INH x 9 months OR RIF x 4 months

Pulmonology Flashcards by Jessica Jordan

Leading cause of morbidity and mortality worldwide

pneumonia

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Common bacterial etiologies of typical pneumonia

Streptococcus pneumoniae

H. influenzae

Moraxella catarrhalis

Staphylococcus aureus

Klebsiella pneumoniae

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Common bacterial etiologies of atypical pneumonia

Mycoplasma

Legionella

Chlamydia

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Viral etiologies of pneumonia

Influenza virus

Respiratory syncytial virus (RSV)

Adenovirus

Parainfluenza virus

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Pneumonia most commonly seen in alcohol abuse

Klebsiella pneumonia

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Pneumonia associated with air conditioning/ aerosolized water

Legionella pneumonia

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Pneumonia most commonly associated with COPD

Haemophilus pneumoniae

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Patient presents with

productive cough
purulent sputum
ill/toxic appearance
rigors, fevers, rales
pleuritic CP
tachypnea

What do you suspect?

Typical pneumonia

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Patient presents with

Dry cough
Clear sputum
Acutely ill
PE > CXR
HA, sore throat, earrache, wheeze, malaise

What do you suspect?

Atypical pneumonia

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Typical pneumonia

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Atypical pneumonia (MC mycoplasma)

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Empirical abx tx of CAP for previously healthy patients with no use of antimicrobials within the previous 3 months

Macrolide

Azithromycin 250 mg
2 PO tbas today and 1 tab PO daily x 4 days

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Empirical abx tx of CAP in the presence of comorbidities such as chronic heart, lung or renal disease; DM; alcoholism; cancer; asplenia; immunosuppression; or use of antimicrobials within the previous 3 months

Fluoroquinolone OR beta-lactam

Levofloxacin 750 mg PO Q 24 hours x 5 days

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CURB-65 admission criteria?

Confusion- AMS

Uremia (BUN >20 mg/dL)

Respiratory rate (>30 breaths per min)

Blood pressure (<90 sys or <60 diastolic)

>65 yo

Score
0-1 = outpatient
2 = admission to medical ward
3 or higher = admssion to ICU

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Tuberculosis etiology

Mycobacterium tuberculosis

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True or False

Latent TB infection (LTBI) is considered infectious

False

These patients are not considered to be infectious nor can they spread the disease

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Patient presents with fever, drenching night sweats, anorexia, and weight loss. He also complains of pleuritic chest pain, dyspnes, and hemoptysis. Patient appears malnourished. What do you suspect?

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CXR shows cavitations with progressive disease, homogeneous infiltrates, hilar/paratracheal lymph node enlargement

primary TB

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Caseating granulomas (aka necrotizing granulomas) is the histologic hallmark for…

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List 4 antituberculous drugs

Isoniazid (INH)

Rifampin (RIF)

Pyrazinamide (PZA)

Ethambutol (EMB)

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LTBI tx

INH x 9 months

RIF x 4 months

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Active TB tx

INH/RIF/PZA/EMB x 2 months

followed by 4 months of additional multidrug tx

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INH side effects

hepatitis

peripheral neuropathy (coadmin Vit B6 to reduce risk)

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RIF side effects

hepatitis

flu syndrome

orange bodily fluid (urine)

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EMB side effects

optic neuritis (red-green vision loss)

Acute Bronchitis tx

1. Cough supressant (codeine) 2. Short acting beta-agonists 3. NSAIDs 4. NOT antibiotics 5. Decongestants

Patient presents with cough, dyspnea, headache, and expiratory rhonchi or wheezes. CXR is negative. What do you suspect?

Acute bronchitis

Illness of infants and young children- inflammation of the bronchioles

Acute bronchiolitis

"Thumb sign" on lateral neck XR makes you think...

Epiglottits

"Steeple sign" on PA neck film makes you think...

