pulmonary Flashcards
low vq ratio
physiologic at base of lugns
disease: astham, copd, acute pulm edema- due to hypoxemia= hypoxic vasocstriction leads t o pulmonary htn if persistent. Then that leads to right heart failure-
chronic bronchitis
associated with COPD!! if untreated!- only medical treatment to reduce mortality in copd is oxygen
high vq ratio
physioligcally at apices of lungs
pathalogic: emphysema, pulm embolism or foreign body
ventilation
strictly regularted by changes in pac02
central chemoreceptro: medulla
peripheral chemoreceptors: carotid bodies
DKA
leads to kussmauls respiration- because DKA stimulate resp centers
forced vital cappacity
measurement of the volume of air expelled from a maximally inflated lung- breathing hard and fast as possible
FEV1
forced expiratory volume in 1 second
crackles/rales
heard during inspiration- discontinuous high pitched sounds
pneumonia, atelectasis, bronchitis, bronchiectasis, pulm edema, or pulm fiboriss
stridor
narrowing of the larynx of trachea
asthma
associated with increased IGE
airway inflammation and bronchoconstriction
asthma, nasal polyps, ASA/nsaid allergy!!!
prolonged expiration with wheezing, hyperresonance
pulm FUNCTION TEST!- gold standard- reversible obstruction
decreased FEv1, Decreased FEV1/FVC
bronchopvocation test: methacholine challenge- mroe than 20% decrease in FEV1,
bronchodilator test: more than 12% INCREASE in FEV1
Peak expiratory flow rate
best way to assess asthma exacerbation severity and response in ED
beta agonists
asthma tx:
beta agonists!- saba- 1st line for acute- most effective and fastest
albulterol, terubtaline, epinephrine: bronchodilator esp peripherally
se.: tachycardia, arrhtymias, cns stimulation
anticholinergics
ipratroium !!- central bronchodilator
se: thirst, blurry vision, dry mouth, urinary retension, acute glaucoma, BPH, dysphagia
steroids
prednisone, methypred, prednisolonoe
se: hyperglycemia, osteopororis,s growth delays, fluid retention
asthma tx: inhated cortico
beclomethasone, triamcinolone,
DOC for long term persistent
se: thrush
laba (long acting beta agonists)
salmeterol,
- not for acute exacerbation of asthma
add to steroids if needed, but taper offf after it is controled
mast cell modifiers
cromolyn- inhibits acute repsone to cold air, exercise
Leukotriene modifiers
useful in asthmatics (MONTELUKAST)- useful for the ones with allergic rhinitis/aspirin induced asthma
theophylline
main side efect: narrow TI:: tox causes seizures, arrhtymias
intermittent asthmam
less than 2 time a day for saba
less than 2x month for night time
fev1 more than 80%
mild asthma
more than 2times a week for saba
more than 3-4 months for night time
fev1 more than 80%
- use low dose ICS
mod asthma
fev1 60-80%
changes in fev1/FVC ratio- reduced by 5%
use low ICS and laba or medium ics
severe asthma
fev 1 less than 60%
high dose ICS
copd
loss of elastic recovil and increased airway resistance
emphysema and chronic bronchitis
risk factors for copd
smoking
alpha 1 antitrypsin deficiency: genetic disease linked to copd in younger patients less than 40 years old- panlobular EMphysema
emphysema
loss of elastic recoil, increased air trapping, - alveolar capillary and alveolar wall destruction- airway obstruction
barrel chest, pursed lip breathing, matched v/q defects, mild hypoxemia, cachectic, pursed lip breathing- pink puffers
chronic bronchitis
productive cough more than 3 months X 2 years
increased airway resistance- then obstruction- prone to microbial infections
productive cough, rales, rhonihi, signs of cor pulmonale, severe V/q mismatch, obses and cyanotic- blue bloaters
copd
PFT/spirometry: gold standard FEV1 is IMPORTANT FACTOR FOR prognosis and mortaliity!! decreased DLCO in emphysema emphysema: ass with bullae multifocal atrial tach
TX COPD
- stop smoking
combo with antichol and beta agaonists!!- BEST
tiotropium, ipratroipum- antichol preferred over beta
beta agonists: abuterol etc
theophilyine
steroids- not as monoteherapy - CAN ADD TO BRONCHODILATORS like salmeterol.
oxygen11!!!: only medical therapy proven to decrease mortality!!!- decreases pulm HTN/cor pulmonale!!
use if +cor pulmonale, o2 sat is less than 88% or pa02 less than 55 mm
copd prevention
vaccinations (pneumo and influenza), pulm rehab, smoking cessation, surgery
copd stage
mild: fev1 more than 80
mod; fev1 50-79
severe: fev1 30-50
very severE: fev1: less than 30
bronchiectasis
transmural inflammation of medium sized bronchi- irreversible bronchial dilation!!
inflammaed airways collapse easily- obstruction- lung infections
H/influenza MC!!!- of bronchiectasis!!
if due to cystic fibrosis: pseudomonals mc
cystic fibrosis mc cause of bronchiectasis
THICK mucopurulet foul smelling, hemoptysis!!!
