Pulmonary Flashcards
what is atopy
wheezing, eczema, and seasonal rhinitis
what is the pathophysiology of ASTHMA
it is an overproduction of IGE which results in there beta 2 receptors.
This leads to inflammation and mucus production and bronchial smooth muscle contraction
Clinical features of asthma
FEV1/FVC
what is bronchitis
infection and inflammation of the bronchial tree
there is also mucous formation
what is the most common cause of bronchitis
80% viral
who is at risk of acute bronchitis
smokers, COPD, DM and immunocompromised
what test should you order for acute bronchitis and why
cxr to rule out pneumonia
how do you treat acute bronchitis
albuterol and an antitussive and hydration
what is the most common infection with cystic fibrosis
pseudomonas
what is the etiology of COPD
smoking
it can also be due to alpha 1 antitrypsin
what pattern is seen on PFT in a patient with COPD
FEV1
what is the pattern for PFT in a patient with restrictive pattern
FEV1 is normal or slight decreased
FVC decreased more than FEV1
FEV1/FVC ratio is increased
TLC is decreased
people with emphysema are know as
pink puffers
they are thin due to increased energy expenditure during breathing
patient tend to lean forward
Patients have a barrel chest increased AP diameter
accessory muscle use
people with chronic bronchitis are know as
blue bloaters
they are over weight and cyanotic due to hypercapnia and hypoxemia
chronic cough and sputum production
what is bronchiectasis
irreversible dilation of the airways due to inflammatory destruction of the airway walls
Secondary infection with Pseudomonas aeruginosa
etiology of bronchiectasis
Cystic fibrosis most common Mechanical obstruction, tumor, mucus Infectious, TB, Pneumonia, MAC hypogammaglobulinemia Chronic aspiration
signs and symptoms of bronchiectasis
chronic cough mucopurulent sputum (foul smelling)
hemoptysis due to rupture of blood vessels near bronchial walls
wheezing
digital clubbing
recurrent or persistent pneumonia
how is bronchiectasis diagnosed?
High rest CT
PFT shows obstructive pattern
CXR is normal in most cases
what is the treatment for bronchiectasis?
Abx for acute exacerbations Bronchial hygiene hydration chest PT Bronchodilators
what is Cystic Fibrosis
defect in chloride channel protein causes impaired chloride and water transport which leads to thick viscous secretions in the respiratory tract, exocrine pancreas, sweat glands, intestines and GU
who is affected by CF
autosomal recessive condition predominantly affecting caucasians
what happens with patients who have CF
typically get obstructive lung disease with chronic pulmonart infections (pseudomnonas), pancreatic insufficiency and other GI problems
what is the treatment for CF
pancreatic enzyme replacement, fat soluble vitamins, chest PT, vaccinations for influenza and pneumococcal and ABX for infections
what is emphysema
permanent enlargement of air spaces distal to terminal terminal bronchioles due to destruction of alveolar walls from protease.
Elastase is released from PMN and macrophages and digest human lung. This is inhibited by alpha1-antitrypsin
what is the pathogenesis of chronic bronchitis
excess mucus production narrows the airways; patients often have a productive cough
Inflammation and scarring of the airways, enlargement in mucous glands and smooth muscle hyperplasia lead to obstruction
signs of COPD
prolonged forced expiratory time during auscultation, end expiratory wheezes on forced expiration, decreased breath sounds and inspiratory crackles Tachypnea, Tachycardia Cyanosis, accessory muscle use hyperresonance on percussion signs of cor pulmonale
How is COPD diagnosed
with PFT i s definitive diagnostic test
Decreased FEV1 and Decreased FEV1/FVC ratio
Increased total lung capacity and functional reserve capacity (indicates air trapping)
Obstructive lung disease FEV1, FEV1/FVC PEFR, Residual volume TLC Vital lung capacity
FEV1-low FEV1/FVC-low PEFR-Low Resid Vol-High TLC-High Vital cap-low
Restrictive lung disease FEV1, FEV1/FVC PEFR, Residual volume TLC Vital lung capacity
FEV1-normal to slightly low FEV1/FVC-normal to high PEFR-Normal Resid Vol-low,norm,high TLC-low Vital cap-low
CXR in COPD
low sensitivity fir diagnosing COPD
Hyperinflation, flattened diaphragm and enlarged retrosternal space
decreased vascular markings
Useful in acute exacerbation to rule out pneumonia
what is the most important intervention for COPD
smoking cessation
it prolongs survival rate but does not reduce it to the level of someone who has never smoked.
