Pulmonology -10% Flashcards
Acute Bronchiolitis
eti, sxs, dx
MCC RSV - fall and winter months
Infants and young children
Sxs:
- tachypnea
- respiratory distress
- expiratory wheezing
Dx:
- nasal washing for RSV culture antigen assay
- CXR - normal
Acute Bronchiolitis
Tx
Hospitalization if
- O2 Sat < 95-96%
- < 3mos old
- RR > 70
- nasal flaring
- retractions
- atelectasis on CXR
Supportive Tx —>
- humidified O2,
- antipyretics,
- B agonist (albuterol),
- neb racemic epinephrine, and
- steroids
O2 is only tx to improve
Ribavirin for severe lung or heart dz in IMC pts
Acute Bronchitis
Cough > 5 days; lasts 1-3 wks
MC Viral/Rhinovirus or Coronavirus, Bacterial - M catarrhalis
Chronic Lung pt - H influ, S pneumo, M. catarrhales
Sxs:
- Cough NO fever ( if + then consider PNA) w/ sputum
- concurrent URI
Dx - clinical - diffuse lung sounds
- if focal lung sounds = CXR
Tx:
- Supportive - NSAIDs, nasal decongestants (Afron), inhaled ipratropium analgesics
- NO ABX
Acute Epiglottitis
dx, tx
X ray lateral film - Thumbprint sign
Secure airway - get cultures for H influ
Tx:
- intubation
- supportive care
- Ceftriaxone* Tx as outpatient if stable
Acute Epiglottitis
eti, sxs
EMERGENCY - Supraglottic inflammation
airway obstruction d/t H. influenzas type B (Hib)
MC unvaccinated children
Sxs: 3 Ds of epiglottis
- Dysphagia
- Drooling
- Respiratory Distress
- tripoding
ARDS
dx
ABG PaO2 and FIO2 ratio - not responsive to 100% O2
- mild 200-300
- mod 100-200
- severe <100
CXR
- bilateral infiltrates => white out pattern
- spares CP angles
Cardiacs Cath of plum artery
- Pulm cap wedge pressure (PCWP) < 18 mmHg = ARDS
- if > 18 mmHg - Cardiopulm edema
Acute Respiratory Distress Syndrome
eti
ARDS - respiratory failure characterized by fluid collecting in lungs = no O2
incr permeability of alveolar-capillary membrane -> development of protein rich pulp edema (non cariogenic pulm edema)
can also be d/t critically ill pts or those with significant injuries I.e. sepsis, severe trauma, aspiration of gastric contents, near drowning
ARDS
sxs
- Severe SOB - unable to breath independently w/o ventilator
- rapid onset of profound dyspnea occurring w/in 12-24 hrs after precipitating event
- Tachypnea
- pink frothy sputum crackles
ARDS
tx
Tx underlying cause
PEEP lowest setting to maintain PaO2 > 60 mmHg and keep O2 sat > 90%
often fatal
Asthma dx
- PFT - dec FEV1, decr FEV1/FVC ratio
- Methacholine challenge test >/= 20% dec in FEV1 Bronchodilator test >= 12% incr in FEV1
- Peak Expiratory Flow Rate used in ED (nl is 400-600) PEFR >15% from initial attempt = response to tx
Severity
- Intermittent
- Daytime < 2/wk but <1d; nocturnal = 2/mo
- FEV1 > 80%
- Mild Persistent
- Daytime > 2/wk but <1d; nocturnal > 2/mo
- FEV1 > 80%
- Mod Persistent
- Daily sx; exacerbation >/=2 / wk, nocturnal > 1/mo
- FEV1 > 60% < 80%
- Severe Persistent - cont daytime sxs, limited physical activty
- FEV1< 60%
Asthma
eti
Chronic, reversible, hyperresponsiveness, inflammatory airway disease w/ recurrent attacks of breathlessness and episodic wheezing
Sxs:
- Atopy - eczema
- asthma’s triad
- nasal polyps
- ASA/NSAID allergy
Asthma
sxs
SXS: triad of dyspnea, wheezing, cough chest tightness
PE
- prolonged expiration with wheezing
- hyperresonance to percussion
- tachycardia
- tachypnea
Early Phase
- Bronchospasm - mucosal edema - minutes to 1-2hrs, responds to bronchodilators
Late Phase
- mucosal inflammation and incr mucus production, recurrent sxs
- occurs 4-6 hrs
- nebs no response
- need CS tx
Asthma
tx
