PULMONARY Flashcards
1
Q
How do you calculate A-a gradient
A
A-a gradient = 149 - [02 - (1.25Co2)]
Normal = Age/4 +4
2
Q
What ekg findings do you see with pulmonary embolus
A
EKG: S1Q3T3 –> S wave in lead I, Q wave in lead III, inverted T wave in lead III.
3
Q
How do you go about diagnosis PE
A
*Chk ABG to look for V/Q mismatch–hypoxemia and increased A-a graident indivate V/Q mismatch. Note O2 may be normal so check A-a gradient
* CXR to exclude PNA and pneumothorax
* EKG has some findings (S1Q3T3, right heart strain). Also r/o MI
1) In pts w/LOW pretest probabilty, neg D-dimer –>excludes PE
2) U/S of lower extremities–for interemediate/high pretest probab
4) CTPA/CTA or V/Q –for intermediate/high pretest probability
4
Q
What tx is preferred for anticoagulation for DVT/PE in pregnancy
A
LMWH is preferred. There is no safe data on use of DOACs
5
Q
What tx is preferred for anticoagulation for PE? For DVT? What is duration?
A
PE
* LMWH (dalteparin or enoxaparin) preferred. Also preferred tx for pregnant women
*IF UNSTABLE and no h/o HIT –>UFH. Also use UFH for kidney dx (Cr clearance <30ml/min impt NOT Cr), severe obesity, rapid need for reversal. Based on PTT so need to chk aPTT.
* IF h/o HIT type II and no kidney dx –> fondaparinux
* IF h/o HIT type II AND kidney dx (Cr clearance <30mL/min) –> argatroban (DOAC) only.
*IF massive PE, thrombolytics
DVT
DOACs preferred
DURATION: long-term anticoagulation with LMWH, DOAC, or wafarin:
* 3 months for PE due to transient RFs
* 3 months + extension to 6-12 months: persistent but reversible RF or hemodynamically significant or big PE
* Indefinitely for recurrent PEs
6
Q
How do you reverse heparin
A
Protamin reverses anticoagulation for UFH and LMWH
7
Q
Describe HIT
A
HIT Type I is of NO clinical consequence. Develops w/in 1-2 days. Comon w/transient decr in plts (do not reach below 100k)
HIT Type II requires tx –>STOP heparin, tx with IV argatroban or bivalirudin. Develps 4-10 days after using heparin (see in UFH >LMWH). Arterial and venous thromboemboli are life-threatening complications
**Always monitor plt count in pts on heparin.If it drops >50% and /or thromboembolic sx start, stop all heparin–EVEN heparin flushes.
8
Q
Describe VTE ppx
A
Use either pharmacological OR mechanical ppx. NOT Both
Pharmacological ppx (subcutaneous LMWH 1st line) preferred
MEchanical (pneumatic compression) can be used for pts at highest bleeding risk
9
Q
What dx comes to mind with triad of CONFUSION + dyspnea + petechia in setting recent large bone fracture
A
Fat emboli. Tx is supportive.
steroids NOT beneficial
10
Q
What is difference btwn Obstructive and Cardiogenic Shock
A
Both obstructive and cardiogenic shock have: (1) LOW CO (2) HIGH SVR. Differ in PCWP
*CARDIOGENIC
-PCWP is elevated cardiogenic shock. Heart unable to pump properly, pressure builds up.
*OBSTRUCTIVE
-Similar to cardiogenic shock in that the impaired heart function is the primary abnormality. BUT in obstructive shock, the heart is prevented from contracting appropriately becs of lungs (not contractility of heart–see w/cardiogencic).
-See low PCWP with obstructive shock
11
Q
OF the 4 types of shock, which have low CO
A
All 4 types of shock have low CO. But sepsis can be variable–in early shock, CO can be high.
12
Q
OF the 4 types of shock, which have high SVR
A
ALL have SVP EXCEPT distributive which can have low …
13
Q
Which type of feeding in ICU setting preferred
A
ENTERAL feeding
14
Q
What does pleural cholesterol state about pleural effusion
A
Pleural cholesterol >45mg/DL have high sensitivity and specificity for EXEDUATIVE effusion
15
Q
What is Light’s criteria for exudative effusion
A
Any one of the following may be present:
(1) Effusion: serum protein ratio >0.6
(2) LDH in effusion > 200U/L
(3) Effusion: serum LDH ratio >0.5
TX: drainage
16
Q
What do the following tell you of pleural effusion:
-WBC >1,000
-WBC > 10,000
-WBC >100,000
A
WBC >1,000: think exudate
WBC > 10,000: think complicated parapneumonic effusion
WBC > 100,000: think empyema
17
Q
Define exudate vs complicated parapneumonic effusion vs empyema
A
Exudate:
-local pathology( PNA, cancer, PE)
-Light’s criteria–1 has to be present: effusion:serum protein ratio >0.6, LDH >200, effusion:serum LDH ratio >0.5
COMPLICATED PARAPNEUMONIC EFFUSION:
-parapneumonic effusion for which cultures grow positive org –>chest tube
EMPYEMA: frank pus
18
Q
What would you expect glucose from pleural effusion 2/2 rheumatoid arthritis to be
A
Glucose <30 mg/dL
19
Q
What if the pleural effusion is milky white but not pus? Define chylous effusion? What causes it?
