Pulmonary Flashcards
Systemic Sarcoidosis
- multi-system dx of unknown etiology with NONCASEATING GRANULOMAS
- often found in African-American females and North European Caucasians
- often arises in 3rd or 4th decade of life
Systemic Sarcoidosis: Hx and PE
can present with fever, cough, malaise, weight loss, dyspnea, and arthritis
Systemic Sarcoidosis: Dx
CXR/CT: lymphadenopathy and nodules used to stage disease
Biopsy: lymph node biopsy or T-VATS lung biopsy shows noncaseating granulomas
PFTS: show restrictive/obstructive patter and decr. diffused capacity
- increased serum ACE levels, hypercalcemia, increased alk phos, lymphopneia, CN defcitic, arrhythmias
Systemic Sarcoidosis: Tx
Systemic corticosteroids indicared for deteriorating respiratory fxn, constitutional sx, hypercalcemia, or extrathoracic organ involvement
Obstructive Lung Disease
- characteried by airway narrowing
- OLD restricts aire movement and cause air trapping
Etiology of Obstructive Lung Disease
ABCT Asthma Bronchiectasis Cystic fibrosis/ COPD Tracheal or bronchial obstruction
Asthma
- reversible airway obstruction secondary to bronchial hyperactivity, airway inflammation, mucous plugging and smooth muscle hypertrophy
Asthma: Hx and PE
- persists with cough, episodic wheezing, dyspnea and/or chest tightness
- exam shows wheezing, prolonged expiratory duration (decr. I/E ration), accessory muscle use
- decreased breath sounds and decreased SpO2 are late signs
Asthma: Dx
- ABGs: mild hypoxia and respiratory alkalosis
- Spirometry: decreased FEV1/FVC
- increased residual volume and total lung capacity
- CBC: possible eosinophilia
- CXR: hyperinflation
Methacholine challenged
- tests for bronchial hyperresponsive
- useful when PFTs are normal but still suspect asthma
Asthma: Tx
Avoid triggers (allergens, URIs, cold air, exercise, drugs, and stress)
Tx of acute asthma
- Oxygen
- Bronchodilating agents (inhaled B2 agonists - first line therapy)
- Ipatropium (never used alone for asthma)
- Systemic corticosteroids, magnesium for severe exacerbations
Tx for chronic asthma
- administer long acting bronchodilators and/or inhaled corticosteroids
- can also use systemic corticosteroids, cromolyn or rarely theophylline
- Montelukas and other leukotriene antagonist s are oral adjuncts to inhalant therapy
B-2 agonists
albuterol or salmeterol
Albuterol
- short acting B-2 agonists
- relaxes bronchial smooth muscle (B 2 adrenoreceptors)
Salmeterol
- long acting B-2 agonist for prophylaxis
Inhaled corticosteroids
- first line treatment for long term control of asthma
Beclomethasone, prednisone
inhibit synthesis of virtually all cytokines
Muscarinic antagonists
(e. g. ipratroprium)
- competitively blocks muscarinic receptors, preventing bronchospasm
Methylxanthines
(e. g. theophylline)
- likely causes bronchodilation by inhibiting phosphodiesterae, thereby decreasing cAMP hydrolysis and increasing cAMP levels
- limited use b/c of narrow therapeutic-toxic index (cardiotoxcity, neurotoxicity)
Cromolyn
- prevents release of vasoactive mediators from mast cells
- useful for exercise induced bronchospasm
- EFFECTIVE FOR PROPHYLAXIS OF ASTHMA
- not effective during acute asthma attack
Antileukotrienes
(e.g. zileuton, monteleukast, zafirlukast)
Zileuton
5- lipoxygenase pathway inhibitor. Blocks conversion of arachodonic acid to leukotriens
Monteleukast, zafirleukast
- block leukotriene receptors
Meds for ASTHMA exacerbation
ASTHMA Albuterol Salmeterol Theophylline (rare) Humidified oxygen Magnesium (for severe exacerbations) Anticholingerics
10 yr old with hx of asthma on daily fluticasone has been using an albuterol inhaler once a day for several weeks. What changes should be made to current regimen?
