Pulmonary - ALL Flashcards
47% of adults have at least one of what 3 conditions?
Uncontrolled HTN
Uncontrolled high LDL
Currently smoking
What three things lead to a improved outcome for a patient?
Informed activated patient
Prepared proactive practice team
Productive interactions
What are major components of a delivery system design?
Health literacy!
Define roles/tasks
Provide clinical case management
What is the definition of the chronic care model?
An organizing framework for improving chronic illness care and an excellent tool for improving care at both the individual and population level
What are the 4 roles of the community in the chronic care model?
Mobilize community resources to meet pts needs
Encourage pts to use programs
Form partnerships with orgs to support and develop serves that fill gaps
Advocate for policies to improve pt care
Who gets screened for diabetes? What is considered positive (aka diabetic)?
Ages 40-70 who are overweight or obese HbA1c >6.5 Fasting glucose >126 Anytime glucose > 200mg/dL 2 hour glucose > 200/dL during 75g oral glucose test
Who gets screened for lung cancer? How?
Ages 55-80 who have 30pk/year history and still smoke or stopped within last 15 years
Low dose CT with contrast
What gets a breast cancer screen according to the American Cancer Society?
Women ages 40-44 choice
Women ages 45-54 - mam every year
Women 55+ have choice to do it every year
High risk (BRCA+, FDR BRCA+ and pt not tested, or >20-25% lifetime risk - MRI and mammogram every year)
Who gets screened for a colonoscopy? How? What population must start at 45? Who else may start early?
Ages 50-75
Colonoscopy
African Americans
FDR <60 with it, start 10 years before diagnosis or at 40, whichever comes first
Who gets screened for osteopososis? How?
Women >65
DEXA scan
What are the three most common causes of chronic cough in non-smokers, no ACE-I, and normal CXR?
Post-nasal drip
Asthma
GERD
If history and physical exam of cough >3 weeks do not point to one of the top three causes, what do you order?
CXR
If a person with cough >3 weeks has purulent sputum, is a smoker, or is on an ACE, what do you do?
Treat accordingly
Is dyspnea a diagnosis?
No, it is just a symptom
When does giving supplemental oxygen improve longevity in COPD?
If sat <90% or PaO2 <60
After giving someone an inhaler after an abnormal spirometry, when should they follow-up? What should you do at the follow-up?
1 month
Repeat spirometry
Should you ever use the interpretation given on a spirometry print out?
No
What is FEV1, FVC, and the FEV1/FVC ratio in obstructive disease?
FEV1 < 80%
FVC < 80%
Ratio < 70%
What is FEV1, FVC, and the FEV1/FVC ratio in restrictive disease?
FEV1 < 80%
FVC < 80%
Ratio > 70% (close to 100%)
What is FEV1, FVC, and the FEV1/FVC ratio in mixed obstructive and restrictive disease?
FEV1 < 80%
FVC < 80%
Ratio > 70% (close to 70% but still greater than)
What are the requirements for asthma during bronchodilator reversibility testing?
Increase in FEV1 >200ml AND 12% above pre-bronchodilator FEV1
What is the methacholine challenge? How is it positive
Gold standard for asthma diagnosis
>20% in FEV1 after administering methacholine
Before performing a pulmonary function test, how long should SABA, LABA, SAMA, LAMA, and caffeine/smoking be withheld for?
SABA - 6 hours LABA - 12 hours SAMA - 6 hours LAMA - 24 hours caffeine/smoking - 30 minutes
What are the 4 different types of hypoxia?
Hypoxic
Hyperemic
Circulational
Histotoxic
What is the definition of hypoxic hypoxia? What is the A-V PO2 difference compared to normal? What are causes?
Low PaO2 when Hb and rate of blood flow are normal
A-V - less than normal
Low ventilation, low PO2 inspired air, altitude, defect in gas exchange surfaces, shunts
What is the definition of hyperemia hypoxia? What is the A-V PO2 difference compared to normal? What are causes?
Low hemoglobin concentrations
A-V - normal
Anemia, CO poisoning
What is the definition of circulational hypoxia? What is the A-V PO2 difference compared to normal? What are causes?
Low or slow blood flow
A-V - greater than normal
Hemorrhage, cardiac pump failure
What is the definition of histotoxic hypoxia? What is the A-V PO2 difference compared to normal? What are causes?
