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PANRE > Pulmonary Panre > Flashcards

Pulmonary Panre Flashcards

1
Q

Pathophysiology of Asthma?

A 
Obstruction, hyperactivity and inflammation; Chronic inflammatory disease
o Reversible:
§ bronchial constriction
§ bronchial edema
§ ↑􀀀# goblet cells
§ smooth muscle hypertrophy
§ airway remodeling
o Mucous plugging
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2
Q

what is the arterial blood gas changes in asthma?

A

initially pH ↑􀀀and pCO2 ↓􀀀during labored breathing

§ when patients worsen (i.e. fatigue), pH ↓􀀀and pCO2 ↑

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3
Q

What is asthma? Trigger?

A

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

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4
Q

How is asthma dx?

A

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

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5
Q

hilar lymphadenopthy differential dx?

A

Young female = Sarcoidosis
Young kid with a fever, from Ohio, zoo keeper = histoplasmosis
Old guy in his 60’s works on ceramics = Berylliosis”

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6
Q

what is sarcoidosis?

A

systemic granulomatous disease that is characterized by noncaseating granulomas that may affect multiple organ systems (increase amount noncaseating granulomas in different organs)

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7
Q

Sarcoidosis MC in ? Age onset?

A

Northern Europeans and African Americans; persons ages 20 to 40 years

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8
Q

CM of sarcoidosis

A

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) )

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9
Q

Hall mark finding of cxr of sarcoidosis

A

mEDIASTINAL LYMPHADENOPATHY seen on chest radiograph is the hallmark finding in 90% of cases; +/- eggshell nodal calcifications

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10
Q

Dx of sarcoidosis?

A
  1. Noncaseating granolas classic nonspecific histological finding, Restricve pattern of PFT ; hypercalcemia and ACE levels 4 x normal

ESR is often elevated

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11
Q

Tx of sarcoidosis

A

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

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12
Q

leading cause of death for sarcoidosis .

A

pulmonary fibrosis

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13
Q

What is severe asthma & status asthmaticus?

A

inability to speak in full sentences, PEFR <40%, altered mental status, pulses paradoxes (inspiratory decrease XBP >10), cyanosis, tripod position, silent chest, tachycardia

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14
Q

What is gold standard exam for asthma

A

PFT

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15
Q

What is the best & most objective way to assess asthma, excaberation severity & pt response in ED

A

Peak Expiratory Flow rate (PEFR)

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16
Q

Methylxanthines MOA? EX?

A 
Theophylline, Bronchodilator that
improves respiratory
muscle endurance
• Strengthens
diaphragm
contractions
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17
Q

Methylxanthines Indications?

A

Long term asthma

prevention

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18
Q

Methylxanthines s/e?

A 
N/V
• Anxiety
• Diarrhea
• Headache
• Toxicity causes
arrhythmias, seizures
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19
Q

Theophylline special considerations?

A 
Not often used
due to limited
therapeutic index
• Must monitor blood
levels
• Higher doses needed
in smokers
• Lower doses needed
in CHF
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20
Q

Monoclonal

antibody ex? MOA?

A 
Omalizumab, Binds to IgE
receptors on cells
associated with
allergic response
• ↓ IgE in serum
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21
Q

Monoclonal

antibody Indications?

A 
Severe, uncontrolled
asthma
• Useful in asthma
triggered by known
allergens
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22
Q

Monoclonal

antibody Adminstration?

A

SC q 2-4

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23
Q

Monoclonal

antibody s/e?

A

Headache

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24
Q

Monoclonal

antibody CI?

A
  • Acute bronchospasm

* Status asthmaticus

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25
Q

Leukotriene receptor

antagonists MOA?

A 
Inhibits leukotriene
binding to its
receptors
• ↓ airway
inflammation
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26
Q

Leukotriene receptor

antagonists Indicatins?

A

Useful in patients
with allergic rhinitis or
aspirin-induced asthma

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27
Q

Leukotriene receptor

antagonists Adminstration

A

PO
• Good for kids who
have trouble with
inhalers

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28
Q

Leukotriene receptor

antagonists s/e

A

Headache

• Gastritis

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29
Q

Most common pathogen in all age groups, settings & geographic regions for bacteria pneumoniae?

