Pulmonary Flashcards
influenza - clinical findings and diagnosis
abrupt onset, fever/chills, HA, myalgias, sore throat, non-productive cough
Dx: usually clinical, nasopharyngeal swab
influenza - prophylaxis and treatment
anti-viral
- oseltamivir/tamiflu PO (>1 yr)
- zanamivir/relenza inhaled (>7 yr)
Prevention: vaccine
- approved for > 6mo
Reye’s syndrome
mixing aspirin with viral illness in children
- presents with hepatitis and CNS complications
- 30% mortality
- typically use acetaminophen in children < 19
acute bronchitis - sxs, PE, Dx
usually viral
sx: cough w/ or w/o sputum, fever, substernal pain
PE: expiratory rhonchi or wheezes
Dx: can use CXR to distinguish from pneumonia (see absence of markings with bronchitis)
acute bronchitis - tx
usually symptomatic
ABX only for elderly, lasting 7-10days, immunocompromised
community acquired pneumonia (CAP) - general info and cause
#1 infectious cause of death in US - acquired by aspiration of colonized upper airway
cause:
- typically bacterial (S. Pneumo > H. influenza > M. cat)
- atypical: Legionella, mycoplasma, chlamydia
community acquired pneumonia (CAP) - clinical findings and dx
tachycardia, tachypnea
fever/chills
cough +/- sputum
altered breath sounds, rales, dullness to percussion due to consolidation
dx: CXR shows patchy, segmental lobar consolidation
community acquired pneumonia (CAP) - outpatinet tx
Typical:
• 1st line: doxycycline (abx type: Tetracycline)
• 2nd line: azithromycin (abx type: Macrolide)
Chronic comorbid or recent ABX use: levofloxacin/moxifloxacin (abx type: Fluoroquinolone)
community acquired pneumonia (CAP) - prevention
pneumococcal vaccine
- age >65 or co-morbid conditions
community acquired pneumonia (CAP) - hints to fungi, bacteria, and viruses involved
P. jirovaci: hypoxemic, “ground glass” infiltrates on CXR
- HIV/AIDS
C. psittaci: birds, zoonotic disease
S. pneumoniae: single rigor, rust-colored sputum
Klebsiella pneumoniae: alcoholics, current jelly sputum
Pseudomonas: cystic fibrosis
Atypicals (mycoplasma or chlamydia): college students
Legionella: air conditioning
RSV: children <1
H. Influenza: COPD
nosocomial pneumonia (hospital-aquired pneumonia) - definition, dx, tx
sxs similar to CAP, but onset is after 48 hours post admission to hospital
dx: blood culture, WBC count, CXR
tx: no uniform consensus (varies)
pneumonia: HIV related - fungi involved, general info, sxs
pneumocystis jiroveci (PCP) - most common opportunistic infection associated with AIDS (CD4<200)
Sx: fever, tachypnea, SOB, non-productive cough (non-specific)
pneumonia: HIV related - dx, tx, prophylaxis
Dx: CXR classic finding - peri-hilar infiltrates in a butterfly wing distribution (no effusion)
Tx: TMP/SMX (Bactrim)
- fatal if not treated
Prophylaxis: TMP/SMX for all AIDS puts with CD4<200
tuberculosis - general info and cause
Primary TB
- 95% become latent TB infections (not infectious, asymptomatic, but have inactive TB in their body)
Secondary TB:
- reactivation TB develops from latent TB infection
cause: M. tuberculosis
- transmitted by resp. droplets
- only 10% infected develop dz
tuberculosis - sxs and dx
Sxs: cough, chest pain, SOB, hemoptysis
- classic sxs complex: fever, drenching night sweats, anorexia, weight loss
PE: post-tussive rales (classic)
Dx:
- CXR (cavitations - dark spots of air in active dx, Ghon complex - in latent dz)
- Sputum culture
- PPD: measure induration (not erythema); positive indicates exposure (not necessarily active dz)
- biopsy: caseating granulomas (hallmark)
- If vaccinated, must get a serum test (Quantiferon)
Pott’s disease
