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NSR 251A: optho, pulm, renal, GU, heme/onc > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

Post-Viral Cough

A
  • aka post-infectious cough
  • no specific etiological agent
  • cough lasting from 3-8 weeks following a viral URI or bronchitis
  • usually normal CXR
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2
Q

Chronic Cough

A
  • cough lasting > 8 weeks in adults
  • cough lasting >4 weeks in children
  • can be sign of underlying condition:
    • GERD
    • ACE inhibitor use (lisinopril)
    • asthma
    • upper airway cough sundrome
    • sarcoidosis, TB, cancer
  • CXR to r/o other causes
  • if cause can’t be identified:
    • consider chest CT scan
    • pft
    • refer to pulmonologist
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3
Q

Chronic Bronchitis

A

“Blue Bloaters”

  • chronic cough with phlegm for 3months of the year for 2+ years → without acute cause
  • PE: crackles and wheezes, percussion = normal
  • Dx: FEV1/FVC = <0.7
    • increased HGB and HCT → chronic hypoxemia
    • CXR: peribronchial and perivascular markings
  • TX: SABAs for mild, LAMA for moderate-severe or LABA +/- ICS
    • SAMA (ipratroprium) = main inhaler for COPD
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4
Q

COPD definition

A

chronic bronchitis + emphysema

proteases > anti-proteases

Causes: smoking, pollution, chronic damage to lungs, family hx, occupational exposure to dust, vapors, fumes and other chemicals, childhood factors (frequent respiratory infx, low birth weight)

alpha 1 antitrypsin deficiency

Post-bronchodilater FEV1/FVC must be <0.7 for a diagnosis by GOLD criteria

tend to be >40 years old

for acute exacerbation aim for SpO2 of 88-92%

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5
Q

Emphysema

A

part of COPD

“Pink Puffers”

  • enlarged air spaces as a result of damage to alveolar septae → decreased lung function → chronic hyperventilation
  • S/sxs: quiet lungs, thin, barrel chest, minimum sputum, underweight, pursed lips to increase resistance of exhale
  • PE: diminished breath sounds, prolonged expiration, and diminished heart sounds, hyperresonance on percussion
  • Dx:
    • CXR: loss of lung markings, hyperinflation, flattened diaphragm, small thin appearing heart
    • subpleural blebs = pathognomonic
  • Tx: SAMA (ipratropium bromide) or albuterol inhaler
    • oxygen
    • PO steroid burst during exacerbation
    • abx if increased sputum production, increased purulence, or increased dyspnea
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6
Q

Acute Bronchiolitis

A

Most commonly caused by RSV in fall and winter

  • common in infants and children
  • S/sxs: wheezing, tachypnea, respiratory distress, fever
    • often have prodromal viral sxs (fever, uri) for 1-2 days followed by respiratory distress
  • PE: expiratory wheezes, may have normal serous nasal discharge
  • Diagnosis: CXR = normal
    • test for influenza, RSV (antigen test or nasal washing monocloncal antibody test)
  • Tx: Supportive tx → humidifed air, antipyretics, beta-agonists, nebulized racemic epi
    • oxygen = mainstay of tx
    • Palivizumab prophylaxis (Synagis) for immunocompromised, premature infants etc
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7
Q

Acute Bronchitis

A

cough > 5 days, can last 1-3 weeks

most often viral (95%), but bacterial = Moraxella, S. pneumo, chlamydia pneumoniae

  • S/sxs: cough >5 days, low fever, malaise, dyspnea, URI sxs
    • may have hemoptysis (most common cause of hemoptysis, followed by carcinoma)
  • PE: less severe than PNA (normal vitals) no crackles or egophany
    • may have rhonchi or wheezing
      • → rhonchi that clears with cough
  • Dx: clinical, can obtain CXR if uncertain
  • Tx: supportive → fluids, rest, corticosteroids if underlying RAD
    • Dextromethrophan (Tessalon Pearls)
    • Guaifenesin (robitussin)
    • SABAs for wheezing
    • antipyrettics
    • Ribavirin if severe lung or heart disease
    • if O2<96% on RA→ hospitalize
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8
Q

Acute Epiglottitis

A

Medical Emergency → usually caused by Hflu

Males> females, DM =risk factor in adults; most common in age 3mo-6yr

  • S/sxs: fever, odynophagia (pain with swallowing), Tripoding , dyspnea
    • 3Ds: drooling, dysphagia (difficulty swallowing), Respiratory distress
  • PE: inspiratory stridor**, muffled hot-potato voice, hoarseness, **Thumb print sign
  • Diagnosis: laryngoscopy
  • tx: secure airway then cx for Hflu
    • intubate if necessary, supportive care
    • ceftriaxone (or 2nd or 3rd gen cephs)
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9
Q

Acute Laryngotracheitis

A
  • aka Croup
  • **barking cough most commonly caused by parainfluenzae virus**
  • abrupt onset of symptoms
  • **Steeple Sign**
  • home treatment: symptomatic care maybe with some dexamethasone
  • Nebulized epi with IV/oral/IM dexamethasone
  • **the WESLEY CROUP SCORE** >12 → send to the hospital
    • mild = 2
    • Moderate 3-7
    • severe >/= 8
    • impending respiratory failure >/=12
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10
Q

Step 1 therapy for Asthma in Adults

A

sxs < 2x/month

  • Controller:
    • TAke ICS whenever SABA is taken
  • Reliever:
    • SABA
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11
Q

SABA

A

short acting beta agonist

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12
Q

Step 2 therapy for Asthma in Adults

A

sxs 2x/month + but less than 4-5days/week

  • Controller:
    • low dose maintenance ICS
  • Reliever:
    • PRN SABA
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13
Q

