Pulm Exam Flashcards
1
Q
A low FEV1, or a low FEV1/FVC, indicates _____
A
Obstructive lung disease
2
Q
A normal DLCO is ____%. Low indicates…
A
80-120
Low = severe restrictive
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.
4
Q
Harming the interstitium ==> ….
A
Less oxygen IN.
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
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
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!
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)
9
Q
Spirometry is over what time period? What are the three most useful results?
A
6 seconds
FEV1, FVC, ratio
10
Q
An FEV1/FVC equal to or under ____ is abnormal, and indicates…
A
70%
Obstructive lung disease
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
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
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.
14
Q
Obstructive lung disease would show ____ on a flow loop; restrictive would show ___.
A
Obstructive = coving Restrictive = everything reduced
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…
16
Q
Low total capacity indicates ___. What’s the opposite?
A
<80 = restrictive >120 = hyperinflation = probable COPD
17
Q
In what obstructive lung disease could DLCO be low?
A
Emphysema
18
Q
Restrictive lung disease means decreased ___, ___, and/or ___.
A
Expansion
Volume
Diffusion
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)
20
Q
What are some prescription drugs that can lead to restrictive lung disease?
A
MTX
Amiodarone
Nitrofurantoin
21
Q
Most likely patient to get IPF?
A
50+yo male, who either smokes or has occupational exposure or GERD
22
Q
What’s the real name for IPF?
A
Idiopathic fibrosing interstitial pneumonia
23
Q
What causes IPF?
A
Gotcha- it’s idiopathic. Definitely NOT inflammation!
24
Q
4 s/s of IPF
A
Insidious dry cough
DOE
Clubbing
Rales
25
How do you treat IPF?
You transplant that mofo
26
Okay, you can’t transplant your IPF patient’s lungs. How do you treat it?
Oxygen/vaxxes/pulm rehab
Nintedanib (an RTKi)
Pirfenidone (an antifibrotic)
27
Pneumoconiosis is d/t...
| What are the three common types?
Occupational dust
1) Coal Worker’s
2) Silicosis
3) Asbestosis
28
ALl types of pneumoconiosis share what three symptoms?
Cough
DOE
SOB
29
What additional symptom might Black Lung or silicosis have?
Fever
30
What additional s/s might asbestosis have?
Inspiratory crackles, clubbing
31
When do symptoms present for Black Lung? For asbestosis?
Coal - asymptomatic for 15yr
| Asbestos - asx for 20-30yr
32
Other names for Coal Worker’s Pneumoconiosis include...
Black Lung
| Anthracosis if mild
33
How do you diagnose and treat Black Lung?
CXR - small upper lung opacities, then fibrosis
| No Tx, no transplant, they die.
34
How do you Dx silicosis?
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
35
Risks of advanced silicosis?
CKD
TB
Lung CA
36
How do you treat silicosis?
d/c working in toxic environment
Can try steroid, but they are eh
Can transplant, but rarely done
37
Who is eligible for a lung transplant?
<65yo
No substance abuse
BMI 20-29
38
How do you diagnose asbestosis?
HxPE
PFTs
CXR/CT - pleural plaques, coarse honeycombing, hazy ground glass
39
How do you treat asbestosis?
Call your lawyer
Quit smoking, or enjoy mesothelioma
Steroids are eh.
40
When I say sarcoidosis, you say
MULTISYSTEMNON-CASEATINGGRANULOMA
41
Sarcoidosis can occur anywhere, especially lungs and heart. What particular patient population did he highlight?
Young AAF
42
Symptoms of sarcoidosis? (3)
Dry cough
Progressive dyspnea
Atypical chest pain
43
How do you diagnose sarcoidosis?
CXR - bilateral hilar adenopathy
CT - Right paratracheal lymphadenopathy with bilateral diffuse reticular infiltrate; sarcoid galaxy sign
BIOPSY - r/o lymphoma.
44
Three types of biopsies for sarcoid?
EBUS
VATS
Cervical mediastinoscopy
45
What is the treatment for sarcoidosis?
Just observe if they’re ASx; steroid course otherwise
46
Pneumonia predominately affects the ___ part of the lung by what mechanism?
Alveoli
| By microaspiration of a virulent organism which takes advantage of a immune system defect
47
Overall, the main cause of community acquired pneumonia is ___. When is that not the case?
Bacterial
Under 5yo - viral
Immunocompromised - parasitic (toxo), fungal (aspergillus, PCP, histo, crypto, cocciodes)
48
Getting pneumonia 48-72hrs post-intubation is called...
Ventilator acquired pneumonia
49
5 categories of pneumonia?
```
CAP
HCAP
HAP
VAP
Aspiration
```
50
Criteria for HAP? What’s another name for it?
48hrs or more after getting hospitalized
| Nosocomial
51
HCAP includes hospitals >48 hrs within ___days, ___, ___, ___, or extensive healthcare contact.
90d
Nursing homes
Hemodialysis
IV/chemo
52
#1 cause of CAP is ___. #2 is ____. #3 is ___.
S. pneumoniae
Myco pneum.
Flu virus
53
Most Sx of CAP are nonspecific like fever/cough/aches; name two more specific symptoms.What about in lil kiddos?
Hemoptysis and pleuritic pain
| Kids - restless and not eating
54
Physical exam findings of CAP include:
CARDIO: (3)
PULM: (4)
CARDIO: tachy, hypotn, hypoxemia
PULM: expiratory wheeze, crackles/rales, tachypnea, and dec/asymmetric breath sounds
55
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?
Myco pneum.
| Watery sputum or lack of sputum
56
HypoNa+ and GI Sx are most often consistent with which etiology of pneumonia?
Legionella pneum.
57
What two special symptoms are most consistent with S. pneum?
Single rigor and rust-colored sputum
58
"Currant jelly sputum" is most often consistent with which etiology of pneumonia? Who does this type of pneumonia most often occur in?
