Pulmonary Flashcards
What immunizations should be given in patients with COPD?
Influenza vaccine every year and S pneumoniae vaccine every 5-6 years for patients older than 65. Give 13 followed by 23 pneumococcal vaccine)
When is Theophylline used and what is its problem?
Used in refractory COPD and narrow therapeutic index
What are three complications of COPD?
- Acute Exacerbations
- Secondary polycythemia (hematocrit greater than 47% in females and 55% in males)
- Pulmonary hypertension and cor pulmonale **
What are 9 things to order in patients with acute SOB (COPD or asthma)
- inhaled albuterol
- oxygen
- EKG
- Pulse ox monitor
- Bolus of steroids (IV methylprednisone) - takes 4-6 hours to take effect
- ABG
- Chest x-ray
- Magnesium
- Inhaled ipratropium
What intervention may help prevent a COPD exacerbation from turning into respiratory failure that requires mechanical ventilation?
BIPAP or CPAP
What is cornerstone of COPD treatment?
Short acting beta agonist (albuterol) and anticholinergic medication (ipratropium)
When is it reasonable to give a patient a long-acting beta agonist (salmeterol or formotorol)?
When the patient is on an inhaled corticosteroid and is requiring frequent use of a short acting beta agonist
Do corticosteroids help FEV1?
Many studies have shown that they don’t help with lung function, however all patients on LABA need to be on inhaled corticosteroids
When do patients need home oxygen therapy
If ABG shows PaO2 < 55 or if O2 stat < 88%
What are two classic types of chronic obstructive pulmonary diseases
Chronic Bronchitis and Emphysema
How is chronic bronchitis diagnosed? How is emphysema diagnosed? (type of diagnosis)?
Chronic bronchitis is a clinical diagnosis, patients with chronic bronchitis present with chronic cough productive of sputum for at least 3 months/year for at least 2 consecutive years.
Emphysema is a pathological diagnosis with permanent enlargement of air spaces and destruction of alveolar walls seen in patients
What type of emphysema is seen in smokers vs the type of emphysema seen in alpha-1 antitrypsin deficiency? What zones of the lungs does each type of emphysema have a predilection for?
In smokers centrilobular emphysema is most common. There is a predilection for upper lung zones.
In alpha-1 antitrypsin deficiency, panlobular emphysema is more common and there is a predilection for lung bases
Describe pulmonary function results in COPD?
Residual Volume? Total Lung Capacity? FEV1? FEV1/FVC?
FEV1/FVC < 0.7
FEV1 is decreased
Total Lung Capacity is increased
Residual Volume is increased
How does smoking cessation affect FEV1?
If a smoker quits, the rate of decline in FEV1 slows to that of someone who has never smoked. However, a person does not recover FEV1 that was lost due to smoking. Just the rate of decline slows to that of someone who has never smoked
What class of medications is contraindicated in COPD and asthma exacerbations?
Beta-blockers
How does metacholine work?
It is a muscarinic agonist that causes asthmatics to develop hyper-responsiveness to airways and patients experience a drop in FEV1
What does ABG show in asthma patients with respect to O2 and CO2?
Patients have hypoxemia and hypocarbia
If an asthmatic has hypercarbia, what should be done?
Hypercarbia indicates impeding respiratory failure because an asthmatic patient should be hyperventilating which should cause a drop in CO2. If CO2 is increased, that means the patient is getting tired (respiratory fatigue) and the patient should be mechanically ventilated
How should a patient with SOB (asthma or COPD) be treated? (9)
- EKG
- Magnesium
- Inhaled albuterol
- Inhaled ipratropium
- Oxygen
- Pulse Ox monitor
- ABG
- IV steroids
- Chest x-ray
Describe the GOLD FEV1 staging criteria for COPD?
FEV1 > 80% = mild
FEV1 between 50-80% = moderate
FEV1 between 30-50% = severe
What can be seen on physical exam for patients with COPD? (4)
Prolonged expiratory time, Wheezing, use of accessory muscles of respiration, and hyper-resonance on percussion
What are some symptoms of COPD
Cough, increased dyspnea, sputum production
What is a suitable treatment for extrinsic allergies and what is the MOA of this class of medication? What if this class of medication fails, what do you give?
