Pulmonology Flashcards
Describe the primary pathophysiology of asthma.
Bronchial hyperreactivity, inflammation of airways, increased mucus production.
Define atopy.
The genetic tendency to develop allergic diseases
What is the atopic triad associated with asthma?
wheeze, eczema, seasonal rhinitis
What findings in pulmonary function testing are indicative of asthma?
FEV1:FVC ratio < 75%
< 12% inc in FEV1 after bronchodilator therapy
WHat ABG findings are indicative of severe asthma?
PaO2 < 60 and PaCO2 > 45
When is CXR indicated in the evaluation of an asthma patient?
Only if pneumonia or other Dx is suspected –> asthma will show hyperinflation
How are hand-held peak expiratory flow meters used in the management of asthma?
Can be used at home to estimate variability and quantify the severity of attacks.
When asthma is suspected but spirometry is non-diagnostic, what testing is performed and what result indicates asthma?
Histamine/Methacholine challenge –> FEV1 decrease of more than 20% is diagnostic for asthma.
Describe the pharmacologic options for long term asthma management.
inhaled corticosteroids, cromolyn (MAST cell stabilizer), nedocromil (anti0inflamatory), LABA, leukotriene antagonists (reduce mucus), theophyline.
Describe the pharmacologic options for short term asthma management.
SABAs, systemic corticosteroids, ipratropium bromide (anti-Ach)
What is the most effective anti-inflammatory for the management of chronic asthma?
Inhaled corticosteroids
Describe the 6 steps of therapy recommended in the management of asthma.
1: SABA PRN
2: Low dose inhaled corticosteroid (ICS)
3: Low dose ICS + LABA or medium dose ICS
4: Medium dose ICS + LABA
5: High dose ICS + LABA
6: High dose ICS, LABA, and PO cosrticosteroid
Define normal FEV1:FVC ratio by age.
< 20: 85%
20 - 39: 80%
40 - 59: 75%
>/= 60: 70%
Describe the PFT findings associated with mild, moderate, and severe asthma.
mild: FEV1 > 80% predicted, ratio normal
moderate: FEV1 60-80% of predicted, ratio dec by 5%
severe: FEV1 < 60% predicted, ratio dec by > 5%
What is the cardinal sign of bronchitis?
Cough for at least 1 week
T/F: Color of sputum is predictive of bacterial involvement in bronchitis.
False
Describe how a diagnosis of bronchitis is made.
Mostly clinical –> CXR negative for pneumonia
What supportive therapy may be used in the management of bronchitis?
hydration, expectorants, analgesics, B2 agonists, antitussives
T/F: Non-prescription cough and cold products should not be used in children less than 2.
True
What is the most common etiology of an acute exacerbation of chronic bronchitis and what is the recommended treatment?
Usually bacterial –> empiric first line treatment is 2nd gen cephalosporin, second line is Bactrim or a second gen macrolide (azithromycin/clarithromycin)
When should antibiotics be used in the management of bronchitis?
Elderly, immunocompromised, underlying respiratory disease –> no statistical benefit of antibiotics in healthy patients.
What is the most common etiology of bronchitis not related to a COPD exacerbation?
Viral –> usually adenovirus
Define COPD.
Progressive, largely irreversible airflow obstruction due to loss of elastic recoil and increasing airway
resistance
Describe the relationship of emphysema and chronic bronchitis.
Both are COPDs that usually coexist with one being more predominant than the other.
What are the risk factors for COPD?
Smoking by far #1. Other is alpha 1 antitrypsin deficiency (protects elastin in lungs from damage by WBCs)
What are the hallmark signs of emphysema and chronic bronchitis?
emphysema: dyspnea on exertion
bronchitis: productive cough
Differentiate emphysema from chronic bronchitis in terms of S/S.
Emph: resp alkalosis, matched V/Q, mild hypoxemia and normal CO2, pink puffers (chachexia and pursed lip breathing), hyperresonant with dec lung sounds.
Bronch: resp acidosis, severe V/Q mismatch, severe hypoxemia and hypercapnea, blue bloaters (obese and cyanotic), rhonchi, rales, wheezing lung sounds.
What is the gold standard testing used for diagnosis of COPD?
PFTs/Spiriometry
What value of spirometry is an important prognostic factor in COPD?
FEV1 –> < 1L indicates increased risk of mortality.
What spirometry findings are expected in COPD?