Categorization
Mild intermittent - (<2x/wk or < 2n/mo) -
- SABA PRN - Albuterol
Mild Persistent (>2x/wk or 3-4 n/mo)
- low dose ICS daily = Albuterol + Fluticasone (or budesonide - only neb one)
Mod Persistent - (Daily sx or > 1n/wk)
- Low dose ICS + LABA Daily Med dose ICS + LABA daily
- Salmeterol or Formoterol (LABA) = never use as monotherapy, usu added to ICS (advair)
Severe Persistent (sx sev x / d and nightly)
- High dose ICS + LABA qd High dose ICS + LABA + PO steroids
Acute exacerbations O2 Neb SABA Ipatropium bromide PO steroids (5-7 days)
COPD
dx, tx
Dx
- CXR - hyperinflation, parenchymal bullae, blebs are pathogno
- Spirometry - smokers >45yo, or >10yrs pack year
- FEV1 / FVC ratio < 0.7, non reversible
- Gold criteria - all FEV1/FVC < 0.7
- Gold 1 - FEV1 >80%
- Gold 2 - FEV 1 > 50 & <79
- Gold 3 - FEV1 > 30 & < 49
- Gold 4 - FEV1 <30
Tx - assessment test - CAT <10 (Group A and C)
-
Group A - SAMA or SABA =
- albuterol or ipatropium = both Atrovent, Combivent
-
Group B - LAMA or LABA or both =
- Triotropium or Salmeterol - LABA can be used as monotherapy or + LAMA
- Group C - LAMA > LABA or BOTH or ICS/LABA
- Group D - LAMA/LABA +/- ICS
Oxygen therapy - only treatment that prolong survival****
COPD
Eti, sxs
Chronic Bronchitis - cough > 3 mos for at least 2 years
- blue bloaters
- purulent sputum, cyanotic (R sided HF)
- wheezes common
Emphysema - destruction of alveolar-capillary membrane; thin, smoker
- *doesn’t smoke (pure emphysema from alpha trypsin deficiency 20-50yo)
- pink puffers, barrel chested
- clear sputum, no breath sounds, no cough
Sxs
- Early dz - tobacco smoke, prolonged expiration, wheezes
- Late dz - inr AP chest diameter
- decr tactile fremitus
- hyperresonance
- decr breath sounds
Croup
Eti:
- Infection of upper airway - obstructs breathing causing barking cough
- MCC - parainfluenza virus
- Children 6mos-3yo, fall - early winter mos
sxs
- barking cough
- stridor
dx
- Steeple sign on PA CXR
tx
- supportive - air humidifier
- antipyretics
- Severe - IV Fluids, neb racemic epi, steroids (Dexamethasone)
Curb-65 Score
Hospitalization for Pneumonia Severity
- Confusion
- Urea > 7 or BUN > 20
- RR > 30
- BP < 90/60
- Age > 65yo
0-1 = low risk
2 = probable admission vs close outpt mgmt
3-5 = admission & manage as severe
Cystic Fibrosis
Autosomal recessive = abn chloride ch transport = altered water andchloride across cells = produce abn mucus that obstructs glands and ducts
Sxs
- Sinusitis in infancy, nasal polyposis**
- bronchitis & pneumonia -> bronchiectasis** Pseudomonas
- Meconium ileus
- FTT
- pancreatic insufficiency - steatorrhea
- infertility M>W
Dx
- Newborn Screening for CF
- Quantitative pilocarpine iontophoresis aka Sweat test = incr sodium and chloride levels > 60 mmol/L
- confirm w/ genetic testing
Tx
- CF regional center
-
Mucociliary clearance = mucolytics - hypertonic saline and Dnase
- Chest PT
- clear pulm infx aggressively
- pancreatic enzyme replacement
- psychological support
- Transplant - option but NOT a cure
- Spec meds = Ivacaftor, Lumacaftor, Tezacaftor
Foreign Body Aspiration
MC in mainstem or lobar bronchus R>L and d/t food
RFs - institutionalization, advanced age, poor dentition, etoh, sedative use
Sxs: Presentation depends on location of obstruction
- Inspiratory stridor - high in airway
- wheezing and decr breath sounds - low in airway
Dx
- Expiratory CXR - hyperinflation to affected side
- ABG - eval ventilation
Tx
- Remove foreign body with bronchoscope
- Rigid bronchoscopy in children
