Pulmonology Flashcards
asthma is…
=REVERSIBLE
- increasing incidence
- wheezing, SOB, cough
- worse at night
- eczema, atopic dermatitis
- inc length of expiration phase
-pulsus paradoxus
asthma causes/exacerbations
-allergens, infection, cold air, exercise, ASA, NSAIDs, beta blockers, tobacco smoke, GERD
- ASA –> dec prostaglandins
- beta blockers –> bronchoconstriction
asthma dx
- severe px: ABG (arterial blood gas) or PEF (peak expiratory flow)
- severe hypoxia, resp acidosis
- CXR: to rule out PNA, CHF, pneumothorax
- PFTs = most accurate test (out-patient setting)
asthma PFTs
- dev FEV1
- dec FVC
- dec FEV1/FVC
- indicates obstruction
- inc TLC (hyperinflation)
- inc residual volume (air trapping)
- REVERSIBLE: FEV1 inc >12% with albuterol
- methacholine –> dec FEV1 20% (bronchial hyper-responsiveness)
acetylcholine & histamine provoke:
bronchoconstriction and inc bronchial secretions
-methacholine = acetylcholine
asthma tx (mild intermittent)
= <2days/week
-short acting beta agonist (albuterol, levalbuterol)
asthma tx (mild persistent)
= >2days/week or >2nights/week
- short acting beta agonist +
- low dose inhaled corticosteroid (beclomethasone, budesonide, flunisolide, fluticasone, mometasone, tricinolone)
asthma tx (moderate persistent)
= daily or >1night/week
- short acting beta agonist + low dose inhaled corticosteroid +
- long acting beta agonist (LABA = salmerterol, formoterol)
- inc dose of ICS
asthma tx (severe persistent)
- max dose of ICS
- LABA and SABA
SE of inhaled corticosteroids (ICS)
dysphonia & oral candidiasis
cromolyn
=inhibitor of mast cell mediator release
-tx exercise-induced asthma
theophylline
=phosphodiesterase inhibitor –> inc cAMP levels
-cardio and neurotoxicity
leukotriene modifiers
= montelukast, zafirlukast, zileuton
- atopic patients
- zafrilukat = hepatotoxic, associated with Churg-Strauss syndrome
asthma acute flare
-O2
-albuterol (nebulized)
+/-ipratropium
-cortocosteroids (immediate administration bc it takes time for onset of effects)
- no epi –last resort
- Mg: helps when refractory to albuterol
- not theophylline, leukotrienes, cromolyn, salmeterol
- intubation: if they develop resp acidosis
best indication of severity of asthma flare
respiratory rate
alpha 1 antitrypsin deficiency
- unable to break down molecules that destroy elastin
- looks like emphysema
- young, non smoker
COPD
- barrel chest from inc air trapping
- SOB
- intermittent exacerbations
- muscle wasting & cachexia due to inflammatory process
- dec FEV1, FVC, FEV1:FVC (<70%)
- inc TLC from air trapping
COPD dx
- CXR = best initial test
- rule out PNA
- inc AP diameter from inc TLC
- air trapping and flattened diaphragms
- PFT = most accurate test
- incomplete improvement with albuterol and no worsening with methacholine (as opposed to asthma)
- ABG: inc CO2 & hypoxia
- EKG: right sided hypertrophy; a fib, MAT
emphysema –> dec DLCO
dec O2 delivered due to destruction of alveolar septae
COPD tx (mortality vs symptom improvement)
improved mortality:
- smoking cessation
- O2 therapy
improved symptoms:
- SABA (albuterol)
- anticholinergic (tio- and ipratropium)*** useful in COPD
- inhaled steroids
- LABA (salmeterol)
- pulmonary rehabilitation
never: cromolyn or leukotrienes
COPD exacerbation tx
-bronchodilators + corticosteroids
same for asthma exacerbation, but less proven benefit
COPD O2 supplementation
- avoid high flow O2 supplementation
- will remove their hypoxic drive to breath
- just raise pO2 > 90%
COPD antibiotic tx
- for mod-severe exacerbation
- inc dyspnea, sputum, or sputum purulence
-protect against strep pneumonia, h influenza, moraxella
- macrolides (azithromycin, clarithromycin)
- cephalosporins (cefuroxime, cefixime)
- amoxicillin/clavulanic acid
- quinolones (levo, moxifloxacin)
-doxycycline,TMP-SMX
bronchiectasis =
destruction, remodeling, dilation of large bronchi
permanent
bronchiectasis causes
CF infections (TB, MAI) PNA (Staph, aspiration) panhypogammagloobulinemeia ABPA tumors RA Kartagener syndrome (immotile cilia)
