Pulmonology Flashcards
diff PFTs
- static lung compartments (TLC,RV ,VC)
- air movement ( FEV1/FVC , FEF25-75%)
- alveolar memb permeability (DLco)
- methacholine challenge test
what is the abnorml value for lung vol / flow rates
<80% : abnormal
> 120%: air trapping
diff bw FEV1/FVC and FEF25-75%
both measure airflow under dynamic condn
FEF usually detects obstructive ds earlier.
obstructive ds + decreased DLco
emphysema
DLco diff from ch bronchitis, asthma , bronchiectasis
restrictive pattern + dec DLco
interstial lung ds / intrapulmonary restriction
not extrapulmonary cause
when is methacholine challenge test said to be positive
dec from baseline FEV1 of 20% or more
increased DLco in___
pulmonary haemorrhage eg: good pasteur
bronchodilator reversibility test used to distinguish
nonreversible obs from reversible obs lung ds
flattened flow vol loop on top and bottom indicates
fixed airway obstruction:eg tracheal stenosis after prolonged intubation
flow vol loop in dynamic extrathoracic airway obstruction
obstruction occurs mostly with inspiration while exp is normal
flattened only on bottom
Do2 (oxygen delivery) depends on
Do2=CO × (1.34 ×Hb ×HbSat) + 0.0031 ×Pao2
depends less on Pao2(minimal change on giving 100% o2)
main: CO and Hb
dont memorise formula
alveolar - arterial gradient formula
PAo2 - pao2
150 - (1.25 x PaCO2) - PaO2
valid if breathing room air
severe hypoxemia but normal gradient
dec in RR as in opiod overdose and resp centre depression
high altitude
what is the first step after finding out a pul nodule in chest xray
look for prior xray
if no prior chest xray available ..what to do?
consider whether the patients is high/low risk
high: >50, smoking
- resection amd biopsy
low: < 35 , nonsmoking, calcified
- Cxray/ CT every 3 mths ×2yrs
why is bronchoscopy not a good option for diagnosing a case of a pul nodule on chest xray
not reach peripheral lesions
mislabel 10% of central cancers by finding only nonspecific inflammatory changes
performed blindly
specimen obtained cam be limited
in which cases it is rasonable to observe pleural effusion without performing thoracocentesis
CHF
viral pleurisy
recent abdominal/ thoracic surgery
light criteria for pleural effusion
- LDH
- LDH effusion/serum ratio
- protein effusion/ serum ratio
values
200
0.6
0.5
eg of condtion causing exudate and transudate
pulmonary embolism
clinical significance: patient has transudative effusion but no apparent cause…consider PE
is thoracocentsis necessaary in parapneumonic effusion?
YES(treatment ll be diff. in un/complicated effusion)
to rule out complicated parapneumonic effusion ( possibility of progressing to empyema)
what is the diff in the Rx of un/complicated parapneumonic effusion
uncomplicated: antibiotics alone
complicated: chest tube drainage
haemorrhagic pleural effusion seen in
meaothelioma
metastatic lung / breast ca
pul thromboembolism with infarction
trauma
lymphocytic predominant pleural effusion seen in
tuberculosis
most senistive amd specific test for pleural TB
biopsy
thoracocentesis should always be done under guidance of USG
yes
Rx of acute exacerbation of asthma
- oxygen
- short acting beta2 agonist(albuterol)
- anticholinergics( less eff, take time to act)
- inhaled steroid spur ( for 7 - 14 days)
which is the most imp medication in Rx of acute excerbation of asthma
short acting beta 2 agonist - like albuterol
which is the most imp medication in chronic Rx of asthma
inhaled steroids
mostvimp side effects of inhaled steroids
oral candidiasis
bad taste
so wash mouth
how to treat nocturnal asthma
long acting beta agonist
when is chromolyn / nedocromil used?
not to be used in acute excerbation: may even proke attack.
used in childhood asthma which is mild and where steroids should be avoided.
