Pulmonology Flashcards
Tactile Fremitus is?
Incr in what?
Decr in what?
Palpable vibrations transmitted through
bronchopulmonary tree to chest wall when patient speaks (i.e. “99”)
- Incr with pneumonia
- Decr w/ COPD
Percussion of chest wall
- Resonant —>generally healthy lung
- Flat or dull —> lobar pneumonia or pleural effusion
- Hyperresonant (low, loud, booming sound) —> COPD or pneumothorax
FEV1/FVC Ratio is ? Nl is ?
volume exhaled in 1 sec / total volume exhaled after maximal exhalation
nl is 75-85%
ABGs: CO2 acts how in the body?
Does what to pH?
CO2 acts as an acid in the body (Opposite!)
• As CO2 incr = incr acid = decr pH (respiratory acidosis)
• As CO2 decr = decr acid = incr pH (respiratory alkalosis)
ABGs: HCO3 acts how in the body?
Does what to pH?
HCO3 acts as a base in the body (SAME!)
• As HCO3 incr = incr base = incr pH (metabolic alkalosis)
• As HCO3 decr = decr base = decr pH (metabolic acidosis)
Normal ABG Values?
pH 7.35-7.45 pO2 80-100 mmHg pCO2 35-45 mmHg HCO3 22-26 mEq SaO2 97-100%
Causes of Respiratory Acidosis
Caused by any process which decr ability of lungs to exchange CO2 for O2.
• Ex. COPD, asthma, heart failure, pneumonia
Causes of Respiratory Alkalosis
Caused by any process which incr respiratory rate
• Ex. fever, anxiety, mechanical overventilation
Causes of Metabolic Acidosis
Caused by any process that incr accumulation of acids or decr amount of bicarbonate
• Ex. diabetic ketoacidosis, renal failure
Causes of Metabolic Alkalosis
Caused by any process that decr acid or incr bicarbonate
• Ex. prolonged vomiting / nasogastric suction
Intermittent Asthma
Daytime Sxs: /= 80% predicted
Mild Persistent Asthma
Daytime Sxs: >2 x wk but not daily
Nocturnal Sxs: > 2 x mo
FEV1 or PEF: >80% predicted
Moderate Persistent Asthma
Daytime Sxs: daily B-agonist use (exacer 2 or more / wk)
Nocturnal Sxs: > 1 x a mo
FEV1 or PEF: >60% to
Severe Persistent Asthma
Daytime Sxs: continual
Nocturnal Sxs: frequent
FEV1 or PEF: = 60% predicted
Asthma: S/S of impending airway failure
- Decreased wheezing or breath sounds
- Fatigue
- Diminished respiratory effort/bradypnea
- Cyanosis
- Inability to speak full word sentences
- Increased accessory muscle use
Diagnostic criteria for Airway Obstruction using spirometry (for Asthma w/u)?
• Airway obstruction = reduced FEV1/FVC (
Diagnostic criteria for “reversibility” using spirometry (for Asthma w/u)?
Reversibility is defined by an increase of >/=12% and 200mL in FEV1 or >/=15% and 200mL in FVC after administration of a
short-acting bronchodilator
Diagnostic eval for asthma (in stable patient).
- Spirometry: looking for both obstruction and reversibility (necessary for Dx)
- bronchoprovacation test (methocholine challenge) if spirometry nondiagnostic and high clinical suspicion.
Diagnostic eval for asthma (in unstable patient).
- Peak Flow (measures trends in asthma control, not used to diagnose asthma).