Klebsiella - COPD and EtOHics
59
Diagnostic methods for pneumonia
HxPE, CXR PA/Lat (gold standard)
| Can also CT s contrast if it'll change Tx, and microbio stuff
60
CXR-ordering criteria for pneumonia
1+: Fever >100, tachycardic, tachypneic (>20)
| OR 2+: Rales, dec breath sounds, no PMHx asthma
61
What is a lobar finding on CXR and what does it suggest?
Single lobe or segment/pattern. Often S. pneum.
62
What CXR findings would suggest viral pneumonia or PCP?
Interstitial or peribronchial
63
TB CXR finding?
Caseating granulomas!
64
For what etiologies might a CXR show necrotizing pneumonia?
Aspiration pneum, Group A Strep, S. pneum, staph
65
Sputum inductions are pretty lame, but when might they be indicated? What is a 'good' sample?
Good sample = <25 ep cells + neutros present
| Get if they're immunocomp, bad COPD, EtOHics, admitting to ICU, or have failed ABx
66
Do all pts get blood cx?
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
67
What labs are good to get for probable INPATIENT pneumonia pts?
CBC c diff
BMP or CMP
CRP/Pro-calcitonin/Lactic acid/ESR
68
Macrolides, go
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
69
Tetracyclines, go
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.
70
Fluoroquinoloooooones
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.
71
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?
5 days of a macrolide, or 5 days of bid doxy
72
Your pt is either immunosuppressed or has some crazy comorbidities. What empiric ABx should you prescribe?
5 days of moxi or levo, or 5 days of a beta-lactam + macrolide or doxy
73
Your pt was healthy before they got pneumonia, but they did use ABx within the last three months. What should you prescribe them?
5 days of moxi or levo, or 5 days of a beta-lactam + macrolide or doxy
74
You're in an area where S. pneum resistance is 'cray cray.' What should you prescribe?
5 days of moxi or levo, or 5 days of a beta-lactam + macrolide or doxy
75
You've got an inpt pt who needs ABx for their pneumonia. Which ones are ya loadin' them up with?
IV levo or moxi, OR IV ceftriaxone or Unasyn + IV macrolide or doxy
Above can be +/- glucocorticoid
76
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...
PSI, CURB/CRB, SMART-COP
77
What is the PSI good for? Why is it meh?
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
78
What is the CURB score criteria? What's its main con?
```
Confusion
Urea >19
RR >30
BP <90mmHg systolic
and >65yo
Not so great on the comorbidities.
```
79
How is the CURB scored? What about the CRB?
ICU if 3+, inpt if 2, outpt if 0 or 1.
| CRB - admit anything 1 or more
80
What's the SMART-COP for?
```
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
```
81
For microbio testing, what's the UAT good for?
S. pneum and legionella
82
For microbio testing, what's the Multiplex PCR good for?
Myco pneum
Pertussis
Chlamydia pneum
RSV/flu/all them viruses
83
What's the "standard for diagnosis" for microbio testing? I put it in quotes because it sucks. What can it pick up on?
Serology - Myco pneum, chlamydia pneum, and legionella, past or present
84
When and how would you transition someone off IV ABx?
If they're afebrile and improved after 48hr.
| Transition to similar class, total of 5-7d.
85
If you're treating CAP outpt, what should you tell the pt?
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
86
Who gets the pneum vax?
>65 yo or smoker/comorbidities (repeat in 6yr if under 65yo)
87
If HAP or VAP is less than 5d, what caused it?
S. pneum, H. flu, MSSA, GNR
88
If HAP or VAP is more than 5d, what caused it?
S. pneum, H. flu, MSSA/MRSA, GNR, Pseudomonas, Acinetobacter
89
How do you Tx HAP/VAP <5d old?
IV Rocephin, IV/po levo, IV Unasyn, or po bid Augmentin
90
How do you Tx HAP/VAP >5d old?
IV Cefepime or Ceftazadime, IV meropenem, IV Zosyn, or IV levo...PLUS IV Vanco or po Linezolid!
91
If your pt is CTD and has HAP/VAP >5d old, how do you Tx it?
IV Cefepime or Ceftazadime or meropenem,
+ IV levo or aminoglycoside,
+ IV Vanco
92
There are 4 big red flags for concern of MDR pneumonia. What are they?
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.
93
Aspiration pneum is usually d/t...How do you Tx it?
Anaerobes, or just stomach content/fluids (nonbacterial)
Tx nonbacterial by IVF, +/- steroid, +/- ventilator
Tx bacterial by IV clinda, or Flagyl+Amoxicillin for 7-10d
94
Sx of nonbacterial aspiration pneumonia?
ABRUPT-onset hypoxemia
| Diffuse crackles/rales/other pulm edema signs
95
Sx of bacterial aspiration pneumonia?
SLOW-onset hypoxemia
96
A CD4+ under 50 puts the pt at risk for __ and __.
MAC and CMV
97
A CD4+ under 100 puts the pt at risk for __ and __.
Toxo and Kaposi sarcoma
98
A CD4+ under 200 puts the pt at risk for __.
PCP
99
PCP Sx are gradual and nonspecific; what signs can clue you into it?
Thrush, hypoxemia, rhonchi/crackles, tachypnea, fever
100
If you suspect PCP, what labs should you order?
CD4, ABG, LDH, 1,3-b-d-g, sputum with gram stain
101
If you suspect PCP, what imaging/diagnostic tests should you order? What would you find if they did have it?
CXR- diffuse bilat interstitial infiltrate
CT - ground glass
DLCO - normal or inc
Gallium citrate screening
102
Mild PCP has what labs? How do you Tx it?
paO2 >70
Alveolar-arterial oxygen gradient <35
po Bactrim 14-21d
103
Moderate PCP has what labs? How do you Tx it?
Alveolar-arterial oxygen gradient 35-45
| IV/po Bactrim + po prednisone 14-21d
104
Severe PCP has what labs? How do you Tx it?
paO2 <70
Alveolar-arterial oxygen gradient >45
IV Bactrim + IV methylprednisone 14-21d
105
What's the preferred ABx ppx for HIV pts against PCP?
Bactrim ss qd or Bactrim ds 3x wk
106
In what HIV pts would we initiate PCP ppx?
