Pulmonary Flashcards
1
Q
Etiologies of obstructive pulmonary disease
“ABCO”
A
Asthma
Bronchiectasis
COPD/CF
Obstruction (tracheal/bronchial)
2
Q
FEV1/FVC ratio of ____ suggests obstruction
A
FEV1/FVC ratio < 70%
3
Q
FEV1/FVC ratio ____ suggests restriction
A
> 70%
4
Q
Other conditions that can cause wheezing other than asthma?
A
COPD, foreign body. anything that causes airway constriction
5
Q
Asthma should be suspected in kids with multiple episodes of ______
A
croup and URIs associated with dyspnea
6
Q
Name some common triggers for asthma
A
allergens, URIs, cold air, exercise, drugs, stress
7
Q
Samter’s triad
A
Asthma, aspirin sensitivity, nasal polyps
8
Q
late signs of asthma
A
no wheezing. no breath sounds. cyanosis. decreased O2 sat.
9
Q
When PFTs are normal but asthma is still suspected what challenge test can be helpful?
A
Methacholine
10
Q
expected ABG for acute asthma exacerbation early on?
A
respiratory alkalosis
11
Q
If a patient with asthma has anormalizing PCO2 and a respiratory acidosis- what might this mean?
A
Impending respiratory failure. Patient might not be able to work as hard to blow off PCO2
12
Q
CXR for asthma
A
normal appearance to hyperinflation and flattening of diaphragm
13
Q
consider intubation for asthma when PCO2 > ___ or PO2 < ____
A
50, 50 mm Hg
14
Q
Cromolyn is useful for?
A
exercise induced bronchospasm and only as prophylaxis not in acute attacks
15
Q
Mild intermittent asthma symptoms occur?
A
< 2 days/week
< 2 night/month
16
Q
treat mild intermittent asthma with?
A
PRN short acting B-dilator
17
Q
FEV in mild intermittent asthma is?
A
> 80%
18
Q
Mild persistent asthma symptoms?
A
> 2 X/week but < 1/day
> 2X/month
19
Q
Meds for mild persistent asthma
A
daily low dose corticosteroid
PRN albuterol
20
Q
Mod persistent asthma symptoms
A
daily
> 1 night/week
21
Q
Meds for mod persistent asthma
A
low-medium inhaled corticosteroid and long acting inhaled B agonist (salmeterol)
PRN albuterol
22
Q
Severe persistent asthma symptoms
A
continual
frequent
23
Q
Meds for severe persistent asthma
A
high dose inhaled CS and long acting inhaled B-agonist
Possible PO CS
PRN albuterol
24
Q
Bronchiectasis
A
caused by recurrent infection and inflammation in bronchi/bronchioles that lead to fibrosis, remodeling, permanent dilation of bronchi
25
CXR for bronchiectasis shows
increased bronchovas markings and "tram lines"
dilated airways and ballooned cysts
26
Presentation of bronchiectasis
chronic productive cough of yellow/green sputum, dyspnea, hemoptysis, hallitosis
27
Treatment for bronchiectasis:
Meds:
Lifestyle:
Surgery:
Meds: antibiotics for bacterial infections. inhaled CS
Lifestyle: cough control, postural drainage, chest PT
Surgery: lobectomy for localized or lung transplant for severe
28
Diagnosis of chronic bronchitis
productive cough for >3 months per year for 2 consecutive years
29
Emphysema diagnosis
destruction and dilation of structures distal to terminal bronchioles (pathologic diagnosis)
30
Smoking causes _____ destruction while A1AT causes _____ destruction
centrilobular ; panlobular
31
what are the only two interventions proven to improve survival in COPD patients?