Moderate persistent asthma w/ daily symptoms
- may benefit from long acting B-2 agonist (salmeterol) for prevention of symptoms
Mild intermittent asthma
< 2 days/ week < 2 nights/month FEV > 80% - no daily meds - prn short acting bronchodilator (albuterol)
Mild persistent asthma
> 2 / weeks but < 1/ day > 2 nights/ month FEV > 80 % - daily low dose inhaled corticosteroids - prn short acting B2 agonist
Moderate persistent asthma
Daily > 1 night/ week FEV 60 - 80% low to medium dose inhaled corticosteroids + long acting inhaled B2 agonist prn short-acting bronchodilator
Severe persistent asthma
Continual, frequent FEV < 60 % High dose inhaled corticosteroids + long acting B2 agonists - possible PO corticosteroids PRN short-acting bronchodilator
Bronchiectasis
- disease caused by cycles of infection and inflammation in the bronchi/bronchioles that lead to fibrosis, remodeling and PERMANENT DILATION OF BRONCHI
Bronchiectasis: Hx and PE
- presents with chronic cough accompanied by frequent bouts of yellow or green sputum production, dyspnea, and possible hemoptysis and halitosis
- exam reveals rales, wheezes, rhonchi, purulent mucous and occasional hemoptysis
Conditions associated with bronchiectasis
- Pulmonary infxns
- Hypersensitivity
- Cystic fibrosis
- Immunodeficiency
- Localized airway obstruction
Bronchiectasis: Dx
CXR: shows increased bronchovascular marking and tram lines (parallel lines outlinting dilating bronchi )
CT: Dilated airways and balloon cysts are seen at end of bronchus (mostly lower lobes)
Bronchiectasis: Tx
- Abx for bacterial infections
- maintain bronchopulmonary hygiene (cough control, postural drainage)
- consider lobectomy for localized disease or lung transplantation
Chronic Obstructive Pulmonary Disease (COPD)
- disease with decreased lung fxn associated with airflow obstruction
- secondary to chronic bronchitis or emphysema
Chronic Bronchitis
- productive cough for > 3 months per year for 2 consecutive years
Emphysema
terminal airway destruction and destruction that may be secondary to smoking (centrilobular) or to alpha-1 antitrypsin deficient (panlobular)
Emphysema: Hx and PE
“Pink puffer”: dyspnea, pursed lips, minimal cough, decreased breath sounds
- late hypercarbia/hypoxia
- tend to have thin wasted apperance
- few exacerbations in between episodes
Chronic bronchitis
“Blue bloater”: Cyanosis with mild dyspnea, productive cough
- often overweight with peripheral edema, rhonchi and early signs of hypercarbia/hypoxia
COPD: Dx
CXR: Hyperinflated lungs: decreased lung markings with flat diaphragms and thin heart/mediastiunum
- parenchymal bullae or subpleural blebs
ABGS: hypoxemia with acute or chronic respiratory acidosis
- consider gram stain or sputum culture if pt has fecer or productive cough
COPD: PFTs
Decreased FEV1/FVC
- normal or decreased FVC
- increased TLC (emphysema, asthma)
- decreased DLco (emphysema)
Acute COPD exacerbation Treatment
- Oxygen
- Inhaled B2 agonists
- Anticholingerics (ipatropium, tiotroprium)
- IV and/or inhaled corticosteroids
- Abx
- Severe cases may need BiPap**
Chronic COPD exacerbation treatment
- Smoking cessation, inhaled B2 agonists, anticholingerics (tiotroprium), systemic/inhaled corticosteroids
- Supplemental oxygen if resting PaO2 < 55 mm Hg or SaO2 < 80% or has cor pulmonale, pulm HTN, or hematocrit < 35%
- Give pneumococcal and flu vaccines
COPD Treatment
COPD Corticosteroids Oxygen Prevention (stop smoking/ flu + pneumoccocal vaccines) Dilators (B2 agonists, anticholinergic)
Restrictive Lung Disease
- loss of lung compliance
- result in increased lung stffness and decreased lung expansion
Causes of atypical pneumonia
- Mycoplasma
- Legionella
- Chlamydia
Causes of nosocomial pneumonia
- GNRs
- Staphylcoccus
- Anaerobes
Causes of immunocompromised pneumonia
- Staphylcoccocus
- Gram positive rods
- Fungi (e.g. aspergillous)
- P. jiroveci (esp with HIV)
- Mycobacteria
Causes of aspiration pneumonia
Anaerobes
Causes of pneumonia in alcoholics/IV drug users
S. pneumoniae
Klebsuella
Staphylococcus
Causes of cystic fibrosis pneumonia
Pseudomonas
Burkholderia
S. aureus
Mycobacteria
Causes of pneumonia in COPD
H. influenzae
Moraxella catarrhalis
S. pneumoniae
Causes of post-viral pneumonia
S. pneumonoia
Staphylococcus
H. influenzae
Causes of pneumonia in neonates
Group B Strep
E. coli
Causes of recurrent pneumnoa
Obstruction Bronchogenic carcinoma Lymphoma Wegener's granulomatosis Immunodeficiency Unusual organisms (e.g. Nocardia, Coxiella burnetti, Aspergillus, Pseudomona
