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ICM2 > Pulm/Peds > Flashcards

Pulm/Peds Flashcards

1
Q

Normal pH, PaCO2, and PaO2

A

7.4, 40, 100

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2
Q

Allen test

A

Check for upper extremity arterial perfusion by occluding both radial and ulnar aa

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3
Q

Metabolic acidosis causes

A

Increased anion gap: Lactic acidosis, Ketoacidosis, Drug poisoning (Aspirin, Ethylene glycol, Methanol) = MULEPAKS
Normal anion gap: HARDUP = Diarrhea, Renal tubular acidosis, Interstitial nephritis

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4
Q

Metabolic alkalosis causes

A

Cl- responsive: Contraction alkalosis, Diuretic use, Corticosteroids, Gastric suctioning or Vomiting
Cl- resistant: Hyperaldosterone state, Hyperventilation

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5
Q

Respiratory acidosis PaCO2 and pH

A

Low pH and High PaCO2

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6
Q

Respiratory alkalosis PaCO2 and pH

A

High pH and Low PaCO2

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7
Q

How can alveolar-arterial gradient show signs of lung problems

A

Alveolar-arterial oxygen gradient is ELEVATED when gas diffusion is impaired
A-a = Alveolar O2 (i.e. atmospheric O2) - arterial O2
Expected normal = Patient age/4 + 4A-a = 0.21(760 atm P - 47 tracheal water vapor P) - PaCO2/(0.8 respiratory quotient) - PaO2

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8
Q

Things limiting O2-Hb dissociation

A

Alkalosis
Hypothermia
Low PCO2
Low 2,3-DPG

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9
Q

Normal PaO2:FiO2

Dissolved to inhaled O2 ratio

A

On room air = 100/0.21 = ~475
Increasing FiO2 won’t fully correct hypoxia from a shunt, i.e. If a patient is on an oxygen canula, this should be much lower

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10
Q

Meaning of decreased and increased V/Q ratio

A

Decreased V/Q = better perfusion than ventilation = shunt (Emphysema, fibrosis, edema)
Increased V/Q = worse perfusion than ventilation = dead space (PE, trachea)

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11
Q

Most air and blood in lungs goes where?

A

Bases of lungs

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12
Q

Pulmonary function tests (PFTs)

A

Spirometry
Lung Volumes
Diffusing capacity

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13
Q

So why are PFTs useful?

A

Explain Dyspnea (Asthma vs VCD)
Hypoxemia etiology (COPD vs Vascular disease)
Follow disease over time (FVC test)
Pre-op testing

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14
Q

FEV1 definition, use

A

Forced expiratory volume in first second, used for FEV1/FVC ratio
Most reproducible flow rate measurement over time
Can give bronchodilator and repeat 15m later in asthma diagnostics
If FEV1/FVC less than 70% = OBSTRUCTION

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15
Q

Obstructive pulmonary diseases

A

Air can’t get out

Asthma, emphysema, chronic bronchitis

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16
Q

Restrictive pulmonary diseases

A

Air can’t get in (restrictive = reduced volume)

Pulmonary fibrosis, Hypersensitivity pneumonitis, Sarcoidosis, Silicosis, Neuromuscular (e.g. ALS)

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17
Q

Variable extrathoracic obstruction (laryngeal cancer) pulmonary cycle

A

Flattening of flow rate on inspiration

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18
Q

Variable intrathoracic obstruction (lung cancer) pulmonary cycle

A

Flattening of flow rate on expiration

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19
Q

Fixed obstruction (intra- or extrathoracic) pulmonary cycle

A

Flattening of flow rate on both inspiration and expiration

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20
Q

Tests for lung functional volume

A

Nitrogen washout and He dilution

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21
Q

COPD pattern of FVC vs TLC

A

Low FVC and High TLC

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22
Q

Diffusing capacity test, what affects it

A

DLCO: breathe in CO, see how much diffused in
DLCO = Kco * Va (Equilibrium CO coefficient * alveolar volume)
Membrane thickness, Lung volume, Air trapping, Carboxyhemoglobin

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23
Q

Stridor

A

Inspiratory sound from turbulent flow below or in the larynx

Extrathoracic obstruction, better with expiration

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24
Q

Stertor

A

Sound from turbulent flow above larynx (snoring)

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25
Q

Ronchi and crackles

A

Same sound
Alveoli popping open on inspiration due to fluid consolidation
Fine crackles = acute, pneumonia, edema
Velcro crackles = fibrosis

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26
Q

Rales and wheezes

A

Same sound
Musical expiratory sound from airway constriction
Intrathoracic obstruction
Improved by inspiration

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27
Q

Rub

A

Pleural sound on either inspiration or expiration
Due to fluid or fibrosis in pleura
To differentiate from cardiac rub, ask patient to change position or hold breath

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28
Q

Variable extrathoracic obstruction shows what on respiratory flow cycle?