ICS

A

inhaled corticosteroid

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14
Q

Step 3 Therapy for Asthma in Adults

A

sxs most days, or waking with asthma once/week +

  • Controller:
    • low dose maintenance ICS-LABA
  • Reliever:
    • PRN SABA
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15
Q

LABA

A

long acting beta 2 agonist

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16
Q

LTRA

A

leukotriene receptor antagonist

i.e. singulair (montelukast)

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17
Q

Step 4 Therapy for Asthma in Adults

A

sxs most days, or waking with asthma once/week+, or low lung function

  • Controller:
    • medium/high dose maintenance ICS-LABA
  • Reliever:
    • PRN SABA
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18
Q

Step 5 Therapy for Asthma in Adults

A
  • Controller:
    • add on LAMA
    • refer for phenotypic assessment
    • +/- anti-IgE, anit-IL5/5R, anti-IL4R
    • consider high dose ICS-LABA
  • Reliever:
    • PRN SABA
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19
Q

Age for pediatric asthma tx

A

6-11 years old

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20
Q

Step 1 therapy for Asthma in Peds

A

sxs <2x/month

  • Controller:
    • low dose ICS whenever SABA is taken; or daily low dose ICS
  • Reliever:
    • PRN SABA
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21
Q

Step 2 Therapy for Asthma in Peds

A

sxs 2x/month+ but less than daily

  • Controller:
    • daily low dose ICS
    • other:
      • daily LTRA, or low dose ICS taken whenever SABA taken
  • Reliever:
    • PRN SABA
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22
Q

Step 3 Therapy for Asthma in Peds

A

sxs most days, or waking with asthma 1x/week+

  • Controller:
    • low dose maintenance ICS-LABA or medium dose ICS
    • Other:
      • low dose ICS + LTRA
  • Reliever:
    • PRN SABA
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23
Q

Step 4 Therapy for Asthma in Peds

A

sxs most days or waking with asthma 1x/week + AND low lung function

  • Controller:
    • medium dose ICS-LABA and refer for expert advice
    • other:
      • high dose ICS-LABA, or add on tiotropium or add on LTRA
  • Reliever:
    • PRN SABA
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24
Q

Step 5 Therapy of Asthma for Peds

A
  • Controller:
    • Refer for phenotypic assessment + add-on therapy. e.g. anti-IgE
    • other:
      • add-on anti-IL5, or add on low dose OCS but consider side-effects
  • Reliever:
    • PRN SABA
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25
Q

SABAs

A

Short acting beta-2 agonists

  • albuterol
  • levalbuterol
  • metaproterenol
  • Terbutaline
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26
Q

Albuterol (Proventil-HFA; Proair-HFA)

A

SABA: MDI and neb

  • dosing: 2puffs Q4-6hours (90mcg/puff)
  • stimulates beta-2 receptors = bronchial muscle relaxation
  • SEs: HypoK especially during continuous neb
    • beta-2 stimulation causes cellular uptake of K+ = decreased srum K+
    • also tachycardia (because not very selective and will stimulate beta-1 receptors)
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27
Q

Levalbuterol (Xopenex-HFA)

A

SABA: MDI and neb

  • steroisomer of albuterol, but higher affinity for beta-2 so less sysstemic sympathetic effects = b/c less binding to beta-1
  • SEs: HypoK
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28
Q

Metaproterenol (Alupent)

A

SABA: PO

  • SEs: palpitations
    • tachycardia
    • hypoK
    • tremor
    • HA, nausea, nervousness
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29
Q

Terbutaline

A

SABA: PO or pareneteral (SQ injection)

  • often used for acute attack (0.25mg SubQ)
  • SEs:
    • SABA
    • tocolytic
    • not approved for children <6yo
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30
Q

LABAs

A

long acting beta-2 agonists

  • salmeterol DPI (Serevent Diskus)
  • Formoterol DPI (Foradil)
  • Arformoterol (Brovana)
    • not for kids
  • Indacaterol (Arcapta)
    • not for kids
  • Olodaterol (striverdi Respimat)
  • (Some Fish Are Inherently Odorous)
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31
Q

Salmeterol DPI (Serevent Diskus)

A

LABA

do not use as monotherapy

  • partial agonist
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32
Q

Formoterol DPI (Foradil)

A

LABA

  • helpful for nighttime sxs
  • full agonist
  • onset = to that of albutero but DO NOT USE FOR ACUTE BRONCHOSPASM
  • SEs: paradoxical bronchospasm
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33
Q

Arformoterol (Brovana)

A

LABA: neb

  • used for COPD only!!
  • 2x more potent than formoterol
  • SEs:
    • ​paradoxical bronchospasm
    • palpitation/tachy/tremor
    • lightheadedness/nervousness/HA/nausea
    • NOT APPROVED FOR CHILDREN
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34
Q

Indacaterol (Arcapta)

A

LABA: DPI

  • for COPD
  • SEs:
    • paradoxical bronchospasms
    • palpitations/tachy/tremor
    • nervousness/lightheadedness/HA/nausea
    • NOT APPROVED IN CHILDREN
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35
Q

Olodaterol (Striverdi Respimat)

A

LABA: inhaler

  • Long half life!! t1/2 = 45hours
  • 2C9 substrate = increased side SEs
    • plus Same SEs as other LABAs
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36
Q

Inhaled Corticosteroids (ICS)

A

MOA: inhibit inflammatory cells (mast cell, eosinophils, neutrophils) and cytokines (histamine, leukotriens)

**Flat dose response curve = double the dose adds limited additional effect **

BID Dosing is better (need more in smokers)

