Pulmonary Panre Flashcards
Pathophysiology of Asthma?
Obstruction, hyperactivity and inflammation; Chronic inflammatory disease o Reversible: § bronchial constriction § bronchial edema § ↑# goblet cells § smooth muscle hypertrophy § airway remodeling o Mucous plugging
what is the arterial blood gas changes in asthma?
initially pH ↑and pCO2 ↓during labored breathing
§ when patients worsen (i.e. fatigue), pH ↓and pCO2 ↑
What is asthma? Trigger?
diffuse inflammation of airways cause by different triggers such as allergens respiratory irritants (eg. air
pollution), infections, exercise, emotional stress, GERD & aspirin (triad: asthma,
aspirin sensitivity & nasal polyps) [Samter’s triad), leading to airway hypersenstiivty & partially/or completely (reverservible) bronchoconstriction
How is asthma dx?
Clinical & PFTS, FEV 1 & ↓ FEV 1 /FVC ratio(if improvement of 15% increased and PEFR 20% improvement post bronchodilator); Decreased FEV1/FVC (75-80%)
> 10% increase of FEV1 with bronchodilator therapy
hilar lymphadenopthy differential dx?
Young female = Sarcoidosis
Young kid with a fever, from Ohio, zoo keeper = histoplasmosis
Old guy in his 60’s works on ceramics = Berylliosis”
what is sarcoidosis?
systemic granulomatous disease that is characterized by noncaseating granulomas that may affect multiple organ systems (increase amount noncaseating granulomas in different organs)
Sarcoidosis MC in ? Age onset?
Northern Europeans and African Americans; persons ages 20 to 40 years
CM of sarcoidosis
50% asymptatmatic. 1. Pulmonary-dry, cough, sob, chest pain 2. HIlar Lymphadenopathy fever 3. Skin-ERTYHEMA NODUSM & LUPUS PERNIO (pathognomonic) 4. Anterior Uveitis (inflammation of its ciliary body) 5. weight loss, 6. arthralgias,(erythema nodosum (more commonly seen in Europeans) )
Hall mark finding of cxr of sarcoidosis
mEDIASTINAL LYMPHADENOPATHY seen on chest radiograph is the hallmark finding in 90% of cases; +/- eggshell nodal calcifications
Dx of sarcoidosis?
- Noncaseating granolas classic nonspecific histological finding, Restricve pattern of PFT ; hypercalcemia and ACE levels 4 x normal
ESR is often elevated
Tx of sarcoidosis
ptomatic patients consists of CORTICOSTEROIDS, methotrexate, and other immunosuppressive medications if steroid therapy is not helpful
90% of cases are responsive to corticosteroids and can be controlled with a modest maintenance dose
Ace Inhibitors for periodic hypertension
leading cause of death for sarcoidosis .
pulmonary fibrosis
What is severe asthma & status asthmaticus?
inability to speak in full sentences, PEFR <40%, altered mental status, pulses paradoxes (inspiratory decrease XBP >10), cyanosis, tripod position, silent chest, tachycardia
What is gold standard exam for asthma
PFT
What is the best & most objective way to assess asthma, excaberation severity & pt response in ED
Peak Expiratory Flow rate (PEFR)
Methylxanthines MOA? EX?
Theophylline, Bronchodilator that improves respiratory muscle endurance • Strengthens diaphragm contractions
Methylxanthines Indications?
Long term asthma
prevention
Methylxanthines s/e?
N/V • Anxiety • Diarrhea • Headache • Toxicity causes arrhythmias, seizures
Theophylline special considerations?
Not often used due to limited therapeutic index • Must monitor blood levels • Higher doses needed in smokers • Lower doses needed in CHF
Monoclonal
antibody ex? MOA?
Omalizumab, Binds to IgE receptors on cells associated with allergic response • ↓ IgE in serum
Monoclonal
antibody Indications?
Severe, uncontrolled asthma • Useful in asthma triggered by known allergens
Monoclonal
antibody Adminstration?
SC q 2-4
Monoclonal
antibody s/e?
Headache
Monoclonal
antibody CI?
- Acute bronchospasm
* Status asthmaticus
Leukotriene receptor
antagonists MOA?
Inhibits leukotriene binding to its receptors • ↓ airway inflammation
Leukotriene receptor
antagonists Indicatins?
Useful in patients
with allergic rhinitis or
aspirin-induced asthma
Leukotriene receptor
antagonists Adminstration
PO
• Good for kids who
have trouble with
inhalers
Leukotriene receptor
antagonists s/e
Headache
• Gastritis
Most common pathogen in all age groups, settings & geographic regions for bacteria pneumoniae?
Streptococcus pneumoniae
Community-acquired pneumonia (CAP) ? Organisms?
Limited or no contact with medical settings
■ Organisms: S. pneumoniae, Haemophilus influenzae , atypical bacteria
( Chlamydia, Mycoplasma, Legionella
Hospital-acquired pneumonia (HAP) & ventilator-associated pneumonia
(VAP) [nosocomial pneumonias) develops?
Develops ≥ 48 hrs after hospital admission (HAP) or after
endotracheal intubation and ventilator (VAP) use, respectively; ↑ risk of multidrug resistant infections
Hospital-acquired pneumonia (HAP) & ventilator-associated pneumonia
(VAP) [nosocomial pneumonias) organisms?