extrapulmonary TB
- commonly in thoracic spine
Ghon/Ranke complexes
seen on CXR in healed primary infection of tuberculosis
PPD: TB skin test reaction
measure induration (not erythema)
positive indicates exposure (not necessarily active dz)
> 5mm: immunocompromised, evidence of TB on CXR
> 10mm: at risk
> 15mm: persons w/ no risk factors
tuberculosis - TX (latent vs. active)
Note: multiple drugs are needed due to resistance
latent:
- INH (isoniazid) x 9mo or
- PZA and RIF x 2 mo or
- RIF x 4 mo
active:
- INH/RIF/PZA/EMB x 2 mo
- INH/RIF x 4mo
side effects of anti-TB medications
INH: hepatitis, peripheral neuropathy (prevent via vit. B6 - pyridoxine)
RIF: hepatitis, orange body fluids, rash
PZA: hepatitis, GI sxs, gout/arthalgias
EMB: optic neuritis, red-green vision loss
epiglottitis - sxs, dx, tx
sxs: rapidly developing sore throat or odynophagia (painful swallow) out of proportion to PE
dx: laryngoscopy, XR (thumb print sign)
tx: 2nd/3rd gen cephalosporin (ceftizomine, cefuroxime) AND dexamethasone to limit pharyngeal edema
prevention: Hib vaccine
pertussis - background, cause, sxs
usually infants, children (inc. in adults since vaccine from childhood wears off)
cause: Bordetella pertussis (via resp. droplets)
sxs: resembles common cold, bronchitis
- “whoop” in children (less common in adults)
- post-tussive emesis
“cough of 100 days”
pertussis - dx, tx, and prevention
dx: PCR is diagnostic standard
tx: ABX to stop spread but does not alter course of sxs
- macrolides 1st line (azithromycin, clarithromycin, erythromycin)
prevent: Tdap, DTaP
pulmonary nodule - definiton and causes
lung nodules, <3cm (if >3cm = mass), isolated, rounded opacity surrounded by normal lung
- 40% are malignant (most are not)
Causes:
- infectious granulomas (most)
- carcinoma
- hamartoma
- metastasis (usually multiple)
- bronchial adenoma (95% carcinoid tumors)
pulmonary nodule - sxs, dx
sxs: most asymptomatic
dx:
1. CXR and compare to old image
- got larger over 30-50 days = malignancy
- rapid growth <30 days = infection
- no growth in 2 yrs = benign
2. CT (w/ biopsy for dx)
- smooth, well-defined = benign
- lobular, speculated, peripheral halo = often cancer
pulmonary nodules - hints to benign vs. malignant
malignant: older (>45 y/o), absent or irregular calcifications, larger (>2cm), new or growing, irregular margins
pulmonary nodules - tx
> 35 y/o: resect unless no change in 2 yr
<35 w/ unchanged lesion: repeat study in 3-6 mo
bronchogenic cancer - general info
- 90% of lung cancer
- leading cause of cancer deaths in men and women
- 5-year survival is 15%
- cigarette smoking is #1 risk factor
bronchogenic cancer - classification and clinical findings
SCLC (small cell): early mets, aggressive clinical course
NSCLC (adeno, squamous, large cell): slower spreading
- more amenable to tx (surgery)
sxs: age 50-80, cough, dyspnea, hemoptysis, anorexia, weight loss
bronchogenic cancer - histological types
adenocarcinoma (most common - 35-40% cases)
- peripheral mass
squamous (25-35% cases)
- central mass (hemoptysis)
large cell (5-10% cases) - peripheral mass
small cell (15-20% cases) - central mass (hemoptysis)
Hint: LA is on coast (peripheral lesion - no hemoptysis)
bronchogenic cancer - dx, tx, sites of METS
Dx: biopsy, cytology (also CT and PET scan)
Tx: depends on type and extent (surgery, chemo, radiation)
METS: bone, brain, adrenal glands, liver
carcinoid tumor - definition and cause
well-differentiated neuroendocrine tumors
- found in GI tract (most common) and lung
cause: low-grade, malignant neoplasm
- rarely METS
carcinoid tumor - sxs, dx, tx
