Pulmonary Flashcards
steeple sign on XR of neck =
croup
Lateral XR of neck with thumbprint sign =
epiglottitis
Infection that causes acute bronchitis
most often viral - RSV, Rhinovirus, Influenza
5-10% bacterial
I came in to see my physician assistant because of…
SOB, wheezing, cough 3+ weeks
acute bronchitis
XR findings of acute bronchitis
hyperinflation of lungs
Acute bronchitis treatment
H. flu vaccine
Supportive care including fluids, rest, use of humidifier
Antibiotics should play a small role here
Smoking cessation
What type of patient gets acute bronchiolitis?
children under 2 yo
Acute bronchiolitis most commonly caused by what infection?
RSV
PE findings of child with acute bronchiolitis
crackles, wheezing
elevated respiratory rate
signs of respiratory distress - chest wall retractions, accessory muscle use, nasal flaring
Acute bronchiolitis treatment
Supportive care: Humidifier, fluids, nebulized Albuterol or epinephrine
Self limiting
I came in to see my physician assistant because my child is…
Difficulty swallowing
Drooling
Hoarseness
Stridor
epiglottitis
Most common cause of epiglottitis
H-flu (prevent with vaccine)
Best abx to treat epiglottitis
2nd or 3rd gen cephalosporin (Cefuroxime or Ceftriaxone/Rocephin)
Clindamycin or Erythromycin
I came in to see my PA because my child…
Low grade fever Congestion Cough Stridor Barking or seal-like cough
Croup
Most common causes of croup
Parainfluenza, RSV, Rhinovirus
Croup treatment
Nebulized epinephrine for severe cases
Alway administer oral steroids
Supportive care
Treatment of influenza
Influenza vaccination
Supportive care
Ribavirin aerosolized
Zanamivir and oseltamivir (expensive, must be started within 48 hrs of infection)
Child with rapid consecutive coughs followed by a deep inspiration with characteristic high pitched whoop
pertussis
Pertussis treatment
Vaccination available as Tdap
Macrolides: Erythromycin or Azithromycin
The most common cause of lower respiratory infection in children and in immunocompromised
RSV
Indications for Ribavirin
severe RSV infections in high risk patients
Risk factors for TB
overcrowding, malnutrition, smoking, DM, HIV
I came in to see my physician assistant because of…
Chronic productive cough with blood tinged sputum
Fever
Drenching night sweats
Weight loss
Tuberculosis
What are positive results of TB skin test?
Normal healthy low risk person positive test at 15 mm of induration
Healthcare worker or moderate risk patient positive at 10 mm
Immunocompromised patients considered positive at 5 mm
How is TB diagnosed with labs and imaging?
TB skin test
Chest XR (apical/upper opacities)
Acid fast bacillus stain of sputum
Culture? (but slow growing, 2-6 wks)
Medical therapy for TB
Initial 6 or 9 month course of four antibiotics
Isoniazid(INH)
Rifampin
Pyrazinamide
Ethambutol
Once antibiotic sensitivities are complete patients usually continue on isoniazid and rifampin for at least 4 more months
Side effects of TB medications
Isoniazid: peripheral neuropathy, hepatitis, rash
Rifampin: orange body fluids, flu like symptoms, hepatitis
Pyrazinamide: arthralgias, hepatitis
Ethambutol: optic neuritis
hot potato voice =
epiglottitis or peritonsillar abscess
Pulmonary disease associated with caves and bird or bat droppings
histoplasmosis
About half of CAP cases are caused by what? Other causes?
strep pneumo
H flu, staph aureus, Klebsiella, influenza, RSV
PE findings of pneumonia
crackles
dullness to percussion
bronchial breath sounds
Chest XR findings of pneumonia
lobar consolidation
air bronchograms
pleural effusions
Treatment of community-aquired pneumonia
macrolides (erythromycin) or doxycycline
What is common name for atypical community acquired pneumonia?
walking pneumonia
How does atypical CAP present differently?
Variable symptoms
Little or no finding on PE
Chest XR with diffuse infiltrates
Criteria to diagnose nosocomial pneumonia
pneumonia after 48 hrs in hospital
Most common cause of nosocomial pneumonia? Most common cause in ICU?