AEROBIC GRAM-NEGATIVE BACILLI ( Escherichia coli, Klebsiella
pneumoniae, Enterobacter species, pseudomonas aeruginosa ) &
GRAM-POSITIVE COCCI ( Staphylococcus aureus [including
methicillin-resistant S. aureus (MRSA), Streptococcus species )
Aspiration pneumonia:
Usually develops in pts with ↓ ability to clear oropharyngeal
secretions (eg. ↓ cough or gag reflex, impaired swallowing)
■ Organisms: similar to CAP/HAP plus anaerobes (eg. Bacteroides )
Strep pneumoniae GRAM STain, sputum
MC cause of CAP, Gram stain: GRAM + COCCI IN pairs, RUST-COLORED SPUTUM ‘ common in patients with splenectomy
klebsiella common in? gram stain? sputum?
Alcoholics, debiliated chronic illness aspirators, GRAM NEGATIVE RODS (BACILLI), currant jelly sputum
Haemophilus influenza common in ? s/s? gram stain? X-ray results?
COPD smokers elderly,gradual onset fever, dyspnea, chest
pain; CXR with patchy infiltrates/pleural effusion; GRAM-NEGATIVE ENCAPSULATED
COCCOBACILLUS
Legionella commonly found in ? symptoms include? associated with what type heart rhythm ? gram stain
outbreaks with air condition, aerosolized water, low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever, increase LFTs ; bradycardia ; (no person to person contact) intracellular GNR (lives in aquatic environment)
Pseudomonas found in what population? environment? Xray results? gram stain?
patients invaded by plastic (think nursing home, G-tube/ET tube,
dialysis, hospitalized); cough, fever, dyspnea; GRAM-NEGATIVE COCCOBACILLUS; CXR with
patchy infiltrates; cystic fibrosis, hot tubs
What type of pneumonia will a postsplenectomy be prone to obtain?
Encapsulated organisms-H. pneumonia, S. pneumoniae
S. Aureus bacteria pneumonia colon sputum? common after what illness? How is it treated?
Salmon colored sputum, lobar, after influenza, MRSA treat with vancomycin
Mycoplasma found in what type of population? s/s?
Young people living in dorms, (+) COLD AGGLUTININS, bullous myringitis, walking pneumonia, low temp
Pneumocystis jiroveci
HIV CD4 <200, immunosuppressed
Moraxella catarrhalis
similar to haemophilus influenza
Histoplasma capsulatum (histoplasmosis
fungal; regional, Mississippi River valley
Coccidioides immitis (coccidioidomycosis
fungal; regional, San Joaquin Valley/
California; erythema nodosum; think about fungal in dirt exposure/construction
Hantavirus
severe respiratory distress/shock; rodent urine/feces; Southwest;
supportive care only
anaerobes
alcoholics, high risk aspiration; CXR with abscess formation, pleural
effusions, air-fluid level
Poor dental hygiene is associated with pneumonia caused by
anaerobes
what pneumonia is characterized by a more precipitous onset and fulminant course
Influenza pneumonia
Lobar consolidation is seen in what pneumonia
CAP
Apical infiltration is seen in
TB
Patients with pneumonia will have physical exam finding of
+) egophony , +) tactile fremitus ( Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus.), (+) dullness to percussion
dx of pneumonia
CXR: patchy, segmental lobar, multilobar consolidation
Blood cultures x 2, sputum gram stain
tx of pneumonia? cap ? HAP?aspiration?
utpatient therapy (antibiotics)
Doxycycline, Macrolides
Inpatient (hospitalize if > 50 with comorbidities, altered mental status, poor fluid status)
Ceftriaxone plus azithromycin, respiratory fluoroquinolones; Cap: basically healthy, out-pt Tx: Macrolide or doxycycline; HAP, in-pt Tx: β-lactam plus macrolide; Aspiration pneumonia -Piperacillin-tazobactam
Prevention of pneumonia?
Prevention: Influenza vaccine (↓ risk of bacterial superinfection), pneumococcal
Chlamydia pneumoniae
College kids, sore throat, long prodrome
Coccidioides (valley fever) found in what type of weather states?
dry states
What is Chronic bronchitis (Level 3)
airflow obstruction due to structural changes in
the airways with mucus hypersecretion & inflammatory response to inhaled toxins,
most commonly cigarette smoke
Chronic bronchitis characterized by?
productive cough on most days of the week ≥3 months in 2
consecutive years
Chronic bronchitis CM?
“blue bloater” → usually present during 5 th decade of life
with obesity, frequent cough with copious sputum production, dyspnea (esp. with
exertion), use of accessory muscles, coarse rhonchi & wheezing, JVD, peripheral
edema, hypoxemia with cyanosis & polycythemia, hypercapnia with respiratory
acidosis
dx of chronic bronchitis?
Clinical
○ Pulmonary function tests: ↓ FEV 1 , post-bronchodilator ↓ FEV 1 /FVC ratio
(<70%); irflow limitation that is irreversible or only partially reversible with bronchodilator is the characteristic physiologic feature of COPD
tx of chronic bronchitis?
Smoking cessation, supplemental O 2
○ Short & long-acting β2-agonists (eg. albuterol, salmeterol), respiratory
anticholinergics (eg. ipratropium), inhaled/oral corticosteroids
○ Acute exacerbations – often due to respiratory infections (esp. H
influenzae) typically require antibiotic treatment
○ Influenza & pneumococcal vaccines
○ Pulmonary rehabilitation
○ Appropriate consults
Complications of chronic bronchitis?
Pulmonary HTN & cor pulmonale
Labs of chronic bronchitis? Gold standard of chronic bronchitis?
Labs: ↑ HGB and HCT common because of a chronic hypoxic state.
