Pulmonary Flashcards
What is the presentation of asthma?
most often young patients with wheezing and dyspnea often associated with illness, exercise and allergic triggers
-airway inflammation, hyper responsiveness, and reversible airflow obstruction
How is asthma diagnosed?
monitor with peak flow, PFT’s, greater than 12% increase in FEV1 after bronchodilator therapy
- FEV1 to FVC ratio <80% (you would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
- in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
What are the treatment guidelines for mild intermittent?
less than 2 times per week or 3-night symptoms per month
-step 1: short-acting beta2 agonist (SABA) prn
What are the treatment guidelines for mild persistent?
more than 2 times per week or 3-4 night symptoms per month
-step 2: low-dose inhaled corticosteroids (ICS) daily
What are the treatment guidelines for moderate persistent?
daily symptoms or more than 1 nightly episode per week
- step 3: low-dose ICS + long acting beta2 agonist (LABA) daily
- step 4: medium-dose ICS + LABA daily
What are the treatment guidelines for severe persistent?
symptoms several times per day and nightly
- step 5: high-dose ICS + LABA daily
- step 6: high-doe ICS + LABA + oral steroids daily
What is acute treatment?
oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
Making sense of forced vital capacity
- forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath
- the amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath
- forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
- you would expect the amount of air exhaled during the first second to be the greatest amount
- in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
What is bronchitis?
cough > 5 days with or without sputum production, lasts 2-3 weeks
- chest discomfort
- shortness of breath
- +/- fever
What is the etiology of bronchitis?
viruses (most common)
-cannot distinguish acute bronchitis from URTI in the first few days
Are labs indicated for bronchitis?
labs are not indicated, unless pneumonia suspected (HR> 100, RR>24, T>38, rales, hypoxemia, mental confusion, or systemic illness) = CXR
What is the tx of bronchitis?
antibiotics not recommended - mostly viral
- symptomatic -based treatments NSAIDs, ASA< Tylenol, and/or ipratropium
- cough suppressants - codeine-containing cough meds
- bronchodilators (albuterol)
What is chronic bronchitis?
defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause
What are the characteristics of chronic bronchitis?
- excess mucus production narrows airways - productive cough
- scarring and inflammation - enlargement of glands - smooth muscle hyperplasia = obstruction
- blue bloaters (2nd to chronic hypoxia)
- common in smokers (80% of COPD patients)
What are the symptoms of chronic bronchitis?
cough, sputum production, and dyspnea (on exertion or at rest)
- prolonged forced expiratory time (takes longer to get all air out)
- during auscultation: end-expiratory wheezes on forced expiration, decreased breath sounds, inspiratory crackles
- tachypnea, tachycardia
- cyanosis
- use of accessory muscles
- hyperresonance on percussion
- increase pulmonary hypertension with RVH, distended neck veins, hepatomegaly
- signs of corn pulmonate
How is chronic bronchitis diagnosed?
- clinical diagnosis: chronic cough, productive sputum > 3 months, at least 2 consecutive years
- PETs: FEV1/FVC ratio of less than 0.7
- CXR - low sensitivity, useful in an acute exacerbation to r/o pneumonia or pneumothorax
- peribronchial and perivascular markings
- increase HGB and increase HCT are common because of the chronic hypoxic state
- alpha-antitrypsin levels - FH premature emphysema?
- ABG - chronic pCO2 retention, decreased pO2
What is the treatment for chronic bronchitis?
- short-acting bronchodilators for mild disease
- long-acting bronchodilators +/- inhaled corticosteroids for moderate to severe disease
- ipratropium bromide is inhaled of choice for COPD
- smoking cessation and supplemental O2 (O2 is single most important medication in the long term)
- antibiotics for acute exacerbations
- flu and pneumococcal vaccines are a must
- surgery: lung resection vs transplant
What is emphysema?
a consequence of the destruction of alveolar space = pink puffers = the body’s natural response to decrease lung function is chronic hyperventilation
What are the characteristics of emphysema?