A

Flat flow rate on inspiration

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29
Q

Variable intrathoracic obstruction shows what on respiratory flow cycle?

A

Flat flow rate on expiration

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30
Q

Bronchiolitis usually due to … ?

Treatment?

A

RSV

Supportive O2 and IV fluids

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31
Q

Croup pathophys, sound, causes

A

Laryngotracheitis
Seal-bark cough, hoarseness, stridor
Parainfluenza, RSV

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32
Q

What tests should be ordered for pediatric pneumonia outpatients?

A

Pulse ox, Flu testing, Mycoplasma IgM
Consider CXR in some circumstances
Blood cultures if patient deteriorates or doesn’t improve

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33
Q

COPD definition, diseases

A

Preventable and treatable disease with persistent airflow limitation and inflammation of airways
Umbrella term for progressive lung diseases like:
Emphysema - ‘pink puffer,’ thin, dyspnea
Chronic bronchitis - ‘blue bloater’ w/ elevated Hb
Irreversible asthma
Severe bronchiectesis

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34
Q

Pathophys of COPD

A

Small airway disease - inflammation, fibrosis, plugs = up resistance
Parenchymal destruction - alveolar walls destroyed

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35
Q

Most common COPD causes

A

Tobacco - question diagnosis w/o smoking in history
Occupational exposure
Also a1-antitrypsin deficiency

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36
Q

COPD symptoms

A

Shortness of breath
Chronic cough
Sputum

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37
Q

COPD diagnosis

A

Use spirometry tests - for detecting obstructive lung disease (COPD and asthma)
If FEV1/FVC is low, then obstructive disease
How low FEV1 is by itself determines severity

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38
Q

Restrictive disorder spirometry results

When to perform?

A

Low FVC, TLC, FEV1
But normal or high FEV1/FVC
Only perform outpatient when patient is stable

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39
Q

COPD comorbidities

A 
CV disease
Osteoporosis
Respiratory infxn
Anxiety, depression
DM
Lung cancer
Bronchiectasis
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40
Q

Additional COPD tests besides spirometry

A

CXR - for excluding other diagnoses
Lung volumes, diffusing capacity - for determining severity
Oximetry, ABG - need for supplemental O2
a1-antitrypsin deficiency screening - Perform if under 45y or when strong FH of COPD
Exercise testing

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41
Q

COPD therapy - general, pharmacological, surgical

A

Smoking cessation and supplemental O2 (24h/d) most helpful
Exercise
Flu, pneumococcal vaccines

b2-agonists (1st for asthma)
Anti-cholinergics (1st for COPD)
Steroids

Lung volume reduction surgery
Lung transplantation

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42
Q

Reasons for COPD exacerbation

A 
Infxn - give abx at first signs to prevent pneumonia
Pulmonary edema
PE
Pneumothorax
Arrhythmia
Exposure
Non-compliance
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43
Q

Varenicline mechanism, use

A

(Chantix)
Nicotine partial receptor agonist
Eases craving, withdrawal
Greatest smoking cessation success

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44
Q

Stop smoking methods

A

Nicotine replacement therapy (Patch, gum, lozenge, inhaler, nasal spray)
Buproprion
Varenicline

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45
Q

Buproprion mechanism

A

NE, dopamine reuptake inhibitor for nicotine cessation

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46
Q

Common newborn skin findings

A

Most infants are well, resolve quickly with these:
Gelatinous skin, esp. if pre-term
Seborrhea (“Cradle cap”)
Transient neonatal pustular melanosis
Sucking blister/Mongolian spot = hyperpigmentation may result
Acropustulosis of infancy
Milia - keratin cysts that resolve
Cutis marmorata
Erythema toxicum
Neonatal acne
Port-Wine-Stain = may have underlying neuro issues

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47
Q

Common newborn head findings

A

Cephalohematoma - subperiosteal, may calcify
Caput secundum - superficial edema
Intracranial hemorrhages - ultrasound through fontanelles

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48
Q

Common newborn eye findings

A

Congenital glaucoma = up IOP, abnormal angle between cornea and iris
Nasolacrimal duct obstruction/stenosis = pus near eye
“Leukocoria” = retinoblastoma, congenital cataract

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49
Q

Common newborn ENT findings

A

Low-set ears (top 1/3 should be level w/ eye) = genetic disorders
Choanal atresia if non-patent nares
Cleft lip or palate - may have bifid uvula
Epstein’s pearls = benign cysts on palate

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50
Q

Common newborn chest findings

A

Clavicles - broken from delivery
Chest asymmetry, or pectus abnormalities
RR 30-60, may be periodic from under-developed respiratory centers
Distress = Tachypnea, nasal flaring, acc mm use, grunting, cyanosis, GROUND GLASS appearance on CXR (pre-terms w/ low surfactant)