G- bacillus and staph aureus
ICU is Pseudomonas
Immunocompromised patients with SOB and cough, should be treated for what?
pneumocystis pneumonia (pneumocystis jirovecii)
Complication of pneumocystis pneumonia
pneumothorax
Chest XR findings of pneumocystis pneumonia
diffuse interstitial infiltrates (ground glass appearance)
Best lab to eval severity of pneumonias
ABG (shows hypoxia)
Pneumocystis pneumonia treatment
TMP-SMX (Bactrim)
+/- steroid for alveoli inflammation
Histoplasmosis treatment
ANTI-FUNGAL
Oral Itraconazole or Amphotericin B for a few months and for prophylaxis
Tidal volume
volume of air moved into and out of lungs during normal resting respirations
Vital capacity
volume of air exhaled slowly after the deepest inspiration possible
What does spirometry measure?
volume and speed of exhalation and inspiration
forced vital capacity (FVC)
volume of air forcefully exhaled after deepest breath possible
FEV 1
volume of air forcefully exhaled in 1 second
Peak expiratory flow rate (PEFR)
highest airflow rate during forced expiration
Bronchospasm leading to airflow obstruction
asthma
What is the atopic triad?
asthma, atopic dermatitis (eczema), allergic rhinitis
What is a paradoxical pulse? Seen in what pulmonary pathology?
pulse that is weaker during inhalation and stronger during exhalations
seen during asthma exacerbation
Spirometry results of asthma
decreased FEV1 and PEFR (both improved with bronchodilator)
normal FVC
What other pulmonary function tests can be done if spirometry is not effective?
histamine or methacholine challenge
How are severities of asthma classified?
Intermittent
- Two or less episodes per week
- Two or less nighttime episodes per month
Mild persistent
- More than two episodes per week
- Three to four nighttime episodes per month
Moderate persistent
- Daily episodes
- One nighttime episodes per week
Severe persistent
- Symptoms continuous
- Night time episodes almost every night
Chronic treatment of intermittent and persistent asthma?
intermittent: SABA
mild persistent: SABA + daily low dose ICS
mod persistent: SABA + daily medium dose ICS + daily LABA
severe persistent: SABA + daily high dose ICS + daily LABA + systemic steroids
Most commonly used SABA, ICS, and LABA for asthma treatment
SABA - Albuterol
ICS - Beclomethasone
LABA - Salmeterol
Acute treatment of asthma exacerbation?
SABA
oxygen prn
consider upping steroid or using anticholinergic
What two conditions are under COPD umbrella?
chronic bronchitis
emphysema
Number one cause of COPD
smoking
Differences between chronic bronchitis and emphysema
chronic bronchitis = “blue bloaters”
bronchi inflammation
productive cough, more hypoxic, larger air volume due to more trapped air
emphysema = “pink puffers”
alveoli collapse
dry cough, less hypoxic and more accessory muscle use, hyperventilation
Diagnostic criteria of COPD cough
3 consecutive months per year in 2 consecutive years
Pulmonary function test results of COPD
FEV1 decreased
FEV1/FVC decreased
Increased lung volume due to air trapping
Pulm findings on PE of COPD
diminished breath sounds
+/- rhonchi in chronic bronchitis
wheezing
Chest XR findings of COPD
hyperinflation with flat diaphragm
emphysema - parenchymal bullae, subpleural blebs
COPD treatment
Stop smoking!
Antibiotics due to repeated infections
SABA (albuterol)
Anticholinergics (ipratropium)
Inhaled steroids (budesonide)
Oral steroid
Oxygen is only medication that changes course of severe COPD
Best diagnostic test for cystic fibrosis
chloride sweat test showing elevated NaCl
Pathophysiology and etiology of cystic fibrosis
Autosomal recessive disease caused by mutation of CFTR protein
This causes viscous mucus leading to recurrent pulm infections, pancreatic insufficiency (malabsorption), biliary obstruction, intestinal obstruction
cystic fibrosis findings on lung exam
hyperresonance to percussion, apical crackles
PFT results of cystic fibrosis
total lung capacity decreased
Common complaints of patient with cystic fibrosis
chronic lung issues recurrent sinusitis diarrhea, abd pain poor growth and weight gain infertility
Cystic fibrosis treatment
Chest and back percussion DNAse enzyme to break down mucus Bronchodilators Inhaled hypertonic saline Antibiotics for recurrent infection Dietary supplements Pancreatic enzyme replacement
Irreversible dilation of the bronchial tubes caused by destruction of the tissue
Bronchiectasis
50% of bronchiectasis cases are caused by ________.