adulthood asthma does not benefit much since it is severe….but can be used in exercise (mild) induced asthma
when is LTs antagonists used in asthma
used in steroid dep asthmatics(chronic oral steroid users ) to minimize steroid use or stop its use dur to side effects
what is the difference bw COPD and asthma
COPD::
nonreversible
noninflammatory condition
inflammation only during excerbation
Rx
what are the types of ventilation
noninvasive: supports breathing without the need for intubation
invasive: (mechanical) follows endotracheal intubation
types of nonivasive ventilation
bilevel positive airway pressure:positive pressure at alternating levels(higher for insp and lower for expiration)
continuous positivr airway pressure: air pressure on a continuous basis ( airways continuously open)
BiPAP used in
COPD
acute resp failure( pneumonia, status asthmaticus)
chronic resp failure
CPAP used in
obstructive sleep apnoea
CHF with pul edema
near drowning
other resp distress
invasive ventilation includes
positive end exp pressure
pattern of obs in asthma
episodic pattern . .with interspersed normal airway tone.
cause of obs in asthma
mucosal inflammation
muscle constriction
hypersecretion
2 types of asthma
INTRINSIC/ IDIOSYNCRATIC/ NONALLERGIC:
secondry to nonimmunologic stimuli like infection, irritating inhalant, cold air , exercise , emoional upset
EXTRINSIC/ALLERGIC /ATOPIC:
precipitated by allergens.
sp IgE are present
other symp like rhinits, utricaria , eczema
MCC of asthmatic excerbation
resp infections ( MC: viruses)
samster`s triad
athma
nasal polyposis(causing reccurent sinus ds)
sensitivity to aspirin and nsaids
variants of asthma
nocturnal cough
exercise induced
why is chest x ray done in asthma
to R/O acute infection of lung
Dx of asthma
obstructive pattern that reverses with bronchodilation
if normal PFTs : do methacholine test - decrease in FEV1 and FEF25- 75 of 20%
MC side effect of beta agonist
tremors
SABA and LABA
SABA
salbutamol/albuterol
terbutaline
LABA
salmeterol
formeterol
beta agoinsts should be used in caution in
CVD hypothytoidism DM htn coronary insufficiency
moa of amino/theophylline
not used routinely
modest bronchodilation
IMPROVING CONTRACTILITY OF DIAPHRAGM AS WELL AS OTHER RESPIRATORY MUSCLES
status of anticholinergics in asthma
ADVANTAGE
used in patients with heart ds
DISADVANTAGE
significant time to achieve max bronchodilation (-90 min)
medium potency
should routine Antibiotic Rx in acute excerbation of asthma be given
no, not proved
only in patients with symptoms ( purulent sputum ) and chest xray findings ( infilterates) consistent wih bacterial pneumonia
use of systemic steroids in asthma
in severe asthma
following status asthmaticus( initially i.v. then orally for 10 - 14 days)
when is LABA used?
persistant asthma
nocturnal symptoms
when is LT modifiers used in astham
for severe asthma resistant to max doses of inhaled steroid
AND
as a last resort before using chronic systemic steroids
status of MAST cell stabilizers in asthma
cromolyn ,nedocromil
- chronic asthma especially in children
- allergic / exercise induced
diff categories of asthma
MILD INTERMITTANT
symptoms 2x/wk
nighttime symp <2x/ mth
MILD PERSISTANT
symptoms 3-6x/wk
nighttime symp 3-4x/mth
MODERATE PERSISTANT
symptoms everyday
nighttime symptoms >5x/wk
SEVERE PERSISTANT
symptoms everyday
nighttime symp frequently
Dx of ABPA
sputum: fungus , eosinophils
blood: eosino, IgE, specific aspergillus Ab
skin test: but does not differentiate bw ABPA and simple allergy to aspergillus
Rx of ABPA
corticosteroids
chronic bronchitis
productive cough for most days of a 3 month period for atleast 2 consecutive yrs
pathognomic differentiating finding on PFTs bw COPD and asthma
COPD :irreversible
cause of obstruction in empysema
decrease in recoil
cause of obstruction in ch bronchitis
mainly increase in airway resisitance
chest x ray finding in emphysema
hyperinflation of bilateral lung fields
diaphragm flattening
small heart
inc retrosternal space
chest x ray finding in ch bronchitis
increased pul markings
Dc of COPD
PFTs
increase in CO2 occurs __ in ch bronchitis and ___ in emphysema
early
late
Rx of stable phase of COPD
anticholinergics (first choice)
can be given synergistically with beta agonist
theophylline
inhaled steroids( very severe case)
why are beta agonists not the first cgoice
COPD patients have underlying heart ds and tachycardia.