A

Streptococcus pneumoniae

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30
Q

Community-acquired pneumonia (CAP) ? Organisms?

A

Limited or no contact with medical settings
■ Organisms: S. pneumoniae, Haemophilus influenzae , atypical bacteria
( Chlamydia, Mycoplasma, Legionella

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31
Q

Hospital-acquired pneumonia (HAP) & ventilator-associated pneumonia
(VAP) [nosocomial pneumonias) develops?

A

Develops ≥ 48 hrs after hospital admission (HAP) or after

endotracheal intubation and ventilator (VAP) use, respectively; ↑ risk of multidrug resistant infections

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32
Q

Hospital-acquired pneumonia (HAP) & ventilator-associated pneumonia
(VAP) [nosocomial pneumonias) organisms?

A

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 )

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33
Q

Aspiration pneumonia:

A

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 )

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34
Q

Strep pneumoniae GRAM STain, sputum

A

MC cause of CAP, Gram stain: GRAM + COCCI IN pairs, RUST-COLORED SPUTUM ‘ common in patients with splenectomy

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35
Q

klebsiella common in? gram stain? sputum?

A

Alcoholics, debiliated chronic illness aspirators, GRAM NEGATIVE RODS (BACILLI), currant jelly sputum

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36
Q

Haemophilus influenza common in ? s/s? gram stain? X-ray results?

A

COPD smokers elderly,gradual onset fever, dyspnea, chest
pain; CXR with patchy infiltrates/pleural effusion; GRAM-NEGATIVE ENCAPSULATED
COCCOBACILLUS

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37
Q

Legionella commonly found in ? symptoms include? associated with what type heart rhythm ? gram stain

A 
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)
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38
Q

Pseudomonas found in what population? environment? Xray results? gram stain?

A

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

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39
Q

What type of pneumonia will a postsplenectomy be prone to obtain?

A

Encapsulated organisms-H. pneumonia, S. pneumoniae

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40
Q

S. Aureus bacteria pneumonia colon sputum? common after what illness? How is it treated?

A

Salmon colored sputum, lobar, after influenza, MRSA treat with vancomycin

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41
Q

Mycoplasma found in what type of population? s/s?

A

Young people living in dorms, (+) COLD AGGLUTININS, bullous myringitis, walking pneumonia, low temp

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42
Q

Pneumocystis jiroveci

A

HIV CD4 <200, immunosuppressed

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43
Q

Moraxella catarrhalis

A

similar to haemophilus influenza

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44
Q

Histoplasma capsulatum (histoplasmosis

A

fungal; regional, Mississippi River valley

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45
Q

Coccidioides immitis (coccidioidomycosis

A

fungal; regional, San Joaquin Valley/

California; erythema nodosum; think about fungal in dirt exposure/construction

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46
Q

Hantavirus

A

severe respiratory distress/shock; rodent urine/feces; Southwest;
supportive care only

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47
Q

anaerobes

A

alcoholics, high risk aspiration; CXR with abscess formation, pleural
effusions, air-fluid level

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48
Q

Poor dental hygiene is associated with pneumonia caused by

A

anaerobes

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49
Q

what pneumonia is characterized by a more precipitous onset and fulminant course

A

Influenza pneumonia

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50
Q

Lobar consolidation is seen in what pneumonia

A

CAP

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51
Q

Apical infiltration is seen in

A

TB

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52
Q

Patients with pneumonia will have physical exam finding of

A

+) egophony , +) tactile fremitus ( Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus.), (+) dullness to percussion

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53
Q

dx of pneumonia

A

CXR: patchy, segmental lobar, multilobar consolidation

Blood cultures x 2, sputum gram stain

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54
Q

tx of pneumonia? cap ? HAP?aspiration?

A

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

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55
Q

Prevention of pneumonia?

A

Prevention: Influenza vaccine (↓ risk of bacterial superinfection), pneumococcal

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56
Q

Chlamydia pneumoniae

A

College kids, sore throat, long prodrome

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57
Q

Coccidioides (valley fever) found in what type of weather states?