- elastase (protease) excess and overinflation (“pink puffers,” barrel chest, pursed lips)
- elastase - released from PMNs and macrophages, ingesting lung tissue (normally inhibited by alpha 1 antitrypsin)
- tobacco smoke - increase PMNs and macrophages, inhibits antitrypsin, and increases oxidative stress on the lung
What are the symptoms of emphysema?
minimal cough, quiet lungs, thin, barrel chest
- acute chest tightness
- worse in the morning
- clear to white sputum
- 50 y/o typical
- dyspnea (MC)
- wheezing
- tachypnea
- dyspnea with mild exertion
- cyanosis
- JVD
- atrophy of limb musculature
- peripheral edema
- “barrel chest” (2:1 anterior: posterior diameter)
- diffuse or focal wheezing
- diminished breath sounds
- hyperresonance to percussion
How is emphysema diagnosed?
pathologic diagnosis: permanent enlargement of airspaces distal to bronchioles due to the destruction of alveolar walls
- decreased DLCO
- PETs (spirometry): diagnostic FEV1/FVC <0.75
- FEV1 decreased
- total lung capacity (TLC), residual volume, FRC increased (indicates air trapping)
- vital capacity decreased - extra air that does come in is not useful - becomes residual volume (dead space)
- chest x-ray will reveal flattened diaphragm , hyperinflation, and small, thin appearing heart
- parenchymal bullae (sub pleural blebs) are pathognomonic
What is the tx of emphysema?
smoking cessation and home O2 are only interventions shown to lower mortality
- give steroids and antibiotics for acute exacerbations: increased sputum production or change in character or worsening SOB
- not responsive to bronchodilators
- IV methylprednisolone if hospitalized
- azithromycin or levofloxacin
- O2 >90%, nasal cannula
- NPPV: BiPAP or CPAP
- can lead to acute respiratory distress syndrome (ARDS)
- look for nocturnal hypoxemia; give CPAP or O2 as needed
What is the criteria for continuous or intermittent long-term O2?
- pao2 55 mmHg
- O2 saturation <88% (pulse oximetry) either at rest or during exercise
- Pao2 55 59 mm Hg + polycythemia or for pulomale
What are the characteristics of small cell lung cancer?
(15% of cases) (central mass) - 99% smokers, does not respond to surgery and metastases at presentation
- presents as recurrent pneumonia
- constitutional SX (advanced disease): anorexia, weight loss, weakness, cough
- location: central, very aggressive
What is small cell lung cancer associated with?
- superior vena cava syndrome (SCLC): obstruction of SVC by a mediastinal tumor, facial fullness, facial and arm edema, dilated veins over the anterior chest, arms, face; JVD
- phrenic nerve palsy - hemidiaphragmatic paralysis
- recurrent laryngeal nerve palsy - hoarseness
- horner syndrome: invasion of the cervial sympathetic change by apical tumor - unilateral facial anhidrosis (no sweating), ptosis, miosis
- malignant pleural effusion
- Eaton-Lambert syndrome (most common in SCLC): similar to myasthenia gravis (proximal muscle weakness/fatigue, diminished DTRs, paresthesias (lower extremity)
- digital clubbing
How is small cell lung cancer dx?
- CXR is most important for DX, but not used for screening
- CT chest with IV contrast (used for staging)
- tissue biopsy - determine the histology type (definitive)
- cytologic examination of sputum - DX central tumors, not peripheral lesions
- fiber-optic bronchoscopy - DX central tumors, not peripheral lesions PET scan
- transthoracic needle biopsy - suspicious masses, highly accurate for peripheral lesions
- mediastinoscopy - advanced disease
What is the tx of small cell lung cancer?
combination chemotherapy needed
- prognosis: limited: 10-13% 5-y survival
extensive: 1-3% 5-y survival
What are the types of non-small lung cancer?
- squamous cell
- large cell
- adenocarcinoma
What are the characteristics of squamous cell lung cancer?