- O2 Saturation
- ABGs
Asthma Tx (Rx) Rescue Meds:
- Inhaled B-agonists (albuterol): relax smooth muscle
2. Inhaled anticholinergics (Ipratropium): reverse vegally-mediated bronchospasm. Most useful in severe exacerbations (
Asthma Tx (Rx) Maintenance Meds
- Inhaled corticosteroids (ICS): Mainstay for persistent asthma. takes 1-2 wks (why needs oral after exacerbation). rinse & spit
- Long Acting Beta Adrenergics (LABA): salmeterol or formoterol. black box for monotherapy. LABA commonly mixed with ICS in same inhaler (i.e. advair)
- Leukotiene Modifiers (montelukast): more effective in pts with allergen-related asthma
Two types of COPD and sxs of each
1) Pink puffers (emphysema) –>mostly dyspnea
• Cough rare, scant clear sputum, breath sounds quiet
2) Blue bloaters (chronic bronchitis) –> chronic cough /purulent sputum / ↑ pulmonary infections
• Dyspnea mild, rhonchi variable, wheezes common
• May appear cyanotic
Tx for COPD: General Measures
- Education (COPD + Smoking Cessation)
- Pneumococcal and yearly influenza vaccines
- Stress consistent and proper inhaler use
- Pulmonary Rehab
Tx for COPD:
Bronchodilators = mainstay of therapy
- Short-acting Inhaled “Rescue” Agents (all patients)
- β2-agonist plus anticholinergic (generally) (i.e. Albuterol plus Ipratropium) - Long-Acting Inhaled “Maintenance” Agents –> advanced patients
- Long-acting anticholinergics (ex. tiotropium, aklidinium)
- Long-acting β2-agonists (LABAs) (ex. salmeterol, formoterol, indacaterol)
- Inhaled corticosteroids (ICS): generally for all stage III-IV with >/= 3 exacerbations per year
Roflumilast (Daliresp®) is used for? indication?
COPD (new 2011): Modestly improved lung function & reduced frequency of moderate to severe exacerbations in patients with severe COPD associated with bronchitis
Bronchiectasis is ?
Disorder of large bronchi characterized by
permanent dilation / destruction of bronchial
walls
Who to screen for lung cancer?
Recommended for:
- pts 55-74 yrs who have smoked ≥30pk-yrs - who either continue to smoke or have quit within past 15 yrs
Location of Lung Tumors?
HASSLE:
- peripheral (A and L): Adenocarcinoma and Large cell
- central (SS): Squamous cell carcinoma and Small cell carcinoma
Most common sites for lung CA metastasis?
- Bones (pain, pathologic Fx)
- Liver (poor prognosis)
- Brain (HA, N/V, seizure, focal neuro change) - lung CA (adeno and small cell) account for 70% of symptomatic brain tumors
Paraneoplastic Syndromes
Hypercalcemia - SCC
SIADH - SCLC
Acute Bronchitis clinical manifestations
cough, usually with sputum production (50%), & evidence of concurrent URI (ex. nasal symptoms)
• Fever is a relatively unusual sign in acute bronchitis (when present consider influenza or pneumonia)
- Note: Purulent sputum doesn’t predict bacterial involvement
- Acute bronchitis cannot be distinguished
from URIs in 1st few days
• Acute bronchitis is suggested by persistence of cough for >5d
• Acute bronchitis cough typically lasts 10-20
days
Indications for CXR in patients with an acute cough syndrome? Purpose?
1) Abnormal vital signs (P >100/min, RR >24, or T >38 ºC)
2) Pulmonary exam findings
Purpose: exclude pneumonia
Acute Exacerbation of COPD (AE-COPD):
Dx and Tx
Dx: (70-80% infectious)
• Sputum gram stain / culture (?)
• Viral Studies (nasopharyngeal swab) (?)
• CXR –> R/O pneumonia (if fever +/- hypoxia)
Tx: Supplemental O2 is critical
• Bronchodilators
- Albuterol + ipratropium (may be nebulized)
• Systemic steroids–>taper over 5-10 days
• Antibiotic Therapy
- Uncomplicated exacerbation:
Doxycycline, cefuroxime, TMP-SMX, azithromycin(?)
