pulmology Flashcards
asthma is what type of disease
immunological (hyper-responsiveness to IgE that has been released from trigger)
asthma is what type of disease
immunological (hyper-responsiveness to IgE that has been released from trigger)
ABG with SEVERE asthma attack
respiratory low Pa02, respiratory acidosis
tests to asthma
FEVI, Peak Flow, lungs and symptoms reversible with bronchodilator
X-ray asthma attack, what if no attack?
big lung and flatten diagram, no attack it will be normal
asthma has what % FEVI/FVC
ABG with severe asthma attack
respiratory low Pa02
tests to asthma
Peak Flow, lungs
X-ray asthma attack, what if no attack?
big lung and flatten diagram, no attack it will be normal
the triad involving asthma
The triad: atopy, nasal polyps, NSAID allergy
acute tx for asthma
O2, Beta-agonists (inhaled albuterol) sc terbutaline,
IV epinephrine
can be added: inhaled ipratropium, Corticosteroids (po/IV)
Magnesium and BiPAP (non-invasive mechanical ventilation)
chronic tx for asthma
Mast cell stabilizers (cromolyn)
Leukotriene inhibitors (montelukast or zileuton
Long acting β2-agonists (salmeterol)
asthma symptoms everyday, every night
severe persistant asthma
intermittent asthma and tx
almost no symptoms, > 2 days a week, most likely only need albuterol
mild asthma tx
use albuterol + low dose inhaled steroids
moderate asthma tx
Short acting and LONG acting beta agonist and inhaled steroid
what if patient is already on short and long acting beta agonist, and inhaled steroid but having break through therapy?
increase inhaled steroid dose or for severe add oral steroids + immune suppressive agent Omalizumab (causes anaphylaxis) works by binding IgE.
majority of PE are caused by_____from where in the body_______
Emboli from the Lower extremities
hampton’s hump and westermark on xray
HH: white lesion 1/2 circle attached to pleura, PE
EKG findings of PE
non-specific ST changes, tachycardia
what is Aa gradient
report card of how well body takes air from environment and shuttles it through alveoli to blood stream
the right heart is working hard with a PE, what are the EKG findings specific to this
S1Q3T3.
big wave p wave (p pulmonale).
Inverted Ts V1-V4.
you suspect PE, but d dimer is positive, what test is done next? (remember pt will be short of breath)
CT pulmonary angiogram and then VQscan (ventilation and perfussion scan)……US of chest will show a huge right ventricle
treatment for PE
HEPARIN, fibrinolysis (only in BAD cases) , mechanical thrombectomy, and IVC filter
signs of pulmonary HTN (right sided heart problem)
right ventricle heaving and prominent P2
what causes pulmonary HTN?
COPD and chronic PEs
tx for pulmonary HTN?
- O2
- vasodilator (sildenafil)
- chronic anticoagulant
- transplant
worst lung cancer
small cell
most common lung cancer
adenocarinoma (50% non-smokers)
where does small cell metastasize to
Iiver, bone, brain, adrenal
what is horner syndrome
pan coast tumor in the apex of the lung compresses the sympathetic nerve causing ptosis and mitosis of the eye
What is SVC obstruction
lung cancer tumors block drainage of vena cava and makes new routes
smoker with cancer symptoms and high calcium =
squamous cell carcinoma
tx lung ca
cut is to cure, then radiation…finally cancer
tx pulmonary nodule
CT guided biopsy (low risk people can follow just with imagining for first couple of months)
pulmonary carcinoid
cancer, pulmonary version grows in the bronchus and releases serotonin. This causes flushing, diarrhea, and bronchospasm
tx for pulmonary carcinoid
otreotide scintigraphy
what cell increases with asthma?
goblet cells
Bronchiectasis (most common cause)
CF
what organs does CF affect
lungs, pancreas, intestines
what organism causes infections in CF
pseudomonas
COPD, liver failure, but no smoking. what is the dx?
Alpha 1 antitypsin
how does the inflammation in asthma and COPD differ?
