Pulmonology Flashcards
FRV1/FVC
ratio of air volume expired in 1 second to FVC.
80% is normal,
and this ratio helps us to understand whether the patient has obstructive or restrictive lung disease
80% is +/- restrictive
Total lung capacity
increased in obstructive lung disease
decreased in restrictive lung disease
Functional vital capacity (FVC)
in obstructive versus restrictive lung disease
FVC is the air volume that can be inspired and then expired
decreased in obstructive lung disease because you can’t move air out very well
decreased in restrictive lung disease because you can’t move air in very well
FEV1 in obstructive versus restrictive lung disease
decreased in obstructive as well as in restrictive lung disease
In obstructive lung disease, FEV decreases even more than FVC, so with obstructive lung disease the FEV1/FVC ratio drops more than 70%
In restrictive lung disease the FEV1/FVC ratio is normal or increased because the FEV1 and FVC decrease at a similar rate
DLCO
relative measure of ability to transfer air from pulmonary alveoli to capillary
Alveolar-arterial gradient
What’s a normal value?
When would A-a gradient be increase?
Compares O2 status of alveoli to arterial blood
Normal= 5-15 mmHg
Increased Aa gradient indicates pulmonary embolism, pulmonary edema, right-to-left shunt, higher concentration of inspired oxygen
Aa gradient equation
PAO2-PaO2
(Atmospheric air pressure x FiO2) - (PaCO2/0.8) - (PzO2)= (713nnHg) * (0.21 PaCO2/0 .8)-(PaO2)= 5-15mmHg is considered a normal A-a gradient
PAO2= alveolar O2 content PaO2= Arterial O2 content
Common cold (viral rhinitis)
inflammation of the upper airways
Causes: rhinovirus, coronavirus, adenovirus
H and P: nasal and throat irritation, sneezing, rhinorrhea, nonproductive cough
(Productive cough tends to be more indicative of PNA or bronchitis)
Treatment: supportive, rest, analgesia, hydration, NO antibiotics
Pharyngitis
Inflammation of the throat
viruses: rhinovirus, coronavirus, adenovirus
bacteria: group A beta-hemolytic streptococci (strep pyogenes)
Symptoms: sore throat, lymphadenopathy, nasal congestion
fever, HA, GI symptoms
Red and swollen pharynx
Tonsillar exudates
Pharyngitis diagnosis- Centor criteria
Add one point if: Fever Tonsillar exudates Tender anterior cervical adenopathy Absence of cough 44yo subtract a point
Cough (absence of) Exudates Nodes T (temperature) OR (plus or minus one point for age)
0-1 points= no antibiotic/no throat culture
2-3 points= throat culture/treat if positive
4-5 points= treat empirically
Treatment: self- limited
antibiotics to prevent ARF
(post-strep glomerulonephritis risk does not change with antibiotic use)
Use beta-lactam antibiotics (penicillin, amoxicillin)
What nonbacterial infections present with tonsillar exudates?
infectious mononucleosis
strep pharyngitis
Tonsillar infections
Streptococcal pharyngitis symptoms Ear pain Difficulty swallowing High fever Tonsillar exudates
Treatment: beta- lactam antibiotics (penicillin, amoxicillin)
What are the diagnostic features of peritonsillar abscess? What is the treatment?
Infection between the tonsil and pharyngeal constrictors caused by streptococcus pyogenes, staphylococcus aureus, and/or bacterioides spp.
Severe sore throat, fever, muffled “hot potato” voice
Classic diagnostic feature is obvious abscess on the tonail or deflection of the uvula to the opposite side
Other signs and symptoms include trismus (“lockjaw”) and drooling
Treatment:
Needle aspiration or I&D
Pain meds and antibiotics: amoxicillin/clavulanate, clindamycin
Viral influenza
H and P: arthralgias, myalgias, nasal congestion, nonproductive cough, high fevers, lymphadenopathy
Flu swab
Treatment: symptomatic treatment, fluid intake, zanamivir and oseltamivir which will decrease severity of symptoms
Annual flu vaccine (especially elderly patients, healthcare workers, immunocompromised, lung disease)
Sinusitis- acute
streptococcus pneumoniae
haemophilus influenzae
moraxella catarrhalis
viral infection
associated with barotrauma, allergic rhinitis, prolonged gastric tube placement, asthma and other chronic resp infection
Complications- may spread to CNS and cause meningitis
Sinusitus- chronic
usually caused by sinus obstruction and anaerobic infection
DM predisposes to mucor mycosis
Sinusitis H and P
sinus pain, purulent nasal discharge, maxillary tooth pain, sinus tenderness to palpation, illumination test (unreliable)
CT sinuses for severe sinusitis Treatment: nasal irrigation analgesics oral decongestants intranasal steroids amoxicillin- clavulanate, doxycycline, or levofloxacin
What are the complications of strep pharyngitis, and which can be prevented with antibiotics?
