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Clin Med II Final - PULM and Critical Care > PULM neoplasms, Pleural dz, Obstructive and Restrictive Dz > Flashcards

PULM neoplasms, Pleural dz, Obstructive and Restrictive Dz Flashcards

1
Q

3 types of Restrictive Pulmonary Diseases

A

Intrinsic: diseases of the lung parenchyma, inflammation or scarring of lung tissue.

Extrinsic: Extra-pulmonary diseases involving the chest wall,

Medication induced interstitial lung disease

  • Amiodarone
  • Methotrexate
  • Nitrofurantoin
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2
Q

Idiopathic fibrosing Interstitial Pneumonia (IPF) is causes by?

Risk Factors / occupation?

A

Unknown – fibroblasts cause thickening of interstitium -> fibrosis

Most common diagnosis among pts w/ intersitial lung dz

  • Smoking
  • Occupational exposure (stone, metal, wood, organic dust)
  • GERD
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3
Q

Diagnostic tests for Idiopathic fibrosing Interstitial Pneumonia (IPF): what would the results of these tests be?

FVC

FEV/FVB

DLCO

6 minute walk test - impaired or not?

CXR

CT

A

↓ FVC

Normal or elevated FEV1/FVC

↓ DLCO

Impaired 6min walk

CXR –Reticular markings

CT - Diffuse patchy fibrosis with pleural based honeycombing

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4
Q

Tx for Idiopathic fibrosing Interstitial Pneumonia (IPF)

A

Medications: no steroids!!

  • Nitedanib: tyrosine kinase inhibitor
  • Pirfenidone (Esbriet): anti-fibrotic drug

Surgery: Lung Transplant

  • Age <65
  • Free of substance abuse, smoking
  • Acceptable BMI (20-29)
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5
Q

Physical Exam findings indicative of Idiopathic fibrosing Interstitial Pneumonia (IPF)

A

Clubbing

Inspiratory rales (crackle)

Insidious dry cough

Exertional dyspnea

Fatigue

Tachypnea

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6
Q

risk factors for Idiopathic fibrosing Interstitial Pneumonia (IPF)

A
  • Smoking
  • Occupational exposure (stone, metal, wood, organic dust)
  • GERD
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7
Q

3 types of Pneumoconiosis

A

coal workers

Silicosis

Asbestosis

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8
Q

Occupations at risk for Silicosis

A

Mining, masonry, glass manufacturing, foundry work and sandblasting

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9
Q

imaging w/ silicosis

A
  • Acute - bilateral, diffuse ground glass opacities
  • Chronic – small, innumerable rounded densities
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10
Q

complications of silicosis

A

Complications:

Mycobacterial infection (TB) - test for TB*****

Aspergillosis

Lung cancer

Chronic kidney disease

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11
Q

Small rounded nodular opacities w/ preference for upper lobes is a finding consistent with ??

A

Coal Workers Pneumoconiosis

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12
Q

Tx of Silicosis

A

No proven specific therapy:

  • Avoid further exposure/supportive care
  • Steroid therapy – acute phase
  • Lung transplantation
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13
Q

CXR and CT findings consistent with asbestosis

A

CXR – thickened pleura, calcified pleural plaques

CCT – hazy ground glass appearance of peripheral pleural space

•Advanced – coarse honeycombing

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14
Q

complication of asbestosis

A

•Malignant mesothelioma

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15
Q

Multisystem granulomatous disorder of unknown etiology.

Characterized by non-caseating granuloma

A

Sarcoidosis

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16
Q

Si/Sx of Sarcoidosis

A

Cough (dry, hacking)

Progressive dyspnea

Atypical chest discomfort

Fever/night sweats**

Weight loss

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17
Q

CXR and CT findings associated with Sarcoidosis

A

CXR: Bilateral hilar adenopathy

CT: Right paratracheal lymphadenopathy along with bilateral diffuse reticular infiltrates

•Sarcoid galaxy sign

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18
Q

Tx for sarcoidosis

asymptomatic and symptomatic patientd

A

Close observation for asymptomatic patients

Symptomatic pts - tapering course of oral corticosteroids over 4-6 weeks. (90% of pts receive benefit)

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19
Q

define DLCO

how is it used to help diagnose restrictive lung diseases

A

•Measures the overall function of the alveolar capillary membrane.

measures gas diffusion (CO) accross capillar membrane

differentiate the etiology of restrictive lung disease:

  • DLCO is low = interstitial lung disease.
  • DLCO is normal = extrathoracic cause
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20
Q

define Atopy

A
  • A genetic disposition to develop an allergic reaction and produce elevated levels of IgE upon exposure to an environmental antigen and especially one inhaled or ingested
  • atopic dermatitis (eczema)
  • allergic rhinitis (seasonal allergies, dust mite allergy etc)
  • asthma
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21
Q