A

dry states

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58
Q

What is Chronic bronchitis (Level 3)

A

airflow obstruction due to structural changes in
the airways with mucus hypersecretion & inflammatory response to inhaled toxins,
most commonly cigarette smoke

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59
Q

Chronic bronchitis characterized by?

A

productive cough on most days of the week ≥3 months in 2

consecutive years

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60
Q

Chronic bronchitis CM?

A

“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

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61
Q

dx of chronic bronchitis?

A

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

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62
Q

tx of chronic bronchitis?

A

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

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63
Q

Complications of chronic bronchitis?

A

Pulmonary HTN & cor pulmonale

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64
Q

Labs of chronic bronchitis? Gold standard of chronic bronchitis?

A

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)

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65
Q

Chest xray findings of chronic bronchitis?

A

increased interstitial markings, particularly at the bases and thickening of the bronchial walls; DIAPHRAGMS ARE NOT FLATTENED

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66
Q

Mild exacerbation of Chronic bronchitis what type of abx?

A

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

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67
Q

Moderate to severe exacerbation of Chronic bronchitis what type of abx?

A

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

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68
Q

65-year-old with COPD having received their first PPSV23 vaccination at age 63 should be revaccinated with PPSV23 in

A

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.

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69
Q

Increasing respiratory failure as indicated by the raising PaCO2 levels in pt with chronic bronchitis, what is next to do?

A

intubation

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70
Q

What is the next appropriate step of management for pt in severe respiratory arrest with markedly impaired mental status;

A

endotracheal intubation and mechanical ventilation

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71
Q

Home oxygen therapy has been shown to do what in COPD puts

A

prolong life and alter the natural history of the disease.

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72
Q

Centriacinar emphysema is characterized

A

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.

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73
Q

is independently associated with an increased risk for all-cause mortality in patients with COPD?

A

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.

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74
Q

RF for mortality in pts with copd?

A

smoking, pulmonary hypertension, and declining lung function, bronchiectasis (independent rf)

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75
Q

which is generally recognized as the most significant symptom of COPD?

A

breathlessness

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76
Q

Which provides the best clues to the acuteness and severity of COPD exacerbation?

A

ABG analysis

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77
Q

When is long term oxygen recommended in copd puts?

A

ong-term oxygen therapy is recommended for patients with a partial pressure of oxygen in arterial blood <55 mm Hg or oxygen saturation <90%

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78
Q

spirometry findings in obstructive lung disease

A

normal or increased total lung capacity, decreased vital capacity, prolonged FEV1, and increased residual volume.

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79
Q

What is Croup (Level 2)?

A

Laryngotracheitis or laryngotracheobronchitis → acute inflammation of the
upper & lower respiratory tracts
○ Most commonly caused by parainfluenza virus, typically in the fall

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80
Q

Cm Croup (Level 2)?

A

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

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81
Q

Dx Croup (Level 2)?

A

Clinical
○ Anteroposterior x-ray study of the neck (not always necessary!): STEEPLE
sign (pencil point sign) [subglottic narrowing]

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82
Q

TX of Croup (Level 2)

A

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

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83
Q

What is emphysema?

A

airflow obstruction due to tissue
destruction & enlargement of air spaces distal to the terminal in
response to inhaled toxins, most commonly CIGARETTE SMOKE

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84
Q

Emphysema is associated to what conditions?

A

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

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85
Q

CM of emphysema?

A

“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

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86
Q

Dx of Emphysema

A

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

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87
Q

Tx of Emphysema?

A

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

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88
Q

Abx for acute exacerbations organisms in Emphysema

A

(usually caused by viral or bacterial infection [H

influenzae, Moraxella catarrhalis, S pneumoniae]

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89
Q

Complications of emphysema?

A

Acute exacerbations may lead to hospitalization with need for
intubation & ventilator use

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90
Q

pathophysiology of emphysema

A

results from alveolar enlargement with loss of septal wall integrity without any evidence of fibrosis.