cystic fibrosis
Chest XR findings of bronchiectasis
Tram tracks or ring like markings – dilated thickened bronchi
Atelectasis
Bronchiectasis treatment
Prophylactic antibiotics may be necessary
Surgical resection if disease is found all in one area
Chest XR with parenchymal bullae, subpleural blebs
emphysema
Types of obstructive pulmonary diseases
Asthma
COPD (chronic bronchitis, emphysema)
Cystic fibrosis
Bronchiectasis
All obstructive pulmonary diseases have what finding on chest XR?
hyperinflation of lung fields
Types of restrictive pulmonary diseases
Idiopathic pulmonary fibrosis
Pneumoconiosis
Sarcoidosis
Pleural diseases
Dry cough
Dyspnea
Fine crackles at bases may be present
Lung volumes are reduced
Idiopathic pulmonary fibrosis
Idiopathic pulmonary fibrosis treatment
Prednisone may help
Oxygen improves symptoms
Lung transplant
Group of diseases which are restrictive and caused by inhalation of specific types of dust.
Pneumoconiosis
nodules in middle and upper lung fields with eggshell calcifications
Silicosis or asbestosis
This is the development of scar tissue within the lungs
Idiopathic pulmonary fibrosis
nodular opacities in upper lung fields. Eggshell calcifications
coal miners lung
Pulmonary function test results of restrictive pulmonary diseases
FEV1 is reduced
FVC is reduced
Lung volumes are reduced
Treatment of any pneumoconiosis
Oxygen will alleviate symptoms
Do not smoke!
Avoid dust of any type
inflammatory disease which is characterized by granulomas throughout the body
Sarcoidosis
Chest XR of sarcoidosis
Hilar adenopathy
Nodules or infiltrates in the parenchyma as in later disease
Pathophysiology of pleural effusion
Excess fluid between the pleural layers which limits breathing by limiting the ability of the lungs to expand
How is US guided thoracentesis useful in evaluating pleural effusion?
Find out the cause of effusion
exudative fluid (inflammation) = pneumonia transudative fluid = CHF, cirrhosis
Sarcoidosis treatment
In most cases observation is first step
Corticosteroids
What is egophony? When is it positive?
on auscultation an E sounds like an A, indicating consolidation
Pleural effusion, pneumonia, idiopathic pulmonary fibrosis
What does dullness to percussion and diminished breath sounds indicate?
fluid in lungs
What do you hear on auscultation of pleural effusion?
diminished breath sounds
pleural friction rub
Pleural effusion treatment
Antibiotics if appropriate
Therapeutic thoracentesis
Chest tube placement
Pleurodesis – obliteration of the pleural space
What is a pneumothorax?
air or gas in the pleural space which will limit the lungs ability to expand
Biopsy showing non-caseating granulomas? Caseating granulomas?
Noncaseating = Sarcoidosis
Caseating = TB
What type of person is at risk for primary pneumothorax (no underlying lung disease)?
Smokers
Young, tall, thin males
Causes of secondary pneumothorax
Underlying lung disease - COPD, asthma, cystic fibrosis, TB, etc.
Hallmark CXR finding of tension pneumothorax
contralateral mediastinal shift
Visceral pleural line on CXR is diagnostic of ______.
pneumothorax
Pneumothorax treatment
A small primary pneumothorax (10-15% of hemithorax involvement) may be watched and will likely resolve on its own
Chest tube is definitive therapy for larger pneumothorax or tension pneumothorax
Pleurodesis - obliteration of the pleural space
What is Cor Pulmonale?
Right-sided heart failure secondary to severe pulmonary disease
EKG and CXR findings of cor pulmonale
EKG: tall peaked T waves, right axis deviation
XR: enlarged R ventricle, enlarged pulm artery
PE signs of right sided heart failure
cyanosis, peripheral edema, ascites, increased JVD
Treatment of right sided heart failure and cor pulmonale?
- Treat the underlying lung disease
- Oxygen
- Diuretics as well as salt and fluid restriction
___________ is a blockage of a main artery into the lungs by something that has traveled from somewhere else in the circulatory system.