Smoking cessation and O2 therapy
32
Treatments for COPD
| "COPD"
C: corticosteroid
O: O2
P: prevention (smoking cessation and pneumo and influenza vaccines)
D: dilators (B-ag, anticholinergics)
33
Parenchymal bullae and subpleural blebs are pathognomonic for?
emphysema
34
Etiologies of restrictive lung disease
Alveolar: edema, hemorrhage, pus
Interstitial: ILD
Inflammatory: sarcoid, cryptogenic organizing pneumonia
Idiopathic pulmonary fibrosis
Neuromuscular: Myesthenia gravis, phrenic nerve palsy, myopathy
Thoracic wall: kyphoscoliosis, obesity, ascites, pregnancy, ankylosing spondylitis
35
Interstitial lung disease
heterogenous group of disorders characterized by inflammation and/or fibrosis of interstitium
36
What are the exposure related types of interstitial lung disease?
coal workers pneumoconiosis, asbestosis, silicosis, berylliosis, hypersensitivity pneumonitis, radiation
37
Systemic disease or connective tissue disease associated interstitial lung disease?
polymyositis/dermatomyositis, sarcoidosis, amyloidosis, vasculitis, dermatomyositis, CREST
38
What might you see on CT for patients with ILD?
Honey-combing (reticular, nodular, ground glass pattern)
39
Presentation of Interstitial lung disease
shallow, rapid breathing, dyspnea on exertion, chronic non-productive cough. cyanosis, inspiratory squeeks or velcro-like crackles, clubbing, right heart failure
40
List medications or interventions that can cause or contribute to interstitial lung disease?
Amiodoarone, busulfan, nitrofurantoin, bleomycin, radiation, long term high O2 concentration
41
PFTs would show
normal FEV/FVC. Low TLC, low FVC, low diffusing capacity
42
Surgical biopsy is the definitive test used to confirm?
IPF
43
In late stages of IPF, the only treatment may be?
lung transplantation
44
Lofgren syndrome
type of sarcoidosis with a triad: arthritis, erythema nodosum, bilateral hilar adenopathy
45
Systemic sarcoidosis is characterized by what on histology
non-caseating granulomas
46
Sarcoid can present as
fever, cough, malaise, weight loss, dyspnea, arthritis
47
```
Diagnosis of sarcoid
CXR/CT:
Biopsy:
PFTs:
Other findings:
```
CXR/CT: lymphadenopathy and nodules
Biopsy: definitive test **- noncaseating granuloma
PFTs: restrictive or obstructive with decreased diffusion capacity
Other: elevated serum ACE levels, hypercalcemia, hypercalciuria, increased alk phos
48
Clinical features of Sarcoidosis
"GRUELING"
```
G: granuloma
aRthritis
Uveitis
Erythema nodosum
Lymphadenopathy (hilar)
Interstitial fibrosis
Negative TB
Gammaglobulinemia
```
49
Treatment for sarcoid?
systemic corticosteroids for deteriorating resp function, constitutional symptoms, hypercalcemia, extrathoracic organ involvement
50
Hypersensitivity Penumonitis
alveolar thickening and noncaseating granuloma caused by environmental exposure to (mold, hot tub, down feathers)
51
Acute presentation of hypersensitivity pneumonitis?
dyspnea, fever, malaise, shivers, cough starting 4-6 hours after exposure
52
Upper lobe fibrosis is a common feature in?
chronic hypersensitivity pneumonitis
53
Name the common pneumoconiosis
asbestosis, berylliosis, silicosis, coal miners
54
history, imaging finding, complications: asbestosis
hx: manufacture tile, brakes, insulation, construction, demolition, shipbuilding (15-20 years after exposure)
Imaging: linear opacities** at lung bases and interstitial fibrosis. calcified pleural plaques
Complications: increased mesothelioma risk (rare) and lung cancer. risk of lung cancer is higher in smokers
55
history, imaging finding, complications: coal miners
hx: coal mine
Imagine: small nodular (<1cm) opacities in upper lung lobe
Complication: progressive massive fibrosis
56
history, imaging finding, complications: silicosis
hx: work in mines or quarries or with glass, pottery, silica
Imaging: small (<1cm) nodular opacities in upper lung zones: eggshell calcifications!