If CD4+ <200, OPC, or CD4+ < 14%
107
Acute bronchitis is usually self-lim in ___ and is caused by... (7)
1-3wks
| Flu A/B, paraflu, RSV, coronavirus, adenovirus, rhinovirus
108
Characteristic Sx of acute bronchitis?
1-3wk cough c or s sputum
Low-grade fever
Wheezing, mild dyspnea, and rhonchi that clear c cough
Chest pain
109
How do you Dx acute bronchitis?
HxPE
Cough >5d
r/o COPD/pneum (only get CXR if you're real on-the-fence about this)
110
As far as acute bronchitis Dx, sputum sucks, except for when...
you tryna r/o TB but it's being tricky
111
How do we feel about procalcitonin?
```
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.
```
112
Besides ABx maybe, what do you do to Tx your acute bronchitis pt?
Antitussive (dextromethorphan, guaifenecin, tessalon pearls)
Bronchodilator (if comorbid or wheezing)
Corticosteroids are a no-go anymore
113
Defining characteristics of the flu include __, __, and __-onset.
Upper and lower resp involvement
Systemic Sx
Sudden-onset
114
4 populations who are at risk if they get the flu:
Pregnant
Peds
Over 65yo
Comorbidities
115
The flu is caused by...
Orthomyxoviridae viruses, types A/B/C, with N or H surface antigens
116
Most flu outbreaks are caused by type __, hemagglutinin types ___, and neuraminidase types __.
A or B
H1-3
N1-2
117
Why do antigenic shifts occur?
Point mutations in RNA changing the surface glycoproteins.
118
Oh so you think it's the flu? Diagnose it.
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.
119
What two diagnostic methods are we *not* gonna bother with for the flu?
Viral Cx or serology
120
Who do we flu test?
Anyone near an outbreak
Anyone at risk for complications (preg, etc)
Anyone immunocompromised
Anyone inpt, even if they already have CAP
Anyone near healthcare
121
How do we Tx the flu?
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
122
What's the difference between a trivalent and a quadrivalent flu vax?
Tri - 2 flu A + 1 flu B antigen
| Quad - 2 of each
123
A pt >65yo wanting the flu vax gets...
Hi-dose TRIVALENT
124
Does the LAIV flu mist suck?
Yes, it sure does.
125
Why might we expect a TB resurgence? (3)
Poverty rising
MDR rising
HIV rising
126
How is TB transmitted?
Respiratory droplets 1-5microns in diameter
127
TB transmission risk is increased when: (5)
```
UnTx'd resp infection
Cavitation present
Acid-fast bacilli present in sputum
Undergoing procedures like intubation, bronchoscopy, autopsy
Using aerosolized Rxs
```
128
5% of individuals progress to active TB, which usually happens within...
2 years of contraction
129
Potential progression of TB?
immediate clearance --> primary disease --> latent infection --> reactivation disease
130
Sx of primary TB include fatigue, ___, ___, ___, and most commonly, ___.
Pharyngitis
Arthralgia
2-3wk cough
Fever
131
Sx of reactivated TB include ___, ___, ___, and __.
Anorexia
Wt loss
Night sweats
Pleuritic/retrosternal chest pain
132
What testing can you do to confirm TB?
TST & PPD - but not definitive pos or neg.
133
What vax can interfere with TB skin testing?
BCG (European TB vax)
134
For the majority of patients, a wheal at or over ___mm is a positive PPD.
15mm
135
For what pts would you consider a wheal >10mm to be a positive PPD?
```
<5yo
<5yrs in the US
IVDA
People who live in communal homes or work in myco labs
People with high-risk conditions
```
136
When would you consider a wheal of 5mm to be a positive PPD?
In HIV/immunosuppressed pts like transplantees
In pts who were known to be exposed recently
In pts with a positive CXR
137
So if TST/PPD aren't that great, how can we definitively Dx TB?
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
138
What five drugs do you give at once to Tx TB in the intensive phase?
```
RIPES
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin (maybe)
```
139
The first phase of TB Tx requires... (4ish)
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
140
The second phase of TB Tx involves...
Prescribe isoniazid + rifampin x 4mo until 2 Cx are neg.
| Treat Under Direct Observation (someone watches them take EVERY SINGLE DOSE).
141
After TB becomes latent and 2 Cx come back neg, do you continue treatment?
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.
142
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?
That's okay! As long as it's less than 3mo, it's okay to interrupt Tx for LATENT TB.
143
MDR-TB is resistant to...
Rifampin and isoniazid, and maybe more
144
XDR-TB is resistant to...
Rifampin and isoniazid, and at least one of the following inj:
Capreomycin
Amikacin
Kanamycin
145
Which pleura has nerves?
Hehe GOTCHUUUU both do. But only parietal has SENSORY ones.
146
___ nerves control the central diaphragm, and ___ nerves control the parietal diaphragm.
Central portion - Phrenic n.
| Parietal portion - Intercostal nn.
147
What is responsible for draining each pleura?
Visceral - pulm. venous system
| Parietal - upper abd lymphatic system
148
How much fluid is normally found in the pleural cavity? Describe normal pleural fluid (5).
```
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
```
149
What in the everloving fandango is the Starling Law of Transcapillary Exchange?
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.
150
What is hydrostatic pressure?
The physical pushy push on the capillary walls.
151
What is oncotic pressure?
The protein concentrations pulling water into capillaries.
152
Hydrostatic pressure >>> oncotic pressure will make fluid...
LEAVE the capillaries
153
Pleural effusion is...
A SYMPTOM of an underlying issue!
154
What's the most common underlying cause of pleural effusion? Which Starling force is affected?
CHF!! Inc hydrostatic pressure
155
How can atelectasis cause pleural effusion...?
It causes an excessively negative intrapleural pressure
156
Pleural effusion d/t nephrotic syndrome occurs because which Starling force is affected?
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.
157
What disease processes can cause drainage from the lungs to be blocked, causing pleural effusion?
A mass like lymphoma or a mediastinal node.
158
How can pneumonia cause pleural effusion?
By increasing the capillary permeability.
159
Money question! How does pleural effusion present??
