

CXR- diffuse bilat interstitial infiltrate
CT - ground glass
DLCO - normal or inc
Gallium citrate screening

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102
Q

Mild PCP has what labs? How do you Tx it?

A

paO2 >70
Alveolar-arterial oxygen gradient <35
po Bactrim 14-21d

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103
Q

Moderate PCP has what labs? How do you Tx it?

A

Alveolar-arterial oxygen gradient 35-45

IV/po Bactrim + po prednisone 14-21d

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104
Q

Severe PCP has what labs? How do you Tx it?

A

paO2 <70
Alveolar-arterial oxygen gradient >45
IV Bactrim + IV methylprednisone 14-21d

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105
Q

What’s the preferred ABx ppx for HIV pts against PCP?

A

Bactrim ss qd or Bactrim ds 3x wk

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106
Q

In what HIV pts would we initiate PCP ppx?

A

If CD4+ <200, OPC, or CD4+ < 14%

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107
Q

Acute bronchitis is usually self-lim in ___ and is caused by… (7)

A

1-3wks

Flu A/B, paraflu, RSV, coronavirus, adenovirus, rhinovirus

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108
Q

Characteristic Sx of acute bronchitis?

A

1-3wk cough c or s sputum
Low-grade fever
Wheezing, mild dyspnea, and rhonchi that clear c cough
Chest pain

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109
Q

How do you Dx acute bronchitis?

A

HxPE
Cough >5d
r/o COPD/pneum (only get CXR if you’re real on-the-fence about this)

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110
Q

As far as acute bronchitis Dx, sputum sucks, except for when…

A

you tryna r/o TB but it’s being tricky

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111
Q

How do we feel about procalcitonin?

A 
Ooh we like that.  Helps determine whether or not to prescribe ABx for acute bronchitis.
<0.1 = no-go.
<0.25 = nah, probably not
>0.25 = yeah, probably
>0.5 = heck yeah.
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112
Q

Besides ABx maybe, what do you do to Tx your acute bronchitis pt?

A

Antitussive (dextromethorphan, guaifenecin, tessalon pearls)
Bronchodilator (if comorbid or wheezing)
Corticosteroids are a no-go anymore

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113
Q

Defining characteristics of the flu include __, __, and __-onset.

A

Upper and lower resp involvement
Systemic Sx
Sudden-onset

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114
Q

4 populations who are at risk if they get the flu:

A

Pregnant
Peds
Over 65yo
Comorbidities

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115
Q

The flu is caused by…

A

Orthomyxoviridae viruses, types A/B/C, with N or H surface antigens

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116
Q

Most flu outbreaks are caused by type __, hemagglutinin types ___, and neuraminidase types __.

A

A or B
H1-3
N1-2

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117
Q

Why do antigenic shifts occur?

A

Point mutations in RNA changing the surface glycoproteins.

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118
Q

Oh so you think it’s the flu? Diagnose it.

A

Rapid flu nose swab - positives are positive, but negatives might be falsely negative.
Can do an immunofluorescence stain with a resp swab
Can do RT-PCR which is ideal.

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119
Q

What two diagnostic methods are we not gonna bother with for the flu?

A

Viral Cx or serology

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120
Q

Who do we flu test?

A

Anyone near an outbreak
Anyone at risk for complications (preg, etc)
Anyone immunocompromised
Anyone inpt, even if they already have CAP
Anyone near healthcare

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121
Q

How do we Tx the flu?

A

Neuraminidase inhibitors (don’t use adamantanes like amantadine/rimantadine anymore)
Zanaminivir 10mg inhaled bid x5d
Oseltamivir 75mg po bid x5d
Peramivir 600mg IV 15-30min

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122
Q

What’s the difference between a trivalent and a quadrivalent flu vax?

A

Tri - 2 flu A + 1 flu B antigen

Quad - 2 of each

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123
Q

A pt >65yo wanting the flu vax gets…

A

Hi-dose TRIVALENT

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124
Q

Does the LAIV flu mist suck?

A

Yes, it sure does.

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125
Q

Why might we expect a TB resurgence? (3)

A

Poverty rising
MDR rising
HIV rising

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126
Q

How is TB transmitted?

A

Respiratory droplets 1-5microns in diameter

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127
Q

TB transmission risk is increased when: (5)

A 
UnTx'd resp infection
Cavitation present
Acid-fast bacilli present in sputum
Undergoing procedures like intubation, bronchoscopy, autopsy
Using aerosolized Rxs
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128
Q

5% of individuals progress to active TB, which usually happens within…

A

2 years of contraction

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129
Q

Potential progression of TB?

A

immediate clearance –> primary disease –> latent infection –> reactivation disease

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130
Q

Sx of primary TB include fatigue, ___, ___, ___, and most commonly, ___.

A

Pharyngitis
Arthralgia
2-3wk cough
Fever

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131
Q

Sx of reactivated TB include ___, ___, ___, and __.

A

Anorexia
Wt loss
Night sweats
Pleuritic/retrosternal chest pain

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132
Q

What testing can you do to confirm TB?

A

TST & PPD - but not definitive pos or neg.

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133
Q

What vax can interfere with TB skin testing?

A

BCG (European TB vax)

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134
Q

For the majority of patients, a wheal at or over ___mm is a positive PPD.

A

15mm

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135
Q

For what pts would you consider a wheal >10mm to be a positive PPD?

A 
<5yo
<5yrs in the US
IVDA
People who live in communal homes or work in myco labs
People with high-risk conditions
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136
Q

When would you consider a wheal of 5mm to be a positive PPD?

A

In HIV/immunosuppressed pts like transplantees
In pts who were known to be exposed recently
In pts with a positive CXR

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137
Q

So if TST/PPD aren’t that great, how can we definitively Dx TB?

