Pulmonary Flashcards
3 common presenting signs of asthma?
Cough, SOB and wheezing
2 things heard on auscultation for asthma?
Decreased lung sounds and hyper resonance
How do we diagnose asthma?
Do a pulmonary function test. If it shows obstructive with the ratio being reduced then this is an abnormal test. Then try to rescue them with broncho dilator and if they are reversed, they have asthma. If the PFT is normal, try to induce them with methyl choline. If you cause them to have asthma, they have it.
3 things to treat an asthma attack?
O2, nebulizer and oral steroids
When can someone be sent home vs. sent to ICU for an asthma attack?
Don’t need 02, are not wheezing and PEFR is over 70%
O2 need is rising, build up of co2, and PEFR is less than 50%
3 big dog treatments for acute asthma attack if it isn’t getting better?
Racemic epi, sub q epi, and mg
What is the only way to diagnose COPD and what will it show?
PFT, obstructive, FEV1/FVC down
What is the qualifier for giving o2?
What is the goal of
Spo2 less than 88 or PaO2 less than 55
Two things to prevent COPD?
Stop smoking
Flue and pneumonia vaccines
How to treat COPD exacerbation?
Antibiotics, doxy and azithromycin
Dilators, albuterol and ipratropium
Steroids
Why do we want to keep COPD folks at 88-92 oxygen?
Their Respiratory drive is driven by hypoxia and not hypercapnia, so we want their o2 a little lower to help with that.
3 symptoms to look for for an acute COPD exacerbation?
Cough, wheeze and sputum
Typical presenting patient with lung cancer?
First step when we think someone has lung cancer?
fever, weight loss, coughing up blood, old man who has smoked for a long time.
CXR
If you see a mass, what to do next?
CT to localize the cancer
How do you take a biopsy if the lesion is by the large proximal airways?
What about if the lesion is out in the periphery?
Middle of the lung?
EBUS, basically a broncoscopy with US
CT guided percutaneous needle bx
video assisted thorascopic surgery
What is another way we can get a diagnosis of lung cancer from another pulmonary conditon?
did a thorancentesis for effusion, sent the fluid to path and found out cancer. stage 4
How do we stage lung cancer?
PET CT
first thing to do with lung cancer?
2nd?
3rd?
stage
PFTs
treat
What is primary prevention of lung cancer all about?
NO SMOKING
How do we screen for lung cancer and who gets it?
55-80
30 pack year hx of smoking
quit less than 15 years
low dose ct
4 factors that lead us to think a lung nodule is not cancer?
less than 8 mm
smooth surface
no smoking
less than 45
4 factors that lead us to think a lung nodule is cancer?
bigger than 2 cm
spiculated surface
hx of smoking
greater than 70
first step when you find a pulmonary nodule?
look at old films because if it has not grown/changed for 2 years, its a stable nodule and you can stop
If it is new or has changed, what do we do?
unstable nodule.
low risk factor pt., serial CTs
high risk factor pt, biopsy
patho, location, 2 paraneoplastic syndromes, and treatment of small cell?
smoking, centrally (trachea and bronchi), ACTC and SIADH, chemo and radiation
patho, location, 1 paraneoplastic syndromes, and treatment of squamous cell?
smoking, central, Parathyroid hormone related peptide (hyoercalcemia), stage, chemo, rad, resection
patho, location, and treatment of adenocarcinoma?
asbestos (people who dont smoke get this), peripheral, stage, chemo, rad, resection
patho, location, 1 paraneoplastic syndromes, and treatment of carcinoid?
serotonin related, anywhere, serotonin syndrome (check 5HIAA in urine), stage, chemo, rad, resection
2 forms of pleural effusion?
transudate and exudate
4 causes of transudate?
CHF nephrotic syndrome gastrosis cirrhosis essentially fluid coming out of capillaries
3 causes of exudate?
malignancy, pneumonia, TB
What to start with when trying to diagnose effusion?
CXR to see that there is fluid
3 image modalities to see if the effusion is loculated?
If it is, how to manage loculated?
US, CT, lateral cxr (best because cheapest)
thoracostomy, if fails, thoracotomy
How do you treat effusion in CHF?
lasix, if that fails, thoracentesis
what is the lights criteria to determine if it is transudate or eudate?
LDH of fluid (greater than 2/3 upper limit of normal)
LDH of fluid/LDH of serum - greater than .6
Total protein of fluid/Total protein of serum - greater than .5
any one is positive it is exudate. All need to be negative
virchows triad?
venous stasis, hypercoagulable state, endothelial injury
big time clinical sign of DVT?
Diagnose?
Treatment?
unilateral leg/limb swelling distal to clot
US
anticoagulate
4 clinical symptoms to remember about PE?
cough up blood, chest pain, right heart strain due to increased pulmonary htn, hypoxia.
what if the wells criteria for PE is less than 2, what do you do?
d dimer to confirm no PE
what is the wells criteria is over 4 in CT and over 6 in VQ, what do you do?
CT angiogram (spiral CT) with contrast VQ scan if they have bad kidneys
How do you treat PE?
heparin to warfarin bridge for 5 days or INR is between 2 and 3, whichever is longer
What is the only indication for IVC filter and PE?
they are bleeding and next PE would kill them
When to use TPA?
BIG FREAKING CLOT
What is the underlying issue with ARDS?
the diffusion barrier is thicker because of the fluid that has leaked out leading to edema. remember, oxygen is diffusion limited.
What does the patient look like with ARDS?
sick as crap, short of breath, hypoxic, probably ICU on ventilator.
How do we diagnose ARDS?
pulmonary edema on CXR and seeing them in respiratory failure basically
What will the PCWP and LV function be in cardiogenic pulmonary edema from CHF and Pulmonary edema in ARDS?
PCWP in CHF up and LV fxn down
PCWP in ARDS normal or down and LV up or normal
how to treat ARDS?
intubate keeping TV down and RR up to keep CO2 under control
PEEP
What is the underlying, big picture problem of DPLD?
restricted fibrotic lung that does not oxygenate
2 clinical symptoms of DPLD?
What will the PFT show?
hypoxic and dry cough
FEV1/FVC will go up
best image modality for DPLD?
best way to diagnose?
high res CT
biopsy
most common treatment for DPLD?
steroids
3 rheumatoid diseases causing pulmonary fibrosis?
lupus, RA, and Systemic sclerosis
buzz words for sarcroid?
black, female, bilateral hilar LA,
what will high res CT show for DPLD?
ground glass opacities
What is the thing that will help you make the diagnoses of sarcoidosis from others?
noncaseating granulomas.
3 extra pulmonary manifestations of sarcoidosis?
heart block, bells palsy, E nodosum
4 step process to diagnose DPLD?
xray, high res ct, PFT and biopsy
two patient populations getting asbestos?
x ray finding for asbestos?
biopsy finding for asbestos?
shipyard and construction workers
pleural plaques
barbell bodies
two patient populations getting sillicosis?
Look like on xray?
rock quarry and sand blastingfibrotic nodules in upper lobes, TB
what lung exposure is associated with RA?
coal miners lung
what is the main difference to remember about hypersensitivity pneumonitis?
this is antigen mediated. fever, cough, sob hours after exposure, but remove the antigen and symptoms go away. dont use steroids just take away antigen
treat sarcoidosis?
steroids
Tb and malignancy will look similar clincially and the exudate will differ if there is an effusion by what?
TB will have leukocytes with ADA positive
