Pulmonary

Question 1

COPD

Answer 1

• chronic, persistent, and progressive inflammation and irreversible airflow limitation
• 4^th leading cause of death worldwide
• M = F
• 3 components:
  
  • 1. Chronic or recurrent bronchitis (cough or sputum for 3mos for 2 consec yrs)
  • 2. Emphysema (cause by parenchymal destruction and loss of recoil)
  • 3. Airway responsiveness (chronic inflamm leading to structural changes and airway narrowing)
• Dec FEV1 and FEV1/FVC ratio
• Increased functional residual capacity
• Parenchymal destruction (with depressed ventilator drive) leads to dec gas exchange manifested as hypoxia, hypercapnia, and dec DLCO
• Dx: need to confirm with spirometry
  
  • CXR
    
    • Emphysema à hyperinflation: flat diaphragm, increased AP diameter, decreased vascular markings, +/- bullae
    • Chronic bronchitis à increased AP diameter, increased vascular markings, enlarged R heart border
  • EKG – cor pulmonale = RVH and RAE, RAD, and R sided HF
    
    • MULTIFOCAL ATRIAL TACHYCARDIA
• Management
  
  • Bronchodilators
    
    • Combo w/ anticholinergics + B2 agonists
    • Anticholinergics: Tiotropium, Ipratropium
      
      • Preferred over B2 agonists in COPD
      • CI = BPH, glaucoma
    • B2 agonists: Albuterol, Terbutaline, Salmeterol (LABA)
      
      • CI: caution in pt’s with DM (can cause hyperglycemia)
    • Theophylline – only for refractory cases
  • Corticosteroids
    
    • May be added to LABA (Ex = Salmeterol + Fluticasone)
  • Oxygen = only medical therapy proven to DECREASE MORTALITY!
    
    • Indications à
      
      • Cor pulmonale
      • O2 sat <88%
      • PaO2 <55mmHg
  • Smoking cessation = single most important intervention

Question 2

GOLD Staging of COPD

Answer 2

• I: mild, FEV1 ≥ 80% predicted
• II: moderate, 50% ≤ FEV1 < 80%
• III: severe, 30% ≤ FEV1 < 50%
• IV: very severe, 30% ≤ FEV1

Question 3

Pneumonia

Answer 3

• Roughly half of nursing home residents with PNA will have sx triad of cough, dyspnea, and fever
• Typical PNA
  
  • MCC CAP = S pneumo, H. influ, Moraxella
  • MCC HAP = Pseudo, S aureus
• Atypical PNA
  
  • Legionella, Chlamydia, and Mycoplasma
• Tx: risk factors for mortality = CURB65
  
  • Confusion, uremia (≥20), RR (>30), BP (systolic/diastolic 90/60)
  • If 0-1 RF = outpt tx
  • If 2 RF = inpt tx
  • If ≥3 RF = ICU
• Predisposing factors = decreased ciliary activity, less effective cough, decreased vital capacity
• Presentation may be atypical
  
  • Less cough, absent fever, absent or unimpressive leukocytosis
  • Often, only confusion and tachypnea are seen
  • CXR
• Aspiration pneumonia – common in the elderly
  
  • Abx are often used but not very effective
  • PEG tubes INCREASE risk

Question 4

OSA

Answer 4

• Repeated obstructive apneas cause by a collapsible upper airway from failure of neuromuscular control of pharyngeal dilatory muscles while asleep
• Episodes of cessation or marked dec of airflow during sleep
• Apnea = airflow cessation for ≥10s
• Dx: made when number of apneas/hypopneas per hour of sleep is ≥15 or when AHI ≥ 5 WITH sxs such as daytime somnolence
• PAP is TOC and 1^st line
• Oral or dental appliances à mild cases or pts who refuse PAP
• RF: increased BMI and large neck circumference
• Aggrevated by alcohol, sedatives, sleep deprivation, nasal congestion, supine sleeping posture
• Consequences: HTN, cardiac arrhythmia, HF, memory impairment
• Obesity = strong risk factor
• MC in 6^th or 7^th decade
• Physical airway obstruction (may be d/t external airway compression, decreased pharyngeal muscle tone, increased tonsillar size or deviated septum)
• Clinical manifestations
  
  • Snoring, unrestful sleep, nocturnal choking
  • Large neck circumference, crowded oropharynx, micrognathia
• Diagnosis
  
  • In-laboratory polysomnography = First line
• Management
  
  • CPAP = mainstay of therapy
  • Behavioral = weight loss, exercise, abstain from alcohol, changes in sleep positioning
  • Surgical correction
    
    • Tracheostomy = definitive tx

Question 5

Lung Masses Including Carcinomas

Answer 5

• Overall 5 year survival rate = 15%
• Smoking = #1 risk factor
• SCLC (small cell lung cancer)
  
  • More likely to spread early and rarely is amenable to surgery
  • Originates in the central bronchi and metastasizes to regional lymph nodes
    
    • Prone to early metastases and aggressive clinical course
• NSCLC (non-small cell lung cancer)
  
  • Grows more slowly and more amenable to surgery
  • Squamous cell = bronchial in origin and a centrally located mass
    
    • Hemoptysis
  • Adenocarcinoma = MC type of bronchogenic carcinoma
    
    • Typically metastatic to distant organs
    • Arises from mucous glands, usually appears in the periphery of the lung
  • Large cell carcinoma = doubling time is rapid and early metastasis
    
    • Central or peripheral masses
• Clinical features
  
  • New or changing cough, hemoptysis, pain, anorexia, weight loss, LAD, hepatomegaly, clubbing of fingers
• Diagnosis
  
  • CXR and CT
  • Cytologic exam of sputum
  • Bronchoscopy – examination of pleural fluid and biopsy
  • PET scan
• Management
  
  • NSCLC à surgery
  • SCLC à combination chemotherapy

Question 6

Dyspnea

Answer 6

• Ddx = MI, COPD, CHF, PNA, PE, bronchitis, and dysrhythmia
• Subjective experience of difficulty breathing, may be tightness in chest, SOB, breathlessness, or feeling of suffocation
• Does not always correlate with pulse ox
  
  • Responds well to low-dose opioids, a circulating fan, O2, and other txs directed at its cause.

Question 7

Cough

Answer 7

• If it is chronic cough (≥6wks), obstructive and restrictive pulm dzs and cough variant asthma must be considered
• Ddx: PND, meds (ACEi), and GERD
• Coughing with hoarseness may be sign of vocal cord dysfn
• Acute cough (<3wks): most in adults caused by viral RTI