CROMolyn or nedoCROMil (mast cell stabilizers), prevent the release of histamien from mast cells. If these medications fail give Omalizamab (monoclonal IgG antibody against IgE)
What is a treatment for atopic disorders?
Montelukast (leukotriene antagonists)
Describe what causes bronchiectasis?
Caused by an anatomic defect in the lung usually due to an infection from childhood.
What anatomic defect does bronchiectasis result in?
Profound dilation of the bronchi
How does bronchiectasis present?
Fever, hemoptysis, chronic cycle of lung infections, high volume of sputum production that can be measured by the cupful.
What is the triad of asthma pathology?
Airway hyperresponsiveness, reversible airflow obstruction, and airway inflammation
What age can asthma begin?
At any age
What is the difference between extrinsic and intrinsic asthma?
In extrinsic asthma, patients are usually younger at onset, and patients are atopic (increased IgE) to environmental factors.
Intrinsic asthma is not related to environmental factors or atopy
What are some triggers for asthma?
Pollen, house dust, mold, pets, cockroaches, exercise, viral infections, smoking
What are three key risk factors for COPD?
Smoking, alpha-anti1 trypsin deficiency, environmental respiratory pollutants (second hand smoke)
What are signs of acute asthma exacerbation?
Use of accessory muscles of respiration, can’t talk in complete sentences, tachypnea, diaphoresis, wheezing
What is one physical exam sign of impending respiratory failure in asthma exacerbations?
Paradoxical abdominal movement during respiratory (abdomen moves in during inspiration and out during expiration)
What is the most common physical exam sign in asthma patients?
wheezing
How is asthma diagnosed?
Decreased FEV1, decreased FVC, decreased FEV1/FVC ratio, bronchodilators increase FEV1 by 12% and metacholine decreases FEV1 by 20%
What are the genetics of cystic fibrosis?
Autosomal recessive, affects white people
What is the most common cause of bronchiectasis?
Cystic fibrosis
What do PFTs show in bronchiectasis?
obstructive lung disease
Describe two prong treatment strategy for bronchiectasis?
Rotating antibiotics (to prevent further respiratory damage and antibiotic resistance) and lung physiotherapy
What does a chest xray show in a patient with bronchiectasis?
tram tracking
What is the most accurate diagnostic test for bronchiectasis?
CT scan
How does cystic fibrosis present? (3)
Obstructive lung pattern with recurrent infections, pancreatic insufficiency, and GI complications
What is most common infection in cystic fibrosis patients?
Pseudomonas
What is the median age of death in cystic fibrosis patients?
Over 30 years old
How is cystic fibrosis treated?(4)
- Treat infections
- rhDNase (breakdown of DNA in lung mucosa)
- fat soluble vitamin supplements
- pancreatic enzyme replacement
What kind of acid base abnormality is common in COPD?
Respiratory acidosis with metabolic alkalosis as compensation
Why is chest xray needed in a patient with suspected COPD exacerbation?
To rule out pneumonia or pneumothorax as potential causes of SOB
When should alpha-anti1 trypsin deficiency levels in a patient be measured?
If the patient has a family history of premature emphysema (occurring in family members before the age of 50)
What two interventions in COPD decrease mortality?
Oxygen therapy and smoking cessation
What is a key finding in asthma induced by aspirin?
Nasal polyps with asthma symptoms
What are three complications of asthma?
- Status asthmaticus
- Acute respiratory failure from respiratory fatigue
- Pneumothorax, atelectasis, pneumomediastinum
What are side effects of inhaled corticosteroid use and how can they be mitigated?
Sore throat, oral candidiasis, mitigated with mouth rinsing and use of spacer
What is treatment for nonacute asthma?
Inhaled albuterol
Describe pink puffers (emphysema) in body size, prominent positioning of the body, chest size, and demeanor?
Thin patients
Leaning forward
Barrel chest
Tachypneic and using accessory muscles of respiration
Describe blue bloaters in terms of respiratory rate, distress level, and thin vs fat
Patient is not thin, not in respiratory distress, normal respiratory rate
What are the symptoms of acute COPD exacerbations
increased dyspnea, increased cough, increased sputum production
Describe corticosteroid treatment protocol for acute COPD exacerbations
Start with IV methylpredinosone, taper with oral steroids. DO NOT use inhaled steroids with acute exacerbations
What are 4 bacterial causes and 1 non-bacterial cause of COPD exacerbations?