91
Q

Foreign body aspiration (Level 2)

A

Can be a life-threatening emergency: Solid or semisolid object lodging in larynx or
trachea → airway obstruction, asphyxia & death

92
Q

MC cause of Foreign body aspiration (Level 2)? RF?

A

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

93
Q

CM of Foreign body aspiration (Level 2)

A

may include: ± Hx of choking, acute onset coughing,

wheezing, stridor, dyspnea, cyanosis; ‘café coronary syndrome, depending on the size/type of object

94
Q

Dx of Foreign body aspiration (Level 2)

A

clinical. Lateral neck x-ray/Chest x-ray/CT scan, however, <20% of aspirated foreign
bodies are radiopaque

95
Q

TX Foreign body aspiration (Level 2)

A

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

96
Q

Leading cause of CA-related death worldwide?

A

Lung cancer, cigarette smoking accounts for

~85%

97
Q

Screening of lung ca?

A

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)

98
Q

Lung cancer 2 types?

A

Non-small cell lung cancers (NSCLC) [~85%], Small cell lung cancer (SCLC) [~15%]:

99
Q

Non-small cell lung cancers (NSCLC) [~85%]:

A

Adenocarcinoma
● Most common; significant number have no Hx of smoking
■ Squamous cell carcinoma-Hypercalcemia, recurrent pneumonia-o Aka: oat cell cancer
■ Large cell carcinom

100
Q

Patient presents → as a non-smoker, with an incidental finding, with a small peripheral lesion, what type of cancer is ?

A

Adenocarcinoma

101
Q

MC type bronchogenic carcinoma (lung)

A

Adenocarcinoma

102
Q

Patient presents → as a smoker with hemoptysis and an abnormal chest X-Ray showing a large central solitary tumor.

A

Squamous cell carcinoma; ronchial in origin and centrally located mass. More likely in a smoker, more likely to have hemoptysis, central bronchus solitary tumor

103
Q

Small cell lung cancer (SCLC) [~15%]:

A

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

104
Q

Lambert-Eaton myasthenic syndrome

A

characterized by muscle weakness of the limbs caused by ACTH/ADH( maybe associated to SCLC

105
Q

s/s of lung cancer

A

o Cough
o Weight loss
o Hemoptysis
o Hoarseness

106
Q

Complications from Lung cancer (3 illness)

A
  1. Superior vena cava syndrome-facial/arm swelling
  2. Pan coast’s syndrome: Shoulder pain , Horner’s syndrome -miosis, ptosis, and anhidrosis , Bony destruction
  3. Paraneoplastic phenomena (releasing hormones into the symptoms )
    o High Calcium
    o SIADH
    o Anemia
    o DVT
    o Cushing
107
Q

dx of lung cancer?

A

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

108
Q

Tx of lung cancer?

A

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)

109
Q

What is Pertussis (Level 2)

A

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

110
Q

CM of pertussis? 3 stages?

A

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

111
Q

dx of pertussis ?

A

Clinical; PCR (preferred test) or nasopharyngeal cultures, serology; a positive
test or high suspicion of Dz needs to be reported to public health

112
Q

tx of pertussis and prevention?

A

Macrolide (erythromycin, azithromycin)
● Prevention: Immunization with acellular pertussis vaccine; vaccinate pregnant
women between 27-36 wks gestation

113
Q

what is Pleural effusion (Level 2)

A

Accumulation of fluid within the pleural space; multiple etiologies

114
Q

cm of Pleural effusion (Level 2)

A 
Vary from asymptomatic → dyspnea, cough, chest pain;
friction rub (“classic”), ↓ breath sounds, dullness to percussion, ↓ tactile fremitus
115
Q

dx of Pleural effusion (Level 2)

A

Clinical, Upright chest x-ray, thoracentesis with pleural effusion?

