Pulmonary Flashcards
Obstructive dz (dilated)
COPD, Bronchiectasis
Obstructive (constricted)
Asthma
Intrathoracic Restrictive (constricted)
Fibrosis, Sarcoidosis, pneumoconiosis
Extrathoracic Restrictive
Chest Cage, kyphosis, spondyloitis, obesity, neurousc (M.gravis, GB syndorme, muscular dystrophy
Normal FEV1/FVC
> 80%
Obstructive dz FEV1/FVC
<80%
Restrictive dz FEV1/FVC
> 80%
COPD
dec FEV1, dec FEV1/FVC, inc TLC, dec DLCO, inc RV
Asthma
dec FEV1, dec FEV1/FVC, inc TLC, nl/inc DLCO, inc RV
Restrictive intrathoracic
dec FEV1, nl FEV1/FVC, dec TLC, dec DLCO, dec RV
Restrictive extrathoracic
dec FEV 1, nl FEV1/FVC, dec TLC, N DLCO, inc RV
best test restrictive vs obstructive
TLC
asthma
restrictive low FEV1, normal FEV1/FVC, low TLC
DLCO 140% predicted, normal FEV1/FVC and TLC
alveolar hemorrhage
Inc DLCO
CHF, MS, ASD/VSD, PDA, pvera
Dec DLCO
COPD, restrictive lung dz, PE, pHTN, anemia
Normal DLCO
asthma, CO poisoning
Fixed extrathoracic
tumors/trachela stenosis both inspir (bottom) and exp(top) loops blunted
Dynamic extrathoracic obstruction
epiglottitis, Vocal cord dysfxn (insp - bottom loop blunted)
Dynamic intrathoracic obstruction
intrathoracic tracheomalacia - exhal (upper) loop blunted
Asthma
reactive to dust, viral, cold, exc, - must show reversible bronchospasm
Asthma dx
PFT - obstructive changes with reversible broncospasm - responds to brochodilators (inc FEV1 by 15%) - if no obst - methacholinie challenge test (15%)
Young man h/o asthma acute asthmatic attack treated with albuterol nebs - f/u now PFT will show
Obstructive defect (still has asthma dx)
35yo M paroxysmal non-prod cough >6months - no ohther sx - spirometry normal, no improvement with anti-histamine/cough meds
methacholine challenge test r/o asthma
woman in car factory SOB at work, worse at end of day, better at home, cxr normal
check peak flow at home AND home
Best way to tx patient with asthma
remove offending agent (PPI do not inc or dec sx of asthma)
Pt with asthma/eczema moves to new apt, asthma worse - with rug
remove rug, get plastic wraps for mattress, pillow etc
Asthma therapy Intermittent 80
no daily meds, rescue short acting beta
therapy mild persistent (>2/wk, 2/month, FEV1 >80%
low dose inh steroid, cromolyn, leukotriene, theophylline
Mod persistent - daily sx, >5/month at night, FEV1 60-80
low - med dose inh steroid + long acting beta (no beta without inh steroid)
Severe persistent
high dose inh steroid + po steroids with attempts to wean
When leukotrienes
mild persistent to reduce dose inh steroids, asa sens asthma
Vasomotor rhinitis, nasal polyps and asthma dx?
ASA sensitive asthma - d/c asthma, start leukotriene (monteleukast)
Pt with ASA sensitivity asthma can use
codeine based analgesic, sodium or choline slicylates, NO COX1 NSAIDS
Pt with shoulder pain takes ibuprofen - coupel hours later with SOB/wheezing
NSAID induced broncospasm
pt with mod asthma on inhaled steroids+long acting beta+theophylline
add monteluekast (leukotriene) to reduced need for steroids
50yo post viral URI several weeks ago with persistent cough, inc’d at night with chest tightness, no heartburn, rec neg cardiac w/u - PFT with mild obstruction - wtd
methacoline challenge test - post viral hypersensitivity - tx with inhaled steroid (budesonide)
Mainstay maintenance therapy for asthma
inhaled steroids
30yo F non-prod cough for several months, no heart burn tob or wheeze, PFT normal, methacholine neg - wtf
check sputum for eosinophils - (non-asthmatic eosinophillic bronchitis)
Pt with athma on beta agonist still with wheeze
add inhaled steroid
Pt with severe asthma exacerbation hospitalized with iv steroid and beta agonist - upon d/c wtd
taper with oral steroid -> start inhaled steroid, beta agonist PRN
In addition to reduction of acute/chronic asthma sx what do inhaled steroids do?
reduction of progressive loss of lung fxn
Pt with asthma on albuterol prn with nocturnal awakening with sx of asthma best medcation
start with inhaled steroids -> THEN add long acting beta agonist
increased mortality in asthma related to…
inc FEV1 responsiveness
Pt with asthma p/w acute exacerbation - ABG 7.46/34/70/94% - pt receives neb tx with albut, after 3rd tx pt with BS b/l but decreased - now RR>30, HR 130, ABG 7.38/46/70/92% wtd
INTUBATE PT
oxygenation goal in asthma
PaO2>60, SaO2>90%
Pt with asthma being treated with b2 agonist, inhaled steroid, montelukast still has sx, removes carpet/rug, no cat - SERUM IGE high - wtd?
