Pulmonary Flashcards
normal vs restrictive vs obstructive values for pulmonary function tests: FVC
normal FVC: 5 L
restrictive: lower
obstructive: normal or lower
normal vs restrictive vs obstructive values for pulmonary function tests: FEV1
normal: 3.75 L
restrictive: lower
obstructive: much lower
normal vs restrictive vs obstructive values for pulmonary function tests: FEV1/FVC
normal: 70-75%
restrictive: higher
obstructive: lower
which blood has a higher hemoglobin saturation and thus higher Po2; venous or arterial blood?
arterial
explain the following lung imaging finding:
border between same density organ is lost
silhouette sign; usually caused by a pneumonia
explain the following lung imaging finding:
dark markings on abnormal white lung
alveoli are fluid filled; air in bronchi visible on xray
at what cardiac size is imaging positive for enlarged cardiac silhouette?
if the size of the heart is greater than half the width of the chest
explain the following lung imaging finding:
fundus of stomach appears as a fluid density or air fluid level behind the heart
hiatal hernia
explain the following lung imaging finding:
jagged edges at the lateral aspect of the image
rib fracture; watch for pneumothorax
explain the following lung imaging finding:
“fluffy” multiple white lines
diffuse interstitial pneumonia
explain the following lung imaging finding:
blunt costophrenic angles
pleural effusion
causes of lungs appearing too white on xray
pneumonia
TB
atelectasis
lung cavity, nodule, or mass
pleural effusion
congestive hearrt failure
chronic interstitial disease (confined to a particular area)
more common causes of diffuse interstitial pneumonia
viral agents or mycoplasma
primary and secondary TB infection lung findings
primary infxn seen in upper lobes with pleural effusion and hilar lymph node enlargement
secondary infxn xray is normal or shows small calcifications in lungs and lymph nodes
causes of lungs to appear too black on xray
pneumothroax (air b/w pleura rising to highest point in chest; black w dec number of vessels)
PE (blood supply to lungs cut off)
____ collects at the highest point in the chest, as opposed to ____ which collects at the lowest point
air = highest
fluid = lowest
image of choice for lung / chest masses
CT to avoid motion artifact from breathing
NON sedating H1 receptor antagonists names and doses
fexofenadine (allegra): 30, 60, 180 mg
loratadine (claritin) : 5-10 mg
certirizine (zyrtec): 5 and 10 mg
NON sedating H1 antagonist AE and CI
loratadine & fexofenadine:
CI with use of erythromycin, ketoconazole, or itraconazole due to fatal arrythmias
avoid in severe renal impairment
no grapefruit/OJ/apple for 4 hours
certirizine:
avoid alcohol, sedative, tranquilizers > CNS depression
diphenhydramine medication class and uses
sedating h1 receptor antagonists
used for allergic rxns from type 1 allergies and insomnia
diphenhydramine AE and CI
AE: seizures, sedation, n/v, dry mouth, epigastric distress, thrombocytopenia, agranulocytosis
CI with CNS depressants and MAO inhibitors
diphenhydramine dosage
12.5, 25, 50 mg
epinephrine MOA and uses
anaphylactic shock; vasodilation of B2 receptors (and vasoconstriction a1)
epinephrine AE
cerebral hemorrhage, CVA, HTN, tachycardia, v fib, shock, n/v, HA, drowsiness
oxymetazoline MOA and uses
nasal spray or eye drop; a1 receptor stimulant; vasoconstriction
used for congestion
oxymetazoline AE/CI
arrythmia, anaphylaxis, asthmatic episodes, HA
do not use with MAO inhibitors or severe HTN
albuterol MOA and uses
short acting b2 adrenergic agonists that causes bronchodilation; acute ashtma; acts in <15 mins, lasts 3-4 hours
medications for short term asthma management
short acting beta agonists
anticholinergics
systemic corticosteroids
magnesium sulfate (IV) - emergency
long term asthma control medications
inhaled corticosteroids
long acting beta agonists
leukotriene modifiers
mast cell stabilizers
biologics (immune; for severe asthma)
albuterol AE /CI
