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Internal Med EOR > Pulmonary 1 > Flashcards

Pulmonary 1 Flashcards

1
Q

MC cause of acute bronchitis

A

viral

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2
Q

MC bacterial causes of acute bronchitis

A

S. pneumoniae
H. influenzae
M. catarrhalis

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3
Q

hallmark sx of acute bronchitis

A

cough > 5 days - initially nonproductive then becomes productive
can last 1-3 weeks

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4
Q

what sx is rare in acute bronchitis

A

fever

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5
Q

PE acute bronchitis

A

often normal but wheezing and rhonchi may be auscultated on PE
rhonchi usually clear w coughing

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6
Q

dx acute bronchitis

A

clinical; acute onset of persistent cough + no findings suggestive of pneumonia (fever, tachypnea, rales, hypoxia, dullness to percussion, decreased or bronchial breath sounds, rales, ego phony)

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7
Q

when is CXR needed for acute bronchitis

A

if you need to distinguish btwn acute bronchitis and pneumonia

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8
Q

tx acute bronchitis

A

self-limited
cough relief - dextromethorphan, guaifenesin if > 2 years
avoid abx in otherwise healthy

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9
Q

what is asthma

A

reversible, often intermittent, obstructive disease of the small airways

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10
Q

3 components to asthma

A

airways inflammation, airway hyperreactivity (hyperresponsiveness) - type 1 , bronchoconstriction

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11
Q

what is the most common type of asthma

A

allergic asthma - begins in childhood and is associated with eczema, allergic rhinitis, and food allergy (atopic triad)

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12
Q

what is the strongest risk factor for asthma

A

atopy

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13
Q

symptom triad for asthma

A

episodic dyspnea
wheezing
cough (especially at night)

may have chest tightness or fatigue

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14
Q

PE for asthma

A

may be normal between exacerbations

wheezing and/or prolonged expiratory phase during normal breathing due to the presence of airflow obstruction, hyper resonance to percussion, decreased breath sounds, tachycardia, tachypnea, use of accessory muscles (due to increased work of breathing)

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15
Q

what should clue you in that the acute asthma flare is an EMERGENCY

A

lack of wheezing!

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16
Q

describe severe asthma and status asthmaticus

A

inability to speak in full sentences, tripod positioning, silent chest, altered mental status, pulsus paradoxes (inspiratory blood pressure drop > 10 mm Hg

PEFR < 40% predicted

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17
Q

dx asthma

A

pulmonary function tests - pre- and post-bronchidilator to identify reversible airflow obstruction

airflow obstruction - decreased FEV1, decreased FEV1/FVC < 0.7, increased lung volumes due to hyperinflation: increased residual volume (RV), total lung capacity (TLC), and RV/TLC

significant reversibility - defined by an increased of 12% or more and 200 mL in FEV1 or FVC after inhaling a short-acting bronchodilator

bronchial provocation with methacholine or histamine challenge - a decrease in FEV1 20% or greater after exposure; reserved for use when asthma is suspected but baseline spirometry is normal or non diagnostic

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18
Q

intermittent asthma

A

symptoms </= 2 days/week
no interference w daily activities

nighttime sx </= 2 times/month

use of rescue inhaler < 2 days/week

lung function - PEV1 > 80% predicted, FEV1/FVC normal

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19
Q

tx for intermittent asthma

A

SABA as needed

albuterol, levalbuterol, terbutaline, epinephrine

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20
Q

mild persistent asthma

A

sx > 2 days/week but not daily
minor limitation in daily activities

nighttime sx 3-4 times/month

use of rescue inhaler > 2 days/week but not daily and not more than once on any day

lung function - FEV1 > 80% predicted, FEV1/FVC normal

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21
Q

tx mild persistent asthma

A

Low-dose ICS daily with SABA as needed
or
Low-dose ICS plus SABA, concomitantly administered as needed

lose dose ICS - beclomethasone, flunisolide, triamcinolone
SABA - albuterol, levalbuterol, epinephrine, terbutaline

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22
Q

moderate persistent asthma

A

daily sx
some limitation in daily activity

nighttime sx > 1 time/week but not nightly

use of rescue inhaler daily

lung function - FEV1 > 60% but < 80% predicted, FEV1/FVC reduced 5%

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23
Q

tx moderate persistent asthma

A

combination low dose ICS and LABA min a single inhaler daily and 1 to 2 inhalations as needed

low dose ICS - triamcinolone, beclomethasone, flunisolide
LABA - salmeterol, formoterol