A
Chylous effusions are white-colored exudative effusions with triglyceride level >110. These effusions usu 2/2 trauma and cancer.
*Remember chylomicrons are mostly made up of triglyceride but do contain some cholersterol. Have apo B48 on protein which is unique to chylomicrons.
20
Q
In which groups is a reactive skin test of >5mm, >10mm, >15mm significant
A
Interpret skin test after 48-72hrs. Means pt has LTBI but not necessarily active disease
> 5mm: HIV, steroids >15mg/day, immunocompromised, close contact
> 15mm: NO RFs/co-morbidities. Healthy
> 10mm: Intermediate–everyone else( high-risk comorbidities, high-risk settings–jails, hospitals)
21
Q
What is treatment for LTBI
A
*3 months: INH and Rifampin ( or RPT)
*4 months: Rifampin
*6-9 months: INH
22
Q
Pleural fluid cell count is usu WHAT for TB
A
lymphocytic
23
Q
You have a high clinical suspicion for TB but sputum smear x3 is negative. What should you consider
A
Pleural bx
24
Q
What are 4-drug regimens for active TB; what are side effects
A
Option #1
- Rifampin
- INH
- Pyrazinamide
- Ethambutol (or streptomycin)
Option #2
- Rifapentine
- INH
- Pyrazinamide
- Moxifloxacin
**SIDE EFFECTS
-Ethambutol: eye effects
-Pyrazinamide: incr uric acid (but no gout)
-Rifampin, INH, pyrazinamide : hepatoxicity
-streptomycin: ototoxic, nephrotoxic
25
Can you breastfeed with active, untreated TB
No!
26
Name 4 endemic fungal diseases:
(1) Histoplasmosis
(2) Coccidiomycosis
(3) Blastomyces dermatidis
(4) Mycetoma
27
Describe histoplasmosis
Area: Mississippi/ Ohio
Dx: usually self-limiting BUT if tx necessary
-systemic dx: amphotericin
-sx persisted >4 wks: itraconazole
Can present similarly to blastomycosis but this coniditon has skin blisters (blastomyces dermatidis)
28
What 3 fungal conditions are endemic in similar geographic areas
-Blastomycosis, Histoplasmosis, Franciscella
**Approach:
(1) IF weeping blister/ nodular skin lesions. BROAD-based budding yeast -->blastomycosis
(2) IF hunter -->franciscella
(3) IF mild, flu-like/ palatal ulcer/ bilateral infiltrates and hepatosplenomegaly. NARROW-based budding yeast -->histoplasmosis
29
What is tx for COPD
(1) SABA/LABA + anticholinergic (tiotropium)
+/- ICS (if eosinophil >300 +/- asthma)
+/- azithromycin (for COPD exacerbation/hospitalization)
30
What is tx for asthma
(1) ICS
-ICS/SABA daily or ICS/LABA prn
-low-dose ICS/LABA daily
-medium dose ICS/LABA daily
-high dose ICS/LABA daily
*Do NOT use LABA alone for asthma tx
31
What is tx for COPD exacerbation
Pt with no e/o hypercapnic respiratory failure:
-bronchodilator tx
-systemic steroids
-Abx (azithromycin, doxycycline, fluroquinolone) -->for "purulent sputum"
32
List 2 LABAs
salmeterol, formeterol
33
What are RFs sleep apnea?
Obesity, neck circumference (>16in women, >17in men), facial deformities, menopause
*An AHI index ≥5 (w/day time hypersomnolence) or ≥15 is diagnostic of OSA
34
What is treament for OSA?
CPAP (or BPAP)
35
Sore throat + PNA + hoarseness = ?
Chlamydia pneumonia
-presents similar to mycoplasma PNA (young adult) BUT with sore throat + hoarseness
-often pt p/w sore throat negative for grp A strep, 2-3 wks later-->PNA + hoarseness
-Tx: AZM or fluroquinolone
*Note chlamydia trachmatis p/w GU and eye dx
36
What test differentiates sarcoidosis vs berylliosis
Sarcoidosis and berylliosis are very similar -->the only test that will differentiate between them is berryllium lymphocyte test
37
Describe asthma severity
Retrospectively determined by what medication is taken.
*Mild asthma (intermittent) can be controlled with Step 1 (sx <2x/mo, ICS whenever SABA taken). All other steps are classified as persistent asthma.
