Pulm Test 1 Flashcards
sputum
-only done on inpatient
-induced sputum from PCP and tuberculosis -> pneumonia if you cant get a normal sputum sample
-if PCP sputum is neg -> bronchoscopy levage, transtracheal aspiration, transthoracic needle aspiration
-PCP induced sputum- PCR
CAP/HAP inpatient labs
-Nasal MRSA swab- HAP!!
pneumonia CXR
-confirms dx
-air bronchograms
-pleural effusion*
-patchy infiltrates
-segmental and lobar consolidations
-fu CXR in 6 weeks
PCP
-fever*, dry cough, tachypnea, SOB
-rapid decompensation to asymptomatic with fever
-induced sputum is dx- cysts- PCR bc fungus -> Wright-Giemsa stain or direct fluorescence antibody (DFA)
-bronchoscopy- bronchoalveolar lavage or transbronchial lung bx if sputum neg and high suspicion
-interstitial!!, diffuse, bilateral CXR -> HRCT is better
-apical infiltrates -> aerosolized pentamidine prophylaxis
-unlikely dx if:
-no ground glass on HRCT
-normal DLCO
-CD4 > 250 within 2 months prior
PCP tx and prophylaxis
-CD4 < 200
-CD4 % < 14%
-prior PCP
sarcoidosis
-CD4+ T cell alveolitis -> noncaseating granulomas
-bilateral hilar and right paratracheal adenopathy
-asthma assoc- wheezing
-parotid gland swelling
-hepatosplenomegaly
-stage 1- bilateral hilar adenopathy +/- paratracheal
-stage 2- hilar adenopathy + infiltrates -> fever, dyspnea
-stage 3- infiltrates
-stage 4- pulmonary fibrosis
sarcoidosis: extrapulmonary manifestations
-ocular:
-Found in 22-50%
Granulomatous uveitis (anterior (80%)>posterior)
Uveitis – acute or chronic
Kerato conjunctivitis, retinal hemorrhages, band keratopathy
-peripheral lymphadenopathy*
-rheumatologic:
-25-39%
-May precede other symp
-Knees (chronic) > ankles > elbows > wrists > small joints of hands (typically 2-6 joints).
-Periarticular swelling > effusions
-Synovial fluid often non-inflammatory
-Tenosynovitis and heel pain may occur
sarcoidosis dx,labs, and tx
-transbronchial lung bx (bronchoscopy) 2x- lung and mediastinal and hilar lymph nodes -> EBUS
-CBC, BUN, Cr, LFTs, electrolytes, urinalysis (Ca)*
-Ca
-ACE**- non specific
-CXR
-PFTs- may show asthma
-electrocardiogram
-eye exam
-PPD
-high alk phos
-tx- monitor unless symptomatic (hypercalcemia, uveitis, neuropathy, scarring lesions) -> prednisone daily for 8-12 weeks -> taper down -> 1 year
interstitial lung disease
-parenchyma (not airways)
-idiopathic
-hypersensitivity pneumonitis
-systemic- connective tissue disorder -> rheumatologic -> must identify if it is bc tx is diff
-sarcoidosis, exposures, other
-inflammatory can progress to IPF
-interstitium is thickened
-bilateral lung abnormalities
-fibrotic disease - little inflammation -> differentiate them
ILD: S&S
-exertional dyspnea
-bibasilar late inspiratory fine crackles (velcro/dry) at the bases** MC
-dry, non productive cough
-exertional desaturation- low FVC or DLCO -> 3% drop in SpO2 with 6s walk
-clubbing
-cardiac abnormality towards end
-cyanosis
-rash, arthritis, myositis -> suggests diff dx
-O2 flow prevent desaturation below 88%
-restrictive PFTs- low FVC and TLC -> FEV1/FVC normal-high
-Minimum: antinuclear antibody (ANA), cyclic citrullinated peptide (CCP), RF (rheumatoid factor)
ILD imaging
-HRCT dx - lung bx to rule other things out
-reticulation- thickening of inter/intralobular septa -> beginning of fibrosis
-honeycombing- collagen that destroys alveoli structure -> end stage fibrosis
-ground glass- hazy, preserved anatomy, diffuse, inflammation
-IPF:
-subpleural, basal predominant
-bases and edges
-no ground glass
-traction bronchiectasis or bronchiolectasis- advanced
IPF tx
-Nintedanib-Ofev
-Pirfenidone-Esbriet
-antifibrotics- dont make pt feel better, just slows progression
-GI adverse rxn
-pulmonary rehab- do more with what you have
-treat GERD
-bronchodilators
-acute exacerbation:
-worsening dyspnea within 30 days
-new ground glass
-with no infection, other causes
-tx- high dose steroids (prednisone) or antibiotics