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51
Q

Common newborn abdominal findings

A

Palpable liver normal
Hydronephrosis most common abdominal mass
Umbilical hernia - diastasis recti - usually resolve before 1y

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52
Q

Common newborn extremity findings

A

Check for hip dysplasia:
Barlow = downward pressure on hips
Ortoloni = abduct hips
Checking for clicks, lumps

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53
Q

Common newborn GU findings

A

Ambiguous genitalia - check renal system by ultrasound

Hypospadias

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54
Q

Common newborn back findings

A

Hair tuft or sacral dimple = may indicate occult spina bifida

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55
Q

Common newborn neuro findings

A

Moro reflex = extend extremities when fall simulated
Plantar and palmar grasp
Rooting response = turn cheek towards stimulus
Suck reflex
Stepping response
Will have (+) Babinski and some clonus initially
Asymmetric tonic neck reflex = “Archer pose”

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56
Q

Trisomy 21 (Down’s) newborn findings

A

Upslanted palpebral fissures
Flat nasal bridge
Protruding tongue
Low-set ears
Brushfield spots on iris (bright, around border)
Simian crease (1 transverse crease on hand)
Large sandal gap between toes 1-2
Thick nuccal fold
Hypotonia (check by raising kid by arms, head won’t follow)

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57
Q

Trisomy 13 (Patau) findings and survival

A

6m survival

Cleft lip, clenched hand, overlapping fingers, polydactyl, clubfoot, heart defects

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58
Q

Trisomy 18 (Edwards) findings and survival

A

Survival to school age

Prominent occiput, low-set ears, clenched hand, rocker bottom feet, severe heart defects

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59
Q

Breastfeeding guidelines

A

Exclusively breastfeed for 6m, then add solid foods
Few CIs: HIV, HTLV-1, TB, alcohol/drugs, active VZV or HSV in mother; Galactosemia in infant
Birth weight should be regained by 10d

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60
Q

Stool progression

A

Meconium initially
Greenish w/ some residual meconium for first wk
Yellow curdish stool w/ regular breastfeeding

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61
Q

Newborn jaundice causes, complications

A

Related to breakdown of fetal RBCs - should clear in a few days
Neuro dysfunction induced when over 25-30mg/dL - more common w/ liver diseases:
Acute bilirubin encephalopathy and Kernicterus (permanent sequellae)
Emergent if jaundiced in first 24h

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62
Q

Things to check w/ ‘Well Child’ checks

A

Height, weight, head circumference, BMI

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63
Q

Signs of child abuse

A

Magical injuries
History doesn’t explain injury or time course
Treatment delay

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64
Q

DDx for milestone losses

A

Inborn metabolism error
Brain tumor
Neurodegenerative disorder

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65
Q

Craniosynostosis

A

Premature fissure closure = abnormal pathologic skull shape

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66
Q

Developmental milestones

A 
3m = Raise head and chest when on stomach, Social smile
6m = Sit unassisted
7m = Respond to name, no
9m = Pincer grasp
12m = Walking on toes
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67
Q

“Fifth disease”

A

Erythema infectiosum from human parvovirus B19

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68
Q

Varicella incubation, progression, appearance

A

14d incubation
New vesicles for 4d
“Dew drop on a rose”

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69
Q

Rubeola common name, incubation, prodrome symptoms, sign, complications

A

Measles
10-14d incubation
Prodrome of 3Cs = Cough, Coryza, Conjunctivitis
Koplik’s spots on buccal mucosa 2d before rash over face spreading to trunk and extremities
Complications: Respiratory infections, encephalitis

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70
Q

Rubella common name, time course, symptoms, sign, complications

A

German measles
3d course
Pinpoint rash starts on face, progresses over trunk, extremities
Forchheimer spots = palatal petechiae
Complications: Acute encephalitis, thyroiditis
Most dangerous as congenital syndrome (Purpuric rash, hearing loss, mental retardation, CV and ocular defects)

71
Q

Erythema infectiosum cause, incubation, progression, complications

A

Due to parvovirus B19
Incubation 7-14d
Slapped cheeks -> Fishnet erythema -> Rash recurrence after resolution
Non-blanching rash
Complications: Arthropathy, birth defects, aplastic crisis in those w/ hemolytic disorders or IC’d patients

72
Q

Roseola infantum cause, incubation, course

A

HHV-6,7
Incubation 5-15d
High fever for 3-4d, but child feels fine -> Macular rash appears as fever disappears

73
Q

Hand-Foot-Mouth disease

A

Coxsackie virus A16 or Enterovirus A71
Incubation 3-6d
Sore lesions (chancre-like) in mouth and on tongue, some on hands and feet
Lasts 7-10d

74
Q

Coxsackie (A esp, sometimes B) viruses cause what?