38
What 4 questions are used to asses asthma control
4 q's are asked to assess asthma control 4wks preceeding clinical visit
(1) presence of day time sx >2x/wk
(2) any night time awakengings
(3) use of SABA >2x/wk
(4) any activity limitiation 2/2 asthma
*The pt w/well-controlled asthma has none of these, the pt with partially controlled asthma as 1-2, and the pt w/uncontrolled asthma as 3-4
39
Describe pertussis
-usu self limited in adults, but deadly for infants
-3 stages: (1) catarrha -most infex (2) paroxysmal --get whooping (3) convalescent
-Tx: macrolide 5-7 days
40
Descr streptococcus pneumoia
-rust-colored
-lobar consolidation on CXR
-lancet-shaped gram positive diplocooci pairs in chains
-Tx: Cephalosporin, higher dose of b-lactam
-vaccines: at 65 yrs-->PCV20. IF not available, then PCV 15 followed in 1yr by PPSV23
41
Desc staph PNA
Often a superinfection following influenza
-hemoptysis w/salmon-pink sputum
-diffuse lung infiltates on CXR and pneumatoceles
-gram positive cocci in clusters
Tx: MSSA --> B-lactam (usu nafcillin)
Tx: MRSA -->vanc, telavancin, linezolin
*Daptomcyin INEFFECTIVE, do NOT use to tx staph PNA
42
How do you treat patient with auto-PEEP and normal BP
*The principle is to shorten inspiration and lengthen expiration. can do this with the following:
(1) Decr RR (may require sedation if pt breathing over the ventilator
(2) Decr TV (has only a small effect)
(3) Incr peak inspiratory flow rate (sm effect)
(4) Treat bronchospasm and reduce airway secretions
43
How do you tx auto-peep in pt that has HYPOTENSION
1) DISCONNECT pt from ventilator, and manually ventilate (bag pt thru ET tube)
2) RETURN pt to ventilator w/new settings:
-Decr TV
-Decr RR
-Incr flow rate (shortens time for inspiration, allowin longer time for expiration)
44
Which COPD pts get long-term supplemental oxygen therapy
COPD pts, regardless of severity, should get long-term oxygen therapy if:
(1) oxygen statuation is ≤ 88 %
(2) partial pressure of oxygen is ≤ 55 mmgHg
45
a Week or less of high-dose steroids can be stopped w/out any additional testing. T/F
TRUE.
A week or less of high-dose steroids would NOT be expected to suppress the hypothalamic-pituitary-adrenal axis . No monitring or return of adrenal function is needed.
BUT if a test was needed (ie >1wk of high-dose steroids)-->used ACTH stimlation test to assess adrenal function
46
What is abx for Aspiration pneumonia
Tx:
B-lactam/B-lactamase inhibitor
Hospitalized:
ampicillin-sulbactam preferred
47
Describe abx that make up B-lactams
*Penicillins: =end with "cillin"
*cephalosporin
*carbapenems
*monobactams
*Beta-lactamase inhibitors (clavulanic acid, sulbactam, tazobactam
48
What are features of HPS (hepatopulmonary syndrome)? What is definitive tx?
HPS: defect in arterial oxygenation 2/2 gas exchange disorder occuring in the setting of liver dx AND in the absence of intrinsic lung dx
-Sx: dyspnea, platypnea (dyspnea worse w/sitting up), hypoxemia, orthodeoxia (hypoxia worse w/sitting up)
-consists of liver cirrhosis, positional deoxygenation, and intrapulmonary shunting 2/2 pulmonary dilations and direct aVMS
-progronsis is poor. Hypoxia may occur via V/q mismatch/shunting
-Definitive treatment for pts with a poor response --> liver transplant
49
Describe Supervior vena cava syndrome?
-SVC is medical emergency
-Sx: SOB, swellign of neck/face, edema of chest +/- hypotension
Causes:
-80% 2/2 malignancy (small cell or squamous cell lung caner)
-non malignant causes: goiter, infx (TB, syphilis, histoplasmosis), fibrosing mediastinitis
50
What is tx for cough/ viral URI
Tx
-daily nasal steroid
-antihistamine
-leukotriene antagonist
-sinus rinse
NONALLERGIC CAUSES
-temp use of ipratropium nasal spray
-remove inciting factors
51
What is tx for lung abscess
Sx: malaise, wt loss, inolent cough w/progressive purulent sputum often fetid
-Dx: CXR shows cavitary lesion +/- septic emboli
-Tx: IV B-lactams+B-lactamase inhibitor -->switch to oral amox-clau w/improvement
-duration: >3wks
52
What is treatment of PJP
-oral/IV bactrim
+ steroids if PaO2 <70 mmHG
52
What is treatment of PJP
-oral/IV bactrim
+ steroids if PaO2 <70 mmHG
53
Describe tx of permission hypercapnia w/tx of asthma exacerbation requiring intubation
Permissive hypercapnia--controlled hypoventillation
-maintainO2 sats ~90%
-low TV
-Low RR
-Incr inspiratory flow rate (prolonged expiratory time)
54
What diagnostic test is CTA useful for? non-contrast CT? HR-CT
CTA: dx pulmonary embolus (also aortic dissection)
HRCT: ILD
non-contrast CT: pulmonary nodule
55
What are examples of extra-thoracic upper airway obstruction? What does flow-curve look like?
Think of a thin rubber wall in neck (instead of trachea)--collapses w/inspiration.
EX: tracheomalacia, vocal cord paralysis
Curve: Flattened at bottom (during inspiration).
56
What are examples of extra-thoracic upper airway obstruction? What does flow-curve look like?
Think of a thin rubber wall in neck (instead of trachea)--collapses w/inspiration. Flow impeded with inspiration.
EX: tracheomalacia, vocal cord paralysis
Curve: Flattened at bottom (during inspiration).
57
What are examples of intra-thoracic upper airway obstruction? What does flow-curve look like?
Flow is impeded on expiration
Ex: intra thoracic tracheomalacia
Curve: flattened at top (during expiration)
58
What do you characteristically find on flow-volume loop for obstructive dx?
Obstructive dx shows characteristic concave scooping of expiratory limb on flow-volume loop. (VS restrivtive dx which shows characteristic narrowing of flow-volume loop.)
59
What is the preferred screening method to reduce lung cancer in high risk individuals?
annual low-dose chest CT.
