Pulmonary Flashcards
What is the length of cough typically in Acute Bronchitis
1-3 weeks
Typical sxs associated with acute bronchitis (4)
Purulent sputum
Wheezing
Rhonchi
URI sxs
Management acute bronchitis
Supportive care; usually resolved in 1-3 weeks
What cells are effected in influenza ;; transmission?
Ciliated cells of the respiratory tract ; decreasing ciliary resistance ; infection spreads to lower respiratory tract
Transmission = respiratory droplets
3 sxs associated with the Flu
Myalgia
Fever
Cough
What are CXR findings in influenza
Bilateral
Or
Reticulonodular opacities
+/- consolidation
Flu management pearls
Osletamivir is drug of choice given with 48-72 hours of sxs onset
[protects agains flu A and flu B]
Rimantidine is another option
[protects only against flu A]
Who is at highest risk of complications from the flu? (3) ;; what bacterial infection can coincide
Pregnant
Less tha 2 years
Elderly > 65 yrs
Staph A and Strep P
Who should receive the flu vaccine
Everyone over the age of 6 months
The flu live vaccine should not be used in what populations (4)
-People age less than 2 or over 49
-Age 2-17 receiving ASA therapy
-Pregnant patients
-If received antivirals in the last 48 hours
5 typical bacteria involved in CAPNA
1 Strep Pneumo
Staph A
Haemophilios Influ.
Klebsiella
Pseudomonas Aerginosa
3 Atypical Bacteria in CAPNA
Mycoplasma pneumoniae
Legionella
chlamydiae pneumoniae
What is the difference in onset for atypical vs typical influenza ;; key sxs differences
Atypical = insidious ; non productive cough
Typical = sudden ;pleuritic chest pain
What is tactile fremitus in CAPNA and percussion does what?
Increased
Dull to percussion
3 positive lab findings in CAPNA
LEUKOCYTOSIS with a. LEFT SHIFT
Elevated procalcitonin
Could have positive blood culture
What does the gram stain look like in strep pnuemoniae
gram positive cocci in pairs ;; lancet shaped
What does the gram stain look like in atypical CAPNA
Not present. No stain.
4 things important about Legionella PNA
PNA sxs + Diarrhea
Hyponatremia
Urine antigen assay testing
Staph A can present with what CXR finding?
Cavitary legions
General management for CAPNA without and with comorbids
Without = Macrolide, Amoxicillin, Doxycycline
With = Augmentin, Cephalexin + Azithromycin
-Resp FQs
CURB 65 score criteria
0-1 HOME TREATMENT
2-3 CLOSE OP / OR ADMISSION
3-5 [30 day mortality 22%] SEVERE ADMISSION
What type of flu vaccine is recommend in sickle cell patients
PCV15 and PCV20
What is another name for pleural effusion
Parapnuemonic effusion
What is the definition of HAPNA ; and VAP?
Within 48 hrs of admission
VAPNA develops within 48-72 hours of intubation
What is the antibiotic of choice in positive abscess aspiration PNA
Ampicillin-Sulbactam or Augmentin
Most common cause of PNA in HIV with CD4 less than what?
PJP PNA ; also same in organ transplant folks
Less than 200
What will be present for PJP on CXR and CT Scan
CXR = Diffuse bilateral infiltrate
CT Scan = Ground Glass appearance
What is the management and prophylaxis for PJP PNA
Management = BACTRIM
Proph = BACTRIM ; if CD4 count less than 200
Management and Prophylaxis for PJP PNA
M = Bactrim
P = Bactrim
What are extra pulmonary diseases assoicated with TB (3)
Meningitis Osteomyelitis , Potts Disease
What is the gold standards dx of choice for TB
Acid Fast Bacilli Stain and Culture
Active TB management
RIPE x 2months
Rifampin Isonazid x 4months
What do we need to know about Side effects of RIPE therapy ?
R= red urine
I = peripheral neuropathies, give B6 pyridoxine
P = [mild joint pain]
E = can cause color blindness
How do you screen vs diagnose TB?
Screen - TST skin test, IGTA blood test
Dx - Positive screen + Positive CXR and Sputum
What do we need to know about TB positive skin testing
Measures transverse diameter of induration
[not erythema]
General positive values of TB based on risk
5 = HIV, Recent Contact, Immune suppressed
10 = High prevalence country in the last 5 years , less 90% ideal body weight, compromised, IV Drug users
15 = Healthy folks
What is the most common malignant pulmonary nodule
Adenocarcinoma
What is the most common benign pulmonary nodule
Granuloma
What is the next step if you see a positive pulmonary nodule on CXR
Low dose CT without contrast; then Biopsy
What is the recommendation for low and high cancer risk patients with pulm nodule 6-8 mm ?