A

Herpangina:
Young children
Prodrome: Sore throat, fever
Painful ulcer lesions on tonsils/uvula/palate

75
Q

Classic childhood exanthems and causes?

A 
I = Measles (Rubeola)
II = Scarlet Fever (GABHS)
III = Rubella (German measles, togavirus)
IV = Filatow-Dukes disease (Obsolete)
V = Erythema Infectiosum (Parvovirus B19)
VI = Roseola Infantum (HHV-6,7)
76
Q

Asthma risk factors

A

Genetics, Male, Hyperresponsive airway, Atopy

Allergen and irritant exposure (dust, smoke), Respiratory infxns

77
Q

Asthma pathology

A

Airway inflammation and Bronchial smooth muscle hyperreactivity

78
Q

Cholinergic system role in asthma

A

ACh binds M3 receptors on airway smooth muscle -> Bronchoconstriction
M2 autoreceptors on presynaptic cholinergic neurons limit ACh release when ACh binds

79
Q

Atopy usually manifests w/ what responses?

A

Allergic rhinitis, Asthma, Hay fever, Eczema

80
Q

Rescue treatment for asthma when no other is available?

A

Activate SNS somehow to cause Epi release, e.g. get in a car wreck
“But this is hard to titrate”

81
Q

Asthma symptoms

A

Coughing, Wheezing, Shortness of breath, Chest tightness

82
Q

Asthma signs

A

Wheezing, Thoracic hyperexpansion, Nasal secretions/polyps, Atopy signs

83
Q

Asthma spirometry

A

Obstructive defect reversible w/ a bronchodilator

FEV1/FVC ratio low, then normal w/ bronchodilator

84
Q 
Asthma treatments (3 classes)
Avoid doing what?
A

Long-term control = Inhaled corticosteroids to limit inflammation (Acute oral dose may help contain additional symptoms)

b2-agonists:
Generally short-acting for rescue = Albuterol/Levalbuterol
Some are long-acting for most of 1d = Salmeterol/Fometerol, used w/ steroids

DON’T USE LONG-ACTING b2-AGONISTS ALONE -> develop tolerance, limits effectiveness of rescue inhaler. Use w/ inhaled corticosteroids

Leukotriene receptor antagonists (Montelukast, Zafirlukast) limit inflammation and secretions. Good for allergies too.

85
Q

Status asthmaticus, signs, treatments

A

Asthma attack unresponsive to b2-agonists = Need urgent evaluation
Silent chest = No air movement = Bad news

Treat w/ upright position, O2, Albuterol x3, IM steroid injection, Ipratroprium nebulizer (anti-ACh), Subcu Epi, IV Terbutaline (b-agonist

May need to intubate for mechanical ventilation, induce w/ KETAMINE (bronchodilatory properties)

86
Q

Causes of wheezing

A 
Asthma
Pulmonary edema
Allergy
Pneumonia
Foreign body aspiration
87
Q

Gold standard for diagnosing pneumonia

A

CXR

But may be negative - still suspect pneumonia if convincing H&P

88
Q

Pneumonia causes

A

Immunodeficiency (i.e. HIV)
TB
Community-acquired pneumonia, Ventilator-AP, Hospital-AP, HealthCare-AP

89
Q

Pneumonia: CURB-65

A

Confusion, Uremic, Respiratory rate over 30, BP below 90/60, Age over 65
If at least 2 of these -> Patient should stay in hospital
Consider ICU admission if at least 3 and bad vitals

90
Q

Considerations for pneumonia treatment

A

Antibiotics should always cover Strep pnumonia if cause is not specifically identified
Should also consider covering CA-MRSA
Usually need to empirically treat within 4h

91
Q

Best marker for determining sepsis treatment

A

Procalcitonin (PCT) - Guides both when to start and stop antibiotics for inpatients w/ sepsis due to pneumonia
0.5mcg/L is the level recommended for starting (over) and stopping (under)

92
Q

Pneumonia associations

A

Bronchiogenic carcinoma patients may initially present w/ pneumonia

93
Q

When to followup w/ pneumonia patients

A

CXR 4-6w later for all patients over 40 and those who do or have smoked

94
Q

Complications of overdiagnosis and overtreatment of pneumonia
What to do instead?