Croup

Croup etiology

**Parainfluenza virus types 1 and 2** RSV adenovirus influenza rhinovirus

Croup tx

Usually self-limiting -stay hydrated Corticosteroids, humidified air/oxygen nebulized epinephrine

Bronchogenic carcinoma is divided into what 2 major categories

* Small Cell Lung Cancer (SCLC) * Non-Small Cell Lung Cancer (NSCLC) * squamous cell carcinoma * adenocarcinoma * large cell carcinoma

SCLC vs NSCLC Which one is more common and which one is more aggressive?

NSCLC is more common (SCLC is 13-15% cases) SCLC prone to early metastasis and aggressive course \*\* **Small** cell lung cancer is a **smaller** percentage of cases, but is typically more **severe**\*\*

Where does SCLC tend to originate

central bronchi tends to metastasize to regional lymph nodes

What are the 3 subgroups of NSCLC? And which is most common?

squamous cell carcinoma (25-35%) adenocarcinoma (**35**-**40**%) large cell carcinoma

Lung cancer that is bronchial in orgin, centrally located mass, and pt is more likely to present with hemoptysis (therefore sputum cytology dx)

Squamous cell carcinoma

This lung cancer usually appears in the periphery of the lung and is not amenable to early detection through sputum examination

adenocarcinoma

SCLC vs NSCLC Tx

* SCLC * combination chemotherapy * patients rarely live \>5 years after dx * NSCLC * surgery * adjuvant chemotherapy may be considered

If a lesion is \>\_\_\_ in size it is referred to as a mass

\>3 cm

Characteristics of **benign** solitary pulmonary nodules

\<30 yo round, oval sharp margins calcified up to 3 cm surrounded by normal tissue

Strongest predisposing factor to asthma is atopy. The atopic triad consists of...

wheeze eczema seasonal rhinitis

3 pathophys components of asthma

obstruction of airflow bronchial hyperreactivity inflammation of the airway

Asthma dx indicated by FEV1/FVC

FEV1/FVC \<75% A \>12% incr in FEV1 after bronchodilator therapy is supportive of dx

Asthma tx

* Step 1 * **SABA** PRN * Step 2 * low-dose **ICS** * Step 3 * low-dose **ICS** + **LABA** * medium-dose **ICS** * Step 4 and above * consult specialist

2 diseases of COPD

emphysema chronic bronchitis

Condition in which the air spaces are enlarged as a consequence of destruction of alveolar septa

Emphysema "pink puffers"

Disease characterized by a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years

Chronic bronchitis "blue bloaters"

Dx studies for COPD

* CXR * hyperinflation and flat diaphragms * Pulmonary * decr FEV1/FVC * CBC * may show polycythemia caused by chronic hypoxemia

COPD management

SMOKING CESSATION anticholinergic inhalers (ipratropium or tiotropium) SABA supplemental oxygen (SaO2 \<88%)

Autosomal recessive disorder that results in the abnormal production of mucus by almost all exocrine glands, causing obstruction of those glands and ducts.

Cystic fibrosis

What are the 4 types of pleural effusions?

1. **Exudative** * Infection, Malignancy, Trauma 2. **Transudative** * ****CHF, renal disease, cirrhosis 3. **Empyema** * ****Infection 4. **Hemothorax** * ****Trauma

Pleural Fluid Analysis * Protein to serum protein ratio \>0.5 * LDH to serum LDH \>0.6 * OR LDH \>2/3 upper limit of normal serum LDH What type of pleural effusion is this?

Exudative

Pleural Fluid Analysis * Protein to serum protein ratio \<0.5 * LDH to serum LDH ratio \<0.6 What type of pleural effusion is this?

Transudative

Pleural Fluid Analysis * WBCs What type of pleural effusion is this?

Empyema

Risk factors for PE- **Virchow's triad**

Hypercoagulable state Venous stasis Vascular intimal inflammation or injury

Approximately ____ % of patients with DVT will experience a PE

50-60%

Patient presents with sudden onset of pleuritic chest pain and dyspnea. Pt is tachycardic and tachypnic. Capnography shows **low** ETCO2 and pt has **low** saO2. What do you suspect?

