Pulmonary Flashcards
Acute bronchitis
MC: viral
- persistent of cough >5d, most often lasts 10-20d after
- if febrile, consider pneumonia or influenza
Sxs:
- cough (wet/dry)
- reported low grade fever (real fever uncommon)
- URI, myalgias, wheezing
- chest wall tenderness from muscle strain
- lungs often clear
Dx:
- CXR: normal or bronchial wall thickening [not typically needed; indicated for abnormal vitals, extremes of age, comorbidities]
Tx:
- supportive care, antipyretics (NSAIDs, APAP, decongestants)
- bronchodilator if wheeze or asthma
- antitussive likely not helpful
- NO abx (consider for elderly, significant comorbidity, high suspicion for pertussis)
- d/c home w/PCP f/u; likely better in 2-3wk
Pertussis
May cause acute bronchitis
Post-tussive vomiting; whoop; severe paroxysmal cough
duration > 1wk
Dx: NP swab w/PCR
Tx: Azithro
Influenza
MC serious viral airway infection of adults (M/M)
Sxs:
- sudden onset: HA, F/C, sore throat, myalgias
- complicated: progressive dyspnea can lead to RF
Dx: NP swab
- rapid IF/EIA for flu A/B
Tx:
Oseltamivir (NA inhibitor)
- pt >2wk; best w/in 48hr x 5d
1’ influenza pneumonia
Rapid INC in severity of pulmonary sxs*
- CXR w/diffuse bilateral opacities
- hypoxemia
- scant sputum production
- culture only yields normal flora
2’ bacterial pneumonia
Initial improvement then relapse of pulmonary sxs
MRSA common
Always treat influenza and CAP
Bacterial pneumonia (general)
2+ sxs: fever, cough, SOB + acute infiltrate on CXR or auscultory findings
- other sxs: pleuritic CP, sputum, hypothermia, chills/rigors, sweats; fatigue, myalgias, abd pain, anorexia, HA
- tachypnea: most sensitive sign for peds
Pneumococcus MC patho across all ages
Dx:
Typical - GS, consolidation on CXR
Atypical - don’t GS; diffuse interstitial pattern on CXR
- sputum: > 25pmn/LPF and < 10sec/LPF + alveolar macrophages
- Blcx x2 if admission (prior to abx)
- suspect sepsis = lactate
- procalcitonin
- urinary ag: pneumococcus or legionella
- invasive procedures reserved for fulminant course (e.g. ICU, complex, unresponsive to abx)
Pneumonia (H flu)
Typical
- fever, chills, pleuritic CP
Smokers
Chronic lung disease (COPD)
Pneumonia (H flu)
Typical
- fever, chills, pleuritic CP
Smokers
Chronic lung disease (COPD)
Splenectomy
Pneumonia (Legionella)
Atypical
Man-made water systems
No human-human transmission
GI sxs, high fever, subtle hyponatremia, relative bradycardia
Dx: sputum w/abundant PMNs but no organism
- may appear more ill than exam or CXR reads
- CXR: patchy unilobar infiltrate progressing to consolidation ~3day
Pneumonia (Mycoplasma)
“Walking pneumonia” - common in healthy kids and young adults
Atypical
bullous myringitis
GI > cardiac > MS > neuro > derm sxs
Dx: cold agglutinins
Pneumonia (Chlamydophila)
Atypical
pharyngitis, laryngitis
Dx: IgM, IgG titers
Pneumonia - other etiologies
Alcohol: Klebsiella - currant-jelly sputum (necrosing lung)
Splenectomy: pneumococcus, H flu
CF: pseudomonas
Leukemia or I/C: aspergillus
Milk/postparturition products: coxiella burnetti (fever; usually a farmer or vet)
Rabbits: tularemia
Rats: yersina pestis (plague)
Psittacine birds: chlamydia psittaci
Bacterial Pneumonia Treatment
Abx w/in 6hr
OP: azithro, doxy, resp FQ
Gen med/ICU: 2g Ceftriaxone IV q 24hr + 500mg azithro IV q 24
- OR 750mg Levoflox IV q 24hr
- add Vanc or Linezolid to cover MRSA
HCAP or I/C: Vanc + anti-pseudo BL
PCP: TMP-SMX
