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Primary Care > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

What is Samter’s Triad?

A

Asthma + Nasal Polyps + ASA/NSAID allergy

*Associated with atopic dermatitis

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2
Q

Extrinsic causes of asthma are allergen-induced. Intrinsic causes include:

A
  • Infection (viral/URI)
  • Meds: BBs, ASA, NSAIDs, ACEI
  • Exercise
  • Emotional
  • Cold air
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3
Q

The classic triad of asthma is:

A
  1. Dyspnea
  2. Wheezing
  3. Cough- esp. at night
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4
Q

PE of asthma reveals…

A

Prolonged expiration with wheeze, hyperresonance, decreased breath sounds, increased HR and RR.

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5
Q

The gold standard for diagnosing asthma is:

A

Pulmonary function test- reversible obstruction

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6
Q

The best way to assess asthma exacerbation severity in the ED is through a _____ test.

A

Peak expiratory flow rate (PEFR)

*If PEFR > 15% initial value (before treatment) then pt is responding appropriately to treatment

**If pulse ox < 90% you are in respiratory distress!

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7
Q

Asthma medications for acute exacerbations…

A
  1. Beta-2 Agonists: BEST!
    - Albuterol. Nebulizers used in ED
  2. Anticholinergics: Central bronchodilator, best in 1st hour
    - Tiotropium (Spiriva) and Ipratropium (Atrovent)
  3. Corticosteroids: ALL but mild exacerbations should leave with short course of PO steroids (3-5 days)
    - Prednisone, Methylprednisolone, Prednisolone
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8
Q

What are some examples of ICS used for asthma?

A
  • Beclomethasone- Qvar
  • Budesonide- Pulmicort
  • Fluticasone- Flovent
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9
Q

If persistent asthma is NOT controlled by ICS you can add a LABA.

What are some examples of LABAs?

A
  • Salmeterol

* and other “terols”

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10
Q

What are some ICS/SABA combos?

A
  • Symbicort (Budesonide/Formoterol)

- Advair (Fluticasone/Salmeterol)

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11
Q

Leukotriene Modifiers/Receptor Antagonists (LTRA) are useful in asthmatics w/ allergic rhinitis/ASA induced asthma. PROPHYLAXIS ONLY.

What are some examples?

A
  • Montelukast- Singulair

- Zafirlukast- Accolate

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12
Q

For classification of asthma severity see p. 40!

A

DO IT FOR THE CHARTS

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13
Q

Acute bronchitis is MC caused by ____ (bacteria/viruses).

A

Viruses

-Adenovirus, Parainfluenza, Influenza, Etc.

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14
Q

What are the signs and symptoms of acute bronchitis?

A

COUGH!!

+/- productive, +/- 1-3 weeks

-Symptoms similar to PNA- HA, myalgias, fever, sore throat, substernal discomfort, expiratory rhonchi/wheezes

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15
Q

How is acute bronchitis treated?

A

-Fluids + rest +/- bronchodilators +/- antitussives in adults

+/- ABX in elderly, COPD, immunocompromised, cough > 7-10 days

-COPD patients- 1st line treatment is 2nd generation Cephalosporin, 2nd line= macrolide or TMP/SMX

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16
Q

____ is the only genetic disease linked to COPD.

A

a-1 antitrypsin deficiency (in patient’s less than 40 years)

*a-1 antitrypsin protects elastin in lungs from damage by WBCs

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17
Q

Abnormal, permanent enlargement of terminal airspaces is known as ______.

A

Emphysema

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18
Q

Productive cough x 3+ months for at least 2 consecutive years is diagnostic of _____.

A

Chronic bronchitis

*chronic airway inflammation–> hypersecretion of mucus, airway narrowing, increased airway resistance

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19
Q

_____ is the MC symptom of emphysema.

*Along w/ accessory muscle use, tachypnea, long expiratory mild cough

A

Dyspnea

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20
Q

Respiratory ______ (acidosis/alkalosis) is associated with emphysema.

A

Alkalosis

*can get acidosis in acute exacerbations

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21
Q

Patients with emphysema have ____ (mild/severe) hypoxemia and often ____ (low, nml, elevated) CO2 levels.

A

Mild hypoxemia and normal CO2

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22
Q

Productive cough is a hallmark of _____.

A

Chronic bronchitis

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23
Q

S/s of Cor Pulmonale may be seen with chronic bronchitis. What is cor pulmonale?

A

Abnormal enlargement of right side of heart, peripheral edema, cyanosis

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24
Q

Respiratory ______ (acidosis/alkalosis) is associated with Chronic Bronchitis.

A

Acidosis

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25
Q

Patients with chronic bronchitis have ____ (mild/severe) hypoxemia and ____ (low, nml, elevated) CO2 levels.

A

Severe, Elevated CO2

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26
Q

What is the gold standard for diagnosing COPD?

A

PFTs/Spirometry

*FEV1 is an important factor in prognosis and mortality. FEV1 < 1L= increased mortality

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27
Q

_____ (Increased/Decreased) vascular markings are seen with Emphysema while _____ (increased/decreased) vascular markings are seen with Chronic Bronchitis.