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24
Q

severe persistent asthma

A

continual sx
extremely limited physical activities

nighttime sx often 7x/week

use of rescue inhaler several times/day

lung function - FEV1 < 60% predicted, FEV1/FVC reduced > 5%

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25
Q

tx severe persistent asthma

A

medium to high dose ICS + LABA

can add LAMA daily

SABA as needed

ICS - beclomethasone, flunisolide, triamcinolone
LABA - formoterol, salmeterol
SABA - albuterol, levalbuterol, terbutaline, epinephrine
LAMA - aclidium, darotropium, tiotropium, glyccopyronium, umeclidinium

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26
Q

tx of acute asthma exacerbaton

A

SABA - for all
inhaled muscarinic antagonist - moderate to severe
systemic glucocorticoids
IV mag sulfate - if life-threatening

may need mechanical ventilation (intubation) and noninvasive positive pressure ventilation if unresponsive to above

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27
Q

what is chronic bronchitis

A

a type of COPD defined as chronic productive cough for at least 3 months a year for 2 consecutive years

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28
Q

pathophys of chronic bronchitis

A

chronic inflammation leads to mucous gland hyperplasia, goblet cell mucus production, mucus hypersecretion, dysfunctional and damaged cilia, and infiltration of neutrophils and CD8+ T cells

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29
Q

3 cardinal sx of chronic bronchitis

A

chronic cough (MC and earliest)
sputum productive
dyspnea, especially on exertion

30
Q

PE for chronic bronchitis

A

crackles (rales)
coarse rhonchi
wheezing
signs of Cor pulmonate - enlarged tender liver, JVD, peripheral edema
cyanosis
peripheral edema
obesity “blue bloaters”

31
Q

dx chronic bronchitis

A

PFT:
obstruction - decreased FEV1, normal or decreased FVC, postbronchodilator decreased FEV1/FVC < 70% predicted
hyperinflation - increased volumes (RV, TLC, RV/TLC, FRC)

roughly normal diffusing capacity of the lungs for carbon monoxide (DLCO)

CXR
EKG for cor pulmonale
CBC - increased hemoglobin and hematocrit
ABG - respiratory acidosis

32
Q

what will CXR show for chronic bronchitis

A

pulmonary HTN - enlarged right heart border, increased AP diameter, vascular markings
normal diaphragms

33
Q

conservative tx COPD

A

smoking cessation - greatest impact
vaccines - flu and pneumococcal
home oxygen - resting hypoxia (PaO2 < /= 55 mm Hg or oxygen sat </= 88% or cor pulmonale
pulmonary rehab

34
Q

tx acute exacerbations chronic bronchitis

A

abx
amoxicillin
doxycycline
clarithromycin
cephalosporins

35
Q

Category A COPD

A

mild or infrequent sx
0-1 exacerbations in the last year without associated hospitalization
FEV1 >/= 80% predicted

36
Q

tx category A COPD

A

SABA as needed

SABA - albuterol, epinephrine, terbutaline, levalbuterol

37
Q

Category B COPD

A

moderate to severe sx (ie, the patient has to walk more slowly than others of the same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness)
0 or 1 exacerbations in the past year without associated hospitalization
50% ≤ FEV1 <80% predicted

38
Q

tx Category B COPD

A

add a LABA or LAMA

LABA - Salmeterol, Formoterol
LAMA - aclidium, darotropium, tiotropium, glyccopyronium, umeclidinium, ipratropium

39
Q

Category C COPD

A

Mild or infrequent symptoms (ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill)
≥2 exacerbations per year with one or more leading to hospitalization
30% ≤ FEV1 <50% predicted

40
Q

tx category C COPD

A

regular treatment with a LAMA

LAMA - aclidium, darotropium, tiotropium, glyccopyronium, umeclidinium, ipratropium

41
Q

category D COPD

A

Moderate to severe symptoms (ie, the patient has to walk slower than others of the same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness)
≥2 exacerbations per year with one or more leading to hospitalization
FEV1 <30% predicted

42
Q

tx category D COPD

A

regular tx with LAMA
severe breathlessnesss - LABA + LAMA
can add inhaled glucocorticoid

43
Q

what surgery can you do in COPD

A

lung reduction surgery
lung transplant

44
Q

what is emphysema

A

a type of COPD that has a pathologic definition - abnormal permanent enlargement of the terminal airspaces (distal to the terminal bronchioles) with no obvious fibrosis