ARF and glomerulonephritis
ARF can be prevented
Signs of a peritonsillar abscess
deviated uvula
trouble opening mouth
muffled “hot potato” voice
look for a bulge in the back of the throat
murmurs that decrease with squatting
HOCM and MVP, because the valve leaflets are further apart with greater afterload
Acute bronchitis
trachea and bronchi
difficult to differentiate from URI in the first few weeks. Generally a clinical diagnosis because the symptoms and radiology are nonspecific. If high fever then evaluate for PNA, and consider influenza
productive cough
shortness of breath
wheezing
sputum culture in persistent cases
Rads- CXR rules out PNA, shows mild congestion
Viruses- MCC
Mycoplasma pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
Treatment- symptomatic, self- limited Abx if increased risk of bacterial infection (other lung disease, smokers, elderly) fluoroquinolones tetracycline erythromycin azithromycin
PNA
inflammation in the alveoli
- CAP
- HAP
Clinical manifestations can break down into typical and atypical
Features of typical PNA presentation
fever cough malaise purulent sputum chest pain SOB
on xray, lobar infiltrate
common organisms: streptococcus pneumoniae staphylococcus aureus haemophilus influenzae GBS
Features of atypical PNA presentation
less severe symptoms
nonproductive cough
headache fatigue
On CXR, diffuse patchy infiltrates
Common organisms:
mycoplasma pneumonia
legionella pneumophila
chlarmydophila pneumoniae
Viral causes of PNA
influenza parainfluenza adenovirus cytomegalovirus RSV (MCC viral PNA in children)
Streptococcus pneumonaie PNA
MCC PNA in adults
sickle cell patients
high fevers, pleuritic pain, productive cough, rust- colored sputum
Treatment: cephalosporins respiratory fluoroquinolones beta- lactams macrolides preferred- amoxicillin unless you have resistance
Haemophilus influenzae
COPD
SCD
slower onset of symptoms
Treatment: beta- lactams fluoroquinolones doxycycline macrolides
staph aureus PNA
- Nosocomial pneumonia in immunocompromised patients
- Seen in higher rate in patients with influenza
- Abscess formation
Treatment: beta lactams, MRSA coverage (incase resistant)
Klebsiella pneumoniae
Alcoholics, aspiration, hospitalized, sickle cell, currant- jelly sputum
Treatment:
cephalosporins
aminoglycosides
pseudomonas aeruginosa PNA
chronically ill, immunocompromised, cystic fibrosis, chronic ventilator, nosocomial pneumonia, rapid onset of symptoms
(very sick, high mortality)
start empiric antibiotics immediately
- piperacillin- tazobactam
- ceftazidime
- cefepime
- imipenem
- meropenem
- doripenem (beta- lactams)
- ciprofloxicim, levofloxacin (fluoroquinolones)
- aminoglycosides
GBS PNA
neonates and infants
respiratory distress and lethargy
Treatment:
beta- lactams
ampicillin and gentamicin
Enterobacter spp.