what two interventions for COPDers has lowered mortality
smoking cessation and oxygen therapy
what is the treatment of COPD
-Inhaled Beta2-agonists (albuterol) long active agents like salmeterol Inhaled -anticholinergics like ipatropium bromide -combo of albuterol and ipatropium -Inhaled steroids like fluticasone or budesonide -Theophylline -O2 therapy -vaccination influenza and pneumococcal
what is contraindicated in COPD and asthma as far as medication goes?
beta blockers because they can mask brochospam
what is the criteria for continuous or intermittent long term oxygen therapy in COPD
PaO2 55mm HG
or
O2 sat
acute COPD excerbation definition
a persistent increase in dyspnea not relieved with bronchodilators
Increased sputum production are common
what is first line treatment in acute COPD excerbation
Broncodilator alone or in combo with anticholinergic
supplemental O2 to keep
When do you use systemic steroid in a COPD exacerbation
for patient requiring hospitalization usually methylprednisolone
DO Not use inhaled steroid with acute exacerbation
asthma triad
- air way inflammation
- Airway hyperresponsiveness
- reversible airflow obstruction
when does asthma start?
can start at any age
extrinsic asthma
patients are atopic produce immunoglobulin E to environmental antigens
May be associated with eczema and hay fever
intrinsic asthma
not related to atopy or environmental factors
triggers include pollen, house dust, mold and cockroaches, cats, dogs, cold air, tobacco smoke
clinical features of asthma
intermittent SOB, wheezing, chest tightness, and cough
Symptoms are worse at night
Wheezing during inspiration and expiration
how is asthma diagnosed
PFT
they will show a obstructive patter
Decrease in FEV1, and FEV1/FVC
Spirometry before and after bronchodilator can confirm diagnosis by proving reversible air way obstruction
If there is an increase in FEV1 or FVC by at least 12% it is considered reversible
Peak Expiratory flow rate Normal mild mod-sev severe
norm:450-650
mild>300
mod-sev:100-300
sev
what is bronchoprovocation test
used when asthma is suspected but PFT are nondiagnostic.
measures lung function before and after inhalation of mathacholine
what is the most common finding of asthma on CXR
normal
can show hyperinflation
ABGs in asthma
should be considered if patient is in significant respiratory distress
Hypercarbia is common
what id the PaCO2 is normal or increased
respiratory failure may ensue.
When respiratory rate is increased that should cause PaCO2 to decrease but Increased PaCO2 is a sign of respiratory muscle fatigue or severe air way obstruction.
Pt should be hospitalized and mechanical vent should be considered
what is the treatment for acute attacks
albuterol inhaler onset is 2 to 5 minutes and last 4to6 hours
what is the treatment of acute severe asthma excarbation?
Inhaled beta2 agonist via MDI or neb assess patients response to bronchodilators with peak expiratory flow and clinically Corticosteroids third line agenst include iv magnesium supplemental O2 to keep sats >90%
intermittent asthma symptoms and night time symptoms
rescue med usage
interfere with normal activity
symptoms
severe persistent asthma sypmtoms night symptoms rescue med use interfer activity lung function
symptoms throughout the day night 7times/week rescue med use several time/day activity inter extereme FEV1
Mild persistent asthma symptoms night symptoms rescue med use activity interfe lung function
symptoms >2days/week night symptoms 3-4 times/month rescue med use > 2 days/week but not daily activity interference minor
what are typical cardiopulmonary pattern in restrictive lung disease
RVH
RAD
right heart strain pattern
what is the key to pnemoconosis?