COPD is mediated with neutrophil, which destroys the lungs. whereas Asthma is just hypertrophy
what is COR PULMONALE
chronic lung disease and hypoxia causes pulmonary vasoconstriction (b/c lungs experience chronically low O2 level and become stenosis) which leads to pulmonary HTN and right-sided heart failure
why does home O2 work for COPD
reduces the narrowing and pressure in the lungs
how do you DX COPD
pulmonary function test
treatment for severe COPD
O2, steroid, beta 2 agonist, and BiPAP
what are blebs with COPD confused with on X-ray
pneumothorax
another name for small cell lung cancer
oat cells
syndrome that occurs with lung cancer
paraneoplastic syndromes
what do pulmonary function tests reveal for CF
mixed obstructive and restrictive pattern
finding for pulmonary function test and restrictive dz?
all get smaller
what do medication can cause restrictive lung disease
amiodarone and nitrofuratoin
patient has x ray that shows reticulonodular & honeycombing with clubbing or erythema nodosum. what category of restrictive diz
ldiopathic pulmonary fibrosis
Bilateral hilar adenopathy, with high ca+ what lung dz?
sarcoidosis
linear opacities at bases and pleural plaques worked in industrial environment
asbestosis
nodular opacities at upper lung field?
coal mining or silicosis
what do medication can cause restrictive lung disease
amiodarone and nitrofuratoin
acute respiratory distress syndrome =
noncardiogenic pulmonary edema (normal sized heart with kerly b-lines)
Hypoxia: pO2 0.5
Normal heart function: no evidence of CHF
Diffuse infiltrates: with normal heart size. BUT
X-ray shows pulmonary edema
what is the diagnosis?
ARDS
ARDS is caused by
sepsis, multiple trauma and aspiration of gastric contents
increased permeability of the alveolar capillary membranes which lead to protein rich edema, PE shows frothy pink or red sputum, diffuse crackles. what is this? tx?
ARDS (end point, lung failure due to sepsis)
Tx: supportive and low levels of positive end expiratory pressure.
what do you do with aspiration of foreign body?
bronchoscopy, remove FB and get cultures if post obstructive pneumo is suspected.
who gets hyaline membrane dz
preterm infants
hyaline membrane is caused by
membrane surfactant
X-ray shows ground glass appearance and domed diaphragm. what is the dx
hyaline membrane disease.
you suspect FB aspiration, what imagines do you order
expiratory film: expiratory view: failure of right lung to deflate on lateral decubitus film indicates a
foreign body in the right main stem bronchus. Right main stem usually lodges here due to anatomy
lateral soft tissue neck.
exam findings for pleural effusion
dullness to percussion, mediastinum usually shifted
x ray shows meniscus, blunting of costophrenic angle
pleural effusion
isolated left-sided pleural effusion
pneumonia, PE, cancers, Boerhaave syndrome
(esophageal rupture), aortic dissection. goes to Left b/c of weakness in wall on that side. CHF will not be isolated to the left side.
exudate effusion due to?
thick nasty fluid, infection, CA or trauma
transudate effusion
thin and watery. due to intake capillaries that are overloaded or low oncotic pressure. caused by medical conditions; CHF, renal or liver failure
is glucose low or high in exudate
low: infections the bugs are eating the sugars
how does treatment differ from exudate vs. transudate
exudate must be pulled out of lung. Transudate may be treated medically.
bilateral pleural effusions suggest
CHF (transudate)
right sided pleural effusion
CHF, pneumonia, PE, cancer
test to figure out effusion vs emphyema
X-ray on side (thick emphyema will not change position) effusion is more watery and will migrate
tx for emphyema
early on use chest tube, may need surgery
imagining that shows difference between parechymal and pleural densities
try x-ray, then go to CT
gold standard to diagnosis effusion
thoracentesis
what tests are sent with thoracentesis fluid?
protein, LDH, glucose, WBC,and gram stain
thoracentesis fluid shows: increased LDH and protein, decreased glucose. what type of effusion
exudative
thoracentesis fluid shows: low LDH, low protein and high glucose
transudative
tx for malignant effusions
drainage pleurodesis. using doxycycline and talc
tx for large pneumo (spontaneous)
Heimlich flutter valve:
x ray shows: collapsed lung, loss of vascular markings in the periphery, visible cupola
pneumothorax
primary cause of pneumo
spontaneous, manfans
secondary
trauma, pneumonia,
tension pneumo is tx with?
needle to chest, decompress and tube
small pneumo
resolved spontaneously, place on O2.