PE PE = v/q mismatch and gas exchange cannot occur at that area --\> low saO2 and ETCO2

Dx studies for PE

* spiral CT * pulmonary angiography * V/Q scan

EKG changes indicating PE/cor pulmonale | (seen in \<20% of patients)

S₁Q₃T₃

D-dimer test- is it useful for dx PE?

D-dimer = saying "I love you" on the first date... once you say it you cant take it back. D-dimer can be useful especially to rule out PE if clinical suspicion is low and d-dimer is negative

PE tx

* **Anticoagulation therapy** * heparin * factor Xa inhibitors (rivaroxaban, apixaban) * minimum of **3 months** * Vena cava interruption (filter) * PREVENTION * ambulation * compression stockings * heparin

\_\_\_\_ is the most important and potent stimulus of pulmonary arterial vasoconstriction. Other causes include acidosis and veno-occlusive conditions.

Hypoxia

Pt presents with dyspnea, retrosternal chest pain, weakness,edema, and fatigue. Physical exam shoes narrow splitting and accentuation of S2 and a systolic ejection click. EKG may show right ventricular hypertrophy and/or atrial hypertrophy. CXR may show enlarged pulmonary arteries. What do you suspect?

Pulmonary hypertension

Mean pulmonary arterial pressure \>\_\_\_\_\_ mmHg is dx of pulmonary hypertension.

\>25 mm Hg

Pulmonary hypertension Dx studies

CXR EKG Echocardiography - estimate pulm arterial pressure Right heart catherization- more precise

Pulmonary HTN Tx

* Oral anticoagulancts * CCB (decr systemic arterial pres) * Prostacyclin (potent pulm vasodilator) * Heart-lung transplantation * Tx of underlying disorders

Examples of Restrictive Pulmonary Diseases

* Idiopathic pulmonary fibrosis/ fibrosing interstitial pneumonia * Pneumoconioses * Asbestosis * silicosis * berylliosis * Sarcoidosis * Berylliosis

* MC dx among pts with interstitial lung disease * more common in **men** aged **50-75 years** * Sx include dry cough, DOE, fatigue * PE may show **clubbing of the fingers** and **inspiratory crackles** * CT shows diffuse, patchy fibrosis with **_pleural-based honeycombing_** * **normal to increased FEV1/FVC** ratio What do you syspect?

Idiopathic pulmonary fibrosis (IPF)

Term for chronic fibrotic lung diseases caused by the inhalation of coal dust or various inert, inorganic, or silicate dusts.

Pneumoconioses

Pneumoconioses disease most commonly found in those who work in insulation, demolition, and contruction. What are these patients at an increased risk for?

**Asbestosis** Incr risk of lung cancer, **meothelioma** (espicially if a smoker)

Multiorgan disease characterized by **noncaseating granulomatous inflammation**. Approx 90% of pts have lung involvment

Sarcoidosis

Clinical features of this disease include... * respiratory sx- cough, dyspnea, chest discomfort * Extrapulmonary findings * erythema nodosum * enlargement of parotid glands, lymph noides, liver, spleen

Sarcoidosis

Sarcoidosis dx studies

* Serum blood tests * leukopenia * eosinophilia * elevated ESR * hypercalcemia * hypercalciuria * ACE levels are elevated in 40-80% of pts * Radiographic findings * **symmetric bilateral hilar adenopathy** * right paratracheal adenopathy * bilateral diffuse reticular infiltrates * Transbronchial biopsy of the lung or fine-needle node **biopsy confirms dx**

Lung injury marked by acute onset of respiratory insufficiency with hypoxemia and bilateral radiographic infiltrates

ARDS

3 clinical settings account for 75% of ARDS cases: what are those 3 causes?

* **Sepsis** syndrome (single most important) * Severe multiple **trauma** * **Aspiration** of gastric contents other causes include shock, toxic inhalation, near-drowning, and multiple transfusion