Pulmo Flashcards
2.2cm peripheral spicy later nodule with eccentric calcification - next best step?
Surgery
Features of spn- factors increasing malignant probability?
7 features
Large size Advance age Female Active or previous smoking Family or personal history of lung ca Upper lobe location Spiculated
Nodule- .8
Less than 6mm - no follow up
More than 8 mm- additional management or follow up
If nodule more than 8mm what will u do ?
Additional if any of 7 features present- intermediate or high probability category- requires biopsy or surgical excision
This has 5 % probability of malignancy
2cm Spiculated nodule, in smoker- >50 percent malignant probability- what to do?
Timely surgical excision, thoracotomy or VATS
Acute PTE- modified wells score
> 4 - high pretest probability
Drug for alcohol withdrawal
Benzodiazepines - lorazepam
Signs of alcohol withdrawal
History of heavy alcohol use
48-96 hours after hospital admission
Sympathetic nervous system activation- agitation, tachycardia , hypertension
Opioid poisonin- hydrocodone
Naloxone
Signs- hypoventilation leading to hypoxemia, somnolent with decreased respiratory rate and pinpoint pupils
Fever causes
> 101 is fever
Infection, rheumatologic , malignancy , medication
Acute PTE- cause fever- cause of tissue necrosis
Clostridium difficile colitis- features
Fever, abdominal tenderness, diahrroea, recent antibiotic use
Bronchiolitis features
Nasal congestion Rhinorrhoea Coarse breath sounds Wheezing with or without crackles Low grade fever Increase work of breathing - chest retra Nasal flaring Grunting
When to hospitalise RSV bronchiolitis child
With respiratory distress Apnea Hypoxia Dehydration Should follow contact and droplet precautions to prevent nosocomial spread
Treatment of bronchiolitis
IVF NASAL BULB SUCTIONING HUMIDIFIED O2 No need of inhaled bronchodilator No antibiotics- use only in secondary pneumonia - fso - high fever , focal crackles, consolidation on x ray
For immunocompromise with severe disease- ribavarin.
Season for RSV bronchiolitis
Winter
When to give palivizumab for infants
Preterm <29 weeks
Chronic lung disease of prematurity
Hemodynamically sig CHD
Complications of RSV BRONCHIOLITIS
Apnea- infants less than 2 months
Respiratory failure
When to do antigen testing or NAAT in RSV
In patients receiving palivizumab prophylaxis - as RSV infection provides active immunity
- then pali should be discontinued
RSV complI in older patients
Recurrent wheezing in 30 percent
IVC filter indications
Complications of anticoagulant
Contraindication
Failure of anticoagulant
Laryngeal Edema features
Post extubation stridor
Resp failure
Occurs in 30 percent - 5 percent requires- reintubation
Risk factors for l. Edema
Female
Small tracheal diameter
Large et tube
Prolonged duration
How to prevent- give iv multiple dose steroids prior to extubation
If signs of Resp failure is there- consider reintubation
Features of extubation failure
Symptoms of impending failure-
Ph <7.35 or paco2- >45
Clinical signs of Resp failure
RR more than 25/min for 2 hours
Risk factors for extubation failure
Weak cough
Frequent SUCTIONING
Poor mental status
Positive fluid balance 24 hours prior ṭo extubation
Pneumonia as intial cause of respiratory failure
Age >65
Comorbid conditions
NI PPV FOR WHOM
Copd patients to prevent re intubation and decrease mortality
Prior to extubation -
Give steriods to decrease the risk of failure
OSA STOP BANG QUESTIONAIRE
Snoring Excessive daytime tiredness Observed apnea or choking or gasping High BP BMI More than 35 ; Age more than 50 Neck size - men >17 inch ; female>16 Male gender
One point for each
0-2 low risk
3-4 - intermediate
>5- high risk
OSA-
Do polysomnography
Due to nocturnal hypoxia- causes cognitive impairment in elderly- irritability, poor concentration, decreased short term memory
Features of sepsis
Hypotension, hypothermia and leukocytosis- infection from undetermined source.
qSOFA score
RR - > 22 /min
Altered mentation
Systolic BP less than 100
One point each
More than 2 means septic
Two major intial interventions to reduce mortality
1) aggressive IVF - 30 ml per kg is given over the first 3 hours
2) early broad spectrum antibiotics - within one hour eg- vancomycin plus cefepime.