Sxs: asymptomatic, localized bronchial obstruction, hemoptysis, cough, recurrent pneumonia
- carcinoid sundrome (10% of pts): flushing, diarrhea, wheezing, hypotension
Dx: CT
Tx: surgical excision
mesothelioma - definition, cause, sxs
primary tumors of pleural liming (80%) and peritoneum (20%)
cause: asbestos
sxs: SOB, non-pleuritic CP, weight loss, dec. breath sounds, digital clubbing
mesothelioma - Dx, Tx, prognosis
Dx: CT with biopsy
Tx: none are effective (chemo, surgery)
Prognosis: mean 8-14 mo
secondary lung cancer - definition, dx, tx
extra-pulmonary metastases
Breast, liver, and colon cancer: most common METS to lung
- almost any cancer can MET to lung
dx: CXR reveals multiple nodules
tx: dx and tx primary tumor
obstructive pulmonary disease - definition and examples of dz
dec. FEV1/FVC
- normally >80%
Total lung capacity normal or increased due to air trapping
asthma
chronic bronchitis
emphysema
cystic fibrosis
asthma
“reversible” airway condition characterized by:
- acute inflammation
- bronchial hyper reactivity
- mucus plugging
- smooth muscle hypertrophy
Atopy: strongest identifiable factor
atopic triad
asthma, eczema, seasonal rhinitis
asthma - causes, sxs
causes:
- allergens (dust), exercise, URI, post-nasal drip, GERD, medictions (beta blockers, ACE-I, aspirin, NSAIDS), stress, cold air
sxs: breathlessness, cough, wheeze, diffuse expiratory wheeze
asthma - dx
spirometry (pre and post therapy)
- decreased FEV1/FVC (<75%)
- positive bronchodilator response (>10% inc, in FEV1)
Definitive test: methacholine challenge
- FEV1 dec. by > 20%
- used if spirometry is non diagnostic
asthma - tx (step therapy)
intermittent vs. persistent
Intermittent:
- <1 per week
- SABA prn
Persistent (mild, moderate, severe)
- Rules of 2’s
- Combo of ICS (inhaled or PO) and LABA / LTRA
asthma - tx (lifestyle and medications)
remove irritants
education on peak flow measures
desensitization
oxygen
Meds:
- inhaled beta-2 agonists (albuterol)
- glucocorticoids (e.g. prednisone)
- anticholinergics (e.g. ipratropium)
asthma - long-term control therapy
inhaled corticosteroids (fluticasone, budesonide) - mainstay for PERSISTENT asthma
long-acting bronchodilators (LABA)
- inhaled beta-2 agonists (salmeterol)
leukotriene inhibitors (montelukast/singulair)
phosphodiesterase inhibitors (theophylline)
bronchiectasis - definition, cause, sxs
permanent dilation/destruction of bronchial walls
cause: congenital (cystic fibrosis), acquired (tumor obstruction or recurrent infections)
- CF: pseudomonas
- non-CF: H. flu
sxs: foul breath, chronic cough w/ copious/purulent sputum, hemoptysis, recurrent pneumonia, weight loss, anemia, persistent basilar crackles
bronchiectasis - dx
CT (high resolution): thickened bronchial walls with dilated airways (“tree and bud” appearance)
- diagnostic test of choice
- “tram track” appearance
bronchiectasis - tx
oxygen aggressive ABX - guided on sputum cx or empiric inhaled bronchodilators - maintenance and acute exacerbationis lung transplantation
COPD: chronic bronchitis/emphysema - definition, cause, dx
airflow obstruction due to chronic bronchitis and emphysema
- most puts have features of both
- 3rd leading cause of death world-wide
cause: smoking (80%), pollutants, recurrent URIs, eosinophilia
Dx: PFT
- normal in early dz
- dec. FEV1/FVC
- inc. RV (residual vol.) and TLC w/ air trapping that occurs
emphysema - definition
permanent air space enlargement distal to terminal bronchiole with alveolar wall destruction
“pink puffers”: cough rare, quiet lungs, thin, barrel chest, pursed lips
Hallmark: exertional dyspnea