add omalizumab (anti-IgE ab)
Asthmatic on b2 agonist prn, inhaled triamcinolone, almeterol and monteleukast - still with frequent exacerbation, does not like to go on logn term oral steroids - wtd
start tiotropium (spiriva)
Chronic cough
upper airway cough syndorme (post nasal drip), asthma, GERD, chronic bronchitis, ACEi, non asthamatic eosinophilic bronchitis
Exc induced asthma
sx peak 10-15 after stopping exc, resove in 30 min mainly in cold weather - Dx with exc challenge test in cold air (drop FEV1 by 10-15%)
Exc induced asthma tx
short acting B2 agon 30 min prior to exc - if no effect then add cromyln Na+
If exc induced asthma SOB on cromyln
add inhaled steroids and monteleukast
Pt moves to minnesota (cold weather) - SOB in cold
start B agonist inhaler
Mechaism of cromyln Na+
mast cell stabilization (dec hitamine release)
Pt with exc induced asthma started on alb inhaler also wakes up at night 3x/wk with sx
start inhaled steroid
Allergic Bronco Pulmonary Asergillosis (ABPA)
colonization of upper airway with aspergillus i asthmatics - intense immed hypersensitive type rxn - inc IgE, +skin rxn to aspergillus Ag, serology +IgM, IgE, +eos, +brownish mucous plugs - > migratory pulm infiltrates (eos PNA)
pt with steroid dep asthma p/w cough, wheezing BROWN mucous plugs - WBC 15% eos, IgE>2000, CXR b/l infiltrates - steroids recently decreased - has parakeet
Allergic Broncopulm aspirgillosis (ABPA) +eos, inc IgE
Tx: inc steroids
Hypersensitivity pneumonitis
neg eos, normal IgE
Alergic angiitis of churg staus
+eos, normal IgE
Loeffler’s syndrome (pulm eosinophilia)
+eos, inc IgE
Fungal ball in cavity ASX
monitor
Fungal ball in cavity with sever hemoptysis
surgery
Hypersensitivity Pneumonitis
farmer’s lung - fever, chills dyspnea after work everyday, works in grian elevator, pet bird (bird fancier’s lung), methotrexate or nitrofurantoin or works with A/C units
Etio - hypersensitivity pneumonitis
inhaling organic dust with thermophilic actinomycetes - gound glass cxr, +serum AB - remove offending agents, +steroids
Pt with dog, cat, 2 parakeets and pigeon - cough, progressive SOB, CXR ground lgass - WBC no EOS - PFT restrictive
hypersensitivity pneumonitis (bird fancier lung)
70yo M chills, fever, non prod cough, pleuritis CP - recent acute pharygitis - received PCN/Amp w/o improvemnt - CXR with RLL infiltrate - BCtx neg, myoplasma,legionella ab neg - Dx?
Chlamydia pneumoniae
Psittacosis
disease asx in birds - comopletent fixation adn serology useful in dx
Pt with asthma on fluticasone inhaler/oral steroids - montelukast added, oral steroids tapered down - pw cough, sob, wk righ thand/foot - 25% eos, normal IgE - cxr dense infiltrates
allergic angiitis/Churg strauss pneumonitis - tx with steroids
Latin american pw asthma, recent immigrant - recurrent cough despite B2 agonists - eos 20%, round infiltrates on CXR - ANCA neg, ANA neg
Loeffler’s syndrome - strongyloides infxn - tx with thiabendazole
35yo non-smoker F pw cough, no sputum, wheezing, nighttime sweats - h/o asthma - b/l crackles on exam - PPD neg, high eos in sputum high ESR
chronic eos PNA - long term steroid treatment
35yo construction worker p/w SOB< no wheeze, no CP, no hemoptysis no exp to toxic fumes - b/l crackles - diffuse opacities/GG - bronch with copius tan fluid - alveolar proteinosis
tx - brochial lavage - defective macrophages causing buildup of surfactant in lungs
COPD
dx: h/o chronic smoking dec FEV1/FVC<0.70
COPD Spirometry determines?