Complication: risk of TB, need annual TB skin test. Progressive massive fibrosis
57
history, imaging finding, complications: berylliosis
hx: high tech fields (space, nuclear, electronic plants)
Imaging: diffuse infiltrates, hilar adenopathy
Comp: chronic corticosteroid treatment
58
Calcified pleural plaques in asbestosis are indicative of?
benign pleural disease
59
Name the eosinophilic pulmonary syndromes
Allergic bronchopulmonary aspergillosis
Loffler syndrome
Acute eosinophilic pneumonia
Drug Induced (NSAID, nitrofurantoin, sulfonamides)
60
Presentation of eosinophilic pulm syndromes
dyspnea, cough, possible blood tinged sputum, and/or fever
61
Diagnosis of pulm syndromes?
CBC: peripheral eosinophilia
CXR: pulm infiltrates
62
Name the causes of hypoxemia (low PO2)
```
V/Q mismatch
Right to left SHUNT
Hypoventilation
Low inspired O2 content
Diffusion impairment
```
63
When will the A-a gradient be normal in cases of hypoxia?
If the problem is hypoventilation or low inspired O2, the A-a gradient will be normal
64
If the problem is V/Q mismatch or shunting, the A-a gradient will?
Increase
65
Initial test for diagnosis of hypoxia?
ABGs. Calculate the A-a gradient
66
Further diagnosis/work up for hypoxia?
pulse ox monitoring.
| CXR: evaluate for infiltrates, ARDS.
67
In hypercapnic patients ______ ventilation to ______ CO2 exchange.
Increase, Increase
68
Mechanical ventilator parameters that affect Oxygenation?
FiO2 and PEEP
69
Mechanical ventilator parameters that effect ventilation?
respiratory rate, tidal volume
70
Summarize approach for working up/managing hypoxic patients when A-a is normal.
If A-a gradient is normal, is PaCO2 increased? If not, hypoxia likely due to decreased FiO2 (high altitude). If PaCO2 is increased, hypoxia likely caused by hypoventilation. (decreased resp drive, neuromuscular disease)
71
Summarize approach for working up/managing hypoxic patients when A-a is NOT normal.
You ask: Is PaO2 correctable with O2? If no, this is due to SHUNT (intracardiac shunt, vascular shunt in lungs). If PaO2 correctable with O2 -> V/Q mismatch (asthma, COPD, ILD, atelectasis, pneumonia, pulmonary edema, pulm vasc disease)
72
Common triggers for acute respiratory distress syndrome
sepsis, pneumonia, aspiration, multiple blood transfusions, inhaled/ingested toxins, trauma
73
What is ARDs?
acute respiratory failure with refractory hypoxemia, decrease lung compliance and pulmonary edema (PaCO2/FiO2 ratio < 300)
74
Pathogenesis of ARDs is thought to be dependent on?
endothelial injury
75
CXR for ARDs?
Diffuse alveolar filling, diffuse opacity
76
Criteria for ARDs diagnosis according to Berlin definition?
1. acute onset < 1 week
2. A PaO2/FiO2 < 300 with PEEP/CPAP > 5 H2O
3. Bilateral pulm infiltrates on CXR
4. Resp failure cannot be completely explained by heart failure
77
Treatment for ARDS
1. treat underlying disease
2. maintain adequate perfusion to prevent end organ damage
3. mechanical ventilation with low tidal volumes (4-6cc/kg of ideal body weight) to reduce lung injury
4. Use PEEP to recruit collapsed alveoli. Titrate PEEP and FiO2 to achieve best Oxygenation
5. goal oxygenation PaO2 > 55 mm Hg or SaO2 > 88%
78
What is oxygenation foal for ARDs patients?
PaO2 > 55 mm Hg or SaO2 > 88 %
79
What is normal pulmonary arterial pressure?
15 mm Hg
80
Mean pulmonary artery pressure greater than ____ defines pulm htn
25
81
What criteria for extubation from mechanical ventilation is the most predictive of success?