116
Q

cxr of Pleural effusion (Level 2)

A

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

117
Q

Ligh criteria of Pleural effusion (Level 2)

A

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

118
Q

Exudate of Pleural effusion (Level 2)

A

Thick; ↑ protein, ↑ LDH, ↓ glucose
● Most common causes: Pneumonia, CA (most common:
breast, lung, lymphoma), pulmonary embolism, TB

119
Q

Transudate Pleural effusion (Level 2)

A

Thin; ↓ protein, ↓ LDH, ↑ glucose
● Most common causes: HF, cirrhosis with ascites,
nephrotic syndrome

120
Q

Tx of Pleural effusion (Level 2)

A

Exudate: Needs physical removal (thoracentesis, chest tube drainage,
surgery)
○ Transudate:
■ Asymptomatic: Typically ∅ Tx Symptomatic: Treat underlying cause; possibly fluid drainage,
diuretics
○ Appropriate consults

121
Q

Pneumothorax (Level 2)

A

Air in the pleural space causing partial or complete collapse of the lung

122
Q

Etiologies of Pneumothorax (Level 2)

A

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

123
Q

Tension Pneumothorax (Level 2) etiologies? dx and tx?

A

Etiologies: Positive-pressure ventilation, traumatic pneumothorax
(eg. flail chest)
■ Medical emergency → Dx & Tx clinically (ie. usually without chest
x-ray)

124
Q

CM of Pneumothorax (Level 2)

A

tachycardia,
tachypnea, dyspnea, pleuritic chest pain; ↓ tactile fremitus, hyperresonance to
percussion & ↓ breath sounds

125
Q

DX of Pneumothorax (Level 2)

A

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

126
Q

tX of Pneumothorax (Level 2)

A

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)

127
Q

What is Pulmonary embolism (PE) (Level 3)

A

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

128
Q

RF of Pulmonary embolism (PE) (Level 3)

A

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

129
Q

CM Pulmonary embolism (PE) (Level 3)

A

• 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

130
Q

DX: Pulmonary embolism (PE) (Level 3)

A
  1. 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
131
Q

VQ scan for Pulmonary embolism (PE) (Level 3) show? used in what type of pt?

A

perfusion defects with normal ventilation
Normal VQ practically rules out PE
Abnormal VQ is non-specific; pregnant pt

132
Q

Criteria (PERC) score?

A

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)

133
Q

Chest x-ray findings of PE?

A

Westermark sign: Focal loss of vascular markings
■ Hampton hump: Wedge-shaped density seen in the peripheral
lung

134
Q

ECG findings of PE?

A

Tachycardia, non-specific ST-T wave changes, S1Q3T3, new RBBB,
right axis deviation

135
Q

tx for PE?

A

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

136
Q

Preventive measures for pe

A

Anticoagulation, DVT prophylaxis

137
Q

Pulmonary HTN defined? Gold std testing?

A
  • Normal lung pressures is 15/5 mmHG
  • Pulm Htn =25 mmgHG/10 mmgh at rest
  • Multiple etiologies
  • Gold Std: right heart catheterization
138
Q

What is Alpha 1 antitrypsin deficiency ? patho? cm? tx?

A

• 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

139
Q

What is Pulmonary nodules (Level 1)

A

A single parenchymal lung lesion ≤3 cm with no associated pneumonia, atelectasis,
lymphadenopathy or pleural effusion & does not touch the hilum, mediastinum or
pleura

140
Q

common non-cancer causes Pulmonary nodules (Level 1)

A

Granuloma, hamartoma, bronchial adenoma

141
Q

Risk of malignancy-decrease & increase risk -Pulmonary nodules (Level 1)

A

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)

142
Q

What is Pulmonary nodules (Level 1)

A

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

143
Q

What is Respiratory syncytial virus infection (Level 2)

A

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

144
Q

cm of Respiratory syncytial virus infection (Level 2)

A

Typically begin with upper respiratory Sx and fever, then

progress to dyspnea, cough, wheezing, crackles

145
Q

dx of Respiratory syncytial virus infection (Level 2)

A

Clinical

○ Rapid antigen tests of nasal washings or swabs, reverse-transcription-PCR

146
Q

tx of Respiratory syncytial virus infection (Level 2)

A

Supportive: Hydration, nasal/oral suctioning, humidified O 2 as needed
○ Antivirals, corticosteroids & bronchodilators are generally not
recommended

147
Q

What is Sleep apnea (Level 2)? how many types

A

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.