Low < 5% = CT at 6-12 mo’s then 18-24 mo’s
High >65% = CT at 6-12 mo’s then 18-24 mo’s
2 common characteristics of squamous cell carcinoma of the lung
Starts centrally
Hypercalcemia common
What is the patho associated with superior vena cava syndrome and scc lung cancer
Obstruction of blood return to the heart by invasion compression or thrombosis of the superior vena cava
-Facial Plethora
-Distended Neck Veins
PNP syndromes associated with Small Cell Cancer
SIADH
Cushings
Carcinoid = flushing diarrhea
Eaton Lambert Syndrome
SVC Syndrome
PNP syndromes associated with Squamous Cell Cancer
High PTH - Hypercalcemia
Horner Syndrome
Pancoast Tumor
PNP syndromes associated with adenocarcinoma
Pulmonary osteoarthropathy
Marantic endocarditis
PNP syndromes associated with Large Cell Cancer
SVC Syndrome
Gynecomastia
Centrally located abnormal CXR concerning for cancer should be evaluated by? (3)
Sputum cytology
Bronchothoracic Bx
Transthoracic Bx
Peripherally located abnormal CXR concerning for cancer should be evaluated by? (3)
CT Transthoracic Bx
Thoracoscopy
Thoracotomy
USPTF for Lung Cancer Screening
20 pack year history and currently smoke or have quite in the last 15 years
Age 50-80
What cells are increased in chronic bronchitis
Goblet cells
Definition of chronic bronchitis
Chronic productive cough for longer the 3 months in at least 2 consecutive years
What type of wheeze is assoc with chronic bronchitis
Expiratory
Gold standard PFT findings associated with chronic bronchitis
Dec FEV1 and FEV1/FVC Ratio less 0.7
NML to increased TLC ; increased residual volume
NML diffusing capacity for carbon monoxide DLCO
What happens to alveoli in emphysema
Loss of elastic recoil and decreased surface area
4 risk factors for emphysema
Alpha 1 antitrypsin Def.
Asthma
Occupational exposure
Smoking
3 findings common in alpha 1 antitrypsin def.
Emphysema + Hepatitis + Vasculitis
Talk about what an emphysematic patient looks like
Pursed lips
Barrel chest [AP diameter increase]
Hyperrersonance
Gold standard PFTS found in emphysema
Reduced Ratio less than 0.7
NML to increased TLC, RV
REDUCED DLCO
Dont forget to prescribe your patients what for COPD?
Smoking cessation!!
When should you give antibiotics in COPD patients
Increased sputum ; Dyspnea or if mechanically ventilated
Pathophysiology and example of TRANSUDATIVE effusion
Imbalance of hydrostatic and oncotic pressures
-Heart Failure
-Cirrhosis
Pathophysiology and example of EXUDATIVE effusion
Increased capillary permeability, decreased lymphatic drainage
-Malignancy
-Infection
-Pulmonary Embolism
EXUDATIVE serum LDH is likely what
Elevated ; greater .6 and elevated 2/3 UPLN Serum LDH
What types of CXR are helpful with pleural effusion
Lateral decubitus
Upright
CXR best for pleural effusion imaging
Lateral decubitus
Upright
Thoracentesis insertion site for pleural effusion
1-2 intercostal spaces below the effusion
5-10 cm lateral to the spine
Definitive mangement of pleural effusion
Pleurodesis or indwelling pleural catheter
Management of pleural effusion less than 15% of chest diameter
Supplement O2 and monitor with serial chest X-ray
Management of PTX greater than 15% of chest diameter?
High concentration o2
Chest tube
Serial chest X-rays
What is virchows triad ; and for what>
Hypercoagable , stasis , endothelial injury
For PE
Remember what 4 factors for determining PE probability
HR > 100 bpm
Previous DVT
Immobilized 3 days or surgery in the last 4 weeks
Hemoptysis
++ malignancy [you know this]
What age folks can be PERCed out for PE? What can they not be taking?
Age less than 50
Exogenous estrogen
What D-dimmer level excludes PE
Less then 500
What is localized oligemia? Also associated with what for PE
Assoc with PE, reference to decreased lung markings surrounding pulm vessel
Wetsermarks Sign and Hampton’s Hump
What type of bundle branch is associated with PE?
RBB
Management in order for PE based on severity :
Hemodynamically stable
>Anticoagulation
Hemodynamically unstable:
>Thrombolytic therapy
>Surgical thrombectomy or embolectomy
>Inferior vena cava filter [contra or previous PEs]
Who should get LMWH after previous PE
If undergoing surgery
Pulmonary hypertension is defined as an arterial pressure of what
Over 20
What 3 things can cause increased resistance in pulmonary hypertension
Sleep Apnea
Fibrosis
Thromboemboli
What two things can cause increased pressure in Pulm hypertension
Left to Right Shunt
Heart Failure
What 3 diseases are associated with vascular thickening and worsening of pulm hypertension
Pulmonary fibrosis
Scleroderma
Sarcoidosis
WHO Pulm hypertension by number, 1-5
1 =Arterial
2=Left heart disease
3=CLDz
4=Thromboembolic
5=Multifactorial
Abnormal sxs of pulm hypertension and why?