- Flexible is diagnostic and therapeutic in adults
Hemoptysis
eti, sxs
Coughing up blood - airway bleeding
MCC
- Bronchitis - hemoptysis, dry cough, cough with phlegm
- Tumor mass - hemoptysis, chest pain, rib pain, tobacco hx, wt loss, clubbing
- Tuberculosis - hemptysis, chest pain, sweating
Sxs:
- blood stained mucus or blood from bronchi, larynx, trachea, or lungs
- Bronchial capillaries rupture d/t acute infx (viral/bacterial bronchitis, bronchiectasis, cig smoking)
- Tiny blood vessles broken
- Vascular engorgement w/ erosions in Pulm HTN or masses
Hemoptysis
dx, tx
Dx
- Cytology
- Sputum/expectorant examination
- Fiberoptic bronch - for CA tissue
- biopsy
- bronchial lavage
- brushing
- Rigid bronch - massive bleeding - better suctioning and airway maintenance capabilities
- High Res CT - pathophys
Tx
- massive hemoptysis - aggressive early consult with pulmnologist
- ABCs - airway maintenance is vital - primary COD d/t aspyhixation
Horner’s Syndrome (Lungs CA)
Cervical sympathetic chain
- unilateral facial anhidrosis (no sweating)
- ptosis
- miosis
Hyaline Membrane Disease
Premature infants - babies born before lungs are producing enough surfactant.
MCC respiratory disease in preterm babies < 30wks
Sxs
- tachypnea
- intercostal retractions
- SOH w/ grunting sounds
- nasal flarings
Dx
- resp acidosis
- CXR - ground glass appearance, diffuse bilat atelectasis
Tx
- antenatal steroids 24-48 hrs of birth - bethametasone IM x 2
- artificial surfactant through endotrach tube
- Mech vent PP
Idiopathic Pulmonary Fibrosis
Restrictive Pulm diseases
Chronic progressive lung disorder from increase scarring = reduces Lung capacity
MC all interstitial lung disease
Sxs
- DOE
- Thoracic pain + dry cough
- Inspiratory crackles, clubbing of fingers
Dx
- PFT = decr lung volume and normal FEV1/FVC ratio; restrictive
- CXR - fibrosis
- CT = diffuse patchy fibrosis, honey combing, ground glass opacities
Tx
- Corticosteroids, O2
- eventually lung transplant * only cure
Influenza
Viral respiratory infx by orthomyxovirus (three strains A, B, C)
sxs
- fever, coryza, cough, headache, malaise
- uncomplicated - body aches and fever
- complicated - dyspnea + above
Dx
- rapid antigen test in clinic
- rapid serology more accurate
- CXR - bilateral diffuse infiltrates
Tx
- symptomatic for most
- antivirals w/in < 48 hrs
- Tamiflu/Oseltamivir or Zanamivir/Relenza for influ A & B
- Zanamivir - c/i in kids < 7yo powder
- Tamiflu/Oseltamivir or Zanamivir/Relenza for influ A & B
- Prevent yearly vaccine - trivalent/quadvalent killed or live attenuated intranasal
- Gullain Barre or egg allergy
Light’s Criteria
Pleurocentesis to determine if Pleural fluid is exudative:
- Pleural fluid protein / serum protein >0.5
- Pleural fluid LDH / Serum LDH >0.6
- Pleural fluid LDH > 2/3 ULN serum LDH
Exudative - infection, malignancy, immune,
MCC - pna, CA, PE, TB
Lung Cancer - Adenocarcinoma
35-40% of cases
MC type of bronchogenic carcinoma 30-40%
MC mucous cells
non-smoker w/ incidental finding and small peripheral lesion
Lung Cancer - Carinoid
1-2%
tumor that produces excess serotonin (niacin B3 deficiency)
Pink purple leasion in the central airway
resistant to chemo/radiation
surgical excision
Lung Cancer
eti, sxs, dx
Two major categories
- Small Cell Lung Cancer (SCLC) - 15% and poor prognosis
- Non-Small Cell Lung Cancer (NSCLC) - 85%
- Ad
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
- carcinoid tumor
Sx
- Cough
- Dyspnea,
- chest pain
- hemoptysis - airway involvement