Normal PaO2 but tissues can’t accept oxygen
A-V - less than normal
CN poisoning
What are symptoms of hypoxia? (RAT BED, FINES (peds))?
Early - restlessness, anxiety, tachycardia
Late - bradycardia, extreme restlessness, dyspnea
Peds - feeding difficulty, inspiratory stridor, nasal flares, expiratory grunting, sternal retractions
What are treatments for hypoxia?
CPAP, BiPAP
Mechanical ventilation
Treat underlying disease
How do you calculate if someone is in acute or chronic respiratory acidosis?
§ Acute: Every 10+ pCO2 -> HCO3 should +1 and pH decrease by .08 - MEMORIZE
Chronic: Every 10+ pCO2 -> HCO3 +4 and pH decrease by .03
How do you calculate if someone is in acute or chronic respiratory alkalosis?
§ Acute: Every 10- pCO2 -> HCO3 should -2 and pH increase by .08 - MEMORIZE
Chronic: Every 10- pCO2 -> HCO3 -5 and pH increase by .03
How do you calculate if someone is in metabolic acidosis (Winter’s formula)?
§ Winter’s Formula: pCO2 = 1.5(HCO3) + 8 (+/-2)
How do you calculate if someone is in metabolic alkalosis?
Every 10+ in HCO3, pCO2 increases by 6
How can you tell if someone has an additional respiratory acidosis on top of a metabolic acidosis?
If serum pCO2 (from CMP) > expected pCO2 (Winter’s formula) -> additional respiratory acidosis
How do you calculate an anion gap?
Uan-Ucat = Na-(Cl+HCO3)
What are common diagnoses of anion-gap metabolic acidosis? (MUDPILERS)
Methanol Uremia Diabetic ketoacidosis, starvation ketoacidosis, EtOH ketoacidosis Paraldehyde INH, iron toxicity Lactic acidosis Ethylene glycol Rhabdomyolysis Salicylates
What can cause a falsely low anion gap?
Low albumin (since albumin is protein, which is an anion in blood)
What two things must you need to get spirometry on someone you suspect of having COPD?
Symptoms - dyspnea, etc
History of exposure to risk facors (Smoke, occupational, environmental tobacco, air pollution, aging, others)
What is the difference between blue bloaters and pick puffers?
Blue bloaters - barrel chest - goblet cell hyperplasia
Pink puffers - thin, keketic, shoulders elevated - emphysema
What does FEV1 determine for COPD?
Severity
What are the GOLD guidelines for COPD? (assess airflow limitation)
Mild - FEV1 > 80% predicted
Moderate - 50% < FEV1 < 80% predicted
Severe - 30% < FEV1 < 50% predicted
Very Severe - FEV1 < 30% predicted
What are the 4 (A, B, C or D) grades for COPD?
A - Few symtpoms, no hospital required exacerbations
B - More symptoms, no hospital required exacerbations
C - Few symptoms, >=1 hospital required exacerbation
D - More symptoms, >=1 hospital required exacerbation
How do you treat each grade of COPD?
A - SAMA or SABA
B - LAMA or LABA
C - ICS + LABA or LAMA
D - ICS + LABA and/or LAMA
What are the requirements for pulmonary rehabilitation for COPD?
Symptomatic patient + FEV1 <50% + spirometry in last 2 weeks
What is the most severe allele form of alpha 1 anti-trypsin?
ZZ
What three things can decrease mortality in COPD?
Smoking cessation
O2 therapy (when SpO2 <88)
Lung volume reduction surgery
What is the most common cause to lead to an acute COPD exacerbation?
Viral infection - rhinovirus
Which class of drugs for COPD exacerbation do not speed resolution? What do they do instead?
LABA - improve patient/doctor perception
What are the two indications for non-invasive positive pressure ventilation during an AECOPD?
pH <7.35
Hypercapnea - PaO2 > 45
How long should steroids be used in an AECOPD?
10 days (no more than 2 weeks)
During an AECOPD, what steroid do you give someone in respiratory failure? Non-respiratory failure?
Failure - solumedrol
Non-failure - prednisone
Do you give antibiotics in an AECOPD? If so, which one?
Yes, doxycycline or azythromycin
Besides trouble sleeping at night, what symptom must you have in order to have insomnia?
Daytime impairment
What are the differences between central sleep apnea and OSA?