Pulmonary embolism
What is Virchow’s triad?
risk factors of pulmonary embolism
- Immobility
- Hypercoagable state
- Vessel injury
How should pulmonary embolism be imaged?
CXR, Helical CT, pulmonary angiography
EKG of pulmonary embolism
sinus tachycardia most common finding
S1Q3T3 pattern in 10%
How to treat pulmonary embolism?
Anticoagulation x 6-12 months; Heparin immediately, Warfarin long term
Thrombolytics
Inferior vena cava filter
Embolectomy
CXR showing Westermark sign and Hampton hump
pulmonary embolism
What test can rule out pulmonary embolism?
Normal VQ scan
right sided heart failure with splitting of S2 and exertional syncope
pulmonary HTN
Gold Standard for pulmonary HTN diagnosis
right heart catheterizations
Pulmonary HTN management
Treat underlying cause
Anticoagulants – warfarin
Diuretics and salt restriction
Oxygen
Calcium channel blockers
Lung transplant
Types of non-small cell lung cancers (NSCLC)
adenocarcinoma, squamous cell carcinoma, large cell
Labs and diagnostic studies to eval for lung tumor
biopsy cytology of sputum CT to look for nodules PET to look for metastasis Thoracocentesis Video assisted thoracic surgery (VATS)
Pulmonary neoplasm most commonly found in large central bronchi
squamous cell carcinoma
Most common lung cancer in non smokers
adenocarcinoma
Most aggressive lung cancer with early metastasis
small cell carcinoma (oat cell)
Definition of pulmonary nodule
less than 3 cm consolidation w/o other lung findings
How should pulmonary nodule be managed?
watchful waiting with serial CT
Acute onset of dyspnea and tachypnea in baby that does not respond to oxygen therapy
ARDS
ARDS treatment
Typically mechanical ventilation
Treat underlying causes
Oxygen supplementation does NOT help
Symptoms of respiratory distress in premature infant with diffuse ground glass appearance on CXR
Hyaline membrane disease
Pathophysiology of hyaline membrane disease
insufficient surfactant production in premature infant
Hyaline membrane disease treatment
Oxygen
CPAP
Intubation
Surfactant spray
How can hyaline membrane disease be prevented?
Give steroids if risk of delivery before 34 weeks gestation
I came in to see my physician assistant because of…
Wheezing
Drooling
Dyspnea
Foul smell
Foreign body aspiration
CXR findings if foreign body aspiration
air trapping
FEV1/FVC ratio in PFTs of obstructive and restrictive lung disease
decreased in obstructive (low FEV1)
same or increased in restrictive (low FVC)
How are asthma and COPD differentiated?
asthma is reversible bronchoconstriction and PFT’s will improve with treatment
COPD is irreversible with chronic decrease in PFT’s
How does the sympathetic and parasympathetic nervous system affect airways?
sympathetic dilates airways
parasympathetic constricts airways
MOA of beta agonists in lungs
stimulates the sympathetic nervous system and dilates bronchioles
Which drug class treats obstructive pulmonary diseases by inhibiting parasympathetic nervous system to open airways?
anticholinergics (ex. ipratropium)
When would you not want to use a beta agonist to open airways?
if patient is on beta blocker or who needs beta blocker for angina or arrhythmias
What are crackles heard on lung exam?
sound of stiff alveoli popping open
A decreased _______ is hallmark of pulmonary fibrotic disease.
DLCO (diffusion defect)
3 causes of pulmonary HTN
Resistance in lungs
Backup from left heart
Increased flow into right heart (eg. VSD)
_________ is most common cause of pneumonia.
strep pneumo
What is Light’s Criteria for pleural effusion?
fluid is exudative if any of following:
pleural fluid protein/serum protein ratio >0.5
pleural fluid LDH/serum LDH ratio >0.6
pleural fluid LDH level >2/3 upper limit for serum LDH
empyema
pus in pleural space; complication of pneumonia or caused by penetrating chest trauma
Hallmark of pleural effusion on XR
blunting of costophrenic angles
What does hyper-resonance on percussion indicate?
more air than usual; seen in asthma, COPD, and pneumothorax
tactile fremitus
feel vibrations on patient’s back as patient speaks
increased vibration if lung filled with something other than air