  • Beclomethasone HFA (QVAR)
  • Budesonide DPI (Pulmicort)
  • Ciclesonide (Alvesco)
  • Fluticasone HFA (Flovent)
  • Fluticasone DPI (Flovent Diskus)
  • Flunisolide (Aerobid)
  • Mometasone DPI (Asmanex)
  • SEs:
    • oral candidiasis
    • cough
    • Dysphonia
    • Adrenal Suppression (at high dose)
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37
Q

Omalizumab (Xolair)

A

monoclono- anti-IgE antibody

  • stops release of inflammatory mediatorys
    • used for moderate to severe asthma
  • significantly reduces ICS use
  • SQ injection
  • SEs:
    • injection site rxn, bruising, redness, pain, stinging, itching etc
    • anaphylaxis (rare)
      • monitor 2 hours after injection for 3 months then 30 min thereafter
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38
Q

Combined ICS/LABA

A
  • Fluticasone/Salmeterol (Advair) DPI
  • Fluticasone/Vilanterol (Breo Ellipta)
    • +3A4 inhibitors (both advair and breo) = increased LABAs = QT prolongation
  • Budesonide/Formoterol HFA (Symbicort)
  • Mometasone/Formoterol (Dulera)
  • SEs: Thrush
    • dysphonia
    • pharyngitis
    • HA
    • nausea
    • tremor
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39
Q

GOLD 1-4

A

for COPD

  • Gold 1: FEV1 >80%
    • mild
  • Gold 2: FEV1 50-79%
    • moderate
  • Gold 3: FEV1 30-49%
    • severe
  • Gold 4: FEV1 <30%
    • very severe
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40
Q

ABCD categorization of COPD

A
41
Q

Stage A COPD Tx

A
  • First Line:
    • SABA prn or SAMA prn (bronchodilators)
  • Second Line:
    • LAMA or LABA or SABA + SAMA
42
Q

Stage B COPD Tx

A
  • First line:
    • LAMA or LABA (long acting bronchodilators)
  • Second Line:
    • LAMA + LABA
43
Q

Stage C COPD Tx

A
  • First line:
    • ICS + LABA or LAMA
  • Second Line:
    • LAMA + LABA
      • LAMA + PDE4i
      • LABA + PDE4i
44
Q

Stage D COPD Tx

A
  • First Line:
    • ICS + LABA and/or LAMA
  • Second Line:
    • ICS + LABA and LAMA
    • ICS + LABA and PDE4i
    • LAMA + LABA
    • LAMA + PDE4i
45
Q

Phosphodiesterase (PDE)-4 inhibitors

A

inhibit breakdown of cAMP = reduction of inflammation

Roflumilast (Dalirespt)

  • for prevention of COPD
  • SEs:
    • diarrhea, decreased appetite, weight loss, abdominal pain
    • headache, insomnia
    • anxiety and depression
  • DDI: CYP 1A2 and 3A4
    • inducers: butalbital, phenytoin, rifampin, carbamazepine (avoid use)
    • inhibitors: amiodarone, clarithromycin, cimetidine, ketoconazole (use with caution)
46
Q

Most common bacterial organisms associated with mild exacerbation of COPD and More Severe COPD

A
  • Mild:
    • strep pneumo, H.flu, Moraxella
  • Severe:
    • E.coli, Klebsiella, enterobacter, pseudomonas
47
Q

Pseudomonas risk factors

A
  1. 4 or more courses of abx over the past year
  2. recent hospitalization (2+ days in past 90)
  3. isolation of pseudomonas during a previous hospital visit
  4. severe underlying COPD
    1. FEV1<50
48
Q

Mepolizumab (Nucala)

A

monoclondal antibody that targets IL-5

  • IL-5 stimulates matural and release of eosinophils in bone more = inflammation
  • Indication: maintenance tx of severe asthma age >/=12 yo
  • SEs:
    • anaphylaxis, angioedema, bronchospasm, hypotension, urticaria, rash
    • herpes zoster has occurred: IZ if appropriate prior to starting therapy
49
Q

Reslizumab (Cinqair)

A

monoclonal antibody against IL-5

  • indications: add on maintenance tx with severe asthma for >/= 18 yo and an eosinophilic phenotype
  • IV infusion only
  • SEs:
    • anaphylaxis, malignancy
    • CPK electation = adverse muscle related rxns
    • oropharyngeal pain
50
Q

Methylxanthines

A

theophylline

inhibit phosphodiesterase = bronchodilation

  • less effective than ICS
  • narrow therapeutic index 5-15mcg/mL
  • metabolized by CYP 1A2 and 3A4
    • DDI: inducers: carbamazeine, phenytin, rifampin, ST. John Wort
      • inhibitors: clarithromycin, telithromycin, ketoconazole, itraconazole, voriconazoe, grape fruit juice
    • SEs:cardiac arrhythmias, seizures
51
Q

LAMAs

A

long acting muscarinic antagonists

  • Tiotroprium
  • alcidinium
  • glycopyrrolate
  • Umeclidinium
52
Q

SABA + Anticholinergic

A
  • Albuterol/Ipratroprium (Combivent Respimat)
  • Duoneb
  • SEs: paradoxical bronchospasm
    • palpitations/tremor/tachy
    • CONTRAINDICATION: soy or peanut allergy
    • NOT for Children
53
Q

Leukotriene Inhibitors

A

only for asthma (LTRA)

  • montelukast (Singulair)
  • Zileuton (Zyflo)
    • SEs: hepatotoxicity
    • DDIs:
      • inducers: rifampin, carbamazepine, St. John’s wort
      • inhibitors: fluconazole, amiodarone, fluvoxamine, metronidazole, voriconazole
54
Q