Anorexia
Right ventricular heart failure
What is the definitive diagnosis for Pulm hypertension
Right heart catheterization with arterial pressure greater than 20
What is a chronic vs. acute cause of cor pormonale
Chronic : COPD
Acute : Large PE
What is an interesting findings in idiopathic pulmonary fibrosis
Nail clubbing and Bibisilar crackles
Two common findings when diagnosing idiopathic pulmonary fibrosis
Honeycombing and Normal FEV1/FVC ratio
What two anti fibrotic medications can be used in IPFibrosis ; definitive
Nintedanib
Pirfenidone
Definitive treatment = Lung Transplant
What can cause
Silicosis
Siderosis
Asbestosis
Which are all types of :
Silicosis = mining
Siderosis = arc welding
Asbestosis = shipyard ; building demolition
PNEUMOCONIOSIS
PTS WITH rheumatoid arthritis can develop what lung syndrome?
Caplan syndrome
Rheumatoid nodules in the lungs
CXR findings sig for pneumoconiosis
Small round nodular opacities in the upper lobes
4 silicosis hazardous jobs
Rock mining
Sand blasting
Masonry work
Stone cutting
What does silicosis look like on CXR
Eggshell calcifications
4 jobs associated with asbestosis
Mining
Ship building
Construction
Pipe fitting
CXR and CT findings for asbestosis
Lower lobe reticular opacities with honeycombing
CT = parenchymal pleural plaques
1 complication of pneumoconiosis
2 = bronchogenic carcinoma
Mesothelioma - asbestosis
3 places possible for mesothelioma spread
Pleural
Pericardial
Peritoneal
What are two things to remember about sarcoidosis
NOn caseating granulomas with T cell and inflammatory cell overgrowth
Produces increased ACE levels
what is lofgrens syndrome
Hilar LAD
Erythema nodosum
Arthritis
CXR for sarcoidosis usually has what
Bilateral hilar adenopathy
PFTs will be what for sarcoidosis
Restrictive
First line and alternative treatment for sarcoidosis
Low dose prednisone
Methotrexate = alternative
What is the Samter triad
ASA sensitivity
Nasal Polyps
Asthma
What is the atopic triad
Allergic rhinitis
asthma
Atopic dermatitis
What is the #1 etiology of ARDS
Sepsis
What type of sputum is common in ARDS
Frothy pink-red sputum
CXR findings in ARDS
Bilateral diffuse opacities
What is the FVC
Measure of forced expire volume until full exhalation
When would you perform the 6 minute walk test
To quantify exercise tolerance and effectiveness of interventions
Hemoptysis ; stridor ; DOB retrieval ; staging of cancer think what diagnostic
Bronchoscopy
Catemenial asthma is what
Only present with menses
Anticholinergic work how for asthma
Lead to bronchial smooth muscle dilation to relieve constriction
When can you step down asthma therapy
After 3 months of control
A1 Anti trypsin think early onset COPD + what else
Hepatic dysfunction
Elongated lungs with diaphragmatic flattening think what on CXR
COPD
COPD therapy that can help ; only proven one
O2 supplementation if hypoxic
What is the step up course for COPD ABCD
BD SABA / SAMA
LABA or LAMA
LAMA
LAMA + LABA
CC are not proven to be helpful
What electrolyte can be helpful in COPD exacerbations
Magnesium
Think what drugs for inducing interstitial lung disease
Amiodarone
Methotrexate
2 complications of IPFibrosis
RVH Dz
Pulmonic HTN
IPFibrosis has what nail changes
Clubbing ;; DRY INSPIRATORY CRACKLES
Pneumoconiosis treatment
Inhaled BD
Supplemental O2
Consider Lung TXPLT
Coal workers pneumo [4]
Ingestion of coal dist leading to coal Macules in the lungs
+RF or +CCP for Rheumatoid arthritis
Pts initially asxs at first
CXR : diffuse small opacities prominent in the upper lung fields
Silicosis [4]
Inhalation of silica particles = glass workers; sand blasters ; miners
UPPER LOBES ; egg shell calcifications
Higher incidence of TB
CXR : small rounded opacities in the upper lobes along with peri hilar node calcifications
Asbestosis [4]
Exposure to SHIPYARDS, construction workers ; piper filters; insulators
Progressive dyspnea resulting in mesothelioma and lung cancer
Cancer of the pleural lining
CXR = linear streaking honey combing pleural plaques
Non caseating granulomatous lung disease
Sarcoidosis
elevated ACE Hypercalcemia elevated ESR