COUGH+DYSPNEA+CHESTPAINNNNN
| +Sx of underlying disease
160
4 physical exam findings for pleural effusion (given that it's over ___mL)...?
Dec tactile fremitus
Dec breath sounds
E to A egophony
Dullness to percussion
If >250mL!
161
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...
150mL
| Upright CXR looking for blunted costophrenic angle
162
If you don't know why a pleural effusion occurred, you can order a ___. Well... not if your pt __ or ___. That'd be dumb.
ThoracentesisIs on anticoags, or has a skin infection there.
163
How much do we drain in a thoracentesis and why?
1-2L ONLY or else you will cause re-expansion pulm edema!
164
4 types of pleural effusion, based on fluid content?
Hemothorax
Hydrothorax
Chylothorax
Empyema
165
Labs to order on a pleural fluid sample?
Protein and LDH!!!!!!
| Also CBC c diff, pH, SG, Glu, Cx/stain/cytology
166
What is Light's Criteria?
Criteria for determining whether a fluid sample is transudative or exudative
167
Okay, but what ARE Light's Criteria?
+Exudative if sampleLDH:SrLDH is >0.6, if sampleLDH is >2/3 of ULN of SrLDH, or if sampleProtein:SrProtein is >0.5.
168
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 SG <1.015
169
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!).
Hydrostatic or oncotic pressures
| CHF, atelectasis, nephrotic syndrome, cirrhosis
170
What is Meig's syndrome?
Fibroma + Ascites + Pleural Effusion
171
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).
Permeability - so diseases that inflame/block drainage
| Pneumonia, pulmonary embolism, or a mass.
172
The most common cause of empyema is ___. (He starred it like 4 times.)
PNEUMONIA SEEDING INTO PLEURAL SPACE
173
In general, besides pneumonia complications, what could lead to an empyema?
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
5-10% of pneumonia pts will end up with an empyema. How?
Pneumonia --> parapneumonic effusion --> gets muy complicado --> empyema.
175
Labs of an empyema fluid sample would show ___, ___, ___, ___, and ___.
```
High WBCs (>50,000)
Low Glu (<60)
High LDH (>1000)
Low pH (<7.2)
And it looks gross and purulent AF
```
176
How do you Tx an empyema?
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
25% of all pleural effusions are ___.
Malignant, and most from lung CA (also most deadly).
178
How do you Tx an MPE?
Lots of thoracenteses/putting a tube in, and Tx the CA.
| Probable pleurectomy/decortication.
179
What is pleurodesis?
A procedure to get rid of the pleural space by making the two pleura stick together, either via chemicals or mechanical abrasion.
180
Indications for a pleurodesis (3)?
In short, it just won't quit:
- Repeated effusions/pneumothoraces.
- Chemo drugs aren't fixing the effusion.
- To help inflate lung after thoracentesis.
181
Chemicals that are used in a pleurodesis are called ___ agents. Name five.
```
Sclerosing:
Doxycycline
Minocycline
Bleomycin
Quinacrine
Talc
```
182
Why are indwelling caths good for pleural effusion pts?
They can go home quicker, and it doesn't hurt as much.
183
Why are indwelling caths risky? (3)
Infection risk
Can get obstructed
Effusion can get loculated (into small spaces like the fissures)
184
How does air enter the pleural cavity in a pneumothorax?
Via the chest wall (like a trauma), or through the parenchyma via the visceral pleura.
185
4 types of pneumothorax
Tension
Traumatic
Primary Spontaneous
Secondary Spontaneous
186
Why does a primary spontaneous PTX occur, and in who?
Rupture of a bleb (goodness that's a cute word)
| 18-40yo tall/thin smokers
187
Why does secondary spontaneous PTX occur?
Underlying lung disease, ESPECIALLY COPD
188
Most common causes of a traumatic PTX?
Rib Fx and iatrogenic
189
Money question! 3 Sx of PTX?
DYSPNEA+CHESTPAIN+SHOULDERPAIN!
190
3 physical exam findings of PTX?
Dec fremitus
Dec breath sounds
Hyperresonant to percussion
191
3 ways to Dx PTX?
CXR
Chest CT
Chest U/S
192
How do you Tx a PTX?
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
What's Graham's Law of Diffusion? (don't overthink it)
Air moves from areas of high concentration to areas of low concentration.
194
Two ways to Tx a PTX
Blebectomy (hehe, bleb) with VATS
| Pleurodesis
195
Tension PTXs are ___ and are usually caused by...Why are they particularly bad?
Progressive
Iatrogenic or lung lac
Mediastinum gets pushed over and causes cardiac arrest.
196
4 special Sx of a tension pneumo?
```
Tension? I'm TouCHeD (...it's a stretch, I know it, this is desperation)
Tachy
Chest pain
Hypotensive
Diaphoretic/cyanotic
```
197
4 physical exam findings of a tension pneumo?
```
Tension? I'm TouCHeD.
Total lack of breath sounds
Contralateral tracheal deviation
Hyperexpansion of chest
Distention of jugular vv.
```
198
__ are the most commonly aspirated foreign body.
Nuts. But balloons/gloves/marbles are more deadly.
199
Most foreign body aspirations end up in ___.
The right lung
200
If a little kid comes in with ___, think foreign body.
Stridor
201
A foreign body aspiration emergency presents as ___, __, and ___.
Severe resp. distress
Mental change
Cyanosis
202
A lower-airway foreign body aspiration will present as __, __, and ___.
Hyperinflated lung
Atelectasis
Pneumonia
203
CXR can help Dx a foreign body aspiration, but if your Hx/PE lead you to suspect it, you'll probably order a...
Bronchoscopy, because you can remove the object with it almost always.
204
What is the definition of a pulmonary nodule?
<3cm ("coin"-sized) intraparenchymal lesion NOT associated with lymphadenopathy or atelectasis
205
CXR is cheap and quick and can detect __, __, __, and __.
CHF
Effusions
Masses (ground-glass)
Pneumonia/infections
206
CXR have two cons:
Overlap (esp on left) makes it hard to see
| Hard to detect small nodules
207
Chest CT are better for seeing small lesions, and can confirm Dxs of ___, ___, ___, and ___.
