Pulmonology Flashcards
Sarcoid path, presentation, dx, tx
Unknown etiology ==> noncaseating granuloma
Usually middle-aged black women Cough, dyspnea, fever, weight loss Eye pain (uveitis) Joint pain (arthritis) Lymphadenopathy Erythema nodosum (fat inflammation = COMMON!)
ACE elevation
Hypercalcemia
XR: bilateral hilar (mediastinal & paratreacheal) adenopathy with reticulonodular infiltrates
Eye exam: erythema with leukocytes (uveitis)
Biopsy: noncaseating granuloma ==> required for dx!
Systemic glucocorticoids
Anterior mediastinal ddx*
4T's Thymoma Teratoma (all nonseminomatous germ cell tumors: yolk, chorio, embryonal ==> elevated AFP and b-HCG) Terrible Lymphoma Thyroid
Emergent vs non-emergent hemoptysis*
> 600mL hemoptysis or >100mL/hr ==> immediate intubation ==> lay on side of suspected bleeding ==> bronch
diagnostic workup
Pulmonary nodule workup* (need more help here)
- Determine risk: high, intermediate, low
High: malignancy hx (breast ca), recent size changes, irregular calcification, pleural involvement, >2cm ==> surgical excision
Intermediate: ??? ==> PET
Low: CXR or CT q3 months for 1 year ==> q6 months onward
Obstructive lung path, ddx, dx*
Obstruction causes gas trapping
ABCT Asthma Bronchiectasis COPD Tracheobronchial obstruction
Increased RV Increased TLC Low-normal FVC (functional vital capacity) Very decreased FEV1 < 75% expected **FEV1 / FVC < 75% expected**
DLCO: increased with asthma*, normal with bronchitis, decreased with emphysema
Lung volume measurements
TLC = IRV + TV + ERV + RV
TV: normal breath = 500mL
ERV: full exhale after normal breath
RV: excess post-exhale; not measured by spirometry
FRC = ERV + RV
IRV: full inhale after normal breath
IC = TV + IRV
VC: total air available for inhale/exhale = ERV + TV + IRV
Restrictive lung path, ddx, dx
Loss of compliance decreases lung expansion ==> lower volumes
AIN’T (compliant)
Alveolar: ARDS, edema, hemorrhage [Wegener’s, Goodpasture’s], pus
ILD: sarcoid, silicosis, fibrosis*
Neuromuscular: myasthenia, polio, phrenic nerve palsy
Thoracic wall: kyphosis, obesity, ascites, pregnancy
Decreased FEV1 but proportionally same as FVC ==> thus FEV1/FVC > 75% expected
FVC < 80%
Decreased diffusion capacity
Very decreased RV
Asthma path, presentation, dx, tx* w/ intubation criteria*
REVERSIBLE obstruction 2/2 hyperreactivity, inflammation, hypertrophy
Cough, wheezing etc.
Prolonged expiratory phase
Hyperresonance
Pulsus paradoxus (>10mmHg decrease SBP w/ inspiration)
Late: decreased breath sounds
*Nocturnal symptoms with sore throat = GERD, even without dyspepsia ==> PPI!
Mild hypoxia
Respiratory alkalosis ==> progressing to acidosis when severe*
Decreased FEV1 / FVC improves with bronchodilator test*
Eosinophilia
------ Acute tx: Albuterol ==> ipratroprium ==> steroids ------ Intubate if: Fatigue Altered MS "Silent chest" PCO2 > 50 PO2 < 50
Chronic tx:
Intermittent: sx < 2x week, nighttime awakenings albuterol
Mild persistent: sx < daily, nighttime awakening < 4x per month, 80% FEV1 ==> albuterol + fluticasone
Moderate: sx daily, nighttime awakening weekly, 60% FEV1 ==> albuterol + fluticasone + salmeterol
Severe: constant sx, FEV1 < 60% ==> albuterol + fluticasone + salmeterol + prednisone
Bronchiectasis path, presentation*, dx, tx
Bronchial infection / inflammation cycle ==> fibrosis ==> thickening & dilation of bronchi
Recurrent infection hx* Purulent mucus (more than bronchitis!) Occasional hemoptysis Rales: crackles Wheezes Ronchi: low pitched moans
XR: increased bronchovascular markings, but non-specific. Must do CT!