Differentiate b/e chronic bronchitis and emphysema

A

Emphysema – pink puffer

  • Major complaint dyspnea
  • Cough is rare
  • Clear mucus
  • Pts thin
  • Accessory muscle use
  • Chest is quiet / soft pitched wheeze

Chronic bronchitis – blue bloater

  • Major complaint – chronic cough
  • Mucopurulent sputum
  • Frequent COPD exacerbations and infections
  • Chest is noisy w/ rhonchi and wheezing
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22
Q

PFT that helps distinguish b/w emphysema and chronic bronchitis/asthma

A

DLCO

emphysema (DEC)

chronic bronchitis/asthma (DLCO normal)

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23
Q

Characteristics of Obstructive Lung Dz:

•FEV1 –
FVC –

  • FEV1/FVC -
  • DLCO
A

•FEV1 – decreased
FVC – normal

  • FEV1/FVC - <70% or <0.7
  • Improvement of FEV1 after bronchodilator (asthma responds better)
  • DLCO to distinguish b/w emphysema and COPD or asthma
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24
Q

define emphysema and the 2 types

A

enlargement of alveolar air spaces that is followed by destruction w/o obvious fibrosis -> loss of elasticity

•Proximal acinar – assoc w/ smokers , abnormal dilation or destruction of thr respiratory bronchiole (coal workers pneumo)

•Panacinar – associated w/ genetic deficiency alpa-1-antitrypsin, enlargement an destruction of all parts of of the acinus

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25
Q

Bronchiectasis is most commonly due to

A

CF ****

less commonly due to Lung infections - TB, fungal, lung, abscess, pneumonia

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26
Q

si/sx of Bronchiectasis

A

Chronic daily cough w/ viscid sputum – thick and sticky

Hx of repeated respiratory infections

Hemoptysis

Urinary incontinence

Pulmonary crackles, wheezing

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27
Q

CXR and CT findings in Bronchiectasis

A

CXR – linear atelectasis

  • Dilated thickened airways
  • Irregular peripheral opacities

CT - bronchial wall thickening, airway dilation

•Mucopurulent plugs, cysts of bronchial walls

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28
Q

Tx of Bronchiectasis

A

Abx – cover for pseudomonas***

Tx underlying dz

Loosening secretions

Progressive condition w/ poor quality of life

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29
Q

Stepwise approach for managing asthma in children 0-4 years of age

A

Intermittent Asthma

•Step 1 – SABA prn (albuterol)

Persistent Asthma

  • Step 2 – Low dose ICS
  • Step 3 – medium dose ICS
  • Step 4 – medium dose ICS + LABA or Montelukast
  • Step 5 – high dose ICS + LABA or Montelukast
  • Step 6 - high dose ICS + LABA or Montelukast + consider systemic glucocorticoids
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30
Q

Stepwise approach for managing asthma in children 5-11 years of age

A

Intermittent Asthma

•Step 1 – SABA prn

Persistent Asthma

  • Step 2 – Low dose ICS
  • Step 3 – either low dose ICS + LABA / theophylline OR medium dose ICS
  • Step 4 – medium dose ICS + LABA
  • Step 5 – high dose ICS + LABA
  • Step 6 - high dose ICS + LABA + short course of oral systemic glucocorticoids
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31
Q

Stepwise approach for managing asthma in patients >12

A

Intermittent Asthma

•Step 1 – SABA prn

Persistent Asthma

  • Step 2 – low dose ICS
  • Step 3 – low dose ICS + LABA (or medium dose ICS)
  • Step 4 – medium dose ICS + LABA
  • Step 5 – high dose ICS + LABA
  • Step 6 – high dose ICS + LABA + short course of oral systemic glucocorticoids
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32
Q

Treatment of Acute Asthma Exacerbation:

A
  • Oxygen ( keep SaO2 >90% but <96%)
  • Systemic glucocorticoid (methylprednisolone vs prednisone)
  • Short acting bronchodilator (stacked nebs / Duoneb)
  • Albuterol
  • Add Ipratropium for severe flares in the ER, then resort back to only albuterol once admitted to the hospital

Magnesium (Intravenous) – for severe flares

•**antibiotics have not been shown to improve outcomes unless there is a concomitant infection

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33
Q

Treatment for COPD based on risk Group

A

A -

PRN

SABA – albuterol

SAMA – Ipratropium

Combo SABA + Ipratropium **

B

LABA – Salumeterol

LAMA – Tiotropium

*persistent symptoms – LABA + LAMA

•Umeclidinium + Vilanterol (Ellipta)