COPD
TB/Pneumonia
CA
Congenital stuff
208
Standard CT slices are ___mm.
| PE Protocol CT or high-res are ___ mm.
5mm.
| 1mm.
209
PET/CT is done with the chemical ___, and are great for __ and __. Are they more sensitive or specific?
FDG
Good for seeing CA (SUV>3) and cardiac perfusion
Sensitive!
210
Lesions under ___mm are hard to see on PET.
8-10mm
211
What are some malignancies that are tough to see with PET and why?
Bronchoalveolar carcinoma and carcinoid tumors - they don't pick up FDG well.
212
Besides cost, what's the biggest drawback of PET?
Can't tell the difference between inflammation and CA.
213
MRIs are great because there's no rad and because they can assess...
Tumor size/mets (not good at solitary ones though)
214
Malignant lesions are __, and have a __ border.
Bigger
| Spiculated (could be smooth too though just a heads up)
215
Calcifications in the lung are more common in hamartomas (benign but ugly) or TB than in CA... except for in what case?
Calcifications are also in osteosarcoma and chondrosarcoma pts (pts with primary CA elsewhere).
216
If a tumor grows real fast, it's probably...
Benign!
217
80% of all BENIGN nodules are d/t...
Infectious granulomatous disease (histo, coccidio, mycobact)
218
10% of all BENIGN nodules are d/t...
Inflammatory nodular disease (sarcoid, RA, Wegener's)
219
The last 10% of BENIGN nodules are...
Hamartomas (popcorn!)
220
If there's a high probability a solitary pulm nodule is malignant, what do you do?
Cut that ish out.
221
If there's a low probability a solitary pulm nodule is malignant, what do you do?
Monitor with serial CT scans.
222
If there's an intermediate probability a solitary pulm nodule is malignant, what do you do?
Image to figure out the size, and if it's under 1cm, it's a low probability, so monitor with serial CT scans.
223
Your intermediate-malignancy-probability solitary pulm nodule turns out to be >1cm. What do you do?
Either biopsy or PET with FDG. That'll determine once and for all whether the probability of malignancy is high or low.
224
A ground-glass opacity is found to be less than 5mm. What do you do?
f/u CT q6mo x 36mo if stable.
225
A ground-glass opacity is found to be more than 5mm, but less than 10cm. What do you do?
f/u CT q3mo x 36mo if stable.
226
A ground-glass opacity is found to be more than 10mm. What do you do?
Either biopsy it or resect it!
227
Smoking is responsible for ___% of all lung CA.
85-90%! Second/thirdhand smoking counts too.
228
The biggest environmental risk factors for lung CA are...
Radon, radiation, and other occupational pollutants.
229
There are __ cigarettes in a pack.
20-25
230
What's important to remember when you're tryna figure out how big a tumor is on CT?
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
What are some benign lung diseases that can increase the risk for lung CA?
Fibrosis
COPD
a1-AT deficiency
TB
232
What is cotinine, and what does it tell us about today's cigarette exposure?
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
What's thirdhand smoking?
Cigarette jank getting stuck in fabric etc and then cute innocent little kiddos put their faces all in it and get sick :(
234
SCLC can be __, __, or combined.
Classic small cell carcinoma, or large cell neuroendocrine
235
NSCLC can be ___ (like __), ___, or ___.
Adenocarcinoma (like BAC)
Large cell carcinoma
Squamous cell carcinoma
236
Most lung CA is an ___.
Adenocarcinoma
237
A large cell carcinoma is __ and __, large and necrotizing.
Malignant and undifferentiated
238
Squamous cell carcinomas are usually ___ and usually occur in what pt popn?
Central
| Smokers
239
On CT, squamous cell carcinomas show...
Cavitation and extensive necrosis
240
Most adenocarcinomas occur where? Name three subtypes.
Peripherally.
| BAC, mucinous, papillary
241
BAC is ____ on CT.
Ground-glass opacity!
242
Besides cough/dyspnea/chest pain, how might lung CA present initially?
Hemoptysis
Recurrence of pneumonia
Unexplained wt loss
243
Later-stage lung CA might present with... (6)
```
Bone pain
Dysphagia
Hoarseness
Horner's
SVC Syndrome
Neuro stuff like HA/syncope
```
244
What are the three characteristics of Horner's Syndrome?
Ptosis, Anhydrosis, Miosis
245
What is a paraneoplastic syndrome?
Signs and symptoms that are the consequence of cancer in the body, but is not due to the local presence of cancer cells
246
You have to get a biopsy to Dx lung CA. What are some ways to go about getting that sample?
```
VATS
Thoracentesis
EBUS
Bronchoscopy +/- lavage
CT guided needle Bx
```
247
If a tumor has M1, it is stage ___.
IV
248
If a tumor has N2+, it is stage ___.
III+
249
If a tumor has N1, it is at least stage ___.
II
250
If a tumor is less than 3cm with N0M0, it's stage ___.
I
251
Lung CA spreads via what three routes?
Blood, lymph, direct invasion
252
What are the 4 most common places for lung CA to metastasize to?
Brain, bone, liver, adrenals
253
If a lung lesion is 2cm or more, you need to get ___. How?
```
A metastatic workup.
Head MRI or CT c contrast
PET/CT
Bone scan if suspected bone CA
Mediastinoscopy to check nodes
```
254
How do you treat Stage I lung CA?
Surg resection + chemo/rad
255
How do you treat Stage II lung CA?
Surg resection + chemo/rad
256
How do you treat Stage III lung CA?
Chemo+rad to downstage tumor
257
How do you treat Stage IV lung CA?
Cisplatin chemo
258
Small cell carcinoma almost always occurs in ___. What are its defining characteristics?
Smokers!!
| Poorly differentiated large hilar mass with bulky mediastinal adenopathy
259
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?
Limited (to one hemithorax)
| Extensive (more common on first presentation)
260
What type of lung lesion is most likely to pop up in a kid?
Carcinoid tumor
261
Carcinoid tumors are rare, __, and usually arise from the ___.