Supplemental O2 in copd does what?
It improves oxygenation of a lung unit that has a low ventilation perfusion ratio.
How is hypoxia caused in copd?
By v/q mismatch
Emphysematous component of COPD causes air flow limitation - which is due to destruction of elastic tissue and bronchiolar collapse. - second component is bronchitis limiting air flow.
Copd exacerbation- causes mucus plugging and bronchospasm - which limits air flow
Lot of vq mismatch areas- reason for hypoxemia in copd- low vq will cause vasoconstricton - so air is directed to good vq areas.
Supplement O2- reach alveoli - increase in q - as it removes vasoconstricton - improves gas exchange to blood- hypoxemia improves.
Emphysema- dead space ventilation increase - leading to high vq in these areas- which is due destruction of alveolar- capillary interface- this mechanism is responsible for hypercapnia. Here 02 improves v . But q doesn’t significantly improve- so less effective mechanism
SPN features
Rounded opacity
Surrounded by lung parenchyma
<3 cm diameter
No LN
If stable for 2-3 years- leave it.
Large size spn
More than 2cm - independently correlates with more than 50 percent malignant probability
Surveillance for more than 8mm lesions
Repeat ct in 3 months - this is only for nodules with low malignant probability - eg- 1cm nodule in 50 yo man- non smoker
IVC filter indications
Complications of anticoagulant
Contraindication
Failure of anticoagulant
How is snoring caused?
Respiration induced soft tissue vibration in the setting of a relaxed upper airway during sleep.
Can be isolated or a part of OSA.
More than 50 percent don’t have OSA
STOP Bang questionnaire - has high negative predictive value
Smoking and alcohol in snoring
Both increases snoring
Alcohol- causes relaxation. Of pharyngeal muscles
Stop these first
If not respond- do oral appliance - physical manipulation of airway- mandible advancement, tongue retraction
Surgical - uvulopalatopharyngoplasty
Prelimi test for OSA
Nocturnal O2 saturation
Gold std- polysomnography
Septic Shock features
Hypothermia, hypotension, leukocytosis - has an ongoing infection from an undetermined site. See if there is sepsis- qSOFA score-
RR more than 22
Altered mentation
Systolic BP less than 100
More than 2 - septic
TB in HIV
New or reactivation can occur
No cavitation occurs
Lobar , pleural or disseminated infection occurs
Features- fever, cough, pleurisy and weight loss
Thoracocentesis- lymphocyte predominant exudative effusion.
Elevated adenosine deaminase- occurs both in malignancy and tb
Pleural effusion occurs due to hypersensitivity to m. Tubercular antigen, pleural fluid is aseptic
So do pleural biopsy - to confirm
ART in Tb
Att started first - then ART after 1-2 weeks delay- to reduce IRIS- immune reconstitution inflammatory syndrome
PCP
Indolent fever, dyspnea, dry cough and bilateral interstitial infiltrates.