(central mass) with hemoptysis 25-30% of lung cancer cases -location: central -may cause hemoptysis -paraneoplastic syndrome: hypercalcemia -elevated PTHrp
What are the characteristics of large cell lung cancer?
fasting doubling rates - responds to surgery rare (only 5%)
- location: periphery 60%
- paraneoplastic syndrome: gynecomastia
What are the characteristics of adenocarcinoma lung cancer?
most common (peripheral mass) 35-40% of cases of lung cancer
- most common
- associated with smoking and asbestos exposure
- location: periphery
- paraneoplastic syndrome: thrombophlebitis
What is the tx of non-small cell lung cancer?
- can be treated with surgery
- treatment depends on staging
- stage 1-2 surgery
- stage 3 chemo then surgery
- stage 4 palliative
What is the tx of small cell lung cancer?
can not be treated with surgery will need chemotherapy
What are the associated manifestations with lung cancer?
- superior vena cava syndrome (facial/arm edema and swollen chest wall veins)
- pancoast tumor (shoulder pain, Horner’s syndrome, brachial plexus compression)
- Horner’s syndrome (unilateral miosis, ptosis, and anhidrosis)
- carcinoid syndrome (flushing, diarrhea, and telangiectasia)
What is community-acquired pneumonia?
(pneumococcal pneumonia) - immunocompetent
-occurs outside of the hospital or within 48 hour of hospital admission in a patient not residing in a long-term care facility
MCC: S. pneumonia (2/3), haemophilus influenza, mycoplasma pneumonia, S. aureus, N. meningitides, M. catarrhalis, K. pneumonia, other GNR
-viruses: influenza, RSV, adenovirus, parainfluenza virus
What are the risk factors for pneumonia?
advanced age, alcoholism, tobacco use, comorbid medical conditions (asthma, COPD)
- acute or subacute onset of fever
- gradual onset cough with or without sputum production
- shortness of breath on exertion
- others: sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia , headache, abdominal pain
- signs: fever or hypothermia, tachypnea, tachycardia, O2 desaturation, inspiratory crackles, and bronchial breath sounds, dullness to percussion
How is pneumonia dx?
- CXR: patchy airspace opacities to lobar consolidation with air bronchograms to diffuse alveolar or interstitial opacities
- not necessary in outpatient because empiric therapy is effective
- recommended if unusual presentation, history, or inpatient
- CT chest is more sensitive or specific
What are the labs for pneumonia?
- sputum gram statin and sensitivity - not sensitive or specific for S. pneumonia
- Urinary Ag test for S. pneumoniae and legionella is as sensitive/specific as gram stain and is readily available
- rapid Ag test for flu is sensitive, not specific
- pre-antibiotic sputum and blood cultures two sticks at separate sites
- CBC and CMP, LFTs, bilirubin
- ABG in hypoxemic patients
- HIV testing in at risk patients
- HIV testing in at-risk patients
- procalcitonin - released by bacterial toxins and inhibited by viral infections
How can pneumonia be prevented?
- pneumovax 23
- prevnar 13
- 65+ and immunocompromised give both, or any chronic illness with increased risk of CAP
- immunocompromised patents at high risk should get single revaccination of 23 6-y after the first dose, regardless of age
- immunocompetent and 65+ y get the second dose of 23 if first received vaccine 6+ y ago (<65)
- influenza: age 65+, residents of LTCF, pulmonary or CV disease, chronic metabolic disorder, or health care worker
What are the characteristics of Nosocomial pneumonia?
Pathogens: S. aureus, K. pneumoniae, E.coli, Pseudomonas aeruginosa
- required at least 2 of the following: Fever Leukocytosis Purulent sputum
- CXR: new or progressive parenchymal opacity
- blood cultures x 2 CBC and CMP
- sputum culture an gram stain
- ABG, thoracentesis if there is an effusion
- procalcitonin
What is outpatient tx of community-acquired pneumonia?
duration of treatment: 5 day minimum or until afebrile x 48-72 hours
- macrolide clarithromycin 500 mg PO BID or azithromycin 500 mg PO first dose, then 250 mg PO daily x 4 day
- doxycycline 100 mg PO BID
What are the pathogens that cause community-acquired pneumonia?