Omalizumab (Xolair)

A

immunomodulator (anti-IgE antibody)

  • inhibits biding of IgE onto mast cells and basophils = stops release of inflammatory mediators

mainly used in COPD, but also for moderate-severe asthma

  • SQ injects Q2-4 weeks in clinic, must be observed 2 hours after injection x 3months, then 30 min thereafter.
    • significantly reduces use of ICS
55
Q

Abx for COPD exacerbation outpt (⅓ cardinal sxs)

A

Mild, no abx needed

cardinal sxs: increased dyspnea, sputum volume, or purulence

56
Q

Abx for COPD exacerbation outpt (⅔) no risk factors

A

macrolide

2nd and 3rd gen ceph

doxy

Septra (TMP/Sulfamethoxazole)

57
Q

Abx for COPD exacerbation outpt (⅔ cardinal signs) with risk factors

A

respiratory FQs (moxi/levo/gemi)

Amoxicillin/Clavulanate (Augmentin)

58
Q

Abx for COPD exacerbations in hospital (⅔ of cardinal) with risk factors for pseudomonas

A

FQ (levo PO or IV)

Cephalosporins (Cefepime IV or Ceftazidime IV)

Zosyn IV (piperacillin + tazobactam)

59
Q

Abx for COPD exacerbations in hospital (⅔ cardinal) with no pseudomonas risk

A

FQ (levo or Moxi)

Cephalosporins (ceftriaxone or cefotaxime)

60
Q

Complicated COPD

A

FEV1<50%

age >65

>/= 3 exacerbations/year

cardiac disease

61
Q

Influenza

A

ssRNA

Hemagglutinin spikes→ allow virus to bind to host(targeted by IZs) , neuraminidase→ allow virus to bud (targeted by meds)

  • S/sxs: sudden onset high fever, chills, malaise, sore throat, headache, and coryza, myalgias (especially legs and lumbosacral), non-productive cough
    • classic triad: FEVER, DRY COUGH, MYALGIAS
  • PE: ill appearance, mild pharyngeal edema, cervical adenopathy +/-, serous nasal drainage
  • Dx: rapid antigen test, serology = more accurate, WBC does not correlate well with severity → often normal or low (if >15K → suggests secondary bacterial)
  • Tx: mild disease & healthy? → supportive tx (acetaminophen, fluids, and rest)
    • hospitalized or at-risk? → neuraminidase inhibitors (Oseltamivir or Zanamivir (Dr. Oz txs the flu)) → need to be initiated within 48 hours of onset
    • empiric antiviral tx: children <2, pregnant, 65+, women up to 2 weeks post-partum, chronic or immunosuppressed
62
Q

Pertussis

A

aka Whooping Cough → causative agent bordetella pertussis → gram -, coccobacillus

common in children <2 yrs, respiratory droplet transmission

  • S/sxs: consider in adults with cough > 2weeks
    • catarrhal stage: cold like sxs, poor feeding and sleeping
    • paroxysmal stage: high-pitched inspiratory whoop between coughing fits → post-tussive emesis is highly indicative of this infx
    • convalescent stage: residual cough (up to 100 days)
  • Dx: nasopharyngeal swab for cx and PCR
  • Tx: supportive care +/- steroids/SBAS
    • Macrolides (clarithromycin, azithromycin)
      • DTaP, TDap Izs
  • Complications: PNA, encephalopathy, otitis media, sinusitis, seizures
63
Q

Bacterial Pneumonia

A

Causative Agents: S. Pneumo (rusty color sputum, common in after splenectomy), S. aureus (salmon colored sputum, lobar, after influenza), Hflu, Klebsiella (alcohol abuse; currant jelly sputum, aspiration); atypicals → mycoplasma (young ppl living in dorms, (+) cold agglutination), chlamydia (college kids, sore throat), legionella (air conditioning, low Na+, GI sxs and high fever)

  • S/sxs: tachycardia, tachypnea, fever, pleuritic chest pain, dyspnea +/- rigors (associated with strep pneumo)
  • PE: CXR: infiltrate/consolidation
    • Typical: percussion → dull, increased tactile fremitus, egophony and crackles
    • atypical: pulmonary exam is often normal (may have crackles)
  • Dx: CXR, blood cxs x 2 , sputum gram stain
  • Tx: outpt → doxycycline, macrolides (500mg 1st day, then 250mg for days 2-5)
    • CURB-65: Confusion, uremia (BUN >19), RR >30, BP <90/<60, age 65+
    • inpatient tx:
      • ceftriaxone + azithromycin, respiratory fluoroquinolones (Moxi, levo)
64
Q

RSV

A

***most common cause of lower respiratory tract infx in children world wide***

leading cause of pna and bronchiolitis

  • S/sxs: rhinorrhea, wheezing/coughing, persists for months, low grade fever, nasal flaring/ retractions, often prodomal sxs for 1-2 days before respiratory distress
  • PE: visible retractions
  • Dx: nasal washing, RSV antigen test
    • CXR can show diffuse infiltrates
  • Tx: oxygen <95-96% → hospitalize, same with tachypnea, difficulty feeding
    • supportive tx
    • should resolve in 5-7 days
    • albuterol via neb, humidified O2
65
Q

Carcinoid Tumors

A

1-2% of lung cancers → carcinoid syndrome

tumors that arise from neuroendocrine cells → lead to excess secretion of serotonin, bradykinin, and histamine

