Pulmonology Flashcards
A patient comes in with a severe asthma exacerbation but you don’t hear any wheezing. What must be occurring?
Act fast. No wheezing is a sign of serious airflow obstruction
How are asthma and other reactive airway diseases confirmed on pulmonary function testing?
Rise in FEV1 > 12 seconds
Should asthmatics with respiratory acidosis be placed in the ICU?
Yes
Besides inhaled steroids, what are alternate long-term controller meds in patients with COPD?
Tiotropium, ipratropium
What is a critical lab to order in patients presenting with COPD and acute SOB?
ABG to assess carbon dioxide retention
Patients with COPD often have what baseline acid-base disturbance? Therefore, should you intubate patients with respiratory ____?
Respiratory acidosis from CO2 retention but also a high bicarbonate from compensatory degree of metabolic alkalosis.
Do not intubate just for respiratory acidosis, only if it is acutely worsening
What are CXR findings in a patient with COPD?
Hyperinflated lung fields, straightening of diaphragm, elongated heart, and substernal air trapping
What abnormality is present on CBC of patients with COPD?
Elevated hematocrit due reactive erythrocytosis from hypoxia (microcytic)
What should you find on PFT in a COPD patient?
FEV1: decreased
FVC: decreased
FEV1/FVC: decreased (
Can patients with COPD tolerate beta1-blockers?
Yes, almost all can
What is recommended chronic medical therapy for COPD?
Tiotropium/ipratropium inhaler Albuterol Smoking cessation Heptavalent pneumococcal vaccine Yearly influenza vaccine Supplementary O2 if low sats regularly
Your patient presents with hyperinflated chest on CXR with a low albumin and prolonged PT. Dx?
Alpha-1 Antitrypsin Deficiency
What is tx of alpha-1 antitrypsin deficiency?
alpha-1 antitrypsin infusion
Buzzwords
CXR with ‘tram tracking’ of bronchi
Bronchiectasis
What is the most accurate test to dx bronchiectasis?
CT chest
What is tx of bronchiectasis?
There is no definitive tx. Chest physiotherapy and rotating antibiotics
Buzzwords
Glass workers, mining, sandblasting, brickyard worker
Silicosis (interstitial lung disease)
Buzzwords
Coal worker gets what ILD
Coal worker’s pneumoconiosis
Buzzwords
Cotton (textile fiber dust) associated with what ILD
Byssinosis
Buzzwords
Electronics, ceramics, fluorescent light bulbs ILD
Berrylliosis
Buzzwords
Mercury associated with ILD
Pulmonary fibrosis
What are PFT findings in a patient with ILD?
FEV1: decreased FVC: decreased FEV1/FVC: normal to increased RV: decreased TLC: decreased DLCO: decreased
What is the most common type of cancer associated with asbestosis?
Lung cancer
NOT mesothelioma
Generally there is no specific form of therapy which helps alleviate ILD. Which is the one form that may respond to steroid trials and why?
Berrylliosis bc it is a granulomatous disease
A patient presents with signs and symptoms very similar to ILD occurring for 3-4 weeks. The patient also has a fever and malaise. What is the likely dx?
Bronchiolitis oblilterans organizing pneumonia (BOOP) aka Cryptogenic organizing pneumonia (COP)
What is the most accurate test for making the dx of BOOP/COP?
Open lung bx
Unlike ILD, BOOP/COP has a response to what medications?
Steroids
Name the following extrapulmonary findings seen in sacoidosis:
Eye Neural Skin Cardiac Renal/Hepatic Electrolyte
Eye: uveitis
Neural: CN VII involvement
Skin: Lupus pernioo (purplish lesion of skin on face), erythema nodosum
Cardiac: restrictive cariomyopathy; conduction defects
Renal/hepatic involvement: often asymptomatic
Electrolyte: hypercalcemia (due to vitamin D production by granulomas in sarcoidosis)
Best initial test for dx sarcoidosis
CXR (enlarged hilar lymph nodes)
Most accurate test for dx of sarcoidosis
Lung or lymph node biopsy with noncaseating granulomas
Buzzwords
Noncaseating granulomas
Sarcoidosis
Buzzwords
Elevations in calcium and/or ACE
Sarcoidosis
Best therapy for sarcoidosis
Steroids
Raynaud’s phenomenon is associated with what pulmonary disorder?
Pulmonary hypertension
What is the most accurate test for pulmonary HTN?
Right heart catheterization
What is bosentan?
An endothelial inhibitor which prevents growth of pulm vasculature and can be used to treat pulm HTN
What are epoprostenol and treprostinil?
Prostacyclin analogs which dilate pulmonary vasculature and are used to treat pulm HTN
A patient presents with acute SOB but CXR and EKG are normal. What is a dx you must consider?
PE
If you’re patient comes in with signs of right heart strain and hypotension what medicine should you quickly administer and for what problem?
May be a massive PE
Thrombolytics
Is it acceptable to provide heparin prior to confirming PE if it is a clear case?
Yes
What is the test of choice for dx of PE (especially when the CXR is abnormal)?
CT angiogram chest
In what situations is the V/Q scan useful in ruling out PE?