C

LAMA – Tiotropium

*LAMA + LABA combo (Ellipta)

Less preferred LABA + ICS

  • Salmeterol/fluticasone (Advair)
  • Formoterol/budesonide (Symbicort)

D

LAMA + LABA combo (Ellipta)

LABA + ICS – preferred if sx of asthma

*LABA + LAMA + ICS

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34
Q

Treatment of Acute COPD Exacerbation

A
  • Oxygen (keep SaO2 >90% but <96%)
  • Systemic glucocorticoids – MUST TAPER
  • Prednisone (oral)
  • Methylprednisolone (Solu-medrol) (intravenous)
  • Short acting bronchodilator
  • Ipratropium & Albuterol nebulizer (Duoneb) à give to hospitalized pts
  • Albuterol nebulizer
  • Antibiotics (if requires hospitalization or infection) **** give even if no infection
  • Cover atypical organisms - Levofloxacin, Azithromycin
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35
Q

Treatment of Acute Bronchiectasis Exacerbation

A

Oral antibiotics (tailor to microscopy when culture data is available) x 10dys

  • Outpatient vs inpatient treatment
  • Nebulized hypertonic saline to thin secretions
  • Chest Physiotherapy (chest PT)
  • Oscillatory positive expiratory pressure (PEP) device to loosen secretions
  • Bronchodilators (short acting beta-agonist)
  • Pulmonary rehab
36
Q

cardinal feature of acute bronchitis

A

Cough – cardinal feature, lasts 1-3 weeks (median duration 18 days)

37
Q

Dx of acute bronchitis is ?

A

patient with acute onset but persistent cough (1-3 weeks) without clinical findings suggestive of pneumonia (eg, fever, tachypnea, rales, signs of parenchymal consolidation)

38
Q

most likely cause of acute bronchitis?

A

Viral - 60%

Rhinovirus

Parainfluenza

Influenza A and B

Coronavirus 1 to 3

Bacteria: ~6% of cases

Bordetella pertussis

Mycoplasma pneumoniae

Chlamydia pneumonia

39
Q

Influenza is caused by?

A

Influenza A and B are RNA viruses à Classified by their surface glycoproteins

  • Hemagglutinin (H) – surface glycoprotein that binds to epithelial
  • Neuraminidase (N) – allows entrance into cell

Influenza A:

H1, H2, and H3

N1 and N2

40
Q

Si/Sx of influenza

A

Abrupt onset fever (100 to 104°F), headache, myalgia and malaise

41
Q

Testing for the flu

A

Rapid Antigen Tests –

  • Quick results (+ or -)
  • Less specific – better sensitivity earlier on in sx)

Molecular Assay – RT-PCR tests

  • Nasopharyngeal swabs
  • More effective / specific
  • Expensive
42
Q

4 drugs approved to treat flu

A
  • Oseltamivir (Tamiflu) – tx ALL pts including pregnancy and children
  • Zanamivir (Relenza) - ag 7 and older
  • Peramivir (Rapivab) – 2 yrs and older
  • Baloxavir marboxil (Xofluza) 12 yrs and older
43
Q

flu vaccine is contraindicated in?

A
  • CI: Guillan-Barre w/in 6 wks of prior flu vaccination
  • EGG allergy is not CI!!
44
Q

Acte Bronchitis is defined as

A

Lower respiratory tract infection involving the large airways (bronchi), without evidence of pneumonia, that occurs in the absence of chronic obstructive pulmonary disease.

45
Q

complications of the flu

A

Pneumonia – primary or secondary bacterial pneumonia

Myositis – mostly legs – unknown mechanism – mostly Influenza B

46
Q

Stages of TB infection (clearance -> non clearance)

A
    1. Immediate clearance of the organism – no infection
  • majority of inhaled bacilli are trapped in the upper airways and expelled by ciliated mucosal cells (<10% reach the alveoli) - MOST COMMON

Those who do not clear the organism

    1. Primary Tuberculosis (~10%) Symptomatic - SICK
    1. Latent infection (~90%) Asymptomatic – unlikely to spread dz
    1. Reactivation disease after a period of latency
47
Q

systemic disease that is a risk factor for TB

A

CKD

Close contact (household members) – most important risk factor for TB

48
Q

si/sx of latent TB vs Active TB

A

Latent TB - ASYMPTOMATIC

  • Unlikely to spread dz
    • TB skin or blood test
  • Normal CXR
  • Normal sputum smear

Active TB - SICK – (less 10%)