CXR: parenchymal bullae and blebs; diagram flattened/hyperinflation
- think, large heart
chronic bronchitis - definition
increased bronchial secretions
cough for >3 mos over at least 2 years
“blue bloaters: mild dyspnea, chronic productive cough, noisy lungs (rhonchi and wheeze), peripheral edema, overweight and cyanotic
CXR: diaphragm not flattened
COPD: treatment
smoking cessation oxygen bronchodilators - LAMA (ipatropium) - SABA and LABA
ABX: for acute exacerbations (TMP/SMX, augmenting/clavulanate, doxycycline)
Influenza and pneumococcal vaccines
surgery: transplant
restrictive pulmonary diseases - definition, three on boards
smaller volume of air in lungs (dec. TLC) and less compliance of lung tissue (FEV1/FVC can be normal or increased)
idiopathic pulmonary fibrosis
pneumoconioses
sarcoidosis
idiopathic pulmonary fibrosis - background and clinical findings
most common dx among pts with interstitial lung disease
- confirm idiopathic since most caused by infection, drugs, or environmental/occupational exposure
collagen deposition in lungs with little inflammation
PE: insidious dry cough, exertional dyspnea, diffuse, fine crackles (velcro at bases) w/ inspiration, clubbing (w/ chronic hypoxia)
idiopathic pulmonary fibrosis - dx, tx. prognosis
Dx:
CXR: low lung vol., patchy, diffuse fibrosis, pleural honeycombing
- biopsy helps to confirm
Tx: controversial (corticosteroids vs. interferon)
Survival: 2-3 yrs after dx
pneumoconioses - definition, causes, tx
chronic lung diseases caused by various precipitating agents
- industrial, inhalation fo mineral and metal dusts
- fibrotic lung develops from ingestion of agents by macrophages leading to cell injury and death
- asbestosis, coal workers pneumoconiosis, silicosis, berryliosis
Tx: supportive
asbestosis - what are people at risk for?
lung cancer and mesothelioma, especially if also a smoker
silicosis - what are people at risk for?
TB - tuberculosis
sarcoidosis - definition, labs, imaging, dx, tx
type of restrictive lung dz that causes inflammatory cells (called granulomas) to form in the body
Labs: ACE elevated (created in lungs), hypercalcemia
biopsy: NON-CASEATING GRANULOMAS
- hilar adenopathy better prognosis; parenchymal worse
Tx: prednisone
features of sarcoidosis - GRUELING
Granuloma RA Uveitis Erythema nudism Lymphadenopathy Interstitial fibrosis Negative TB test Gammaglobulinemia (immunoglobulins increased since may be immune-related)
pleural effusion
abnormal collection of fluid in the pleural space
- 25% associated with malignancy
- MUST distinguish b/t transudate and exudate
transudate pleural effusions
transudative contains fluid
- results from increased hydrostatic pressure pushing fluid out of vessels (e.g. heart failure) and/or decreased osmotic pressure pulling fluid in due to decrease proteins within vessels (dec. protein synthesis in liver disease or inc. protein loss in kidney disease)
- INTACT capillaries
exudative pleural effusions
exudative contains fluid and protein
- inflammation causes vasodilation and stasis of fluid in vessels as well as increased inter endothelial spaces (so protein leak out)
- related to an inflammatory process (e.g. malignancy)
- LEAKY capillaries
pleural effusions - 5 types
- exudates: malignancy, infection, trauma, PE
- note: PE can be transudative (20%)
- unilateral - transudate: CHF, atelectasis, renal/liver dz
- bilateral - empyema: direct infection of exudate
- hemothorax: trauma
- chylothorax: TB
pleural effusions - clinical findings
asymptomatic (if small) dyspnea/cough (if large) percussion dullness decreased tactile fremitus diminished/absent breath sounds bilateral (transudates) vs. unilateral (exudates)