What organs are involved in sarcoidosis [4]
Cardiac restrictive cardiomyopathy
Skin : erythema nodusum ; arthritis
Constitutional : malaise ; fever ; dyspnea
Organomegaly
CXR of sarcoidosis
Mediastinal and hilar LAD
Pulmonary nodules vs masses
Less than 3 cm - nodules
Mass = greater 3cm
MC malignant pulmonary nodule
Adenocarcinoma
Small cell lung cancer are usually where
Central discrete NO discrete intraluminal mass
If central mass with intraluminal mass think what lung cancer
Squamous cell
Where do lung Adenocarcinoma often arise from
Mucous glands
Complications of lung cancer SPHERE ; that can be a pts first presentation
SVC syndrome
Pancoast tumors
Horners syndrome
Endocrine Tumores / carcinoid SIADH=small cell
Recurrent laryngeal symptoms
Effusions
Should you recommend surgery for small cell lung cancer
No ROLE , just chemo and radiation
MC location for carcinoid tumor
GI tract
Why is there flushing diarrhea and bronchospasms in carcinoid tumors
Serotonin release
PE percussion causes what ; tactile fremitus
Dullness
Decreased
TRANSUDATIVE effusion think about
Hypoalbuminemia [cirrhosis, nephrotic syndrome]
Malnutrition’
CHF
Constrictive pericarditis
EXUDATIVE effusions think
Malignancy
Pancreatitis
Post cardiac surgery
PTX think what physical exam
Hyperresonance to percussion
Diminished breathe sound
Reduced lung expansion
Location for ND / Chest tube
2-3 Mid clavicular = acute unstable, ND
4-5 mid axillary = stable, chest tube
Recurrent PTX treatment
VATS or pleurodesis
U/S for PTX +
Barcode sign
= no lung sliding
Age of croup infection commonly
6 mo - 5 years
Does croup usually have fever
NO
MC pathogen in epiglottis
HIB
Strep
Good abx for epiglottis
Ceftriaxone
What is an example of gram negative PNA
Klebsiella = ETOH
Pseudomonas = cystic fibrosis
HAP vs VAP Mc pathogens
HAP = Staph A
VAP = Acinobacter
Greater than what age for flu vaccine
6 months
Paramyxovirus think [3]
Rsv
Parainfulenza —> croup
TB risk factors
Incarcerated
Drug use
Homeless
Droplets —> alveoli —> macrophages engulf infection [becomes active or latent]
Chronic cough w rusty sputum hemoptysis
TB
Does TB screening decide active vs latent disease
NO!
Definitive test for TB diagnosis
Culture of sputum
What does CSF look like in TB meningitis
Lymphocytic pleocytosis
Elevated protein
Decreased glucose
What does pleural fluid have in pleural TB
Elevated adenosine deaminase levels
Spinal TB is defined as
POTTS dz
Military TB is defined as what on CXR
Small nodular densities that are in a diffuse machine gun like pattern
Active TB treatment
6 month of TXM :
Initial 2 months RIPE
Last 4 months IR
Latent TB TXM options [3]
9 months of I
3 moths of IR
4 months of R
Rifampin ADR
Hepatitis ; rash
Interferes with retroviral agents
Pyrazinimide ADRs
Hyperuricemia ; monitor uric acid levels
Pertussis transmitted by
Droplets - respiratory
Cataraall ; paraxysmsal ; convalascent [STAGES]
CXR of PCP PNA
Diffuse interstitial or alveolar infiltrates
Elevated LDH
PCP PNA first line
Bactrim
CD4 count below what is risk for fungal PNA
200
Normal PA pressure
8- 20 mmHg
HTN = greater than 25
Pulmonary HTN findings [3]
Split S2 with Loud pulmonic component ; tricuspid regurgitation
Hepatosplenomegaly JVD peripheral edema
Palpable RVHeave
Get a right sided cath to eval pressures
Cor pulmonale is what
Right sided HF with no Left sided HF
massive PE ; ARDS = acute
COPD ILS = chronic
EKG Echo
TXM = 02 ; decrease pulm vascular resistance
4 RF for OSA
Macroglossia
Micrognathia
Tonsillar hypertrophy
Obesity
High risk OSA STOP BANG
5-8
What does psmn test in OSA
Apnea hypopnea index [5-15] is mild
Obesity hypoventilation syndrome has what
Day time hypercapnia
What is a good ratio to get to mange ARDS
Pa o2 / Fi o2
When should a patient be placed in prone position for ARDS
P/F ratio less than 150
Cystic fibrosis is what genetic disorder
Autosomal recessive
CF would be what to percussion
Hyper-resonant
MC cause of respiratory distress in preterm infants
Hyaline membrane disease
Lack of surfactant
What medication should be administered to pre term infants to accelerate lung maturation
Betamethasone
