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Pulmonary Flashcards

1
Q

influenza - clinical findings and diagnosis

A

abrupt onset, fever/chills, HA, myalgias, sore throat, non-productive cough

Dx: usually clinical, nasopharyngeal swab

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2
Q

influenza - prophylaxis and treatment

A

anti-viral

  • oseltamivir/tamiflu PO (>1 yr)
  • zanamivir/relenza inhaled (>7 yr)

Prevention: vaccine
- approved for > 6mo

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3
Q

Reye’s syndrome

A

mixing aspirin with viral illness in children

  • presents with hepatitis and CNS complications
  • 30% mortality
  • typically use acetaminophen in children < 19
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4
Q

acute bronchitis - sxs, PE, Dx

A

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)

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5
Q

acute bronchitis - tx

A

usually symptomatic

ABX only for elderly, lasting 7-10days, immunocompromised

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6
Q

community acquired pneumonia (CAP) - general info and cause

A 
#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

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7
Q

community acquired pneumonia (CAP) - clinical findings and dx

A

tachycardia, tachypnea
fever/chills
cough +/- sputum
altered breath sounds, rales, dullness to percussion due to consolidation

dx: CXR shows patchy, segmental lobar consolidation

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8
Q

community acquired pneumonia (CAP) - outpatinet tx

A

Typical:
• 1st line: doxycycline (abx type: Tetracycline)
• 2nd line: azithromycin (abx type: Macrolide)

Chronic comorbid or recent ABX use: levofloxacin/moxifloxacin (abx type: Fluoroquinolone)

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9
Q

community acquired pneumonia (CAP) - prevention

A

pneumococcal vaccine

- age >65 or co-morbid conditions

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10
Q

community acquired pneumonia (CAP) - hints to fungi, bacteria, and viruses involved

A

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

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11
Q

nosocomial pneumonia (hospital-aquired pneumonia) - definition, dx, tx

A

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)

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12
Q

pneumonia: HIV related - fungi involved, general info, sxs

A 
pneumocystis jiroveci (PCP)
 - most common opportunistic infection associated with AIDS (CD4<200)

Sx: fever, tachypnea, SOB, non-productive cough (non-specific)

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13
Q

pneumonia: HIV related - dx, tx, prophylaxis

A

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

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14
Q

tuberculosis - general info and cause

A

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

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15
Q

tuberculosis - sxs and dx

A

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)
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16
Q

Pott’s disease

A

extrapulmonary TB

- commonly in thoracic spine

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17
Q

Ghon/Ranke complexes

A

seen on CXR in healed primary infection of tuberculosis

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18
Q

PPD: TB skin test reaction

A

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

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19
Q

tuberculosis - TX (latent vs. active)

A

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
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20
Q

side effects of anti-TB medications

A

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

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21
Q

epiglottitis - sxs, dx, tx

A

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

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22
Q

pertussis - background, cause, sxs

A

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”

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23
Q

pertussis - dx, tx, and prevention

A

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

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24
Q

pulmonary nodule - definiton and causes

A

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)
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25
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
26
pulmonary nodules - hints to benign vs. malignant
malignant: older (>45 y/o), absent or irregular calcifications, larger (>2cm), new or growing, irregular margins
27
pulmonary nodules - tx
>35 y/o: resect unless no change in 2 yr <35 w/ unchanged lesion: repeat study in 3-6 mo
28
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
29
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
30
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)
31
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
32
carcinoid tumor - definition and cause
well-differentiated neuroendocrine tumors - found in GI tract (most common) and lung cause: low-grade, malignant neoplasm - rarely METS
33
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
34
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
35
mesothelioma - Dx, Tx, prognosis
Dx: CT with biopsy Tx: none are effective (chemo, surgery) Prognosis: mean 8-14 mo
36
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
37
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
38
asthma
"reversible" airway condition characterized by: - acute inflammation - bronchial hyper reactivity - mucus plugging - smooth muscle hypertrophy Atopy: strongest identifiable factor
39
atopic triad
asthma, eczema, seasonal rhinitis
40
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
41
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
42
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
43
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)
44
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)
45
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
46
bronchiectasis - dx
CT (high resolution): thickened bronchial walls with dilated airways ("tree and bud" appearance) - diagnostic test of choice - "tram track" appearance
47
bronchiectasis - tx
``` oxygen aggressive ABX - guided on sputum cx or empiric inhaled bronchodilators - maintenance and acute exacerbationis lung transplantation ```
48
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
49
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
50
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
51
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
52
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
53
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)
54
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
55
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
56
asbestosis - what are people at risk for?
lung cancer and mesothelioma, especially if also a smoker
57
silicosis - what are people at risk for?
TB - tuberculosis
58
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
59
features of sarcoidosis - GRUELING
``` Granuloma RA Uveitis Erythema nudism Lymphadenopathy Interstitial fibrosis Negative TB test Gammaglobulinemia (immunoglobulins increased since may be immune-related) ```
60
pleural effusion
abnormal collection of fluid in the pleural space - 25% associated with malignancy - MUST distinguish b/t transudate and exudate
61
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
62
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
63
pleural effusions - 5 types
1. exudates: malignancy, infection, trauma, PE - note: PE can be transudative (20%) - unilateral 2. transudate: CHF, atelectasis, renal/liver dz - bilateral 3. empyema: direct infection of exudate 4. hemothorax: trauma 5. chylothorax: TB
64
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) ```
65
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
66
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
67
pleural effusion - tx
transudates - correct underlying condition - therapeutic thoracentesis if dyspnea exudates - drain empyemas - pleurodesis (prevents fluid build-up) for malignency
68
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)
69
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
70
pneumothorax
abnormal accumulation of air in pleural space
71
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
72
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
73
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
74
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
75
pleuritic chest pain
pain worsens with movement of pleura - breaths, coughs, sneezes
76
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)
77
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
78
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)
79
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
80
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
81
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
82
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)
83
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
84
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
85
pulmonary embolism - prevention
early ambulation pneumatic compression low dose heparin LMWH (low molecular weight heparin)
86
pulmonary hypertension - definition
pulmonary artery pressure rises to level inappropriate for given cardiac output - self-perpetuating once initiated - women>men - 30-50 y/o
87
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
88
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
89
pulmonary hypertension - dx
multifactorial - CXR/CT: inc. vasculature - PFTs: lung pathology - ECHO/TTE: RVH, pulm. artery pressure - catheterization: determine degree of HTN
90
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
91
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
92
cor pulmonale - cause
acute: think PE chronic: think COPD ``` pulmonary vascular dz: - PE, vasculitis, ARDS respiratory disease: - obstructive (asthma, COPD) - restrictive (ILD, lung resection) ```
93
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
94
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
95
Acute Respiratory Distress Syndrome (ARDS) - definition
acute (12-18 hrs) hyperemic respiratory failure after systemic or pulmonary insult W/O heart failure
96
Acute Respiratory Distress Syndrome (ARDS) - cause
sepsis: MOST COMMON others: toxic inhalation, near drowning, aspiration
97
Acute Respiratory Distress Syndrome (ARDS) - clinical findings
respiratory distress, tachypnea, fever, crackles, rhonchi
98
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!
99
ground glass opacities on CXR
indicates exudative or transudative fluid in lungs | - lines apparent in CXR

PANCE Review (16 decks)

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