Pulmonalogy Finals Flashcards
What are the 2 main medication that can trigger asthma attack?
- Beta-blockers- mainly non selective
- Aspirin
non selective BB- Carvidelol, labetalol, propanolol
Which IL and WBC we will see in Type II inflammation in asthma pt?
IL-4,5,13
IgE + eosinophils
trough TH2
Dgx of Asthma
clinical Dgx
קליניקה מתאימה + הפרעה חסימתית הפיכה בספירומטריה
FEV1 / FVC < 80%
What is the definition of reversible obstuction in asthma?
by spirometry criteria
FEV1 elecation in 200ml + 12%
15 min after bronchodilators / few weeks after Tx start with steroids
What is positive metacholine test?
decrease in FEV1 in 20% after low dose of metacholine < 400 mkg
if negetive- definitly not asthma
if positive- might asthma or other
and after bronchodilaters we will want to see improvment at least in 200ml + 12% in FEV1
How we can tell if a pt have type II inflammation asthma?
Exhaled NO
indication for eosinophilic inflammation
does not use to Dgx asthma
when we will hospitelized asthma pt?
when PEFR (FEV1) < 60% or persistent severe tachypnea for 4-6 hours
Option of Tx in acute exacervation of asthma
SABA + IV /PO steroids + consider adding sulfate Mg IV and LTRA
which type of tx are added to acute asthma on hospital
- NIPPV
- Oxygen + helium
- Abx- only when signs of infection
Which type of medication is given in all levels of chronic asthma
whats the reliever
Low dose ICS / Formoterol (LABA that start in 15 min)
Reliever that replace SABA
What is the Tx for stage II asthma
permenent tx with low dose ICS + reliever
What is the Tx for Stage III-IV-V at chronic asthma
eleveted doses of ICS:
III- med. doses
IV- high dose
V- add LAMA
in all add LTM (luekotrient modifier) / and or LAMA (mainly in step 5 LAMA)
When we will give biological therapy for asthma pt?
severe cases
שלא הצליחו להיות מאוזנים על הטיפול במינונים גבוהים
step 6
Why we never give LABA alone and only with steroids
LABA alone is a/w increase risk of mortalitiy
suffix of beta-agonist
Terol / Tamol
like salbutamol, albuterol = ventoline
Suffix of muscarine antagonist
Ium
like ipartorpium
ICS options
Budesonide / Fluticasone
in Which type of medication can we use in the following situations:
- Aspirin- exacerbated respiratoy disease
- Exercise induce bronchoconstiction
- alternate theapry to ICS for step II in kids
and what is effectivness compared to ICS or bronchodilators?
Montelucast
anti-leukotrient
effectivness in improving lung function and reduce excer.
anti-leukotrients < Bronchodilators < ICS
ICS is the most effective
Which biologic medication can be given to Asthma
- Omalizumab- anti IgE
- Mepo/Resli/Benralizumab- anti IL-5, IL-5R
- Dupilumab- antil L-4/13
אמא אומרת מי פה הורס לי? זה הבן הרע המסומם (dope)
ema omeret mepo resli? ze benra dope.
When we will give Omalizumab
severe asthma + IgE > 30 + ellergy
SC every 2/4 weeks
When we will give anti IL5/IL5R
Mepo o-resli? ze h-ben ra
mipolizumab / reslizumab / Benralizumab
Severe Asthma + Eosinophils > 300
Which biological medication can be gevin for severe uncontrole asthma with FeNO 20-25
Dupilumab
can lead to paradoxial eosinophila
anti-IL4/13
Triaf of Aspirin Excaerbated respiratory disease
- Asthma
- nasal polyps
- Chronic sinusitis
Tx- Montelukostat / other biological Tx for IL5 or 4
What blood results will see in Allergic broncopulmonary Aspergilossis (ABPA)
abd what is the Tx?
IgE > 1000
Eosinophils > 500
Skin test- positive for aspergillus
specific IgG + IgE aspergillus Ab.
mainly in immunodepressents with COPD / Asthma
**Tx- Oral steroids + Voriconazole/ Itraconazole **
How we Dgx COPD by pulmonary tests spirometry?