A

Active TB - with sputum (Cx/AFB stain/NAA)
Draw blood for IGRAs (QFT-GIT and TSPOT), esp. if they had the BCG vax
CXR
Still do PPD

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138
Q

What five drugs do you give at once to Tx TB in the intensive phase?

A 
RIPES
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin (maybe)
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139
Q

The first phase of TB Tx requires… (4ish)

A

Get baseline LFTs first
Take on an empty stomach
Prescribe intensive dose of RIPES drugs x 2 mo
Then redo sputum Cx/AFB stain, and redo CXR

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140
Q

The second phase of TB Tx involves…

A

Prescribe isoniazid + rifampin x 4mo until 2 Cx are neg.

Treat Under Direct Observation (someone watches them take EVERY SINGLE DOSE).

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141
Q

After TB becomes latent and 2 Cx come back neg, do you continue treatment?

A

YES, but it doesn’t need to be DOT anymore, they can do it themselves.
Get another set of baseline LFTs.
Prescribe isoniazid x 9mo + rifampin x 4mo.

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142
Q

Your patient is gonna be far away from a pharmacy for two months during their latent TB treatment. It’s latent, so like, that’s no big deal, right?

A

That’s okay! As long as it’s less than 3mo, it’s okay to interrupt Tx for LATENT TB.

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143
Q

MDR-TB is resistant to…

A

Rifampin and isoniazid, and maybe more

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144
Q

XDR-TB is resistant to…

A

Rifampin and isoniazid, and at least one of the following inj:
Capreomycin
Amikacin
Kanamycin

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145
Q

Which pleura has nerves?

A

Hehe GOTCHUUUU both do. But only parietal has SENSORY ones.

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146
Q

___ nerves control the central diaphragm, and ___ nerves control the parietal diaphragm.

A

Central portion - Phrenic n.

Parietal portion - Intercostal nn.

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147
Q

What is responsible for draining each pleura?

A

Visceral - pulm. venous system

Parietal - upper abd lymphatic system

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148
Q

How much fluid is normally found in the pleural cavity? Describe normal pleural fluid (5).

A 
0.1-0.2 mL/kgLow-protein (<2%)
Glucose level about the same as plasma
LDH less than half of plasma level
WBCs <1000/mm3
pH 7.6-7.64
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149
Q

What in the everloving fandango is the Starling Law of Transcapillary Exchange?

A

A formula that we barely use but basically says that 1) hydrostatic pressure, 2) oncotic pressure, and 3) permeability all affect how fluid moves from/to blood vessels, and that sometimes diseases (1) congestion, 2) plasma protein issues, and 3) inflammation or burns, respectively) mess with those, making more fluid scoot on in/out.

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150
Q

What is hydrostatic pressure?

A

The physical pushy push on the capillary walls.

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151
Q

What is oncotic pressure?

A

The protein concentrations pulling water into capillaries.

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152
Q

Hydrostatic pressure&raquo_space;> oncotic pressure will make fluid…

A

LEAVE the capillaries

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153
Q

Pleural effusion is…

A

A SYMPTOM of an underlying issue!

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154
Q

What’s the most common underlying cause of pleural effusion? Which Starling force is affected?

A

CHF!! Inc hydrostatic pressure

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155
Q

How can atelectasis cause pleural effusion…?

A

It causes an excessively negative intrapleural pressure

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156
Q

Pleural effusion d/t nephrotic syndrome occurs because which Starling force is affected?

A

Dec oncotic pressure–> think about it, the low plasma proteins mean less water gets pulled into capillaries (dec oncotic pressure) which means it’s stuck in the lungs.

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157
Q

What disease processes can cause drainage from the lungs to be blocked, causing pleural effusion?

A

A mass like lymphoma or a mediastinal node.

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158
Q

How can pneumonia cause pleural effusion?

A

By increasing the capillary permeability.

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159
Q

Money question! How does pleural effusion present??

A

COUGH+DYSPNEA+CHESTPAINNNNN

+Sx of underlying disease

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160
Q

4 physical exam findings for pleural effusion (given that it’s over ___mL)…?

A

Dec tactile fremitus
Dec breath sounds
E to A egophony
Dullness to percussion

If >250mL!

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161
Q

A pleural effusion under __mL will probably only be picked up on CT. If it’s more than that, get a __ CXR and look for…

A

150mL

Upright CXR looking for blunted costophrenic angle

162
Q

If you don’t know why a pleural effusion occurred, you can order a ___. Well… not if your pt __ or ___. That’d be dumb.

A

ThoracentesisIs on anticoags, or has a skin infection there.

163
Q

How much do we drain in a thoracentesis and why?

A

1-2L ONLY or else you will cause re-expansion pulm edema!

164
Q

4 types of pleural effusion, based on fluid content?

A

Hemothorax
Hydrothorax
Chylothorax
Empyema

165
Q

Labs to order on a pleural fluid sample?

A

Protein and LDH!!!!!!

Also CBC c diff, pH, SG, Glu, Cx/stain/cytology

166
Q

What is Light’s Criteria?

A

Criteria for determining whether a fluid sample is transudative or exudative

167
Q

Okay, but what ARE Light’s Criteria?

A

+Exudative if sampleLDH:SrLDH is >0.6, if sampleLDH is >2/3 of ULN of SrLDH, or if sampleProtein:SrProtein is >0.5.

168
Q

Besides not meeting any of Light’s Criteria, what lab value from your pleural fluid sample would lead you to think it’s transudative?

A

A SG <1.015

169
Q

Transudative effusions are usually d/t which Starling forces being affected?
Name four diseases that would cause transudative effusions (think of earlier cards, when we were talking about Starling Law!).

A

Hydrostatic or oncotic pressures

CHF, atelectasis, nephrotic syndrome, cirrhosis

170
Q

What is Meig’s syndrome?

A

Fibroma + Ascites + Pleural Effusion

171
Q

Exudative effusions are usually d/t which Starling forces being affected?
While any disease can technically cause it, name three that definitely would (think about which Starling force is affected and how it could get that way).