Frequency/tidal volume ratio < 105
82
Causes of pulmonary htn include?
left heart failure, mitral valve disease, increased pulm vein resistance, hypoxic vasoconstriction 2ndary to chronic lung disease, chronic thromboembolic disease, idiopathic
83
Exam findings for patients with pulm htn
loud, palpable S2, often split, flow murmur, S4 or parasternal heave.
84
Pulm htn findings on chest c-xray
1. enlargement of pulm arteries
2. ECG shows RVH
3. Echo (initial test) and right heart cath (definitive test) show signs of right ventricle overload
85
Pulm embolism presents as
sudden onset or subacute dyspnea, pleuritic chest pain, low-grade fever, cough, tachypnea, tachycardia, hemoptysis (rare)
86
Dyspnea, tachycardia and a normal CXR should raise suspicion for?
PE
87
Initial test if low suspicion of PE?
D-dimer
88
Is D-dimer sensitive or specific?
sensitive. It's most useful to "rule out"
89
What is the definitive test for diagnosing PE?
CT pulmonary angiogram with IV contrast/spiral CT
90
Hampton hump
a wedge shaped infarct that may be seen on CXR and is indicative of PE
91
Westermark sign
oligemia/collapse of vessels that may be seen on CXR distal to a PE
92
ECG findings for PE
most common is sinus tachycardia
| Classic S1Q3T3 is rate- signifies acute right heart strain
93
When should you use a V/Q scan to help with PE diagnosis?
If contraindications to CT scanning. (kidney disease, pregnancy)
94
Treatment for PE Acute and Chronic
Acute: Heparin bolus and then Heparin infusion or LMW heparin subcu
Chronic: Anticoag for 3-6 months (INR 2-3)
95
When should an IVC filter be placed?
In patients with lower extremity DVT if anticoagulation is contraindicated or if patients experience recurrent emboli while anticoagulated
96
What is the most effective DVT prophylaxis?
early ambulation
97
Diagnose lung nodule based on hx clues
1. recent immigrant
2. southwestern US
3. Ohio River Valley
1. TB
2. Coccidiodomycosis
3. Histoplasmosis
98
Divide lung cancers into 2 broad groups
small cell lung cancer
| non-small cell
99
what are the most common types of NSCLC
adenocarcinoma, squamous cell carcinoma, large cell carcinoma
100
What type of lung cancer is most likely to metastasize at an early stage?
small cell lung cancers
101
What lung cancers are found centrally?
Squamous cells and small cells
102
```
Characteristics of benign lung nodules:
age:
smoke:
change:
calcification:
margin:
size:
```
```
age: < 35
nonsmoker
no change from old CXRs
central, uniform, popcorn calcification
smooth margin
< 2 cm
```
103
```
Characteristics of malignant lung nodules:
age:
smoke:
change:
calcification:
margin:
size:
```
```
Age 45-50
smoker
new or enlarging lesions
absent/irregular calcification
irregular margin
Size > 2
```
104
Location, characteristics, histology: small cell (oat cell) carcinoma
L: central
characteristics: undifferentiated-> very aggressive
may produce ACTH (cushing syndrome), SIADH, or antibodies against presynaptic Ca2+ channels (Lambert-Eaton syndrome) or neurons (paraneoplastic myelitis/encephalitis). Amplification of myc onc genes common.
Histology: neuroendocrine Kulchitsky cells - small dark blue cells (chromogranin A (+))
105
Location, characteristics, histology: Adenocarcinoma
L: peripheral
Character: most common lung cancer in non-smokers and overall
Histology: glandular, stains mucin (+)
106
Location, characteristics, histology: squamous cell carcinoma
L: central
Characteristic: hilar mass arising from bronchus. Produces PTH -> hyperCalcemia
Histology: Keratin pearls and intercellular bridges
107
Location, characteristics, histology: Large cell carcinoma
L: peripheral
Characteristic: anaplastic undifferentiated tumor, *poor prognosis*, less responsive to chemo, remove surgically
Histology: pleomorphic giant cells. can secrete B-hCG
108
Location, characteristics, histology: Bronchial carcinoid tumor
Character: excellent prognosis. mets rare. symptoms due to mass effect. Carcinoid syndrome (5-HT secretion -> flushing, diarrhea, wheezing)
Histology: nets of neuroendocrine cells. chromogranin A +
109
Is small cell carcinoma operable?