A

Unnecessary C. diff colitis

Make sure to use appropriate antibiotics strongly and early, then de-escalate when possible

95
Q

Pneumonia treatments

A

If no disease in last 3m: Macrolide/Doxy
If some complicating disease, infxn, or factor: Respiratory quinolone OR b-lactam + Macrolide/Doxy
If inpatient: Respiratory quinolone OR Ceftriaxone + Azithro/Doxy
If ICU: Ceftriaxone (Aztreonam if allergic) + IV Azithro/Respiratory quinolone - NEVER MONOTHERAPY IN ICU

96
Q

Pneumonia prevention

A

Smoking cessation
Influenza vaccine - live for 2-49y, inactive for IC’d and healthcare workers
Pneumococcal vaccine - 13- and 23-valent for elderly and IC’d

97
Q

Common signs, associations w/ different types of lung cancer

A

Smoking
Chronic non-productive cough w/ occasional hemoptysis
Mass (over 3cm)/nodule on imaging
Wheezing, Stridor, Dyspnea, Hoarseness
Neurologic
Nail clubbing
SVC syndrome from R lung mass - Upper edema

Metabolic - Cushing’s syndrome in small cell or bronchial carcinoid
SIADH in small cell
Hypercalcemia, hyperinsulinemia w/ squamous cell type
Gynecomastia w/ large cell carcinoma

98
Q

Small cell carcinoma appearance, sites, treatment

A

Lympocyte-like carcinoma = round, oval nuclei
Combined cell type often (small cell plus adeno-, squamous, or large cell types)
Most are proximal lesions
Often already metastasized once detected
Neurosecretory granules

Chemo and radiation
Surgery not possible

99
Q

Lung cancer causes

A

Smoking - nicotine not carcinogenic, but lots of carcinogens in smoke - Number, duration, age of initiation, depth of inhalation, tar/nicotine levels in cigarettes
Similar alterations caused from smoking other drugs

Atmospheric pollutants:
Nickel, Chromium, Arsenic compounds
Benzpyrene, Chloromethyl ether (esp. small cell)
Radioactive material, e.g. Radon (small cell)
Asbestos
Mustard gas
Iron/silica exposure

Genetic: Loss of short arms of chr3 or chr11

100
Q

Common types of lung cancer

A 
Non-small cell:
Squamous cell carcinoma (20%)
Adenocarcinoma (38%), including:
Bronchoalveolar carcinoma (3-4%) - presents as pneumonia that doesn't resolve
Large-cell carcinoma (5%)
Small-cell (13%)
Carcinoid tumor (1-4%)
101
Q

Why does cancer kill patients?

A

Cancer cells invade and compromise vital structures

OR Cancer makes patient hypercoagulable -> Throw thromboemboli -> Death from large PE

102
Q

Adenocarcinoma origin, causes, metastasis

A

Probably arises from mucin-secreting cells in peripheral bronchi
Caused by exogenous carcinogens, interstitial fibrosis, scleroderma
Often metastasizes to liver, adrenal (include in chest CTs), bone, brain

103
Q

Squamous cell carcinoma origin, appearance

A

Usually from large bronchi mucosa = proximal, hilar lesions
Mucosal lining most susceptible
Hyperplasia of mucin-secreting columnar epithelial cells -> Replacement w/ metaplastic stratified squamous epithelium

104
Q

Large cell carcinoma cell appearance, site and appearance, treatment

A

Undifferentiated
Usually limited to periphery, similar to adenocarcinoma
Usually large, peripheral, can be treated surgically

105
Q

Carcinoid tumor name, site, markers, symptoms, imaging, treatment

A

Bronchial adenoma
Submucosal gland lesions in bronchial wall
Rapid growth and invasion of surrounding structures - highly vascular
Neuroendocrine markers, dense core granules

Symptoms of hemoptysis, pulmonary infections, dyspnea
CXR shows pneumonia, hilar mass, or a rare peripheral nodule
DO NOT BIOPSY due to hemorrhage risk, just remove it

106
Q

Hamartoma appearance, cells, treatment

A

Benign tumor of disorganized normal lung elements
No capsule, but lesion is round and sharply defined
Biopsy to eliminate malignant cancers from DDx
“Shells out”
Usually remove if peripheral

107
Q

TNM lung cancer staging, important demarcations

What is surgically resectable?

A

Define wrt local extent of the Tumor, regional lymph Nodes, and distant Metastasis

T2 - Larger than 3cm, but at least 2cm from carina
T3 - Larger than 7cm, within 2cm of carina

N2 - Ipsilateral mediastinal and/or subcarinal LN involvement

M1 - Distant metastasis present (Always Stage IV)

Stage IIIA and earlier often surgically resectable (T3, N2, M0)

108
Q

Pancoast syndrome cause, symptoms

A

Neoplasm in lung apex
Shoulder, arm pain, weakness
Hoarseness
Horner’s syndrome (Miosis, Ptosis, Anhydrosis)

109
Q

Skin manifestations of lung cancer, association

A

Acanthosis nigricans - brownish hyperpigmentation

Common w/ bronchial adenocarcinoma

110
Q

Vascular manifestations of lung cancer

A

Thrombophlebitis, Recurrent or migratory arthritis, PE, Non-bacterial endocarditis