predictors of IPF severity and progression
-worser outcomes:
-low DLCO <35% -> lower survival
-worsening 6MWT
-pulmonary hypertension
-FVC decreasing (>10% is bad)
-O2 sat < 88% with walk test, small distance walk, HR recovery low
-dyspnea
-hospitalization
pneumoconiosis
-restrictive and fibrotic
-progressive massive fibrosis/ complicated coal workers lung- upper lung fibrosis
-alveolar macrophages
-silicosis- calcification of peripheral hilar lymph nodes -> eggshell
-everywhere to upper
-asbestosis- dyspnea, crackles, clubbing, cyanosis
-linear streaking at bases
-honeycombing
-pleural calcification (50%)**
-plaques
-worse with smoking
-long term exposure
-HRCT*
tuberculosis
-progressive primary tuberculosis- necrosis and cavitation -> secondary
-TB infection- granulomas -> 3-6 weeks for containment (still can get TB -> PPD will show + now)
-consider sarcoidosis -> granuloma
TB symptoms
-malaise
-anorexia
-weight loss
-fever
-night sweat
-chronic cough MC -> dry then productive
-blood streaked sputum
-May reveal posttussive apical rales
TB dx
-chest imaging -> if +
-3 sputum 8 hrs apart, 1 in the morning -> AFB (not dx), PCR, culture
-PPD or QuantiFERON gold
-bronchoscopy if high suspicion and neg
-check for hepatitis, hiv
MDRTB
-isolate until AFB is neg
-if > 2 months still + -> MDRTB
-treat for 18-24 months
-monthly sputum cultures during tx -> see if tx is working
TB imaging
-Small homogeneous infiltrates
-Hilar and paratracheal lymph node enlargement
-Segmental atelectasis
-+/- pleural effusion
-Cavitation with progressive primary tuberculosis
-necrotizing granuloma
-Reactivation:
-Fibrocavitary apical disease
-Nodules, and pneumonic infiltrates
-“Miliary” pattern:
-Diffuse small nodular densities
-seen with hematologic or lymphatic dissemination of the organism
-Resolution CXR:
-Dense nodules in the pulmonary hila
-Upper lobe fibronodular scarring
-Bronchiectasis with volume loss
-Ghon (calcified primary focus)- calcified granulomas ***
-Ranke (calcified primary focus + calcified hilar lymph node)
when to tx PPD
->=5mm- pt with…HIV, close contact with exposure, abnormal chest x-ray, immunosuppressed (disease or meds)
->=10mm- pt with…less than 4 years, foreign born country with high incidence, high risk settings, comorbidity
->=15mm- patient with…healthy person with low likelihood of tube TB
TB tx: DOT, HIV-, HIV+, extrapulmonary, latent, etc.
-Directly observed therapy (DOT)- MDRTB, HIV+, or antiretrovirals or methadone especially
-2 months- Daily isoniazid, rifampin, pyrazinamide, ethambutol -> if working
-at least 4 months or 3 months after neg sputum -> isoniazid and rifampin
-pyridoxine (vitamin B6) daily
-HIV+ - longer tx and rifamycin drug interactions
-extrapulmonary TB- 9 months with surgical drainage and debridement of necrotic bone is skeletal TB
-corticosteroid therapy-
-TB percarditis
-TB meningitis
-latent- rifampin daily 4 months
-drug toxicity (hepatotoxicity) screening questions monthly
lung abscess
-parenchymal necrosis and cavitation from infection
-anaerobic MC -> insidious
-aerobic and opportunistic pathogen MC in immunocompromised -> acute and abrupt
-aspiration MC
-periodontal disedase
-alcohol disease -no gag reflex
-tx- augmentin / clindamycin for several months (IV to oral)
-surgery- refractory hemoptysis and tx failure
-higher mortality:
-Immunocompromised patients
-Significant comorbidities
-Infection with P. aeruginosa, S. aureus, and K. pneumoniae
lung abscess S&S
-cough
-purulent sputum*
-pleuritic chest pain
-fever
-hemoptysis
-rales or crackles over the abscess
-bad breath*
lung abscess CXR and CT
-dx
-cavities
-MC posterior upper lobes and superior lower lobe
-air fluid level common
-laying down- upper, standing- lower lobe, right lung MC
-CT:
-size and location
-blood, sputum cultures, pleural fluid cultures
Acid and Bases: compensations