Lung biopsy (Gold Standard)
Diagnosis is clinical but confirmed by biopsy ↑ Reid index (gland layer is > 50% of total bronchial wall)
Chest xray findings of chronic bronchitis?
increased interstitial markings, particularly at the bases and thickening of the bronchial walls; DIAPHRAGMS ARE NOT FLATTENED
Mild exacerbation of Chronic bronchitis what type of abx?
use narrow spectrum abx:
amoxicillin: 500 mg orally three times daily for 3-10 days
doxycycline: 100 mg orally twice daily for 3-10 days
trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily for 3-10 days
Moderate to severe exacerbation of Chronic bronchitis what type of abx?
will need more broad spectrum abx
cefuroxime: 500 mg orally twice daily for 3-10 days; 750 mg intravenously every 8 hours
amoxicillin/clavulanate: 875 mg orally twice daily for 3-10 days more
trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily for 3-10 days
levofloxacin: 500 mg orally once daily for 3-10 days, or 750 mg orally once daily for 5 days
ciprofloxacin: 500 mg orally twice daily for 7-10 days
65-year-old with COPD having received their first PPSV23 vaccination at age 63 should be revaccinated with PPSV23 in
5 years, n a patient with COPD who presents at age 65 years or older having already received PPSV23, administer 1 dose of PCV13, if not previously received, and another dose of PPSV23 at least 1 year after PCV13 and at least 5 years after PPSV23.
Increasing respiratory failure as indicated by the raising PaCO2 levels in pt with chronic bronchitis, what is next to do?
intubation
What is the next appropriate step of management for pt in severe respiratory arrest with markedly impaired mental status;
endotracheal intubation and mechanical ventilation
Home oxygen therapy has been shown to do what in COPD puts
prolong life and alter the natural history of the disease.
Centriacinar emphysema is characterized
y focal destruction limited to the respiratory bronchioles and the central portions of the acini. This form of emphysema is associated with cigarette smoking and is typically MOST SEVERE IN THE UPPER LOBES.
is independently associated with an increased risk for all-cause mortality in patients with COPD?
Bronchiectasis remained an independent risk factor after adjustment for dyspnea, partial pressure of oxygen, body mass index, presence of potentially pathogenic micro-organisms in sputum, presence of daily sputum production, number of severe exacerbations and peripheral albumin, and ultrasensitive C-reactive protein concentrations.
RF for mortality in pts with copd?
smoking, pulmonary hypertension, and declining lung function, bronchiectasis (independent rf)
which is generally recognized as the most significant symptom of COPD?
breathlessness
Which provides the best clues to the acuteness and severity of COPD exacerbation?
ABG analysis
When is long term oxygen recommended in copd puts?
ong-term oxygen therapy is recommended for patients with a partial pressure of oxygen in arterial blood <55 mm Hg or oxygen saturation <90%
spirometry findings in obstructive lung disease
normal or increased total lung capacity, decreased vital capacity, prolonged FEV1, and increased residual volume.
What is Croup (Level 2)?
Laryngotracheitis or laryngotracheobronchitis → acute inflammation of the
upper & lower respiratory tracts
○ Most commonly caused by parainfluenza virus, typically in the fall
Cm Croup (Level 2)?
Initially URI Sx followed by development of hoarseness,
brassy, BARKING COUGH (usually worse at night); fever, prolonged inspiration,
INSPIRATORY STRIDOR; Dz usually lasts 3-4 days & is self-limited, but some pts can
develop significant respiratory distress
Dx Croup (Level 2)?
Clinical
○ Anteroposterior x-ray study of the neck (not always necessary!): STEEPLE
sign (pencil point sign) [subglottic narrowing]
TX of Croup (Level 2)
Out-pt: Antipyretics, hydration
○ In-pt: ↑ RESPIRATORY DISTRESS, FATIGUE, CYANOSIS, HYPOXEMIA, DEHYDRATION →
HOSPITALIZATION FOR HUMIDIFIED O 2 , possibly racemic epinephrine,
corticosteroids, or intubation; appropriate consults
What is emphysema?
airflow obstruction due to tissue
destruction & enlargement of air spaces distal to the terminal in
response to inhaled toxins, most commonly CIGARETTE SMOKE
Emphysema is associated to what conditions?
conditions: α-1-antitrypsin deficiency (autosomal codominant
condition) → ↓ ability to neutralize elastase released by neutrophils [elastase
destroys lung connective tissue]; these pts present with emphysema at a younger
age(made have liver problems
CM of emphysema?
“PINK PUFFER” → usually present during 5 th decade of life
with dyspnea & tachypnea (esp. with exertion), tripod positioning, mild cough,
PURSED LIP BREATHING WITH LONG EXPIRATORY PHASE; BARREL CHEST (2:1
ANTERIOR-POSTERIOR CHEST DIAMETER), ↓ heart & lung sounds, non-cyanotic;
eventually, accessory muscle use, weight loss, muscle wasting
Dx of Emphysema
CXR reveals loss of lung markings and HYPERINFLATION
PARENCHYMAL BULLAE AND BLEBS ARE PATHOGNOMONIC, flattening of diaphragm.
PFTs show a decreased FEV1 / FVC ratio post-bronchodilator ↓ FEV 1 /FVC ratio
(<70%)
○ Chest x-ray
Tx of Emphysema?
Smoking cessation, supplemental O 2
○ Short & long-acting β2-agonists, respiratory anticholinergics, inhaled/oral
corticosteroids
○ Abx for acute exacerbations-same as chronic bronchitis )
○ Influenza & pneumococcal vaccines
○ Pulmonary rehabilitation
○ Appropriate consults
Abx for acute exacerbations organisms in Emphysema
(usually caused by viral or bacterial infection [H
influenzae, Moraxella catarrhalis, S pneumoniae]
Complications of emphysema?
