Pulmonary 12% Flashcards
Cough persist >5 days; 95% viral; in chronic lung patients consider H. influenzae, S. pneumoniae, M. catarrhalis; normal vital signs, no rales, no egophony.
Acute bronchitis
RSV first episode of wheezing in infants, young children, tachypnea, respiratory distress.
Acute bronchiolitis
Caused by Hib; CXR “Thumbprint Sign”; treat with Ceftriaxone (Rocephin)
Acute epiglottitis
Caused by Parainfluenza virus in the winter months; patients < 3 years old; CXR “Steeple Sign”; treatment is supportive (air humidifier), if severe IV fluids and racemic epinephrine
Croup
Fevers, chills, coryza, myalgia; diagnose with rapid antigen test; Zanamivir and Oseltamivir (Tamiflu) treat influenza A and B must be given within 48 hours. Amantadine and Rimantadine treat only influenza A. Annual vaccine for everyone 6 months and older unless contraindicated.
Influenza
Bordetella pertussis (gram negative capsule); patients < 2 years old; high-pitched “inspiratory whoop”; treat with Macrolide.
Pertussis (Whooping Cough)
Patients will present with fever, dyspnea, tachycardia, tachypnea, cough +/- sputum.
Bacterial pneumonia
Influenza pneumonia: Most common in adults, characterized by a more precipitous onset and fulminant course.
Adenovirus: Tends to cause symptoms fast, will present with GI symptoms and lasts about 1 week. May differentiate from bacterial mycoplasma pneumonia as mycoplasma is slow and insidious.
RSV: Children <1 year old
Parainfluenza: Children 2-5 years old.
Viral pneumonia
Apical infiltration
Tuberculosis
Lobar consolidation
Community-Acquired Pneumonia
COPD, smokers, postsplenectomy
Haemophilus influenzae
College kids, sore throat, long prodrome
Chlamydia pneumoniae
Young people living in dorms, (+) cold agglutinins, bullous myringitis, walking pneumonia, low temp
Mycoplasma
Ventilators, Cystic fibrosis, patients become sick fast - treat with 2 antibiotics
Pseudomonas
Air conditioning, aerosolized water, low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
Legionella
Rust colored sputum, common in patients with splenectomy
S. Pneumonia
Salmon colored sputum, lobar, after influenza, MRSA treat with vancomycin
S. Aureus
Histoplasma, Coccidioides (valley fever), Cryptococcus
Fungal pneumonia
Immunocompromised patients usually symptomatic, found in soil can disseminate and can cause meningitis
Cryptococcus
Bird or bat droppings (caves, zoo, bird), Mississippi or Ohio river valley causes mediastinal or hilar lymphadenopathy (looks like sarcoidosis)
Histoplasma capsulatum
Caused by fungal inhalation in western states. Look for this in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments.
Coccidioides (valley fever)
HIV-related pneumonia
Pneumocystis jiroveci
Infants, young children, tachypnea, respiratory distress, wheezing. Diagnosed by nasal washing. Supportive measures include, albuterol via nebulizer, antipyretics and humidified oxygen admit if O2 sat < 95% and/or retractions
Respiratory syncytial virus infection (RSV)
Mycobacterium tuberculosis - transmitted by respiratory droplets. Classic findings include fever, night sweats, anorexia and weight loss.
Tuberculosis
PPD Rules: Area of induration = raised area (not the red area).
< 5 mm in HIV.
< 10 mm in high-risk area (healthcare worker or possible known exposure).
< 15 mm for non exposed.
Diagnose TB with _____
sputum for AFB smears and cultures.
Latent TB - treat with _____
Isoniazid for 9 months.
Active TB treatment: ______
quad therapy (RIPE): Rifampin (RIF); Isoniazid (INH); Pyrazinamide (PZA); Ethambutol (EMB)
Patients with active TB will need ____ for therapy cessation.
two negative AFB smears and TWO negative cultures in a row
TB prophylaxis for household members:
Isoniazid for 1 year.
GI tract cancer that has metastasized to the lungs.
Carcinoid tumors
Most common type of carcinoid tumor.
Adenoma - slow growing, rare metastasis
Carcinoid tumors present with ______
haemoptysis, cough, focal wheezing or recurrent pneumonia, carcinoid syndrome - cutaneous flushing, diarrhea, wheezing and low blood pressure (hallmark sign)
Carcinoid tumors on CXR are seen as ______
pedunculated sessile growth in the central bronchi
Lung CAs:
Small cell; non small cell: large cell, adenocarcinoma
99% smokers; does not respond to surgery; mets at presentation; central mass; very aggressive.
Small cell lung CA
85% of lung CA cases.
Non small cell lung CA
25-35% of lung CA cases; hemoptysis; central location; paraneoplastic syndrome: hypercalcemia; elevated PTH.
Squamous cell lung CA
5% of lung CA; fast doubling; rare response to surgery; paraneoplastic syndrome: gynecomastia; peripheral location 60%.
