Pulmonary Flashcards
best test to assess presence of reactive airway disease in patient with NO current symptoms
methacholine stimulation testing
- will decrease FEV1 >20% in asthmatic pt
pt presents to ED with acute SOB - you are unsure of etiology; what is a good test to perform?
PFTs pre and post bronchodilator - will tell you if it is due to reactive airway disease
ventilator settings in asthmatic if pt needs to be intubated
low RR
small TV
high flow
initial therapies/management to order in acute asthma exacerbation
- oxygen
- continuous oximeter
- CXR and ABG
- inhaled albuterol
- bolus of steroids (methylpred)
- inhaled ipratropium
- magnesium
when is cromolyn or nedocromil useful
extrinsic allergies, ie hay fever
when is montelukast useful
atopic disease
when are tiotropium/ipratropium appropriate
COPD
when is omalizumab used
high IgE levels with no control with cromolyn
obstructive PFTs + normal DLCO
asthma
obstructive PFTs + decreased DLCO
emphysema (OOPD)
restrictive PFTs with proportionally decreased DLCO
extrathoracic restriction
- obesity, kyphosis
restrictive PFTs with disproportionately low DLCO
interstitial lung disease
pulmonary alveolar proteinosis
Alveolar filling with floccular material that is PAS+; CXR shows a batwing appearance
Dx. BAL
Tx. whole lung lavage
CCS: acute handling of SOB in COPD pt
- oxygen and ABG
- always reassess after O2 bc it may make the SOB worse by eliminating hypoxic drive - CXR
- Albuterol
- Ipratropium
- Bolus of steroids
- Chest, heart, neuro and extremity exam
- if fever, sputum or new infiltrate –> add abx
what abx are used in acute exacerbation of COPD
ceftriaxone and azithromycin
- add if increasing dyspnea, increase in sputum and sputum purulence
EKG findings in COPD
RAH: biphasic P waves in V1
RVH: deep S wave in V1 and tall R wave in v5/6 > 35 mm
Lab findings in COPD
- increased hematocrit
- reactive erythrocytosis - microcytic
- increased serum bicarb (metabolic compensation)
- ABG: respiratory acidosis, low pO2
chronic medical therapy of COPD
- tiotropium or ipratropium inhaler
- albuterol, levalbuterol or pirbuterol
- pneumococcal and influenza vaccine
- smoking cessation
- inhaled steroids - if FEV1 < 50 and >3 exacerbations/year
who gets home oxygen therapy in COPD?
- No sx of RHF and normal htc?
- pO2 < 55 and O2 sat < 60 and O2 sat < 90%
a 35 year old man presents with SOB. You do a CXR and see changes consistent with emphysema and this is supported by PFT results. Lab findings include low albumin level and elevated prothrombin time - dx?
alpha 1 antitrypsin deficiency
CF: bronchiectasis
repeat episodes of lung infections
cupfuls of sputum
hemoptysis
most accurate test for bronchiectasis
high resolution CT scan of chest
Tx. bronchiectasis
chest PT
rotating antibiotics
what drugs may cause ILD
nitrofurantoin
TMP-SMX (Bactrim)
only form of ILD that is responsive to steroids
berylliosis (granulomatous disease)
Pt presents with cough, rales, SOB along with fever, malaise and myalgias. CXR shows bilateral patchy infiltrates and chest CT shows interstitial disease with alveolitis - dx?
