Pulmonary Flashcards
Drug induced asthma
17 yo kid takes aspirin
Can be also beta-blocker, ACEi, NSAIDs
Asthma classifications
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Intermittent asthma
Definition
Tx
Daytime sxs > 2/ week
Nocturnal sxs , FEV1>80%
Mild persistent asthma
Definition
Tx
Daytime sxs > 2/ week, >2/ month, but 80%
Tx:
Moderate persistent asthma
Definition
Tx
Daytime daily sxs with daily beta-agonist use
Nocturnal sxs > 1/week
FEV1 > 60%- 80%
Tx:
Severe persistent asthma
Definition
Tx
Continual Daytime sxs with daily beta-agonist use
Nocturnal sxs frequent
FEV1
Peak Flow
Bedside FEV1
3 attempts and average it
Asthma diagnostic evaluation
Step 1: spirometry before and after short acting bronchodilator therapy
FEV1
Asthma treatment
Routine rescue med:
—albuterol !!
Maintenance : inhaled corticosteroids for persistent asthma
—budesonide
—fluticasone
Add on maintenance : inhaled long acting beta adrenergic (LABA)
—Salmeterol
Asthma related to allergy –additional treatment
Montelukast
COPD physical exam
Increased AP diameter
Decreased tactile fremitus
Hyperresonance
Decreased breath sounds
COPD diagnosis
CXR +/- CT
Perenchymal Bullae and blebs
PFTs for staging
Stages of COPD
I– mild , FEV1> 80% predicted
II– mod, FEV1 50-79%
III– severe, FEV1 30-49%
IV– very severe, FEV1
COPD treatment
Bronchodilators are mainstay!!
Short acting rescue agent
----beta2 agonist + anticholinergic
-- albuterol + ipratropium
Long acting maintenance agent :
----long acting anticholinergics
-- tiotropium
----long acting beta2 agonist
-- salmeterolMost common cause of bronchiectasis
Cystic fibrosis
1 cancer related death
Lung cancer
When to SCREEN for lung cancer ??
Age 55-75 if smoked > 30 pack years and are still smoking or quit within 15 years
This is standard of care and is frequently not done!!!!
2 classifications of lung cancer
Non small cell lung cancer
Small cell lung cancer
Where is adenocarcinoma??
Peripheral nodule or mass
Where is squamous cell carcinoma ?
Endobronchial mass
Persistent cough, hemoptysis, recurrent PNA
Where makes you think of Large cell carcinoma ?
Mass with Peripheral location
Where makes you think of Small cell lung cancer ?
Hilar mass
“Oat cell”
How does the word HASSLE make you remember location of lung cancers?
HASSLE
AL are on periphery of word
Adeno
Large cell
SS are in the middle
Squamous
SSC
What is a Pancoast Tumor ?
Fast growing lung cancer with:
Horner’s syndrome (miosis,ptosis,anhidrosis)
Rib destruction
Brachial plexopathy – hand muscle atrophy, pain, weakness
Horner’s syndrome
Miosis
Ptosis
Anhidrosis
Paraneoplastic syndromes associated with lung cancer ??
Hypercalcemia — SCC
SIADH — SCLC
Outside production of ADH causing decreased renal clearance of free water with a subsequent decrease in sodium
Treatment of lung cancer?
NSCLC–> surgical resection +/- chemo and radiation
SCLC –> Chemo is mainstay
Prognosis –> 5 yr survival is 15%
Mesothelioma
Pleural based mass
Influenza treatment
Supportive
Zanamavir
Osaltamivir
COPD exacerbation treatment
Oxygen is critical
Albuterol / ipratropium inhaler or neb
CAP
Typical pathogens
Strep pneumo
H. Flu
M. Cat
CAP
Atypical pathogens
Legionella
mycoplasma pneumoniae
Chlamydia pneumoniae
CAP pearls for strep pneumo
Single rigor
pleurisy / pleural effusions
“Rust colored” sputum
CAP pearls for H flu
Pt has COPD too
CAP Pearls for M cat
None
CAP pearls for Legionella pneumophilia
Fever
Hyponatremia
Diarrhea
Aerosolized water - cruise ship
Sicker than CXR looks
CAP pearls for mycoplasma pneumoniae
Cough
Similar to bronchitis but feel sick for weeks
Walking PNA
CAP treatment outpt
Doxycycline
Macrolides like Azithromycin
FQ like levofloxicin
CAP treatment for inpt
Ceftriaxone plus Azithromycin
Allergy: Respiratory FQ
How long to treat PNA ?
Pneumococcal PNA : 72 hrs
Atypical PNA : 2-3 weeks
H. Flu gram stain for CAP
“Pleomorphic”
“Pleural plaquing”
Mesothelioma
“Pleural based mass”
Pneumoconiosis
Tuberculosis
Need to review high points later
MAC
Common in AIDS pts with CD4
Sarcoidosis
High ACE
Hypercalcemia from high calcitriol
CXR : bilateral perihilar lymphadenopathy
Biopsy : noncaseating granulomas**
Idiopathic pulmonary fibrosis
Velcro crackles
“Ground glass”
“Honey-combing”
Restrictive PFTs
Quick eyeball pleural fluid results and protein is
Transudative : protein
Most common cause of transudative effusion ?
Heart failure in 90%
Most common cause of exudative effusion?
PNA - treat the underlying condition
Exudative effusion associated with malignancy – what cancer?
Commonly lung or breast cancer
Most common cause of pneumothorax
Primary PTX: tall thin M smoker
Secondary PTX: COPD
When does a pneumothorax get a chest tube?
If > 15-20%, require chest tube decompression
DVT diagnosis
“Screening test” – Venous US
“Gold standard” - venography (even though clinically we don’t do this, bc use US, this is the “definitive test”)
CXR findings for PE
EKG finding
Westermarks sign
Hamptons hum
S1Q3T3
PE diagnosis ?
NOT V/Q
Gold standard is pulmonary angiography** (although clinically would not do this ever)
Cor pulmonale
Right heart failure due to lung disease
OSA definition
Apnea greater than 10 seconds and
occurs > 7-10x / hr
Pulmonary HTN definition
Pulm artery pressure > 25 on right heart cath
Asthma
Episodic wheezing
Largely REVERSIBLE airway obstruction
Chronic inflammatory condition
Types of non-small cell lung cancer
Squamous cell carcinoma, adenocarcinoma, and large cell carcinoma are all subtypes of non-small cell lung cancer
Most common lung cancer
Non-Small Cell Lung Cancer. About 85% of lung cancers are non-small cell lung cancers.
Types of lung cancer
Non-small cell 85%- subtypes: adeno (MC), squamous, large cell Small cell (15%) - no subtype (smokers, grows fast)
Noncaseating granuloma
Sarcoidosis
If local pleural disease, like PNA or malignancy, would you expect a Exudative or transudative effusion ?
Exudative
DOC for uncomplicated COPD
Doxycycline
Tmp-SMX
Cefuroxime
DOC for complicated COPD
Amoxicillin / clavulanate
Or
Levofloxicin
DOC for typical CAP outpt
Doxy
Azithromycin
Levofloxicin
DOC if covering for atypical PNA
Ceftriaxone + Azithromycin
Or
Levofloxicin