111
Q

Lung cancer diagnostic tests

A

Cytology of sputum for centrally located tumors
CXR, CT
PET
Bronchoscopic biopsy

112
Q

Lung cancer treatments

A 
Radiation therapy
Radiofrequency ablation
Surgery for Stages I and II (Adjuvant chemo/rad w/ S2)
Chemotherapy/Radiation for S3
Chemo or targeted therapy for S4
113
Q

Mesothelioma cause, presentation, gross appearance

A

Asbestos exposure
Dyspnea, chest pain
Neoplastic growth surrounds and encases lung, invades neighboring pleura, pericardium

114
Q

TB growth rate, affect on treatment, antibiotics, contagiousness

A

One division per 20h = hard to kill since most antibiotics target more rapidly dividing organisms, cultures take 3-6w
Streptomycin = first treatment, targets ribosomes
Isoniazid = targets cell wall, ups host NO
Close contact and active disease usually needed for transmission, antibiotics make hosts noninfectious

115
Q

TB risk factors

A

Host: Substance abuse, malnutrition, cancer, DM, gastric bypass surgery, HIV, steroid use, TNF inhibitors

Environmental: Household contacts, born in an endemic area, low socioeconomic class = crowded community w/ poor sanitation

116
Q

When people present w/ TB

A

Infants, adolescents, elderly, HIV

117
Q

TB infection signs

A 
Initial:
Fever lasting weeks
Pleuritic chest pain, substernal pain from enlarged LNs
CXR signs occasionally
POSITIVE PPD

Reactivation and disseminated disease occurs rarely in those who aren’t IC’d:
Fever, night sweats, weight loss, fatigue
Sepsis, meningitis, pericarditis, skeletal disease, UTI
Cough, dyspnea, hemoptysis, pneumothorax
May have pulmonary crackles, clubbing

118
Q

TB labs

A

Often normal early
High CRP
CXR w/ bilateral upper lobe infiltrates, cavities, but may be normal
CT more sensitive

119
Q

PPD test

A

Inject TB protein subcutaneously
If positive -> Large diameter of indurated skin at site
False positives w/ previous vaccination, other mycobacterial infection
False negatives w/ advanced HIV, IC’d, or active infxn (no CD4 response yet)

120
Q

Active TB diagnostic test

A

Acid-fast stain or fluorescent stain

121
Q

Latent TB treatment

A

Prevent reactivation and spread, especially in those who might expose many others
Isoniazid for 9m, add vitamin B6 for preventing neuropathy, scan liver enzymes for hepatitis signs
Alt: Rifampin 4m, but not as effective

122
Q

Active TB treatment

A

All get 4Rx combo until cultures and sensitivities are determined: Isoniazid, Rifampin, Pyrazinamide, Ethambutol for 2m, tailor therapy after 2m
Once sputum smears are negative, treat another 4m with Isoniazid and Rifampin
Fluoroquinolones may also be used

123
Q

TB vaccine

A

BCG vaccine - based on attenuated M. bovis

Common, but old and needs updating

124
Q

Interstitial lung disease causes, affected tissues

How to identify?

A

Most often idiopathic - lots of tissues may be affected
Exposures - chicken coops, silica, smoking

Disease of interstitium: fibrous septae (most commonly affected tissue = interstitial pulmonary fibrosis), alveolar walls, lymphatics, capillaries

H&P: Exposure history, Velcro rales, dry cough
Use CT scans

125
Q

Pulmonary fibrosis association, findings, pathophysiology, presentation timing

A

Associated w/ smoking
Bibasilar inspiratory crackles, Clubbing, Dyspnea, Cough, Restrictive pathology (Low Total Lung Capacity)
Symptoms start about 6m before clinical presentation

126
Q

Monitoring ILD progression monitoring, treatment

A

Pulmonary function tests
6min stress tests
O2 requirement

No response to steroids, smoking cessation
Periods of rapid clinical deterioration will occur
Clinical trials: Pirfenidone, Nintedanib

127
Q

Causes of granulomatous lung diseases

A 
Infections (TB)
Sarcoidosis
Hypersensitivity pneumoitis
Wegener's granulomatous
Reaction to tumors, foreign bodies
128
Q

Key features of granulomas

A

Discrete
Avascular
Epithelioid histiocytes

Necrotic:
Caseous = TB
Abscess-like granuloma = Fungi
Degeneration/Fibrosis = Wegener’s, necrotising sarcoid, Churg Strauss, Rheumatoid nodule

Non-necrotic:
W/o interstitial inflammation: Sarcoid
W/ interstitial inflammation: Hypersensitivity pneumonitis