exposure
what are the types of pneumoconiosis related to environmental exposure
Asbestosis (ships, insulation, pleural plaquing)
Silicosis (sandblasting, foundry work
Black lung coal miners lung
Interstitial lung disease with granulomas
Sarcoidosis
Histocytosis
Wegners’s granulomatosis
churg-strauss
alveolar filling disease
good pasture
Idopathic hemosiderosis
alveolar proteinosis
what is sarcoidosis?
non infectious granulomatous disease
90% lung involvement
they are noncaseating granulomas
who does sarcoidosis usually affect?
young to middle age
what is the work up for sarcoidosis and what do the results look like
Leukopenia, eosinophilia Hypercalcemia/hypercalciureia Increased ESR/CRP \+RF Increased serum ACE
what does a CXR look like for sarcoidosis
nodular lesions with bilateralhilar lymphadenopathy
how is sarcoidosis dxed
transbronchial biopsy
what is the treatment for sarcoidosis
steroids only for symptoms
most cases resolve or significantly improve in 2 years
what is erythema nodosum
is a reddish painful tender lumps commonly located on the front of legs below the knees
found in sarcoidosis
what are symptoms of sarcoidosis
anterior and posterior uveitis erythema nodosum conjunctivitis heart arrhythmias bells palsy
what do PFT look like for sarcoidosis
decreased VC and TLC decreased diffuse lung capacity
decreased FEV1/FVC
what is asbestosis?
diffuse interstitial fibrosis of the lung caused by inhalation of asbestos fibers
when does asbestos develop
15 to 20 years after exposure
what does asbestos look like on a CXR
honey combing with pleaural plaques
hazy infiltrates with bilateral linear opacities
what causes silicosis
exposure to sandblasting, mining, stone cutting and glass manufacturing
What are people who have silicosis at risk of getting
TB
What does silicosis look like on CXR
egg shell calcifications
localized and nodular peribronchial fibrosis most common in upper lobes
what is the treatment for silicosis
removal from exposure
what causes berylliosis?
exposure to beryllium from fluorescent lightbulbs and aerospace engineering
how is berylliosis diagnosed
beryllium lymphocyte proliferation test
how is berylliosis treated
steroids
what causes idiopathic pulmonary fibrosis
its unknown
what is the presentation of IPF
gradual onset of progressive dyspnea, nonproductive cough
what is the mean survival of ITP
3-7 years
what does the CXR look like with IPF
ground glass or honeycomb or normal
how is IPF diagnosed
open lung biopsy
what is the treatment of IPF
no effective treatment but supplemental oxygen, steroids and lung transplant have shown to be beneficial
what is acute respiratory failure?
when there is inadequate oxygenation of blood or ventilation or both
hypoxia is defined as
PaO250mm hg
hypercapnia is defined as
PCO2>50
how is ARDS diagnosed
hypoxemia that is refractory to oxygen therapy ratio of PaO2/FiO20.5
what are the causes of ARDS
Sepsis most common
trauma
overdose
near drowning
what does pertussis look like under a microscope
gram negative coccobacillus
how is pertussis diagnosed
clinical suspicion
patients will have severe or prolonged cough or post tussive vomiting
how are kids treated who have pertussis
supportive therapy and hospitalization
Positive tests are
how are adults treated
azithromycin or clarithromycin
Tdap booster
Vaccinate pregnant women
what are the two types of lung cancers
Small Cell lung cancer
Non-small cell lung cancer
which lung cancer is more common?
non-small cell
non small cell cancer involves which cancers?
squamous cell
adenocarcinoma
large cell
bronchoalveloar cell carcinoma
what are risk factors for lung cancer?