45
Q

types of emphysema

A

centrilobar (proximal acinar) - MC associated w smoking

panacinar (pan lobar, diffuse) - associated w alpha-1 anti trypsin deficiency

paraseptal (distal acinar) - seen with either of above or spontaneous pneumothorax if isolated

46
Q

pathophysiology of emphysema

A

chronic inflammation, decreased protective enzymes (A1A), and increased damaged enzymes known as proteinases cause destruction of the alveolar-capillary membrane (destruction of the capillaries + alveolar wall destruction and dilation)

loss of elastic recoil and airway collapse makes expiration an active process and increased compliance leads to airway obstruction (air trapping)

47
Q

sx emphysema

A

dyspnea - hallmark
chronic cough - often mild
weight loss

48
Q

PE emphysema

A

hyperinflation - decreased distant breath sounds, increased AP diameter, hyper resonance to percussion

obstruction - end-expiratory wheezing and prolonged expiration. accessory muscle use

cachectic and non-cyanotic

pursed lip expiration

49
Q

CXR for emphysema

A

hyperinflation - flattened diaphragms, increased AP diameter, decreased vascular markings, bull and/or blebs

50
Q

Dx emphysema

A

PFT
obstruction - normal or decreased FVC, FEV1/FVC < 70% predicted; decreased FEV1
hyperinflation - increased RV, TLC, RV/TLC, FRC (functional residual capacity)

Decreased DLCO in emphysema due to destruction of alveolar-capillary pulmonary membrane

ABG
Normal CBC

51
Q

what is cor pulmonale

A

right ventricular hypertrophy with eventual RV failure resulting from pulmonary HTN secondary to pulmonary disease

52
Q

in cor pulmonale what is seen in EKG

A

right axis deviation

53
Q

MC cause of cor pulmonale

A

COPD

54
Q

what is the gold standard diagnostic test to directly measure pulmonary pressures and assess response to vasodilation meds in cor pulmonale

A

right heart catheterization

55
Q

tx cor pulmonale

A

treat underlying dz
diuretics are not helpful
chest pain usually does not respond to nitrates

56
Q

PE cor pulmonale

A

Lower extremity edema, neck vein distention, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2

57
Q

Obesity hypoventilation syndrome (OHS), also known as

A

Pickwickian syndrome

58
Q

Pickwickian syndrome

A

condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels

59
Q

sx hypoventilation syndrome

A

sluggish/sleepy during day

60
Q

what can occur secondary to hypoventilation syndrome

A

pulmonary hypertension, cor pulmonale, secondary erythrocytosis

61
Q

what is idiopathic pulmonary fibrosis

A

progressive extensive remodeling and scarring of the lungs due to an unknown cause

62
Q

sx idiopathic pulmonary fibrosis

A

progressive dyspnea
nonproductive cough
fatigue

63
Q

PE idiopathic pulmonary fibrosis

A

diffuse, fine, dry, bibasilar end-inspiratory velcro crackles (rales)
clubbing of the fingers

64
Q

dx idiopathic pulmonary fibrosis

A

CXR
Chest CT
PFT
Histopathology

65
Q

what will CXR show for idiopathic pulmonary fibrosis

A

reticular opacities (honeycombing) most marked at lung bases

66
Q

what will chest CT show for idiopathic pulmonary fibrosis

A

preferred imaging; reticular honeycombing, focal ground-glass opacification

67
Q

PFTs for idiopathic pulmonary fibrosis

A

restrictive pattern - normal or increased FEV1/FVC, normal or decreased FVC, decreased lung volumes (VC, RV, FRC, TLC)
decreased DLCO

68
Q

histopathology for idiopathic pulmonary fibrosis

A

usual interstitial pneumonia - abnormal proliferation of mesenchymal cells; patchy temporally and nonuniform distribution of fibrosis. sub pleural cystic airspaces (3-10 mm) honeycomb cysts

69
Q

tx idiopathic pulmonary fibrosis

A

antifibrotic drugs (pirfenidone or nintedanib), oxygen therapy, and eventually lung transplant (only possible cure)

70
Q

median survival for idiopathic pulmonary fibrosis

A

Most patients deteriorate and the median survival is about 3 years from diagnosis

71
Q
A

Internal Med EOR (17 decks)

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