129
Q

Radiologic appearance of sarcoidosis

A

I: Bihilar lymphadenopathy
II: Pulmonary infiltrate w/ BHL
III: PI w/o BHL
IV: Honeycombing

130
Q

Sarcoid treatments

A

I: None

II-IV: Steroids usually

131
Q

Histiocytosis X mechanism, histo, pathology, findings, treatment

A 
Mononuclear phagocyte system disorder = accumulation
X bodies in cytoplasm
Small cysts
Mixed obstructive/restrictive pathology
Quit smoking
132
Q

Eosinophilic granuloma history

A

Mononuclear phagocyte system disorder = accumulation
20-40yo smoker
Non-productive cough, dyspnea, pleurisy

133
Q

Wegener’s granulomatosis triad, test and physical findings, CT, treatment, course

A 
Necrotising granulomas in URT, LRT later + Glomerulonephritis + Generalized necrotising vasculitis
c-ANCA positive
Cavitated pulmonary nodules in any zone
Saddle nose
High-dose corticosteroids
Frequent relapses
134
Q

Hypersensitivity pneumonitis cause, prognosis

A

Due to exposure = Remove exposure

Poor prognosis w/ chronic exposure

135
Q

Lymphangioleiomyomatosis demographic, symptoms, associations, CT

A

Pre-menopausal women
Dyspnea, pneumothorax, cough, pleurisy, hemoptysis
Associated w/ renal angiomyolipomas and tuberous sclerosis
Multiple thin-walled cysts w/ even lung distribution

136
Q

How to evaluate ILD

A

Extensive history of age, gender, comorbidities, smoking, occupation, hobbies, pets, FH, duration of symptoms
Physical exam, labs, imaging, PFT

137
Q

What two diseases don’t happen in smokers?

A

Sarcoidosis

Ulcerative colitis

138
Q

PE findings w/ ILDs

A

Inspiratory crackles
Cardiac murmur, edema
Clubbing
Rash, arthritis, skin changes

139
Q

Use of bronchoscopy in ILDs

A

Rule out infxn - Don’t give immunosuppressants if the patient has one!

140
Q

Causes of interstitial shadowing on CXR

A

Lung parenchymal disease
Cardiogenic pulmonary edema (Cardiac hypertrophy, or if MI)
Compare to old scans to make sure

141
Q

When to refer IPF patients for lung transplant

A

IPF patients = progressive, irreversible disease -> Refer early (worst survival while waiting)
COPD patients = Not as progressive, must maximize therapy and limit risk factors before referral
CF = early for bilateral replacement

Age limits = must be younger than 65yo

142
Q

Typical volume of pleural fluid

A

5-25mL

143
Q

Physiological causes of pleural effusion (3)

A

Increased drainage of fluid into pleural space
Increased production of fluid by cells in the pleural space
Decreased lymph drainage of fluid from the pleural space

144
Q

Diseases causing pleural effusion, mechanism

A 
CHF = Up pulm capillary pressure = Transudate
Pneumonia = Up pulm capillary permeability = Exudate
Atelectasis = Up intrapleural pressure
Hypoalbuminemia = Down oncotic pressure = Transudate
Malignancy = Down pleural membrane permeability or Lymph blockage = Exudate
145
Q

Pleural effusion physical findings

A

Dyspnea, pleurisy, cough

Dullness to percussion, decreased tactile fremitus, asymmetric chest expansion, decreased breath sounds, egophony

146
Q

Tests for pleural effusion, what to watch for?

A

CXR, US, CT, pleurocentesis

Does shadow move w/ changes in position (upright vs. supine vs. decubitus)

147
Q

How to differentiate between total atelectasis and massive pleural effusion?

A

Are heart/mediastinum shifted away from (effusion) or towards (atelectasis) pathology?

148
Q

Thoracentesis indications, complications

A

Pleural effusion w/ unknown etiology
Therapeutic for symptomatic relief
Air-fluid level in pleural space
Concern for empyema, parapneumonic effusion, hemothorax, malignancy

Determine if transudate/exudate

Pneumothorax, re-expansion of pulmonary edema, malignant seeding
DON’T PERFORM if elevated INR to avoid bleeding

149
Q

Where to perform thoracentesis

A

Upper border of lower rib

150
Q

Diseases w/ Low glucose and low pH in pleural fluid

A

RA, malignancy, empyema, esophageal rupture, TB

151
Q

Causes of chylothorax vs pseudochylothorax

Appearance?

