Pulmonology Flashcards
most important lab test in evaluation of respiratory compromise?
arterial blood gas measurement
hallmark of acute respiratory failure
rise in PCO2 accompanied by drop in pH
what PFTs establish the diagnosis of COPD (vs asthma)
postbronchodilator FEV1 < 80% and FEV1/FVC < 0.70
low DLco
when is DLco low in a patient?
conditions w/ barriers to diffusion (interstitial edema, interstitial infiltrates, tissue fibrosis) OR loss of lung tissue (emphysema)
pulmonary embolism on PFTs
no change in spirometry or lung volumes
decreased DLco
cough variant asthma
episodic cough and chest tightness, worse after respiratory infections
provocative concentration 20
methacholine dose that leads to 20% decrease in FEV1 in a challenge test; if < 4 mg/ml diagnosis is asthma; > 16 mg/ml is normal
FP results on methacholine challenge can be due to
allergic rhinitis COPD heart failure cystic fibrosis bronchitis
when is methacholine challenge test useful?
in evaluating pts w/ suspected asthma who have episodic symptoms and normal baseline spirometry
PFTs in pt with neuromuscular respiratory failure
increased RV/TLC ratio
normal FEV1/FVC ratio
low maximum respiratory pressures
normal DLco
increased RV/TLC ratio can be seen in..
obstructive disorders
neuromuscular disorders
main CF of hepatopulmonary syndrome
dyspnea, platypnea (worse when sitting up), orthodeoxia (fall in PP of O2 when upright), hypoxemia in setting of chronic liver disease, normal CXR
characteristic findings in pt with severe aortic stenosis
narrow pulse pressure delayed, diminished carotid upstroke sustained apical impulse late peaking systolic ejection murmur radiating to carotids S4
characteristics findings in pt with ASD
fixed splitting of s2/ RV heave
atrial arrhythmias
pulmonary midsystolic flow murmur OR tricuspid diastolic flow rumble
radiographic changes in spontaneous pneumothorax
loss of normal lung markings in periphery
well-defined visceral pleural line
vocal cord dysfunction - symptoms
difficult to tell apart from asthma
- throat/neck discomfort
- wheezing/stridor
- anxiety
diagnostic test of choice in suspected vocal cord dysfunction
- laryngoscopy - reveals adduction of vocal cords during inspiration
- flow-volume loops - inspiratory loop is flattened due to narrowing of airway at level of vocal cords during inspiration
most common pulmonary manifestation in patient with systemic sclerosis
pulmonary arterial hypertension
physical signs of pulmonary arterial HTN
loud P2, fixed split S2
pulmonic flow murmur
tricuspid regurgitation
PFTs in pulmonary arterial HTN
isolated decreased DLco
normal airflow and lung volumes
presence of which two findings points towards interstitial lung disease?
late inspiratory crackles
lung volumes < 80% predicted
what diagnostic test should be done in suspected pulmonary artery HTN
echocardiography
what features of pleural effusion make it more likely that it should be treated with chest tube drainage vs. antibiotics alone (7)
- assoc w/ pneumonia
- presence of loculated fluid
- pH < 7.2
- glucose level < 60
- LDH > 1000 IU/L
- positive gram stain or culture
- presence of gross pus in pleural space
when is a CT scan ordered with pleural effusion?
- to detect very small effusions
- to determine thickness of pleural lining
- to distinguish empyema from lung abscess
- to detect underlying malignancy
lung auscultation findings in pleural effusion
dullness on percussion
diminished tactile fremitus
absent breath sounds over effusion
lung auscultation findings in lobar pneumonia
dullness on percussion
reduced breath sounds
increased tactile fremitis
lung auscultation findings in pneumothorax
decreased breath sounds
hyperresonance on percussion
pt presents with predominantly lymphocytic pale yellow pleural effusion (> 80% lymphocytes)
consider primary TB
- do pleural biopsy to evaluate
dx. chylothorax
milky pleural fluid
pleural fluid TG conc. > 110 mg/dL
low pleural fluid cholesterol conc
MCC of chylothorax
cancer
trauma
others: pulmonary TB, chronic mediastinal infection, sarcoidosis, lymphangioleoimyomatosis, radiation fibrosis
in pt. with acute asthma exacerbation what does a normal or slightly elevated PCO2 mean?