Acute exacerbations may lead to hospitalization with need for
intubation & ventilator use
pathophysiology of emphysema
results from alveolar enlargement with loss of septal wall integrity without any evidence of fibrosis.
Foreign body aspiration (Level 2)
Can be a life-threatening emergency: Solid or semisolid object lodging in larynx or
trachea → airway obstruction, asphyxia & death
MC cause of Foreign body aspiration (Level 2)? RF?
Food. Others: Seeds, nuts, bone fragments, small toys, coins, dental appliances. boys>girls, children (esp. 1-3 yo), oropharyngeal procedures,
intoxication/sedation, institutionalization, old age, poor dentition, impaired
swallow/cough reflex
CM of Foreign body aspiration (Level 2)
may include: ± Hx of choking, acute onset coughing,
wheezing, stridor, dyspnea, cyanosis; ‘café coronary syndrome, depending on the size/type of object
Dx of Foreign body aspiration (Level 2)
clinical. Lateral neck x-ray/Chest x-ray/CT scan, however, <20% of aspirated foreign
bodies are radiopaque
TX Foreign body aspiration (Level 2)
Acute: Heimlich maneuver, back blows, possibly manual extraction
○ Subacute/chronic: Appropriate consult; RIGID BRONCHOSCOPY (BEST) or flexible
bronchoscopy; possibly surgery
○ Delayed extraction → ↑ RISK OF INFECTION, INFLAMMATION & EDEMA, PRESSURE
NECROSIS & PERFORATION
○ Appropriate consults
Leading cause of CA-related death worldwide?
Lung cancer, cigarette smoking accounts for
~85%
Screening of lung ca?
Yearly low-dose CT scan in pts with ≥30 pack-yr Hx who currently
smoke or quit within the past 15 yrs, between ages 55yo-74/80 yo (varies by
organization)
Lung cancer 2 types?
Non-small cell lung cancers (NSCLC) [~85%], Small cell lung cancer (SCLC) [~15%]:
Non-small cell lung cancers (NSCLC) [~85%]:
Adenocarcinoma
● Most common; significant number have no Hx of smoking
■ Squamous cell carcinoma-Hypercalcemia, recurrent pneumonia-o Aka: oat cell cancer
■ Large cell carcinom
Patient presents → as a non-smoker, with an incidental finding, with a small peripheral lesion, what type of cancer is ?
Adenocarcinoma
MC type bronchogenic carcinoma (lung)
Adenocarcinoma
Patient presents → as a smoker with hemoptysis and an abnormal chest X-Ray showing a large central solitary tumor.
Squamous cell carcinoma; ronchial in origin and centrally located mass. More likely in a smoker, more likely to have hemoptysis, central bronchus solitary tumor
Small cell lung cancer (SCLC) [~15%]:
The REALLY BAD ONE!
■ Almost always occurs in smokers; ~80% have metastasis at time of
Dx
■ Typical sites of metastasis for all types of lung CA: liver, bone, brain,
adrenal; Associated with ACTH and ADH – hyponatremia and hypercalcemia
Lambert-Eaton myasthenic syndrome
characterized by muscle weakness of the limbs caused by ACTH/ADH( maybe associated to SCLC
s/s of lung cancer
o Cough
o Weight loss
o Hemoptysis
o Hoarseness
Complications from Lung cancer (3 illness)
- Superior vena cava syndrome-facial/arm swelling
- Pan coast’s syndrome: Shoulder pain , Horner’s syndrome -miosis, ptosis, and anhidrosis , Bony destruction
- Paraneoplastic phenomena (releasing hormones into the symptoms )
o High Calcium
o SIADH
o Anemia
o DVT
o Cushing
dx of lung cancer?
Chest x-ray; CT scan, positron emission tomography (staging)
○ Bronchoscopy with biopsy; cytology (pleural effusion, sputum).
Non Small Cell - Adenocarcinoma (peripheral mass), squamous cell = hemoptysis + central mass
Small cell - mediastinal mass or lymph nodes on one side - 99% smokers
Tx of lung cancer?
Appropriate consults; depending upon type & stage: surgery, chemo- &/or
radiation-therapy, mutation-targeted therapy. 1. Non-small cell
o Stage 1-2 surgery
o Stage 3 chemo then surgery
o Stage 4 symptom based on palliative approach
2. Small cell tumors (can not really see where is at and only treated with CHEMO)
What is Pertussis (Level 2)
Highly contagious respiratory infection caused by BORDETELLA PERTUSSIS SEEN most
commonly in children & adolescents; adults usually have milder Dz
● Can be fatal in young children, especially <6 mo
CM of pertussis? 3 stages?
Catarrhal stage (10-14 days): URI Sx (sneezing, coryza, anorexia)
○ Paroxysmal stage: ↑ frequency & severity of cough with repeated bouts of
rapid, consecutive coughs (≥5 coughs during a single expiration) followed by
a hurried, high-pitched, deep crowing inspiration (“whoop”); vomiting is
common
○ Convalescent stage: Sx begin to diminish ~4 wks after Sx onset; average
duration of illness: 7 wks
dx of pertussis ?
Clinical; PCR (preferred test) or nasopharyngeal cultures, serology; a positive
test or high suspicion of Dz needs to be reported to public health
tx of pertussis and prevention?