A

Permeability - so diseases that inflame/block drainage

Pneumonia, pulmonary embolism, or a mass.

172
Q

The most common cause of empyema is ___. (He starred it like 4 times.)

A

PNEUMONIA SEEDING INTO PLEURAL SPACE

173
Q

In general, besides pneumonia complications, what could lead to an empyema?

A

Trauma/surg - things that go into the lung and let bacteria into the lung with them.
Also a ruptured esophagus for the same reason.

174
Q

5-10% of pneumonia pts will end up with an empyema. How?

A

Pneumonia –> parapneumonic effusion –> gets muy complicado –> empyema.

175
Q

Labs of an empyema fluid sample would show ___, ___, ___, ___, and ___.

A 
High WBCs (>50,000)
Low Glu (<60)
High LDH (>1000)
Low pH (<7.2)
And it looks gross and purulent AF
176
Q

How do you Tx an empyema?

A

draaaaain that nasty thing (thoracentesis), and keep it draining with a tube (placed via VATS thoracoscopy) or with a Clagett window.
+ ABx/fibrinolytics intrapleurally
Might have to do decortication/pulm resection.

177
Q

25% of all pleural effusions are ___.

A

Malignant, and most from lung CA (also most deadly).

178
Q

How do you Tx an MPE?

A

Lots of thoracenteses/putting a tube in, and Tx the CA.

Probable pleurectomy/decortication.

179
Q

What is pleurodesis?

A

A procedure to get rid of the pleural space by making the two pleura stick together, either via chemicals or mechanical abrasion.

180
Q

Indications for a pleurodesis (3)?

A

In short, it just won’t quit:

  • Repeated effusions/pneumothoraces.
  • Chemo drugs aren’t fixing the effusion.
  • To help inflate lung after thoracentesis.
181
Q

Chemicals that are used in a pleurodesis are called ___ agents. Name five.

A 
Sclerosing:
Doxycycline
Minocycline
Bleomycin
Quinacrine
Talc
182
Q

Why are indwelling caths good for pleural effusion pts?

A

They can go home quicker, and it doesn’t hurt as much.

183
Q

Why are indwelling caths risky? (3)

A

Infection risk
Can get obstructed
Effusion can get loculated (into small spaces like the fissures)

184
Q

How does air enter the pleural cavity in a pneumothorax?

A

Via the chest wall (like a trauma), or through the parenchyma via the visceral pleura.

185
Q

4 types of pneumothorax

A

Tension
Traumatic
Primary Spontaneous
Secondary Spontaneous

186
Q

Why does a primary spontaneous PTX occur, and in who?

A

Rupture of a bleb (goodness that’s a cute word)

18-40yo tall/thin smokers

187
Q

Why does secondary spontaneous PTX occur?

A

Underlying lung disease, ESPECIALLY COPD

188
Q

Most common causes of a traumatic PTX?

A

Rib Fx and iatrogenic

189
Q

Money question! 3 Sx of PTX?

A

DYSPNEA+CHESTPAIN+SHOULDERPAIN!

190
Q

3 physical exam findings of PTX?

A

Dec fremitus
Dec breath sounds
Hyperresonant to percussion

191
Q

3 ways to Dx PTX?

A

CXR
Chest CT
Chest U/S

192
Q

How do you Tx a PTX?

A

Decompress if big, or supportive if small.

O2 if needed but don’t go crazy or else you’ll make the lung re-expand too quick.

193
Q

What’s Graham’s Law of Diffusion? (don’t overthink it)

A

Air moves from areas of high concentration to areas of low concentration.

194
Q

Two ways to Tx a PTX

A

Blebectomy (hehe, bleb) with VATS

Pleurodesis

195
Q

Tension PTXs are ___ and are usually caused by…Why are they particularly bad?

A

Progressive
Iatrogenic or lung lac
Mediastinum gets pushed over and causes cardiac arrest.

196
Q

4 special Sx of a tension pneumo?

A 
Tension? I'm TouCHeD (...it's a stretch, I know it, this is desperation)
Tachy
Chest pain
Hypotensive
Diaphoretic/cyanotic
197
Q

4 physical exam findings of a tension pneumo?

A 
Tension? I'm TouCHeD.
Total lack of breath sounds
Contralateral tracheal deviation
Hyperexpansion of chest
Distention of jugular vv.
198
Q

__ are the most commonly aspirated foreign body.

A

Nuts. But balloons/gloves/marbles are more deadly.

199
Q

Most foreign body aspirations end up in ___.

A

The right lung

200
Q

If a little kid comes in with ___, think foreign body.

A

Stridor

201
Q

A foreign body aspiration emergency presents as ___, __, and ___.

A

Severe resp. distress
Mental change
Cyanosis

202
Q

A lower-airway foreign body aspiration will present as __, __, and ___.

A

Hyperinflated lung
Atelectasis
Pneumonia

203
Q

CXR can help Dx a foreign body aspiration, but if your Hx/PE lead you to suspect it, you’ll probably order a…

A

Bronchoscopy, because you can remove the object with it almost always.

204
Q

What is the definition of a pulmonary nodule?

A

<3cm (“coin”-sized) intraparenchymal lesion NOT associated with lymphadenopathy or atelectasis

205
Q

CXR is cheap and quick and can detect __, __, __, and __.

A

CHF
Effusions
Masses (ground-glass)
Pneumonia/infections

206
Q

CXR have two cons:

A

Overlap (esp on left) makes it hard to see

Hard to detect small nodules

207
Q

Chest CT are better for seeing small lesions, and can confirm Dxs of ___, ___, ___, and ___.

A

COPD
TB/Pneumonia
CA
Congenital stuff

208
Q

Standard CT slices are ___mm.

PE Protocol CT or high-res are ___ mm.

A

5mm.

1mm.