beta agonist can ppt heart failure
drugs that increase theophylline levels
FQs
clarithromycin
H2 blockers
certain beta blockers
CCBs
drugs that decrease theophylline levels ( due to increased clearance)
rifampin
dilantin
phenobarbital
SMOKING
only interventions that can decrease the mortality in COPD
home oxygen
smoking cessation
when should home oxygen therapy be instituted in COPD patients
PaO2 <55 mm Hg
PaO2 <59 mm Hg if cor pulmonale is present
MCC of COPD acute excerbation
viral lung infections
specific treatment for acute excerbation of COPD
oxygen( till 90%)
inhaled bronchodilators: ipratropium + albuterol
systemic corticosteroids for 2 wks ( inhaled not given)
antibiotics
no benefit of i.v. theophylline but if the patient was using give it now also beacause abrupt discontinuation may worsen symptoms
avoid opiates and sedatives
postural drainage
stop smoking
how to use MDI
which is the commonest micro org seen in bronchiectasis
pseudomonas
tram traking and signet ring sign in chest xray is seen in
bronchiectasis
rotating antibiotics concept is used in
bronchiectasis
(patirnts should be Rx with antibiotics when sputum production increases or they have mild symptoms.
chronic prophylaxis is not recomended)
sirgical therpy in bronchiectasis is useful in case of __
localised bronchiectasis
reticular / reticulonodular pattern in Chest X ray seen in
intertitial lung disease
drug used in IPF
pirfenidone ( antifibroti effects)
what are the dermatologic manifestations in sarcoidosis
lupis pernio( ch raised purplish indurated lesion of skin found on face)
erythema nodosum
non scarring alopecia
papules
LÖFGREN SYNDROME
distinct sarcoid syn with acite presentation
includes eryhtema nodosum , arthritis , hilar adenopathy.
HEERFORDT WALDENSTROM SYNDROME
distinct sarcoid syndrome wih acute presentation
fever
parotid enlargement
uveitis
facial palsy
if a patient is asymptomatic amd has BILATERAL HIALR ADENOPATHY on routine chest XRay … assume this to be
sarcoidoisis and follow with imaging
definitive diagnosis of sarcoidosis is via
BIOPSY
when are steroids used in sarcoidosis
in the setting of organ impairment:
uveitis
CNS
heart
hypercalcemia
sarcoidosis and ACE levels
60% show rise in ACE levels
ACE levels should not be used to diagnose sarcoidosis but can br used to follow the course of ds
can u have raised PTT and still have bleeding
yes ..in antiphospholipid Ab syndrome (anticardiolipin Ab syn/ lupus anticoagulant)
factor V leidd3n deficiency seen in which races
european decent
presentation of fat embolism
TRIAD : acute dyspnea , petechiae ( neck and axilla & confusion)…H/O trauma
findings in ARDS
dysnoea , crackles & rhonchi , hypoxemia +/- hypercapnoea , white out chest xray , elevated pul pressure
Rx of fat embolism
supportive( not heparin or anticoagulation)
one of the major complication / end result of sleep apnoea
right sided heart failure
best diagnostic test for sleep apnoea
polysomnography
imp lab findings in sleep apnoea
ABG- O2 dec and CO2 inc & RAISED BICARBONATE
Rx of sleep apnoea
OBSTRUCTIVE :weight loss , CPAP , surgery .CENTRAL: acetazolamide/ progesterone (breathe faster)
diff be central and obs sleep apnoea
no muscle retractions in central sleep apnoea during polysomnography
causes of atelectasis
post op ( lack of insp/ cough), foreign body ,tumor , pneumothorax