Obstruction: dec FEV1, FVC, and ratio
Hyperinflation: Increased RV, TLC, FRC
What is the most effective choice of bronchodilators in long term management of COPD?
Combo therapy with B-2 agonist and inhaled anti-Ach
What anti-Ach’s are commonly used in the management of COPD?
Tiotropium (Spiriva) - long acting
Ipratropium (Atrovent) - short acting
What are the contraindications of Anti-Ach use in COPD?
Glaucoma and BPH
What B-2 agonists are commonly used in the management of COPD?
Albuterol and terbutaline - short acting
Salmeterol - long acting
What are the contraindications and precautions in the use of B-2 agonists?
CI: severe CAD, precautions: DM, hyperthyroid
Describe the use of theophyline in management of COPD.
B-2 agonist that is rarely used s/p narrow therapeutic window. Smokers require a higher dose.
Describe the use of corticosteroids in management of COPD.
Adjunct - not monotherapy
What is the only therapy proven to decrease mortality in COPD, what is the MOA, and when is it indicated?
O2 –> reduces pulmonary vasoconstriction s/p hypoxia. Use when SpO2 < 88%
What is the first and most important step in the management of COPD?
smoke cessation
What vaccinations are recommended for COPD patients?
Pneumococcal and flu
Why is azithromycin a particularly useful abx in COPD patients?
It has anti-inflamatory properties in the lungs.
How is chronic bronchitis defined?
Productive cough more than 3 months for 2 consecutive years.
Describe the PFT values associated with stage I, II, III< and IV COPD.
I: FEV1 > 80% of predicted
II: FEV1 50-80% of predicted
III: FEV1 30-50% of predicted
IV: FEV1 < 30% of predicted
Describe the management associated with stage I, II, III< and IV COPD.
I: SABA PRN and decrease risk factors
II: SABA PRN + LABA or LAMA
III: SABA, LABA + LAMA, pulmonary rehab, ICS
IV: SABA, LABA + LAMA, rehab, ICS, O2
What two types of cancer make up the vast majority of lung cancers?
Small cell carcinoma (15%)
Non-small cell carcinoma (85%)
What are the primary risk factors for lung cancer?
Smoking, occupational exposures, poor indoor air quality, genetics, oncogenic viruses.
What is the most common type of lung cancer in a non-smoker?
Adenocarcinoma (a type of non-small cell)
Describe the cellular pathogenesis in the development of lung cancer.
normal epithelium –> squamous metaplasia –> dysplasia –> carcinoma in situ –> invasive carcinoma
What symptoms are common in lung cancer and how many symptoms are usually found on initial presentation?
cough, anorexia, weight loss, fatigue, anemia, fever, pain –> more than 80% have at least 3 symptoms
What symptoms usually develop when pulmonary lesions are present.
cough, hemoptysis, dyspnea, chest pain
Define pancoast tumor.
Rare form of lung cancer that forms at the very top of the lung. Invasion to surrounding tissue causes shoulder and arm pain.
What two types of cancer are most associated with smoking?
Small cell carcinoma (highest association) and squamous cell carcinoma
Differentiate small cell carcinoma from squamous cell carcinoma in terms of their location.
Small: always occurs centrally
Squamous: usually central but can be peripheral
When and how does small cell lung carcinoma typically present?
Present at very late stage often as ACTH (Cushing’s Syndrome) or ADH (SIADH) secreting tumors.
Name and describe the most common type of adenocarcinoma.
Bronchioalveolar cell carcinoma (BAC) –> associated with non-smokers, very slow growing, can be mucinous, non-mucinous, or mixed.
What is a carcinoid tumor?
A neuroendocrine tumor (NET) that can be a type of lung cancer.
What is carcinoid syndrome?
Functional NET that secretes a high amount of serotonin causing one or more of: facial flushing, sweating, diarrhea, dyspnea, wheezing, weakness, tachycardia, HTN.
Differentiate between typical and atypical carcinoid tumors.
Typ: slow growing and rarely metastasize
Atyp: faster growing and more likely to met.
Typical accounts for 90% of carcinoid tumors.
In what patients are typical and atypical carcinoids usually seen?
Young, non-smokers
What are the most aggressive types of lung cancer and in what patients are they seen?
Small cell carcinoma large cell neuroendocrine tumors –> both more common in smokers.
What is the definition of a solitary pulmonary nodule?