pleural effusion - dx
Dx: thoracentesis is GOLD STANDARD for dx and tx (therapeutic to remove fluid)
- send for protein, LDH, pH, total and cell counts, glucose (bacteria eat), cytology
pleural effusion - role of imaging
Imaging: helps to define size
CXR can detect as little as 50mls
- lateral decubitus for free flowing v. loculated
- upright (blunting of costophrenic sulcus)
CT can detect as little as 10mls
pleural effusion - tx
transudates
- correct underlying condition
- therapeutic thoracentesis if dyspnea
exudates
- drain empyemas
- pleurodesis (prevents fluid build-up) for malignency
pleural effusion - how to distinguish transudate vs. exudate
Light’s criteria:
- compares amount of protein or LDH in the fluid vs. serum
- higher than normal protein or LDH in pleural fluid compared to serum are signs of exudate (infection/inflammatory process)
lactate dehydrogenase (LDH)
LDH is an enzyme found in almost every cell of your body
When cells are damaged or destroyed, this enzyme is released
pneumothorax
abnormal accumulation of air in pleural space
pneumothorax - 3 types
spontaneous
- can be primary (no underlying dz, usually tall, think male) or secondary (due to underlying dz, COPD, asthma, CF, ILD)
traumatic: penetrating or blunt trauma
tension: MEDICAL EMERGENCY
- lung collapse due to penetrating trauma, CPR
- see contra lateral mediastinal shift
- get hypotension from impaired venous return
pneumothorax - clinical findings (spontaneous vs. tension)
spontaneous:
- ipsilateral/unilateral CP (sudden and pleuritic)
- absent breath sounds
- hyper resonance, dec. tactile fremitus
tension (in addition to above):
- resp. distress, falling O2
- hypotension, distended neck veins, tracheal deviation
pneumothorax - dx
CXR: end expiratory chest film shows visceral pleural air
- see lung line (absence of lung markings beyond line)
tension: air on affected side w/ contralateral mediastinal shift
pneumothorax - tx
spontaneous:
- small (<15% diameter of hemithorax on CXR): rest, cough and CP relief, serial CXRs
- large (>15%): chest tube and above measures
tension: immediate needle decompression
- 2nd ICS and MCL
pleuritic chest pain
pain worsens with movement of pleura - breaths, coughs, sneezes
virchow’s triad
risk factors for PE
- hyper coagulable state (e.g. cancer)
- venous stasis (prolonged rest, cast)
- vascular intimal inflammation or injury (e.g. surgery/trauma)
pulmonary embolism (PE) - definition and risk factors
occlusion of pulmonary arterial circulation from an embolized substance
- #3 leading cause of death in hospital pts
risk factors:
- virchow’s triad
- consider: surgical procedures, abdominal cancer, OCPs, pregnancy
pulmonary embolism - etiology
Most come from thrombus:
- 95% deep calf veins (DVT)
- also air (central lines), amniotic fluid (active labor), and fat (long bone fx)
pulmonary embolism - clinical findings
SUDDEN dyspnea, tachypnea, pleuritic chest pain (on inspiration)
MOST COMMON SXS: dyspnea w/ tachypnea
MOST COMMON SIGN: tachycardia
homan’s sign: calf pain w/ passive dorsiflexion of foot w/ knee flexed
pulmonary embolism - ECG findings and labs
ECG: NOT diagnostic
- sinus tachycardia
- S1-Q3-T3
ABG: hypoxia
D-dimer: negative w. low clinical suspicion = strong evidence AGAINST DVT
D-dimer
blood test that measures plasma levels of degraded fibrinogen
- if low clinical suspicion of PE (PERC score, Wells criteria), negative result can be used to r/o PE
- if high clinical suspicion, cannot be used to r/o PE and further imaging (CT) must be used