Macrolide (erythromycin, azithromycin)
● Prevention: Immunization with acellular pertussis vaccine; vaccinate pregnant
women between 27-36 wks gestation
what is Pleural effusion (Level 2)
Accumulation of fluid within the pleural space; multiple etiologies
cm of Pleural effusion (Level 2)
Vary from asymptomatic → dyspnea, cough, chest pain; friction rub (“classic”), ↓ breath sounds, dullness to percussion, ↓ tactile fremitus
dx of Pleural effusion (Level 2)
Clinical, Upright chest x-ray, thoracentesis with pleural effusion?
cxr of Pleural effusion (Level 2)
Upright chest x-ray: Meniscus, blunting of costophrenic angle
■ Bilateral: Heart failure (HF), nephrotic syndrome, acute
pancreatitis
■ Isolated right-sided: HF, cirrhosis with ascites, pneumonia,
pulmonary embolism, CA, TB
■ Isolated left-sided: Pneumonia, pulmonary embolism, CA, TB,
esophageal rupture, aortic dissection
Ligh criteria of Pleural effusion (Level 2)
Light criteria (“classic”) for exudate:
● Ratio of pleural fluid protein to serum protein >0.5
● Ratio of pleural fluid LDH to serum LDH >0.6
● Pleural fluid LDH >2/3 upper limit of normal serum LDH
level
● If all 3 are absent = transudate
Exudate of Pleural effusion (Level 2)
Thick; ↑ protein, ↑ LDH, ↓ glucose
● Most common causes: Pneumonia, CA (most common:
breast, lung, lymphoma), pulmonary embolism, TB
Transudate Pleural effusion (Level 2)
Thin; ↓ protein, ↓ LDH, ↑ glucose
● Most common causes: HF, cirrhosis with ascites,
nephrotic syndrome
Tx of Pleural effusion (Level 2)
Exudate: Needs physical removal (thoracentesis, chest tube drainage,
surgery)
○ Transudate:
■ Asymptomatic: Typically ∅ Tx Symptomatic: Treat underlying cause; possibly fluid drainage,
diuretics
○ Appropriate consults
Pneumothorax (Level 2)
Air in the pleural space causing partial or complete collapse of the lung
Etiologies of Pneumothorax (Level 2)
Spontaneous :
■ Tall, thin, ♂ in early 20s; often smokers
■ Secondary to ruptured bleb or bulla in pts with underlying lung Dz
(eg. COPD)
○ Trauma : Gunshot wound, stab wound
○ Iatrogenic : Medical procedures (eg. central line insertion, thoracentesis)
○ Tension pneumothorax : Progressive ↑ in intrapleural pressure throughout
respiratory cycle (air continues to enter pleural space but can’t get out) →
lung collapse, mediastinal shift (in opposite direction) & ↓ venous return
to the heart
Tension Pneumothorax (Level 2) etiologies? dx and tx?
Etiologies: Positive-pressure ventilation, traumatic pneumothorax
(eg. flail chest)
■ Medical emergency → Dx & Tx clinically (ie. usually without chest
x-ray)
CM of Pneumothorax (Level 2)
tachycardia,
tachypnea, dyspnea, pleuritic chest pain; ↓ tactile fremitus, hyperresonance to
percussion & ↓ breath sounds
DX of Pneumothorax (Level 2)
Clinical
○ Upright inspiratory chest x-ray:
■ Radiolucent air & absence of lung markings (pneumothorax <10%
may be missed)
■ Collapsed lung
■ Tracheal deviation & mediastinal shift with large or tension
pneumothorax
■ “Minimal (small) pneumothorax”: 2-3 cm from apex to cupola;
various criteria
tX of Pneumothorax (Level 2)
O2 → helps pleural reabsorption of air
○ Primary spontaneous pneumothorax <20% without respiratory or cardiac
Sx & no progression of pneumothorax on chest x-ray after 6 & 24-48 hrs →
observe
○ Larger or symptomatic pneumothorax & secondary or traumatic
pneumothoraces:
■ Needle or transcatheter aspiration (eg. pigtail catheter with
Heimlich valve)
■ Chest tube insertion (tube thoracostomy) with continuous suction
■ Tension pneumothorax: emergent needle thoracostomy (2 nd intercostal space, midclavicular line with 14-16 gauge over the
needle catheter)
What is Pulmonary embolism (PE) (Level 3)
DVT travels venous system-right atrium -right ventricle towards lung =pe; Partial or complete occlusion of pulmonary trunk &/or ≥1 pulmonary arteries by
thrombi that most often originate in the deep veins of the calf, thigh or pelvis
RF of Pulmonary embolism (PE) (Level 3)
A. Factor V leiden, Major Surgery, Trauma, Immobilization, Lupus, Malignancy, Pregnancy, Oral Contraceptives, Smoker
B. Impaired venous return, endothelial injury, hyper coagulability (revolved around - Virchow Triad -Stasis, hypercoagulable state & trauma
CM Pulmonary embolism (PE) (Level 3)
• Sudden onset chest pain and sob ; dyspnea, pleuritic
chest pain, cough, hemoptysis; tachypnea (most common sign), tachycardia,
crackles; in SEVERE CASES, hypotension, presyncope, syncope or cardiopulmonary
arrest
DX: Pulmonary embolism (PE) (Level 3)
- Clinical prediction scores: Wells score, Pulmonary Embolism Rule-Out. 2. Pulse-oximetry (↓ O 2 saturation); arterial blood gas (↑ A-a gradient) 3. ECG. 4. Chest xray. 5. Ventilation-perfusion scan. 6. Duplex u/s for dvt. 7. pulmonary arteriography.
D-dimer may be useful to rule out PE
VQ scan for Pulmonary embolism (PE) (Level 3) show? used in what type of pt?
perfusion defects with normal ventilation
Normal VQ practically rules out PE
Abnormal VQ is non-specific; pregnant pt
Criteria (PERC) score?
Determine pre-test probabilities
■ Low probability & positive PERC score or intermediate probability
→ screen with high-sensitivity D-dimer
■ Positive D-dimer or high probability → CT angiography (imaging
study of choice in stable patients)
Chest x-ray findings of PE?