  • ***often start at appendix, mesastasize to liver then travel via blood stream to the lungs***
  • S/sxs: flushing, diarrhea, wheezing, and low blood pressure
    • vasodilation and flushing = increased histamine and bradykinin
  • PE: heart valve dysfunction → tricuspid regurge due to increased serotonin that causes collagen fiber thickening, fibrosis
  • Dx: CT-scan, octreoscan (radiolabeled somatostatin analog binds to receptors on tumor cells)
    • urinalysis: shows increased 5-hydroxyindoleacetic acid (5-HIAA) = main metabolite of serotonin
    • pellagra (vitamin B3 deficiency/ niacin)
  • Tx: surgical excision
    • octreotide: somatostatin analog binds to somatostatin receptors and decreases the serotonin being secreted by the tumor
    • niacin supplement
66
Q

Squamous Cell Carcinoma

A

non-small cell lung cancer

characterized by keratin production

  • S/sxs: cough, weight loss, night sweats, hemoptysis (superficial squamous cells burst in lungs), chestpain/back pain, SOB
  • located in bronchial tubes (where it starts)
    • paraneoplastic syndrome → hypercalcemia of malignancy = think stones, bones, and psychiatric overtones
      • → mediated by PTHrP (parathyroid hormone related peptide)
    • Tx: stage I and II: surgery
      • Stage IIIa: surgery +chemo
      • Advanced disease (IIIB and IV):
        • treat the driver mutation
          • if PDL1 is expressed by tumor → pembrolizumab (PDL1 inhibitor)
          • if PDL1 expression <50% → tradition chemo + PDL1 inhibitor
    • Pancoast Tumor: should pain, horner’s syndrome, brachial plexus compression
    • Horner’s Syndrome: unilateral miosis, ptosis, and anhydrosis
67
Q

Adenocarcinoma

A

non-small cell cancer

most common type of lung cancer, and most common type of lung cancer to occur in never smokers

  • begins in periphery of lungs
  • also associated with smoking and asbestos exposure
  • paraneoplastic syndrome: thrombophlebitis
  • tx:
68
Q

Adenocarcinoma

A

non-small cell cancer

most common type of lung cancer, and most common type of lung cancer to occur in never smokers

  • begins in periphery of lungs
  • PATHOLOGY:
    • neoplastic gland formation
  • also associated with smoking and asbestos exposure
  • paraneoplastic syndrome: thrombophlebitis
  • tx:Tx: stage I and II: surgery
    • Stage IIIa: surgery +chemo
    • Advanced disease (IIIB and IV):
      • treat the driver mutation
        • if PDL1 is expressed by tumor → pembrolizumab (PDL1 inhibitor)
        • if PDL1 expression <50% → tradition chemo + PDL1 inhibitor
69
Q

Large Cell Carcinoma

A

non-small cell carcinoma

very fast doubling time but causes sxs late

  • rare: only 5%
  • usually begins on the outer edges of the lungs
  • paraneoplastic syndrome: gynecomastia
  • Tx: stage I and II: surgery
    • Stage IIIa: surgery +chemo
    • Advanced disease (IIIB and IV):
      • treat the driver mutation
        • if PDL1 is expressed by tumor → pembrolizumab (PDL1 inhibitor)
        • if PDL1 expression <50% → tradition chemo + PDL1 inhibitor
70
Q

Small Cell Lung Cancer

A

“All of the Ss”

  • grow very quickly → 54-132 day doubling rate
    • (if faster growth than this = decreased risk of malignancy)
  • aggressive and metastic
  • All the Ss:
    • Smoking, Sentrally located, Super Aggressive, SVC syndrome, Sitting to Standing (Lambert-Eaton Myasthenic Syndrome), Sodium/SIADH→ leads to low sodium through SIADH
    • TX: surgical excision is NOT an option
      • limited stage disease → chemo and radiation
      • extensive stage disease → chemo + immunotherapy
  • Superior Vena Cava Syndrome: cancer pushes on superior vena cava and traps blood in upper body
  • Lambert-Eaton Myasthenic Syndrome: similar to myasthenia gravis → proximal muscle weakness
  • Syndrome of Inappropriate Secretion of ADH (SIADH):
    • euvolemic hyponatremia → retaining too much water
  • Cushing Syndrome: too much cortisol
    • central obesity, purple striae, hyperglycemia
    • Carcinoid syndrome: flushing, diarrhea, telangiectasia
71
Q

When to Screen for Lung Cancer

A

pts 50-80 yo; with >20 year pack hx of smoking, with either current smoking or having quit <15 years ago

72
Q

Pulmonary Nodules

A

nodule <3cm (coin lesion), mass >3cm

  • smooth, well defined edges → most likely benign
  • ill-defined, lobular, spiculated edges → most likely cancer
  • when found as incidental finding:
    • Fleischner society pulmonary nodule recommendation
  • when found as part of cancer screening:
    • Lung-RADS
73
Q

Pleural Effusion

A

excess fluid in the pleural space

  • S/sxs: dyspnea, discomfort or sharp pain that worsens with inspiration
  • PE: dullness to percussion
    • decreased tactile fremitus, decreased breath sounds
      • may have a pleural friction rub
  • CXR: blunting of costophrenic angles + meniscus sign
    • lateral decubitus film (pt lying on their side) = best to detect smaller effusions
      • differentiates b/w loculations and empyema from new effusions and scarring
  • Tx:
    • thoracocentesis is both diagnostic and therapeutic
    • if empyema (pleural fluid pH <7.2, glucose <40mg/dL, or positive gram stain of pleural fluid) → can inject streptokinase to break up loculations
    • chronic effisions or recurrent and causing sxs:
      • pleurodesis (pleural space is artificially obliterated) or by intermittent drainage with an indwelling catheter
74
Q

loculations

A

the compartmentalization of a fluid-filled cavity into smaller spaces (locules) by fibrous septa