-respiratory acidosis compensation -> acute- H+ into the cells and HCO3- reabsorb -> chronic- H+ excreted as NH4+ and HCO3- reabsorb
-respiratory alkalosis- -> acute- paper bag -> chronic- H+ reabsorb and HCO3- absorbed
-metabolic acidosis- hyperventilation
-metabolic alkalosis- hypoventilation
acid and bases: what causes each
-respiratory acidosis- hypoventilation, opioids, COPD, asthma, muscle strength, obstructive sleep apnea
-respiratory alkalosis- hyperventilation, pain, anxiety, hypoxemia
-metabolic acidosis with anion gap (>14)- MUDPILES
-metabolic without anion gap- diarrhea, renal tubule stenosis
-metabolic acidosis- reabsorb Na and excrete Cl and H+:
-metabolic alkalosis volume responsive- dehydration, emesis, diuretics, NG suction
-metabolic alkalosis nonresponsive to volume- HTN- hyperaldosteronism (renal tubule stenosis, Conn) or genetics
FVC and FEV1 range / ratio, variables, volumes
> 80% Normal
70-79% Mild reduction
50%-69% Moderate reduction
<50% Severe reduction
-FEV1/FVC ratio- 90% is normal -> 60% COPD
-depends on age, race, sex, height
-5L within 3s -normal (plateu)
-4L over 10 seconds- obstructive
-3L (max) within 1 second- restrictive
-RV- 80-120
-TLC, FRV, RV - spirometry cant measure
bronchodilator response
-FEV1 increase by 12% and >200ml -> reversible obstructive
-asthma
-if PFTs are normal to begin with and you want to test for asthma -> bronchoprovacation -> methacholine, histamine -> >20% decrease in FEV1
diffusing capacity
-SA of alveoli
-thickness of alveolar membrane
-blood flow
-rxn rate of CO with Hgb
-decreased DLCO- obstructive, parenchymal (alveolar), PE, pulmonary HTN, anemia
-increased DLCO- polycythemia, pulmonary hemorrhage, left to right shunt
predicting how deadly a pandemic is
-how many people infected
-virulence
-what types of people it effects
-prevention/effectiveness
COVID
-High-level viral shedding evident in upper respiratory tract
-virus usually absent after >9 days after symptoms
-62% to 71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite
extrapulmonary manifestations of COVID
-derm- petechiae, liveido reticularis, erythematous rash, urticaria, vesicles, pernio-like lesions
-cardiac- takotsubo cardiomyopathy, myocardial injury/myocarditis, cardiac arrhythmias, cardiogenic shock, myocardial ischemia, acute cor pulmonale
-endocrine- hyperglycemia, diabetic ketoacidosis
-GI- diarrhea, nausea/vomiting, abdominal pain, anorexia
-neurologic- headaches, dizziness, encephalopathy, guillain barre, ageusia, myalgia, anosmia, stroke
-thromboembolism- DVT, pulmonary embolism, catheter related thrombosis
-hepatic- elevated ALT/AST, elevated bilirubin
-renal- acute kidney injury, proteinuria, hematuria
COVID stages and tx
-asymptomatic/presymptoms
-stage 1- mild- symptoms but NO SOB
-stage 2- moderate- >94% O2, lower respiratory disease, NO hypoxia, SOB
-stage 3- severe- <94% O2, infiltrates, hyperinflammation
-critical- failure, septic shock, multiorgan dysfunction
-stage 2- remdesivir, dexamethasone, O2
-stage 3- dexamethasone, O2
-hospitalized- VTE prophylaxis if benefits outweigh bleed risk -> heparin, fondaparinux
RSV
-droplet OR touching surfaces contaminated
-<2 yo almost all have
-virus progresses to lower respiratory tract, and symptoms such as cough, wheezing, and dyspnea can develop
-can give to others if asymptomatic
Risk for severe illness:
-severe disease: pneumonia, asthma, COPD exacerbation
-Cardiopulmonary disease (eg, COPD, asthma, CHF, CAD) -> high hospitalization
-Kidney disease
-Liver disease
-Diabetes mellitus
-Chronic or progressive neurologic or neuromuscular conditions
-Moderate to severe immunocompromise
-Hematologic disorders
-Frailty
-Advanced age or premature infant
RSV dx and tx
-Dx: Included in the respiratory panel
-Treatment: supportive, +/- steroids, bronchodilators
-Prevention: vaccination, ages 60 and older, pregnant women between 32-36 weeks or after birth