Westermark sign: Focal loss of vascular markings
■ Hampton hump: Wedge-shaped density seen in the peripheral
lung
ECG findings of PE?
Tachycardia, non-specific ST-T wave changes, S1Q3T3, new RBBB,
right axis deviation
tx for PE?
ABCs, supportive care (eg. O 2 )
○ Mainstay of Tx: Anticoagulation
■ Initial: Unfractionated heparin, low-molecular weight heparin,
fondaparinux
■ Maintenance: Warfarin, factor Xa inhibitors (eg. apixaban), direct
thrombin inhibitors (eg. dabigatran)
○ Pts with hypotension, impaired right ventricular function → thrombolytics,
embolectomy
○ Inferior vena cava filters can be used for pts with absolute
contraindications to anticoagulants, massive PE, recurrent venous
thromboembolism
○ Appropriate consults
Preventive measures for pe
Anticoagulation, DVT prophylaxis
Pulmonary HTN defined? Gold std testing?
- Normal lung pressures is 15/5 mmHG
- Pulm Htn =25 mmgHG/10 mmgh at rest
- Multiple etiologies
- Gold Std: right heart catheterization
What is Alpha 1 antitrypsin deficiency ? patho? cm? tx?
• Looks like emphysema type COPD
Born w/o or low amounts of enzyme
o The enzyme naturally inhibits the lung from self-destruction when repairing damage
In smokers the enzyme is inhibited by cigarette smoke
These patients lack the enzyme so the alveoli get destroyed
• Looks like a pink puffer
Non-smoker
Young age 20-30
• Treatment is like emphysema
Consider with advanced emphysema in a young pt
What is Pulmonary nodules (Level 1)
A single parenchymal lung lesion ≤3 cm with no associated pneumonia, atelectasis,
lymphadenopathy or pleural effusion & does not touch the hilum, mediastinum or
pleura
common non-cancer causes Pulmonary nodules (Level 1)
Granuloma, hamartoma, bronchial adenoma
Risk of malignancy-decrease & increase risk -Pulmonary nodules (Level 1)
risk: Small lesion (<1.5 cm), well-defined borders, calcifications that are
diffuse, central, popcorn pattern, laminar or concentric, and no change in
size for ≥2 yrs
○ ↑ risk: Large lesion (>3 cm), irregular borders, calcifications that are
eccentric or stippled; average doubling time for malignant tumor is 120
days (range: 7-590 days)
What is Pulmonary nodules (Level 1)
Aka coin lesions. A single parenchymal lung lesion ≤3 cm with no associated pneumonia, atelectasis,
lymphadenopathy or pleural effusion & does not touch the hilum, mediastinum or
pleura
What is Respiratory syncytial virus infection (Level 2)
RSV (RNA virus) causes lower respiratory tract infections primarily in infants &
young children, usually occurring in the winter or early spring → can lead to
bronchiolitis and/or pneumonia. Immune response to RSV does not protect against reinfection, but antibodies
decrease severity of recurrent illness
cm of Respiratory syncytial virus infection (Level 2)
Typically begin with upper respiratory Sx and fever, then
progress to dyspnea, cough, wheezing, crackles
dx of Respiratory syncytial virus infection (Level 2)
Clinical
○ Rapid antigen tests of nasal washings or swabs, reverse-transcription-PCR
tx of Respiratory syncytial virus infection (Level 2)
Supportive: Hydration, nasal/oral suctioning, humidified O 2 as needed
○ Antivirals, corticosteroids & bronchodilators are generally not
recommended
What is Sleep apnea (Level 2)? how many types
Sleep disorder characterized by pauses in breathing or periods of shallow
breathing during sleep
● Pts may not be aware of their disorder; frequently brought up by spouse/family
member; ♂ 2x > ♀; most commonly seen in ages 55-60 yo. obstructive, central mixed.
Central Sleep apnea
Cheyne-Stokes respirations; usually due to dysfunction of normal
central respiratory drive (eg. stroke, brain tumors)
Obstructive Sleep apneaMoa? RF
Most common; usually due to ↓ muscle tone &/or ↑ soft tissue bulk around the airway (abundance of tissue) → episodes of partial or complete airway
obstruction during sleep with periods of apnea or hypopnea >10 sec
■ Risk factors: Overweight/obesity, LARGE NECK (>16-17”), small
mandible (micrognathia), allergies, GERD, enlarged tonsils or
tongue, FHx, smoking, Et-OH, sedative or tranquilizer use
↑ risk of Mixed sleep apnea are
risk of driving or work-related accidents
○ ↑ risk of HTN, MI, stroke, DM, HF, dysrhythmia (eg. A Fib
dx of sleep apnea?
Clinical – including Hx by sleeping partner
○ Overnight sleep study (polysomnography)
tx of sleep apnea?
Lifestyle changes (↓ Et-OH, weight loss, smoking cessation, sleeping on
side)
○ Appropriate consultations for:
■ Mouthpieces (eg. mandibular advancement splint)
■ Breathing devices (eg. continuous positive airway pressure [CPAP])
■ Surgery
Viral pneumonia (Level 3)
Inflammation of lung parenchyma due to viral infection
mc cause of pneumonia in infants & children ? )
RSV virus (mc) -viruses
In adults, the most common cause of viral pneumonia
influenza A or B virus, others include RSV, parainfluenza virus, adenovirus
cm of Viral pneumonia (Level 3)
Fever, chills, non-productive cough, myalgia, headache, runny nose,
tachypnea, dyspnea, wheezing, rhonchi, crackles, ↓ breath sounds
dx of Viral pneumonia (Level 3)
Clinical
○ Chest x-ray: BILATERAL PERIHILAR & PERIBRONCHIAL THICKENING; PATCHY
INTERSTITIAL INFILTRATES
○ Rapid antigen detection tests, PCR, serology, cultures
tx of Viral pneumonia (Level 3)? Complications? prevention?