- Complicated exacerbation:
Amoxicillin / clavulanate or levofloxacin
Acute Exacerbation of COPD (AE-COPD):
Clinical Manifestations
- ↑ volume or change in character of sputum
- ↑ frequency & severity of cough
- ↑ dyspnea / respiratory rate
Community-Acquired Pneumonia: Clinical Manifestations
Often present with >/= 1 of following:
• Fever or hypothermia
• Rigors & sweats
• New cough +/- sputum production
• Dyspnea
• Constitutional symptoms (fatigue, myalgias,
abdominal pain, anorexia, or headache) common
Clinical presentation Pearls for S. pneumoniae CAP
- Single rigor (often r/t transient bacteremia)
* Pleurisy (pleural effusions common)
Clinical presentation Pearls for H. influenzae CAP
Common in patients with underlying obstructive lung disease (ex. COPD)
“Typical” CAPs and presentations pearls
- S. Peneumoniae: Single Rigor; Pleurisy
- H. influenzae: common in COPD
- M. catarrhalis: nothing special
“Atypical” CAPs and presentation pearls
- L. pneumophila
• May present with high fever, hyponatremia, & diarrhea
• Appear more ill than their CXR would predict - M. pneumoniae
• Cough illness presentation common
• Extrapulmonary symptoms common (ex. bullous myringitis)
• More common in healthy kids & young adults (“Walking
Pneumonia”) - C. pneumoniae
• Similar to M. pneumoniae but often older patients
Management of TB (i.e. + TST or IGRA/Quant-Gold)
If (+) TST or IGRA–> refer to rule out active TB
prior to treatment for LTBI
1) Evaluate for symptoms (ex. fever, cough, weightloss, etc.) & perform exam
2) CXR
• If (-) –> treat for LTBI
• If (+) –> work-up & treat for active TB
Make sure to check HIV status.
Treatment for active TB
4 drugs for 2 months then 2 drugs for 4 months “RIPE drugs”
- 4 drugs: Rifampin (RIF), Isoniazid (INH),
Pyrazinamide(PZA), Ethambutol(EMB) x 8 wks
Then:
• 2 drugs (INH & RIF) X 16 wks
Treatment of Latent Tuberculosis
Isoniazid (INH) X 9 months has most data
Sarcoidosis Clinical Manifestations
Incr. incidence in North American blacks & northern European whites
1. Pulmonary: >90% present with pulmonary findings (DOE, dry nonproductive cough, BIL perihilar lymphadenopathy)
2. Non-Pulmonary:
• Skin: erythema nodosum, lupus pernio
• Heart: conduction abnormalities
• Ocular: uveitis
• Parotid gland enlargement
3. Biopsy (bronchoscopy or mediastinoscopy) is definitive diagnosis–>
shows noncaseating granulomas
Transudate vs Exudate W/U
- CXR/Chest CT
- thoracentesis
- protein and LDH (exudate vs transudate)
- Exudate: >0.5 protein, >0.6 LDH, low glucose
- pH, total cell count w/ diff, glucose, cytology, gram stain/Cx
“Virchows Triad” is:
describes what?
• 1) Hypercoagubility
• 2) Venous stasis
• 3) Endothelial injury
Describes pathophysiology of venous thromboembolism
Common acquired ETIOL of venous thromboembolism:
• Major surgery • Trauma • Malignancy • Age (>45yrs) • OCP or HRT • Pregnancy / postpartum • Medical conditions (ex. serious infection)
Clinical presentation of DVT
- Ipsilateral edema
- Ipsilateral pain
- Ipsilateral warmth
- Palpable cord (reflects a thrombosed vein)
- Homan’s sign unreliable
Clinical presentation of PE
- Sudden / unexplained dyspnea
- Pleuritic chest pain
- Cough
- Tachypnea
- Tachycardia
Dx of PE
Nonspecific Measures
1. ECG abnormal (70%)
• S1Q3T3 classic; new-onset sinus tachycardia most common
2. CXR
• Usually reveals atelectasis, parenchymal infiltrates, & pleural effusions
• Historic Findings
- Westermark’s Sign: prominent central pulmonary artery with local oligemia
- Hamptom’s Hump: increased opacity from intraparenchymal hemorrhage
Specific Measures
- Helical (Spiral) CT = CT Angiography (CTA = “PE Protocol”
- Ventilation / Perfusion Lung Scanning (V/Q Scan)
- Pulmonary angiography = gold standard