Cigarette smoke accounts for >85% 2nd hand smoke Asbestos Radon COPD there is a linear relationship between pack years and risk of lung cancer
when cancer has the lowest association with smoking of all lung cancers
adenocarcinoma
how is NSCLC staged
TNM system
how is SCLC staged
Limited- which is confined to chest plus supraclavicular nodes but not cervical or axillary
Extensive which is outside of the chest
what symptoms are most common of squamous cell
cough, hemoptysis, obstruction, wheezing and dyspnea
recurrent pneumonia
what are lung cancer constitutional symptoms?
anorexia, weight loss, weakness
What do symptoms of local invasion by lung cancer present like
- superior vena cava syndrome which cause facial fullness, face and arm edema, dilated veins over the anterior chest and arms
- Phrenic nerve palsy causing hemidiaphtagmatic paralysis
- Hoarsness
- Horners Syndrome lack of sweating, ptosis and miosis
- Pancoast tumor causes shoulder pain upper extremity weakness and horners syndrome
what is the treatment for NSCLC?
Surgery is the best option
you need to make a definitive pathological diagnosis before surgery
If patient has metastatic disease they are not candidates for surgery
Radiation is important adjunctive therapy
what is the treatment for SCLC for limited disease
chemo and radiation are initially used
what is the treatment for SCLC for extensive disease
chemo alone is used as initial tretment
what features favor a benign vs malignant nodules
Age- the older the patient the more likely it is to be malignant 50% chance over age 50
Smoking- smokers have higher risk of malignancy
Size of nodule- larger the nodule the more likely it is to be malignant >2cm
Borders- malignant nodules have more irregular borders
Calcifications-eccentric asymmetric calcification suggest malignancy. Dense central calcification suggest benign
Change in size
what cancers are usually peripherally located
Adenocarincoma
Large cell carcinoma
which lung cancers are centrally located
SCLC
Squamous
A person presents with flushing, diarrhea and bronchospasm. What type of cancer do they have
the person has pulmonary carcinoid
they are presenting with carcinoid syndrome
what is a pleural effusion?
fluid in the plural space
what are symptoms of pleural effusion
SOB
cough
chest pain
what are signs of pleural effusion
decreased air entry
dullness
wheezes and crackles
what does a pleural effusion look like of a CXR
meniscus
blunting of costophrenic angle
Bilateral pleural effusion would be more likely CHF
what causes transudative effusion
due to either elevated capillary pressure in visceral or parenteral pleura or decreased plasma oncotic pressure
what causes a exudative effusion
causes by increased permeability of pleural spaces
what should you do if you suspect a exudative effusion
test pleural fluid for cell count, glucose, pH, amylase, triglycerides
what is found in exudative effusions?
Protein >0.5
LDH>0.6
LDH> 2/3 upper limit of normal serum LDH
what is the most common cause of a Pleural effusion
CHF
what causes exudative effusions
Malignancy
Bacterial Pneumonia
Viral infection
Pulmonary embolism
what will the results of Protein LDH Glucose look like in exudative effusions
Protein-high
LDH-high
glucose-low because bacteria and cells are in the fluid and are using the glucose
what will the results of Protein LDH Glucose look like in transudative effusions
Protein-low
LDH-low
glucose-high
how are exudative effusions treated
surgical drainage or removal
how is transudative effusions treated
drugs
causes of transudative effusions
CHF
Cirrhosis
Nephrotic syndrome
Peritoneal dialysis
what does a bilaterally effusions suggestive of
CHF
isolated left sided pleural effusion
pneumonia, cancer, boerhaave (esopaheal) rupture
aortic dissection
lsolated right sided effusion
pneumonia, cancer, CHF, PE
what is a parapneumonic effusion
pleural effusion in the presence of pneumonia
this can lead to
what is a pneumothorax
air in the pleura space
what causes a traumatic pneumothorax
iatrogenic
always get CXR after the procedure of Transthroacic needle aspiration
thoracentsis
central line placement
what causes a spontaneous pneumothorax
occurs with out any trauma
what is a primary simple pneumothorax
occurs in a healthy individual without any underlying lung disease
which is causes by bleb ruptures into pleural space
common in tall young men
what is secondary complicated pneumothorax
occurs as complication of underlying lung disease COPD, asthma, TB
what are symptoms of pneumothorax
ipsilateral chest pain with sudden onset
dyspnea
cough
what are physical signs of pneumothorax
decreased breath sounds over affected side
hyperresonance over chest
decreased or absent tactile fremitus on affected side
mediastinal shift towards side of pneumothorax.