A

Decreased vascular markings= Emphysema

Increased vascular markings= Chronic Bronchitis (w/ enlarged right heart border)

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28
Q

Cor pulmonale is suggestive of what chronic conditions?

A

Pulmonary HTN–> RVH, RAE, right axis deviation, and Rside HF

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29
Q

Bronchodilators are a mainstay of treatment for COPD. Especially _____ (class of med) + _____ (class of med).

A

Anticholinergics + B2 agonists

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30
Q

What are some popular anticholinergics used with COPD?

A
  1. Tiotropium (Spiriva)- inhaled long-acting

2. Ipratropium (Atrovent)

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31
Q

FYI

A

SABA relax muscle bands after they are already tight

Anticholinergics prevent the bands from tightening

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32
Q

Anticholinergics preferred over SABA in COPD!

A

Anticholinergics are CI in BPH and Glaucoma

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33
Q

Common Beta2 agonists for COPD are:

A

Albuterol, Terbutaline; Salmeterol (long-acting)

*CI in patients with severe CAD, caution in patients with DM (HYPERglycemia), hyperthyroidism

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34
Q

ICS NOT USED AS MONOTHERAPY IN PATIENTS WITH COPD!!

A

May be added to LABA

*S/E- thrush, infxns, osteoporosis, hyperglycemia, fluid retention, and renal calculi

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35
Q

____ is the only medical therapy shown to decrease mortality!

A

O2

decreases pulmonary HTN by decreasing hypoxia-mediated pulmonary vasoconstriction

36
Q

____ (specific abx) has been shown to have anti-inflammatory properties in the lung.

A

Azithromycin

37
Q

GOLD Classification: all stages- FEV1/FVC <70%

A

Gold I: Mild: FEV1 >80% predicted

GOLD II: Mod: FEV1 50-79%

GOLD III: Severe: FEV1 30-50%

GOLD IV: Very Severe: Cor pulmonale, resp. failure, HF, FEV1 < 30%

38
Q

Know COPD risk stratification chart

A

p. 42

39
Q

The MC cause of CAP is _____.

A

Strep pneumo

40
Q

2nd MC cause of CAP, esp w/ patient populations including: COPD, EtOH abuse, DM, kids, <6y, and elderly is _____.

A

H flu

41
Q

____ PNA is especially common in elderly, smokers, and immunodeficient.

A

Legionella

42
Q

____ PNA is seen in severe EtOHics. See cavitary lesions on CXR.

A

Klebsiella

43
Q

Histoplasma capsulatum is found most often in the Mississippi and Ohio river valleys and is associated with soil containing _____.

A

Bird and bat droppings

44
Q

HAP occurs after ____ hours of admission in hospital.

A

48 hours

45
Q

Signs and Symptoms of typical PNA include:

A

Sudden fever, productive cough (purulent sputum), pleuritic CP, rigors, tachyHR, tachyRR

*Elderly or confused patients may not have resp s/s, fever, or inc. WBC; may have AMS, depressed mental fxn

46
Q

R upper lobe is associated with ____ PNA and R lower lobe is associated with ____ PNA.

A

Upper- Klebsiella

Lower- Anaerobes

47
Q

1st line treatment for CAP, Outpt:

A

Macrolide or Doxy (FQ if comorbids, recent ABX)

*Macrolides used: Clarithro, Azithro

48
Q

1st line treatment for CAP, Inpt:

A

Beta lactam + Macrolide (or Doxy) OR broad spectrum FQ

49
Q

1st line treatment for CAP, ICU:

A

Beta lactam + Macrolide OR broad spectrum FQ

50
Q

1st line treatment for HAP:

A
  • Anti-pseudomonal AG or FQ
  • Suspect MRSA: add vanc or linezolid
  • Suspect legionella: add Levofloxacin or Azithro
  • Suspect PCP: add Bactrim +/- steroids
  • If beta-lactam allergy: FQ +/- Clinda, aztreonam, AG
51
Q

1st line treatment for Aspiration (anaerobes):

A

Clinda or Flagyl or Augmentin

52
Q

What are some anti-pseudomonal beta lactams?

A

Zosyn (piperacillin/tazobactam), Cefepime, Imipenem, Meropenum, Ceftazidime

53
Q

Respiratory FQs used:

A

Levofloxacin, Moxifloxacin, Gemifloxacin

54
Q

A granuloma is a collection of macrophages produced in response to inflammation or infxn by foreign substance.

A

Just FYI

55
Q

Health care workers, immigrants from high-prevalence areas, homeless, and the immunodeficient (HIV, DM, IVDA, ETOHics, malignancy) are all at high risk for what pulmonary infxn?

A

Tuberculosis

56
Q

Primary TB is the outcome of the initial infxn and is usually self-limiting

A

FYI

*90% control initial primary infxn via granuloma formation- becomes a chronic, LATENT, infxn

57
Q

Granulomas become _____ (TB key word)

A

CASEATING- central necrosis, acidic w/ low O2, making it hostile for TB to grow

58
Q

What populations are at risk for SECONDARY (reactivation) TB?