Usually with sputum
BAL is second line
Histo in HIV
Febrile wasting illness- fever, fatigue, weight loss, vomiting and dyspnea
X-ray - diffuse infiltrates
Lung cancer Screening recommendation
Yearly with low dose CT
55-80 years
Eligibility for screening based on smoking history- pt with more than 30 pac year history and who is a current smoker or quit smoking with last 15 years
Termination- above 80 years, quit more than 15 years ago , less life expectancy
Smokers have 10-30 fold increase risk . Cumulative risk- 30 percent in heavy smokers to 1 percent in non smokers
Smoking cessation
Reduce COPD , copd exacerbations and luṅG ca
Lung ca by 80-90 % if left more than 15 years ago in comparison with current smokers
Rapid sequence intubation
Rapidly acting sedative- etomidate, propofol, midazolam
Paralytic agent- succinylcholine , rocuronium
No benzodiazepines - decrease respiratory drive
Nippv- for copd exacerbation
New Rbbb in PE
Means RV strain- bedside echo - RV DYSFUNCTION, decreased contractility and RV thrombus
Massive embolism- pul HT leading to dilatation of tricuspid valve annulus and moderate TR
INFERIOR AND POSTERIOR WALL HYPOKINESIA - in MI
Capnography- quantitative waveform or calorimetric analysis
Normal rectangular waveform- all waves are present - measures end tidal co2
If flat- et is in esophagus
Calorimetric test- paper changes from purple to yellow
Pertussis
Lethal Relentless coughing fits Post tussiv emesis Apnea Lymphocyte predominant leukocytosis Sick contacts with cough paroxysms
Mycoplasma pneumonia
School age and young adults
Malaise, headache and fever
Rhinorrhoea and sore throat
Progress to atypical pneumonia - walking pneumonia - doesn’t cause bronchiolitis
Croup- laryngotracheitis
Hoarseness
Barky cough
Inspiratory stridor
Parainfluenza
Fall or early Winter month- 6months to 3 years
Rx- mild- no stridor- humidified ( to soften the secretions and prevent drying)air-+ steroids (single dose oral or im)
Moderate or severe- stridor at rest- corticosteroids plus nebulized epinephrine
Prevention- hand washing , decontamination of surfaces, proper ventilation
Pa neck - steeple sign- subglottic Edema
Self limited- resolves within a week
Cough variant asthma
Non productive cough
Due to exertion or cold air exposure- bronchospasm
Allergens- dust and mites are triggers
Wheezing and rhochi are absent
Treatment is same as asthma
Treatment of asthma
Intermittent(<2/2)- SABA Mild persistent(more than 2/ 3-4 times a month) Low dose ICS
MODERATE( daily/more than once weekly)- low dose ICS and LABA or medium dose ICS
SEVERE PERSISTENT- ( throughout the day/ 4-7 times a week) - step 4- medium dose ICS and LABA
STEP 5- high dose ICS and LABA and consider omalizumab for allergics
Step 6- step 5 + oral steroids
Trachea alavida
Coughing
Sob
Stridor
Weakness of tracheal walls - expiratiory air way collapse
Chest tightness - present in asthma
Transient tachypnea of new born
TTN- due to retained Fetal lung fluid - decreased clearance
Cesarean, prematurity, maternal diabetes
Cf- tachypnea, increase work of breathing
Clear breath sounds
Cxr- hyperinflation, fluid In fissures, cardiomegaly, prominent vascular markings and small effusion
Rx- supportive care- O2 , nutrition
Resolves in 1-3 days
RDS
in premature infants - lack of surfactant
Persistent wheezing and steriod dependence- have chronic lung disease
Cxr- GGO with air bronchograms
Vsd murmur
Holosystolic
Calcification in spn
Popcorn, laminated, central and diffuse homogenous- benign
Eccentric, reticular or punctate- malignant
Acute bronchitis
With copd- give antibiotics
For those with increased dyspnea, sputum volume and purulence
Mitral stenosis
Recurrent laryngeal nerve compression- due to LAE- ortners syndrome
Mitral facies- pink purplish patches on cheeks
Loud S1 , loud s2 if pulmonary ht
Opening snap - high frequency early diastolic sound
Mid diastolic rumble- best at apex
Cxr- pbf to upper lobes , dilated pulm vessels, LAE, flattened left heart border
Ecg- p mitrale, broad and notched p waves, atrial tachyarrhthmias, RVH ( tall R waves in v1 and v2 )
TTE- MV thickening / calcification / decreased mobility , coexisting MR
