Pulmonology Flashcards
Asthma characteristics
Chronic inflammation characterized by reversible airway obstruction and bronchospasm
Triggers: allergens, pollution, URI, exercise, beta blockers, aspirin (rare)
Presentation: Cough Wheezing Chest tightness Dyspnea Tachypnea Tachycardia Prolonged expiratory duration Decreased breath sounds Accessory muscle use Pulses paradoxus Cyanosis
Labs:
Decreased peak flow, decreased FEV1/FVC ratio
ABG - mild hypoxia, respiratory alkalosis
CXR: hyper inflation - air trapping
Indications for home 02
Pulse ox symmetry less than 88%
Pulmonary hypertension
Peripheral edema
Polycythemia
COPD - features, dx, general management all stages
Clinical features: Productive cough Recurrent respiratory infections Dyspnea Wheezing Rhonchi
FEV1/FVC less than 80% - obstructive lung disease
FEV1/FVC less than 70% - diagnostic of COPD
Tx:
stop smoking
yearly influenza vaccine
Pneumococcal vaccine - 19-65; single vaccine after 65 if more than 5 yrs from initial
COPD staging
GOLD 1: FEV1 > 80% predicted - mild
GOLD 2: FEV1 50-80% - moderate
GOLD 3: FEV1 30-50% - severe
GOLD 4: FEV1 less than 30% - very severe
COPD management - Category A
GOLD 1 or 2 with mild or infrequent symptoms
0-1 exacerbations per year
Short acting bronchodilator - albuterol, ipatropium
COPD management - Category B
GOLD 1 or 2 with moderate to severe symptoms
-stop to catch breath when walking on level ground, walk slowly
Short acting bronchodilator
Long-acting bronchodilator: B2-agonist or anticholinergic (tiotropium, ipratropium)
COPD management - Category C
GOLD 3 or 4 with mild or infrequent symptoms
Short acting bronchodilator
Long acting bronchodilator
inhaled steroid
COPD management - Category D
GOLD 3 and 4 with moderate to severe symptoms
Short acting bronchodilator Long acting bronchodilator inhaled steroid \+/- theophylline Home O2 \+/- phosphodiesterase-4 inhibitor - roflumilast
Emphysema
Destruction of alveoli and bronchioles
- centriacinar - smoking
- panacinar - alpha-1-antitrypsin deficiency
Features: Dyspnea, productive cough, wheezing, rhonchi, decreased breath sounds Barrel chest, use of accessory muscles Prolonged expiratory duration Pursed lip breathing (increases PEEP) Morning headaches Decreased heart sounds JVD
Dx:
PFT: decreased FEV1/FVC, increased total lung capacity - air trapping
ABG: low O2, high CO2 - during exacerbations
CXR: flat diaphragm, hyperinflation, subpleural blebs/bullae, decreased vascular markings
DLCO decreased
Tx:
Stop smoking
Fast acting beta agonist, inhaled anticholinergics, inhaled corticosteroids
Home O2
A1-antitrypsin augmentation -> lung transplant
Complications Chronic respiratory decompensation Cor pulmonale Frequent respiratory infection Comorbid lung cancer common
Chronic bronchitis
Productive cough for three months in each of two successive years
Can proceed or follow development of airflow limitation
Tx:
Stop smoking
azithromycin, respiratory fluoroquinolone (levofloxacin), amoxicillin/clavulanate
Etiologies of bronchiectasis
Permanent dilation
unknown in 50%
Cystic fibrosis
Immunodeficiency
Dyskinetic cilia: Kartagener syndrome (dextrocardia, sinusitis, bronchiectasis), ADPKD
Pulmonary infections: TB, fungal infection, lung abscess
Obstruction: FB, tumor, LN
Other etiologies: Young syndrome, RA, Sjogen syndrome, allergic bronchopulmonary aspergillosis, smoking
Bronchiectasis
features: Persistent, productive cough Hemoptysis Frequent respiratory infections Dyspnea copious sputum wheezing, rales hypoxemia
CXR: multiple cysts and bronchial crowding
CT: dilation of bronchi, bronchial wall thickening, bronchial wall cysts, dilation and thickening of the airways
Tx:
pulmonary hygiene - hydration, sputum removal
Chest physiotherapy