nervousness, tremor, tachycardia, HA, palpitations, n/v, bronchospasm
avoid use with CNS stimulants
ipratropium med class and uses
anticholinergic bronchodilator (parasympathoLYTIC); asthma/COPD bronchospasm relief in combo with SABAs; esp in emergency settings
fluticasone/budesonide med type, asthma use, dosage
inhaled corticosteroids; dec inflammation in airways
used daily
salmeterol med type, asthma use, dosage
long acting beta 2 agonist; used with ICS for long term control, not for acute sx
1-2 inhalations daily; 1.5 hours before exercise for exercise induced
montelukast med type, asthma use, dosage
leukotriene modifier, dec inflammation/bronchoconstriction, taken daily PO
cromolyn med type, asthma use, dosage
mast cell stabilizer, prevents degranulation of inflammatory mediators from mast cells
usually inhaled/nasal/opti - dosed frequently
prophylaxis only
guaifenesin med class, MOA, uses
mucolytic; decreases viscosity of secretions, expectorant (does NOT suppress cough)
acetylcysteine med class, MOA, uses
reduces viscocity of respiratory tract fluid; mucolytic at high doses
used for pneumonia, bronchitis, TB, CF, emphysema, etc
antidote for acetominophen overdose
acetylcysteine SE/cautions
rhinorrhea, stomatitis, n/v, bronchospasm
activated charcoal dec effectiveness
glucocorticoid AE/caution
water retention and CV problems
long term: osteoporosis, peptic ulcer
inhaled steroids less systemically absorbed
steroid drug suffixes
-sone
-zone
-onide
cromolyn AE/caution
throat irritation
do not use during acute asthma attacks
ipratropium bromide AE/CI
arrythmias
not for single use in acute attack bc no sympathetic activity
rescue/acute inhalers versus maintenance inhalers
rescue/acute:
- sympathomimetics only: epinephrine, albuterol, metoproterenol
maintenance inhalers:
- steroids, advair, intal, atrovent
black box warning for long acting beta 2 agonists
inc risk of asthma related death; works very well at managing sx, not treating cause of asthma so person is just as asthmatic - sudden rebound attack when meds leave system (usually happening with missed doses)
ex of med: salmeterol
a-adrenergic agonists names and MOA/uses
psuedoephedrine (sudafed) -
phenylephrine (sudafed PE) - less eff/AEs
decongestants; stimulates a1 receptors > vasoconstriction
phenylephrine AE/CI
arrythmia, anaphylaxis, asthmatic episodes, HA
DO NOT USE W MAO INHIBITORS or severe HTN
pseudoephedrine HCl AE/CI
anxiety, nervousness, palpitatinos, HA, insomnia
DO NOT USE WITH MAO INHIBITORS
a-adrenergic agonists (pheynephrine, psuedoephedrine) AE
exacerbation HF, pulmonary HTN, renal toxicity, visceral ischemia
antitussives
opiates: codine/hydrocodone; dec central respiratory drive
dextromethorphan (robitussin): cough suppressant, acute coughs/flu
benzonatate: non narcotic, local anesthetic, acute/coughs/flu
benzonatate (tesselon pearles) AE/CI
ester or PABA allergy, use with other anesthetics
cough duration classifications
acute: 0-3 weeks
subacute: 3-8 weeks
chronic: >8 weeks
acute cough algorithm
life threatening (pneumonia, severe asthma/COPD exacerbation, PE, HF)
non life threatening:
- infections (URI, LRI)
- exacerbations (asthma, bronchiectasis, UACS/post nasal drip, COPD)
- environmental/occupational
subacute cough algorithm
- postinfectious (pneumonia, pertussis, bronchitis, new onset/exacerbation UACS, ashtma, GERD, bronchitis)
- non-post infectious: chronic cough workup
chronic cough algorithm
chest xray if hasn’t been done!
ACEis, smoking, cancer, UACS, GERD, asthma
ashtma signs/sx
wheezing, dyspnea, cough, nocturnal sx
bilateral wheezing, hyperresonance to percussion, PFTs normal/abnormal
conditions that can mimic asthma
CHF
PE
GERD
foreign body aspiration
upper airway obstruction > stridor (tumors, tracheal stenosis)
how do NSAIDs cause asthma exacerbation?
NSAIDS only block COX pathway, so all arachadonate goes through lipoxygenase pathway > leukotrienes
exercise induced asthma usually occurs when during exercise?
5-10 mins after starting
what drugs can induce/exacerbate asthma?