209
Q

PET/CT is done with the chemical ___, and are great for __ and __. Are they more sensitive or specific?

A

FDG
Good for seeing CA (SUV>3) and cardiac perfusion
Sensitive!

210
Q

Lesions under ___mm are hard to see on PET.

A

8-10mm

211
Q

What are some malignancies that are tough to see with PET and why?

A

Bronchoalveolar carcinoma and carcinoid tumors - they don’t pick up FDG well.

212
Q

Besides cost, what’s the biggest drawback of PET?

A

Can’t tell the difference between inflammation and CA.

213
Q

MRIs are great because there’s no rad and because they can assess…

A

Tumor size/mets (not good at solitary ones though)

214
Q

Malignant lesions are __, and have a __ border.

A

Bigger

Spiculated (could be smooth too though just a heads up)

215
Q

Calcifications in the lung are more common in hamartomas (benign but ugly) or TB than in CA… except for in what case?

A

Calcifications are also in osteosarcoma and chondrosarcoma pts (pts with primary CA elsewhere).

216
Q

If a tumor grows real fast, it’s probably…

A

Benign!

217
Q

80% of all BENIGN nodules are d/t…

A

Infectious granulomatous disease (histo, coccidio, mycobact)

218
Q

10% of all BENIGN nodules are d/t…

A

Inflammatory nodular disease (sarcoid, RA, Wegener’s)

219
Q

The last 10% of BENIGN nodules are…

A

Hamartomas (popcorn!)

220
Q

If there’s a high probability a solitary pulm nodule is malignant, what do you do?

A

Cut that ish out.

221
Q

If there’s a low probability a solitary pulm nodule is malignant, what do you do?

A

Monitor with serial CT scans.

222
Q

If there’s an intermediate probability a solitary pulm nodule is malignant, what do you do?

A

Image to figure out the size, and if it’s under 1cm, it’s a low probability, so monitor with serial CT scans.

223
Q

Your intermediate-malignancy-probability solitary pulm nodule turns out to be >1cm. What do you do?

A

Either biopsy or PET with FDG. That’ll determine once and for all whether the probability of malignancy is high or low.

224
Q

A ground-glass opacity is found to be less than 5mm. What do you do?

A

f/u CT q6mo x 36mo if stable.

225
Q

A ground-glass opacity is found to be more than 5mm, but less than 10cm. What do you do?

A

f/u CT q3mo x 36mo if stable.

226
Q

A ground-glass opacity is found to be more than 10mm. What do you do?

A

Either biopsy it or resect it!

227
Q

Smoking is responsible for ___% of all lung CA.

A

85-90%! Second/thirdhand smoking counts too.

228
Q

The biggest environmental risk factors for lung CA are…

A

Radon, radiation, and other occupational pollutants.

229
Q

There are __ cigarettes in a pack.

A

20-25

230
Q

What’s important to remember when you’re tryna figure out how big a tumor is on CT?

A

You might have cut across the edge and not the middle, so it might be bigger than it looks!! /when you f/u CT, you might get the middle that time, so it might look like it grew even if it didn’t.

231
Q

What are some benign lung diseases that can increase the risk for lung CA?

A

Fibrosis
COPD
a1-AT deficiency
TB

232
Q

What is cotinine, and what does it tell us about today’s cigarette exposure?

A

A nicotine metabolite used to measure cig exposure, esp. for nonsmokers. # of nonsmokers with +cotinine is going down now that you can’t smoke in public.

233
Q

What’s thirdhand smoking?

A

Cigarette jank getting stuck in fabric etc and then cute innocent little kiddos put their faces all in it and get sick :(

234
Q

SCLC can be __, __, or combined.

A

Classic small cell carcinoma, or large cell neuroendocrine

235
Q

NSCLC can be ___ (like __), ___, or ___.

A

Adenocarcinoma (like BAC)
Large cell carcinoma
Squamous cell carcinoma

236
Q

Most lung CA is an ___.

A

Adenocarcinoma

237
Q

A large cell carcinoma is __ and __, large and necrotizing.

A

Malignant and undifferentiated

238
Q

Squamous cell carcinomas are usually ___ and usually occur in what pt popn?

A

Central

Smokers

239
Q

On CT, squamous cell carcinomas show…

A

Cavitation and extensive necrosis

240
Q

Most adenocarcinomas occur where? Name three subtypes.

A

Peripherally.

BAC, mucinous, papillary

241
Q

BAC is ____ on CT.

A

Ground-glass opacity!

242
Q

Besides cough/dyspnea/chest pain, how might lung CA present initially?

A

Hemoptysis
Recurrence of pneumonia
Unexplained wt loss

243
Q

Later-stage lung CA might present with… (6)

A 
Bone pain
Dysphagia
Hoarseness
Horner's
SVC Syndrome
Neuro stuff like HA/syncope
244
Q

What are the three characteristics of Horner’s Syndrome?

A

Ptosis, Anhydrosis, Miosis

245
Q

What is a paraneoplastic syndrome?

A

Signs and symptoms that are the consequence of cancer in the body, but is not due to the local presence of cancer cells

246
Q

You have to get a biopsy to Dx lung CA. What are some ways to go about getting that sample?

A 
VATS
Thoracentesis
EBUS
Bronchoscopy +/- lavage
CT guided needle Bx
247
Q

If a tumor has M1, it is stage ___.

A

IV

248
Q

If a tumor has N2+, it is stage ___.

A

III+

249
Q

If a tumor has N1, it is at least stage ___.

A

II

250
Q

If a tumor is less than 3cm with N0M0, it’s stage ___.

A

I

251
Q

Lung CA spreads via what three routes?

A

Blood, lymph, direct invasion

252
Q

What are the 4 most common places for lung CA to metastasize to?

A

Brain, bone, liver, adrenals

253
Q

If a lung lesion is 2cm or more, you need to get ___. How?