FEV1 / FVC < 0.7
w/o reversability after bronchodilators
what are the 5 stages of GOLD criteria for COPD
by spirometry
I- mild FEV1 > 80%
II- FEV1 ~ 50-79%
III- FEV1 ~ 30-49%
IV- FEV1 < 30%
in all we will see FEV1/ FVC < 0.7
Tx for Acute excer. of COPD
- SAMA + SAMA
- **Abx- **fluroquinolone, amoxi/clavinulate
- **Systemic Steroids- ** perdnisone for 5-10 days (unhospitelized pt) / IV in-hospitel
- Oxygen - O2% > 90%
acute excercabation
When we will use ventilention mechine in COPD pt?
NIPPV»_space; Pco2 > 45
רק במטופל יציב, שיכול לשתף פעולה ובהכרה מלאה, ללא השמנה קיצונית, כוויות משמעותיות
הנשמה פולשנית- במצוקה נשימתית ניכרת למרות טיפול, חמצת נשימתית קשה, מצב הכרה ירוד . % תמותה בהנשמה 17-30%
What is the indications of O2 supplement in chronic COPD pt
restring O2% < 88%
or
< 89% + PAH, RHF, aretrocytosis
What are the 2 C/I for Lung volume reduction surgery in COPD?
- DLCO < 20%
- FEV1 < 20% + diffuse emphysema on CT
high risk of mortality in surgery
Tx for COPD
- LAMA
- LABA
- LAMA+ LABA- most beneficial fromeach medicaiton alone
- ICS- will never be given alone in COPD(must LABA/ LAMA)
all reduce excer. + improve symptoms
recall- in Asthma - LABA is never alone. alwyas with ICS
in COPD- ICS is never alone
מהם היתרונות שנמצאו במחקרים על שיקום ריאות
- משפר איכות חיים
- דיספניאה ויכולת ביצוע מאמצים
- מפחית תדירות אשפוזים
Which advaence medications can be given to COPD who not respond to other medication?
Roflumilast- PDE4i, mainly for COPD severe + chronic bronchitis. GI symptoms common
Azytromycin- anti microbial + anti-inflammatory. lower excer reccurence, non smokers does not depend on pulmonary infection
Which type of vaculitis is in correlation of alpha1-AT deficieny
GPA (wegner)
alpha1-AT inhibit PR3 perodixase
Tx for alpha1- AT deficinecy?
and what is the indication
alpha1 -AT augmentation therapy
given the enzyme IV once a week
only for severe loss < 11 + pulmonary disease
What are the 3 light criteria?
Exudate vs transudate
- Protien serum/effusion > 0.5
- LDH serum/ effusion > 0.6
- LDH in effusion > 2/3 of upper normal limit
only need one to determine exudate
How many % Light criteria mistakely recognize Transudate as exudate?
and how can we overcome this problem?
25% of times
measure gradient
protein in serum - protein in effusion if > 3.1 = Transudate
Which levels of BNP in pleural effusion is diagnostic for CHF
BNP > 1500
What are the 3 main causes of Transudate?
- CHF- not need to pancture unless- unilateral/ a-symmetric / fever or pain / Tx for CHF does not improve effusion
- Chirrosis- mainly in right side
- Nephrotic syndrome- part of anasarca
Tx for para-pneumonic effusion
indication for Therapuetic thoracentesis
thick of pleural effusion > 1 cm = Therapuetic thoracentesis
הנוזל מרחק את הריאה מקיר בית החזה במעל 1 ס”מ
What are the indication of complicated para-pneumonic effusion
- pus = empyema
- positive culture
- glucose < 60
- PH < 7.2
- septations
1 is the most importent 5 the least
empyema = collection of pus in pleural cavity
What is the steps in Tx of complicated para-pneumonic effusion?
1.insert chest tube
2.if not working- insert trough the chest tube fibrinolytic medication like- DNAse
3.Thoracoscopy
steps
- pus = empyema
- positive culture
- glucose < 60
- PH < 7.2
- septations
בספר רשום קודם כל לחזור על ניקור טיפולי ואז להתקדם לנקז בשאלות משחזורים ישר נקז
most common cause of Exudate
and second most common cause
- Para-pneuomonic
- Malignancy- lungs/ Breast / lymphoma
a man present with dyspnea which is not proportional for is pleural effusion.
what might be the cause
Malignancy
What is the only cause a/q mesotholioma?