Severity of disease
Gold Criteria Mild COPD
FEV1/FVC80 - tx short acting bronchodil prn, alb+=ipratropium
Gold Criteria Mod COPD
FEV1/FVC<80% - tx - shart acting bronco dil prnn plus long acting broncodil (tiotropium +-salmeterol+- rehab
Gold Criteria Severe COPD
FEV1/FVC <50%, short/long acting bronchodil + inh steroids
Gold Criteria very severe COPD
FEV1/FVC<30 - use long term O2 therapy, inh steroids, + bronchodilators short and long
Major risk factor for COPD
Smoking
Main tx for COPD
bronchodil, antichol, supp O2 SaO2>90%
Therapy survival benefit for COPD
O2 supp at least 15hrs/day
Pt with COPD hypoxia on O2 therapy, PO2 signficantly improves - cause of low PO2 is…
V/Q mismatch
Bronchodilators do what for COPD
reduce hyperinflation, dec RV, improve sx and exc tolerance - DO NOT IMPROVE MORTALITY
Tiotropium is better than Ipratropium
True
Side effect of salmeterol
dry mouth
Pt with COPD, +tob - best way to preserve lung fxn
quit smoking
Inc’d mortality in COPD
decreased free fat mass
COPD O2 sat goal
88-92%
Criteria for starting O2 on COPD pt
PaO288% with eveidence of Cor pulmonale, erythrocytosis (Hct>55%)
Best way to mamage COPD with secondary erythrocytosis
continuous O2 supp
Consequence of overcorrection of hypoxia
hypercarbia
Consequence of abrupt O2 supp d/c
respiratory arrest
Pt with COPD SOB during gold resting PO2 62
check O2 during exc - if <55 then start O2 supp
COPD Pt with daytime sleepiness/fatigue, resting PO2 64
check PO2 at night if <55 start supp O2
COPD pt travelsing by plane - resting PO2 64 -
If estimated PaO270
60yo COPD pt 2L O2 requirement wants to fly
needs to have airline arrange for O2 supp
Role of inhaled steroids COPD
decrease exacerbations
COPD acute exacerbation tx (with inc cough/sputum/sob
tiopropium + B agonist, IV steroids, empiric abx (azith/doxy -> NO ERYTHRO)
Adv COPD pt Pulm rehab
DOES NOT improve FEV1, does NOT dec mortality, does improve sx, QOL, dec exacerbations
Pulm rehab
program excercise training of muscles of ambulation
Pulm rehab doesn’t work, still low exc tol, ABG 7.42, PO2 62, pCO2 48 - FEV120, b/l upper lobe emphysema
lung volume reduction surgery
Acute Mountain Sickness
Leading cause altitude sickness - h/a, n/v/fatigue, dizziness, 6000ft, management=descent, dexanelimine, prevent with acetazolamide
High altitude pulm edema
leading cause of death with altitude sickenss - h/a, n/v/fatigue, dizzines PLUS SOB - 8000 to 12000 ft - tx descent, dexamethalazone, prev with acetazolamide or nifedipine
Thophylline decrease clearance by…
CHF, Liver dz, hypoxia, fever, cipro, erythro, OCP
Young woman h/o asthma on multiple meds and OCP c/o n/v - tachycardia/tremors
related to theophylline use
COPD with Po2 60 pCO2 50 - exacerbation of COPD - PO2 55 and pCO2 60 - refuses intubation
BIPAP
50yo COPD p/w SOB,cough - awake but in severe distress, using accessory muslces - pCO2 74, pO2 50, pH 7.18, HR 120, RR 36
intubate, mech ventillation
Mortality reduction COPD
flu vaccine
30yo M extensive bullous emphysema, b/l basal bullous cyts
check serum alpha 1 antitrypsin level
58yo F recurren tcough, foul smelling yllow sputum with hemoptysis, h/o PNA >1 yr ago - prominent cystic spaces in RLL, streamking oapcity, tram lines
dx bronchiectasis, high res CT scan - h/o PNA
Dyskinetic cilia syndrome
Bronchiectasis/sinusitis, infertiility, sinus inversus, Dx kartagener’s syndrome,confirm sperm motility test then testicular bronchi or sinus bx
Recurrent PNA cough/sputum x 1 year, mother died of lung dz
check High res CT
22yo M recurrent PNA, bronchitis since childhood, no allergy or GERD, IgG electrophoresis nl - +clubbing, cxr apical bullous
check sweat chloride
Cystic Fibrosis
inc’d ris kof endobronchial infxn with pseduomonas, staph, strep Pneum
tx: chest PT, abx (anti pseudom, topical tobramycin, inhaled hypertonic saline, bronchodil, ribonuclease, if bleed - bronch artery embolization
Reduce decline in lung fxn with CF patient colonized with pseudomonas