Bacterial: S pneumoniae, H influ, Moraxella catarrhalis, and Mycoplasma pneumoniae
Viruses
What antibiotic treatments are good for COPD exacerbation?
Ceftriaxone and Azithromycin should be used in community acquired pneumonia
What % of lung cancers are small cell and what % of lung cancers are non-small cell lung cancers?
25% of all lung cancers are small cell and 75% of all lung cancers are non-small cell
What are some non-small cell lung cancers?
Squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and bronchoalveolar cell carcinoma.
Which lung cancer has the lowest association with smoking?
Adenocarcinoma
What % of lung cancers are attributable to smoking?
> 85%
Besides smoking, what are some other risk factors for lung cancer?
Asbestos - found in shipbuilding, construction industry, car mechanics, paintaining (synergistically works with smoking to increase chance of cancer)
Radon - found in basements
COPD - independent risk factor after smoking is taken into account.
What type of test is necessary to differentiate small cell and non-small cell lung cancers?
Tissue diagnosis
What are some symptoms of lung cancer?
Dyspnea, cough, hemoptysis, wheezing, recurrent pneumonia (post-obstructive), anorexia, weight loss, weakness
What are 5 clinical features caused by local invasion of lung cancers?
- Superior Vena Cava Syndrome
- Phrenic nerve palsy
- Recurrent laryngeal nerve palsy
- Horner’s syndrome
- Pancoast Tumor
Describe the pathology and clinical features of SVC syndrome? (3-4 clinical features)
What lung cancer is most likely to cause SVC syndrome?
Obstruction of SVC by a mediastinal tumor. Clinical features include facial fullness, facial and arm edema, dilated veins over anterior chest, arms and face, JVD
Most commonly associated with small cell lung cancer
What clinical feature occurs when lung cancer causes recurrent laryngeal nerve palsy?
Hoarseness
What causes Horner’s syndrome in lung cancer and what are the clinical features of Horner’s syndrome?
Caused by an apical tumor invading the cervical sympathetic chain
Horner’s syndrome: ptosis, miosis (constricted pupil), and unilateral facial anhidrosis (no sweating)
What is a Pancoast tumor? What are the clinical features of a Pancoast tumor?
An apical tumor involving C8 T1-T2 nerve roots which causes shoulder pain that radiates down the arm. Also causes upper extremity weakness due to brachial plexus invasion. Associated with Horner’s syndrome 60% of the time.
If a patient with lung cancer has a pleural effusion with malignant cells, how is the prognosis.
Prognosis very poor. Equivalent to patient having lung cancer with distant metastasis.
Describe Eaton-Lambert Syndrome and what cancer is it associated with?
Associated with small cell lung cancers. Causes proximal muscle weakness, fatigue, paresthesias, diminished deep tendon reflexes
When can a chest x-ray help indicate a benign lesion on lungs?
If the lesion has been stable on CXR for 2 years
When is a needle biopsy indicated in lung cancer (vs a peribronchial biopsy during bronchoscopy)
Indicated in peripheral lesions
Patients with non-small cell lung cancer are not candidates for surgery when?
They have metastatic disease outside the chest
Which adjuvant therapy works best for non-small cell lung cancer after resection?
Radiation therapy
Chemotherapy is of uncertain benefit.
How is small cell lung cancer managed?
Combination of chemotherapy and radiation therapy. For extensive disease, chemotherapy is used alone as initial treatment. If patient responds to initial chemotherapy treatment, prophylactic radiation decreases incidence of brain metastases and prolongs survival.
In these patients, surgery has a limited role because the tumors are too small to resect.
What are some factors that make a solitary pulmonary nodule more likely to be malignant?
- Age (older = more likely to be malignant)
- Smoking
- Size (large the nodule, the more likely to be malignant (> 2 cm)
- Borders - malignant nodules have irregular borders. Benign lesions have smooth discrete borders
- Calcification: Eccentric asymmetric calcification suggests malignancy. Dense, central calcification suggests benign lesion.
- Change in size - enlarging nodules suggests malignancy
What is the algorithm for evaluation of a solid pulmonary nodule?