- Wt loss - B signs - weight loss, fever, nt swts
Dx
- CXR to screen
-
Bronchoscopy and biopsy or FNA - gold standard
- Squamous Cell or SCLC - central mass
- Adenocarcinoma - peripheral mass
- LC and Carcinoid - throughout lungs
- TNM Staging
Lung Cancer - Large Cell
rare 5%
rapid doubling time
rarely response to surgery
peripheral
Lung Cancer - SCLC
15% ; Highly aggressive
always occurs in smokers
rapidly growing, mets by dx ; mediastinal mass
cannot be tx with sx, needs chemo/XRT
a/w
- ACTH and ADH - hyponatremia and hypercalcemia
- Lambert-Eaton myasthenic syndrome - muscle weakness of limbs d/t ACTH/ADH
- SVC syndrome
- Horner syndrome
- SIADH - decr Na
Lung Cancer - Squamous Cell Carcinoma
25-35% of cases
Bronchial in origin and centrally located mass
MC in smokers
likely to have persistent cough, recurrent PNA, hemoptysis,
central bronchus solitary tumor
** Hypercalcemia ** paraneoplastic syndrome
Lung Cancer
Treatment
NSCLC
Surgical resection
Adj chemo and Radiation if advanced (Stage 4 = palliative (mets)
SCLC
chemo only
5 year prognosis = 15%
Pancoast Syndrome
A/w Squamous Cell Carcinoma
tumor at lung apex, apical mass
crushes brachial plexus + cervical sympathetic chain
- Shoulder pain
- UE weakness
- Horner’s syndrome - miosis, anhidrosis, ptosis
Pertussis
Whooping cough - severe hacking cough followed by high pitched intake of breath (sounds like whoop)
Gram neg bacteria = Bordetalla pertusis
Consider in adults with cough > 2 wks, patients < 2yo
- catarrhal stage - cold like sxs, poor feeding, sleeping
- Paroxysmla stage - high pitched inspiratory whoop
- Convalescent stage - residual cough (100 days)
Dx - Nasopharyngeal swab of secretions and culture
Tx - with Macrolide (clarithomycin/azithromycin)
- supportive care w/ steroids + B2 agonists
- vaccinations
- 5 doses - 2, 4, 6, 15-18mos, 4-6 yrs (DTap)
- 11-18 yo = 1 dose Tday
- Expectant mothers Tdap each pregnancy at 27-36 wks
Pleural Effusion
Accumulation of excess fluids in pleura space
Sxs
- dyspnea
- vague discomfort or sharp pain that worsens during inspiration
- decrease tactile fremitus, decr absent breath sounds
Dx
- Determine whether pleurocentesis
- exudative (infection, malignancy, immune) or
- transudative (transient changes in hydrostatic pressure - cirrhosis, MCC CHF, nephrotic syndrome, ascites, hypoalbuminemia
-
Lateral decubitis CXR
- Isolated L Pleural effusion = exudative
- R sided = transudative
- Chest CT
- US - guided thoracentesis - gold
Tx
- Thoracentesis
Pleuritic Chest Pain
Inflammation of tissues that line lungs and chest cavity (pleura)
sudden, intensely sharp , stabing, burning pain in chest when inhaling and exhaling
exacerbated by deep breathing, coughing, sneezing, or laughing
MCC - PNA, pericarditis, pericardial effusion, pancreatitis
Pneumonia - Bacterial
S pneumo > H influ > Moraxella catarrhalis = show on gram stain
Atypical - Legionella, Mycoplasma pneumo, Chlamydophila pneumo
Sxs
- fever, dyspnea, cough, myalgias, rigors/sweat, new cough
- +/- sputum - rust - pneumococcal
- S pneumo - single rigor, pleurisy
- H influ - underlying COPD
- Legionella - high fever, hypoNa, bad abd pain + diarrhea, appears more ill than CXR
- M. pneumo - walking pneumo, extrapulm sxs bullous myringitis (bloody TM)
Dx
- CXR - Patchy, segmental lobar, multilobar consolidation
- Blood cultures x 2 - only inpatient
- Sputum gram stain
Tx
- Outpatient - macrolides (azithromycin), Doxy, resp FQ (Levofloxacin)
- Pneumococcal => tx until pts afebrile for 72 hrs (x5d)