Asbestosis
aorund 80% of pt with Hx of exposure
No connection to smoking
in PE, which type of pleural effusion we expect?
almost always Exudative
What define Pleural effusion as reasult of TB?
mainly in primary TB
lympocytes dominant
Marker of TB in effusion- high ADA or INF-y
Tx as pulmonary TB- RIPE
What is the Tx for Chylothorax?
how we Dgx?
Dgx
CT + lymphangiogram
+
TG > 110 in effusion
Tx
Chest tube + octerotide
להמנע מניקוז ממושך של הנוזל- סיכון לתת תזונה ופגיעה חיסונית.
2 main reason for Chylothorax?
mediastinal Tumor
Traume
affect the thoracic duct
What is the cheracteristics of RA pleural effusion?
Exudate + monocytes + PNM + low glucose
most common extra articular in RA- pleural disease
low glucose in pleural effusion (exudate) can seen in 3 main situations
- bacterial infeciton
- Malignancy
- RA
Primary spontanous pneumothorax
cause and treatment
cause»_space; epical bulb
mainly in tall think males
Tx
simple aspiration»_space; Stapling of bulb and Pleural abrasion
ננסה אספירציה, לא עובד נעשה סטמפלינג והדבקה של הפלאורות
if reccurent episode- jsut spaling + pleural abrasion
Main cause of Secondary spontaneous pneumothorax and Tx
COPD
Emergency- always chest tube
if candidate for surgery- Stapling of bulb and Pleural abrasion
if not candidate- Pleurodesis
when most tension pneumothorax occurs?
Tx?
mainly during ventilation / CPR
Tx
Needle»_space; Chest tube
High PIP
what is the Hallmark of obstuctive disorder (in spiromytry)
FEV1/FVC < 0.7
What is the hallmark in sirometry of restrictive disease
FEV1/FVC < 80% or normal
*also TLC < 80%
What is the meaning of DLCO when its low and normal?
DLCO normal- no problem in lung tissue- extra pulmonary cause
DLCO low- ILD
What are the main causes of extra-pulmonary restrictive disease
Neuromascular
polio
MG
ALS
Stractural
Scolicosis shape of spine
Morbid obesity
Which type of extra-pulmoanry restrictive disoder we will see only low FRC when RV + TLC are normal
Stractural
Scolicosis shape of spine
Morbid obesity
When we will see normal FRC (passive volume)
but low TLC and high RV
Neuromascular
polio
MG
ALS
all the volume that requires muscles will be low
When we see normal spirometry and isolated low DLCO
PAH
anemia
which type of disease can cause low DLCO
- ILD
- anemia
- PAH
- PE
- emphyzema
- lung resection
Which drugs a/w ILD
Bleomycin, busulfan
Amiodaron
MTX
RTX
AZA
anti-TNF
Nitrofurantoin
which type of ILD is a/w smoking, the pathological process is fibrosis (and not inflammation) , will present around age > 40, with clubbing, and progressive dyspnea + dry cough?
Idiopathic pulmonary fibrosis
What can we hear in IPF?
קרפיטציות אינספירטוריות שנשמעות כמו Velcro
Dgx of IPF?
clinical presentation + typical HCRT
no biopsy is needed
Tx for IPF?
Nintedanib + pirfenidone
נינתן דה פירבנידון (פיברוזיס אנד דונ)
מאטות הדרדרות בתפקודי הריאות ויתכן שמשפרות השרדות
Which type of Tx if not recommended of IPF
Steroids and immunosupresive- increase morbidity and mortality
Cryptogenic Orginizing pneumonia
presentation
HRCT
Tx
presentation
Flu like disease, but prolong
HCRT- Sub-pleural patches consolidations
Tx- Steroids (prolong use)
Acute eoshinophilic pnuemonia
true or false:
1. present in elderly males
2. present with fiver, dyspnea
3. respond to Abx
4. treatment with Abx
5. Dgx by BAL with eosinophils > 25%
- present in elderly males- False- young males 20-40
- present with fiver, dyspnea - true
- respond to Abx- false
- treatment with Abx- false- with Steroids
- Dgx by BAL with eosinophils > 25%- true
Steroids- great prognosis.
when I say Framer lung or bird / chicken workers
you say?