you are thinking a simple pneumo, but the patent’s blood pressure drops and O2 sat drops =
tension pneumo
where to place needle to decompress
2nd mid-clavicular line 2 intercostal space, or 5-6th rib mid-axillary
when do you place Tube thoracostomy?
hemopneumothorax, persistent or recurrent
pneumothorax
tx sicker kids with bronchiolitis
hospitalization, steroids, Ribavirin for confirmed RSV
usually caused by RSV and during winter, wheezing in kids under 2 years old, usually viral. Fever, mild respiratory distress
Acute Bronchiolitis
steep sign
croup
Wheezes kid, you think acute bronchiolitis, all sudden wheezes stop…think
collasped airway
do you need labs with acute bronchiolitis?
no you can swab for RSV
tx sicker kids with bronchiolitis
hospitalization, steroids, Ribavirin for confirmed RSV
thumb print sign
epiglotitis
steep sign
croup
croup is most commonly caused by?
Parainfluenza virus type 1 in kids 3 months to 3 years
old in Fall and early Winter
tx for croup if patient comes to ER or office
humidified air or oxygen, nebulized epinephrine q15-20min,
oral/IM/IV dexamethasone (0.6mg/kg up to 10mg), IV fluids if necessary
The most common “complication” from a typical influenza
pneumonia
what do you use to treat pneumonia caused by influenza
antiviral—can move to be bacteria
best influenza test
Reverse transcription polymerase chain reaction (RT-PCR) is best
pertussis is caused by
Bordetella Pertussis is a Gram negative coccobacillus causing respiratory infection
● HIGHLY contagious
test to confirm pertussis
viral cultures, PCR and serology
tx for pertussis
supportive. if
if kids have not been vaccinated for pertussis give
DTaP. For adults give booster Tdap
x ray findings for reactivation TB
fibrocavitary apical disease and ghon complexes
does the TST skin test differentiate between active or latent forms
no
definitive dx requires the id of m. tuberculosis from?
cultures or DNA/RNA amplification
does acid fast bacilli on sputum confirm dx?
no, only supports dx
Hallmark histologic finding
caseting granulomas
isoniazid, rifampin, pyrazinamide, and ethambutol are
TB drugs
how is active TB treated
with all drugs for 2 month, followed by 4 months of additional drug therapy
SE effects of isoniazid
hepatitis, periperial neuropathy
SE effects of Rifampin
hepatitis, flu syndrome, orange body fluid
how are pt with HIV treated
therapy for a least 1 year
what is the bacilli Calmette guerin vaccine
TB vaccine given to individuals in high risk settings
typical pneumonia organisms
Strep pneumoniae, Haemophilus influenzae, Klebsiella, Moraxella
common most organisms overall
Strep pneumoniae, gram + dipplococci
typical pneumonia signs and symptoms
abrupt onset fever/chills, cough with sputum, abnormal vitals, abnormal lung exam, and an obvious lobar infiltrate on CXR
Atypical pneumonia organisms
Mycoplasma (MOST COMMON), chlamydophila, legionella, and viruses like influenza, RSV,
and parainfluenza
current colored sputum
Klebsiella
what is the difference between, pneuococcal polysaccharide vaccine and pneumococcal conjugate vaccine
PPSV: children 2-5 who have not been previously immunized and those over 65yo
PCV: four doses for children 6 weeks and 15 weeks
rust colored sputum
Strep pneumoniae
low grade fever, cough, bullous myringitis, cold agglutinins
mycoplasma pneumo
high procalcitonin levels suggest what type of pneumonia
bacteria
who not to give vaccine to?
egg allergy
what is the difference between, pneuococcal polysaccharide vaccine and pneumococcal conjugate vanccine
PPSV: children 2-5 who have not been previously immunized and those over 65yo
PCV: four doses for children 6 weeks and 15 weeks
treatment for typical pneumonia
marcolide (clarithromycin, azthromycin or doxycycline)
X-ray chest for atypical infection
fluffier infiltrate
college student has what type of pneumonia
chlamydia and mycoplasma
Alcohols have what type of pneumonia
klebsiella
most common cause of bacterial pneumonia in HIV
streptococcus
COPD + pneumonia
H. flu
air condition + pneumonia
legionella
bird dropping + pneumonia
histo or chlamydia
tx: CAP but person is sick enough to be admitted
3rd gen cephalosporin+macrolide, or a FQ by itself
tx CAP with co-morbidities
fluoroquinolone (FQ) OR Augmentin + a macrolide
tx CAP
macrolide like azithromycin, or maybe doxycycline
influenza can cause pneumonia do antivirals help
yes. zanamivir and oseltamivir
Hospital acciqured bugs include
s. aureus, gram negative bacilli
what bug causes ICU pneumo
pseudomonas
tx hospital /ICU pneumo with?