A 
A metastatic workup.
Head MRI or CT c contrast
PET/CT
Bone scan if suspected bone CA
Mediastinoscopy to check nodes
254
Q

How do you treat Stage I lung CA?

A

Surg resection + chemo/rad

255
Q

How do you treat Stage II lung CA?

A

Surg resection + chemo/rad

256
Q

How do you treat Stage III lung CA?

A

Chemo+rad to downstage tumor

257
Q

How do you treat Stage IV lung CA?

A

Cisplatin chemo

258
Q

Small cell carcinoma almost always occurs in ___. What are its defining characteristics?

A

Smokers!!

Poorly differentiated large hilar mass with bulky mediastinal adenopathy

259
Q

What’s the difference between the two stages of small cell lung CA? Which one is more likely to be in a newly presenting pt?

A

Limited (to one hemithorax)

Extensive (more common on first presentation)

260
Q

What type of lung lesion is most likely to pop up in a kid?

A

Carcinoid tumor

261
Q

Carcinoid tumors are rare, __, and usually arise from the ___.

A

Differentiated, GI tract

262
Q

Carcinoid tumors can be typical or atypical. Which are more common? Which are more likely to metastasize?

A

Typical are 4x as common

Atypical are more likely to metastasize

263
Q

If carcinoid tumors are usually benign, why might they be bad?

A

They commonly arise in the proximal airways, causing bronchial obstruction.

264
Q

What do carcinoid tumors look like on CT?

A

Hilar or perihilar round/ovoid opacities

265
Q

What two rare syndromes might occur with carcinoid tumor?

A

Acromegaly

Carcinoid syndrome

266
Q

How do you Tx a carcinoid tumor?

A

En bloc surg resection if you can; intraluminal bronchosopic resection if you can’t. Rad is okay; chemo is pretty useless.

267
Q

A Pancoast tumor is aka a ___ tumor. Where does it occur?

A

Superior sulcus

On apex of lung, near subclavian

268
Q

What are some structures/vessels that a Pancoast tumor might affect?

A

Subclavian vessels, ribs, vertebrae, vagus n, recurrent laryngeal n, sympathetic ganglion

269
Q

Most Pancoast tumors are ___ tumors, but they can be just about any type, so figure that out first. Then how do you Tx it?

A

Squamous cell carcinoma

Shrink it with chemo/rad then surg resection

270
Q

The most common clinical presentation of Pancoast tumor is ___ and __.

A

Shoulder pain + Horner’s Syndrome

271
Q

What are the most common CAs that metastasize TO the lung?

A

Melanoma
Sarcoma
Prostate/Breast/Colon/Bladder/Kidney Carcinomas

272
Q

Why do most lung CAs NOT from smoking occur in young women?

A

Estrogen promotes lung CA - use EGFRi to Tx

273
Q

Who should get preventative CT screening for lung CA?

A

55-80yos c a 30+yr pack-history

274
Q

What is bronchiectasis?

A

Permanent, abnormal dilation/collapse and destruction of the bronchial walls usually d/t infection

275
Q

Half of all cases of bronchiectasis are caused by __.

A

Cystic fibrosis

276
Q

Bronchiectasis presents as…

A

Daily chronic cough c viscid sputum

277
Q

Cystic fibrosis has an abnormal __ and __ transport that puts them at risk for ___ respiratory infections.

A

Cl- and Na+

Pseudomonas

278
Q

Sx of bronchiectasis?

A

Hemoptysis/rhinosinusitis/productive cough
Recurrent pleurisy
Urinary incontinence
+/- Cystic fibrosis Sx

279
Q

Auscultation of bronchiectasis would reveal __ and __.

A

Wheezing and chronic crackles

280
Q

5 labs to order for bronchiectasis?

A 
CBC
Ig Panel
Antibody titers post-vax
Sputum Cx/stain
Sweat Cl- Test for CF
281
Q

Imaging to order for bronchiectasis? What would they reveal?

A

CXR - linear atelectasis, irregular mucopurulent plugs

CT - airway dilation, bronchi thickened, bronchial cysts

282
Q

A bronchiectasis pt would have PFTs that …

A

Show low FEV1/FVC ratio

Low FVC if advanced

283
Q

Why would you order a bronchoscopy for a bronchiectasis pt?

A

To collect sputum samples and assess for foreign body or tumor to r/o those

284
Q

How do you Tx bronchiectasis?

A

Tx the underlying infection (po abx x 10d)
Can neb hypertonic saline to thin secretions
SABA
Chest PT or pulm rehab

285
Q

Virchow’s Triad, go.

A

Stasis, hypercoag, endothelial injury

286
Q

The main Sx for massive PE is…

Why is it bad?

A

HYPOTN (<90 systolic for 15+min)

And then they die within 2hr d/t RV failure unless you give them tPA.

287
Q

3 locations of PE

A

Saddle
Segmental
Subsegmental

288
Q

What are the 5ish inherited thrombophilic disorders?

A 
Factor V Leiden
Prothrombin mutation
Protein C/S def
Antithrombin III def
Antiphospholipid syndrome
289
Q

Sx of PE are ___, ___, and ___!

A

Palpitations
Sudden SOB
Pleuritic chest pain

290
Q

Physical exam of PE would show __, __, and __.

A

Tachycardia, tachypnea, hypoxia

291
Q

A Wells score under __ is low PE risk, and over __ is high PE risk.

A

<2>6

292
Q

A Wells score under __ is low DVT risk, and over __ is high DVT risk.

A

<1

>2

293
Q

Is a d-dimer more sensitive or specific?

A

Sensitive. It’s not specific because it’s inc in any inflammation.

294
Q

On who would you order a d-dimer?

A

Low-probability DVT pts to r/o DVT

Low-moderate probability PE pts to r/o PE

295
Q

Imaging of choice for suspected PE is ___. When would you choose something else?

A

Chest CT with contrast!

