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Internal Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

asthma is…

A

=REVERSIBLE

  • increasing incidence
  • wheezing, SOB, cough
  • worse at night
  • eczema, atopic dermatitis
  • inc length of expiration phase

-pulsus paradoxus

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2
Q

asthma causes/exacerbations

A

-allergens, infection, cold air, exercise, ASA, NSAIDs, beta blockers, tobacco smoke, GERD

  • ASA –> dec prostaglandins
  • beta blockers –> bronchoconstriction
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3
Q

asthma dx

A
  • 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)
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4
Q

asthma PFTs

A
  • 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)
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5
Q

acetylcholine & histamine provoke:

A

bronchoconstriction and inc bronchial secretions

-methacholine = acetylcholine

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6
Q

asthma tx (mild intermittent)

A

= <2days/week

-short acting beta agonist (albuterol, levalbuterol)

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7
Q

asthma tx (mild persistent)

A

= >2days/week or >2nights/week

  • short acting beta agonist +
  • low dose inhaled corticosteroid (beclomethasone, budesonide, flunisolide, fluticasone, mometasone, tricinolone)
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8
Q

asthma tx (moderate persistent)

A

= daily or >1night/week

  • short acting beta agonist + low dose inhaled corticosteroid +
  • long acting beta agonist (LABA = salmerterol, formoterol)
  • inc dose of ICS
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9
Q

asthma tx (severe persistent)

A
  • max dose of ICS

- LABA and SABA

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10
Q

SE of inhaled corticosteroids (ICS)

A

dysphonia & oral candidiasis

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11
Q

cromolyn

A

=inhibitor of mast cell mediator release

-tx exercise-induced asthma

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12
Q

theophylline

A

=phosphodiesterase inhibitor –> inc cAMP levels

-cardio and neurotoxicity

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13
Q

leukotriene modifiers

A

= montelukast, zafirlukast, zileuton

  • atopic patients
  • zafrilukat = hepatotoxic, associated with Churg-Strauss syndrome
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14
Q

asthma acute flare

A

-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
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15
Q

best indication of severity of asthma flare

A

respiratory rate

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16
Q

alpha 1 antitrypsin deficiency

A
  • unable to break down molecules that destroy elastin
  • looks like emphysema
  • young, non smoker
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17
Q

COPD

A
  • 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
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18
Q

COPD dx

A
  • 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
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19
Q

emphysema –> dec DLCO

A

dec O2 delivered due to destruction of alveolar septae

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20
Q

COPD tx (mortality vs symptom improvement)

A

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

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21
Q

COPD exacerbation tx

A

-bronchodilators + corticosteroids

same for asthma exacerbation, but less proven benefit

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22
Q

COPD O2 supplementation

A
  • avoid high flow O2 supplementation
  • will remove their hypoxic drive to breath
  • just raise pO2 > 90%
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23
Q

COPD antibiotic tx

A
  • 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

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24
Q

bronchiectasis =

A

destruction, remodeling, dilation of large bronchi

permanent

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25
Q

bronchiectasis causes

A 
CF
infections (TB, MAI)
PNA (Staph, aspiration)
panhypogammagloobulinemeia
ABPA
tumors
RA
Kartagener syndrome (immotile cilia)

cause repeat persistent lung infections

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26
Q

bronchiectasis dx

A

best initial = CXR

most accurate = high resolution chest CT

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27
Q

bronchiectasis tx

A
  • postural drainage (dislodge plugged bronchi)
  • treat infections (same as for COPD exacerbations)
  • surgical resection (focal lesions)
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28
Q

allergic bronchopulmonary aspergillosis (ABPA)

A

hypersensitivity/allergy to fungal antigens that normally colonize bronchial tree

  • often in asthma or atopic pts
  • brown flecked sputum
  • cough, wheezing, hemoptysis, bronchiectasis
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29
Q

ABPA dx

A
  • peripheral eosinophilia
  • elevated IgE
  • pulmonary infiltrates on CXR or CT
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30
Q