When the CXR is normal (the more normal the CXR the better V/Q is at ruling out). However, only a truly normal V/Q scan can rule out PE. If there is some question they can be unreliable
What is the sensitivity and specificity of the D-dimer test (general, not exact values)? In what situations is it most useful?
Highly sensitive but not very specific
Very good test in patients with a low probability of PE bc a negative will rule out PE
What is the most accurate test for PE? But what is it’s downfall?
Angiography but it is invasive and has a mortality risk
What are D-dimers?
Fragments of fibrin which have been chopped up by plasmin. They can only be chopped off a few hours after a clot forms because after factor VIII stabilizes fibrin.
What is the immediate standard of care in PE?
Heparin and oxygen
Patients will need warfarin for 6 months after the PE
If a patient presents with PE and is unstable (with hypotension) what medicine can be given?
Thrombolytics
Best initial test to dx pleural effusion?
Most accurate test to dx pleural effusion?
Initial: CXR
Accurate: Thoracentesis
What are the threshold values for protein and LDH that are used to distinguish a transudative from an exudative pleural effusion?
Protein > 50% serum
LDH > 60% serum
Both the above support exudative
How are the below pleural effusions managed?
Small
Large
Large and recurrent
Small: Can do no therapy or diuretic
Large: Chest tube drainage
Large and recurrent: pleurodesis (pleural space obliterated by fusing two pleural surfaces)
*If pleurodesis fails then decortication
If weight loss and CPAP aren’t helpful in OSA then what may be indicated?
Surgical resection of uvula, palate, and pharynx
How is central sleep apnea managed?
Avoid alcohol and sedatives
Acetazolamide (creates metabolic acidosis which ignites respiratory drive)
Medroxyprogesterone: central respiratory stimulant
An asthmatic patient presents with worsening symptoms, brown mucous plugs, recurrent infiltrates, central bronchiectasis, and peripheral eosinophilia with high IgE.
Dx?
Diagnostic testing?
Tx?
Allergic bronchopulmonary aspergillosis (ABPA)
Aspergillus skin testing, measure IgE levels, circulating precipitins, A. fumigatus-specific antibodies
Tx: oral corticosteroids and if refractory then itraconazole
Diffuse, patchy infiltrates on CXR may indicate what serious condition?
ARDS
What is PO2/FiO2 and how is it a helpful value?
If
What is the tidal volume goal of ARDS?
6mL/kg
What is the mgmt of ARDS?
Ventilatory support with PEEP and TV goal of 6mL/kg
Possibly diuretics and dobutamine
Prone positioning
How can the wedge pressure from a Swan-Ganz be used to distinguish different forms of shock?
It will be high in cardiogenic but low in septic and hypovolemic
Generally, ho does cardiac output differ among different shock states?
High in septic
Low in caridogenic and hypovolemic
Most common organism causing CAP
Pneumococcus
Most common organism causing HAP
Gram-negative bacilli
Best initial test for dx of PNA
Most accurate test
Initial: CXR
Accurate: Gram stain and culture sputum
Tx of outpatient PNA
Macrolide (azithromycin or clarithromycin) Respiratory fluoroquinolone (levofloxacin or moxifloxacin)
Tx of inpatient PNA
Ceftriaxone and azithromycin
or Fluoroquinolone as single agent
Tx of ventilator-associated PNA
Imipenem or meropenem, piperacillin/tazobactam, or cefepime
Gentamicin and
Vancomycin or linezolid
Buzzwords
Cause PNA with recent viral syndrome
Staphylococcus (superimposed infection)
Buzzwords
Cause PNA in alcoholics
Klebsiella
Buzzwords
Cause of PNA with GI symptoms and confusion
Legionella
Buzzwords
Cause of PNA in young, healthy patients
Mycoplasma
Buzzwords
Cause of PNA in people present at birth of live animal
Coxiella burnetti
Buzzwords
Cause of PNA in Arizona construction workers
Coccidiodomycosis
Buzzwords
Cause of PNA with HIV and CD4
Pneumocystis
What is best tx of pneumocystis pneumonia?
Trimethoprim/sulfamethoxazole and possibly steroids
*Steroids indicated if PO2 35
Best initial test for TB dx
Confirmatry test for TB
Initial: CXR
Confirmatory: Acid fast stain and culture of sputum
Tx of TB
Isoniazid (6 months)
Rifampin (6 months)
Pyrazinamide (2 months)
Ethambutol (2 months)
All TB meds can lead to what toxicity?
Liver toxicity
Stop if LFTs reach 5x upper limit
Specific side effect of isoniazid
Peripheral neuropathy
Specific side effect of rifampin
Red/orange body secretions
Specific side effect of pryazinamide
Hyperuricemia
Specific side effect of ethambutol
Optic neuritis
Describe PPD thresholds
15mm: those without increased risk
10mm: healthcare workers, alcoholics, immigrants, homeless, prisoners (high risk)
5mm: active drug users, HIV positive, close TB contacts
What is 2-stage testing in TB?
If a patient hasn’t been tested in a long time then do two serial tests to make sure truly negative
A positive IFN-gamma release assay for TB exposure is an indication for what treatment?
Isoniazid