Azithromycin (anti-inflamm effect)
35yo non tob h/o RA no asthma/allergies - p/w cough/dyspnea on exertion, recent viral URI - +JVD, no wheeze, CXR normal - PFT severe obstr FEV1/FVC
Bronchioitis obliterans - can occur after RA, carcinoid, lung tx
35yo F s/p radiation tx for breast CA p/w SOB, diffuse insp crackles - PaO2 52, PCO2 30, PFT dec DLCO, no response to abx
cryptogenic organizing PNA - dec DLCO, bx rapidly progressive organizing PNA or acute interstitial PNA - tx STEROIDS
Interstitial lung dz
sarcoid idiopathic Pulm Fibrosis hypersensitivity pneumonitis COP Allergic bronchopulm aspergillosis lyphogioleiomyomatosis Churg strauss
Sarcoid - indications for steroids
progressive pulm dz, eye involvement, CNS involvement, myocardial involvement, persistent hyperCA, disfiguring lesions
24yo F fever, pain, swelling both ankles (erythema nodsum - tender erythematous nodules - wtd
CXR r/o sarcoid - bil hilar LAD - no tx, adenopathy +parenchymal infiltrate - steroids if symptoms, diffuse infiltrates - no adenopathy - steroids if symptom
26yo F f/weakness, tenderness over legs - erythematous lesions, CXR b/l mediastinal adnopathy with infiltrates
BAL T4/T8 4:1, start steroids if eye involved, TB bx for non-caseating granulomas
All following elevated in sarcoidosis
Calcium in serum/urine, ACE, helper T cells
Idiopathic Pulm Fibrosis
insidous onset dry cough, gradual progressive dypsnea, cyanosis, clubbing, CXR diffuse infiltrative progess, reticular opacities, ground glass, honeycombing, PFT FEV1 low, FEV/FVC normal DLCO dec, BAL inc neutrophil
Tx: supportive care, O2 PRN, pneumovax, flu shot +- steroids
Asbestosis
Chronic exp x 10yr, lower lobe fibrosis, PFT - RESTRICTIVE patter - a/w mesothelioma, broncogenic CA, Pleural/diaphragm calcified plaques (no lung impairment)
Silicosis
chronic exp x 20 yrs (sandblasting, granite cutting) - upper lobe fibrosis with inc’d MTB incidence
EGG SHELL Calcifications with hilar LAD
58yo M SOB< CP, reporducible on palpation, 15lb wt loss over couple months, asbesthos exp - used to smoke, no BS in L base - pleural effusion L
mesothelioma/bronchogenic CA
Berylliosis
metal workers (computers, aerospace, electronics/lights b4 1950's) - can cause tracheobonchitis Bx - non-caseating granuloma A/w lung Ca
Male smoker with SOB, progressive - honeycomb on chest xray interstitial upper lung fields - PFT restrictive - BAL - langerhans cells (giant cells - also on bx
Langerhan cell granuloma/esoinophilic grnauloma/histiocytosis x
c/b - PTX
Tx: quit tobacco
Premenopausal woman on OCP with sudden SOB, CXR with PTX, honey comb appearance on CXR with CHYLOUS EFFUSION
lymphangioleiomyomatosis
Consequences of hyopxemia
pulm HTN, secondary erythrocytosis, exc intolerance, impaired mental fxn, precip sleep apena
COPD dx with pulm HTN - etiology?
hypoxia
Tx for pulm HTN pt with COPD
O2 tx keep SaO2 90-95%
Pulm arterial HTN
Idiopathic, hertiable, drug (Fen,fen), conn tissue d/o, HIV, portal HTN, congential heart dz
Pulm HTN from LH dz
systolic/diastolic dysfxn - valvular dz
Pulm HTN from lung dz/hypoxia
COPD, ILD, mixed restr/obst, chronic high altitude
Chronic throboembolic pulm HTN
PE of prox or distal pulm vasc
dx V/Q scan
Pulm HTN unclear mech
hematologist, sarcoid, langerhans, lymphagioleiomyomatosis, met d/o, tumor infiltration
Pulm pressures
normal 25/15 - RVH (RAD, tall Rwave V1/2, split loud second heart snd - lous P2
Pt with near syncope, SOB< SQ calcification, split 2nd heart dound, JVP, pedal edema
TTE
Pt with telangiectasias and SOB, h/o syncope, JVP 10cm, loud P2, pansystolic murmur L sternal border - echo with RV dilation and mod TR wtc
RHC with vasodilator testing
45yo F h/o PE 4ya tx’d with a/c with SOB, loud P2 EKG with RAD and P pulmonale - echo RV dil - next dx step?
r/o CTEPH - V/Q scan
Pt with +v/Q scan - wtd?
eval for thromboembolectomy
If pt with RHC responds to vasodilators?
start nifedipine or diltiazem
If pt with RHC with NO response to vasodilators?