ASA
NSAIDs
beta blockers
histamine
asthma four step classification
(higher step = more chance of death = more medication)
1: mild intermittent (<2/week) - short acting rescue inhaler
2: mild persistent (>2/week, <1/day)
3: moderate persistent (daily)
4: severe persistent (constant)
pneumothorax vs
atelectasis
pneumothorax: lung being collapsed by area, trachea deviates AWAY from lesion
atelectasis: lung losing body and collapsing in on itself; trachea deviates TOWARD lesion
types of pleural effusion
transudate (CHF; starling forces)
exudate (infectious; immune proteins)
empyema (walled off infxn)
hemorrhagic (PE)
chyliform (lymph fluid)
pleural effusion vs pneumothorax lung sounds
pneumo: dec lung sounds
pleual effusion: inc breath sounds
bronchiolitis
dangerous in infants and elderly; usually viral in nature
xray shows hyperinflation and peribronchial infiltrates
acute bronchitis common causes
acute inflammation trachea/bronchi usually due to: influenza, RSV, coxsackie, adenovirus, rhinovirus
often follows or is associated with acute sinusitis or pharyngitis
bacteria less common: strep pneumo, h flu, morazella catarrhalis
consolidated/lobar pneumonia etiology
strep pneumo, h flu, gram neg bacteria, moraxella catarrhalis, staph aureus
klebsiella pneumo in chronic alcoholics, e coli in diabetics
atypical/”walking” pneumonia etiology
mycoplasma, chlamydia pneumoniae
viral pneumonias
what lung pathology should be considered in ddx of altered mental status in the elderly?
pneumonia; elderly pts often have fewer/less severe sx or atypical presentations
most common causes of hospital acquired pneumonia
gram negative bacilli
lung abscess etiology, signs/sx
mostly bacterial;
50% due to aspiration of bacteria when pt is recumbant (coma, anesthesia, substance use, stroke), or those with problems swallowing or coughing
sx: fever, chills, pain, weakness, wt loss, foul/musty smelling sputum mixed w blood (rusty sputum)
TB patho
acid-fast intracellular parasitic mycobacteria
usually starting in upper lobes; primary infxn becomes walled off, lesions shrink and heal, leaving behind caseating granulomas
testing/dx TB
tuberculin skin test; bacteriologic culture is dx
airborne transmission
often asx
reactivation = upper lobe infiltrates on CXR
aspergillosis transmission, dx
fungal infection caused by soil pathogens; airborne transmission (construction)
XR: solitary lesions, round intracavitary mass, + sputum culture and ab
cryptococcal pneumonia transmission, dx
encapsulated yeast in pigeon droppings; portal of entry in lung but often causes meningitis
asx, XR shows large solitary nodule, pneumonitis
dx biopsy and culture; LP to r/o meningitis
cryptococcal pneumonia tx
amphotericin B
histoplasmosis dx/transmission
most common US mycosis; midwest/south central US
asx or atypical pnuemonia; patchy ilfiltrates on XR with hilar/medistinal adenopathy, flu like sx
XR: apical lung lesions, cavitation, fibrosis
dx: sputum culture/biopsy
coccidiomycosis/valley fever etiology
“valley fever”
infectious fungal lung; arthospores become airborne from fungal mycelia in soil
common in deserts after rainstorms
coccidiomycosis/valley fever signs/sx/dx
incubation up to 4 weeks: fever, malaise, dry cough, chest pain, night sweats, anorexia
NO hemoptysis
fine macular, urticarial rash, erythema nodosum (good prognosis)
tx: antifungal
first two ddx to consider with hemoptysis
TB
lung cancer
general description of chronic obstructive lung disease
airflow limitation from obstruction that is not fully reversible; lungs fill with air behind obstruction and become over inflated. difficult to breathe overcoming that resistance
lung tissue destroyed from chronic infection
interstitial (restrictive) lung dz general description
infiltration of inflammation and scarring of lung parenchyma > wide spread lung fibrosis > inc elastic recoil, dec compliance
lung is smaller in volume, patient has to work harder to breath against decreased compliance (lungs more like rubber)
two major lower respiratory diseases/COPD dx
emphysema “pink puffers” - normal pCO2 due to reactive polycythemia adjusting to new normal (RF: cig smoking, def serum 1 alpha protease inh)
chronic bronchitis “blue bloaters” - increased pCO2 bc episodic
why would you give a bronchitis patient antibiotics if acute bronchitis is usually viral?