If renal failure, allergic to contrast, or preg

296
Q

What 3 other imaging studies (not a CT) could you use to help Dx PE? What would each show if the pt DID have a pretty obvious PE?

A

CXR - Hampton’s Hump Sign
V/Q scan - normal ventilation and multiple perfusion deficits
Pulm angio - but it’s invasive so nah

297
Q

What will the ECG of a PE pt show?

A

SINUS TACH

298
Q

What special things might pop up on a PE pt’s ECG?

A

S1Q3T3
RV T-wave inversion
RBBB
Nonspecific ST/T changes

299
Q

Why might an echo be helpful in PE Dx?

A

R/O MI

300
Q

What is the primary Tx of PE? Secondary?

A

tPA or embolectomy, then anticoag therapy (or IVC filter but no)

301
Q

What four things would make you consider your PE pt a high-risk one?

A

HD unstable
RV enlarged
RV hypokinesis
Elevated troponin

302
Q

How is PE Tx different for a CA pt?

A

They stay on LMWH long-term.

303
Q

Anticoag therapy is recommended for 3-6mo if the PE was…

A

Provoked (post-op, estrogen, trauma)

304
Q

Anticoag therapy should be continued indefinitely if the PE was…

A

Unprovoked (travel, idiopathic, antiphospholipid)

305
Q

Asthma is a chronic __ disease characterized by ___, __ symptoms.

A

inflammatory

paroxysmal, reversible

306
Q

What are the three most common diseases associated with an atopic patient?

A

Atopic dermatitis
Allergic rhinitis
Asthma

307
Q

Is asthma obstructive or restrictive? Why?

A

Obstructive - smooth muscle constricts around airways and immune system makes basement membrane thicken

308
Q

What is the difference between fatal asthma and normal asthma?

A

In fatal, collagen deposits in basement membrane and airway muscle hypertrophies

309
Q

What are the three long-term consequences of asthma?

A

Chronic airway inflammation + reversible bronchoconstriction + hyperresponsiveness to triggers

310
Q

The classic Sx of asthma are __, __, and __.

A

Intermittent dyspnea
Persistent nonproductive cough
Wheezing

311
Q

The main physical exam findings of asthma are __ and __.

A

Inability to speak full sentences in one breath

Widespread, high-pitched, musical expiratory wheeze during exacerbation

312
Q

When might an asthma attack have wheezing not just on expiration? What else might you hear in that case?

A

During a severe attack, and if it’s really bad, might have no breath sounds (emergency)

313
Q

If someone presents with asthma, what other physical exam findings might you look for that are unrelated to asthma specifically?

A

Signs of atopy: pale/swollen turbinates, adults with nasal polyps, or atopic dermatitis

314
Q

Besides HxPE, how would you Dx asthma?

A

Spirometry pre and post-bronchodilation (or methacholine challenge)
Peak flow meter
Allergy testing for triggers
can CXR to r/o other Dxs

315
Q

What would spirometry results be for an asthmatic?

A

Obstructive, so dec FEV1, dec ratio (<0.7)

And post-bronchodilation (albuterol MDI 400mcg) would be a 12% or better improvement

316
Q

Asthma Sx are usually worst…

A

At night or early a.m.

317
Q

What, briefly, are the four categories of asthma, and what’s the difference between them?

A

Intermittent - Sx <2d/wk
Mild Persistent - Sx >2d/wk
Moderate Persistent - Sx daily
Severe Persistent - Sx always

318
Q

What would spirometry show for each of the four asthma categories?

A

Intermittent - FEV1 normal unless exacerbation, ratio >0.85
Mild Persistent - FEV1 normal, ratio >0.8
Moderate Persistent - FEV1 60-80%, ratio 0.75-0.8
Severe Persistent - FEV1 60%, ratio <0.75

319
Q

How do you Tx intermittent asthma, regardless of age?

A

Prescribe SABA PRN

320
Q

If your pt has persistent asthma, and you’ve already prescribed them the PRN SABA, what generally are the next steps if it isn’t controlled?

A

+ lo-dose inh steroid, then med-dose inh steroid
then, that + LABA (or montelukast if under 5yo, or theophylline if under 11yo)
then inc to hi-dose inh steroid + LABA

If all that fails, short po steroid course.

321
Q

Which ABx are best to prescribe for an acute asthma exacerbation?

A

Don’t do that that’s dumb. Unless they have an infection at the same time.

322
Q

How do you Tx a severe asthma exacerbation?

A

O2 if under 90%sat - keep below 96%
Systemic steroid
Albuterol
IV Mg2+

323
Q

Can someone have asthma AND COPD at the same time?

A

Yep yep. Chronic obstructive asthma (aka not fully reversed by bronchodilation) is called COPD.

324
Q

Name four comorbidities that can exacerbate asthma.

A

Obesity
Cigarette smoking
Allergic rhinitis (esp. ASA-caused)
GERD

325
Q

Three types of COPD are ___, ___, and __.

A

Emphysema
Chronic Bronchitis
Chronic Obstructive Asthma

326
Q

Name three differences between COPD and classic asthma.

A

Age of onset (50-60yos vs peds)
Reversibility (nah/not much vs yeah)
Associated risks (smoking vs atopy)

327
Q

What happens to the bronchial wall in COPD? What happens to the submucosal glands?

A

Bronchi get inflamed/fibrous

Submucosal glands get hypertrophied and hypersecrete mucus

328
Q

What happens to the alveoli in COPD and why?

A

They’re predisposed to collapse d/t loss of elastic lung fibers (which prevents expiration and traps air in)

329
Q

In the end, all that COPD-pathophysiological mess leads to what three results?

A
  1. Airway obstruction.
  2. Decreased exchange surface area.
  3. V/Q mismatch.
330
Q

Your pt quit smoking years ago, but they’re presenting with what you think is COPD now. Did you get the Dx wrong…?