Central - brain fails to signal respiratory muscles
OSA - respiratory effort, but no airflow detected
What are the three cardinal symptoms of OSA? (3 S)
Snoring, sleepiness, significant
What is the gold standard to diagnose sleep apnea? What classifies it?
Polysomnography
AHI or RDI > 15 events per hour
> 5 events per hour plus symptoms
What is the only lab useful when trying to diagnose OSA?
TSH - must rule out hyperthyroidism
What is the gold standard treatment for OSA?
CPAP
When might BiPAP be helpful when treating OSA?
If patient has COPD
What is the gene mutation associated with CF?
CTFR - 7q (DeltaF508 caucasian descent)
What are the two steps to diagnose CF?
Step 1 - phenotype feature (chronic sino-pulm disease, nutri. deficiencies, male urogenital, Na depletion), CF in sibling, OR + newborn screen
Step 2 - Sweat Chloride Test
What is considered a positive Sweat Chloride test? Intermediate?
> 60 - abnormal CF
Intermediate - 40 < value <60
If Sweat Chloride Test is intermediate (40-60) or <39 with high suspicion, what can be done to rule in/out CF?
23-panel ACMG DNA testing
What are common clinical manifestations of CF?
Malabsorption with steatorrhea
Fat soluble vit. deficiencies
Nasal Polyps and clubbing of nails
What is bronchiectasis?
Irreversible dilaation of the cartilage containing airways
What i s considered a good sputum culture in CAP?
> 25 neutrophils, <10 squamous cells
What infection often proceeds CAP? What gene does i contain that leads to necrotizing pneumonia, abscesses, and empyema due to MRSA?
Influenza
Panton-LValentine leukocidin (PVL)
What is the best way to obtain a sputum sample from someone on a vent? How many colonies are needed?
Protected specimen brush - 10^3
What intervention (or lack thereof) leads to increased mortality in VAP?
Initial treatment with ineffective antibiotic therapy
What is SMART-COP? What is positive? What does it tell you?
> =3 = 92% chance patient will need intensive support
○ S: Low Systolic BP - 2
○ M: Multilobar chest-x-ray involvement - 1
○ A: Low Albumin Level - 1 (acute phase reactant, goes down, sign of infection)
○ R: High Respiratory Rate - 1
○ T: Tachycardia - 1
○ C: Confusion - 1
○ O: Poor Oxygenation - 2
P: Low Arterial pH - 2 (metabolic acidosis)
What is CURB-65? What is positive? What does it tell you?
○ C: Confusion ○ U: Urea > 7mmol/L ○ R: Respiratory Rate > 30/min ○ B: BP; systolic <90 or diastolic <60 ○ 65: Age > 65 ○ >2 = hospital >=3 =ICU
What are the only two lung bacteria that can cross fissures?
Actinomyces and Klebsiella
What is the difference between aspiration pneumonitis and aspiration pneumonia?
Pneumonitis - chemical irritation, can lead to…
Pneumonia - infectious, occurs 48-72 hours after aspiration
What treatment is required for an empyema?
Surgical drainage
If legionella is suspected, what test must be ordered?
Urine antigen test
What disease are Levinthal-Coles-Lillie Bodies seen in?
Psittacosis
They are bodies contained in macrophages
What cell predominates in the airways in asthma?
Eosinophils
What is the most common symptom of asthma?
Cough (night)
What are 5 signs of an acute asthma exacerbation?
Accessory muscles of respiration Pulse >110 Inability to speak Peak flow/SaO2 diminished RR >25-30 b/min
What are the three mainstays of treatment for AECOPD?
SABA
Corticosteroids
Antiobiotics
What is intermittent asthma? How is it treated?
<=2 days/week of day symptoms
<=2 x/month night awakeness/symtoms
SABA
What is mild asthma? How is it treated?
> 2 days/week of day symptoms
3-4 x/month night awakeness/symtoms
Low dose ICS
What is moderate asthma? How is it treated?
daily day symptoms
>1x/week night awakeness/symtoms
Low dose ICS + LABA OR med dose ICS OR Med dose ICS + LABA
What is severe asthma? How is it treated?
Often 7x/week night awakeness/symptoms
High dose ICS + LABA OR High dose ICS + LABA + oral steroid
If a bronchoalveolar lavage brings up milky fluid, what is the diagnosis?
Pulmonary Alveolar Proteinosis (surfactant)
Does decrease DLCO indicate severity in interstitial lung diseases?