ceftriaxone, cefepime and imipenem
_____ is the most common cause of opportunistic infections in HIV
pneumocystis jiroveci
pneumocystis jiroveci occurs when CD4 counts drop below what number
how do you dx pneumocystis pneumonia
sputum spain via induced sputum or bronchalveloar lavage
tx for HIV with pneumocystis infections
Bactrim (trimethoprim-sulfamethoazole) . Also, used prophylactic when CD4 counts are below 200 cells
what type of pneumo with Cystic fibrosis
pseudomonas
what type of pneu if you are under one
RSV
pneum associated with post viral infection
staph. aureus
what physical exam finding are consistent with chronic silicosis.
Diffuse rhonchi and low pitched rales
Idiopathic pulmonary fibrosis findings
honeycombing and restrictive
What is the therapy of choice for a patient diagnosed with Coccidioidomycosis?
A.
The first line drug of choice for Valley Fever is fluconazole. Patient may remain on therapy up to 6 months to prevent relapse while recovery is monitored via serum complement fixation titers.
Which acid-base abnormality is most commonly associated with chronic obstructive pulmonary disease?
respiratory acidosis
name the 3 stages of pertussis
The three phases of pertussis that have been described are catarrhal, paroxysmal, and convalescent. The catarrhal phase is characterized by upper respiratory symptoms such as nasal congestion, rhinorrhea, and sneezing and this phase is when the patient is most infectious. The paroxysmal phase is the phase of intense episodes of coughing with post-tussive vomiting. The convalescent phase is the phase in which symptoms begin to resolve, but the patient may have a lingering cough for weeks.
ou suspect that he has a partial obstruction of the trachea due to a foreign body. What is the most appropriate next step in the care of this patient?
Bronchoscopy is the definitive test to confirm the diagnosis of tracheal foreign body, and removal can be accomplished at the same time.
young women with cough for 3 months and obstructive lung symptoms, she does not have asthma, what might she have?
Alpha-1-antitrypsin deficiency This deficiency allows the natural proteases produced in the lungs to break down the alveolar walls resulting in the emphysema-like symptoms.
You have recently diagnosed a patient with a pulmonary embolism. While beginning anticoagulation therapy with heparin and warfarin, at what point can you discontinue heparin?
When the INR is greater than 2.0 (for 24 hours) heparin therapy can be discontinued. Warfarin therapy should be continued with an INR goal of between 2.0 and 3.0.
Which of the following organisms is likely to cause a lobar pneumonia
Streptococcus pneumoniae
fungal pneumonia, which of the following drugs would be contraindicated?
steroids
A common complication in placing a subclavian central venous catheter is which of the following?
Pneumothorax
gold standard to dx TB
putum cultures revealing Mycobacterium tuberculosis are the gold standard in diagnosis of pulmonary TB. Typically sputum samples are obtained in the morning on three consecutive days.
what are the lung cancer screen recommendations for smokers and what imaging is used?
recommend low-dose chest CT scan annually for high-risk individuals (age 55-74 years with 30-pack year smoking history)
On physical exam you note clubbing of the fingers and inspiratory crackles diffusely throughout both lungs. Chest x-ray reveals pleural plaques with a reticular pattern through both lung bases. What is the most likely diagnosis for this patient?
Asbestosis
ou suspect she may have pulmonary hypertension. What is the next best step in the diagnostic workup of this patient?
Trans-thoracic echocardiogram
By what mechanism do inhaled corticosteroids enhance the overall effectiveness of other pharmacologic agents used in the treatment of asthma?
The preservation of beta-2 receptors in the lungs allows medicines such as albuterol to remain tolerance free over time.
In the treatment of pulmonary tuberculosis, what should be coadministered with isoniazid to reduce the risk of peripheral neuropathy?
b6
x-ray findings of foreign body in the lungs
Ipsilateral hyperlucency and hyperexpansion of the ipsilateral hemithorax