60
What is auto-PEEP? How does it occur?
Ventilation with inadequate expiratory time can result in dynamic hyperinflation with increasing levels of PEEP
-Increased PEEP can result in decreased venous return and hypoventilation.
61
Describe ABPA
Defn: allergic rxn to aspergillous results in chronic cough, & recurrent pulmonary infilrates with eosinophila in pts with asthma or CF.
Dx: sputum clx--eosinophillia and aspergillus, elevated eosinophills and/or elevated IgE
Tx: itraconazole, steroids, voriconazole
62
With EXTRA-thoracic upper airway obstruction--is the obstruction at inspiration or expiration
Obstruction occurs at INSPIRATION
Ex: vocal chord paralysis or tracheomalacia
63
With INTRA-thoracic upper airway obstruction--is the obstruction at inspiration or expiration
Obstruction occurs at EXPIRATION
Ex: intrathoracic tracheomalacia
64
What conditions cause NORMAL A-a gradient? What conditions INCREASE A-a gradient?
NORMAL:
-Hypoventilation (incr PaCO2)
-High Altitude (low PiO2)
ELEVATED:
-diffusion defect (rare)
-V/Q mismatch
-Right-to-Left shunt
-Increased O2 extraction
65
What are sx of pulmonary embolus vs dilated cardiomyopathy? What are different types of dilated cardiomyopathy?
Pulmonary Emboli
-pleuritic pain, sudden onset dyspnea, tachycardia
-Dx: EKG, ABG, CXR. 1st line: CTPA
Dilated cardiomyopathy
-OVERT HF sx --> dyspnea + VOLUME overload (edema lungs/legs)
-Types: (1) stress cardiomyopathy (2) peripartum (3) toxin-induced
-Dx: echo
66
What are normal pulmonary artery catheterization pressures
PCWP: 4-12 mmHg
RA: <8 mm Hg
RV: (15-30)/ (1-7)
67
What shock states do you see diastolic pressure equal in all 4 chambers
TAMPONADE (also constrictive pericariditis)
-Low CO, High SVR, High PCWP
68
What is bronchiectasis? Sx.? Dx?
BRONCHIECTASIS
-dilation of bronchi caused by inflammation. Bronchi fill w/mucus & pus--then become fibrotic.
-Sx: chronic cough w/ purulent sputum, older-middle aged.
-Dx: HRCT (CXR may show tram tracks)
69
For CAP, outpt with NO RFs--what basic 5 pathogens should you consider? What are 3 empiric abx that can be used?
BASIC 5
(1) Strep
(2) H influenza
(3) M pneumoniae
(4) C pnuemoniae
(5) Virus
3 EMPIRIC ABX:
-AZM
-Doxycycline
-Clarithromycin
70
CAn you tx pseudomonas with CTX?
NO!
71
Describe Pulmonary Artery Catheter readings for "Sepsis" aka distributive shock
SEPSIS:
-CO high;SVR low; PCWP low
**The hallmark of early sepsis is hyperdynamic heart (high CO), with very low SVR. typically the pt in early shock is volume depleted and THIRD SPACING- the fluids given for resuscitation 2/2 low SVR-- a distributive type of shock!
72
Desc vocal chord dysfunction? Dx?
VOCAL CHORD DYSFUNCTION
-issue with INSPIRATION (unlike asthma where probl is w/expiration)
-suspect in pt who exp SOB, dysnpea, cough, chest tighness despite asthma tx
-flow volume loop: plateau in inspiratory airflow c/w extrathoracic obstruction
-Dx: laryngoscope
73
Describe theophylline toxicity.
Theophylline
-Used to tx COPD refractory to 1st line agents ICS, LABA, and anticholinergic
-BUT narrow therapeutic range makes toxicity a major concern!
Sx: n/v, tremors, metabolic (hypokalemia, hyperglycemima)
-Many meds can ppt toxicity including macrolides and fluroquinolones
74
Descr cryptogenic organizing pneumonia (COP). Tx?
Tx: prednisone
-Sx: FEVER +flulike illness, cough
-Think: failure to respond to abx!!!
**Impt to differentiate COP from Idiopathic pulmonary fibrosis (IPF) becs COP has GOOD prognosis!
75
What are abx for (community acquired pneumonia) CAP, no RFs? RFs?
NO RFs
(1) Macrolide( local resistance <25%): azithromycin, clarithromycin
(2) amoxicillin
(3) doxycycline
RFs
(1) fluoroquinolone
(2) 2-drug combo:Oral β-lactame PLUS
-macrolide or doxycycline
76
What should make you think Legionella?