ABPA tx

A
  • oral steroids (prednisone)
  • no inhaled steroids bc not a high enough dose
  • itraconazole or voriconazole for recurrent episodes
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31
Q

CF

A
  • autosomal recessive mutation for Cl transport (CFTR)

- damage Cl & water transport across apical surface of epithelial cells in exocrine glands

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32
Q

CF px

A

-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
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33
Q

CF infections

A

mucus plugging allows bacteria to grow (<– WBCs dump DNA into airways)

  • H flu
  • Pseudomonas aeruginosa
  • Staph aureus
  • Burkholderia cepacia
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34
Q

CF dx

A
  • inc sweat Cl test
  • pilocarpine –> in ACh –> inc sweat production
  • Cl>60 = CF
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35
Q

CF tx

A
  • antibiotics to eliminate colonization
  • sputum culture
  • inhaled aminoglycosides (tobramycin)
  • inhaled rhDNase = breaks down DNA in resp mucus
  • inhaled bronchodilators (albuterol)
  • lung transplantation
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36
Q

CF hemoptysis tx

A
  • rigid bronchoscopy
  • bronchial embolization via IR

-“bad lung-side down” to prevent bleeding into “healthy” lung

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37
Q

community acquire pneumonia (CAP) organisms

A

-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
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38
Q

dullness to percussion due to?

A

effusion

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39
Q

egophany due to?

A

consolidation

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40
Q

Klebsiella px

A

hemoptysis

“currant jelly”

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41
Q

Anaerobes px

A

foul smelling sputum

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42
Q

Mycoplasma pneumonia px

A

dry cough

bullous myringitis

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43
Q

Legionella px

A

GI symptoms: abdominal pain, diarrhea

CNS symptoms: headache, confusion

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44
Q

Pneumocystis patients?

A

AIDS: CD4<200

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45
Q

dry cough causes?

A

-involve interstitial space, not alveoli –> less sputum

mycoplasma
virus
coxiella
pneumocystis
chlamydia
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46
Q

CAP dx

A

CXR = best initial test

sputum gram stain

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47
Q

atypical PNA

A

not visible on gram stain

mycoplasma, chlamydophila, legionella, coxiella, viruses

30-50% of CAP
CXR: interstitial infiltrates; spares air spaces; hazy lung fields

48
Q

thoracentesis used for what?

A

-tx for pleural effusions

49
Q

empyema =

A

infectious pleural effusion

tx: thoracentesis & chest tube for drainage

LDH>60%
protein>50%
pH<7.2

50
Q

Strep pnemo dx

A

tested via urine antigen

51
Q

Mycoplasma pneumonia dx

A

PCR
cold agglutins
serology
special culture media

52
Q

Chlamydia dx

A

rising serologic titers

53
Q

Legionella dx

A 
urine antigen (similar to Strep pneumo)
culture on charcoal-yeast extract
54
Q

Pneumocystis jiroveci (PCP) dx

A

bronchoalveolar lavage (BAL)

55
Q

CAP tx outpatient

A

previously healthy: macrolide (azithromycin or clarithromycin) OR doxycycline

comorbidities: respiratory floroquinolones (levofloxacin or moxifloxicin)

56
Q

CAP tx inpatient

A

respiratory floroquinolone (levofloxacin or moxifloxacin)

OR

ceftriaxone and azithromycin

57
Q

CAP vs HAP

A

CAP: PNA before hospital visit or within 48 hours of hospitalization

HAP: >48 hours of hospitalization

58
Q

reasons to hospitalize

A
  • 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

59
Q

pneumococcal vaccine administration to?