CT: thickened, dilated bronchi ==> sputum analysis
Decreased FEV1 / FVC ratio
Abx
Corticosteroids
Lung exercises
COPD path, presentation, dx, tx*
Obstruction 2/2 Bronchitis: productive cough > 3 months/yr x2 yrs Emphysema: terminal airway dilation 2/2 smoking or alpha-1-antitrypsin (unopposed elastase activity) ----- SPECTRUM Bronchitis: blue bloaters Dyspnea Overweight Rhonchi & wheezes Early hypercarbia*
Emphysema: pink puffers Dyspnea Thinner Hyperresonance* Decrease breath sounds* & wheezes Later hypercarbia* ----- Bronchitis: Hypoxemia Early hypercarbia* XR: PROMINENT vascular markings, flat diaphragms NORMAL DLCO
Emphysema: Hypoxemia Late hypercarbia* XR: MINIMAL vascular markings, pleural blebs & parenchymal bullae DECREASED DLCO ------ Chronic: Oxygen & smoking cessation ==> only proven survival tx Corticosteroids Prevention (pneumococcal & flu vaccines) Dilation (albuterol, ipratroprium)
Acute exacerbation*
Ipratroprium + albuterol + systemic steroid
Keep 02 < 95% ==> too much 02 reduces deoxyhemoglobin, which has higher affinity for C02, thus increasing C02 retention ==> hypercarbia MS change, seizure
Intubation: try non-invasive PEEP first, then intubate if refractory, pH <7.1, or MS changes
Interstitial lung disease path, presentation, dx*, tx
Inflammation and fibrosis of inter alveolar septa 2/2:
amiodarone, IPF, silicosis etc.
Dyspnea
NON-productive cough
CT: Reticulonodular ground glass w/ honeycombing*
Decreased TLC, FVC
Decreased DLCo
Increased A-a gradient*
Normal FEV1 / FVC*
Biopsy showing interstitial fibrosis to confirm
Lung transplant
Hypersensitivity pneumonitis path, presentation, dx, tx**
Environmental exposure causing alveolar inflammation ==> progresses to pulmonary fibrosis
Weird exposure, like a bird-handler
Dyspnea
Fever, chills
Rales
XR: bilateral, lower lung hazy, ground glass
Avoid antigen (even if its their job!) ==> steroids speed recovery
Pneumoconiosis path, ddx w/ presentations, complications, dx
Inhalation of small particles ==> restrictive lung disease
Asbestosis:
Construction or shipbuilding
Mesothelioma & other lung cancers
Restrictive lung disease: decreased diffusion capacity*, decreased TLC, normal FEV1/FVC
CXR: opacities @ lung bases; pleural plaques
Coal miner’s black lung pop:
Small upper lung nodular opacities
Restrictive lung disease: decreased diffusion capacity*, decreased TLC, normal FEV1/FVC
Massive fibrosis
Silicosis: Mines, rock quarries, pottery Small upper lung nodular opacities with ovoid eggshell calcifications on XR Restrictive lung disease Increased TB risk needing annual test
Berylliosis:
Aerospace, nuclear, electronics, dental
Diffuse infiltrates with hilar adenopathy
Lifelong steroids
Alveolar gas equation & shunt vs V/Q mismatch
PA(alveolar)02 = 150 - [Pa(arteriolar)02/0.8]
Normally = 10-15
Shunt: no V, all Q ==> no response to 02
Other: responds to 02
ARDS path, presentation, dx, tx including ventilation settings*
Endothelial injury ==> decreased lung compliance, pulmonary edema, impaired gas exchange, pulmonary HTN
Acute onset 12-48 hrs
Tachypnea
Tachycardia
Hypoxia
Widened A-a gradient Respiratory acidosis Pa02 / Fi02 < 200 Stanz Ganz < 18 [not cardiac origin] CXR: bilateral diffuse infiltrates
Ventilation:
High PEEP to open alveoli (risk of tension pneumo*)
Keep TV low to reduce alveolar injury (so don’t answer increase TV)
Fi02 < 40 to prevent oxygen poisoning
Cor pulmonale name, path, ddx, presentation, dx, tx
Pulmonary hypertension
Pulmonary artery pressure > 25 2/2:
- Pulmonary artery HTN
- L-sided heart disease ==> pulmonary venous pressure
- Hypoxic vasoconstriction 2/2 lung disease
- PE
- Idiopathic
Dyspnea Fatigue Maybe hemoptysis Progresses to R-sided CHF sx: edema, JVD, ascites Loud, split S2 (P2 closes before A2)
CXR: enlarged pulmonary artery, enlarged R heart border
ECG: RV hypertrophy / R-axis deviation
O2
Diuretics
Pulmonary embolism path, presentation, dx, tx
Pulmonary vascular occlusion 2/2 clot (usually iliac*, femoral, popliteal upper leg)
*Virchow's triad: venous stasis, endothelial injury, hypercoagulability Immobility history Dyspnea ==> 75% Chest pain ==> 65% Fever Hemoptysis* Hypoxia HYPOcarbia 2/2 hyperventilation ==> respiratory alkalosis Prominent P2 Pleural effusion*
Well’s criteria:
If low risk ==> D-dimer: sensitive, not specific
If high risk ==> spiral CT / angiogram with contrast (or V/Q scan if renal failure)
CT: wedge-shaped pleural opacification*
Elevated A-a gradient
Respiratory alkalosis with pO2
Elevated PA and RA pressure with normal PCWP*
If high risk: immediate anticoagulation* ==> CT ==> embolectomy or thrombolytic if positive
Chronic: warfarin with INR 2-3 or filter if warfarin contraindicated
General non-small cell lunger cancer PE signs
Horner’s: apical tumor ==> miosis, ptosis, anhidrosis
SVC syndrome: SVC obstruction ==> JVD & facial swelling
Brachial plexus arm pain 2/2 superior sulcus tumor location*
Adenocarcinoma path, unique subtype, presentation, dx*, tx
Most common lung cancer
Bronchoalveolar: only one not associated with smoking*
Smoker (except bronchoalveolar!)