Complications: parapneumonia effusion, empyema
Other:
- may take 5-7d for fever to disappear
- switch to PO when clinically improved, stable, can ingest oral meds, and GI functioning
- smoking cessation and vaccination
CURB-65
1 point for each:
- confusion
- urea>7
- RR>30
- SBP<90 or DBP<60
- age >65
0-1: outpatient
2: short stay vs. supervised outpatient
3-5: hospital, assess for ICU
Aspiration Pneumonia
RF: CVA, dysphagia, severe deconditioning, esophageal disorder
Et: acute aspiration of gastric contents may lead to respiratory failure
- anaerobic pulmonary infection, typically polymicrobial
Sxs:
- may progress to lung abscess
- fever, chills, shakes, productive cough, pleuritic CP
- may present w/wt loss and foul sputum (abscess)
Dx: CXR - infiltrate dependent position
- may show cavitary lesions +/- air-fluid levels
- swallow study to determine if aspiration
Tx:
- Amp/Sulbactam 4.5g q 6hr IV
- Ceftriaxone + clinda 900mg q 8hr IV OR metro 500 q 8hr IV
Pcn allergy - levo/moxiflox PLUS clinda/metro
Viral pneumonia
CAP: influenza (adults)
- secondary infection: MRSA
- peds: RSV and parainfluenza
- transplant/AIDS: CMV
- severe: varicella zoster
Sxs:
- HA, fever, chills, sore throat, myalgias; dehydration, hypoxemia
- dyspnea = viral
- lasts 7-10d w/residual fatigue
Dx:
- negative procal
- respiratory viral panel via NP
- neg flu PCR cannot r/o flu
- CXR: diffuse bilateral opacities
Tx: 2’ bacterial pneumonia - Ceftaroline OR Vanc + Oseltamivir
Carcinoid Tumor
MC small bowel tumor (appendix > ileum > rectum > bronchus)
- neuroendocrine tumor from Kulchitsky cells
- SECRETES SEROTONIN*
Sxs: usually asx; can have vague nonspecific abd pain, bowel obstruction
- pellagra skin changes d/t DEC niacin production
- Carcinoid syndrome: severe diarrhea, flushing, bronchospasm (also cramps, telangiectasia)
- Cushing Syndrome & Acromegaly: bronchial carcinoids are MC cause of ectopic ACTH production and extrapituitary GHRH secretion
Dx:
- 24hr urine for 5-HIAA
- urine/serum 5HT level
- CXR: round/ovoid central opacities or SPN
- Bx, CT, Bronch
Tx: resect localized tumor
- carcinoid syndrome: IV octreotide, hepatic chemoembolization
- diarrhea alone: Zofran
Pulmonary nodules
Benign: infection (TB, fungi)
- hamartomas: middle aged, lobulated lesion (“popcorn lesion”)
- calcifications
- no tx
CA: bronchogenic, often adenocarcinoma
SPN in a smoker = cancer until proven otherwise
- RF: age, smoking, exposures, prior CA hx, underlying lung dz
- spiculated, corona radiata
- doubling time: 20-400d
Sxs: usually asx, may have constitutional sxs w/CA
Dx:
- High Res CT (best) w/CT guided bx
- 1+ cm AND intermediate probability of malignancy = PET CT combo + MRI of brain
Refer to pulm to decide if CT surg is indicated for biopsy
Asthma General
MC chronic disease of childhood
- episodic wheezing, chronicity, hyper-responsive airways w/REVERSIBLE airway obstruction
RF: exercise, cold, dust, vapors, pollens, danders, occupational, smoke, air pollution
- drug induced: BB, ACE, ASA
- comorbid conditions exacerbating: viral URI, GERD, PND
Sxs:
- worsening dyspnea, inc cough esp at night; inc wheezing and chest tightness
- use of accessory muscles most reliable indicator of obstruction*
Asthma Dx
Routine CXR unnecessary - unless:
- new onset wheezing
- pneumonia, PTX suspicion
- respiratory failure
Spirometry (if >5yo) - Obstructive:
- Dec FVC and FEV1/FVC ratio