if they have an acute exacerbation with chronic bronchitis it is likely bacterial superinfection
acute onset of dyspnea or hypoxemia with normal chest XR first ddx
PE until proven otherwise
PE dx and tx
V/Q scan, CT angio
anticoagulation, preventing recurrence
cystic fibrosis etiology and patho
AR disorder of exocrine glands
dx: >80 adult, >60 kids sweat chloride. pancreatic insufficiency, esp in kids
chronic pseudomonas aeruginosa or staph aureus bronchitis and beconhiectasis with recurrent exacerbation
what is bronchiectasis
irreversible dilatation of bronchial tree; obtruction can arise from tumor, foreign bodies, impacted mucus, external compression
congenital form rare, cystic fibrosis most common form
signs/sx bronchiectasis
prurlent sputum, or dry cough
rales and clubbing
recurrent pulmonary infxn
hemoptysis
loss of lung volume and honeycombing and cystic spaces
collagen vascular disease etiology/patho
common in SLE, scleroderma
2/3 pts with CVD will have clinical pulmonary dz; pleural dz in all CVD except poly/dermatomyosis
pulmonary nodules can occur in RA
ddx hemoptysis and hematuria
goodpastures
dx IgG deposits in glomeruli and presence of antiglomeruli BM ab in serum
silicosis etiologic agent & mechanism of lung injury
crystalline silicon dioxide via inhalation; alveoli filled with eosinophilic debris
sandblasting, mining, tunnerling, quarrying, stonecutting, polishing
asbestosis etiologic agent & mechanism of lung injury
strength/flexiblity/resistance
pulmonary fibrosis with asbestos bodies; pleural collagen plaques, pleural effusion
inc risk bronchogenic carcinoma and mesothelioma
most common cause of death due to cancer in the US for men and women
bronchogenic carcinoma
adenocarcinoma radiologic findings & 5 year survival rate
most common
peripheral mass, solitary nodules
27%
squamous cell bronchiogenic carcinoma radiologic findings & 5 year survival rate
common
hilar mass, atelectasis, post obstructive pn, hypercalcemia
37%
large cell bronchiogenic carcinoma radiologic findings & 5 year survival rate
large peripheral mass
27%
small cell bronchiogenic carcinoma radiologic findings & 5 year survival rate
hilar mass central location, adenopathy, sx SiADH
<1%
central vs obstructive apnea
central- cessation of air flow, no movemnt of rib cage or abdomen
obstructive - paradoxical motion of rib cage and abdomen without air flow
can also be a mixed type. all typed have fall in O2 sat
ARDS etiology/path
life threatening condition in which inflammation in the lungs and accumulation of fluid in the air sacs (alveoli) leads to low blood oxygen levels
common causes: pneumonia, septic shock, trauma, aspiration of vomit, chemical inhalation
ARDS signs/sx
SOB
labored, rapid breathing
low BP/shock
so sick theyre unable to complain of sx
acute pulmonary edema is usually associated with what pathology?
usually associated with CHF; may appear suddenly with chronic heart failure or be first manifestation of cardiac dz
acute pulmonary edema signs/sx
severe dyspnea, worse with lying supine
productive frothy pink sputum
diaphoresis
tachycardia
cyanosis
wheezing
rales
CXR: blurred vascular outline, inc heart size and interstitial markings
cheyne stokes respiration is often seen when?
advanced CHF and neuro dz
alternating tachypnea and apnea
cough classification by duration
acute: 0-3 weeks (CXR if u believe consolidation)
subacute: 3-8 weeks (CXR if u believe consolidation)
chronic: >8 weeks; get CXR
hemoptysis is _ until proven otherwise
lung cancer or TB
acute onset dyspnea or hypoxemia with normal CXR is _ until proven otherwise. what would next steps be?
PE
+Homans sign
order pulmonary angiography
what are the non-small cell lung carcinomas?
squamous cell carcinoma
adenocarcinoma
large cell carcinoma
are non small cell or small cell lung CA more common?
non-small cell
pancoast tumor presentation
superior sulcus tumor at apex of lung
mesothelioma presentation
malignancy of pleura associated with asbestosis
hemorrhagic pleural effusion (exudative), pleural thickening
blastomycosis presentation, dx, tx
fungal infxn with wart like skin lesions
chest pain, cough, fever, night sweats, pink papules, veg plaques w verrucous arciform borders
dx: sputum microscopy, CXR
tx: itraconazole
emphysema presentation
pink puffers: barrel chest, pursed lips, slow forced expiration
perm dilation of acinus with eventual destruction of alveolar walls
normal pCO2 = reactive polycythemia
chronic bronchitis preentation
blue bloaters: persistent cough with sputum for at least 3 months in at least 2 consecutive years
obese, cor pulmonale, cyanotic, can have acute exacerbatinos (bacterial superinfections)
pleuritis/pleurisy presentation, workup
causes include viral resp ifxn or pneumonia
pain localized, sharp, and inc with cough/sneeze/deep breath
friction rubs with auscultation, “leathery squeak” component
workup pneumonia
CXR, sputum culture
tx pulmonary edema
furosemide
morphine
nitroglycerin
oxygen
pos airway pressure
pulmonary fibrosis presentation, dx
lung dz of chronic alveolitis and interstitial inflammation
common w smoking
dry inspiratory crackles, clubbing, medial survivial rate 3 years
dec FVC, dec TLC
dx requires HRCT (honeycombing, ground glass appearance, interstitial pneumonia pattern)
sarcoidosis
non caseating granulomas