- Look at old chest x-ray.
2 a. Nodules change in size for > 2 years?
2 b. New Nodule?
2 c. Films not available?
If answer yes to any of above, get a CT with thin sections through nodule.
If answer no, to 2a, follow up yearly and stop workup.
If CT with thin sections shows suspicious for malignancy, biopsy and resect. If CT findings are benign, follow every 3 months.
Which lung cancers are central?
Squamous and Small Cell Lung Cancers
What cancers are more common in the anterior mediastinum? (Four Ts)
Four Ts: Thyroid, Teratogenic tumors, thymoma, and terrible lymphoma
What does pleural effusion mean?
Fluid in the Pleural space
What are the causes of transudative effusions (2 pathophysiological)
elevated capillary pressure or decreased plasma oncotic pressures (hypoalbuminemia)
What are the pathophysiological causes of exudative effusions (2)?
Caused by increased permeability of pleural surfaces or decreased lymphatic flow from pleural surface because of damage to pleural membranes or vasculature.
What is the diagnostic criteria for exudative effusions?
At least one of Light’s criteria must be met:
Protein (pleural)/protein (serum) >.5
LDH (pleural)/LDH (serum) >.6
LDH > two-thirds the upper limit of normal serum LDH
CHF is the most common cause of ________ effusion?
transudative
Pneumonia is the most common cause of ______ effusion?
exudative
Malignancies are the most common cause of _____ effusions?
exudative
Pulmonary embolism is the most common cause of _____?
Transudative
Viral Disease is the most common cause of _____?
Exudative
Cirrhosis with ascites is the most common cause of ____?
Transudative
What should be seen on CXR with a pleural effusion?
Blunting of the costophrenic angles
What does elevated pleural fluid amylase indicate? (3)
Esophageal rupture, pancreatitis, or malignancy
What does milky opalescent pleural fluid indicate?
Chylothorax
What does frankly purulent pleural fluid indicate?
Empyema
What does bloody pleural fluid indicate?
Malignancy
When is a thoracentesis not indicated for a pleural effusion?
If it is less than 10 mm thick on lateral internal decubitus CXR
What is the treatment for transudative effusions?
Diuretics and sodium restriction
Thoracentesis if it is causing dyspnea
What is the treatment for exudative effusions?
Treat underlying disease
What is the treatment for parapneumonic effusions?
Uncomplicated effusions: antibiotics alone
What is the treatment for complicated effusions or empyema?
Chest tube drainage
Intrapleural injection of thrombolytic agents (streptokinase or urokinase)
What is empyema?
Pus in the pleural space
Define a pneumothorax?
Air in the normally airless pleural space
What patient population is spontaneous pneumothorax more common in?
Tall lean young men (patients with normal pulmonary reserve) or patients with underlying lung disease (COPD, interstitial lung disease, asthma, CF, TB) (ie patients without pulmonary reserve).
Caused by rupture of subpleural blebs (air-filled sacs on the lung).
What are the signs and symptoms of a pneumothorax?
Ipsilateral chest pain, usually sudden in onset, dyspnea, cough, decreased breath sounds over affected side,
MEDIASTINAL SHIFT TOWARDS SIDE OF PNEUMOTHORAX
What is treatment for pneumothorax?
If small and asymptomatic, observation (should resolve in 10 days).
If large and patient is symptomatic, needle aspiration or chest tube insertion to allow lungs to re-expand
What is the definition of tension pneumothorax?
Accumulation of air within the pleural space such that tissues surrounding the opening into the pleural cavity act as valves, allowing air to enter but not the escape.
How is tension pneumothorax different from a pneumothorax (in terms of mediastinal shift)?
Shifts mediastinum away from side of pneumothorax (one way valve in tension pneumothorax)
What are some physical exam signs for tension pneumothorax?
Hypotension - cardiac filling is impaired due to compression of the great veins
Distended neck veins
Shift of trachea away from pneumothorax
Hyperresonance to percussion and decreased breath sounds
What is the treatment for tension pneumothorax?
Considered a medical emergency, if tension in the pleural space is not relieved, the patient is likely to die of hemodynamic compromise (inadequate CO or hypoxemia)
Are all mesotheliomas malignant?
NO, benigns mesotheliomas have an excellent prognosis.