Asymptomatic lesion <3cm diameter surrounded by normal lung parenchyma
What are the risk factors for a solitary nodule to be malignant?
Advanced age, smoking, prior malignancy
What diagnostic findings indicate a solitary nodule is more likely to be malignant?
- Larger size increases chance of malignancy
- Doubling in size within 400 days inc malignancy
- Lobulated or spiculated borders indicate malignancy
- Ground glass or part solid nodules inc malignancy
- Calcification > 200 hounsfield units
- Location in upper lobes more likely malignant
What are the most common characteristics of a benign lung nodule?
Solid, smooth borders, unchanged in size over two years.
What imaging is used to evaluate pulmonary nodules?
CT initially –> PET scan and biopsy definitive
Which lung cancer patients are best candidates for primary surgical therapy?
Stage 2 and some stage 1. Stage 1 non-surgical candidates get radiotherapy.
Describe the prognosis for small cell lung carcinoma.
Initial response to chemo is very good. But remission tends to be short lived. Two year survival = 20-40% in early stages and 5% in late stages.
What are the most common pathogens responsible for community acquired and hospital acquired penumonia?
CAP: Strep pneumo (H. Flu in Pts with pulm disease)
HAP: Pseudomonas
Differentiate community acquired from hospital acquired pneumonia.
CAP: Not in a hospital, SNF, pneumonia < 48 hours after hospital admission.
HAP: Pneumonia develops > 48 hours after admission
What are the most common pathogens responsible for aspiration pneumonia?
Outpatient: anaerobes
In-patient: Staph aureus and gram neg bacteria
Differentiate between typical and atypical pneumonia.
Typ: Strep pneumo, lobar on CXR, fever, productive cough, pleuritic C/P, PE –> dull percussion, bronchial breath sounds, inc tactile fremitus and egophony.
Atyp: Mycoplasma, diffuse patchy infiltrates on CXR, low fever, dry cough, malaise, sore throat, HA, N/V/D, physical exam normal
Correlate specific types of pneumonia with CXR findings.
Abscess = staph aureus
Right upper lobe with bulging fissure and cavitations = Klebsiella
T/F: Clinicians can track the effectiveness of pneumonia treatment based on improvements in repeat CXRs.
False: CXR resolution lags behind clinical improvement for weeks
Correlate sputum findings to likely pathogen.
Rusty / blood tinged = strep pneumo
Currant jelly = klebsiella
Green = h.flu / pseudomonas
Foul smelling = anaerobes
State the common abx administered for different types of pneumonia.
CAP outpatient: macrolide or doxy (FQ only if co-morbid conditions / recent abx use)
CAP inpatient: B lactam + macrolide OR broad spectrum FQ
CAP ICU: B lactam + macrolide OR B lactam + broad spectrum FQ
HAP (pseudomonas): anti-pseudomonal B lactam, anti pseudomonal aminoglycoside or FQ
Aspiration: clindamycin or augmentin +/- metronidazole
Describe the vaccine recommendations for pneumonia.
PCV 13 = childhood vaccination
PPV 23 Age >65 = revaccinated every 5 years
PPV 23 Age < 65 = revaccinate every 5 years if chronic disease.
What is the most common cause of pneumonia from an atypical bacteria and what is the classic presentation?
Mycoplasma –> aka walking pneumonia
Patients in what circumstances are at risk for contracting Legionella pneumonia and how do they present?
Cooling towers, AC, contaminated water
S/S: anorexia, N/V/D, increased LFTs, HypoNa
What patients are at highest risk for Klebsiella and what is the hallmark finding on CXR?
Alcoholics –> cavitation lesions on CXR
What are the three types of atypical bacteria that cause pneumonia?
Myoplasma, Chlamydia, Legionella
What is the most common location and pathogen in an aspiration pneumonia?
Anaerobes in right lower lobe
What is the most common bacterial pathogen to cause pneumonia in an immunocompromised patient?
Pseudomonas
What are the most common causes of viral pneumonia in children and adults?
Kids: RSV and parainfluenza
Adults: flu
What is the most common fungal pathogen to cause pneumonia in an immunocompromised patient and what are the S/S?
Pneumocystis jiroveci (PCP) S/S: fatigue, dry cough, dyspnea on exertion, pleuritic chest pain
What fungal pathogen is common in the Mississippi and Ohio river valleys?
Histoplasmosis
Define the terms insomnia, hypersomnia, and parasomnia and state which is more associated with obstructive sleep apnea.