Differentiated, GI tract
262
Carcinoid tumors can be typical or atypical. Which are more common? Which are more likely to metastasize?
Typical are 4x as common
| Atypical are more likely to metastasize
263
If carcinoid tumors are usually benign, why might they be bad?
They commonly arise in the proximal airways, causing bronchial obstruction.
264
What do carcinoid tumors look like on CT?
Hilar or perihilar round/ovoid opacities
265
What two rare syndromes might occur with carcinoid tumor?
Acromegaly
| Carcinoid syndrome
266
How do you Tx a carcinoid tumor?
En bloc surg resection if you can; intraluminal bronchosopic resection if you can't. Rad is okay; chemo is pretty useless.
267
A Pancoast tumor is aka a ___ tumor. Where does it occur?
Superior sulcus
| On apex of lung, near subclavian
268
What are some structures/vessels that a Pancoast tumor might affect?
Subclavian vessels, ribs, vertebrae, vagus n, recurrent laryngeal n, sympathetic ganglion
269
Most Pancoast tumors are ___ tumors, but they can be just about any type, so figure that out first. Then how do you Tx it?
Squamous cell carcinoma
| Shrink it with chemo/rad then surg resection
270
The most common clinical presentation of Pancoast tumor is ___ and __.
Shoulder pain + Horner's Syndrome
271
What are the most common CAs that metastasize TO the lung?
Melanoma
Sarcoma
Prostate/Breast/Colon/Bladder/Kidney Carcinomas
272
Why do most lung CAs NOT from smoking occur in young women?
Estrogen promotes lung CA - use EGFRi to Tx
273
Who should get preventative CT screening for lung CA?
55-80yos c a 30+yr pack-history
274
What is bronchiectasis?
Permanent, abnormal dilation/collapse and destruction of the bronchial walls usually d/t infection
275
Half of all cases of bronchiectasis are caused by __.
Cystic fibrosis
276
Bronchiectasis presents as...
Daily chronic cough c viscid sputum
277
Cystic fibrosis has an abnormal __ and __ transport that puts them at risk for ___ respiratory infections.
Cl- and Na+
| Pseudomonas
278
Sx of bronchiectasis?
Hemoptysis/rhinosinusitis/productive cough
Recurrent pleurisy
Urinary incontinence
+/- Cystic fibrosis Sx
279
Auscultation of bronchiectasis would reveal __ and __.
Wheezing and chronic crackles
280
5 labs to order for bronchiectasis?
```
CBC
Ig Panel
Antibody titers post-vax
Sputum Cx/stain
Sweat Cl- Test for CF
```
281
Imaging to order for bronchiectasis? What would they reveal?
CXR - linear atelectasis, irregular mucopurulent plugs
| CT - airway dilation, bronchi thickened, bronchial cysts
282
A bronchiectasis pt would have PFTs that ...
Show low FEV1/FVC ratio
| Low FVC if advanced
283
Why would you order a bronchoscopy for a bronchiectasis pt?
To collect sputum samples and assess for foreign body or tumor to r/o those
284
How do you Tx bronchiectasis?
Tx the underlying infection (po abx x 10d)
Can neb hypertonic saline to thin secretions
SABA
Chest PT or pulm rehab
285
Virchow's Triad, go.
Stasis, hypercoag, endothelial injury
286
The main Sx for massive PE is...
| Why is it bad?
HYPOTN (<90 systolic for 15+min)
| And then they die within 2hr d/t RV failure unless you give them tPA.
287
3 locations of PE
Saddle
Segmental
Subsegmental
288
What are the 5ish inherited thrombophilic disorders?
```
Factor V Leiden
Prothrombin mutation
Protein C/S def
Antithrombin III def
Antiphospholipid syndrome
```
289
Sx of PE are ___, ___, and ___!
Palpitations
Sudden SOB
Pleuritic chest pain
290
Physical exam of PE would show __, __, and __.
Tachycardia, tachypnea, hypoxia
291
A Wells score under __ is low PE risk, and over __ is high PE risk.
<2>6
292
A Wells score under __ is low DVT risk, and over __ is high DVT risk.
<1
| >2
293
Is a d-dimer more sensitive or specific?
Sensitive. It's not specific because it's inc in any inflammation.
294
On who would you order a d-dimer?
Low-probability DVT pts to r/o DVT
| Low-moderate probability PE pts to r/o PE
295
Imaging of choice for suspected PE is ___. When would you choose something else?
Chest CT with contrast!
| If renal failure, allergic to contrast, or preg
296
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?
CXR - Hampton's Hump Sign
V/Q scan - normal ventilation and multiple perfusion deficits
Pulm angio - but it's invasive so nah
297
What will the ECG of a PE pt show?
SINUS TACH
298
What special things might pop up on a PE pt's ECG?
S1Q3T3
RV T-wave inversion
RBBB
Nonspecific ST/T changes
299
Why might an echo be helpful in PE Dx?
R/O MI
300
What is the primary Tx of PE? Secondary?
tPA or embolectomy, then anticoag therapy (or IVC filter but no)
301
What four things would make you consider your PE pt a high-risk one?
HD unstable
RV enlarged
RV hypokinesis
Elevated troponin
302
How is PE Tx different for a CA pt?
They stay on LMWH long-term.
303
Anticoag therapy is recommended for 3-6mo if the PE was...
Provoked (post-op, estrogen, trauma)
304
Anticoag therapy should be continued indefinitely if the PE was...
Unprovoked (travel, idiopathic, antiphospholipid)
305
Asthma is a chronic __ disease characterized by ___, __ symptoms.
inflammatory
| paroxysmal, reversible
306
What are the three most common diseases associated with an atopic patient?
Atopic dermatitis
Allergic rhinitis
Asthma
307
Is asthma obstructive or restrictive? Why?
Obstructive - smooth muscle constricts around airways and immune system makes basement membrane thicken
308
What is the difference between fatal asthma and normal asthma?
In fatal, collagen deposits in basement membrane and airway muscle hypertrophies
309
What are the three long-term consequences of asthma?