No
What is the most common cause of idiopathic interstitial pneumonia?
Idiopathic pulmonary fibrosis
What is the treatment for idiopathic pulmonary fibrosis?
Lung transplant
What is the most common granulomatous disorder of interstitial lung disease? How is it treated?
Sarcoidosis
Steroids
What do you think if you see hilarlymphadenopathy and elevated ACE level?
Sarcoidosis
What interstitial lung disease is primarily in women of child bearing age and is actually considered an obstructive disease?
Lymphangioleimyomatosis (LAM)
Where does LAM fibrose, causing it to be an obstructive disease?
Fibrosis small to medium size airways
What are two presentations of LAM?
Spntaneous pneumothorax
Chylous effusions
What is the only treatment for LAM?
Lung transplant
What is the most common test done to look for interstitial pulmonary fibrosis? What is gold standard?
High resolution CT - most commonly done
Biopsy - GOLD standard
What are three common symptoms of interstitial pulmonary fibrosis?
Dyspnea
Fatigue
Weightloss
What imaging study should be ordered first for a pleural effusion? What next?
CXR
Ultrasound!!
What are the three most common causes of a transudative effusion?
CHF, Hepatic hydrothorax, nephrotic syndrome
What is the most common cause of an exudative pleural effusion?
Pneumonia
What are Light’s Criteria?
Measure serum (blood) and pleural fluid protein and LDH ◊ PF protein/serum protein > .5 = exudate ◊ PF LDH/serum LDH >.6 = exudate PF LDH > 2/3 upper limit of normal serum LDH = exudate
What is the imaging of choice for a pneumothorax?
CXR
How much air does it take to see a pneumothorax on upright? On lateral decubitis?
50cc - upright
5cc - lateral decubitis
What are 6 risk factors for a DVT?
Immobilization REcent surgery Malignancy Obesity - independent! Oral contraceptives Coagulopathies (Factor V leiden)
What is Virchow’s Triad for DVTs?
Endothelial damage
Venous Stasis
Hypercoagulable state
What imaging is run for DVTs? Gold standard?
Ultrasound - most often
Venography - GOLD standard
If a DVT ultrasound is negative but you highly suspect a DVT, what should you do?
Repeat ultrasound
What is the treatmet for DVT? What should it be bridged with?
Wafarin
Bridge with Heparin
What are the three treatment timelines for given DVTs?
First DVT and reversible cause - 3 months
Idiopathic DVT - 6 months
Recurrent DVT - lifetime
Who should get DVT prophylaxis?
All pts
What is the GOLD standard imaging for a PE?
CT with contrast
What can be seen on EKG that can indicate right ventricular stain and possible indicate a PE?
S1Q3T3
What is different for treating a PE than a DVT?
use of tPA
What bacteria is associated with Silicosis?
Mycobacterium kansaii
When do you see ferruginous bodies?
ASbestosis lung disease
What lung disease is associated with exposure to flurescent light bulbs?
Berylliosis
What environmental lung disease is worse on Mondays and better throughout the week?
Byssinosis
What two populations are at increased risk for TB?
HIV and children under 5
Before giving biologics, what bacteria must you test for?
TB
What is considered a positive Mantoux TB test? (3 groups)
5mm for IC
10mm for healthcare workers
15 for people with low risk
Measure height! Not erythema
How can TB be checked for in people who have received the BCG vaccine or cannot come back to have their skin test checked in 48-72 hours?
Interferron gamma blood test
How is sputum for a TB culture obtained for most people? Children?
Spontaneous - most people
Gastric lavage - children
To not have TB, how many negative sputum tests do you need?
3
What is the treatment algorithm for active TB?
4 drugs for 2 months - RIPE
If negative sputum at 2 months, continue R and I for 4 months
If positive sputum and cavitating lesion or HIV, continue R and I for 7 months
If positive sputum but no HIV or cavitating lesion, continue R and I for 4 months
Where is adenocarcinoma usually located in the lung? Squamous? Small cell?
Adeno - outside
Squamous and Small cell - central
What is the gold standard diagnosis for lung cancer?
Biopsy
What are the two times to do a PET scan?
Growing nodule on serial CT or if performing surgery on stage 1 cancer to ensure no other lesions present
What are Eaton-Lambert, SIADH, and Cushing associated with?
Small cell lung cancer
Which lung cancer should you give Bevacizumab?
Adenocarinoma