Abx when sputum production increases
Inhaled b2-agonists and corticosteroids may reduce sxs
Resection of severely diseased regions - hemorrhage, substantial sputum production, inviability
Complications:
Cor pulmonale
Massive hemoptysis
frequent abscess formation
Characteristics of malignant pulmonary lesions
Smoker Over 45 New or progress lesion irregular or asymmetric calcifications >2 cm Irregular margins
Get PET, bx, immediate ressection
Characteristics of benign pulmonary lesions
Under 35 No change from prior films Central/uniform lesion with smooth margins Less than 2 cm No evidence of LAD
Follow with CXR in 3-6 mo
Adenocarcinoma of lung
MC lung cancer, and in nonsmokers and females
Peripheral, on pre-existing parenchymal scars
Associated with smoking
Large cell carcinoma of lung
Peripheral
anaplastic, undifferentiated giant cells
Strongly associated with smoking
Poor prognosis
Squamous cell carcinoma of lung
2nd MC type of lung cancer
Central - hilar mass from bronchus
Associated with smoking
Hypercalcemia - paraneoplastic syndrome, PTH-r protein
CXR/CT: cavitated lesion
Small cell carcinoma of lung
Central
Associated with smoking
Paraneoplastic: ACTH (Cushing Sn), ADH (SIADH), antibodies against presynaptic calcium channels (Lambert-Eaton Sn)
Pancoast tumor
usually non-small cell
Apex of lung
Can compress cervical sympathetic ganglion
-> Horner syndrome (miosis, ptosis, anhidrosis)
Superior vena cava syndrome
Edema/ flushing a face and arms
SOB, dysphagia, HA
Compression by lung tumor
Lung cancer treatments
non-small cell - surgical resection if possible, radiation, chemotherapy
Small cell: chemotherapy primarily
Malignant mesothelioma
pleura or pericardium
heavily associated with asbestos exposure
No association with smoking
presentation: Chest pain Dyspnea Dullness to percussion Exudative pleural effusion Chest wall mass
Tx: Surgery - pleurectomy, decortication Radiotherapy Chemotherapy Poor prognosis
Asbestos exposure cancer risk
more likely to get bronchogenic lung cancer than mesothelioma
Laryngeal cancer
Associated with tobacco use - smoking, smokeless tobacco; alcohol use
Presentation: Hoarseness Dysphasia Ear pain hemoptysis
Dx: larygnoscopy with bx
Tx: partial or total laryngectomy, radiation, chemo
Idiopathic pulmonary fibrosis
Ineffective repair of alveolar epithelial cells injured by smoking, pollutants, microaspirations
over 40 yo
Presentation: Progressive exercise intolerance Dyspnea Dry crackles JVD Tachypnea Possible digital clubbing
PFT: decrease lung volume, normal FEV1/FVC ratio
Radiology: honey come appearance - reticular
Bx: fibrosis with decreased parenchymal architecture
Tx: pirfenidone nintedanib sildenafil Corticosteroids Antibiotics One transplant
Only survive 3 to 5 years after diagnosis
Sarcoidosis
"A GRUELING Disease" ACE elevated in serum Gammaglobulinemia RA Uveitis Erythema nodosum LAD - b/l hilar LAD Idiopathic Noncaseating Grandulomas D vitamin production by activated macrophages in granulomas -> hypercalcemia
Pulmonary involvement: cough dyspnea and chest pain
Radiology: noncaseating granulomas, b/l hilar LAD, pulmonary infiltrate, skin lesions
Tx: Glucocorticoids, cytotoxic drugs, +/- lung transplant
Frequently show anergy to skin test or PPD
Silicosis
mining, demolition of concrete, stonecutting, sandblastng
Upper lobes
“eggshell” calcifications of hilar LN
Increased susceptibility to TB
risk of lung CA increased x2
Coal workers disease
mining coal
Anthracosis - generally asx or mild
-urban dwellers, tobacco smokers
Simple coal workers disease - small fibrotic lung nodules
Complicated: progressive massive fibrosis and necrosis
Presents as chronic bronchitis
No increased lung cancer risk, unless radon or smoking exposure