Nosocomial pneumonia
elderly patients
3rd generation cephalosporins
-carbapenem
Mycoplasma pneumoniae
walking PNA
MCC in young adults
diffuse bilateral infiltration on CXR
Pt doesn’t appear ill
less severe sx
rash
positive cold- agglutinin test (IgM)
Treatment- macrolides
Legionella pneumophila
aerosolized water, and can be passed from person to person
slow onset
nausea, diarrhea
confusion, ataxia
Treatment: macrolides, fluoroquinolones
Chlamidophile pneumoniae
another atypical pneumonia
- mycoplasma pneumoniae
- legionella pneumophila
- chlamydophila pneumoniae
Very common in the very young and very old
- slow onset of symptoms
- frequent sinusitis
- Treatment with doxycycline, macrolides
Empiric therapy for PNA (cover s. pneumoniae and atypical organisms)
Note: resistance to macrolides is growing
- Resp fluoroquinolone like levofloxicin, moxi, gemifloxifin alone
- or combine a beta-lactam with doxycycline or a macrolide
Most common PNA agent in children
RSV
Most common PNA agent in adults
strep pneumo
PNA with Higher rate after influenza
s. aureus
PNA with currant jelly sputum
klebsiella
PNA with associated with CF
pseudomonas
PNA MC in neonates
GBS
PNA Associated with elderly
enterobacter (Gram negative)
PNA common in young adults
mycoplasma
PNA associated with aerosolized water
legionella
Neonates (first 28 days of life) most common causes of PNA
- GBS is most common
- E. Coli
- Chlamydia trachomatis (long incubation, sx appear 12 weeks later)
- Herpes simplex virus
MCC PNA in children
RSV
Strep pneumoniae
chlamidophila pneumoniae
in older children, think about mycoplasma pneumoniae
MCC PNA in adults
Streptococcus pneumoniae Haemophilus influenza Mycoplasma pneumoniae Chlamydophila pneumoniae Influenza
MCC PNA in elderly
Streptococcus pneumoniae Haemophilus influenzae Influenza Staphylococcus aureus Anaerobes Gram- negative rods
What are the indications for pneumococcal vaccination in adults?
- age 65 and older
- Serious long-term health problems such as heart disease, sickle cell disease, alcoholism, leakage of cerebrospinal fluid, lung disease, diabetes, or cirrhosis
- resistance to infections if lowered due to Hodgkin disease, multiple myeloma, cancer treatment with xrays or drugs, treatment with long-term steroids, bone marrow or organ transplant, kidney failure, HIV/AIDS, lymphoma, leukemia, other cancer, nephrotic syndrome, damaged spleen or no spleen
- Cigarette smokers age 19-54
PNA and gram-positive cocci in clusters
s. aureus
gram- positive cocci in pairs in the context of PNA
s. pneumoniae
gram- negative rods in 80 year-old with PNA
e. coli
gram positive cocci in neonate PNA
GBS
gram neg rods in neonate PNA
e. coli
Fungal PNA with PMHx of travel to SW US
coccidiomycosis
Fungal PNA with PMHx of caves, spelunking, bats
histoplasmosis
Fungal PNA with PMHx of trave l to eastern North America
blastomycosis
Fungal PNA with PMHx of travel to s. America
paracoccidiomycosis
Antifungals used to treat fungal PNA
Amphotericin B
Ketoconazole
Itraconazole
Fluconazole
Pneumocystic jiroveci (PCP)
Immunocompromise
-HIV patients (CD4 count220 (rising LDH despite appropriate treatment portends a poor prognosis)
What is the usual treatment:
21 days of antibiotics with choices including
-TMP-SMX (IV or PO)
-Pentamidine (IV)
-Primaquine (PO) + clindamycin (IV or PO)
Tuberculosis (primary and secondary)
mycobacterium tuberculosis
Primary TB: person who has never been infected with TB contracts disease
Symptoms vary widely: fever, CP, cough common
CXR: hilar lymphadenopathy, or normal, possible Ghon complex
Body often heals from the primary infection by primary fibrosis, allowing the person to move on to latent TB (asymptomatic), which can possibly last for years
Ghon focus vs Ghon complex. Both associated with primary tuberculosis
primary TB focus in a small area of lower lung, granulomatous inflammation
visible on CXR once it has calcified
If seen in combination with hilar lymphadenopathy, a Ghon focus is called a Ghon complex
How do you interpret a positive PPD?
current infection
past exposure
vaccination
5mm PPD is considered positive in
highest risk pop
HIV+
Close contact with TB
CXR findings suggestive of TB
10mm PPD is considered positive in
homeless immigrants IV drug users chronically ill healthcare workers recently incarcerated
15mm PPD is considered positive in
anyone, including low-risk
15mm is always considered positive
Significance of negative PPD skin test
negative no infection anergic malnutrition immunocompromise sarcoidosis
Secondary TB
reactivation of dormant tubercles
fibrocaseous cavitary lesions
symptoms:
fever, hemoptysis, weight loss, night sweats
complications: parenchymal tuberculoma (brain grey matter) Meningitis Pott's disease (vertebral bodies) lymphadenitis renal disease GI disease miliary TB
Labs to confirm TB
sputum culture takes 2-4 weeks
Acid-fast sputum stain every morning for 3 days
negative- probably not TB, discharge, follow up with cultures
positive= TB