Ins: Difficulty falling and staying asleep
Hyper: Excessive daytime sleepiness
Para: Abnormal behavior during sleep –> sleep walking, terrors, nightmares, etc.
Hypersomnia higher association with sleep apnea
What are the risk factors for sleep apnea?
obese, middle aged, HTN, CHF
Describe narcolepsy.
Sudden, brief sleep attacks, cataplexy, sleep paralysis, hypnagogic hallucinations (occur at start of sleep), which may precede sleep
Define cataplexy.
Condition in which strong emotion or laughter precipitates sudden collapse, though remaining conscious.
Define and describe polysomnography.
Sleep study –> evaluates EEG, HR, RR, SpO2
In addition to a sleep study, what other test is important to evaluate in a person complaining of sleep disturbances?
TSH
What components are involved in counseling a person to improve sleep hygiene?
avoid alcohol, caffeine, nicotine, exercise
prior to bed; establish regular sleep hours; relaxation techniques; avoid prolonged daytime naps.
What are the primary treatments for sleep apnea and narcolepsy?
Apnea: Weight reduction and CPAP
Narc: dextroamphetamine and modafinil (stimulants)
Define nocturnal myoclonus and state the most appropriate treatment.
Def: involuntary muscle twitches during sleep
Treatment: clonazepam
What is the treatment for sleep terrors or sleep walking?
Benzos
Define and describe tuberculosis.
Chronic infection with mycobacterium tuberculosis that involves formation of a granuloma.
What is the hallmark symptom of tuberculosis?
Persistent, dry cough for about 3 weeks. Can have hemoptysis in advanced stages.
Aside from the hallmark symptom, what other S/S are commonly present in tuberculosis?
Fever, night sweats, anorexia, weight loss, pleuritic chest pain, dyspnea, post-tussive rales
What is the gold standard diagnostic evaluation for tuberculosis?
Acid fast bacillus cultures x 3 days –> need 3 negative cultures to deem non-infectious.
Describe the use of radiography to evaluate TB.
Used for yearly screening in PPD positive patient or to exclude active TB.
What is required for definitive diagnosis of TB?
m. tuberculosis from culture (6-8 weeks to grow) or DNA/RNA amplification techniques (1-2 days)
Describe what is indicated by a positive PPD test and state the parameters for a positive test.
Identifies presence of infection but doesn’t differentiate active from latent.
> 5mm in HIV/immunosuppressed, recent contact with active TB or CXR indicating TB.
> 10mm in IVDU, recent immigrants, healthcare workers, Hx of DM, CKD, scoliosis, and age < 4
> 15mm everyone else - no risk factors
Differentiate between primary, latent, and secondary TB.
1: First exposure, usually isolated to the middle of the lungs forming an area called a Gohn focus
Lat: Inactive period of the Gohn focus after the first exposure
2: Latent TB that becomes active TB with lesions most common in the lung apices.
T/F: Primary TB can become active without entering a latent phase.
True: But this is rare –> called Primary progressive TB
Describe 2 ways latent TB can become active TB.
Reactivation of the latent infection (most common) or from a reinfection after an additional exposure to TB
Describe the pathophysiology of secondary TB.
Formation of a granuloma described a casseous, cheese-like necrosis on gross exam.
Describe the treatment for latent TB.
Isoniazid for 9 months …or…
Rifampin for 4 months …or…
Rifampin and Pyrazinamide for 2 months
Describe the treatment for active TB.
Some combination of isoniazid, rifampin, pyrazinamide, and ethambutol for 6-9 months. HIV patients require treatment for at least 1 year.
When are patients with active TB considered to no longer be infectious?
2 weeks after initiation of therapy.
How are patients with latent TB treated prophylactically?
Isoniazid for 6-12 months
What are the AEs associated with each of the TB treatment drugs?
Iso: peripheral neuropathy, hepatitis
Rif: orange body fluid and skin
Pyr: hyperuricemia and photosensitive rash
Eth: optic neuritis (reg-green vision)
What must be coadministered with isoniazid?
Vitamin B6
Describe 4 steps for maintenance of public health after diagnosing a case of active TB.
- Report the infection
- Isolate patient for minimum of 2 weeks
- BCG vaccine for patients in high risk areas
- Kids or immunocompromised with known exposure should be treated for at least 12 weeks then given a PPD skin test –> stop treatment if negative.