75
Q

Pneumothorax

A

collapse lung caused by an accumulation of air in the pleural space

  • Primary: occurs in absence of underlying disease (tall, thin males age 10-30)
    • secondary: in presence of underlying disease (COPD, asthma, CF, interstitial lung disease)
      • Tension Pneumothorax: penetrating injury → air into pleural space increased and unable to escape
  • S/sxs: acute onset ipsilateral chest pain and dyspnea
    • non-exertional, sudden
  • PE: decreased tactile fremitus, deviated trachea, hyperresonance, diminished breath sounds
    • tension pneumo: mediastinal shift to the contralateral side and impaired ventilation, increased JVP, systemic hypotension
  • Dx:
    • CXR: pleural air
    • ABG: shows hypoxemia
  • Tx: depends on size
    • <15% (small)= will resolve spontaneously
      • can also do high flow 100% oxygen
    • >15% (large) and symptomatic = chest tube placement
    • need to do serial CXR every 24 hours until resolved
    • tension pneumo:
      • MEDICAL EMERGENCY!!! large bore needle to allow air of the chest + chest tube for decompression
  • Pt Education:
    • avoid pressure changes 2+ weeks
76
Q

Cor Pulmonale

A

Right Ventricular enlargement → eventually leads to R heart failure secondary to a lung disorder that causes pulmonary HTN

  • Etiology:
    • COPD (most common), pulmonary embolism, vasculitis, asthma, ARDS
  • S/sxs:
    • worsening dyspnea, purulent sputum production, inspiratory crackles, ventricular gallop
  • PE: lower extremity edema, JVD distention, hepatomegaly, parasternal lift
    • tricuspid/pulmonic insufficiency loud S2
    • EKG: S1Q3T3
    • ****occurs after pulmonary HTN*****
  • Dx: tx the underlying condition b4 the cardiac structure change becomes irreversible
    • diuretics are not helpful and MAY BE HARMFUL!
77
Q

Pulmonary Embolism

A

obstruction of pulmonary blood flow due to a blood clot (usually thrombosed from a DVT)

  • Risk Factors: Virchow’s Triad:
    1. Damage (trauma, infx, inflammation)
    2. Stasis: immobilization, surgery, prolonged sitting > 4 hours
    3. hypercoagulability: protein C or S deficiency, factor V leiden mutation, Oral contraceptive pills, malignancy, pregnancy, smoking
  • S/sxs: Classic Triad:
    • dyspnea, pleuritic chest pain, hemoptysis (classic but rare), cough
  • PE: Tachypnea (most common sign), tachycardia, low-grade fever, lung exam = normal
    • if large PE = syncope, hypotension, pulseless electrical activity
  • Dx: helical (spiral) CT angiography
    • pulmonary angiography = GOLD STANDARD (may order if high suspicion and negative CT or VQ scan)
    • D-Dimer or ABG = respiratory alkalosis secondary to hyperventilation
  • Westermark sign: avascular markings distal to PE
  • Hampton hump: wedge-shaped infiltrate due to infarction
  • atelectasis = most common abnormal finding
  • Tx: Heparin and oral direct thrombin inhibitors (dabigatran)
78
Q

Pulmonary HTN

A

blood pressure in lungs is usually very low (15/5) pulmonary HTN → >25mmHg

usually caused by underlying disorder: constrictive pericarditis, mitral stenosis, L ventricular failure

  • Risk Factors: middle-aged or young women (mean age = 50), BPMR2 gene defect → usually inhibits pulmonary vessel smooth muscle growth and vasoconstriction
  • S/sxs:
    • dyspnea on exertion, fatigue, chest pain, edema
  • PE: loud pulmonic component of S2 due to prominent P2, may have a fixed or paradoxically split P2
    • signs of R heart failure:
      • JVD, ascites, hepatojugular reflux
      • lower limb edema
      • pulmonary regurg, R ventricular heave, systolic ejection click
    • Dx: R heart catheterization = GOLD STANDARD
      • CXR: enlarged pulmonary arteries, lung fields may not be clear, depends on underlying cause
      • Echocardiogram: increased pressure in pulmonary arteries, Right ventricles→ dilated pulmonary artery, dilation/hypertrophy of R atrium/ventricle
      • ECG: right heart strain pattern: T-wave inversion in R precordial leads (V1-4), and inferior leads (II, III, aVF) cor pulmonale
  • Tx:
    • identify and tx underlying cause
      • heart-lung transplant = definitive
79
Q

Idiopathic Pulmonary Fibrosis

A

scarring of the lungs due to unknown cause

***most common in men >40, smokers***

  • S/sxs: Worsening dyspnea, non-productive (dry) cough
    • PE: fine, dry, bibasilar inspiratory crackles
    • clubbing of fingers
  • Dx:
    • CXR: basal predominant reticular opacities (honeycombing)
    • Chest CT: Preferred imaging**** reticular honeycombing, focal ground-glass opacifications, bronchiectasis
    • PFTs: demonstrate a restrictive pattern (opposite of asthma)
      • → decreased lung volume with a normal or increased FEV1/FVC
  • Tx: lung transplant → only cure
80
Q

Asbestosis

A

lung disease caused by asbestos

Occupation: insulation, demolition, construction, shipworker

  • S/sxs: dyspnea on exertion, cough
  • PE: bibasilar crackles
    • restrictive lung pattern: normal or increased FEV1/FVC, normal or decreased FVC, decreased lung volume (shifted to the R on loop)
  • Dx:
    • CXR:
      • reticular linear pattern with basilar predominance, opacities, and honey combing
      • “shaggy heart sign” ground glass obscures the heart
    • Biopsy: may show linear asbestos bodies
  • Tx: no therapy → bronchodilators, O2, corticosteroids, +/- lung transplant
    • ***can progress to bronchogenic carcinoma or mesothelioma***
81
Q