Large cell lung CA
Most common 45-50% of lung CA cases; peripheral location; associated with smoking and asbestos exposure; paraneoplastic syndrome: thrombophlebitis.
Adenocarcinoma
Ill defined, lobular or spiculated pulmonary nodule suggests ________
Cancer.
Biopsy.
Calcification, smooth well-defined edged pulmonary nodule suggests _________
Benign disease.
If not suspicious < 1 cm it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr.
Obstructive pulmonary disease; greater than 12% increase in FEV1 after bronchodilator therapy monitor with peak flow meter; FEV1 to FVC ratio < 80%.
Asthma
How much air a person can exhale during a forced breath; during the first forced breath.
Forced expiratory volume (FEV); FEV1
Total amount of air exhaled during the FEV test.
Forced vital capacity (FVC)
Asthma: Less than 2 times per week or 3 night symptoms per month; treatment.
Mild Intermittent;
Step 1: Short acting beta2 agonist (SABA) PRN
Asthma: More than 2 times per week or 3-4 night symptoms per month; treatment.
Mild Persistent;
Step 2: Low-Dose inhaled corticosteroids (ICS) daily
Asthma: Daily symptoms or more than 1 nightly episode per week; treatment.
Moderate Persistent;
Step 3: Low-Dose ICS + Long acting beta2 agonist (LABA) daily
Step 4: Medium-Dose ICS +LABA daily
Asthma: Symptoms several times per day and nightly; treatment.
Severe Persistent:
Step 5: High-Dose ICS +LABA daily
Step 6: High-Dose ICS +LABA +oral steroids daily
Foul breath, purulent sputum, hemoptysis and chronic cough along with a CXR demonstrating dilated and thickened airways with “tram tracks” and “plate-like” atelectasis (scarring)
Bronchiectasis
½ of bronchiectasis cases are due to _________
Cystic fibrosis
Gold standard for bronchiectasis diagnosis is ______
CT of the chest
Bronchiectasis treatment.
Ambulatory oxygen, aggressive antibiotics, CPT (chest physiotherapy = bang on the back) and eventually lung transplant.
Chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause.
Chronic bronchitis
“Blue Bloaters!” (due to chronic hypoxia); common in smokers (80% of COPD patients).
Chronic bronchitis
Chronic bronchitis objective findings
Rales, rhonchi; CXR: peribronchial and perivascular markings; ↑ HGB and HCT common because of chronic hypoxic state; ↑ pulmonary HTN with RVH, distended neck veins, hepatomegaly.
Chronic bronchitis AND Emphysema treatment.
Short acting bronchodilators for mild disease, long acting bronchodilators +/- inhaled corticosteroids for moderate to severe disease, Ipratropium bromide is inhaler of choice for COPD
Smoking cessation and supplemental O2 (O2 is single most important medication in long term)
Antibiotics for acute exacerbations.
Flu and pneumococcal vaccines are a must.
A condition in which air spaces are enlarged as a consequence of destruction of alveolar septae.
Emphysema
The body’s natural response to ↓ lung function is chronic hyperventilation = “Pink Puffers!” CO2 Retainers - the body must increase ventilation to blow off CO2.
Emphysema
Emphysema objective findings
Minimal cough (compared to chronic bronchitis), quite lungs, thin, barrel chest CXR reveals loss of lung markings and hyperinflation - Parenchymal bullae and blebs are pathognomonic Normal hematocrit (HCT)
Young patient with a history of chronic lung disease, pancreatitis or infertility; Autosomal recessive mutation in CFTR gene; Recurrent respiratory infections (especially Pseudomonas)
Cystic fibrosis
Cystic fibrosis objective findings.
CXR may reveal hyperinflation, mucus plugging and focal atelectasis; Labs will reveal an elevated quantitative sweat chloride test (gold standard)
Cystic fibrosis treatment.
Chest physiotherapy, high fat diet, supplement fat soluble vitamins (A, D, E, K), antibiotics for acute exacerbations
Pleural effusion symptoms
Dyspnea, and a vague discomfort or sharp pain that worsens during inspiration
Differentiate pleural effusion exudate and transudate with pleurocentesis and Light’s Criteria.
Exudate: (local pleural disease) - protein ratio ↑, LDH ↑, infection, malignancy, trauma
Transudate: Congestive heart failure, atelectasis, cirrhosis
Pleural effusion exam
Decreased tactile fremitus, dullness to percussion and and diminished breath sounds over the effusion
Pleural effusion CXR
Lateral decubitus x-ray and upright films: Blunting of costophrenic angle. Mediastinal shift away from effusion
Pleural effusion treatment
Thoracentesis is the gold standard
Pneumothorax: Tall thin males 10-30 years old
Spontaneous pneumothorax
Spontaneous pneumothorax treatment.
If > 15%, chest tube insertion with serial radiographs every 24 hours until resolved
Pneumothorax: Etiology: Penetrating injury;
Physical exam: Hyperresonance to percussion and tracheal shift to contralateral side.