Mild dz - sildenafil, tadafil, bosentan
Mod dz to severe (limits on physical activity) - IV epoprosterol + sildenafil
Severe dz and hypotensive - inhaled Iloprost
Maintenance tx pulm HTN
Coumadin
Pulm Embolism
usually from DVT (mostly above Knee - sudden onset SOB, tachypnea, pleuritic CP, pre/syncope, hemoptysis, loud P2, split 2nd heart sound, CXR normal - S1Q3T3, A-a gradient >20 if hyperventilating PO2 may be normal - taxoifen, OCP, nephrotic syndrome, breast CA, protein C/S def, long flight or drive
V/Q scan
Normal - no PE
2 or > seg or larger defect with no matching ventil def - > +PE, treat
sugseg perfusion defects or matching ventillation and perfusion deficets or single large defect - PE low or intermed - check for DVT - tx if postive if ng then pulm angiogram
Tx for PE
LMW or heparin 7-10 days - then coumadin for 3-6 months
High clinical suspicion
start tx before confirmation
Best test r/o low prob PE
D-dimer (if neg no PE)
Best test r/o mod to high prob PE
V/Q scan
Best test dx chronic PE
V/Q scan
Contraindications to A/C
neursx, eye sx, open prostatectomy
Indication for thrombolytics
acute massive PE with hypotension - large DVT (Iliofemoral DVT)
Indication for IVC filter
If another PE pt may die, contraindication to A/C - emboli post A/C
52yo M midl CHF is a/w sudden onset of SOB and right sided pleuritic pain on furosemide and digozin - CXR with cardiomegaly - split 2nd heart snd HR 100 - V/Q scan showed small subsegmental match/unmatched deficits - contrast scan lower extrem neg wtd?
CT angiogram
44yo M multiple pelvic hip fx and undergoes hip replacemnt - two days after surgery fever, mental confusion and sob - chest xray and diffuse pulm infiltrates - pO2 44 , pCO2 30mm, pH 7.48 EKG wiith sinus tach - inubated and transferred to ICU - dx?
Non cardiogenic pulm edema due to fat emboli
Tx for non-cardiogenic pulm edema 2/2 fat emboli
No A/C no steroids
Post delivery patient becomes hypotensive and SOB
amnitotic fluid embolism
Pt with sudden onset SOB< tachy, hypoxeia and inc’d A-a gradient
V/Q scan
Pulm HTN, SOB, tachy, echo with RV strain -
V/Q scan
Pt with SOB, tachy cardia, echo RV strain - V/Q scan with 2 large deficits normal ventillation
Anticoagulation
Pulm HTN, SOB, tachy, V/Q scan 3 defects 2 matched with ventillaory defects one with unmatched defciit - lower extrem US neg
pulm angiogram
Pulm HTN with SOB, V/Q with 2 large unmatched defects, hypotensive
T-PA
DVT
D-dimer good neg predictive value
If D-dimer + further w/u needed
Infection good predictor for DVT
LMWH dec’s DVT but not mortality
Pt with unprovoked DVT 5 months ago now in ED with bleed, coumadin stopped -> wtd?
ASA 325
DVT ppx
High risk - Knee replacement, Total hip - ppx LMWH 4 weeks or warfarin or fondaparinex
DVT ppx with elev Cr
unfractionated hep, ext pneumatic compression, early mobilization
Pt with DVT started on A/C with swelling of leg, 2 months later leg swells again - wtd?
below knee compression stocking
Elderly pt with colon CA 2ya p/w swelling of leg
check LE US (high risk patient)
45yo p/w swellinig/pain in right leg - wtd?
D-dimer (low risk pt)
Hospital Aquired PNA
leading cause of death among hospital aquired infections - 48hr or more after admission
Ventilator Associated PNA
within 48 to 72hrs after intubation
Healthcare associated PNA
pt either hospitalized w/in 90 days of infxn, resided in NH, chemotx or wound care within 30 days of infxn or attends a hosptial or HD clinic
Pt with cholecystitis s/p chole develops PNA
48hr imipenum +aminoglycoside
Strep Pneumo
MCC of PNA
Myoplasma
PNA in yound adults
H flu/M catarrhalis
COPD/DM pts
Legionella
cool damp places/water coolers
Pseduomonas
nosocomial, neutropenics
Klebsiella
alcoholics, NH residents
Mixed flora
cavities, lung abscess
Good sputum sample
25WBCs
pt with cough/yellow expectoration pas 2 days low grade tempHR 84 BP ok lungs with few rales
over the counter anti-tussives
Pt with URI sx >2wks tx’d with doxycycline w/o improvement - inc’d cough with post-cough vomiting - exam with SUBCONJ HEMORRHAGE -> organism?
sputum PCR for bordetella
Pt with PNA tx’d with Ctx/azithro x 5 days then changed t PO meds - on abx fells better - continues to have cough, 6 wks later opacity persists - dx?
underlying malignancy or bronchial carcinoid
Pt with recurrent PNA - CT chest fibrosis in Lt lower lobe area - etiology?
post obstructive PNA
40yo pt with hemoptysis and streaks blood x 3 weeks - 4lb wt loss, cough, CXR normal - management?
bronchoscopy
25yo p/w purulent nasal discharge, HA for past 2 days, cough+, tx with?
decongestants, analgesics
Bacterial sinusitis
< 7 days have bacterial sinusitis - No abx unless sx > 7 days or have fever/pain - no routine CT for dx
22yo M with c/o purulent nasal d/c for 3 days and temp 101 with maxillary pain wtd?