NO- treat with chemo
110
Kulchitsky cells
small dark blue neuroendocrine cells of small cell carcinoma. They are positive for chromogranin A
111
Hypertrophic osteoarthropathy
clubbing
112
which type of lung cancer is associated with clubbing
adenocarcinoma
113
Bronchioalveolar subtype (great prognosis) of adenocarcinoma will show what on CXR?
Hazy infiltrates similar to pneumonia
114
Histology for bronchioalveolar subtype of adenocarcinoma
grows along alveolar septa-> apparents thickening of alveolar walls
115
Which type of cancer is NOT associated with smoking?
bronchoalveolar subtype of adenocarcinoma
116
Lung cancer mets are often found in "LABBs"
Liver
Adrenals
Brain
Bones
117
What type of lung cancer is associated with gynecomastia?
Large cell
118
ACTH, SIADH ass lung cancer?
small cell
119
Hypercalcemia, PTH ass lung cancer?
squamous cell
120
Lung cancers associated with dermatomyositis?
ALL
121
Lung cancer associated with peripheral neuropathy, subacute cerebellar degeneration, lambert-eaton syndrome?
small cell
122
Lung cancer associated with migratory thrombophlebitis, nonbacterial verrucous endocarditis?
adenocarcinoma
123
lung cancers associated with anemia, DIC, eosinophilia, thrombocytopenia, acanthosis nigricans?
ALL
124
Lung cancer assocaited with hypercoagulability
adenocarcinoma
125
Horner syndrome
miosis, ptosis, anhidrosis
126
Common cause of horner syndrome?
Pancoast tumor at apex of lung
127
SVC syndrome
obstruction of SVC with supraclavicular venous engorement and facial swelling
128
hoarseness as presenting symptom in lung cancer
secondary to recurrent laryngeal nerve involvement
129
Diagnosis of lung cancer
CXR or CT (initial test)
Fine needle aspiration (CT guided) for peripheral lesions
Bronchoscopu (biopsy or brushing) for central lesions
130
Pleural effusion
abnormal accumulation of fluid in pleural space
131
How do you classify pleural effusions?
Transudative or Exudative
132
Transudative pleural effusion:
2ndary to elevated PCWP or decreased oncotic pressure
133
Exudative
2ndary to increase pleural vasc permeability
134
Causes of transudative pleural effusion
CHF, Cirrhosis, Nephrotic Syndrome
135
Cause of exudative pleural effusion
Pneumonia, TB, Malignancy, PE, Collagen vascular disease (RA, SLE), Pancreatitis, Trauma
136
Diagnosis of pleural effusion
Initial test- CXR shows costophrenic angle blunting. Lateral decubitus view to assess loculation
137
When is thoracentesis indicated?
for new effusions > 1 cm in decubitus view except when there are bilateral effusions and clinical evidence of CHF.
138
Lights criteria
Pleural protein/serum protein > .5
Pleural LDH/serum LDH > .6
Pleural fluid LDH more than 2/3 upper limit of normal
139
How can you classify an effusion as an exudate?
If it meets any of Light's criteria
140
Complicated parapneumonic effusions and empyemas require _______ and _____ for treatment
antibiotics and chest tube drainage
141
Presentation of pneumothorax
| P-THORAX
```
Pleuritic chest pain
Tracheal deviation
Hyperresonance
Onset sudden
Reduced breath sounds and dyspnea
Absent fremitus (asymmetric chest wall)
X-ray shows collapse
```
142
Treatment of tension pneumothorax?
Needle decompression (2nd intercostal space midclavicular line) first and then chest tube placement
143
Diagnosis of tension pneumothorax should be made?
Clinically and followed by immediate treatment
144
Treatment for small pneumothoraces?
Supplemental O2 is helpful. most will resorb spontaneously
145
Large, symptomatic pneumothoraces require?
chest tube placement