MC CAUSE OF MASSIVE HEMOPTYSIS
study of chocie for bronchiectasis
high resolution CT SCANS!- tram track appearnace
obstructive pattern in PFT!!
mac treatment
clarithromycin and ethambutol
bronchiectasis tx
abx
flouroquinolone, aminoglycoside, cephalosporin
azithro
cystic fibrosis
prevents chloride trasport- thick viscous mucus buildsup in lungs, pancreas, liver, intestines and reproductive tracts
growth delays and infertility
meconium ileus at birth
steattorhea, vitamin ADEK deficiency
recurrent resp infections - pseudomonas, chronic sinusitis
elevated sweat chloride test- pilocarpine induces sweating
bronchiectasis seen in CXR
tx for cystic fibrosis
airway clearance treatment
pancreatic enzyme repalcement
fat soluble vitamins replacement (ADEK)
restrictive disroders
decreased lung volume, normal or increased FEV1/FVC!!!
decreased total lung capacity, decreased FVC
decreased compliance
ex: sarcoidosis, pneumoconiosis, idiopathic pulm fiboriss
sarcoidosis
grannulomatous disorder of unknown
african american women
exaggerated t cell response to antigens—accumulation causes granuloma to form- they take up space and disrupt structure or function
dry cough, dyspena, chest pain, lymphadenopathy - hilar nodes, erhythema nodosum, lupus pernio (violaceous discoloration of nose, ear, cheek, chin), ANTERIOR UVEITIS - inflammation of iris/ciliary body- ciliary flush!
mycoardial, rheumatologic, neurologic
TISSUE biopsy: non ceseating granulomas!!- no central necorosis, bilateral hilar lymphadenopathy, interstitial lung disease
sarcoidsis
increased ace, hypercalcemia, eosinophilia,
spontaneous remisson in 2 years usually
ORAL CORTICOSTEROIDS TX OF CHOICE!!
idiopathic fibrosisng interstitial pneumonia (pulm fiborisis)
restrictive component
clubbing of fingers
HONEY COMBING- diffuse reticular opacities- ground glass opacities, decreased lung volumes, increased or normal FEV1/fvc
tX: only curative is lung transplant
penumonocinosis
inahlation of mineral dustr- trigers inflmmation- restrictive lung disease
silicosis
minig, quarry work with granite, slate, pottery, sandblasting
EGG SHELL CALCIFICATIONS of the hilar and mediastinal nodes!
nodular opacities in upper lobes
no proven treatment
coal workers
coal
small upper lobe nodules- may have OBSTRUCTIVE PATTERN!!!
berryliosis
electronics, aeorspace, cermaics, tool and dye, flourescent light bulbs-
dyspena, cough, weight loss, fever
tx: corticosteroids, or supportive o2,
byssinosis
cotton exposure
asbestosis
destriction or renovation of old building, ship building, pipe fitting, insulation
risk of bronchogenic carcinoma MC
malignant mesothelioma of the pleura (rare)
dyspnea on exertion, nonproductive cough
LOWER LOBES AFFECTED!!!- pleural plaques- pleural thickening,
supportive tx
pleural effusion
CHF is most common cause of transudate effusion, nephrotic sydnrome, cirrhosis, hypoalubminemia
exudate: infeciton/inflammation- increase vascular perameability
decreased tactile fremitus, decreased breath sounds, dull to percussion
blunting of costophrenic angles!!
exudates: more than 0.5 protein
more than 0.6 LDH
THORACENTEISS: gold standard
if empyema- pleural fluid ph less than 7.2, glucose less than 40, positive gram stain of pleural fluid
pneumothorax
collapse of lung due to incresed positive pleural pressure
- bleb rupture
primary: no lung disease;: tal, thin men, smokers
secondary: underlying lung disease (COPD, asthma)
trumatic: cpr, peep, subclavian line placement, thoracentiesis
tesnion: pushes lungs trachea and vessels of heart to CONTRALATERAL SIDE!!