S. pneumoniae, M. pneumoniae, C. pneumoniae, respiratory viruses: flu
What is the tx of community-acquired pneumonia for a pt that is at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?
Respiratory FQ: moxifloxacin 400 mg PO daily, levofloxacin 750 mg PO daily
-macrolide plus beta lactam (HD amoxicillin 1 g PO TID or augmentin 2 g PO BID)
What is the tx of community-acquired pneumonia for smokers?
cefdinir
What are the pathogens that cause inpatient, non-ICU community-acquired pneumonia?
S. pneumonia, Legionella, H. influenzae, Enterobacteriaceae, S. aureus, pseudomonas
What is the tx of community-acquired pneumonia for inpatient, non-ICU pts?
respiratory FQ: IV levofloxacin 750 mg daily or IV ciprofloxacin 400 mg q 8-12 hours
What is the tx of community-acquired pneumonia for inpatient, non-ICU pts that are at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?
At risk for pseudomonas:
IV macrolide plus IV beta-lactam
(HD ampicillin 1-2 g q 4-6 h or cefotaxime 1-2 g q 4-12 h or ceftriaxone 1-2 g q 12-24 h)
What are the pathogens that cause community-acquired pneumonia that are hospitalized or ICU pts?
S. pneumoniae, legionella, H. influenzae, Enterobacteriaceae, S. aureus, pseudomonas
What is the tx of community-acquired pneumonia for pts that are hospitalized or ICU pts?
duration 5-day minimum or until afebrile x 48-72 h
-azithromycin or respiratory FQ (moxifloxacin, levofloxacin) plus anti-pneumococcal beta-lactam: cefotazime, caftriaxone, UNASYN
What is the tx of community-acquired pneumonia for pts that are hospitalized or ICU pts that are at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?
-antipneumococcal and antipseudomonal beta-lactam: zosyn, cefepime, imipenem or meropenem plus ciprofloxacin or levofloxacin
or
-antipneumococcal beta-lactam (cefotazime, ceftriaxone, UNASYN) plus aminoglycoside (gentamicin, tobramycin, amikacin) plus azithromycin or respiratory FQ)
-if at risk for MRSA: add vancomycin or linezolid 600 mg BID
What are the pathogens that cause nosocomial pneumonia?
S. aureus, K. pneumoniae, E. coli, Pseudomonas aeruginosa
What is the tx of nosocomial pneumonia?
one of the following
- ceftriaxone 1-2 g IV q 12-24 h
- moxifloxacin 400 mg PO or IV
- levofloxacin 750 mg PO or IV
- ciprofloxacin 400 mg IV q 8-12 h
- UNASYN 1.5-3 g IV q 6 h
- Zosyn 3.375-4 mg IV q 6 h
- Ertapenem 1 g IV daily
What is the tx of nosocomial pneumonia for pts that are at risk for resistance: Abx last 90 days, age >65, immunosuppression, comorbid illness?
One agent from each:
Antipseudomonal
-cefepime 1-2 g IV BID or ceftazidime 1-2 g IV q 8 h
-imipenem 0.5 - 1 g IV q 6-8 h or meropenem 1 g IV q 8 h
-Zosyn 3.375-4.5 g IV q 6 h
-PCN allergy: aztreonam 1-2 g IV q 6-12 h
Second antipseudomonal
-levofloxacin 750 mg IV daily or ciprofloxacin 400 mg IV q 8-12 h
-IV gentamicin, tobramycin, amikacin
MRSA coverage
-IV vancomycin
-linezolid
What are the characteristics of obstructive sleep apnea?
irregular breathing and snoring patters which
- occurs at night due to reduced tone in muscles around the airway making them unable to support the weight of the parapharyngeal tissue
- obesity is the leading risk factor for obstructive sleep apnea
- aggravated by ingestion of ETOH or sedatives before sleeping, nasal obstruction (eg, cold)
- can occur in children due to adenotonsillar hypertrophy
What are the signs and symptoms of obstructive sleep apnea?