A
  • everyone >65YO
  • chronic heart disease, liver, kidney, or lung disease
  • aplenic pts
  • malignancy, DB, AIDS, HIV
60
Q

healthcare PNA

A

> 48 hours after admission

  • gram(-) –> E coli or Pseudomonas
  • no macrolide tx
61
Q

HCAP tx

A
  • gram (-) coverage
  • antipseudomonal cephalosporins (cefepime or ceftazidime)
  • antipseudomonal penicillin (pipercilling/tazobactam = zosyn)
  • carbapenems (imipenem, meropenem, doripenem)
62
Q

ventilator associated PNA

A
  • interferes with normal mucociliary clearance

- damages normal ability to clear colonization

63
Q

VAP dx & tx

A
  • 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)
64
Q

subcutaneous emphysema

A

=air abnormally leaking into soft tissue of chest wall

-causes: chest tube

65
Q

imipenem causes

A

seizures (lowers threshold)

-excreted from kidney; thus AKI can cause toxicity

66
Q

lung abscess

A

-cause by aspiration PNA

  • stroke + loss of gag reflex, seizure, intoxication, endotracheal intubation
  • right upper lobe when lying flat
67
Q

lung abscess px & dx

A
  • 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)
68
Q

lung abscess tx

A

clindamycin

69
Q

PCP PNA px

A
  • AIDS pts
  • CD4 <200

-severe dyspnea on exertion, dry cough, fever

70
Q

PCP dx

A
  • CXR -bilateral interstitial infiltrates
  • ABG -hypoxia

-elevated LDH

71
Q

PCP tx

A

-TMP-SMX
=tx & prophylaxis
-steroids to dec mortality

  • mild: atovoquone
  • TMP-SMX toxicity: clindamycin, primaquine, pentamidine
72
Q

adverse effects of TMP-SMX

A

rash

bone marrow suppression

73
Q

azithromycin in HIV protects against?

A

atypicals, MAI (mycoplasma) when CD4<50

74
Q

TB risk factors

A
  • recent immigration (past 5 years)
  • prisoners
  • HIV
  • healthcare workers
  • close contact to TB
  • steroid use
  • hematologic malignancy
  • alcoholics
  • DB
75
Q

TB px

A

fever, cough, sputum, weight loss, hemoptysis, night sweats

> 3 weeks

76
Q

TB dx

A
  • 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

77
Q

typical TB CXR

A
  • upper lobe cavity infiltrate

- cavity = reactivation of latent infection

78
Q

TB tx

A

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

79
Q

9 months of TB tx

A

osteomyelitis, miliary TB, meningitis, pregnancy (pyrazinamide not used)

80
Q

rifampin SE

A
  • hepatotoxicity

- red body secretions

81
Q

isoniazid SE

A
  • hepatotoxicity

- peripheral neuropathy (tx with pyridoxine = B6)

82
Q

pyrazinamide SE

A
  • hepatotoxicity
  • hyperuricemia (only tx if they have gout)

-NOT FOR PREGNANT PTS

83
Q

ethambutol SE

A
  • hepatotoxicity
  • optic neuritis
  • color change

-dec dose in renal failure

84
Q

steroids in TB

A
  • dec constrictive pericarditis

- dec neurologic complications

85
Q

PPD testing

A
  • screening only for risk groups
  • NOT for symptomatic pts
  • NOT diagnostic
86
Q

PPD

A
  • 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
87
Q

positive PPD, next?

A

9 months of isoniazid

88
Q

when to biopsy a pulmonary nodule?

inc risk for malignancy

A
  • > 40YO
  • change in size in serial films
  • smoker
  • spiculated borders
  • > 2cm
  • atelectasis (post-obstructive process)
  • adenopathy
  • sparse, eccentric calcification
89
Q

infectious vs malignant nodule?

A
  • both have enlarging lung lesions

- infectious doubles in size in <30 days (faster than cancer)

90
Q

malignant pulmonary nodule tx?