A

Nah, COPD happens even in former smokers regardless of whether they quit or not.

331
Q

A COPD exacerbation is often caused by…

A

Pulmonary infection

332
Q

If you have a nonsmoker young pt who is not from a polluted developing city, but presents with COPD Sx, what should you probably test for just in case?

A

A1-AT deficiency

333
Q

What is the medical definition of chronic bronchitis?

A

Chronic, daily productive cough >3mo for two years in a row s other explanation

334
Q

What is emphysema? What are the two types?

A

Permanent airspace enlargement with loss of elasticity and no fibrosis.
Panacinar or proximal acinar (centrilobular)

335
Q

Where does panacinar emphysema occur? What pts are most likely to present with this?

A

Both bronchioles and the alveoli

a1-AT def pts, sometimes smokers

336
Q

Where does proximal acinar emphysema occur? What pts are most likely to present with this?

A

Bronchioles - not the alveoli at first.

Coal workers, smokers

337
Q

CXR of a pt with moderate emphysema will look like…

A

A vertical heart + hyperlucent lungs

338
Q

CXR of a pt with severe emphysema will look like…

A

A vertical heart + hyperlucent lungs + blebs (hehe blebs <3), which are also visible on CT

339
Q

The 5 main Sx of COPD are…

A 
CHRONIC COUGH WITH SPUTUM (except scant sputum if emphysema)
DOE
Wheezing
Chest tightness
Wt changes
340
Q

What might you see on inspection of a COPD pt in the physical exam?

A

Barrel chest
Cyanosis
Use of accessory muscles/tripoding

341
Q

What might you note on palpation/percussion of a COPD pt in the physical exam?

A

Decreased diaphragmatic excursion

342
Q

What might you hear on auscultation of a COPD pt in the physical exam?

A

Prolonged expiration with wheezing

343
Q

Advanced COPD will also have s/s of what?

A

RHF, wasting

344
Q

What’s the phrase for differentiating between emphysema and chronic bronchitis? What’s the chief complaint of each?

A

Pink puffer vs blue bloater (dyspnea vs chronic cough)

345
Q

Besides HxPE, how do you Dx COPD?

A

Get bicarb labs +/- A1-AT (also check Hgb and BNP to r/o other)
CXR (mostly to r/o other)
PFTs + DLCO (dec DLCO in emphysema only)

346
Q

Besides Rxs, how do we Tx COPD?

A

QUIT SMOKIN’
Pulm rehab
Get vaxxes
Maybe chronic O2 therapy

347
Q

First-line COPD prescription is:

A

SABA +/- ipratropium (Combivent most common choice)

348
Q

How do you Tx an acute COPD exacerbation?

A

Get SaO2 between 90 and 96%
po prednisone starting at 60mg qd x 10-14d, or IV methylpred
DuoNeb (SABA + ipratropium) q6h if hospitalized
If d/t infection: levo 750mg po qd or azithro

349
Q

If your COPD pt presents with an FEV1 <50%, what do you do?

A

Hospitalize them!

350
Q

What are some high-risk comorbidities that would get you to hospitalize your COPD-exacerbation pt?

A

DM, ARF, CHF, arrhythmia, pneumonia

351
Q

Why would I add a maintenance med to my COPD pt’s regimen?

A

They get a lot of exacerbations, or their Sx just won’t quit, or their COPD is progressing (cause it’ll do that til they die.)

352
Q

Give me three maintenance meds I can add to my COPD pt’s regimen.

A

Salmeterol (LABA)
Tiotropium (LAMA)
Advair (LABA + steroid)

353
Q

Ruh-roh, your COPD pt is officially end-stage. What Tx options do you have?

A

Chronic steroids + chronic oxygen

354
Q

What is a normal pulm artery pressure and how do you measure it?

A

8-20mmHg via R heart cath

355
Q

What is the pressure of pulm HTN? What about borderline pulm HTN? Is that the same as pulm artery HTN?

A

mean PAP equal to or >25mmHg
Borderline - 21 to 24mmHg
NOoooOOoo

356
Q

What are the three key Sx of pulm artery HTN?

A

Dyspnea + Chest Pain + Syncope

357
Q

What is the MAIN CAUSE of pulm HTN?

A

INCREASED PULM A. RESISTANCE

358
Q

What are two other causes of pulm HTN, besides inc pulm vasc resistance?

A

Inc pulm blood volume

Elevated L atrial pressure (like valve issues etc)

359
Q

Why might a pt’s pulmonary vasc resistance increase?

A

Inc afterload –> RVH –> RV dilation –> dec CO

360
Q

What’s the imaging study of choice to order for a pt you suspect pulm HTN in? Why?

A

TTE - it can estimate pulm a. systolic pressure

361
Q

Pulm HTN is likely if a TTE shows __ and __.

A

Pulm a. systolic pressure > 50mmHg and tricuspid regurg velocity > 3.4

362
Q

What do you need to Dx pulm HTN?

A

R HEART CATH shows PAP > or equal to 25mmHg at rest

363
Q

How can a R heart cath measure L heart pressures?

A

PCWP (balloon)

364
Q

Pulm HTN is classified in groups, 1-__. Describe each.

A 
1-5:
1 - secondary to PAH 
2 - secondary to L heart disease
3 - secondary to hypoxemia/lung disease
4 - secondary to VTE
5 - secondary to somethin' either weird or we don't know what it is
365
Q

Which pulm HTN group is most common? Which is least common?

A

3 is most

1 is least

366
Q

What comorbidity is found in 20% of mild pulm HTN pts?

A

OSA

367
Q

Pulm HTN is categorized into four functional categories. Describe each.

A

I - no limitations, no Sx
II - slight limitations, no Sx at rest
III - marked limits, ok at rest
IV - all activity causes Sx. RHF. +/- Sx at rest.

368
Q

Why does Group I pulm HTN (aka __) occur?