- atypical pna (legionella, pertussis) => x 2-3 wks
- Inpt - Ceftriaxone + azithromycin, or resp FQs
- Prevnar and Pneumovax - vaccines
PNA - Fungal
Common in IMC pts (AIDS, steroid use, organ transplant)
Coccidiodes (valley fever)
- non remitting cough/bronchitis non responsive to conventional tx
- Fungal inhalation in Western States
- Dx with ELISA for IgM and IgG
- Tx with fluconazole/itraconazole
Pulmonary aspergillosis - health immune systems
- fluconazole/itraconazole
Cryptococcus - soil, disseminate and amenintitis
- LP for meningitis
- Tx with amp B
Histoplasmosis - apical pulmonary lesions resembling cavitary TB, worsening cough and dyspnea, progression to disabling respiratory dysfx
- bird or bat droppings - Mississippi Ohio River Valley
- Signs - mediastinal or hilar LAD (sarcoid)
- tx with amp B
HIV - PJP (Pneumocystis jiroveci) -Common in HIV pts with CD4 count < 200
- CXR - diffuse interstitial or bilateral perihilar infiltrates
- dx - bronchoalveolar lavage PCR, labs, HIV tests, low O2 despite supplemental oxygen
- Tx with bactrim and steroids
PNA - Viral
Adults - Flu MC
Kids - RSV
quick onset
Dx
- CXR - bilateral interstitial infiltrates
- rapid antigen testing for flu
- RSV nasal swab
- cold agglutinin titer negative
Tx
- Flu with Tamiflu (A & B) if sxs < 48hrs onset
- symptomatic tx = B2 agonists, fluids, rest
Pneumoconiosis
Restrictive Lung Diseases
Pulmonary fibrosis with a known cause
Abestosis
- Insulation, demolition, construction
- CXR - reticular, linear pattern, w/ basilar predominancy, opacities, honeycombing
- can turn into mesothelioma
Coal Workers
- coal mining,
- Nodular opacity in upper lung fields; hilar adenopathy not necessarily prominent
Silicosis
- mining, sandblasting, stone or quarry work
- eggshell calcification of hilar nodes
- incr risk of TB and progression to massive fibrosis
Berylliosis
- high tech fields, nuclear power, ceramics, foundries
- diffuse infiltrates, hilar adenopathy
- req’s chronic steroids
Pneumothorax
Collapsed lung caused by accumulation of air in pleural space
Spontaneous vs traumatic
- primary - abs of underlying dz (tall, thin, male age 10-30 at greater risk), smoker
- Secondary - presence of underlying dz (COPD, asthma, CF, ILD)
Acquired
- Iatrogenic
- Traumatic -> penetrating or blunt trauma
- Barotrauma - mechanical ventilation
SXS:
- Acute onset ipsilateral chest pain and dyspnea - decreased tactile fremitus
- deviated trachea
- hyperresonance
- Diminished breath sounds
Tx - depends on size
- small < 15% of diameter of hemithorax - resolves spontaneously w/o chest tube placement
- large > 15% diameter & symptomatic - chest tube placement
- Serial CXR q 24 hrs until resolve
Pulmonary Embolism
eti, sxs
blockage in one of pulmonary arteries in lungs
MCC - deep veins of LEs
RF:
- Virchow’s Triad
- Hypercoagulable state (sx, CA, OCP, preg, smoking, long bone fracture)
- Venous stasis
- Epithelial injury
Sxs
- Dyspnea MC
- pleuritic chest pain
- Tachycardia –> EKG with S1Q3T3, non spec ST waves
- Tachypnea
Pulmonary Embolism
Treatment
Hemodynamically stable
- Anticoags
-
UFH or LMWH => Warfarin - 3 mos bridge with heparin 3-5 days
- INR range 2-3
- LMWH and hep for cancer and pregnant patients**
- factor Xa inhibitors Rivaroxaban or PO Direct Thrombin Inhibitors Dabigatran
-
UFH or LMWH => Warfarin - 3 mos bridge with heparin 3-5 days
- Minimal antigoag for 3 mos w/ reversible RFs
- if unprovoked - 6 mos then reeval
- If two eps unprovoked - long term anticoag
- IVC filter - stable pt who can’t take anticoags or unsuccessful