A

resection

-many false negatives with PET, cytology, needle biopsy

91
Q

PET scan

A
  • malignancy has increased uptake of tagged glucose

- high sensitivity

92
Q

VATS (video-assisited thoracic surgery)

A
  • frozen section in operating room

- immediate conversion to open thoracoscopy and lobectomy if malignancy found

93
Q

benign pulmonary nodules by location:

  • immigrant
  • SW, USA
  • Ohio river valley, USA
A
  • TB
  • coccidiomycosis
  • histoplasmosis
94
Q

pneumoconioses types:

  • coal
  • sandblasting/ rock/ mining/ tunneling
  • shipyard workers/ pipe fitting/ insulators
  • cotton
  • electronic manufacturers
  • moldy sugar cane
A
  • coal worker’s
  • silicosis
  • asbestosis
  • byssinosis
  • berylliosis ***granulomas
  • bagassosis
95
Q

is fibrosis reversible?

A

NO

96
Q

interstitial lung disease dx

A
  • CXR = best initial
  • chest CT = more accurate (“honeycombing”)
  • lung biopsy = most accurate
97
Q

interstitial lung disease PFTs

A
  • decreased FEV1, FVC, TLC, RV
  • FEV1/FVC ratio is normal
  • decreased DLCO (septal thickening)
98
Q

berylliosis tx

A

responds best to steroids

granulomas represent inflammation

99
Q

sarcoidosis px

A
  • noncaseating granulomas (lung)
  • young African American woman
  • erythema nodosum
  • lymphadenopathy (hilar, bilateral)
  • heart block
  • restrictive cardiomyopathy
100
Q

sarcoidosis dx

A
  • 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
101
Q

sarcoidosis tx

A

-prednisone
(few pts fail to respond)

-asymptomatic pts do not need to be treated

102
Q

Virchow’s triad = predisposing factors to thromboembolism

A
  1. ) stasis of blood flow (immobility, CHF, recent surgery)
  2. ) hypercoagulability (Factor V Leiden, malignancy)
  3. ) endothelial injury (trauma, surgery, recent fracture)
103
Q

PE px

A

tachypnea + tachycardia + cough + hemoptysis

  • leg pain from DVT
  • pleuritic CP
  • fever
  • hypotension
104
Q

PE dx

A
  • 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)
105
Q

when do you use a D-dimer test?

A

when pretest probability of PE is low

106
Q

(+) lower extremity doppler study… next?

A
  • no further dx

- treat for PE (unfractionated heparin)

107
Q

PE tx

A
  • 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

108
Q

causes of pulmonary HTN

A

-left sided heart failure = MCC
-L–>R shunt
-hypoxic vasoconstriction from COPD
-PE
(chronic hypoxemia)
-idiopathic

109
Q

pulmonary HTN px

A
  • exertional syncope
  • exertional CP
  • dyspnea, fatigue
  • right heart failure, edema, JVD
110
Q

pulmonary HTN dx

A
  • 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)
111
Q

pulmonary HTN tx

A
  • prostacyclin analogues –> pulmonary artery vasodilation
  • endothelin antagonists (bosentan)
  • phosphodiesterase inhibitors (sildenafil)
  • oxygen slows progression
  • not CCBs

-cure: lung transplantation

112
Q

symptoms of OSA

A
  • daytime somnolence
  • snoring
  • headache (early morning hypercarbia)
  • impaired memory & judgement
  • depression
  • HTN
  • erectile dysfunction
113
Q

OSA dx

A

polysomnography = sleep study = most accurate

-shows multiple episodes of apnea

114
Q

OSA tx

A

-treat risk factors (men, overweight)

  • weight loss
  • CPAP –positive airway pressure throughout the night

-avoid sedative

115
Q

ARDS px

A

=overwhelming lung injury or systemic disease
-endothelial injury in aleveoli –> leaky –> alveoli fill with fluid

  • severe hypoxia
  • poor lung compliance
  • noncardiogenic pulmonary edema
116
Q

ARDS dx

A
  • CXR = dense bilateral infiltrates –> white out
  • air bronchograms = hyperlucent air within congestion
  • PaO2/FiO2 ratio <18 mmHg)
117
Q

ARDS tx

A
  • mechanical ventillation
  • low tidal volume (6mL/kg)
  • PEEP

-steroids can reduce pulmonary fibrosis

Internal Medicine (9 decks)

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