LEGIONELLA
-Org inhaled from soil or water
-similar to mycoplasma pneumoniea
-SEE GI Sx (diarrhea)
-Note: urinary antigen ONLY detects serogroup 1
-Tx: macrolides or fluoquinolones
77
What are 2 abx for empiric treatment of MRSA
Standard therapy PLUS:
linezolid or vancomycin
78
What are abx for empiric tx of pseudomonas
1) antipseudomonal fluroquinolone
2) antipseudomonal b-lactam
PLUS macrolide
* antipseudomonal b-lactam: piperacillin-tazobactam, cefepime, ceftazidime, aztreonam, imipenem, or meropenem
*macrolide: azithromycin, clarithromycin
79
What are RFs for pseudomonas
80
What are empiric tx for PNA treated in ICU
1) Intravenous β-lactam plus a macrolide
2) IF contraindicated, β-lactam plus respiratory fluoroquinolone
81
What are empiric tx for PNA treated in hospital (non-ICU)
1) IV β-lactam* PLUS macrolide
2) fluoroquinolone
*IV B-lactam: CTX, ceftaroline, ampicillin-sulbactam
82
What are empiric tx for CAP? With comorbidities
CAP, no comorbidities
(1) Amoxicillin
(2) Doxycycline
(3) Macrolide (if local pneumococcal resistance <25%)
CAP, comorbidities
(1) fluoroquinolone
(2) Oral β-lactam + plus macrolide/ doxycycline
83
Differentiate the following pulmonary pathogens
-Chlamydia pneumonia
-Chlamydia psittaci
-Staph aureus
-
(1) Chlamydia Pneumonia
-SORE throat, hoarsness, febrile illness.
(2) Chlamydia Psittaci
-SEVERE pna, extensive INTERSITIAL pattern on CXR
(3) Staph aureus
-usu AFER flu-like illness
84
What is tx for amiodarone-induced pulmonary toxicity
-stop amiodarone
-start another antiarrythmic drug
-ORAL steroids
85
What is a parapneumonic effusion?
Pleural effusion+ bacterial pneumonia
-Can be either complicated (loculated) or simple (fee-flowing)
86
Name 3 gram-positive cocci seen with PNA
-strep pyogens
-strep pneumoniae
-staph aureus
87
Discuss spirometry findings for key dx:
(1) FEV1/FVC <0.7 (or below the LLN) (2)Increase from baseline of ≥10% in FEV1, FVC, or both with bronchodilator therapy
(3) Equal reductions in FEV1 and FVC
(4) TLC is normal/increased
(5) Patient with LOW lung volumes + NORMAL DLCO.
(1) FEV1/FVC <0.7 (or below the LLN) indicates airflow obstruction.
(2) An increase from baseline of ≥10% in FEV1, FVC, or both with bronchodilator therapy relative to the predicted value indicates reversible airway obstruction-->ASTHMA.
(3) Equal reductions in FEV1 and FVC suggest restrictive lung disease
(4) TLC is normal or even increased in pure obstructive disease and decreased in restrictive disease
(5) n patients with low lung volumes, a normal DLCO suggests an extrapulmonary cause (e.g., obesity).
88
What dx should come to mind in pt REPEATEDLY fails abx tx for pneumonia
CRYPTOGENIC ORGANIZING PNEUMONIA (COP)
-Histology: patchy proliferation of granulation tissue
-Sx: cough, fever, and malaise over weeks to months. Initial CXR demonstrate patchy opacities that mimic pneumonia
-Tx: STEROIDS
89
Sarcoidosis TX--T/F:
(1) Do you tx asx sarcoidosis (usu stage 1, b/l hilar adenopathy on CXR)
(2) Do you tx erythema nodosum w/steroids?
DON'T BE TRICKED
(1) Do NOT treat asx sarcoidosis
(2) Erythema nodosum ->tx w/NSAIDS (not steroids)
90
What is vaccine for pneumococcus.
All patients aged ≥65 y:
- PCV20 alone
- or PCV15 followed by PPSV23 1 yr later
91
Describe 1st line tx for hyperthermia
1) evaporative cooling (mists, fan ,etc)
IF young, can do immersive cooling --but NOT 1st line treatment
92
Threshold to evaluate single pulmonary nodule?
Pt with no RFs for, pulmonary nodule <6mm requires no further followup.
**
93
Describe sarcoidosis
SARCOIDOSIS
-multi-system granulomatous inflammatory condition; 90% have pulmonary component
-doNOT treat asx pulmonary sarcoidosis
-
94
What ventilator settings adjust pH, PCO2?
What ventilator settings adjust oxygenation?
Ph, PC02
-TV, RR,
Oxygenation
-FiO2, PEEP
95
Describe long-term adverse effects of these 3 drugs:
-bleomycin
-radiation
-immunotherapy
-drug-induced lung injury (2 drugs)
1) Bleomycin: pulmonary toxicity, most commonly bleomycin-induced pneumonitis
2) Radiation: radiation-induced pneumonitis
3) Immunotherapy: pneumonitis
4) drug-induced lung injury
-nitrofuratoin
-amlodipine
-methotrexate
96
What alternative dx should I consider if asthma is difficult to control?
VOCAL CORD DYSFUNCTION
-Consider alternative diagnoses when asthma is difficult to control.
-Consider in pt w/SOB, dyspnea, tightness DESPITE ADEQUATE AStHAM tx
-Dx: laryngoscope
97
Desc COPD tx:
-LAMA
-LAMA + LABA
-LAMA +LABA + ICS (if esoinophils >=300)
+/- azithromycin: reduces hospitalizations
+/- roflumilast; reduce symptoms and exacerbations in patients)
+/- oxygen for severe resting hypoxemia (arterial PO2 <55 mm Hg or O2 saturation <88%)
For symptomatic patients with an FEV1 <50% of predicted, pulmonary rehabilitation is recommended.