abx - amox-clavulanate (augmentin)
40yo sore throat and h/a x 3 days - grandchild with cold - 99 deg with pharyngeal erythema, anterior cervical LAD
rapid strep test - confirm with throat ctx
Centor criteria for strep
fever, no cough, tonsillar exudate, cervical LAD
0-1 no abx or throat ctx
2-3 throat ctx - tx if +
4 or 5 tx empirically with abx
pt with runny/blocked nose, itchy eyes, sore throat - swelling below eyes, coblestone pharynx no LAD dx?
allergic rhinitis
Nasal congestion/rhinorrhea for several months, h/o allergies usually controlled with decongestants and antihitamines - using OTD meds and getting worse - red edematous mucousa of nares
rhinitis medicamentosa - rebound congestion from vasoconstrictors - stop vasoconstrictors start intranasal steroids
24yo hot potato voice, fever, unable to swallow, drooling - tonsils touching each other, dev of uvula
peritonsillar abscess (Quincy)
pt with sore throat few day sand severe pain when moves neck, pain on swallowing - brawny edema of hypopharynx and tenderness of palpation of SCM - dx?
internal jugular vein thrombosis (Lemierre’s dz)
DM pt with fever from NH, no teeth CXR RL consoldiation - best empirc abx?
newer fluoroquinolone (strep pneumo) - if worsens still febrile and hypotensive then resistant - start vanco or linezolid
alcoholic pt with cough/red currant jelly sputum - g neg bacilli with capsure, cxr bulging fissure dx?
klebsiella PNA - 3rd gen cephalosporin (ceftx) + amminoglycoside
If above pt worse (etoh abuse with red currant jelly)
ESBL - start impipenum or meropenum
S/E flurouinolone
inc QTC -> ventricular arrythmia
elerly woman floroquinolone s/e
tendon rupture
which abx have hypoglycemia s/e
Levofloxacin
CAP tx period
1 week
HAP pseudomonas tx period
2 weeks
Pt with PNA - early ambulation leads to…
early d/c from hospital
65yo DM pt with PNA tx’d with abx - wtd prior to d/c
23 valent pneumococcal vaccine
Pt wit LLL PNA tx with Abx with persistent fever, elev WBC for 2 weeks, CXR still with infiltrates
CT scan r/o lung abscess or empyema
Fever, cough, DIARRHEA, mental confusion, pulm infiltrated, DEC SODIUM, inc BUN
legionella - urine legionella Ag -> macrolide +- rifampin x 2 weeks
AIDs pt with sudden onset SOB, hypoxic on ABG, PTX on CXR - chest tube inserted - wtd
PCP tx (bactrim + steroids)
Acute ill pt with PNA and intubated - lancet shaped diplococci - WBC 15, 103 deg - tx’d with PCN - 2 days later still temp, wbc 11, greenish secretions from ET tube grows pseduonas
continue PCN
PNA temp 103, WBC 17K tx’d with fluroquinolone - 3 days later WBC 11K - unchanged lobar infiltrate - WTD?
no further testing - continue to tx
Pt a/w RL pna - temp 102, WBC 16, started on Ceftx, next day BCtx growing PCN sensitive srep pneumo, - pt changed to PCN - on 5th day shows growth of MRSA (contaminent)
continue PCN
Pt with recent Seizure -3 days later UL infiltrate - organism?
Peptostreptococcus
Pt with Sz 1 month ago now with fever, foul smelling sputum, CXR cavity with fluid level, sputum shows mixed flora dx?
Lung abscess -> PCN with clindamycin - several days later no fever, same cavity but fluid decreases, WBC dec -> continue abx
25yo with ear ache fever cough - inflammed typanic membrane with hemmorhage - CXR patchy infiltrate
Myoplasma -> tx macrolide (erythromycin)
35yo non-smoker with gradual onset cough few weeks - WBC < 5, Epith 25/cm2 CXR b/l infiltrates -> tx?
Macrolide
50yo COPD, acute onset of cough, rusty sputum, fever, chills LLL consolidation dx?
Strep pneumo - macrolid+ceftx
Common pathogens in neutropenics
Pseudomonas, aspergillus, staph, strep
CURB65
Confusion bUn>19 RR>30 sBP65 0-low risk - home tx 1 - outpt tx 2 short inpt, clsoely supervised outpt 3 severe PNA - hospitalize consider ICU 4 or 5 - ICU tx/intubation
55yo COPD SOB, cough, sputum white-> green, low temp scattered rhonci - organism?