- Inc RV, TLC, compliance, DLCO
- FEV1 best measure for severity
Methacholine challenge testing
- if no hyper-responsiveness, unlikely asthma
PEF: monitors trends
Asthma Mgmt
O2 before and after all aerosol tx
Respiratory therapy: albuterol/ipratropium 1.25-2.5mg aerosolized x 3
- prednisone 1-2 mg/kg [Dexamethasone works as well]
- unresponsive to SABA: IV Mg 50 mg/kg
Intubate: Dec LOC, apnea, exhaustion, Inc PaCO2, PaO2<60 or pH<7.2
Admit: hypoxia, PF<60%, continuous SOB, underlying CP dz, inability to tolerate meds, poor compliance
D/c: SABA MDI w/spacer + pred x 5d; ICS maintenance
- f/u in 1wk
- asthma action plan
Bronchiectasis
Abnormal dilated, distorted, thick-walled medium-sized bronchi chronically inflamed/infected
- focal: aspiration, tumor, LN
- diffuse: infectious, congenital, autoimmune
Sxs: frequent bronchitis requiring repeated abx
- progress to chronic mucopurulent sputum production; lots of purulent, frothy**
- cough, SOB, hemoptysis, recurrent pleurisy, crackles, rhonchi, wheezing
Dx:
- CBC w/diff; quant Ig
- HRCT* defining test
- PFTs: obstructive pattern [Dec FEV1, Dec FEV1/FVC ratio]
- sputum analysis/culture
Mgmt:
- control infection w/abx
- improve bronchial hygiene
- pulmonary toilet: hydration, mucolytics, physiotherapy, bronchodilators, steroids
- pulm rehab, surgical resection, refer to pulm
Primary ciliary dyskinesia
Kartagener’s syndrome - bronchiectasis, sinusitis, situs inversus
Autosomal rec syndrome
Absence/shortening out arms responsible for propelling mucus out of respiratory tract
COPD General
- IRREVERSIBLE disease - dyspnea on exertion, cough, sputum + airflow limitation and chronic inflammation of lungs
- chronic bronchitis: Inc bronchial secretion w/cough >3mo x 2 consecutive yrs
- emphysema: permanent air space enlargement distal to terminal bronchial w/wall destruction
Inflammatory changes lead to mucus hypersecretion and ciliary dysfunction
- can lead to vascular changes, pulmonary HTN, cor pulmonale
RF: smoking, occupational, age, ETX, pollution, AAT deficiency, chronic asthma, poor SES
Sxs:
- prolonged expiration/wheezes on forced expiration
- barrel chest, accessory muscle use, tripod pose, pursed-lip breathing, central cyanosis
COPD Dx
PFTs: obstructive
- Dec FEV1, FEV1/FVC
- Inc TLC, FVC
R/o lung cancer w/chronic cough*
- CXR: inc lung volume, hyperinflation, hyperlucency, bulla/blebs
- ECG/Echo: r/o cardiac involvement
- Pox: rest, exertion, sleep
- ABGs: if hypoxic on Pox or FEV1 < 50%
Quantify symptom severity using mMRC or CAT
COPD Mgmt
Stop Smoking
A: SAMA or SABA or combo
B: LAMA (tiotropium) or LABA (salmeterol)
C: ICS + LABA or LAMA
D: ICS + LABA +/- LAMA
Other: O2, pulm rehab, vaccinations
Stage 0: clinical sxs w/normal spirometry
Stage 1: sxs, FEV1/FVC <0.7, FEV1>80%
Stage 2: FEV1 50-79%
Stage 3: FEV1 30-49%
Stage 4: FEV1 <30% or <50% w/chronic respiratory failure
Acute Exacerbation COPD
Cause
- inf: bacterial (H flu, pseudo, S. pneumo, M cat) or influenza
- other: smoking, compliance, CHF, pollution, allergens
RF: AMS, 3 exacerbation in 1y, BMI >20, marked changes in vitals, comorbidities, poor activity, severe COPD
Sxs: INC sputum, INC cough, INC dyspnea**
- +/- constitutional
- confusion = respiratory compromise
Dx: sputum GS/cx, viral studies
- unchanged CXR, variable PFT changes
Tx: O2, bronchodilators (duoneb), systemic glucocorticoids (IV methylprednisolone or OP pred) +/- abx