cause repeat persistent lung infections
bronchiectasis dx
best initial = CXR
most accurate = high resolution chest CT
bronchiectasis tx
- postural drainage (dislodge plugged bronchi)
- treat infections (same as for COPD exacerbations)
- surgical resection (focal lesions)
allergic bronchopulmonary aspergillosis (ABPA)
hypersensitivity/allergy to fungal antigens that normally colonize bronchial tree
- often in asthma or atopic pts
- brown flecked sputum
- cough, wheezing, hemoptysis, bronchiectasis
ABPA dx
- peripheral eosinophilia
- elevated IgE
- pulmonary infiltrates on CXR or CT
ABPA tx
- oral steroids (prednisone)
- no inhaled steroids bc not a high enough dose
- itraconazole or voriconazole for recurrent episodes
CF
- autosomal recessive mutation for Cl transport (CFTR)
- damage Cl & water transport across apical surface of epithelial cells in exocrine glands
CF px
-thick mucus from exocrine gland
- nasal polyps, sinusitis
- bronchiectasis, bronchitis, PNA, pulmonary HTN, cor pulmonale, ABPA
- R ventricular hypertrophy
- GERD
- malabsoprtion of vit ADEK
- hepatic steatosis, portal HTN
- biliary cirrhosis, cholelithiasis
- pancreatitis–>DB, insulin deficiency
- meconium ileus
- infertility (azoospermia), amenorrhea (abnormal menstruation or inc cervical mucus blocks sperm)
- digital clubbing, arthritis
CF infections
mucus plugging allows bacteria to grow (<– WBCs dump DNA into airways)
- H flu
- Pseudomonas aeruginosa
- Staph aureus
- Burkholderia cepacia
CF dx
- inc sweat Cl test
- pilocarpine –> in ACh –> inc sweat production
- Cl>60 = CF
CF tx
- antibiotics to eliminate colonization
- sputum culture
- inhaled aminoglycosides (tobramycin)
- inhaled rhDNase = breaks down DNA in resp mucus
- inhaled bronchodilators (albuterol)
- lung transplantation
CF hemoptysis tx
- rigid bronchoscopy
- bronchial embolization via IR
-“bad lung-side down” to prevent bleeding into “healthy” lung
community acquire pneumonia (CAP) organisms
-Strep pneumo = most common
- H flu - COPD
- Staph - after influenza
- Klebsiella - alcoholism, DB
- anaerobes - poor dentition
- Mycoplasma - young healthy (college; “walking PNA”)
- Chlamydia - hoarse voice
- Legionella - contaminated water source
- Chlamydia psittaci - birds
- Coxiella burnetii - animals, vets, farmers
dullness to percussion due to?
effusion
egophany due to?
consolidation
Klebsiella px
hemoptysis
“currant jelly”
Anaerobes px
foul smelling sputum
Mycoplasma pneumonia px
dry cough
bullous myringitis
Legionella px
GI symptoms: abdominal pain, diarrhea
CNS symptoms: headache, confusion
Pneumocystis patients?
AIDS: CD4<200
dry cough causes?
-involve interstitial space, not alveoli –> less sputum
mycoplasma virus coxiella pneumocystis chlamydia
CAP dx
CXR = best initial test
sputum gram stain
atypical PNA
not visible on gram stain
mycoplasma, chlamydophila, legionella, coxiella, viruses
30-50% of CAP
CXR: interstitial infiltrates; spares air spaces; hazy lung fields
thoracentesis used for what?
-tx for pleural effusions
empyema =
infectious pleural effusion
tx: thoracentesis & chest tube for drainage
LDH>60%
protein>50%
pH<7.2
Strep pnemo dx
tested via urine antigen
Mycoplasma pneumonia dx
PCR
cold agglutins
serology
special culture media
Chlamydia dx
rising serologic titers
Legionella dx
urine antigen (similar to Strep pneumo) culture on charcoal-yeast extract
Pneumocystis jiroveci (PCP) dx
bronchoalveolar lavage (BAL)
CAP tx outpatient
previously healthy: macrolide (azithromycin or clarithromycin) OR doxycycline
comorbidities: respiratory floroquinolones (levofloxacin or moxifloxicin)
CAP tx inpatient
respiratory floroquinolone (levofloxacin or moxifloxacin)
OR
ceftriaxone and azithromycin
CAP vs HAP
CAP: PNA before hospital visit or within 48 hours of hospitalization
HAP: >48 hours of hospitalization
reasons to hospitalize
- hypotension 30
- pO2 30
- Na 125
- pulse >125
- confusion
- temp >104F
- > 65YO or comorbidities
hypoxia + hypotension
CURB 65 = confusion, uremia, resp distress, BP low, age 65
pneumococcal vaccine administration to?