what is the treatment for a primary pneumothorax
if small pneumothorax and patient is asymptomatic:
Observation and should resolve in 10days
If larger pneumo administer supplemental oxygen
chest tube insertion
what is the treatment for secondary pneumo
chest tube and drainage
what is a tension pneumothorax
accumulation of air within the pleural space that tissues surrounding the opening to the pleural cavity act as a valve and allow air to enter but not escape
what causes a tension pneumothorax
Mechanical ventilation
CPR
Trauma
what are clinical features of tension pneumothorax
hypotension
distended neck veins
shift of trachea away from tension pneumo
decreased breath sounds on affected side
hyperresonance to percussion on side of pneumo
how is tension pneumothorax treated
treated as medical emergency due to hemodynamic compromise
large bore needle in second or third intercostal space MCL followed by chest tube placement
what is pulmonary hypertension
mean arterial pressure greater than 25 mmHg at rest of 30mm Hg during exercise
how is pulm hypertension diagnosed
ECG shows right ventricle hypertrophy
echo will show dilated pulmonary artery
dilation and hypertrophy of RA and RV
Right heart Cath
how is pulm HTN treated
oxygen
vasodilators (sildenafil, epoprstenol) CCB
anti coagulation
lung transplant
what is primary pulmonary hypertension
HTN in the absence of disease of heart and lung
what establishes the diagnosis of primary pulm htn
cardiac cath
what is Cor pulmonale
RVH with eventual RV failure from pulmonary HTN secondary to pulmonary disease
what is the most common cause of Cor pulmonale
COPD
what are signs of Cor pulmonale
decreased exercise tolerance
cyanosis and digital clubbing
JVD, hepatomegaly, edema
how is cor pulmonale diagnosed
CXR will show enlargement of RA,RV and pulmonary arteries
ECG will show right axis deviation, Peaked P waves, RVH
ECho RVH dilitation but normal LV size and function
treatment for cor pulmonale
treat pulmonary disorder
use diuretic cautiously
long term oxygen
what is a pulmonary embolism
occurs when a thrombus in another region of the body embolizes to the pulmonary vascular tree via RV and pulmonary artery
what are risk factors for DVT
age >60 malignancy prior DVT/PE cardiac disease obesity trauma/surgery pregnancy/estrogen use
sypmtoms of PE
dyspnea pleuritic chest pain cough hemoptysis syncope
signs of PE
tachypnea rales tachycardia S4 Increased P2 shock low grade fever
what do ABGs look like on a patient with a PE
PaO2 low
PaCO2 low and pH is high
what does the A-a gradient look like in a PE
increased A-a gradient
Low pO2 despite high FiO2
how to diagnosed a PE if low suspicion
D dimer
if negative PE ruled out
if positive then do a CT-PA
how to diagnose a PE if high suspicion
CT PA if positive PE ruled in
CT PA negative consider U/S VQ scan
causes of elevated D-dimer
aortic dissection MI Preg surgery trauma infection/inflammation
treatment for PE
oxygen to fix hypoxemia
anticoagulation therapy start immediately if suspicion is high
give a bolus followed by continuous infusion for 5 to 10 days with a goal INR of 1.5-2.5
start warfarin on day 1 and continue for 3 to 6 months or more
thrombolytic therapy
Inferior vena cava filter if anticoag is Contraindicated
which lung is most commonly involved with pulmonary foreign body
the right lung because of the anatomy where the right bronchus is more straight
how does foreign body aspiration present?
some develop acute respiratory distress
most often patient appear well but later develops respiratory disfunction
SOB, fever, tachypnea, hypoxemia
how is a foreign body diagnosed?