98
Describe the difference between IPF (idiopathothic pulmonary fibrosis) vs NSIP (nonspecific internstial pneumonia)
NSIP
-younger age
IPF
-older age
-assoc w/smoking
-"Velcrove" sound
-honeycombing on CT
-poor prognosis
99
Describe small cell vs non small cell lung cancer
SMALL CELL LUNG CANCER
-bukly symptomatic masses +mediastinal invovlement
-paraneoplastic synrome -->SIADH (hyponatremia), lamber-eaton syndrome
NON SMALL CELL LUNG CANCER (NSCLS)
-80% lung cancers are NSCLS -->most common, and ALL dx of lung cancer in non smokers. 3 types
(1) adenocarcinoma: peripheral/lung parenchyma
(2) squamous cell: assoc w/SMOKING, usu central
(3) large cell: undifferentiated, peripheral mass + necrosis
100
Describe 3 hyperthermia syndromes NOT related to heat stroke
(1) NEUROLEPTIC malingnant syndrome
-antipsychotics (haloperidol, risperidone, quitinapine, olanzapine), antiemetics or w/drawal of antiparkinson meds
- NO myoclonus, NO hyper reflexia
-Tx: Dantrolene, Bromocriptine
(2) Malignant hypothermia
-xposure to anesthesia
-tx: Dantrolene
(3) Sertonin syndrome
-w/in 24hrs of inciting drug
-MYOCLONUS, HYPER REFLEXIA
-tx: benzos, cyphoheptadine
101
Name 5 drugs that can cause drug-induced diffuse parenchymal lung dx
1) amiodaraone
2) bleomycine
3) methotrexate
4) nitrofuratoin
5) busulfan
Tx: glucorticoids
102
What is common presentation for diffuse parenchymal lung diseases?
-dsypnea
-diffuse dx on CXR
- restrictive pattern + decreased DLCO (elevated A-a gradient)
103
What is classification of diffuse parenchymal lung disease?
(1) Known causes
-Drug-induced
-Smoking-related (respiratory bronchiolitis-associated)
-Radiation
-Chronic aspiration (mainly in the lower lobes; focal consolidation on CT)
-Occupational/environmental
-Connective tissue dx (SLE)
-Hypersensitivity
(2) Unknown causes
-Idiopathic pulmonary fibrosis (Chronic, aged >50; honeycombing, "velcrove"
-Idiopathic NONSPECIFIC interstitial pneumonia (younger population; honeycombing UNCOMMON)
-Cryptogenic organizing pneumonia (patchy opacities mimic PNA)
-Sarcoidosis (b/l hilar adenopathy; noncaseating granulomas are hallmark.
(3) Rare DPLD With Well-Defined Feature
-Lymphangioleiomyomatosis (premenopausal women; spontaneous pneumothorax and chylous effusions)
-Chronic eosinophilic pneumonia (“radiographic negative” heart failure, peripheral blood eosinophilia and eosinophilia on bronchoalveolar lavage)
-Pulmonary alveolar proteinosis (~ 39 years. Males predominate among smokers, but not nonsmokers. proteinaceous material in and around alveolar macrophages on brochoscopy; periodic acid-Schiff stain positive; “crazy paving” pattern on CT.)
104
What are 7 KNOWN CAUSES of diffuse parenchymal lung disease?
Known causes
1)Drug-induced
2)Smoking-related (respiratory bronchiolitis-associated)
-3)Radiation
-4)Chronic aspiration (mainly in the lower lobes; focal consolidation on CT)
-5)Occupational/environmental
-6) Connective tissue dx (SLE)
-7) Hypersensitivity
105
How do you treat large PE AND hemodynamic instability (hypotension)
thrombolytic therapy w/ tpa
106
Define pulmonary HTN using mean arterial pressure
-Pulmonary hypertension (PH) has been defined as a resting mean PULMONARY artery pressure of > 25 (14-20 nl) AND normal PCWP.
**Note this is different from blood pressure support--A mean arterial pressure of 65 mm Hg is considered the threshold at which there is sufficient pressure for organ perfusion in most humans**
107
How do you dx chronic PE? How do you tx?
DIAGNOSIS
Current guidelines recommend a V/Q scan to rule out CTEPH in all patients being evaluated for PH
TREATMENT
Anticoagulation AND consideration of thromboendarterectomy
108
How do you diagnose pulmonary embolism? How do you diagnose DVT
PE
1) CTPA
2) if renal dysnfuction V/Q scan (also use to dx chronic thromboembolism and in obese pts)
DVT
1) lower extremity u/s
2) IF u/s neg, then CTPA
109
What is treatment of pulmonary embolism?
What is treatment of DVT?
What is treatment of chronic PE?
PE
1) No hospitalization preferred-->DOAC
-1st line: apixiban, rivaroxaban
-note other doacs require 5 days of IV anticoagulant (LMWH/UFH)
2) IF hospitalized:
-LMWH 1st option
-UFH if unstable or kidney dx
-Fondaparinux if HIT II
-thrombolytics w/tpa for massive PE AND hemodynamic compromise (hypotensive)
-warfarin
-IVC filter IF need anticoagulant and pt has high bleed risk
*Remember summary:
**Initial parenteral administration (LMWH, UFH, or fondaparinux,) followed by oral administration of dabigatran, edoxaban, or warfarin
**monotherapy (oral anticoagulant started WITHOUT initial parenteral anticoagulant) with apixaban or rivaroxaban.
**DOACs are preferred to warfarin.
DVT
-1st choice DOAC
-LMWH if pregnant
-duration IF provoked 3-6months, extend for unprovoked
Chronic PE
-anticoagulation AND thromboendarectomy
110
If you see PH<7.2 AND glucose <60, what should you think?
