Pulmonology Flashcards
CXr Solitary pulmonary nodule (SPR)
The first step in the evaluation of a pulmonary nodule is to look for a prior x-ray. Finding the same pulmonary nodule on an x-ray done years ago may save you from doing any further workup. If no prior x-ray is available, then consider whether this patient is high or low risk for lung cancer.
In low-risk Patient
- <35 years
- Non-smoker
follow every 3 months / 2 yrs, stop folowing if growth stops
In high-risk Patient
>50 yrs
Smoking history
Do open-lung biopsy and remove the nodule
Pleural Effusions - Parapneumonic Effusions
Parapneumonic effusions are effusions caused by **bacterial pneumonia.
A thoracocentesis is mandatory also in this setting to rule out a complicated parapneumonic effusion **
Uncomplicated parapneumonic effusions: These are exudative, predominantly neutrophilic effusions reflecting increasing passage of interstitial fluid as a result of inflammation associated with pneumonia. The fluid may be slightly cloudy or even clear, without any organisms noted on Gram stain or culture. They resolve with appropriate antibiotic treatment of the pneumonia.
Complicated parapneumonic effusions: These occur as a result of bacterial invasion into the pleural space that leads to an increased number of neutrophils, decreased glucose levels, pleural fluid acidosis, and an elevated lactic dehydrogenase (LDH) concentration. These effusions often are sterile because bacteria are usually cleared rapidly from the pleural space. The fluid is typically cloudy and is classified as complicated because it requires drainage for resolution.
Empyema thoracis: This develops as frank pus accumulates in the pleural space. Laboratory studies indicate that preexisting pleural fluid is required for the development of an empyema because empyema is not seen after direct inoculation into a “dry” pleural space. The pus is seen after thoracentesis or any drainage procedure of the pleural space and is generally characterized as thick, viscous, and opaque.
Superior vena cava syndrome
Clinical Findings
Markedly dilated veins or venules (often in vertical parallel clusters on the chest above the level of the heart) constitute the earliest cutaneous finding in SVC
These result from increased collateral flow through the subcutaneous vessels of the chest wall. The engorged vessels shrink or disappear with relief of the obstruction of blood flow.
Other signs
that may result from the venous congestion include hoarseness, facial edema, plethora of the head and neck, conjunctival suffusion, and proptosis.
COPD
X-ray findings
Hyperinflated lungs
Flattened Diaphragms
Slender heart
Pack-Years of Smoking
• To calculate smoking pack-years:
– Divide the number of cigarettes smoked per day by 20 (the number of cigarettes in a pack)
– Then multiply by the number of years smoked
(70 cigarettes/day ÷ 20 cigarettes/pack)
X
10 years
=
35 pack - years
(35 cigarettes/day ÷ 20 cigarettes/pack) X 20 years = 35 pack-years
(20 cigarettes/day ÷ 20 cigarettes/pack) X 35 years = 35 pack-years
COPD
Home O2 Supplementation (Reduces Pulmonary Htn)
When do you administer O2 at home
what ammount of O2 you should give
USE IF (significant disease)
A. Resting PaO2 <= 55 or SaO2 <88%
B. Resting PaO2 <= 56 - 59 and Cor Pulmonale (JVD Edema)
B2. Pulmonary HT or HCT >55%
C. Resting >60 and Desaturate with mild exercise
- Ask patient to climb some stairs
- If PaO2<60 give O2 only when exercise or sleep
MOST SEVERE HYPOXEMIA IS AT NIGHT
O2 dose titrated such that SaO2 is maintained at >90% during sleep, normal walking, and at rest
When used 15h /day benefits are significant
COPD Vacines
for all patients
- Influenza Vaccine yearly
- Pneumococal vaccine Every 5 yrs
- H. Influenza once a liftetime
COPD 60-60
What is 60-60 COPD
“60-60” group
O2 = CO2
!!If you give to much oxigen => retain CO2 due to blunting of Hyperventilation
COPD
Admision Criteria
Admit to Hospital If
1. CO2 (65) and O2 modif are signifiant 2. Symptoms are severe 3. Pneumonia is suspected 4. Home O2 Exacerbation
COPD
ICU & Intubation
- Altered level of Consciousness
- Hemodynamically unstable
COPD
- What is the best predictor of survival and of progression
- Do you do PFT in acute exacerbations?
- Do you do PFT for patients with COPD scheduled for lung surgery? what FEV1
- Answer:
* FEV1 is the best predictor of survival - FEV1 = 25%-50% (of predicted) = Moderate (Can walk couple of blocks before stoping with SOB)
- FEV1 < 25% (of predicted) = Severe (SOB at rest)
- If FEV1 60% of predicted and patient can not walk without SOB then it is due to other pathology
- Answer
NO! you do it when they are at their baseline, in Outpatient setting, it can get a false + response due to the exacerbation
- Answer
Always!!! FEV1 >50% of predicted
ASTHMA
Modified Guidelines
Modified Guidelines for outpatient
Mild
- <2 atk / wk
- Minimal night symptoms
** MDR ALBUTEROL**
Moderate
MOST PEOPLE FIT HERE 80% - 90%
- Maybe daily / Most of the wk
- Night symptoms
** MDR Steroids / Albuterol/ LABA (if night wheezing)**
DDx GERD/Post nasal Drip
_ Severe_
- Symptoms despite treatment
- Frequent spitalization (intubated)
- Nocturnal symptoms
REGULAR TX / LABA / ANTI-LEUKOTRIENE / PO. STEROIDS
COPD
Plethoric Vs Cachectic
What test distinguishes them?
Plethoric if Bronchitis Predominant
Cachectic if Emphysema predominant
DDX between them is DlCO
- Emphysema has decreased DlCO
- Bronchitis has normal DlCO
Bronchiectais Presentation
Most comon presenting bacteria class
Most common bacteria family
- Purulent Copious Sputum
- Hemoptysis (massive)
-
Recurent Pneumonias
- G- Pneumonias
- Pseudomonas
- If someone presents with G- Pneumonias must suspect Bronchiectais
Bronchiectasis Cillia Dismotility Syndrome
Kartagener Syndrome
Chest x-ray demonstrates dextrocardia, hyperinflation of the lungs and extensive linear tram-track opacities suggestive of bronchiectasis. In addition there is calcification of hilar nodes, best seen on the left.
Bronchiectasis
Tram-Track sign
Side-by-side comparison of the in-vivo tram track sign on the left and the experimental analog on the right. The arrows point to the thickened bronchiole walls seen in the CF patient