Hypersensetivity pneumonitis
In this type of ILd must search for the reason!
Most common reason for Bronchoectasis?
|Reccurent infections
Bronchoactasis- non-reversabile dilation of airways
Bronchoactasis:
upper lobe causes
lower lobe causes
middle lobes
central airways
- upper lobe causes- CF, radiations
- lower lobe causes- reccurent aspirations (like in scleroderma- esophagus dismotility)
- middle lobes- MAC, kartenger (Primary cilliary dyskinesia)
- central airways- ABPA (aspergillosis)
Which bugs ar the most common etiology for bronchoectasis?
Hemophilus and pseudomonas
Clinical presentation of Bronchoectasis
שיעול פרודקטיבי עם כיח סמיך +ייתכן המופטזיס
can progress to cor-pulmonale and secondary amyloidosis
Imaging of choice for Broncheacatsis and what we will see?
CT
Singet ring sing (airway X 1.5 from the near Blood vessel)
thickness of airway/ small to medium
Main reasons for Bronchoectasis
CF
Kartenger (PCD)
aspergillos
smoking
obstuction by tumor
Which test must have taken when there are Focal bronchoectasis?
Bronchoscopia
rule out obstruction - tumor / foreign body
make sense beacuse its not a diffusal process
Empiric Tx in excerbation of broncheoctasis?
empiric cover for H.influenza + psuedomonas
Flueroquinolones- like levofloxacin
for 7-10 days
Tx for broncheoctasis with Hemophilus specific or non TB mycobacteria- mainly MAC
H. influenza- augmentin
NTM (must grow in 2 different cultures)- macrolide, rifampin, ethembutol
Tx for ABPA (aspergillus)
Steroids + long term on Itraconazole
Tx for Broncheoctasis with Hypergamaglobulinemia
IVIG
Main different between Central to Obstructive sleep apnea
Central- w/o breating effort
Obstructive- theres a breathing effort
Dgx of OSA?
obstructvie Sleep apnea
עייפות במהלך היום / תסמיני הפרעות לילות בשינה (נחירות וכאלה)
+
AHI ≥ 5
או
AHI ≥ 15
(AHI) is an index used to indicate the severity of sleep apnea. It is represented by the number of apnea and hypopnea events per hour of sleep
sleep apnea
What is the definiton of episode of apnea?
at least 10 seconds with apnea / hypopnea (decrease > 30% in flow)
Risk factor for OSA?
obesity - 40-60%
Males
Complication of OSA?
- Resistance HTN- Tx with CPAP
- risk for CV disease- stroke, DM, CHF, arrytmihas
*do not cause Cor-pulmonale
HTN- w/o reduce in 10% in night
first line Tx in OSA?
- lifestyle change
- CPAP- first line
- התקנים אוראליים- מי שלא סובל סי-פאפ
- ניתוח של דרכי אוויר עליונות- פחול יעיל מ-CPAP
Cheye stokes breathing is a/w?
Central apnea
mainly in CHF and stroke
CPAP is not helping here!
could also be seen in: CNS- encephalitis
polio/ ALS
drugs, Severe kyposcolicosis
opiods, high pressure CPAP, hypoxia (high altitude)
nocosomial disease
What we will see in
* Coal mine lungs
* and Brilium?
Caol mine- upper airways, small round nodoles
Berilum- look like sarcoidosis
Eggshell pattern is a/w
Silicosis
mainly upper lung
Silicosis is a/w increase risk to which type of pulmonary infection and lung cancer?
TB
bronchogenic carcinoma
What is the imaging findings see on asbestosis?
pleural plaques, some are calcified, somtimes with effusion.
mainly effect the lower lobe
True or false
Asbestosis have a synergestic affect with smoking
ture
means high risk for all type of cancers
In asbestosis, which type of cancer is a/q higher risk?
Bronchogenic carcinoma = most high risk
Mesothelioma- less but asbest exposure is the only risk factor known for this type of cancer