148
Q

Central Sleep apnea

A

Cheyne-Stokes respirations; usually due to dysfunction of normal
central respiratory drive (eg. stroke, brain tumors)

149
Q

Obstructive Sleep apneaMoa? RF

A

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

150
Q

↑ risk of Mixed sleep apnea are

A

risk of driving or work-related accidents

○ ↑ risk of HTN, MI, stroke, DM, HF, dysrhythmia (eg. A Fib

151
Q

dx of sleep apnea?

A

Clinical – including Hx by sleeping partner

○ Overnight sleep study (polysomnography)

152
Q

tx of sleep apnea?

A

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

153
Q

Viral pneumonia (Level 3)

A

Inflammation of lung parenchyma due to viral infection

154
Q

mc cause of pneumonia in infants & children ? )

A

RSV virus (mc) -viruses

155
Q

In adults, the most common cause of viral pneumonia

A

influenza A or B virus, others include RSV, parainfluenza virus, adenovirus

156
Q

cm of Viral pneumonia (Level 3)

A

Fever, chills, non-productive cough, myalgia, headache, runny nose,
tachypnea, dyspnea, wheezing, rhonchi, crackles, ↓ breath sounds

157
Q

dx of Viral pneumonia (Level 3)

A

Clinical
○ Chest x-ray: BILATERAL PERIHILAR & PERIBRONCHIAL THICKENING; PATCHY
INTERSTITIAL INFILTRATES
○ Rapid antigen detection tests, PCR, serology, cultures

158
Q

tx of Viral pneumonia (Level 3)? Complications? prevention?

A

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)

159
Q

what is Hyaline Membrane Disease

A

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

160
Q

Presentation Hyaline Membrane Disease

A

Presentation: WITHIN MINS-HRS OF BIRTH → tachypnea, nasal flaring, grunting, cyanosis,
accessory muscle contractions

161
Q

dx Hyaline Membrane Disease

A

clinical; CXR (RETICULAR GROUND GLASS OPACITIES

162
Q

tx of Hyaline Membrane Disease

A

Tx: surfactant via endotracheal tube, continuous positive airway pressure (CPAP)
o Prevention: administration of glucocorticoids to at-risk mom between 24-36 wks
gestation

163
Q

what is Obesity Hypoventilation Syndrome? aka?Increase risk of ?

A

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

164
Q

s/s Obesity Hypoventilation Syndrome

A

overlap with obstructive sleep apnea except all pts are obese & ♂≈♀

165
Q

Obesity Hypoventilation Syndrome dx

A 
OVERNIGHT SLEEP STUDY WITH CONTINUOUS NOCTURNAL CO2 MONITORING (GOLD STANDARD),
serum bicarbonate (>27 mEq/L), arterial blood gas
166
Q

Obesity Hypoventilation Syndrome tx

A

similar to obstructive sleep apnea; multi-disciplinary care

167
Q

Short-acting β-2

agonist (SABA) Names & MOA

A 
Albuterol
Levalbuterol
Terbutaline
Bronchodilator
• ↓ bronchospasm,
airway edema &amp;
resistance
• Smooth muscle
relaxation
168
Q

Short-acting β-2

agonist (SABA) Indications

A 
• # 1 for acute
exacerbation (most
effective &amp; fastest
acting)
• Hyperkalemia
• Terbutaline also for
delaying premature
labor•
2. COPD
169
Q

Short-acting β-2

agonist (SABA) administration

A

•• Inhaled
• Terbutaline PO &
subq as well

170
Q

Short-acting β-2

agonist (SABA) s/e?

A
  • β-1 cross reactivity
  • Tachycardia
  • Muscle tremors
  • Hypokalemia
  • Anxiety
171
Q

Short-acting β-2

agonist (SABA) CI

A

Cardiac arrythmias

172
Q

Short-acting β-2

agonist (SABA) special considerations

A

Safe in pregnancy (does

not cross placenta)

173
Q

Anticholinergics name & moa?