UNSTABLE
- Thrombolectomy - if unstable or massive PE
Respiratory Syncytial Virus
MCC LRTI in children - get by age 3
leading cause of PNA and bronchiolitis
sxs
- Rhinorrhea
- wheezing/coughing that persists for months
- low grade fever
- nasal flaring/retractions
- nail bed cyanosis
Tx
- hospitalization if
- tachypnea w/ feeding difficulties
- visible retractions
- O2 Sat <95%
- Supportive care
- albuterol via neb
- antipyretics
- humidified O2
- Steroids (controversial)
- Resolves in 5-7 days
Vaccines for children with lung issues or premature –> synagis prophylaxis (palivizumab) 1x/m for 5 mos in Nov
Sarcoidosis
Restrictive Lung Disease
Granulomatous disease => noncaseating granulomas that affects multiple organ systems
20-40yo, Northern europeans or AAs
Sxs
- fever, weight loss, arthralgias, erythema nodosum
Dx
- Hypercalcemia; ACE levels x 4 UNL
- ele ESR
- Biopsy of peripheral lesions or fiberoptic bronch for central pulm lesions
- Serial PFT for progression
Tx
- Corticosteroids, methotrexate, immunosuppressive meds
- ACE-I for periodic HTN
Screening for Lung Cancer
USPSTF
Annual low dose CT, if
- 55-80 yo
- >30 pack year hx
- current smokers or
- quit within last 15 years
Incidental finding on CXR
- send for CT
- if suspicious - need bx
- Ill defined borders, lobular or spiculated = cancer
- If not suspicious < 1cm
- monitor q 3mos, 6 mos, yearly for two years
- calcifications, smooth, well defined edges = benign
Mets- Adeno and Small cell = BRAIN METS
bone
SVC Syndrome
a/w SCLC
obstruction of SVC by tumor resulting in
- facial fullness
- JVD
- dilated veins in anterior chest
Tension PTX
penetrating injury -> air in pleural space increasing and unable to escape
Mediastinal shift leading to TRACHEAL deviation to contralateral side or severe JVD
CXR = pleural air
ABG = hypoxemia
medical emergency - large bore needles to allow air out of chest
Needle decompression - 2nd ICS, midclavicular line, above rib
Tuberculosis
eti, sxs, dx
Mycobacterium tuberculosis
RF - endemic area, IMC (HIV), recent immigrants (<5yo), prisoners, health care workers
transmission - inhalation of aerosolized droplets
Sxs:
- fatigue, productive cough, bloody sputum
- night sweats, wt loss, post tussive rales
- miliary TB = spread outside lungs - neuro or GI
- vertebral column (Pott disease)
Dx:
- Sputum for AFB smears - have to be 3 AFB negatives
- NAAT - quicker dx
- CXR - cavitary lesions, infiltrates, ghon complexes in apex of lungs
- Bx - caseating granulomas
Tuberculosis
Treatment
Empiric tx
PPD + & CXR negative - latent TB => Isoniazid 9 mos +B6 for neuropathy
PPD + & CXR positive - active TB => quad therapy (RIPE) x2 mos, then 2 drugs for 4 mos
- Rifampin - red orange urine, hepatitis
- Isoniazid - perip neuropathy (B6 pyridoxine 25-50mg/day)
- Pyrazinamide - hyperuricemia (gout)
- Ethambutol - optic neuritis (eye changes), red green blindedness
Need two negative AFB smears and cultures to stop therapy
Prophy isoniazid for household members - for 1 year
dc therapy if transaminases > 3-5 x ULN
Tuberculosis
Screening
PPD - Tb skin test
Mantoux Test Rules - tests positive if
- >5mm at high risk, fibrotic changes on CXR, IMC HIV/Drugs, steroids/TNF antagonist daily, or close contact w/ infectious TB
- > 10mm in pts < 4yo, and risk factors = health care facilities, IVD, recent immigrants with high prevalence, renal insufficiency, prison, homeless shelter, bypass surgery
- > 15mm if no other risk factor
Well’s Criteria
PE - dx
Negative suspicion - rule out