Coal Worker’s Pneumoconiosis

A

aka black lung disease

occurs when coal dust is inhaled and leads to scarring in the lungs

  • S/sxs: dyspnea, cough, fine crackles
    • caplan syndrome: coal worker pneumoconiosis + RA (serologically positive)
  • PE: bibasilar crackles
    • restrictive lung pattern: normal or increased FEV1/FVC, normal or decreased FVC, decreased lung volumes
  • Dx:
    • CXR: small nodules especially in the upper lung fields with hyperinflation of the lower lobes in an obstructive pattern (looks like emphysema)
    • Lung Biopsy: show dark “black” lungs (not needed for diagnosis)
  • Tx: supportive care
82
Q

Silicosis

A

inhalation of silicone dioxide

Risk factors: quarry work with granite, slate, quartz, pottery, sandblasting, glass, etc

  • s/sxs:
    • acute: dyspnea, cough, weight loss, fatigue
    • chronic: often asymptomatic, dyspnea on exertion, non-productive cough, crackles
  • Dx: many small (<10mm) round nodular opacities (miliary papttern) mostly in the upper lobes
    • eggshell calcification of hilar and mediastinal nodes
      • bilateral nodular densities that progress
  • Tx: removal from exposure= MAINSTAY
    • nonspecific management: corticosteroids, O2, rehab
83
Q

Berylliosis

A

granulomatous pulmonary disease caused by exposure to beryllium

used for aerospace material→ high risk: ceramics, tool and dye manufacturing, jewelry making, fluorescent light bulbs

  • S/sxs: dyspnea, cough, joint pain, fever weight loss
  • Dx:
    • CXR: hilar lymphadenopathy, and increased interstitial lung markings (looks like sarcoidosis) → diffuse infiltrates
  • tx: chronic corticosteroid use
    • oxygen
    • methotrexate if corticosteroids do not work
    • associated with risk of lung, stomach, and colon cancer
84
Q

Sarcoidosis

A

unknown cause, chronic multisystem inflammatory granulomatous disease (exaggerated T-cell response to antigens or self-antigens that leads to central immune system activation, granuloma formation, and peripheral immune depression)

Risk factors: female, African American, N. Europeans, age 20-40

  • S/Sxs: dry cough, dyspnea, chest pain, and crackles
    • affects lymph nodes as well
    • may have abnormal masses or nodules (granulomas)
  • PE:
    • erythema nodosum (classic), lupus pernio, maculopapular rash, anterior uveitis, restrictive cardiomyopathy, arrhythmias, heart block
  • Dx: serum blood tests show: hypercalcemia and ACE levels x4 normal
    • ESR = elevated
    • CXR: Bilateral hilar lymphadenopathy
    • Diagnosis: biopsy of peripheral lesion or fiber-optic bronchoscopy for central pulmonary lesion
    • PFTS: restrictive pattern
  • Tx:
    • Symptomatic pts: CORTICOSTEROIDS (1mg/kg prednisone) methotrexate and other immunosuppressive meds
    • ACE inhibitors for periodic HTN
    • → leading cause of death = pulmonary fibrosis
85
Q

Obstructive Sleep Apnea

A

intermittent obstructive airflow → results in periods of apnea at night

Risk factors: OBESITY!!! structural abnormalities of the upper airway, family hx, alcohol/sedatives/opiates, hypothyroidism

  • S/sxs:
    • SNORING and daytime sleepiness! caused by disrupted nocturnal sleep
      • personality changes: poor mood and mental dysfunction
      • morning headaches, polycythemia
      • can lead to systemic and pulmonary HTN and Afib
    • Diagnosis:
      • Polysomnography = GOLD STANDARD
        • can also do home sleep apnea testing but rarely covered by insurance
      • Obesity-Hypoventilation Syndrome: -obesity (>30BMI), -awake alveolar hypoventilation PaCO2 >45mmHg, -alternative causes of hypercapnia and hypoventilation ruled out
  • Tx:
    • WEIGHT LOSS, exercise, avoiding alcohol/sedatives, and not sleeping supine
    • oral appliances → mild to moderate
      • → BiPAP or CPAP
    • Uvulopalatopharyngoplasty (UPPP) → remove extra tissue from oropharynx
    • tracheostomy
86
Q

Acute Respiratory Distress Syndrome (ARDS)

A

type of respiratory failure that is fluid collection in the lungs and prevents exhange of O2

  • usually occurs in critically ill or someone with significant injuries
  • S/sxs; rapid onset of sever dyspnea occurring 12-24 hours after a precipitating event
    • PE: tachycardia, pink, frothy sputum, diffuse crackles
  • Dx: sxs develop within 1 week, bilateral diffuse infiltrates on CXR (not explained by congestive heart failure)
    • CXR: shows air bronchograms & bilateral fluffy infiltrate
  • tx:
    • identify and tx underlying cause
      • tracheal intubation
87
Q

Influenza

A

ssRNA

hemagluttinin and neuraminidase

tx: neuraminidase inhibitors
vaccines: target hemagluttinin

Type A = most common

Type B= humans only

Type C = nonsymptomatic, little medical concern

SHIFT vs DRIFT

88
Q

Histoplasmosis

A
  • Histoplasma
  • Systemic fungi and mold → yeast at 37C
  • inhalation from bats/ birds: CAVES and TREE REMOVAL
  • acute pneumonia sometimes developes
  • infect Macrophages
  • bone marrow disruption
  • apical pulmonary lesions resembling cavitary TB
  • tx: itraconazole
89
Q