  • Cough – persistent for 3 wks
  • Diurnal fevers (nighttime)
  • Hematopysis
  • Night sweats
  • Weight loss, Anorexia
  • Malaise

Findings:

  • Lung apices involved
  • Erythema nodosum
49
Q

Diagnostic tests used for Latent TB

A

T_uberculin Skin Test (TST) or Mantoux test, PPD_

  • Delayed type hypersensitivity test – can be positive if vaccinated for TB (BCG vaccination)
  • Looking for INDURATION not erythema
  • Positive >15mm

IGRA serum test – can detect latent TB vs vaccination rxn - used to confirm positive TST skin test

  • QuantiFERON TB GOLD
  • T-SPOT.TB

IF POSITIVE? -> EXCLUDE ACTIVE TB

50
Q

Tx of Latent TB

A

Rifampin and Isoniazid

51
Q

Diagnostic Tests for active TB

A

Sputum Nucleic acid amplification - Xpert MTB/RIF (Ultra)** -> IF positive then tx for TB

Sputum AFB Microscopy

Mycobacterial culture – MGIT system

52
Q

Tx of active TB

A

Intensive phase (2 mo) – RIPE

  • Isoniazid, Rifampin, pyrazinamide and ethambutol
  • pyrazinamide can be excluded due to hepatoxicity, gout or pregnancy

C_ontinuation Phase (4-7 mo)_

  • Isoniazid and rifampin
  • 7 mo if pyrazinamide excluded from RIPE
53
Q

When treating active TB it is important to monitor?

A

LFTs

Avoid Tylenol and ETOH while being treated

Peripheral neuropathy, maculopapular rashes

54
Q

Extrapulmonary TB spreads to what sites most commonly?

A
  • Lymph node (most common) à Scrofula - painless swollen LN
  • Pleural TB à pleural effusion
  • GU
  • Skeletal
55
Q

Define Miliary TB with si/sx

A

Hematogenous dissemination of mycobacterium tuberculosis

Failure to thrive

Night sweats

Fever

Dysfunction of organ systems

56
Q

Complications of TB

A
  • Pneumothorax
  • Bronchiectasis
  • Bronchiolithiasis
  • Extensive Pulmonary Destruction
  • Sepsis
  • Lung Cancer
  • VTE
  • TB Spread – extra pulmonary involvement
57
Q

CXR findings noted in TB

A

Ghon Focus - localized lymphadenopathy, usually peripheral and associated with hilar adenopathy

Cavitary reactivation of latent tuberculosis in posterior apical segment of right upper lobe

58
Q

CXR findings of Miliary TB

A
59
Q

COVID 19 Diagnostics

A

Nucleic Acid Amplification Tests (NAAT) - PCR assay from the upper respiratory tract is the preferred initial diagnostic test (highly sensitive)

Antigen Test - less sensitive then NAAT but results in <1 hour (nasopharyngeal swab)

Antibody Test - CDC does not reccommend antibody testing to diagnost acute infection

60
Q

CXR of COVID 19

A

consolidation

ground glass opacities with bilateral peripheral and lower lung zone distributions with peak severity 10-12 days after onset

may be normal in early or mild disease

61
Q

Chest CT

A

bilateral wih peripheral distribution and involve lower lobes

ground glass opacities -83%

ground glass opacifications with mixed consolidation - 58%

adjacent pleural thickening - 52%

interlobal septal thickening - 48%

air bronchograms - 46%

62
Q

COVID 19 lab features associated with worse outcomes

A

Lymphopenia*

D-Dimer

63
Q

Define “pulmonary nodule”

A

A lesion that is both within and surrounded by pulmonary parenchyma. (also called ‘coin’ lesion)

Less than 3 cm in size and not associated with atelectasis or lymphadenopathy.

•A lesion > 3 cm in diameter is called a mass.

64
Q

Benign Causes of pulmonary nodule

A

Infectious granulomas comprise about 80% of all benign nodules. (Histoplasmosis, coccidiomycosis, mycobacterium.)

Inflammatory nodules comprise 10 % of benign nodules

(Rheumatoid, Wegener granulomatosis, Sarcoidosis.)

Hamartoma – 10% of benign tumors. Benign tumors of the lung that are comprised of cartilage, fat, muscle.

(‘Popcorn’ calcification)

65
Q

Larger lesions are more likely to be (benign / malignant)

A

malignant

66
Q

compare and contrast benign vs malignant pulmonary lesions

A

Border:

  • Malignant lesions will have a more irregular or spiculated border.
  • Benign lesions will have a smooth and discrete border.