Chronic airway inflammation + reversible bronchoconstriction + hyperresponsiveness to triggers
310
The classic Sx of asthma are __, __, and __.
Intermittent dyspnea
Persistent nonproductive cough
Wheezing
311
The main physical exam findings of asthma are __ and __.
Inability to speak full sentences in one breath
| Widespread, high-pitched, musical expiratory wheeze during exacerbation
312
When might an asthma attack have wheezing not just on expiration? What else might you hear in that case?
During a severe attack, and if it's really bad, might have no breath sounds (emergency)
313
If someone presents with asthma, what other physical exam findings might you look for that are unrelated to asthma specifically?
Signs of atopy: pale/swollen turbinates, adults with nasal polyps, or atopic dermatitis
314
Besides HxPE, how would you Dx asthma?
Spirometry pre and post-bronchodilation (or methacholine challenge)
Peak flow meter
Allergy testing for triggers
can CXR to r/o other Dxs
315
What would spirometry results be for an asthmatic?
Obstructive, so dec FEV1, dec ratio (<0.7)
| And post-bronchodilation (albuterol MDI 400mcg) would be a 12% or better improvement
316
Asthma Sx are usually worst...
At night or early a.m.
317
What, briefly, are the four categories of asthma, and what's the difference between them?
Intermittent - Sx <2d/wk
Mild Persistent - Sx >2d/wk
Moderate Persistent - Sx daily
Severe Persistent - Sx always
318
What would spirometry show for each of the four asthma categories?
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
How do you Tx intermittent asthma, regardless of age?
Prescribe SABA PRN
320
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?
+ 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
Which ABx are best to prescribe for an acute asthma exacerbation?
Don't do that that's dumb. Unless they have an infection at the same time.
322
How do you Tx a severe asthma exacerbation?
O2 if under 90%sat - keep below 96%
Systemic steroid
Albuterol
IV Mg2+
323
Can someone have asthma AND COPD at the same time?
Yep yep. Chronic obstructive asthma (aka not fully reversed by bronchodilation) is called COPD.
324
Name four comorbidities that can exacerbate asthma.
Obesity
Cigarette smoking
Allergic rhinitis (esp. ASA-caused)
GERD
325
Three types of COPD are ___, ___, and __.
Emphysema
Chronic Bronchitis
Chronic Obstructive Asthma
326
Name three differences between COPD and classic asthma.
Age of onset (50-60yos vs peds)
Reversibility (nah/not much vs yeah)
Associated risks (smoking vs atopy)
327
What happens to the bronchial wall in COPD? What happens to the submucosal glands?
Bronchi get inflamed/fibrous
| Submucosal glands get hypertrophied and hypersecrete mucus
328
What happens to the alveoli in COPD and why?
They're predisposed to collapse d/t loss of elastic lung fibers (which prevents expiration and traps air in)
329
In the end, all that COPD-pathophysiological mess leads to what three results?
1. Airway obstruction.
2. Decreased exchange surface area.
3. V/Q mismatch.
330
Your pt quit smoking years ago, but they're presenting with what you think is COPD now. Did you get the Dx wrong...?
Nah, COPD happens even in former smokers regardless of whether they quit or not.
331
A COPD exacerbation is often caused by...
Pulmonary infection
332
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?
A1-AT deficiency
333
What is the medical definition of chronic bronchitis?
Chronic, daily productive cough >3mo for two years in a row s other explanation
334
What is emphysema? What are the two types?
Permanent airspace enlargement with loss of elasticity and no fibrosis.
Panacinar or proximal acinar (centrilobular)
335
Where does panacinar emphysema occur? What pts are most likely to present with this?
Both bronchioles and the alveoli
| a1-AT def pts, sometimes smokers
336
Where does proximal acinar emphysema occur? What pts are most likely to present with this?
Bronchioles - not the alveoli at first.
| Coal workers, smokers
337
CXR of a pt with moderate emphysema will look like...
A vertical heart + hyperlucent lungs
338
CXR of a pt with severe emphysema will look like...
A vertical heart + hyperlucent lungs + blebs (hehe blebs <3), which are also visible on CT
339
The 5 main Sx of COPD are...
```
CHRONIC COUGH WITH SPUTUM (except scant sputum if emphysema)
DOE
Wheezing
Chest tightness
Wt changes
```
340
What might you see on inspection of a COPD pt in the physical exam?
Barrel chest
Cyanosis
Use of accessory muscles/tripoding
341
What might you note on palpation/percussion of a COPD pt in the physical exam?
Decreased diaphragmatic excursion
342
What might you hear on auscultation of a COPD pt in the physical exam?
Prolonged expiration with wheezing
343
Advanced COPD will also have s/s of what?
RHF, wasting
344
What's the phrase for differentiating between emphysema and chronic bronchitis? What's the chief complaint of each?
Pink puffer vs blue bloater (dyspnea vs chronic cough)
345
Besides HxPE, how do you Dx COPD?
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
Besides Rxs, how do we Tx COPD?
QUIT SMOKIN'
Pulm rehab
Get vaxxes
Maybe chronic O2 therapy
347
First-line COPD prescription is:
SABA +/- ipratropium (Combivent most common choice)
348
How do you Tx an acute COPD exacerbation?
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
If your COPD pt presents with an FEV1 <50%, what do you do?
Hospitalize them!
350
What are some high-risk comorbidities that would get you to hospitalize your COPD-exacerbation pt?
DM, ARF, CHF, arrhythmia, pneumonia
351
Why would I add a maintenance med to my COPD pt's regimen?
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
Give me three maintenance meds I can add to my COPD pt's regimen.
Salmeterol (LABA)
Tiotropium (LAMA)
Advair (LABA + steroid)
353
Ruh-roh, your COPD pt is officially end-stage. What Tx options do you have?
Chronic steroids + chronic oxygen
354
What is a normal pulm artery pressure and how do you measure it?
8-20mmHg via R heart cath
355
What is the pressure of pulm HTN? What about borderline pulm HTN? Is that the same as pulm artery HTN?
mean PAP equal to or >25mmHg
Borderline - 21 to 24mmHg
NOoooOOoo
356
What are the three key Sx of pulm artery HTN?