hyperresonance to epercussion, decreased fremitus, decreased breath sounds
TENSION: JVP, pulsus paradoxus, hypotension
OBSERVATION IF less than 15-20% with oxygen and repeat CDR
chest tube placement if large or severe-
needle aspiration: if tension pneumothorax followed by chest tube placement- needle at 2nd intercostal space @ midclavicular line
pulm nodules
pulmoary mass if more than 3 cm TB most comon cause- grnulomatous! tumors inflammation THYMOMA- mc mediastinal tumor calcification in benign tumors, cavitary malig : irregular, speculated, rapid,
needle asp or bronchosopy: needle for peripheral, bronchoscopy for middle lesions
resection
bronchial CARCINOID TUMORS
slow growth, low METS
well diffeentiated- neuroendocrine tumors
may secrete SERATONIN, ACTH, ADH, melanocyte stimulating hormone
carcinoid syndrome: diarrhea due to too much seratonin, wheezing, flushing,
bronchoscopy shows pink to purple well vascularized central tumor
bronchogenic carcinoma
cigg most common cause
asbestosis 2nd cause
METS TO BRAIN, BONE, LIVEr, lymph nodes and adrenals!!!
adenocarcinoma
peripheral, smokers, women, nonsmokers 0- MC type
typicaly peripheral!
squamous cell
CENTRAL location!!- hemoptysis, sputum cytolgy can pick it up, CAVITARY lesions (central necrosis), hyper CALCEMIA, & pancoast syndrome- ALL C!
pancoast : shulder pain, horner’s- miosis, ptosis, anhydrosis, atrophy of hand and arm muscles
HYPERCALCEMIA!
large cell
very aggressive
smal oat cell
mets early, centra, aggressive, surgery not treatment
SVC syndrome - dilated neck veins, prominent chest veins Superior vena cava (SVC) syndrome (facial swelling, cyanosis, dilated neck veins).
SIADH/hyponatremia
cushing’s syndrome
lambert- eaton syndrome- abx against calcium gated channels @ neuromuscular junction
PE
lower extremities ABOVE THE KNEEES- iliofemoral or pelvis
fat emboli, air emboli (central lines)
helical Ct scan- best initial test for suspected PE
pulmonary angiography; gold standard
vq scan: for low probability- to rule it out
doppler ultrasound: lower extremity DVT
CXR mostl normal!!-
westermark’s sign- avascular markings
hamptons hump: wedge shaped infiltrate
S1Q3T3
heparin overdose
protamine sulfate is antidote
heparin induced thrombocytopenia
stimulates immuen response- complex activates platelets, causing thromboycytopniea and thrombosis- use other anticoags not WARFARIN!
tx for pe
warfarin for at least 3 months
overalp with herapin for 5 days and INR 2-3 for at least 24 hours
IVC filter
for those anticoag contradicted or unsuccessful
thrombolysis of clot
if unstable/MASSIVE PE!
pulmonary htn
idopathic pulmonary arterial hypertension- primary
SECONDARY: copd most common cause
accentuated s2, right sided heart failure, cor pulmonale,
gold standard: right-heart catheterization
cbc: polycythemia
tx: calcium channel blockers for primary or sildenafil, oxygen
h.influenza
gram negtaive ros
2nd mc cause of CAP after strep pneumo
COPD, bronchiectasis, cystic fibrosis,
mycoplasma
mc cause of atypical, less than 40
bullous myringits
doesn’t respond to beta lactams- no cell walls
legionella
contaminated water supplies- air conditionser
GI symptoms, hyponatremia
intracellular GNR
klebsiella
ETOH, gram negative rods
currant jelly
pseudomonas
hiv, cysstic fibrosis, bronchiectasis, gram neg rods
histoplasma
missisippi and ohio river valley- bird/bat droppigns
coccidioides
southwest united states (in desert areas)
hospital aquired
pseudomans, MRSA, 48 hours after hospitalization admission
signs of consolidated pneumnoia
bronchial breat hsounds, dullness to percu, increased tactile fremitus, egophany , crackles
cap
macrolides or doxy first line
cap inpatient
beta lactam and macrolides or broad spectrum FQ
cap in icu
beta lactam and macrolide
beta lactam and FQ
hospital acquired
anti pseduomonal beta lactam and anti psuedomonal AG or FQ
vanco if MRSA
levoflox or azithro if legionella
bactrim
abx
beta lactams: ceftriaxone, cefotaxime,
macrolides: clarithro, azithro
respiratory fq: omxi, levo
aminoglycosides: amika, gentamicin, tobramycin
pneumo vaccine
pcv13: less than 2 years old get 4 doses
high risk children: also get ppsv23 after pcv13
adults more than 65 get ppsv23 if more than 5 years since last dose.