Growth:

  • Lesions that are malignant tend to have an interval increase in size between 4-6 months.
  • Therefore, nodules that grow very rapidly are more likely benign.
  • Air Bronchogram
67
Q

risk factors for development of lung cancer

A
  • Smoking: 85-90% *Packs/yr (20-25 cigarettes in a pack)
  • Occupational/Environmental
  • Radon, Asbestos, Wood smoke, Diesel exhaust, Air pollution
  • Genetic Factors/Family History
  • Benign lung disease (Fibrosis, COPD, Alpha-1 antitrypsin deficiency, TB)
  • Ionizing Radiation
  • *Second-Hand Smoke/Third hand smoke
68
Q

Most common type of lung cancer – especially in nonsmokers

A

Adenocarcinoma

  • Adenocarcinoma in situ
  • Minimally invasive adenocarcinoma
  • Invasive adenocarcinoma
69
Q

commonly found in the lung periphery,

persistent subsolid nodules have a much slower growth rate

carry a high risk of malignancy

what type of pulmonary lesion??

A

Adenocarcinoma

70
Q

define the TNM stage

A

TNM Stage -> guide therapy

  • Local (T= Tumer)
  • Regional (N = nodes)
  • Distant (M = Metastasis) à stage IV
71
Q

lung cancer that occur Centrally and are classically associated w/ a Hx of smoking!!!

A

Squamous cell Carcinoma

72
Q

imaging of squamous cell carcinoma shows

A

extensive central necrosis and cavitation

73
Q

Type of lung cancer almost exclusively found in smokers and most common in heavy smokers.

A

Oat Cell (Small Cell)

74
Q

small cell lung cancer is described as

A

Poorly differentiated neuroendocrine tumor that commonly occurs as a large hilar mass with bulky mediastinal adenopathy.

Has a rapid doubling time, high growth fraction, and early development of widespread metastases.

75
Q

Dx of Small Cell lung cancer

A

Two stage system:

•Limited Disease: Disease confined to the ipsilateral hemithorax and within a single radiotherapy field

•Extensive Disease: Metastatic disease outside the ipsilateral hemithorax

•At presentation: 60-70% of patient will have extensive stage; 30-40% will have limited stage.

76
Q

prognosis of small cell lung cancer

A

Much more fatal

Limited Disease: 15-20 months - 5 yr survival: 10-13%

Extensive Disease: 8-13 months - 5 yr survival 1-2 %

77
Q

Malignant epithelial neoplasm lacking glandular or squamous differentiation that usually presents as large peripheral mass with prominent necrosis

A

Large Cell

78
Q

how large cell lung cancer is diagnosed

A

Usually a diagnosis of exclusion, to include all poorly differentiated NSCLCa that are not further classifiable.

79
Q

Diagnosis of large cell lung cancer includes what type of tests

A
  • CT guided needle biopsy
  • Bronchoscopy +/- Lavage
  • Endobronchial Ultrasound biopsy (EBUS)
  • Video-assisted Thoracoscopic Surgery (VATs) biopsy
  • Thoracentesis
80
Q

neuroendocrine differentiation

  • made up of peptide and amine producing cells.
  • They appear throughout the body: GI tract, Thymus, lung, and ovaries.
A

Carcinoid tumors

81
Q

most common primary lung neoplasm in children.

A

carcinoid

82
Q

si/sx of carcinoid lung cancer

A

indolent clinical behavior.

Cough

Wheeze

Hemoptysis

Recurrent Pneumonias ***

Asymptomatic

Carcinoid syndrome- rare with bronchial carcinoid.

Acromegaly

Bronchial obstruction à lung deflates

83
Q

2 cell types in carcinoid tumors

A

They are comprised of two main cell types:

  • Typical carcinoid have an excellent prognosis and are about 4 x more common than atypical.
  • Atypical carcinoid have a greater tendency to metastasize
84
Q

how carcinoid tumors appear on imaging

A

Tumors appear as round, ovoid opacities and may be hilar or perihilar.

Commonly arise in the proximal airways causing bronchial obstruction

85
Q

Tx of carcinoid tumors

A

En bloc surgical resection is the treatment of choice.

non surgical candidates, intraluminal, bronchoscopic resection

86
Q

prognosis of carcinoid tumors

A

Typical – more common and better prognosis

Atypical – greater tendency to metastasize

metastatic carcinoid, the role of chemotherapy and radiation therapy is limited.

87
Q

List the most common malignancies that metastasize to the lung

A

Malignant melanoma

Sarcomas

Carcinomas of the:

  • Breast
  • Kidney
  • Bladder
  • Colon
  • Prostate

Clin Med II Final - PULM and Critical Care (3 decks)

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