Complicated parapneumonic effusion
-In the setting of suspected infection, a pleural fluid pH level of less than 7.2 AND glucose <60 mg/dL [2.2 mmol/L] is the best indicator of a complicated pleural effusion --
-Tx: requires drainage.
**Note: glucose <60 also seen with: TB, rheumatoid pleuritis, esophageal rupture
111
How do you treat difficult to control asthma + Elevated IgE:
Elevated IgE: Omalizumab
112
What is obesity hyperventilation syndrome? obstructive sleep apnea (OSA)?
Obesity hyperventilation syndrome
-daytime hypercapnia
-Tx: BPAP
Obstructive sleep apnea
-daytime sleepiness
-Tx: CPAP
113
What are the different types of non invasive positive pressure inhalation (NPPV)?
NPPV
-CPAP: continuous pressure during inspiration and expiration [OSA, pulmonary edema]
-BiPAP: increased pressure during inspiration [obesity hypoventilation synrome, COPD exacerbation, neuromuscular]
114
What are 10 Contraindications to the use of NPPV?
Contraindications to the use of NPPV include: 1)persistent altered mental status,
2) increased airway secretions,
3) emesis,
4) gastric distention,
5) airway obstruction,
6) recent esophageal surgery,
7) cardiac arrest,
8) inability to protect the airway,
9) facial trauma/surgery (including oral, nasal, or sinus),
10) patient intolerance of the mask.
115
What is bronchiectasis? Presentation? Dx? Tx?
DEFINITION
chronic suppurative lung disease associated with irreversible enlargement of the airways due to destruction of airway architecture.
PRESENTATION
-any patient with a chronic cough, especially if the patient has a history of frequent respiratory infections or if the cough is productive.
-Features that should alert the clinician to consider bronchiectasis, especially without significant smoking history, include clubbing and previous sputum cultures growing uncommon pathogens such as Pseudomonas aeruginosa, Aspergillus, or nontuberculous mycobacteria
DIAGNOSIS
high-resolution chest CT; diagnostic criteria include airway diameter greater than that of its accompanying vessel and lack of distal airway tapering.
TREATMENT
-should be determined whether there is an underlying cause that can be treated
116
What is preferred tx for Uncomplicated Provoke PE? duration?
DOAC
-apixaban or rivaroxaban do NOT require parenteral tx
-dabigatran, edoxaban (must complete 3days parenteral tx w/fonapeinus, LMWH
Duration: 3-6 months
117
What is recommended f/u for solitary nodule:
<6 mm
>=6 mm
LOW-RISK
<6 mm: No follow-up
6-8 mm: CT at 6-12 months, then CT q2yrs for 5 yrs
>8 mm: CT at 3 months, PET/CT, or tissue sampling
HIGH-RISK
<6 mm: CT at 12 months
6-8 mm: CT at 6-12 months, then CT q2yrs for 5 yrs
>8 mm: CT at 3 months, PET/CT, or tissue sampling
**PET is not useful for the determination of malignant potential in lung nodules less than 8 mm in size.
118
Define pulmonary hypertension
PULMONARY HYPERTENSION
-PH is defined by a resting mean pulmonary arterial pressure of ≥20 mm Hg and a pulmonary capillary wedge pressure ≤15 mm Hg.
-The current classification system subdivides PH into five groups.
-Group 1 is distinguished by disease localized to small pulmonary arterioles resulting in high pulmonary vascular resistance and is referred to as PAH.
-Groups 2 through 5 refer to important secondary causes of PH and include left-sided heart disease, respiratory disorders (COPD, interstitial lung disease, and sleep-disordered breathing), and chronic venous thromboembolic disease.
119
How is dx of COPD confirmed (using FEV1/FVC)?
The diagnosis of COPD is confirmed by an FEV1/FVC ratio of less than 0.70 without a significant bronchodilator response.
120
How is bronchiectasis diagnosed?
HRCT
Also do immunoglobulin measurement
121
Discuss dx of PAH vs HF using mean arterial pressure
PAH
-MAP >20 (nl 10-20) and PCWP <15 (nl 6-12)
Left Heart Failure
-MAP >20 AND PCWVP >15
122
What are findings of massive PE on echo?
-acute RV failure
-RV dilation (w/septal blowing)
-elevated RV systolic pressure
123
Desc presentation of PE
sudden onset dyspnea, tachycardia, chest pain
124
What is treatment for IPF
1) Lung transplantation
2) SLOWS progression but not curative: Pirfenidone, Nintedanib
*Poor prognosis. NO steroids!
125
Do you treat aspiration pneumonia?
Anaerobic infections are uncommon causes of CAP.
- IF Outpt: amoxicillin or amoxicillin-clavulanate
-IF hospt: addition of anaerobic coverage is recommended only if lung abscess or empyema is present.
126
How do you diagnose (middle-high pre-test probabily) ACUTE PE? Chronic PE?
#1) CTPA
-less invasive than pulmonary angio
2) Echo
-IF pt unstable, can use echo
3) V/Q
-recurrent or chronic thomboemboli?
127
WHEN SHOULD YOU SUSPECT PULMONARY HTN? SX? What is definitive test?