Supportive care (hydration, O 2 , antipyretics)
○ Influenza: Oseltamivir if treated within 48 hrs of Sx onset
○ Appropriate consults
● Complications: Secondary bacterial pneumonia
● Prevention:
○ Hand washing
○ Immunizations (eg. influenza)
what is Hyaline Membrane Disease
Infant respiratory distress syndrome that occurs in premature infants due to IMPAIRED
SURFACTANT SYNTHESIS & secretion → perfusion without ventilation & atelectasis
● Infants usually have enough surfactant by 35 wks gestation
Presentation Hyaline Membrane Disease
Presentation: WITHIN MINS-HRS OF BIRTH → tachypnea, nasal flaring, grunting, cyanosis,
accessory muscle contractions
dx Hyaline Membrane Disease
clinical; CXR (RETICULAR GROUND GLASS OPACITIES
tx of Hyaline Membrane Disease
Tx: surfactant via endotracheal tube, continuous positive airway pressure (CPAP)
o Prevention: administration of glucocorticoids to at-risk mom between 24-36 wks
gestation
what is Obesity Hypoventilation Syndrome? aka?Increase risk of ?
Presence of awake alveolar hypoventilation (PaCO2 >45 mmHg) in obese pts, not
attributable to other causes
● AKA: Pickwickian syndrome; diagnosis of exclusion
~90% of pts have co-existing obstructive sleep apnea; associated with ↑ risk of
cardiovascular morbidity & mortality
s/s Obesity Hypoventilation Syndrome
overlap with obstructive sleep apnea except all pts are obese & ♂≈♀
Obesity Hypoventilation Syndrome dx
OVERNIGHT SLEEP STUDY WITH CONTINUOUS NOCTURNAL CO2 MONITORING (GOLD STANDARD), serum bicarbonate (>27 mEq/L), arterial blood gas
Obesity Hypoventilation Syndrome tx
similar to obstructive sleep apnea; multi-disciplinary care
Short-acting β-2
agonist (SABA) Names & MOA
Albuterol Levalbuterol Terbutaline Bronchodilator • ↓ bronchospasm, airway edema & resistance • Smooth muscle relaxation
Short-acting β-2
agonist (SABA) Indications
• # 1 for acute exacerbation (most effective & fastest acting) • Hyperkalemia • Terbutaline also for delaying premature labor• 2. COPD
Short-acting β-2
agonist (SABA) administration
•• Inhaled
• Terbutaline PO &
subq as well
Short-acting β-2
agonist (SABA) s/e?
- β-1 cross reactivity
- Tachycardia
- Muscle tremors
- Hypokalemia
- Anxiety
Short-acting β-2
agonist (SABA) CI
Cardiac arrythmias
Short-acting β-2
agonist (SABA) special considerations
Safe in pregnancy (does
not cross placenta)
Anticholinergics name & moa?
Ipratropium (short acting) Counteracts vagal mediated bronchoconstriction • Central bronchodilator • Synergistic with β-2 agonists
Anticholinergics indications?
Most useful if given within 1st hour in asthma; Preferred over shortacting β-2 agonists in COPD • Combination therapy shows greatest response
Anticholinergics administration?
Inhaled
Anticholinergics S/e?
Anticholinergic effects:
• Thirst
• Dry mouth
• Urinary retention
Anticholinergics CI?
Glaucoma
• BPH
Systemic
corticosteroids names & Moa
Anti-inflammatory • Prevents bronchoconstriction • ↑ smooth muscle relaxation • Inhibits cytokine production
Methylprednisolone
Prednisolone
Prednisone
Systemic
corticosteroids indications?
Onset 4-8 hours
Systemic
corticosteroids administration?
- PO
* IV
Systemic
corticosteroids S/E
Worsens infections
• Hyperglycemia
• Fluid retention
Systemic
corticosteroids CI
Serious infections
Systemic
corticosteroids special considerations
Discharge patients on short course 3-5 days unless CI which usually doesn’t need tapering • >1 wk of PO steroids needs taper to prevent adrenal insufficiency
Epinephrine Moa? indications? Adminstration
Rapid bronchodilation, Use in emergency
airway obstruction, Inhaled
• IM
What is Bronchiectasis
permanent dilation or destruction of the bronchial walls
It is best considered the common endpoint of various disorders that cause chronic airway inflammation
The dilation and destruction of larger bronchi is caused by chronic infection and inflammation. Common causes are cystic fibrosis, immune defects, and recurrent infections, though some cases seem to be idiopathic
Most common cause is Cystic fibrosis
< 18 years-old Staphylococcal infections
> 18 years old Pseudomonas infection
BRonchiectasis -dx?
CXR – linear (“tram track”) lung markings, atelectasis, dilated and thickened airways “Plate-like” atelectasis (scarring)
Gold standard diagnosis is – CT of the chest
Tx of bronchiectasis
Ambulatory oxygen, aggressive antibiotics, CPT (chest physiotherapy = bang on the back) and eventually lung transplant
Inhaled corticosteroids (ICS) Drug class & names
Long term, maintenance Beclomethasone Budesonide (COPD) Flunisolide Fluticasone (COPD) Mometasone Triamcinolone
Inhaled
corticosteroids (ICS) MOA?
Anti-inflammatory • Prevents bronchoconstriction • ↑ smooth muscle relaxation • Inhibits cytokine production
Inhaled
corticosteroids (ICS) indications? Adminstration?