Dx. BOOP/COP
- similar presentation to ILD but with systemic findings
most accurate diagnostic test for BOOP/COP
open lung biopsy
Tx. BOOP/COP
steroids
associated findings with sarcoidosis
- Eyes - anterior uveitis
- Bells palsy
- Skin - lupus pernio, erythema nodosum
- Restrictive CM
- hypercalcemia - vit D production by granulomas
- elevated ACE levels
best initial test: sarcoidosis
CXR
most accurate diagnostic test: sarcoidosis
lung or lymph node biopsy –> non caseating granulomas
Tx. sarcoidosis
steroids
P/E findings in pulmonary HTN
loud P2
TR
RV heave
Raynaud’s phenomenon
secondary causes of pulmonary HTN
mitral stenosis polycythemia vera COPD chronic pulmonary emboli interstitial lung dz
PFTs in pulmonary HTN
decreased DLCO
normal PFTs
gold standard diagnostic test for pulmonary HTN
right heart catheterization
- increased pulmonary pressure (>25 at rest or > 30 with exercise)
Tx. pulmonary HTN
- bosentan (endothelin inhibitor)
- epoprostenol/treprostinil (prostacyclin analogs - pulmonary vasodilators)
- Nitric oxide gas (vasodilate w/o systemic effects)
- sildenafil
- CCBs
ABG results in PE
hypoxia
increased Aa gradient
respiratory alkalosis
poor prognostic factors in PE
- increased troponins
- hypotension
- hemodynamically unstable
gold standard to confirm PE
spiral CT
- test of choice if XR is abnormal
when are D-dimers appropriate in dx. of PE
when you have a low probability of PE in a patient and you want to RULE OUT the disease
single most accurate test for PE
angiography
pt with PE presents a few days after with low grade fever - what do you do
14% of pts will have a fever and you do not need to give abx even though clinical picture may resemble pneumonia
Management of PE
- oxygen
2. heparin (warfarin for 6 months with INR 2-3; IVC if contraindication to anti-coag)
when do you use thrombolytics in tx of PE
if pt is hemodynamically unstable (BP < 90) and low risk of bleeding
when do you use embolectomy in tx of PE
if pt is in shock and death likely within hours or if failed/contraindicated thrombolytics
pleural effusion
- best initial test
- most accurate test
initial = CXR accurate = thoracentesis
characteristics of exudative pleural effusion
pleural/ serum protein > 0.5
pleural / serum LDH > 0.5
what tests should be ordered on pleural fluid?
gram stain/culture, acid fast stain total protein LDH glucose cell count w/ diff TG pH
mild sleep apnea
5-20 apneic events/hour (apnea lasts > 10 sec)
severe sleep apnea
> 30 apneic events/hour
tx. obstructive sleep apnea
weight loss
CPAP/BiPAP
if not effective –> resection of uvulate, palate and pharynx
tx. central sleep apnea
- avoid alcohol /sedative
2. may respond to acetazolamide or medroxyprogesterone
Asthmatic pt presents with worsening asthma symptoms and recently began coughing up brownish mucus plugs and has recurrent upper lobe infiltrates on XR. Labs show eosinophillia and elevated serum IgE. Dx? First step?
dx. allergic bronchopulmonary aspergillosis
first test: aspergillus skin test
Tx. ABPA
corticosteroids
- refractory disease: itraconazole
Dx. test findings in ARDS
- normal PCWP (< 18 mmHg)
2. pO2 / FiO2 ratio < 200
Tx. ARDS
- Ventilatory support
- TV at 6 ml/kg
- PIP < 35 cm h20
- PEEP > 10 cm H20 - prone positioning
- possible use of diuretics and positive inotropes (dobutamine)
- transfer to ICU
Pulm artery cath results for hypovolemia
CO low
PCWP low
SVR high
Pulm artery cath results for cardiogenic shock
CO low
PCWP high (>18)
SVR high
Pulm artery cath results for septic shock
CO high
PCWP low
SVR low
who should get admitted for pneumonia?
elderly pts > 65 significant comorbidities vitals: tachycardia, hypotension, PO2<60 failure of outpt tx or unable to take meds PO change in mental status poor support system multilobular involvement
pneumonia:
best initial test
most accurate test
initial- CXR
accurate - sputum gram stain and culture
Tx. outpatient pneumonia
macrolide (azithromycin) OR respiratory FQ (levo or moxi)
Tx. inpatient pneumonia
ceftriaxone and azithromycin
FQ single agent
Tx. ventilator assoc. pneumonia
- imipenem, Zosyn or cefepime
2. Gentamycin and Vanc
recurrent pneumonia in smoker
bronchogenic carcinoma
-order CT scan and flexible bronchoscopy
pneumonia following viral syndrome
staphylococcus
pneumonia in alcoholics
klebsiella
- carbapenems
pneumonia in young, healthy patients
mycoplasma
pneumonia with GI symptoms and confusion
legionella
pneumonia in persons present at the birth of an animal
coxiella burnetti
pneumonia in arizona construction workers
coccidioidomycosis
pneumonia in HIV pt with CDC <200
PCP
Tx. PCP
Bactrim
Steroids - if PO2 35
cough induced by expiration is an indication of…
airway hyperreactivity
- recognized clinical clue for asthma
allergen most frequently assoc. with asthma
house dust mites
patient that is receiving treatment for TB and is improving clinically, develops a new pleural effusion - what test should you do?