Pulmonary hypertension should be suspected in patients with progressive dyspnea, elevated central venous pressure, prominent venous a wave, fixed splitting of S2, and the murmur of tricuspid regurgitation.
-R-sided S3 or S4 gallop (hear best at left sternal border)
DIAGNOSE
Right heart catheterization and measurement of pulmonary artery pressure is the diagnostic gold standard for pulmonary hypertension
128
What distinguishes "OSA" from "obesity hypoventilation syndrome"
Obesity hypoventilation syndrome has: daytime hypercapnia
-use ABG to eval
129
What is treatment of LATENT TB
For patients without HIV, select any of the following:
-3 months of isoniazid plus rifapentine given once weekly
-3 months of isoniazid plus rifampin given daily
-4 months of rifampin given daily
130
What do you see with obesity HYPOventilation syndrome
- daytime hypercapnia (arterial PCO2 >45 mm Hg [5.9 kPa])
- HF and volume overload
- pulmonary hypertension
131
Describe these occupational lung diseases:
- Silica
- Beryllium
Describe:
-Idiopathic pulmonary fibrosis
SILICA
-Exposure: think sandblasting
-Imgaing: ground-glass, nodular, interstitial, or fibrotic infiltrates.
BERYLLIUM
- Exposure: aerospace, car, nuclear, and telecommunication
- Imaging: granulomatous lung dx, reticular nodular; middle/uppler lobes
IPF
-Imaging: HONEYCOMB cysts, lowe lobe
132
Desc findings seen in Hantavirus
HANTAVIRUS
- hemoconcentration, thrombocytopenia, incr lymphocyte count, myelocytosis
133
When do you use CPAP vs BPAP
CPAP
-OSA
-Pulmonary edema
BPAP or noninvasive bilevel positive pressure
-EVERYTHING else (COPD exacerbation, Obesity hypoventilation syndrome, Neuromuscular dx, kyphosis)
134
ICU CAP tx
3rd-generation cephalosporin or ampicillin-sulbactam plus a macrolide or quinolone
135
CAP tx to avoid in pregnant pts
Quinolones and tetracyclines
136
Mimics ARDS but pt coughs up blood?
Diffuse alveolar hemorrhage (Option B) is the result of bleeding into the alveolar spaces secondary to the disruption of the alveolar-capillary basement membrane. Most patients present with hemoptysis, although this might be absent and the diagnosis nevertheless suggested by the appearance of new diffuse or focal infiltrates and falling hemoglobin level
DX: sequential bronchoalveolar lavages
137
Which TEST will help predict patient's responsiveness to inhaled glucocorticoids?
Fractional exhaled nitric oxide (FeNO) (Option C) will help predict this patient's responsiveness to inhaled glucocorticoids. Although FeNO should not be used as a diagnostic tool for asthma, it can be used to support this diagnosis in situations in which additional objective evidence is needed.
138
What are 2 most common causes of postinfluenza bacterial pneumonia
STREP, STAPH
139
Describe chlamydia pneumonia
-gradual onset of sx
-ERYTHEMA multiforme lesions
-Tx: azithromyin
-Atypical pneumoniae
140
what does hypersensitiviy pneomonitis show on:
-xray
-hrct
Chest x-ray may be normal or show diffuse micronodular disease. HRCT shows diffuse centrilobular micronodules and ground-glass opacities.
141
What is treatment of massive pulmonary hemoptysis
Bronchitis, bronchogenic carcinoma, and bronchiectasis are the most common causes
Angiography can localize and treat bronchial artery lesions.
142
What is anti synthase syndrome?
Inflammatory myopathy (rheum) + ILD
Tx: steroids
143
Describe the following high altitude illnesses:
- acute mountain sickeness
- high altitude cerebral edema
- high altitude pulmonary edema
ACUTE MTN SICKNESS
-elevation: 2000-2500m
-tx: acetazolamide
-ppx: acetazolamide
HIGH ALTITUDE CEREBRAL EDEMA
-elevation: 3000-4000m
-tx: Descent, supplemental oxygen, hyperbaric therapy
-ppx: acetazolamide
HIGH ALTITUDE PULMONARY EDEMA
-elevation: >=2500m
-tx: oxygen and descent from altitude; nifedipine; PDE-5 inhibitors
ppx: nifedipine
144
Describe hypersensitivity pneumonitis findings --sx & imaging
Sx: +/- fever, cough, fatigue
Exam: INSPRATORY crackles
CXR: normal or diffuse micronodular disease.
HRCT: diffuse CENTRILOBULAR micronodules and ground-glass opacities.
Tx: antigen removal
145
describe methanol
Methanol:
Occurs in windshield wiper fluid and moonshine
Can cause retinal damage'
OSMOLAR GAP: metabolic acidosis
Treat with fomepizole or ethanol
146
describe ethanol
Ethylene Glycol:
Occurs in antifreeze
Can cause acute renal failure
OSMOLAR GAP: metabolic acidosis
Treat with fomepizole or ethanol
147
sleep apnea neck circumference menomonic--16/17/18
One possible mnemonic to remember the neck circumference values for OSA is "16/17/18 rule", which stands for:
16 cm (6.3 inches) for women
17 cm (6.7 inches) for men who are not obese
18 cm (7.1 inches) for men who are obese
Of course, it's always a good idea to double-check the specific criteria used by your clinical practice or guidelines.