Tension pneumothorax
Tension pneumothorax treatment.
Large bore needle decompression 2nd intercostal space midclavicular line.
Right ventricular enlargement and eventually failure secondary to a lung disorder that causes pulmonary artery hypertension.
Lung disorders such as PE, vasculitis, ARDS, COPD (most common), Asthma, and ILD causes pulmonary artery hypertension.
Cor pulmonale
Cor pulmonale symptoms
65-year-old man who presents with a chronic productive cough, dyspnea, and wheezing.
Cor pulmonale exam
Cyanosis, distended neck veins, and a prominent epigastric pulsation. Findings include peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift
Patient recovering from a recent surgery presents with sudden onset of pleuritic CP, dyspnea, apprehension, cough, hemoptysis, and diaphoresis. P 120bpm with RRR. Lungs: tachypnea, crackles.
Pulmonary embolism
Virchow’s triad.
Hypercoaguable state, venous stasis, vascular injury.
PE risk factors.
CA, surgery, pregnancy, OCP, long bone fx (fat emboli)
Homan’s sign
Dorsiflexion of the foot causes calf pain - indicative of DVT
PE EKG and CXR findings.
Tachycardia, ST changes; Westermark’s sign and Hampton’s Hump (triangular infiltrate secondary to intraparenchymal hemorrhage).
PE testing.
Spiral CT; pulmonary arteriography (gold standard)
PE treatment
Heparin > Coumadin (INR 2.5) x 3-6 months
Usually caused by an underlying disorder such as constrictive pericarditis, mitral stenosis, LV failure, mediastinal disease compressing the pulmonary veins.
Pulmonary hypertension
Pulmonary hypertension history
History of underlying disorder (such as COPD) with worsening dyspnea, especially at rest and retrosternal chest pain.
Pulmonary hypertension exam
Narrow splitting of S1, loud P2, systolic ejection click, and parasternal lift
Pulmonary hypertension diagnostics
Pulmonary artery pressure >25 mmHg - diagnose with right heart catheterization
The most common of all interstitial lung diseases.
Be sure to rule out other common causes such as drugs, and environmental or occupational exposures.
Idiopathic pulmonary fibrosis
Idiopathic pulmonary fibrosis diagnostics
CT chest: diffuse patchy fibrosis with pleural based honeycombing.
PFTs will demonstrate a restrictive pattern - opposite of what you would see with asthma.
Decreased lung volume with a normal to increased FEV1/FVC ratio.
Pneumoconiosus types. (Restrictive Pulmonary Disease)
Asbestosis, silicosis, berylliosis, coal worker’s pneumoconiosis
Pneumoconiosus type: ship building, demolition, construction; CXR: interstitial fibrosis and pleural thickening; mesothelioma
Asbestosis
Pneumoconiosus type: mining, sandblasting, stone or quarry work; CXR: nodular opacities of upper lung fields, “eggshell” calcification of hilar lymph nodes.
Silicosis
Pneumoconiosus type: high tech fields, nuclear power, ceramics, foundries; CXR: diffuse infiltrates, hilar adenopathy.
Berylliosis
Pneumoconiosus type: coal miners; CXR: nodular opacities.
Coal worker’s pneumoconiosis
Restrictive Pulmonary Disease - Pulmonary manifestations (most common), erythema nodosum, parotid gland enlargement.
Sarcoidosis
Sarcoidosis CXR findings.
Bilateral hilar lymphadenopathy seen on chest radiograph is the hallmark finding in 90% of cases.
Sarcoidosis diagnosis and treatment.
Biopsy: non-caseating granulomas and ↑ ACE levels
Treatment: 90% of cases are responsive to steroids and can be controlled with a maintenance note.
Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event.
Acute respiratory distress syndrome
Acute respiratory distress syndrome exam
Tachypnea, frothy pink or red sputum and diffuse crackles.
Acute respiratory distress syndrome CXR findings
Air bronchograms and bilaterally fluffy infiltrate
Acute respiratory distress syndrome treatment
Tracheal intubation with lowest level of PEEP
Affects premature infants. It occurs when infants are born before the lungs are producing adequate amounts of surfactant. Surfactant helps to prevent the lungs from collapsing. As the airways collapse, infants will struggle more and more to breath until they become acidotic and multisystem organ failure begins.
Hyaline membrane disease
Hyaline membrane disease CXR findings
Diffuse bilateral atelectasis causing a “ground glass appearance” and air bronchograms
Hyaline membrane disease treatment and prophylaxis.
Antenatal corticosteroids to mother and exogenous surfactant as both treatment and prophylaxis
Foreign body aspiration - presentation (depends on location of obstruction) high vs. low
High in the airway - Inspiratory stridor.
Low in the airway - Wheezing and decreased breath sounds.
Foreign body aspiration location
80% in mainstem or lobar bronchus, 20% in upper airway, right > left
Foreign body aspiration treatment
Remove foreign body with bronchoscope