A

PAH

d/t abnormalities in all three vessel layers

369
Q

Besides excluding all other disorders, what do you need to Dx PAH?How do you r/o the other 4 groups?

A

PAP >25mmHg at rest
r/o Group 2: PCWP <15mmHg
r/o Group 3: no chronic lung disease
r/o Group 4: no VTE

370
Q

If it’s not idiopathic, what are some reasons PAH might occur?

A

Genetics/connective tissue issues/VSD or ASD
Crack is whack, y’all. So are appetite suppressants and meth.
HIV
Portal HTN

371
Q

Why can L heart disease cause Group 2 pulm HTN?

A

HTN of the L atrium means pulm. a. systolic pressure has to inc to get blood through.

372
Q

Group 3 pulm HTN is only caused by severe lung diseases, like severe __, __, or __.

A

COPD, interstitial lung disease, OSA

373
Q

Why can VTE cause Group 4 pulm HTN?

A

Cause if you block off some of the baby veins, then the ones that are left have to take in higher pressure

374
Q

Group 5 pulm HTN can be caused by hematologic stuff like __ or __, systemic stuff like __, metabolic stuff like __, or other/unknown stuff.

A

Sickle-cell or myeloproliferative
Sarcoidosis
Glycogen storage disorder

375
Q

R heart disease that is caused by L heart disease is called…

A

R heart disease, suckaaa. Not cor pulmonale, if that’s what you said.

376
Q

What is cor pulmonale?

A

RVH–>RHF caused by pulm HTN.

377
Q

Apart from the usual COPD/PAH/OSA that causes pulm HTN that causes cor pulmonale, what structural abnormality can cause it?

A

Kyphoscoliosis

378
Q

Okay but WHY does pulm HTN cause cor pulmonale?

A

High PAP –> RVH –> RVF

379
Q

In whom is cor pulmonale the most scary?

A

Group 1 pulm HTN pts (–> dead)

380
Q

Pulm HTN is usually ASx for __, then presents as __, __, and __ if severe.

A

about 2yrs

Fatigue, DOE; dyspnea at rest

381
Q

Money question! What are the four big Sx of RHF?

A

Syncope on exertion
Angina
Peripheral edema
Abd pain d/t hepatic congestion

382
Q

Money question! What are the big physical exam findings of RHF on auscultation?

A

At pulmonic region: initial loud S2, later an S2 split
At RV: S3
At tricuspid: regurg (high pitched systolic murmur)

383
Q

What are the non-auscultation findings of RHF on exam?

A

Ascites
Inc JVP
Hepatomegaly
Peripheral edema

384
Q

Cardio-wise, what imaging/labs should you get for a cor pulmonale pt? What would you expect to see?

A

CXR (normal, or cardiomegaly/pulm a. enlarged)
ECG (RVH)
TTE (inc pulm a. systolic pressure; R heart changes; possible L heart changes. Check for PFO too)

385
Q

Pulmonology-wise, what imaging/labs should you get for a cor pulmonale pt? What would you expect to see?

A

PFTs (low FEV1 and ratio)
Overnight pulseox (low)
V/Q scan (to check for VTE)
Polysomnography (to check for OSA)

386
Q

Primary Tx for pulm HTN is…

A

Tx the underlying cause!
Group 2 - Tx HF (diuretics, antiHTNs, etc)
Group 3 - O2
Group 4 - anticoag, or if bad thromboendartectomy

387
Q

Primary Tx for Group 1 pulm HTN (PAH) is…

A 
Not really any; skip to advanced Tx:
Diuretics
Anticoags
CCB (preferred)
ERAs
PDE-5is
Prostacyclin 
... or just replace the lung.
388
Q

What is advanced Tx of pulm HTN?

A

Fixing the actual pulm HTN - throw that case to a specialist!

389
Q

Which pulm HTN pts should go on anticoag therapy?

A

PAH (Group 1)

Group 4

390
Q

Which pulm HTN pts should go on digoxin?

A

Group 3

Anyone with an SVT d/t RV dysfxn

391
Q

In which pulm HTN pts is advanced therapy NOT recommended?

A

Group 3 - it’s just eh

Group 2 - epoprostenol can be harmful

392
Q

In which pulm HTN pts is advanced therapy recommended?

A

Group 1 always
Group 5 if d/t sarcoidosis
Group 4 can consider

393
Q

What is vasoreactivity testing?

A

Giving epoprostenol, adenosine, or inh NO to a pulm HTN pt who you wanna move onto advanced Tx, to test whether they’d be a candidate for a CCB

394
Q

If a pt fails vasoreactivity testing, prescribe __, __, or __.

A

PDE-5i
ERA
Prostacycline/Treprostinil/Iloprost

395
Q

Prostacycline is aka __. We like it a lot. Route of administration?

A

Epoprostenol, via central venous cath pump

396
Q

ERAs are especially good for what kind of pts and why? What are they?

A

PAH because PAH lungs have high endothelin

-entans

397
Q

Why does Viagra help Tx pulm HTN?

A

All the -ifils inc nitric oxide which causes vasodilation.

398
Q

What other drug class besides PDE5is act on nitric oxide?

A

Guanylate cyclase agonists (Riociguat)

399
Q

Last-resort pulm HTN Tx?

A

Lung transplant or atrial septostomy

400
Q

First-choice advanced pulm HTN Tx?

A

CCBs, unless they fail vasoreactivity or it stops working

401
Q

Your pulm HTN pt failed vasoreactivity, and has moderate disease. What should you prescribe first?

A

Either a PDE5i or an ERA

402
Q

Your pulm HTN pt failed vasoreactivity and has severe disease. What do you prescribe first? What if that doesn’t work?

A

Ideally, prescribe prostacycline, or another prostanoid if not that.
Then, if they don’t improve or get worse, do some combo Tx.
Then surg if that doesn’t work.

Clin Med (4 decks)

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