A 
Ipratropium
(short acting)
Counteracts
vagal mediated
bronchoconstriction
• Central
bronchodilator
• Synergistic with β-2
agonists
174
Q

Anticholinergics indications?

A 
Most useful if given
within 1st hour in asthma; Preferred over shortacting
β-2 agonists in
COPD
• Combination therapy
shows greatest response
175
Q

Anticholinergics administration?

A

Inhaled

176
Q

Anticholinergics S/e?

A

Anticholinergic effects:
• Thirst
• Dry mouth
• Urinary retention

177
Q

Anticholinergics CI?

A

Glaucoma

• BPH

178
Q

Systemic

corticosteroids names & Moa

A 
Anti-inflammatory
• Prevents
bronchoconstriction
• ↑ smooth muscle
relaxation
• Inhibits cytokine
production

Methylprednisolone
Prednisolone
Prednisone

179
Q

Systemic

corticosteroids indications?

A

Onset 4-8 hours

180
Q

Systemic

corticosteroids administration?

A
  • PO

* IV

181
Q

Systemic

corticosteroids S/E

A

Worsens infections
• Hyperglycemia
• Fluid retention

182
Q

Systemic

corticosteroids CI

A

Serious infections

183
Q

Systemic

corticosteroids special considerations

A 
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
184
Q

Epinephrine Moa? indications? Adminstration

A

Rapid bronchodilation, Use in emergency
airway obstruction, Inhaled
• IM

185
Q

What is Bronchiectasis

A

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

186
Q

BRonchiectasis -dx?

A

CXR – linear (“tram track”) lung markings, atelectasis, dilated and thickened airways “Plate-like” atelectasis (scarring)

Gold standard diagnosis is – CT of the chest

187
Q

Tx of bronchiectasis

A

Ambulatory oxygen, aggressive antibiotics, CPT (chest physiotherapy = bang on the back) and eventually lung transplant

188
Q 
Inhaled
corticosteroids (ICS) Drug class &amp; names
A 
Long term, maintenance 
Beclomethasone
Budesonide (COPD)
Flunisolide
Fluticasone (COPD)
Mometasone
Triamcinolone
189
Q

Inhaled

corticosteroids (ICS) MOA?

A 
Anti-inflammatory
• Prevents
bronchoconstriction
• ↑ smooth muscle
relaxation
• Inhibits cytokine
production
190
Q

Inhaled

corticosteroids (ICS) indications? Adminstration?

A

1 for maintanence; inhaled ; COPD-Not mono therapy Add to long acting β-2
agonist (LABA) if good
response with inhaled
corticosteroids

191
Q

Inhaled

corticosteroids (ICS) side effects?

A 
Fewer SE than with
systemic steroids
• Oropharyngeal
candidiasis
• Hoarseness
• Hyperglycemia
Osteoporsis
(long term use)
192
Q

Inhaled

corticosteroids (ICS) CI ?

A
  • Acute bronchospasm

* Status asthmaticus

193
Q

Inhaled

corticosteroids (ICS) special considerations?

A 
Use spacer &amp; rinse
mouth after use to help
prevent oropharyngeal
candidiasis; COPD 
frequently administered
in combination with LABA
(eg. fluticasone/salmeterol,
budenoside/formoterol)
194
Q 
Long-acting β-2
agonist (LABA) Drug class and names?
A
  1. Formoterol
    Salmeterol
  2. Long term, maintenance
195
Q

Long-acting β-2

agonist (LABA) MOA?

A

Bronchodilator with
same MOA as short
acting

196
Q

Long-acting β-2

agonist (LABA) Indications

A 
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
197
Q

Long-acting β-2

agonist (LABA) adminstration? SE?

A 
Inhaled powder; • β-1 cross reactivity
• Tachycardia
• Muscle tremors
• Hypokalemia
• Anxiety
198
Q

Mast Cell Stabilizers names?

•

A

Cromolyn

Nedocromil

199
Q

Mast cell stabilizers MOA?