- everyone >65YO
- chronic heart disease, liver, kidney, or lung disease
- aplenic pts
- malignancy, DB, AIDS, HIV
healthcare PNA
> 48 hours after admission
- gram(-) –> E coli or Pseudomonas
- no macrolide tx
HCAP tx
- gram (-) coverage
- antipseudomonal cephalosporins (cefepime or ceftazidime)
- antipseudomonal penicillin (pipercilling/tazobactam = zosyn)
- carbapenems (imipenem, meropenem, doripenem)
ventilator associated PNA
- interferes with normal mucociliary clearance
- damages normal ability to clear colonization
VAP dx & tx
- protected brush specimen (dangerous)
- bronchoalveolar lavage
- tracheal aspirate
- 1 antipseudomonal beta-lactam (ceftazidime, cefepime, pipercillin/tazobactam, imipenem, meropenem, doripenem)
- 1 aminoglycoside (gentamicin or tobramycin)
- 1 MRSA agent (vancomycin or linezolid)
subcutaneous emphysema
=air abnormally leaking into soft tissue of chest wall
-causes: chest tube
imipenem causes
seizures (lowers threshold)
-excreted from kidney; thus AKI can cause toxicity
lung abscess
-cause by aspiration PNA
- stroke + loss of gag reflex, seizure, intoxication, endotracheal intubation
- right upper lobe when lying flat
lung abscess px & dx
- foul smelling sputum
- caused by anaerobes
- CXR = best initial –> cavity with air fluid level
- chest CT = most accurate
- lung biopsy to find microbiology etiology (NEVER sputum culture)
lung abscess tx
clindamycin
PCP PNA px
- AIDS pts
- CD4 <200
-severe dyspnea on exertion, dry cough, fever
PCP dx
- CXR -bilateral interstitial infiltrates
- ABG -hypoxia
-elevated LDH
PCP tx
-TMP-SMX
=tx & prophylaxis
-steroids to dec mortality
- mild: atovoquone
- TMP-SMX toxicity: clindamycin, primaquine, pentamidine
adverse effects of TMP-SMX
rash
bone marrow suppression
azithromycin in HIV protects against?
atypicals, MAI (mycoplasma) when CD4<50
TB risk factors
- recent immigration (past 5 years)
- prisoners
- HIV
- healthcare workers
- close contact to TB
- steroid use
- hematologic malignancy
- alcoholics
- DB
TB px
fever, cough, sputum, weight loss, hemoptysis, night sweats
> 3 weeks
TB dx
- CXR = best initial
- AFB = most specific
- 3 negative AFB = negative TB test
- bronchoscopy with BAL or pleural biopsy if high suspicion but negative tests
-PPD = screening
typical TB CXR
- upper lobe cavity infiltrate
- cavity = reactivation of latent infection
TB tx
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
-ehtambutol give prior to sensitivity testing; removed if TB sensitive to other drugs
-stop ethambutol and pyrazinamide after 2 months
-continue rifampin and isoniazid for next 4 months
=6 months of total therapy
9 months of TB tx
osteomyelitis, miliary TB, meningitis, pregnancy (pyrazinamide not used)
rifampin SE
- hepatotoxicity
- red body secretions
isoniazid SE
- hepatotoxicity
- peripheral neuropathy (tx with pyridoxine = B6)
pyrazinamide SE
- hepatotoxicity
- hyperuricemia (only tx if they have gout)
-NOT FOR PREGNANT PTS
ethambutol SE
- hepatotoxicity
- optic neuritis
- color change
-dec dose in renal failure
steroids in TB
- dec constrictive pericarditis
- dec neurologic complications
PPD testing
- screening only for risk groups
- NOT for symptomatic pts
- NOT diagnostic
PPD
- induration = +
- erythema is not +
- > 5mm : HIV, glucocorticoid, transplant receptors
- > 10mm : recent immigrant, prisoner, HC worker, hematologic malignancy
- > 15mm : no risk factors
- CXR if positive PPD
positive PPD, next?
9 months of isoniazid
when to biopsy a pulmonary nodule?
inc risk for malignancy
- > 40YO
- change in size in serial films
- smoker
- spiculated borders
- > 2cm
- atelectasis (post-obstructive process)
- adenopathy
- sparse, eccentric calcification
infectious vs malignant nodule?