Hx of loud snoring -witnessed cyclical snoring, restlessness, thrashing of extremities during sleep
- apnea - cessation of breathing
- fatigue, interrupted sleep, and excessive daytime sleepiness
- nocturia + insomnia
- personality changes, poor judgment, memory impairment, inability to concentrate
- other: depression, hypertension, headaches worse in AM, impotence
- signs: appears sleepy narrow oropharynx, excessive soft tissue folds, large tonsils, pendulous uvula, large tongue deviated nasal septum “bull neck” appearance
How is obstructive sleep apnea dx?
polysomnography
Five or more predominantly obstructive respiratory events per hours of sleep (for polysmnography) or recording time (for HSAT) in a patient with one or more of the following
- sleepiness, non restorative sleep, fatigue, or insomnia symptoms
- waking up with breath-holding, gasping, or choking
- habitual snoring, breathing interruptions, or both noted by a bed partner or other observer
- hypertension, mood disorder, cognitive dysfunction, coronary artery disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus
- fifteen or more predominantly obstructive respiratory events per hour of sleep (for polysomnopgraphy) or recording time (for OCST), regardless of the presence of associated symptoms or comorbidities
What is the treatment for obstructive sleep apnea?
Weight loss and continuous positive airway pressure devices (CPAP)
- alternative treatments include positional therapy, mandibular advancement devices, and surgical interventions
- only 75% use after 1 year
- if O2<90% switch to BiPAP (higher pressure during inspiration, lower pressure during expiration)
- if both ineffective, add O2 therapy UPPP - works in 50%
What are the characteristics of tobacco use/dependence?
- cigarette smoking causes transitional cell carcinoma of the bladder
- a heavy smoker who smokes 2 packs per day for 20 years will lose 14 years of life
- binds nicotinic receptor in CNS causing the release of dopamine (reward - increase pleasure, attention, mental processing, and working memory), acetylcholine, and glutamate
- inhibits GABA inhibition - increase GABA
- increase BP, HR, cardiac contractility, GI tract activity, and decreases muscle tone
- metabolized by the liver, the half-life of nicotine 1-2 hours so must smoke every 1-2 hours
What is the tx of tobacco use/dependence?
Smoking cessation
-70% want to quit, 50% try to quit, and only 5% do quit
-withdrawal begins within 2 hours and peaks with 1-2 days may feel awful for months after the last cigarette
First-line
-varenicline (chantix) - best efficacy
-bupropion SR (Wellbutrin, zyban)
-nicotine replacement therapy (NRT) - recommended for inpatient use
-support
Second-line
-nortriptyline and clonidine
-cognitive-behavioral therapy for every patient
-most relapses occur within the first 3 mo of quitting 35-40% relapse between 1-5 y after quitting
-recommend follow up after starting medication in 1-2 wk to monitor for adverse effects and provide reinforcement
What are the characteristics of the patch?
starting on quit day
- if >10 cigarettes/day use the highest dose (21 mg/d) x 6 wk, then 14 mg/d x 2 wk, then 7 mg/d x 2 wk
- apply new patch each morning to non hairy skin site, remove and replace next morning
- rotate daily to avoid skin irritation
- remove at bedtime to avoid vivid dreams and insomnia, if experienced
What are the characteristics of gum (nicorette)?
- 4 mg dose recommended for 25+ cigarette/day smokers
- chew the gum whenever an urge to smoke arises
- one piece of gum every 1+/- 2h x 6 wk, for 3 mo total duration
- avoid acidic beverages before and during use (coffee, carbonated beverages) - lowers oral pH causing nicotine to ionize and reducing nicotine absorption
- side effects related to vigorous chewing (excess nicotine release)
What are the characteristics of lozenges?