A

Elderly, HIV+, steroid use, malignancy

59
Q

Reactivation TB is MC in _____ lobes with cavitary lesions. It is CONTAGIOUS.

A

Apex/Upper lobes–> more O2 here

60
Q

Signs & Symptoms of active TB are:

A
  • chronic, productive cough w/ pleuritic CP
  • hemoptysis if advanced
  • night sweats, fever/chills
  • fatigue
  • anorexia/weight loss
61
Q

PE findings for TB?

A

Signs of consolidation, Rales/rhonchi near apices, dullness

62
Q

___ is used to screen for TB. Look for transverse induration (redness is not a positive)!

A

PPD

  • If ≥5mm in at risk pops then it is POSITIVE
  • *If ≥15mm in persons w/ NO risk factors it is POSITIVE
63
Q

The gold standard test for DX in a person w/ suspected TB is:

A

Acid-fast Smear & Sputum culture (AFB)

*TB r/o after 3- smears

64
Q

____ indicated to exclude active TB.

A

CXR

*Also for yearly screening in pts w/ known positive PPD to r/o active TB

65
Q

The Quantiferon-TB Gold assay is a blood test w/ improved specificity, no reader bias, no booster phenomenon, and NOT affected by prior BCG vaccination.

A

FYI

66
Q

The initial 4 drug regimen for the treatment of active TB is:

A
  1. Rifampin (RIF)
  2. Isoniazid (INH)- take Pyridoxine (B6) w/ this to prevent peripheral neuropathy
  3. Pyrazinamide (PZA)- can cause hepatitis and hyperuricemia
  4. Ethambutol (EMB)- can cause optic neuritis OR Streptomycin (STM)- Ototoxicity and Nephrotoxicity
67
Q

4 TB drugs are taken for __ months w/ total treatment duration of __ months.

A

All 4= 2 months (then drop PZA after 2 months, and drop EMB or STM if culture shows sensitivity to both RIF and INH)

Total treatment time= 6 months

*NOT considered infectious 2 weeks after treatment initiation

68
Q

Treatment of LATENT TB infections reduces risk of reactivation in future. Treatment is:

A
  • Likely INH Sensitive: INH + B6 for 9 months

- HIV+: INH + B6 for 12 months

69
Q

INH prophylaxis is warranted in kids < __ years w/ exposure to contacts w/ active dz.

A

4

70
Q

____ cancer is the MC cause of cancer deaths; MC 50s-60s

A

Lung

71
Q

Non Small Cell Carcinoma makes up about 85% of cases. The MC type of NSCC is _____.

A

Adenocarcinoma (35%)- from mucus glands

72
Q

____ is at type of NSSC that is usually centrally located and is associated with Cavitary lesions, hyperCalcemia, and Pancoast Syndrome (CCP).

A

Squamous Cell

*Pancoast Syndrome- tumors at superior sulcus and shoulder pain, Horner’s syndrome (miosis, ptosis, anhidrosis)

73
Q

Small Cell (Oat Cell) Carcinoma is metastatic early! Surgery is usually not a treatment option.

A

May see Trousseau’s Syndrome- vessel inflammation due to blood clots which are recurrent and occur in different locations

74
Q

How is lung cancer diagnosed?

A

CXR and CT for staging

75
Q

How is lung cancer treated?

A

NSSC: Surgical resection

Small cell: Chemo (+/- radiation)

76
Q

2 types of sleep apnea: Central and Obstructive…

A
  1. Central- reduced CNS resp. drive

2. Obstructive- physical airway obstruction

77
Q

Signs and Symptoms of sleep apnea…

A

Snoring, unrestful sleep, nocturnal choking

78
Q

Labwork of someone with OSA may show…

A

Polycythemia- due to chronic hypoxemia, hypercapnia and hypoxemia on ABGs

79
Q

Surgical corrective options for someone with OSA are:

A
  • Tracheostomy- definitive
  • Nasal septoplasty
  • Uvulopalatopharyngoplasty
80
Q

_____ Test assesses level of nicotine dependence. Higher the score= more dependent.

A

Fagerstrom

81
Q

The most important indicators are ____ and ____.

A

of ciggs

Time to first cigg

82
Q

1st line therapy for nicotine dependence…

A
  1. NRT- patch, gum, lozange, nasal spray (rx), inhaler (rx)
  2. Bupropion (Zyban)
  3. Varenicline (Chantix)
    - 2nd line: Nortriptyline and Clonidine
83
Q

____ is best choice of NRT for pregnant women due to ability to dose intermittently.

A

Gum (NOT patch)

84
Q

Advantage of gum and lozenge is that they _____.

A

Relieve cravings

85
Q

Oral inhaler and nasal spray are CI in patients with ____.

A

Severe reactive airway dz

86
Q

Bupropion is CI in what patient populations?

A

Seizures, hx of anorexia/bulimia, undergoing d/c of ETOH or sedatives

87
Q

Nausea, visual disturbance, insomnia, abnormal dreams, and increased CVD risk and suicide risk are associated with what treatment?

A

Chantix

Primary Care (12 decks)

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