PULMONOLOGY Flashcards
Acute Asthma exacerbation
treatment
ICU
can do PFTs before and after bronchodilators . no place for PFTs is asymptomatic.
treatment: albuterol, steroid bolus , ipratropium, O2, Mg
ICU is asthma & respiratory acidosis with CO2 retention
persistent respiratory acidosis –>intubation & ventilation
nonacute Asthma
albuterol
uncontrolled add inhaled steroid
still uncontrolled add long acting b-agonist (salmeterol, formeterol)
oral steroid last resort
COPD/Emphysema
how do you handle acute episode
acutely: O2, ABGs (CO2 retention), CXR, albuterol, ipratropium, steroid bolus, chest/heart/neuro/extremity exams
mild respiratory acidosis –>CPAP//BiPAP
intubate if drop in pH indicative of worsening respiratory acidosis. don’t intubate on CO2 retention alone because it might be chronic
alpha-1 antitrypsin deficiency
presentation
diagnosis
look for case of early COPD in nonsmoker who has bull at lung bases
diag: CXR show COPD lungs
blood low albumin, high prothrombin time
low alpha-1 antitrypsin deficiency levels
treat with alpha-1 antitrypsin infusion
Bronchiectasis
caused by anatomic lung defect usually from childhood infection. profound dilation of bronchi, recurrent episode of lung infection that give rise to copious amount of sputum, fever and hemoptysis
rotate antibiotic to minimize resistance
Interstitial Lung Disease
possible causes
presentation
diagnosis
asbestos–>asbestosis
coal worker–>coal worker pneumoconiosis
glass, mining, sandblasting, brickyards–>silicosis
cotton–>bysssinosis
fluorescent light, ceramics, electronics–>berrykkiosis
mercury–>pulmonary fibrosis
TMP-SMZ, nitrofurantoin–>pulmonary fibrosis
presentation: clubbing, dry/velcro rales, loud P2 heart sound (pulmonary HTN)
right atrial and ventricular hypertrophy on EKG
no systemic findings or fever
diag
CXR: interstitial fibrosis
CT more detail
lung biopsy
PFTs show decreased: FEV1, FVC both go down so will have normal FEV1/FVC ratio
also low DLCO, total lung capacity, residual volume
Bronchiolitis Obliterans Organizing Pneumonia
(aka cyrptogenic pneumonia)
- what is it
- presentation
- diagnosis
- treatment
- rare bronchiolitis or inflammation of small airways with chronic alveolitis of unknown origin
- presents more acutely than ILD, wks to months
cough, rales, dyspnea + systemic findings (fever, maliase, myalgias. no occupational exposures in hx - CXR and CT chest so interstitial dx and alveolitis
definitive: open lung biopsy - steroid NOT antibiotics
Pulmonary Hypertension
treatment
- bosetan, ambrisentan and macitentan = endothelin inhibitors that prevent growth of pulmonary vasculature
- epoprostenol, treprostinil = prostacyclin analogs that act as pulmonary dilators
Pulmonary Embolism
- diag
- role of CT Angiogram, V/Q scan, doppler, d-dimer, angiography
diag:
CXR can be normal. may show atelectasis, wedge shaped infarct
EKG: sinus tach, nonspecific ST-T wave changes
ABG: hypoxia with increased A-a gradient, mild respiratory alkalosis
right hear strain + hypoxia = thrombolytics
- CT angiogram confirmatory f/u of abnormal CXR
V/Q scan accurate when CXR is normal
if LE doppler positive don’t need further testing
d-dimer for low suspicion. not specific
Angiography - LMWH & O2
NOACs (-abans, -atran) if hemodynamically stable
warfarin for 3-6 months after heparin
IVC filter if contained to anticoagulation
thrombolytics-hemodynamically UNSTABLE (hypotensive)
Pleural Effusion
1. diag test
- CXR in decubitus position to see fluid flowing freely
thoracentesis most accurate
Exudate
Ca & infection
protein level high >50% serum level
LDH high >60% serum level
Transudate
congestive failure
protein level low <50% serum level
LDH level low <60% serum level
tests on pleural fluid: gram stain and culure acid-fast stain total protein (& serum protein) LDH (& serum LDH) Glucose pH cell count with diff triglycerides
treatment:
if small no therapy
if secondary to CHF then diuretics
if big (eep due to empyema) then chest tube drainage
if big & recurrent & uncorrectable then pleurodesis
if pleurodesis failed then decortication
Sleep Apnea
treatment
OSA & surgery post-op risks
Central
Obstructive :
weight loss, CPAP, BiPAP
puts with OSA at increased risk of preoperative failure from procedures involving sedation, neuromuscular blocker, opioids, or anesthesia. presents with hypoxia and hypercapnia.