CXR
what are symptoms of TB
cough, weight loss, fatigue, fever, night sweats, chest pain, hemoptysis
typically happens over weeks
how does primary TB show up on CXR
homogeneous infiltrates, hilar/paratracheal lymph nose enlargement, segmental atelectasis, cavitations with progressive disease
what does reactivation TB look like on CXR
fibrocavitiy apical disease, nodules, infiltrates, posterior apical segment of the right upper lobe
what is a gohn complex
calcified primary focus
what is a ranke complex
calcified primary focus and calcified hilar lymphnodes represent healed infection
how is TB diagnosed
identification of Mycobacterium tuberculosis from cultures or by DNA or RNA amplification techniques
what is the histological hallmark of TB
caseating granulomas
what is the treatment for active TB
RIPE Rifampin, Isoniazid, Pyrazinamide, ethambutol for 2 months then RI for 4 months watch LFTs
what are the side effects of Isoniazid
hepatitis, peripheral neuropathy
side effects of Rifampin
hepatitis, flu, orange body fluid
side effects of ethambutol
red-green vision loss
a PPD is considered positive at >5mm for what patients?
HIV positive person
Recent contact with active TB carrier
Person with evidence of TB on CXR
Immunocompromised on steroids
a PPD is considered positive at >10mm for what patients?
recent immigrants from high TB areas
HIV neg injection drug users
mycobaerioogy lab peopel
residents and employees in high risk settings
Pts with certain med conditions like DM, sillicosis
a PPD is considered positive at >15mm for what patients?
people with no risk factors
what is the Bacille Calmette guerin
vaccine administered to a Tb neg person in cases with high risk for intense prolonged exposure
what is the most common cause of respiratory disease in preterm infant
hyaline membrane disease
what causes hyaline membrane disease
deficiency in surfactant
how is hyaline membrane disease treated
intermitten ventilation
exogenous surfactant
how does hyaline membrane disease present
rapid labored breathing, grunting, retractions, fast heart rate
what is community acquired pneumonia
occurs in community or within first 48-72 hours of hospitalization
what is the most common CAP
streptococcus pneumonia
what is nosocomial pneumonia
occurs during hospitalization after first 48-72 hours
what is the classic presentation of CAP
sudden chill followed by fever pleuritic chest pain and productive cough
crackles
increased tactile fremitus
what is the presentation of atypical pneumonia
sore throat, headache followed by nonproductive cough and dyspnea
low to no fever
less severe lung exam
which bacteria are the typical bugs
SHaKeM Strep pneumo Haemophilius infl Klebsiella Moraxella
which bugs cause atypical pneumona
MC LIRP Mycoplasma Chlamydophilia Legionella RSV parainfluenza
what are the two recommendation to prevent pneumonia
Flu shot
pneumococcal vaccine
who should receive pneumococcal vaccine
patients >65
young patients with high risk like heart disease, sickle cell, pulmonary disease, diabetes, alcoholic cirrhosis and asplenic individual
how is pneumonia diagnosed
PA and Lateral CXT
when do you admit a patient with CAP
hypotension
hypoxic
how is CAP treated
patients with out comorbid conditions are treated with azithromycin or clarithromycin
If comorbid condition treat with fluroquinolone
what is the treatment for HAP
cephalosporins with pseudomonal coverage
ceftazidome or cefepime
carbapenems: imipenem
pipercillin/tazobactam
how is ventilator pneumonia treated
Ceftazidime or cefepime
Or zosyn or inapenem
aminoglcoside or fluroquinolone
vanco or linezolid
what antivirals are used for the flu
zanamivir or oseltamivir
what type of pneumonia are HIV patients at risk for
PCP
pneumocystis jiroveci
what is the treatment for PCP
bactrim
what is the most common pneumonia in HIV patients
Strep pneumo
patient has rust colored sputum rigors, high WBC,
strep pneumo
gram positive encapsulated diplococci
elederly, alcoholic with COPD, currant jelly sputum
klebsiella
pneumonia seen in COPD, smokers, elderly
Haemophilus influenza
gram neg encapsulated coccobacillus
patients invaded with plastic like nursing home, G-tube/ET tube, CF, hot tubs
pseudomonas
gram neg coccobacillus
neonate with staccato cough
chlamydophilia
sick old men, COPD, out breaks associated with air conditioning
Legionella
alcoholics have high risk of aspiration with abscess formation
Anaerobic
flea from rodents can cause this pneumonia
yersinia pestis