pulmonary embolism - CXR and VQ Scan
CXR:
- most common is atelectasis at bases
- Westermark’s sign: vasoconstriction in embolized zone
- Hampton’s hump (classic): wedge shaped infarct
VQ scans:
- normal practically rules out PE
- abnormal is non-specific (need further eval)
pulmonary embolism - dx
spiral CT angiography
- method of choice
pulmonary arteriography
- gold standard, but not used as much since CT is easier
venography
- gold standard for dx of LE DVT (not PE)
- LE venous doppler used for DVTs but not good for PE dx
pulmonary embolism - tx
anticoagulation: 3-6 months
- heparin to Coumadin (INRs 2-3 x normal)
- LMWH
- novel oral anticoags (NOACs): rivaroxaban, apixaban, dabigatran
thrombolytic therapy
- streptokinase, alteplase, urokinase
- only if hemodynamically unstable
IVC filter
surgery: only for saddle emboli
pulmonary embolism - prevention
early ambulation
pneumatic compression
low dose heparin
LMWH (low molecular weight heparin)
pulmonary hypertension - definition
pulmonary artery pressure rises to level inappropriate for given cardiac output
- self-perpetuating once initiated
- women>men
- 30-50 y/o
pulmonary hypertension - causes
most common it is secondary to other causes:
- COPD, connective tissue disorder, scleroderma
- inc. pulmonary venous pressure
- constrictive pericarditis, LV failure, mitral stenosis
pulmonary hypertension - clinical findings, labs, and ECG
dull, retrosternal chest pain (angina-like), dyspnea, fatigue, effort syncope
- sxs related to underlying cause
labs: polycythemia
ECG (right-sided findings): rt axis deviation, rt ventricular hypertrophy
pulmonary hypertension - dx
multifactorial
- CXR/CT: inc. vasculature
- PFTs: lung pathology
- ECHO/TTE: RVH, pulm. artery pressure
- catheterization: determine degree of HTN
pulmonary hypertension - tx
treat underlying cause (e.g. oxygen for COPD, anticoags for emboli, diuretics or salt restriction for for pulmonale)
vasodilators: CCBs, epoprostenol (PGI2), prostacyclin
cor pulmonale - definition
failure of rt side of heart caused by prolonged high blood pressure in the pulmonary arteries (pulmonary HTN) and rt ventricle of the heart
rt ventricular enlargement leads to rt ventricular failure
cor pulmonale - cause
acute: think PE
chronic: think COPD
pulmonary vascular dz: - PE, vasculitis, ARDS respiratory disease: - obstructive (asthma, COPD) - restrictive (ILD, lung resection)
cor pulmonale - clinical findings
fatigue, exertional dyspnea, syncope w/ exertion
inc. chest diameter
labored resp effort w/ retractions
hyper-resonance to percussion
- diminished breath sounds, wheezing, distant heart sounds, cyanosis
cor pulmonale - dx and tx
Dx:
- CXR
- ECG: RAD > 30, inverted t waves in RV precordial leads
Tx:
- oxygen
- dec. pulm vasc. resistance and pulm. HTN
- treat underlying disorder
Acute Respiratory Distress Syndrome (ARDS) - definition
acute (12-18 hrs) hyperemic respiratory failure after systemic or pulmonary insult W/O heart failure
Acute Respiratory Distress Syndrome (ARDS) - cause
sepsis: MOST COMMON
others: toxic inhalation, near drowning, aspiration
Acute Respiratory Distress Syndrome (ARDS) - clinical findings
respiratory distress, tachypnea, fever, crackles, rhonchi
Acute Respiratory Distress Syndrome (ARDS) - CXR, Dx, and Tx
CXR: diffuse pulmonary infiltrates that SPARES costophrenic angles
- normal heart size (NOT related to HF)
Dx: clinical
Tx: underlying cause plus supportive care
- high mortality rate!
ground glass opacities on CXR
indicates exudative or transudative fluid in lungs
- lines apparent in CXR