1 for maintanence; inhaled ; COPD-Not mono therapy Add to long acting β-2
agonist (LABA) if good
response with inhaled
corticosteroids
Inhaled
corticosteroids (ICS) side effects?
Fewer SE than with systemic steroids • Oropharyngeal candidiasis • Hoarseness • Hyperglycemia Osteoporsis (long term use)
Inhaled
corticosteroids (ICS) CI ?
- Acute bronchospasm
* Status asthmaticus
Inhaled
corticosteroids (ICS) special considerations?
Use spacer & rinse mouth after use to help prevent oropharyngeal candidiasis; COPD frequently administered in combination with LABA (eg. fluticasone/salmeterol, budenoside/formoterol)
Long-acting β-2 agonist (LABA) Drug class and names?
- Formoterol
Salmeterol - Long term, maintenance
Long-acting β-2
agonist (LABA) MOA?
Bronchodilator with
same MOA as short
acting
Long-acting β-2
agonist (LABA) Indications
Good for nighttime symptoms • Used in combination or added to ICS only if persistent asthma not controlled by ICS alone • Once asthma is controlled, taper off of LABA
Long-acting β-2
agonist (LABA) adminstration? SE?
Inhaled powder; • β-1 cross reactivity • Tachycardia • Muscle tremors • Hypokalemia • Anxiety
Mast Cell Stabilizers names?
•
Cromolyn
Nedocromil
Mast cell stabilizers MOA?
Inhibits mast cells and leukotrienemediated degranulation • Prevents release of inflammatory mediators
Mast cell stabilizers indications and administration
• Exercise-induced
bronchospasm
• Asthma maintanence; Inhaled
Mast cell stabilizers se? CI?
- Throat irritation, Dysgeusia (lack of taste or decrease sensitivity of taste), N/V
Leukotriene
Inhibitors Drugs? Moa?
Zilueton; Inhibits 5-lipoxygenase which blocks leukotriene production • ↓ airway inflammation
Leukotriene
Inhibitors Drugs Indications?
PO prophylaxis >12 yo
Leukotriene
Inhibitors Drugs se & CI?
Hepatotoxic; Liver disease
Leukotriene receptor
antagonists names ?
Montelukast
Zafirlukast
Leukotriene receptor
antagonists Moa?
Inhibits leukotriene binding to its receptors • ↓ airway inflammation
Leukotriene receptor
antagonists indications?
Useful in patients
with allergic rhinitis or
aspirin-induced asthma
Leukotriene receptor
antagonists administration?
PO
• Good for kids who
have trouble with
inhalers
Leukotriene receptor
antagonists s/e
- Headache
* Gastritis
Methylxanthines names?
Theophylline
Methylxanthines MOA?
Bronchodilator that improves respiratory muscle endurance • Strengthens diaphragm contractions
Methylxanthines indications? administration?
Long term asthma
prevention; Used only in refractory
cases for copd ; PO
Methylxanthines se?
• N/V • Anxiety • Diarrhea • Headache • Toxicity causes arrhythmias, seizures
Methylxanthines special considerations?
• Not often used due to limited therapeutic index-Toxic >20mg/L • Must monitor blood levels • Higher doses needed in smokers • Lower doses needed in CHF
Oxygen moa and indications?
Decreases hypoxiamediated pulmonary vasoconstriction; Only medical therapy shown to ↓ mortality • Use with cor pulmonale or O2 sat <88% or PaO2 < 55 mmHg
Outpt CAP
≤65 yo
Otherwise healthy
No Abx in 3 mo MC etiology? Other etiology? Treatment?
- S. pneumoniae
- Mycoplasma, C.pneumoniae, Viral, H. flu
- Macrolide or doxy ex. Azithro or doxy
Outpt CAP
>65 yo or comorbidity (COPD,
HF, RF, liver dx, ETOH) or Abx
within 3moMC etiology? Other etiology? Treatment?
- S. pneumoniae 2. H. flu (COPD), Aerobic gram negative rods, (Klebsiella in ETOH), S. aureus, Legionella
- Fluoroquinolone or
β-lactam + macrolide/doxy
ex. Levo/moxi or augmentin +
azithro/doxy
CAP requiring admission MC etiology? Other etiology? Treatmen
- S. pneumoniae 2. H. flu, Anaerobes, Aerobic gram negative rods, Legionella, Chlamydia
- Fluoroquinolone or
antipneumococcal
β-lactam + macrolide/doxy
ex. Levo/moxi or ceftrixone +
azithro/doxy
Hospital/institution acquired MC etiology? Other etiology? Treatmen
1. Gram negative rod • Pseudomonas 2. E. coli • Klebsiella • S. aureus • Acinetobacter 3. Extended spectrum cephalosporin or carbapenum with antipseudomonal activity + aminoglycoside or fluoroquinolone to cover pseudomonas until labs back
Critically ill ICU Not improving with initial therapy MC etiology? Other etiology? Treatment
- MRSA
- Add vanco or linezolid,
broaden gram negative
coverage
● Most common cause of pneumonia in HIV/AIDs?
Strep pneumoniae
when does Pneumocystis jiroveci (PCP) occurs?
low CD4 count <200, elevated LDH, indolent/atypical,
progressive SOB, exercise-induced hypoxia
tx for pcp, 1st line, 2nd line ?
- First-line therapy is TMP-SMX
- Second-line therapy is pentamidine or dapsone. Side effects of pentamidine: hyperglycemia and hypotension. Side effect of dapsone: methemoglobinemia
If room air paO2 < 70mmHg or A-a gradient > 35, you need to add prednisone