Central:
avoid EtOH and sedatives
acetazolamide–>metabolic acidosis –>increase resp drive
medroxyprogesterone = central respiratory stimulant
Swan-Ganz (Pulmonary Artery) Catheterization
high or low CO, wedge P, SVR in hypovolemic, cardiogenic shock and septic shock
hypovolemia: low CO, low wedge P, high SVR
cardiogenic: low CO, high wedge P, high SVR
septic: high CO, low wedge P, low SVR
Pneumonia most likely organism: Community & Hospital acquired diagnosis outpatient treatment inpatient treatment VAP
CAP: pneumococcus
HAP: gram negative bacilli
admit old people with respiratory distress
diag: CXR, sputum gram stain & culture
ABGs if hypoxic
treatment:
outpatient
macrolide (azithromycin, clarithromycin)
respiratory FQ (levofloxacin, moxifloxacin)
inpatient
ceftriaxone & azithromycin
FQ alone
ventilator associated:
imipenem/meropenem, piperacillin/tazobactam or cefepime
getamicin and
vancomycin or linezolid
pneumonia associations
- recent URI
- alcoholics
- GI symptoms, confusion
- young, healthy patients
- arizona construction worker
- HIV with CD4<200
- ppl around animal birth
- recent URI-staph
- alcoholics -klebsiella
- GI symptoms, confusion -legionella
- young, healthy patients-mycoplasma
- arizona construction worker-coccidiocomycosis
- HIV with CD4<200- PCP
- ppl around animal birth - coxiella brunette
active Tb
treatment
after + acid-fast stain & culture, initiate 4 meds:
- isoniazid, 6 months, AE: peripheral neuropathy
- rifampin, 6 months, AE: red/orange bodily fluids
- pyrazinamide, 2 months, AE: hyperuricemia
- ethambutol, 2 months, AE: optic neuritis
all of these meds are hepatotoxic . stop if transaminases reach 5X ULN
if meningitis, military Tb, pregnancy, cavitary Tb , osteomyelitis then may need more than 6 months
PPD test interpretation
screening cutoffs
IGRA
what do you do if a PPD is +?
5mm: close contact, steroid users, HIV +
10mm: homeless, immigrants, EtOHs, HCWs, prisoners
15mm: everybody without increased risk
IGRA: in vitro blood test that is used for detection of latent Tb. same indication as PDD but more specific.
+PPD
1.CXR to look for evidence of active dx
PPD test interpretation
screening cutoffs
IGRA
what do you do if a PPD is +?
5mm: close contact, steroid users, HIV +
10mm: homeless, immigrants, EtOHs, HCWs, prisoners
15mm: everybody without increased risk
IGRA: in vitro blood test that is used for detection of latent Tb. same indication as PDD but more specific.
+PPD
1. CXR to look for evidence of active dx
2. if CXR is abnormal, then sputum staining for Tb
3. if sputum +, then full dose, 4 drug therapy
otherwise latent Tb is treated with 9 months of INH
ventilator adjustments
1.improve oxygenation
- increase FiO2 or PEEP
2. RR and TV correlate with ventilation, control CO2
postoperative hypoxemia
common causes
- airway obstruction/edema
immediately after surgery
2.residual anesthetic effect
immediately after surgery
- bronchospasm
soon after surgery - pneumonia
1-5 days after surgery
fever, high WBC, purulent secretions
5.atelectasis
2-5 days after surgery
retained secretions, reduced cough
treat with chest physiotherapy and oral suctioning
- pulmonary embolism
usually after 3rd day post -op
COPD
1. what are indicators of poor prognosis
- FiO2 <40% and age
effect of big PE on right heart
PE–>pulmonary HTN–> RV dysfunction, tricuspid annulus dilation and functional tricuspid valve regurgitation
EKG can show RBBB without ST segment changes so not MI
PE
- heparin vs fibrolytic therapy
- what can post PE symptoms be confused with?
- initial treatment of hemodynamically stable patients with PE is anticoagulation with LMWH or unfractionated heparin. IV fibrolytic therapy is reserved for patient that are hemodynamically unstable
- fever, elevated WBC, streaky opacities in lungs can occur after PE. can be confused with pneumonia
what are small cell carcinoma and squamous cell carcinoma of the lung associated with
Small cell carcinoma-sIADH
squamous (“sCamous”): PThrP–> high Ca
ARDS
- what is effective at decreasing mortality
mechanical ventilation that delivers lover tidal volume and limits plateau pressure more effective than NO inhalation, prostacyclin, exogenous surfactant, steroids
COPD
Pulmonary Cachexia Syndrome
severe COPD associated with PCS which is characterized by loss of lean muscle mass due to energy imbalance and systemic inflammation
effect of hypophosphatemia on respiratory muscle in hospitalized patient
hypophosphatemia major cause res muscle weakness and can lead to failure of being able to wean patient off respirator .
continuous glucose infusions leading cause of hypophosphatemia in hospitalized patients.
low phosphate impairs ATP generation so skeletal muscles can’t perform work