- both have enlarging lung lesions
- infectious doubles in size in <30 days (faster than cancer)
malignant pulmonary nodule tx?
resection
-many false negatives with PET, cytology, needle biopsy
PET scan
- malignancy has increased uptake of tagged glucose
- high sensitivity
VATS (video-assisited thoracic surgery)
- frozen section in operating room
- immediate conversion to open thoracoscopy and lobectomy if malignancy found
benign pulmonary nodules by location:
- immigrant
- SW, USA
- Ohio river valley, USA
- TB
- coccidiomycosis
- histoplasmosis
pneumoconioses types:
- coal
- sandblasting/ rock/ mining/ tunneling
- shipyard workers/ pipe fitting/ insulators
- cotton
- electronic manufacturers
- moldy sugar cane
- coal worker’s
- silicosis
- asbestosis
- byssinosis
- berylliosis ***granulomas
- bagassosis
is fibrosis reversible?
NO
interstitial lung disease dx
- CXR = best initial
- chest CT = more accurate (“honeycombing”)
- lung biopsy = most accurate
interstitial lung disease PFTs
- decreased FEV1, FVC, TLC, RV
- FEV1/FVC ratio is normal
- decreased DLCO (septal thickening)
berylliosis tx
responds best to steroids
granulomas represent inflammation
sarcoidosis px
- noncaseating granulomas (lung)
- young African American woman
- erythema nodosum
- lymphadenopathy (hilar, bilateral)
- heart block
- restrictive cardiomyopathy
sarcoidosis dx
- CXR = best initial (hilar lymphadenopathy)
- lymph node biopsy = most accurate (non-caseating granulomas)
- elevated ACE
- hypercalciuria
- hyperCa (granulomas make vitamin D)
- PFT –> restrictive lung disease
sarcoidosis tx
-prednisone
(few pts fail to respond)
-asymptomatic pts do not need to be treated
Virchow’s triad = predisposing factors to thromboembolism
- ) stasis of blood flow (immobility, CHF, recent surgery)
- ) hypercoagulability (Factor V Leiden, malignancy)
- ) endothelial injury (trauma, surgery, recent fracture)
PE px
tachypnea + tachycardia + cough + hemoptysis
- leg pain from DVT
- pleuritic CP
- fever
- hypotension
PE dx
- CXR (often normal)
- EKG (sinus tachy; S1Q3T3)
- ABG (hypoxia + respiratory alkalosis –from tachypnea)
- confirm with spiral CT angiogram
- D-dimer –> very sensitive, poor specificity (negative excludes, positive means nothing)
- angiography = most accurate (rarely used)
when do you use a D-dimer test?
when pretest probability of PE is low
(+) lower extremity doppler study… next?
- no further dx
- treat for PE (unfractionated heparin)
PE tx
- IV heparin = best initial
- start oral warfarin simultaneously
- IVC filter if anticoagulation contraindicated, recurrent emboli on heparin, RV dysfunction
- thrombolytics –pts hemodynamically unstable
- direct-acting thrombin inhibitors –hx of HITT
-NEVER USE ASA for DVT tx
causes of pulmonary HTN
-left sided heart failure = MCC
-L–>R shunt
-hypoxic vasoconstriction from COPD
-PE
(chronic hypoxemia)
-idiopathic
pulmonary HTN px
- exertional syncope
- exertional CP
- dyspnea, fatigue
- right heart failure, edema, JVD
pulmonary HTN dx
- CXR = best initial (dilation of proximal arteries)
- Swan-Ganz Katheter = most accurate (measures pulmonary capillary wedge pressure = LA pressure = LVED pressure)
- EKG (RAD, RV hypertrophy)
- echo (R heart hypertrophy)
- V/Q scanning
- CBC (polycythemia)
pulmonary HTN tx
- prostacyclin analogues –> pulmonary artery vasodilation
- endothelin antagonists (bosentan)
- phosphodiesterase inhibitors (sildenafil)
- oxygen slows progression
- not CCBs
-cure: lung transplantation
symptoms of OSA
- daytime somnolence
- snoring
- headache (early morning hypercarbia)
- impaired memory & judgement
- depression
- HTN
- erectile dysfunction
OSA dx
polysomnography = sleep study = most accurate
-shows multiple episodes of apnea
OSA tx
-treat risk factors (men, overweight)
- weight loss
- CPAP –positive airway pressure throughout the night
-avoid sedative
ARDS px
=overwhelming lung injury or systemic disease
-endothelial injury in aleveoli –> leaky –> alveoli fill with fluid
- severe hypoxia
- poor lung compliance
- noncardiogenic pulmonary edema
ARDS dx
- CXR = dense bilateral infiltrates –> white out
- air bronchograms = hyperlucent air within congestion
- PaO2/FiO2 ratio <18 mmHg)
ARDS tx
- mechanical ventillation
- low tidal volume (6mL/kg)
- PEEP
-steroids can reduce pulmonary fibrosis