Dyspnea + Chest Pain + Syncope
357
What is the MAIN CAUSE of pulm HTN?
INCREASED PULM A. RESISTANCE
358
What are two other causes of pulm HTN, besides inc pulm vasc resistance?
Inc pulm blood volume
| Elevated L atrial pressure (like valve issues etc)
359
Why might a pt's pulmonary vasc resistance increase?
Inc afterload --> RVH --> RV dilation --> dec CO
360
What's the imaging study of choice to order for a pt you suspect pulm HTN in? Why?
TTE - it can estimate pulm a. systolic pressure
361
Pulm HTN is likely if a TTE shows __ and __.
Pulm a. systolic pressure > 50mmHg and tricuspid regurg velocity > 3.4
362
What do you need to Dx pulm HTN?
R HEART CATH shows PAP > or equal to 25mmHg at rest
363
How can a R heart cath measure L heart pressures?
PCWP (balloon)
364
Pulm HTN is classified in groups, 1-__. Describe each.
```
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
Which pulm HTN group is most common? Which is least common?
3 is most
| 1 is least
366
What comorbidity is found in 20% of mild pulm HTN pts?
OSA
367
Pulm HTN is categorized into four functional categories. Describe each.
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
Why does Group I pulm HTN (aka __) occur?
PAH
| d/t abnormalities in all three vessel layers
369
Besides excluding all other disorders, what do you need to Dx PAH?How do you r/o the other 4 groups?
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
If it's not idiopathic, what are some reasons PAH might occur?
Genetics/connective tissue issues/VSD or ASD
Crack is whack, y'all. So are appetite suppressants and meth.
HIV
Portal HTN
371
Why can L heart disease cause Group 2 pulm HTN?
HTN of the L atrium means pulm. a. systolic pressure has to inc to get blood through.
372
Group 3 pulm HTN is only caused by severe lung diseases, like severe __, __, or __.
COPD, interstitial lung disease, OSA
373
Why can VTE cause Group 4 pulm HTN?
Cause if you block off some of the baby veins, then the ones that are left have to take in higher pressure
374
Group 5 pulm HTN can be caused by hematologic stuff like __ or __, systemic stuff like __, metabolic stuff like __, or other/unknown stuff.
Sickle-cell or myeloproliferative
Sarcoidosis
Glycogen storage disorder
375
R heart disease that is caused by L heart disease is called...
R heart disease, suckaaa. *Not* cor pulmonale, if that's what you said.
376
What is cor pulmonale?
RVH-->RHF caused by pulm HTN.
377
Apart from the usual COPD/PAH/OSA that causes pulm HTN that causes cor pulmonale, what structural abnormality can cause it?
Kyphoscoliosis
378
Okay but WHY does pulm HTN cause cor pulmonale?
High PAP --> RVH --> RVF
379
In whom is cor pulmonale the most scary?
Group 1 pulm HTN pts (--> dead)
380
Pulm HTN is usually ASx for __, then presents as __, __, and __ if severe.
about 2yrs
| Fatigue, DOE; dyspnea at rest
381
Money question! What are the four big Sx of RHF?
Syncope on exertion
Angina
Peripheral edema
Abd pain d/t hepatic congestion
382
Money question! What are the big physical exam findings of RHF on auscultation?
At pulmonic region: initial loud S2, later an S2 split
At RV: S3
At tricuspid: regurg (high pitched systolic murmur)
383
What are the non-auscultation findings of RHF on exam?
Ascites
Inc JVP
Hepatomegaly
Peripheral edema
384
Cardio-wise, what imaging/labs should you get for a cor pulmonale pt? What would you expect to see?
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
Pulmonology-wise, what imaging/labs should you get for a cor pulmonale pt? What would you expect to see?
PFTs (low FEV1 and ratio)
Overnight pulseox (low)
V/Q scan (to check for VTE)
Polysomnography (to check for OSA)
386
Primary Tx for pulm HTN is...
Tx the underlying cause!
Group 2 - Tx HF (diuretics, antiHTNs, etc)
Group 3 - O2
Group 4 - anticoag, or if bad thromboendartectomy
387
Primary Tx for Group 1 pulm HTN (PAH) is...
```
Not really any; skip to advanced Tx:
Diuretics
Anticoags
CCB (preferred)
ERAs
PDE-5is
Prostacyclin
... or just replace the lung.
```
388
What is advanced Tx of pulm HTN?
Fixing the actual pulm HTN - throw that case to a specialist!
389
Which pulm HTN pts should go on anticoag therapy?
PAH (Group 1)
| Group 4
390
Which pulm HTN pts should go on digoxin?
Group 3
| Anyone with an SVT d/t RV dysfxn
391
In which pulm HTN pts is advanced therapy NOT recommended?
Group 3 - it's just eh
| Group 2 - epoprostenol can be harmful
392
In which pulm HTN pts is advanced therapy recommended?
Group 1 always
Group 5 if d/t sarcoidosis
Group 4 can consider
393
What is vasoreactivity testing?
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
If a pt fails vasoreactivity testing, prescribe __, __, or __.
PDE-5i
ERA
Prostacycline/Treprostinil/Iloprost
395
Prostacycline is aka __. We like it a lot. Route of administration?
Epoprostenol, via central venous cath pump
396
ERAs are especially good for what kind of pts and why? What are they?
PAH because PAH lungs have high endothelin
| -entans
397
Why does Viagra help Tx pulm HTN?
All the -ifils inc nitric oxide which causes vasodilation.
398
What other drug class besides PDE5is act on nitric oxide?
Guanylate cyclase agonists (Riociguat)
399
Last-resort pulm HTN Tx?
Lung transplant or atrial septostomy
400
First-choice advanced pulm HTN Tx?
CCBs, unless they fail vasoreactivity or it stops working
401
Your pulm HTN pt failed vasoreactivity, and has moderate disease. What should you prescribe first?
Either a PDE5i or an ERA
402
Your pulm HTN pt failed vasoreactivity and has severe disease. What do you prescribe first? What if that doesn't work?
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.