A

Chylo = Trauma, malignancy (acute, normal pleural surface, normal cholesterol)
Pseudo = Chronic effusion, usually TB or RA (fibrous pleura, high cholesterol)
Both are milky in appearance

152
Q

Chest tube indications

A

Empyema, hemothorax, parapneumonic effusion, malignant effusion

153
Q

Transudate vs. Exudate classification

A

Transudate if ALL THREE of these are true:
Pleural fluid protein : serum protein ratio 0.5 at most
Pleural fluid LDH : serum LDH ratio 0.6 at most
Pleural fluid LDH below 2/3 of serum LDH or 200 at most

154
Q

RDS CXR appearance

A

Diffuse ground glass appearance through whole lung fields

155
Q

Cause of RDS

A

Surfactant deficiency, usually in preterm babies -> Poor compliance, atelectasis, increased breathing work, hypoxia

156
Q

RDS risks

A

Fetal hyper insulinism/IDM impedes production
Males, whites worse
Multiple gestation

157
Q

When does surfactant start appearing?

A

When Type II alveolar cells are present at 20w

No viable lung tissue before this time

158
Q

Surfactant makeup, manufacture

A

90% lipid, 8% protein
Phosphatidylcholine - hydrophilic head, two hydrophobic tails, saturated and unsaturated
SP-A,B,C,D
Made in T2 alveolar cells SER, stored in lamellar bodies, exocytosed, converted to tubular myelin
Much is recycled

159
Q

Surfactant proteins

A

B - most important, for surface tension reduction
A - for regulating secretion
D - for viral defense
C

160
Q

Compounds inhibiting surfactant production

A

Meconium
Amniotic fluid
Blood-related compounds

161
Q

Laplace’s Law

A

P = 2T/r

Greater radii = Less pressure needed to keep distended

162
Q

Why was RDS called hyaline membrane disease?

A

Alveoli overdistend -> Epithelial damage -> Proteins leak into airspace, further impairing surfactant function = Thick hyaline membrane lining alveoli on histology

163
Q

RDS clinical diagnosis

A

Premature infant w/ central cyanosis due to R->L shunt (PDA) and pulmonary edema, tachypnea, labored breathing, fine rales on auscultation

164
Q

RDS treatment

A

Intratracheal surfactant admin

Assisted ventilation

165
Q

RDS prognosis

A

Related to gestational age and birth weight
May develop bronchospastic disease due to ventilation trauma
Chronic lung disease may develop

166
Q

Cystic fibrosis genetics, pathophys, survival, evolutionary benefit

A

Autosomal recessive mutation to CFTR on chromosome 7 - over 1900 mutations identified, dF508 phenylalanine deletion most common

Cystic Fibrosis Transmembrane conductance Regulator = cAMP-activated Cl- channel; mutations cause defects of CFTR limiting Cl- flow in EXOCRINE epithelial cells -> Dry thick secretions obstructing ducts due to stasis, pH imbalance -> Inflammation w/ impaired PMNs -> Infection, especially w/ Pseudomonas

Median survival ~41y now
Provides protection against cholera toxin as carrier

167
Q

CF pathophys of sweat glands, sinuses, salivary glands, lungs, pancreas, GI, liver, GU

A

Poor salt reabsorption -> Elevated NaCl in sweat
Hypertrophy of exocrine cells -> Chronic pansinusitis and POLYPS
Plugging and dilation of gland ducts
Sequential obstruction: Mucus plugging -> Infection -> Bronchiolitis -> Bronchitis -> > Bronchiectasis -> Cor pulmonale, hemoptysis, pneumothorax -> Respiratory failure
Atrophic pancreas from no Cl- movement to activate cells -> w/ steatorrhea and malnutrition OR pancreatitis
Increased mucus secretion, fat-laden feces -> Obstruction: Meconium ileus (pathognomonic), intussusception
Cholelithiasis or atrophic gallbladder, eventual cirrhosis
Viscous cervical mucus -> Endocervicitis, amenorrhea
Epididymis obstruction, immotile sperm

168
Q

CF findings

A

Poor growth, delayed maturation, decreased muscle mass, fat-soluble vitamin deficiencies
Polyps, inflamed mucus membranes, rhinorrhea
Increased chest diameter, wheezes, crackles, hyperresonance
Fatty stools

169
Q

CF diagnostic tests

A

Newborn screen for immunoreactive trypsin (IRT)

SWEAT TEST for high Cl- content on at least 2 occasions

170
Q

pHTN symptoms, definition, associations

A

Shortness of breath
Pressure over 25mmHg at rest
Associated with scleroderma, congenital sys->pulm shunts, portal hypertension, HIV; L-sided CHF; COPD, interstitial lung disease; PE

171
Q

Genetic pHTN causes

A

Bone morphogenetic protein receptor tII (BMPR2) and activin receptor-like kinase 1 (ALK1) mutations

172
Q

pHTN findings

A

Increased P2, Murmur, Edema

173
Q

pHTN tests

A

V/Q scanning, CXR

ICM2 (5 decks)

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