ages 2-64 with chronic disease! - need ppsv23
TB
granuloma formation
chronic latent: ceseating - central necrosis- granuloa formation- makes ith ostile forMTB to grow- not contagious
reactivation tb: localized in APEX/upper lobes with CAVITARY lesions- contagious`
more than 5mm
hiv, immunocomp p(pred therapy), close contacts of patients with active TB
more than 10
high risk populations, recent conversation
more than 15 mm
no known risk factors for TB
false positive for ppd
improper reading, cross reaction with an atypical (MAC), within 2-10 years of BCG
active tb diagnosis
AFB cultures- gold standard, acid fast smear and sputum culture X 3 days!!
reactivation: apical (upper lobe)
primary tb: middle/lower lobe
ghon’s complex:
residual evidence of healed primary TB
ghon’s : calcified primary focus and lymph nodes
ranke’s : healed fibrocalcific ghon complex
tx for active tb
ripe: rifampin, inh, pyrzazinamide, ethambultol- no longer infectious after 2 weeks after initiation
ripe for 2 months and thenINH and RIF for 4 months
total duration is 6 months
rifampin
thrombocytopenia, orange colored secretions
inh
hepatitis, peripheral neuropathy - give with b6
pyrazinamide
hepatitis and hyperuricemia: caution in gout or liver disease
photosens derm rash
ethambutol
ooptic neuritis- visual changes- color problems,
streptomycin
ototox, neephrotox
latent tb
inh+pyroxidine (b6) times 9 months
inh and vitamin b6 X 12 months
acute bronchitis
adenovirus most likely- infl of trachea and bronchi
symptomatic treatment
pertussis
very contageoious
cattharal- uri symptoms- most contagious
paroxysmal: cough fits with inspiratory whooping and after cough fits- post cough emesis
convalescent: resolution of the cough
PCR- gold standard
MACROLIDES IS DOCL erythryo and azithro
bactrim if allergic to macrolides
bronchiolitis
2 months-2 year old- after RSV, adenovirus
acute bronchiolitis
RSV most common reason- paramyxovirus! wheezing, tachypnea, nasal flare, cyanosis, retractions hyperinflation, peribronchial cuffing pulse OX! humidiefied O2 !!!- MAIN ONE~
epiglotitits
h flu most common
inspiratory stridor, tripod!1
drool, dysphagia, distress
laryngoscope- definitive
thumb print sign on lateral cervical radiograph
DO NOT USE TONGUE DEPRESSORS! if high suspicion
management: dexamethason to reduce edema, ceftriaxone
croup
barking cough
parainfluenza virus mc cause
stridor- inspiratory and exporatory, hoarseness, dyspnea,
steeple sign (subglotting narrow of trachea(
mild: humidifed air mist and , hydration, DExamethasone
moderate: dexamethasone +nebulized EPI, +supportive
severe: dexamethasone +nebulized epi, +hospitalization
infelunza
abrupt onset.
myagias in legs and lumbosacral area
supportive therapy for healthy
antivirals for high risk: WITHIN 48 hours of the onset of symptoms: neuraminidase inhibitors: ostemavir
infelunza vaccine
given annually.
CI: eggs, gelatin or thimerosal allergies
ards acute respiratory distress syndrome
acute hypoxemic respiratory failure!!
SEPSIS most common
pro- inflammatory cytokines- alveolar damage- pulm edema- loss of surfactant- decreased blood oxygeniation
SEVERE refractory hypoxemia is ARDS
bilateral pul infiltrates on CXR
pcwp more than 18 mmg- cardiac pulm edema
pcwp: less than 18 mmg- ARDS
pulmoarny capillary wedge pressure
TX: PEEP
sleep apnea
obstructive or central (CNS reduced respiratory drive)
CPAP tx
cheyne-stokes
cyclic breathing in response to hypercapnia- period of apnea about 15-60 seconds-
mudpilers- anion gap metabolic acidosis
methanol, uremia, dka, propylene glycol, ISoniazid, lactic acidosis, ethylene glycol, renal failure/rhabdo, salicylates
cocciodiomycosis
Fungal infection
fluconozaole tx
The patient presented a week ago with signs and symptoms of coccidioidomycosis, also known as San Joaquin Valley fever. The treatment for coccidioidomycosis is antifungals, so the patient was most likely started on fluconazole. A severe side effect of antifungals is hepatotoxicity which presents with fatigue, nausea, vomiting, and jaundice.
glucagon
treatment for beta blocker overdose