Cryptococcosis

A
  • yeast that can end up in the brain but is inhaled!
  • **Defining opportunistic infection in aids patients**
  • skin lesions that look similar to acne, molloscum contagiosum, or basal cell carcinoma
  • CNS: low grade fever, ocular or facial palseys, headache
  • Lungs: pneumonia, AIDS (severe dyspnea)

tx: Fluconazole for non CNS, CNS: amphotericin B

90
Q

Pneumocystis

A
  • yeast: pneumocystis jirovecii
  • **only issue for immunocompromised people**
  • aerosolized: fever, dyspnea and DRY cough

tx: Bactrim (sulfamethoxazole/trimethoprim )

high risk for HIV pts with CD4 counts <200/mcL

91
Q

Strep pneumoniae

A
  • gram + diplococci, ENCAPSULATED
  • causes pneumonia:
    • rusty mucus
    • productive cough
    • fever
    • malaise
    • sudden onset chills and rigors (violent shaking)
  • causes: bacteremia and meningitis
  • tx: Ceftriaxone
92
Q

Viral PNA

A

most common cause in adults: Influenza; most common cause in children RSV, Parainfluenza virus

  • S/sxs: persistent sxs of sore throat, HA, myalgias, malaise for more than 3-5 days then new respiratory sxs -→ dyspnea, cyanosis
  • Dx: CXR: bilateral lung involvement with interstitial infiltrate
    • Rapid antigen test for influenza
    • RSV nasal swab
    • cold agglutinin titer to r/o Mycoplasma (should be negative with this)
  • Tx: flu → oseltamivir, zanamivir
    • RSV → Ribavirin
92
Q

Viral PNA

A

most common cause in adults: Influenza; most common cause in children RSV, Parainfluenza virus

  • S/sxs: persistent sxs of sore throat, HA, myalgias, malaise for more than 3-5 days then new respiratory sxs -→ dyspnea, cyanosis
  • Dx: CXR: bilateral lung involvement with interstitial infiltrate
    • Rapid antigen test for influenza
    • RSV nasal swab
    • cold agglutinin titer to r/o Mycoplasma (should be negative with this)
  • Tx: flu → oseltamivir, zanamivir
    • RSV → Ribavirin
93
Q

Asthma

A

reversible chronic, inflammatory airway disease → recurrent attacks of breathlessness and wheezing that affects the trachea to the terminal bronchioles

  • caused by mast cell mediators
  • diminished FEV1 that is improved with inhaler
  • s/sxs: dyspnea, wheezing, cough, chest tightness (NOT PAIN)
    • worse at night
      • increased mucus production
  • PE: wheezing, prolonged expiratory phase
  • Diagnosis:
    • GOLD STANDARD: FEV1/FVC < 75-80% in adults, below 85% in children
      • >12% increase in FEV1 after bronchodilator
      • exhaled nitric oxide = can be used to measure eosinophilic airway inflammation
      • if pt <5 yo = RAD, not asthma
    • GINA guidelines
94
Q

Cystic Fibrosis

A

Autosomal Recessive Disorder mutation in the CFTR gene → abnormal production of mucus by most exocrine glands → pulm infx most common cause of death (staph and HIB acute, chronic = pseudomonas)

  • lungs normal at birth then begin to develop pulmonary disease often during infancy or childhood
  • infancy: meconium ileus, failure to thrive (FTT), diarrhea from malabsorption (can lead to rectal prolapse)
  • pulmonary:: CF = most common cause of bronchiectasis in the US (dilation and destruction of the bronchi due to chronic infx and inflammation
  • PE: rhonchi and crackles
    • CXR may show hyperinflation, mucus pluggung and focal atelectasis
  • Dx: elevated sweat chloride test on two different days
    • use pilocarpine → NaCL >60mEq/L
  • Tx: CFTR genotyping to see if they are approved for CFTR modulator therapy
    • hypertonic saline and chest physiotherapy → clears the secretions from the airways
    • tx infections
    • replacement of pancreatic enzymes: supplement fat-soluble enzymes (A, D, E, K)
95
Q

Foreign Body Aspiration

A

usually lodges in the larynx or trachea

can lead to chronic, recurrent infx if left for a while→ PNA, ARDS, asphyxia

  • Risk factors: >85 yo, <2 yo, poor dentition, alcohol use, sedative use, institutionalization
  • S/sxs: Inspiratory stridor
  • Dx: CXR first
  • tx: rigid bronchoscopy = preferred for children
    • soft or rigid bronchoscopy for adults
    • surgical removal
    • Cxs if PNA is suspected
96
Q

Newborn Respiratory Distress Syndrome

A

aka Hyaline membrane disease

  • affects preterm infants when they have not produced enough surfactant → poor lung compliance and atelectasis
  • ***most common cause of respiratory distress in pre-term infants***
  • Risk factors: caucasion, male, multiple births, maternal diabetes
  • S/sxs:
    • respiratory distress at birth (tachypnea >60 /min, tachycardia, chest wall retractions, grunting, nasal flaring, cyanosis)
  • Dx: CXR: diffuse bilateral atelectasis that cause a ground glass appearance and air bronchograms
  • Tx:
    • antenatal steroids within 24-48 hours of birth → betamethasone IM x 2
    • artificial surfactant via ET tube
    • mechanical ventilation with positive pressure
97
Q

Bronchiectasis

A

chronic widening or enlargement of the bronchi and their branches → increased risk of infection

NSR 251A: optho, pulm, renal, GU, heme/onc (9 decks)

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