need to intubate and mechanically ventilate the pt –> sign of impending respiratory failure
indications for intubation and mechanical ventilation in pts with acute asthma attack
- respiratory acidosis
- hypoxemia
- fatigue
what do you give a pt. who developed unstable asthma disease after respiratory tract infection?
short course of oral steroids
nebulizer therapy at home in asthma management should be reserved for who?
pts who cannot use MDI properly
what do you do if your asthma patient becomes pregnant?
if asthma is well-controlled, keep her on the same regimen (SABA and inhaled corticosteroids are safe in pregnancy)
what do you give next to a patient with persistent asthma not well controlled by low-mod dose inhaled corticosteroids?
add long acting B-agonist
when do you consider theophylline and/or leukotriene antagonists in tx. of asthma?
in pts who remain symptomatic despite addition of long-acting B agonist to corticosteroids therapy
main reason why pts with asthma do not respond well to specific asthma therapy
poor inhaler technique
Tx. of acute exacerbation of COPD
oral or IV steroids
short acting B2 agonist/anticholinergic
antibiotics
what antibiotics are used in acute COPD?
fluoroquinolone OR
third generation cephalosporin + macrolide
criteria for Rx continuing oxygen therapy in COPD patients
- PO2 < 55 mmHg OR
- O2 sat < 88% w/ wo hypercapnia
- pts with symptoms of pulm HTN, cor pulmonale, RHF or Hct > 56%
when do you use methylxanthines in COPD pts?
only after long-acting bronchodilators have been tried
what two therapies improve survival among COPD pts?
continuous O2 therapy
smoking cessation
when should you consider inhaled corticosteroid therapy in COPD pt?
pt whose lung function is < 50%
pts with severe/ frequent exacerbations
(esp. beneficial when combined with LABA)
suitable COPD candidates for NPPV
- pts with moderate-severe dyspnea
- use of accessory respiratory muscles
- RR > 25/min
- pH < 7.35 w/ PCO2 > 45 mmHg
C/I to NPPV
impending respiratory arrest cardiovascular instability altered mental status high aspiration risk production of copious secretions extreme obesity surgery, trauma deformity of upper airway or face
what do you Rx. for a pt with COPD on maximal medical treatment?
pulmonary rehabilitation
when do you consider lung transplant in COPD pts?
- pts who are hospitalized w/ COPD exacerbation complicated by hypercapnia
- pts with FEV1 < 20% and either homogenous dz on HRCT or DLCO < 20%
ideal candidate for lung reduction surgery
- predominantly upper lobe disease
- FEV1 bw 20-35% predicted
- DLco > 20% predicted
- hyperinflation
- no significant comorbidities
what test do you need to do in a pt that presents with early onset COPD, esp. emphysema involving the lung bases?
a1-antitrypsin level
diagnostic test to demonstrate sleep apnea
polysomnography and arterial blood gases
how do you diagnose obesity-hypoventilation syndrome?
alveolar hypoventilation (PaCO2 > 45) in absence other known causes
pt presents with subacute respiratory symptoms resembling respiratory tract infection but unresponsive to antibiotics; CXR shows bilateral alveolar-filling opacities - dx?
cryptogenic organizing pneumonia
key radiographic feature of COP
tendency for COP opacities to “migrate” or involve different areas of the lung on serial examinations
most specific CXR finding in asbestosis
bilateral partially calcified pleural plaques
next best test in someone suspected of having diffuse parenchymal lung disease i.e. pt with CT disease and respiratory symptoms
high resolution CT scan
drug-induced lung toxicity
presents as hypersensitivity reaction with symptoms of fatigue, low grade fever, cough and peripheral eosinophilia
what drug(s) should be used for venous thromboembolism prophylaxis in hospitalized, medically ill patients?
unfractionated heparin
LMWH
fondaparinoux - C/I in renal impairment
uses of lepirudin (direct thrombin inhibitor)
when a patient has heparin-induced thrombocytopenia
what test do you do in someone w/ suspected PE, with elevated creatinine (i.e. kidney disease)
V/Q scan
- avoid CT angiography due to contrast
how do you treat DVT?
therapeutic heparin and warfarin
- heparin for atleast 5 days
- warfarin only once INR > 2.0 for 24 hrs