thoracentesis
ideal vent settings in ARDS
- TV < 6 ml/kg
- limited plateau pressure < 30-35 Cm H2O
- want to achieve PaO2 of 55-80 mmHg - ventilator rate < 35 / min
single most important prognostic factor in COPD
after adjusting for age, FEV1 (if <40% indicates severe obstruction)
what ventilator settings allow you to improve oxygenation in ARDS?
maintain PaO2 of 55-80 or O2 sat 88-95% by adjusting the FiO2 or the PEEP (increasing)
who is permissive hypercapnia not safe in?
pts with elevated ICP or a seizure disorder
RF for post-op pulmonary complications
upper abdominal/thoracic surgeries underlying chronic lung dz history of smoking in last 8 weeks baseline PaCO2 > 45 duration of surgery >3-4 hours use of general anesthesia age > 50 obstructive sleep apnea
screening for lung ca
annual low dose chest CT in patients age 55-80 who have a > 30 year pack year smoking history and are either current smokers or quit within the last 15 years
termination of lung ca screening
age > 80 or
patient successfully quit smoking for >15 years or
pt has other medical problems significantly limiting life expectancy
pt with sarcoidosis comes in and has bilateral erythema nodosum and hilar adenopathy – management?
high rate of spontaneous remission with good prognosis –> no treatment except observation and periodic check up
tx of sarcoidosis if pt is symptomatic or has decreased pulmonary function
corticosteroids
best initial test in tb
CXR
confirmatory test TB
sputum acid fast stain
when do you know that TB is noninfectious
3 consecutive negative results on sputum acid fast smears performed on different occasions
Tx. TB
Isoniazid and Rifampin for 6 months
Pyrazinamide and Ethambutol - can stop after 2 months
main side effect of TB drugs - when should you stop them due to this s/e
liver toxicity; stop is LFTs > 5x upper limit of normal
isoniazid toxicity
peripheral neuropathy (give with pyridoxine)
rifampin toxicity
red orange colored bodily secretions
pyrazinamide toxicity
do NOT use in pregnancy - teratogenic
hyperuricemia
ethambutol toxicity
optic neuritis
what TB conditions require treatment for > 6 months
osteomyelitis meningitis miliary TB cavitary TB pregnancy if they are a child with any of the above - require 12 months
management: asymptomatic pt with TB but no evidence of active TB who has previously been treated for active TBI or LTBI
does not require further TB treatment
MC location of epistaxis
anterior nasal septal mucosa –> Kiesselbachs plexus or Littles area
- trickling of blood in upright position
next step in management if you cannot stop an episode of anterior epistaxis with nostril pinching
- cotton pledget impregnated with vasoconstrictor (phenlyephrine 0.25%) and lidocaine 2%
- followed by silver nitrate chemical cautery or needlepoint electrocautery
CF: posterior epistaxis
MC in older adults (men in 50s) with HTN and arteriosclerosis
- Woodruff’s plexus
- blood visible in posterior oropharynx in upright position
Bezold abscess
neck abscess resulting from an erosion through the medial aspect of the mastoid tip –> swelling behind the ears in pt with other clinical findings consistent with AOM
management: button battery lodged in esophagus
immediate removal under direct endoscopic visualization
- if already in the stomach - outpatient management OK
patient presents with loud snoring but no other signs or symptoms of OSA, what advice do you give them?
lose weight, stop smoking and avoid alcohol near bedtime
what can be used to reduce incidence of ear and sinus barotrauma during diving?
non sedating decongestants i.e. pseudoephedrine