A 
Inhibits mast cells
and leukotrienemediated
degranulation
• Prevents release
of inflammatory
mediators
200
Q

Mast cell stabilizers indications and administration

A

• Exercise-induced
bronchospasm
• Asthma maintanence; Inhaled

201
Q

Mast cell stabilizers se? CI?

A
  1. Throat irritation, Dysgeusia (lack of taste or decrease sensitivity of taste), N/V
202
Q

Leukotriene

Inhibitors Drugs? Moa?

A 
Zilueton; Inhibits
5-lipoxygenase which
blocks leukotriene
production
• ↓ airway
inflammation
203
Q

Leukotriene

Inhibitors Drugs Indications?

A

PO prophylaxis >12 yo

204
Q

Leukotriene

Inhibitors Drugs se & CI?

A

Hepatotoxic; Liver disease

205
Q

Leukotriene receptor

antagonists names ?

A

Montelukast

Zafirlukast

206
Q

Leukotriene receptor

antagonists Moa?

A 
Inhibits leukotriene
binding to its
receptors
• ↓ airway
inflammation
207
Q

Leukotriene receptor

antagonists indications?

A

Useful in patients
with allergic rhinitis or
aspirin-induced asthma

208
Q

Leukotriene receptor

antagonists administration?

A

PO
• Good for kids who
have trouble with
inhalers

209
Q

Leukotriene receptor

antagonists s/e

A
  • Headache

* Gastritis

210
Q

Methylxanthines names?

A

Theophylline

211
Q

Methylxanthines MOA?

A 
Bronchodilator that
improves respiratory
muscle endurance
• Strengthens
diaphragm
contractions
212
Q

Methylxanthines indications? administration?

A

Long term asthma
prevention; Used only in refractory
cases for copd ; PO

213
Q

Methylxanthines se?

A 
• N/V
• Anxiety
• Diarrhea
• Headache
• Toxicity causes
arrhythmias, seizures
214
Q

Methylxanthines special considerations?

A 
• 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
215
Q

Oxygen moa and indications?

A 
Decreases hypoxiamediated
pulmonary
vasoconstriction; Only medical therapy
shown to ↓ mortality
• Use with cor pulmonale
or O2 sat <88% or PaO2
< 55 mmHg
216
Q

Outpt CAP
≤65 yo
Otherwise healthy
No Abx in 3 mo MC etiology? Other etiology? Treatment?

A
  1. S. pneumoniae
  2. Mycoplasma, C.pneumoniae, Viral, H. flu
  3. Macrolide or doxy ex. Azithro or doxy
217
Q

Outpt CAP
>65 yo or comorbidity (COPD,
HF, RF, liver dx, ETOH) or Abx
within 3moMC etiology? Other etiology? Treatment?

A
  1. S. pneumoniae 2. H. flu (COPD), Aerobic gram negative rods, (Klebsiella in ETOH), S. aureus, Legionella
  2. Fluoroquinolone or
    β-lactam + macrolide/doxy
    ex. Levo/moxi or augmentin +
    azithro/doxy
218
Q

CAP requiring admission MC etiology? Other etiology? Treatmen

A
  1. S. pneumoniae 2. H. flu, Anaerobes, Aerobic gram negative rods, Legionella, Chlamydia
  2. Fluoroquinolone or
    antipneumococcal
    β-lactam + macrolide/doxy
    ex. Levo/moxi or ceftrixone +
    azithro/doxy
219
Q

Hospital/institution acquired MC etiology? Other etiology? Treatmen

A 
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
220
Q 
Critically ill
ICU
Not improving with initial
therapy
MC etiology? Other etiology? Treatment
A
  1. MRSA
  2. Add vanco or linezolid,
    broaden gram negative
    coverage
221
Q

● Most common cause of pneumonia in HIV/AIDs?

A

Strep pneumoniae

222
Q

when does Pneumocystis jiroveci (PCP) occurs?

A

low CD4 count <200, elevated LDH, indolent/atypical,

progressive SOB, exercise-induced hypoxia

223
Q

tx for pcp, 1st line, 2nd line ?

A
  1. First-line therapy is TMP-SMX
  2. 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

PANRE (15 decks)

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