- resembles a “tic-tac”, dissolves rapidly and delivers nicotine more rapidly
- 4 mg dose for smokers who smoke within 30 min of waking up; 2 mg for all other smokers
- similar dosing schedule to gum, maximum 5 lozenges every 6 h or 20/d
- place in mouth and dissolves over 30 min, no chewing necessary
What are the characteristics of chantix?
partial agonist at alpha4beta2 subunit of the nicotinic acetylcholine receptor
- binds to and produces partial stimulation of the alpha4beta2 nicotinic receptor, reducing symptoms of withdrawal
- binds to alpha4beta2 subunit with high affinity, blocking nicotine in tobacco smoke from binding to the receptor, reducing the reward aspects of cigarette smoking
What is the administration of Chantix?
- quit smoking 1 wk after starting medciation (stable blood levels achieved)
- 0.5 mg daily x 3 d, then 0.5 mg BID x 4 d, then 1 mg BID up to 12 wks
- risk of nauses minimized by taking with food and a full glass of water, or by increasing dose
- abnormal dreams can be reduced by taking the evening dose of Chantix earlier in the day, lowering the dose or skipping evening dose
What are the characteristics of Bupropion?
enhanes central nervous system nonadrenergic and dopaminergic release
- safe for use in patients with stable CVD or COPD
- good choice for patients concerned about post-cessation weight gain or with comorbid depression
- approved for use in pregnancy (first or second-line)
- safe for adolescents (not the first line, limited data)
What is the administration of Bupropion?
- takes 5-7 d to reach steady-state blood levels
- start one week prior to quit-date
- 150 mg/d x 3 d, 150 mg BID thereafter at least 12 wks
What is tuberculosis?
a disease caused by bacteria called Mycobacterium tuberculosis (acid-fast bacilli)
- presentation: fatigue, productive cough, night sweats, weight loss, post - tussive rales
- RF: endemic area, immunocompromised (HIV), recent immigrants (<5 y/o), prisoners, healthcare workers
- transmission: inhalation of aerosolized droplets
What is the screening of tuberculosis?
screening with tuberculin skin test (TST) or interferon-gamma release assays IGRAs
What are the Mantoux test rules?
test if positive if induration
- > 5 mm at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
- > 10 mm in patients age <4 or some risk factors = hospitals and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
- > 15 mm if there are no risk factors
How is tuberculosis dx?
with sputum for AFB smears and mycobacterium tuberculosis cultures - have to be 3 AFB negative
- NAAT helps diagnosis better and sooner
- CXR: cavitary lesions, infiltrates, goon complexes in the apex of the lungs
- biopsy = caveating granulomas
- military TB = spread outside lungs = vertebral column: Pott disease; scrofula (TB to cervical lymph nodes)
What is the tx of tuberculosis?
start empiric treatment in those who likely have it
- PPD positive + CXR negative: latent TB = isoniazid for 9 months (+B6 to prevent neuropathy)
- PPD positive + CXR positive: active TB = Quad therapy (RIPE): rifampin, isoniazid, pyrazinamide, ethambutol - all are hepatotoxic
Four drugs x 8 weeks (RIPE) then two drugs x 16 week (RI)
- rifampin - red-orange urine, hepatitis
- isoniazid - peripheral neuropathy (B6 = pyridoxine 25-50 mg/day)
- pyrazinamide - hyperuricemia (gout)
- ethambutol - optic neuritis (eye changes), red-green blindness
What is needed for therapy cessation of tuberculosis?
patients with active TB will need two negative AFB smears and cultures in a row negative for therapy cessation
- prophylaxis for household members = isoniazid for 1 year
- D/C therapy if transaminases > 3-4 x ULN
- Pt’s on INH should take supplemental Vitamin B6 (pyridoxine 25-50 mg/day) to prevent neuropathy
What should you monitor during tuberculosis tx?
monitor serum creatinine, take meds on empty stomach since food can reduce absorption, watch for hepatotoxicity, aware of drug interactions especially with HIV meds