H.Flu non-typable
50yo farmer 3 month cough, inc dyspnea, skin lesion on nose with pleurtic CP -> CXR alveolar/fibronodular infiltrates
Blastomycosis (thick walled infiltrates)
22yo F OCP 3 days fever, pleuritic CP, non prod cough/fatigue CXR clear
Pleurodyna 2/2 coxsackie virus - sx therapy
Pt with URI 3 wks ago - fatigue, inc JVD echo EF 20% - cause?
coxsackie B3 virus
Pt from southwest - arizona, NM, texas with fever and LUNG infiltrates, thin walled cavity on CXR
Cocoidomycosis - thin walled - self limited or fluconazole -> systemic -> Amphotericin B
Influenaza season
NOv to march - f/cough/myalgia - vaccine any age > 6 months Tx Oseltamivir (tamiflu), zanamivir
Influenza outbreak in NH tx?
vaccine+tamiflu(oseltamivir x 2 weeks - if no vaccine then oseltamivir/amantadine x 6 weeks
Pt post influenza more prone to…
staph PNA
Which flu med NOT with asthma/COPD
zanamivir (or BB, adenosine, dihydropyridine)
Female pt with UTI on nitrofurantoin - SOB/fever, crepitice over lung fields with ground glass
Dx nitrofurantoin rxn
PPD
> 5mm - HIV, rec TB contact, old CXR TB scar, organ tx, prednisone >15mg/day at least 3 months, anti TNF, rituximab
10mm - HC workers, etoh, homeless, foreign born, NH resdients, dz with high risk of TB, IVDA, silicosis, DM, CRF gastrectomy, chemo, lymophoma, leukemia, malnutrition
PPT+ wtd?
CXR
CXR small patch fibronodular opacity no cough -
induce sputum AFB
CXR neg after +PPD
tx with INH x 9 months
alternate to INH with liver enzyme elevation or HCV
rifampin x 4 monthsbest
best tx pt PPD+ (compliance wise)
INH 900/rifampin 900 weekly x 3 months (direct observed therapy)
Multidrug resistant TB - asymptomatic roommate PPD 5mm CXR neg - wtz?
PZA/ethambutol for 6 months or PZA+quinolone (levoq/moxiflox) x 6 months
Nurse (filipino with PPC x 20mm) BCG in childhood
CXR if neg begin INH and B6 (if 10 or less check gamma IFN if + active TB tx
Ukrain resident PPD 10mm BCG in chilhood CXR neg
check IFN gamma
Pt on INH/B6 - 3 moths on tx now tired and nausea x 2 days
d/c INH, check AST/ALT, bilirubin check (liver failure) stat
Best Screen latent TB
Gamma IFN
What is good about gamma IFN vs PPD
decrease confounding with BCG
Inner city pt, PPD+, CXR+ started on rif, inh, pza, ethambutol isolated until 3 afb neg still ctx + 1 later wtd
continue 4 meds x 1 more month
Pt dx with pulm MTB - homelss lives in shelter periodically wtd?
INH/rifampin/pza/ethambutol x 2 weeks then inh/rif, pza ethambutol twice wekly x 6 weeks then inh/rfampin twic weekly x 4 months
Pt from E eurobe/asia with pleural effusion - tap done neg for AFB - wtd?
needs VATs pleural bx
Management of MTB resistant to INH - what drug improves outcome?
Fluoroquinolone
Homeless pt with RUL infiltrate and pleural effusion wtd?
airborn isolation
Pleural effusion lytes criteria
transudate 3g tot protein, fluid/serum protein ratio >0.5, total LDH >200, fluid serum LDH ratio >0.6
Causes Transudate effusion
CHF, Nephrosis, cirrhosis, hypothyroid
Causes Excudate effusion
neoplasm, infection, inflammation (RA, SLE, Pancreatitis), esophageal perforation (gastrograffin), dresslers syndrome (post cardiac sx)
Mesolthelioma/malignance with bloody effusion
chylous eff >115 TGA->trauma, mediastinal lymphoma/lymphangioeiomyomatosis
pseudochylous like in TB, Rh arth
Gluc 80-TB, gluc 60-CA, Gluc 30-Rh arthritis
54yo with pleural effusion dx tap reveals fluid serus <0.6 cause of pleural effusion?
Cirrhosis
Rh arthritis pt with recurrent effusions after repeated taps wtd?
tub thoracostomy and sclerosing agent
Pleural fluid with glucose o29 - cause?
Rh arthritis (<30)
55yo M s/p CABG 4 weeks ago p/w fever, dyspnea, non-productive cough, pleuritic CP - pericardial rub - ESR 68, WBC 10, cardiomegaly with b/l basal atelectasis and small pelural effusion - ABG PO2 80, PCO2 34 pH 7.45 - tap done 350cc removed - protein ratio >0.5, LDH ratio >0.6 - V/Q scan with several matched defects - dx?
Post cardiotomy syndrome (dressler’s)
25yo athlete SOB while sprinting with pleuritic CP - BS dec on R side - hyperresonance on percussion
spontaneous PTX -> chest tube insertion
if recurs pleurodysis
When to tap parapneumonic effusion
If effusion >10mm on lat decubitus CXR, PNA not responding to abx, frank empyema needing chest tube, loculated fluid needs thoractomy
Pt with PNA continues to spike temp on Abx, cxr with pleural effusion, protein >3g, LDH rat>0.6, chest tube placed, 72hrs later pt still febrile - loculation on chest CT
VATS (surgery c/s)
Chest physical exam
Pleural effusion -> dull percussion, dec BF, Fremoitus absent
Pneumonia ->dull percussion-> bronchial BS, in fremitus
PTX - hyper percussion, dec BS, inc frem
Best way to diff PTX from pleural eff o PE
percussion (hyper on PTX)
Pt with SOB - exam dec BS on left, inc vocal frem on L - dx?