Cough
Weight loss
Hemoptysis
CXR: peripheral** location (multi nodular if bronchoalveolar)
FNA (bc peripheral)
Resectable if early
Squamous cell carcinoma path, presentation, unique pe findings, dx*, tx
SCC
Smoker
Cough
Weight loss
Hemoptysis
Horner’s: apical tumor ==> miosis, ptosis, anhidrosis
SVC syndrome: SVC obstruction ==> JVD & facial swelling
Brachial plexus arm pain 2/2 superior sulcus tumor location*
HYPERCALCEMIA 2/2 PTHrP*
CXR: central perihilar location* with potential necrosis/cavitation
Bronchoscopy
Resectable if early
Large cell carcinoma
Neuroendocrine origin
Uncommon
Poor prognosis
Pleural effusion path, presentation, dx**, tx
Transudative = high capillary pressure (CHF*, cirrhosis) or low oncotic pressure (nephrotic syndrome) Exudative = increased vascular permeability
Transudative: above Exudative: Infection, malignancy, PE* Dyspnea Pleuritic chest pain Dullness to percussion* Decreased breath sounds* Decreased fremitus* (only pneumonia consolidation increases fremitus) Pleural friction rub maybe
CXR: costophrenic angle blunting
**Thoracentesis unless bilateral or CHF ==> bronchoscopy afterward
Exudate pH < 7.4
LIGHT’S criteria for exudative effusion:
pleural:serum protein > 0.5
pleural:serum LDH > 0.6
pleural LDH > 2/3 normal serum LDH value
Chest tube & drain if complicated / big
Cystic fibrosis path, presentation*, dx, tx
Autosomal recessive chloride ion transporter dysfunction
Recurrent nasal & pulmonary infection
BILATERAL POLYPS
Digital clubbing
Sweat test or quantitative pilocarpine iontophoresis
Consolidation PE*
Louder, longer expiratory breath sounds that effusion
Increased* fremitus (effusion doesn’t)
Egophony
Whispered pectoriloquy
Exercise induced asthma presentation, tx
Wheezing w/ exercise or cold
Associated with atopic dermatitis
Albuterol BEFORE exercise
DVT path, presentation, dx, tx*
Clot
Painful swelling
ultrasound
Heparin ==> stabilize clot (won’t lyse it) and retard growth
Bridge to warfarin once INR = 2-3 ==> 3-6 months*
Aspirin sensitivity syndrome path, presentation, dx, tx
Aspirin blocks COX ==> arachidonic acid shifts to 5-lipoxygenase pathway ==> increased leukotrienes ==> bronchoconstriction and polyp formation
MUST consider for any pt with wheezing & aspirin in stem
Nasal blockage 2/2 polyps
Wheezing
Occurs minutes to hours post-aspirin ingestion*
Clinical
Monteleukast
Empyema path, presentation, dx, tx
Pleural effusion infection 2/2 effusion or other trauma
Dyspnea
Fever
CT Low glucose (2/2 WBC and bacterial metabolic activity)
If pH < 7.2 or glucose < 60 ==> drainage +/- fibrinolysis If complex (loculated, rind) ==> surgery
Non-productive cough ddx in non-smoker w/ tx*
ACE-inhibitor ==> remove
GERD ==> PPi
Post-nasal drip ==> antihistamine
Asthma ==> albuterol
Recurrent pneumonia in same place workup*
Usually 2/2 to obstruction (usually cancer), Ig deficiency, aspiration (alcoholics, GERD, elderly)
Serum Ig levels
CT to r/o cancer ==> bronchoscopy if obstructive cause found
A-1 antitrypsin vs emphysema dx*
Emphysema = centrilobular AAT = panlobular
Atypical pneumonia path, presentation, dx, tx
Mycoplasma*, Chlamydia, Legionella, Coxiella etc.
*NONPRODUCTIVE cough, unlike pneumonia
Extrapulmonary signs: erythema multiforme rash, headache, sore throat
Mycoplasma: no cell wall ==> no gram stain
Endotracheal tube complication*
Enters R mainstem bronchus
Alpha-1-antitrypsin deficiency path, presentation, dx, tx
Deficiency of liver-produced enzyme that inhibits digestive enzymes (pancreatic trypsin and neutrophil elastase [lung]) with wide phenotypic variation
Emphysema, bronchitis etc.
Cirrhosis, hepatosplenomegaly
Serum levels of alpha-1-antitrypsin levels Hepatocyte inclusions (unreleased alpha-1-antitrypsin) with positive PAS reagent + diastase resistance
Purified A1AT
Lung transplant
Small cell lunger cancer path, presentation, dx, tx
Neuroendocrine tumor, commonly paraneoplastic associations
Smoker!
Cough, weight loss, hemoptysis
CXR: central location*
Hyponatremia 2/2 SIADH
Non-resectable ==> chemo only!