L side consolidation (PNA)
Pt a/w SOB, CXR lower lobe infiltrate and pleural effusion, temp 102.5, HR 110, pleural tap exudative fluid - next day pt worse and more hypoxic with PO2 of 52, CXR complete whiteout of left side - trachea not deviated - dx?
L hemithroax consolidation - needs intubation
Pt with PNA, large consolidation on LL, abg while lying on L side 54, while lying on R side 65 - cause?
intrapulmonary shunting 2/2 PNA
Pt with cryptogenic cirrhosis with ascites and pedal edema, SOB on sitting or standing up - pulse ox 92% lying down, sitting 82% DLCO 70% - etiology?
intrapulm R to L shunt (hepatopulm syndrome (orthodeoxyia see every 4 beat bubble in LA on bubble study in TTE)
Sleep Apnea
Apnea - no breathing for 10 seconds - >10/h - sleep apnea syndrome
increased snoring prevents good sleep causing sleepiness?
T
Hypoxemia causes daytime sleepiness in OSA
F
hypoventilation at right leading to recurrent arousals leas to daytime sleepiness
T
Nighttime alkalosis leads to daytime sleepiness
F
OSA pt with apnea hypopnea index >30 has?
inc’d mortality
Sleep Apnea definitioin
> 95% obstructive, snoring, wakes up with h/a, distrubed sleep, neck >17 inches, neuropsych manifestations, somnolence, accidents, firing, high risk for MI/CVA/HTN
Dx with polysomnography - r/o treatable cuase - enlarged tonsils, tumor, hypothyroid
Tx no sedation, no etoh, protriptylin e9mild), mod sleep apnea nasal cpap, , uvulopalatopharygoplasty works 50% of time
45yo pt with lethargy, BMI 41, HTN, lift in R parasternal area, panniculus, edema, echo with TR - wtd?
sleep study - etiology of leg edema - pulm HTN from RHF
Secondary HTN cause in pt with obestiy
OSA
Cause of HTN in pt with OSA
inc’d sodium retention
Tx for OSA
improved quality of life, cogn fxn, daytiem sleepiness, HTN, dec mortality
Pt with difficult to tx HTN on 4 meds with OSA - best management?
renal denervation
22yo BMI 24 tx herself for allergic rhinitis with OTC meds for past few days now unable to sleep well and tired during day dx?
Rhinitis medicamentosa - tx - d/c meds start steroids
45yo F BMI 35 p/w DOE - JVD, FEV1/FVC 0.7, mild edema, RVH on echo, no valvular lesions - PCO2 55, PO2 58
dx Obesity hypoventillationi syndrome->pulm HTN
Why do ppl with severe obesity have PCO2 elevation?
hypoventillation - check sleep study
48yo M dx with OSA - sleepy during day, c/o fatigue, Leg edema, TFT nromal - most appropriate Tx
nasal CPAP
Pt with daytime sleepiness, mod musc wk at onlet of sleep gets hallucinations - brother with similar episodes
narcolepsy (autoimmune dz) - tx with modafinil (expensive) or methyphenidate or sodium oxybate)
Elderly pt with gradual onset SOB, daytime sleepiness, pedal edema and rales - breaths funny at night and doesn’t breath several seconds - BMI 28, EF 30% - most likely cause of daytime sleepiness?
CHF - cheyne stokes breathing (widening of QRS >120)
Pulmonary nodules
4-6 low risk f/u CT 12 months if no changes, no f/u, high risk initial CT 6-12 months, then 18-24 months if no changes
6 to 8 - low risk initial CT 6 to 12 months, then 18 to 24 months if no change, high risk initial f/u 3 to 6 months the 9 to 12 adn 24 months if no change
>8mm low risk f/u CT 3,9,24 months, CT, PET and/or bx - same for high risk
60yo pt with 1.5cm solitary nodule on CXR wtd first
see old CXR
53yo with pulm nodule 1.2 cm - last year 0.9cm wtd?
resection
Bronchoalveolar lavage (BAL)
Normal = inc’d PMN
Sarcoid - inc’d lymph CD4>CD8
hypersensitivity Pneumonitis inc’d lymp, CD8>CD4
Eos pNA - peripheral infiltrates - inc’d eos
PJP in HIV - silver metahanamine +
CMV - inclusion bodies
PNA in ARDS - bacteria >10^3
Amiodaraone PNA - foamy witih lamellar inclusions - r/o thyroid issues
