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
Berylliosis
aerospace manufacturing
Noncaseating granulomas
Increased risk of lung cancer
Goodpasture’s syndrome
progressive autoimmune disease of lungs and kidneys
Anti-glomerular basement membrane Ab
Presentation: hemoptysis dyspnea Respiratory infection proteinuria granular casts hematuria
Dx:
anti-GBM ab
Bx: crescentic GN and IgG deposits along glomerular capillaries
Tx:
plasmapheresis, corticosteroids, immunosuppressive agents
Granulomatosis with polyangiitis (Wegner)
Triad:
Necrotizing granulomas of the upper and/or lower respiratory tract
Necrotizing or granulomatous vasculitis in lungs and upper airways
Focal necrotizing, often crescentic, glomerulonephritis
Presentation: hemoptysis dyspnea myalgias chronic sinusitis ulcerations of nasopharynx saddle nose deformity
c-ANCA
Tx: corticosteroids, cyclophosphamide methotrexate rituximab plasma exchange
A-a gradient
Compares O2 status of alveoli to arterial blood
Normal 5-15
increased in PE, pulmonary edema, right to left shunt
PAlvO2 - PartO2
713 x 0.21 - (PaCO2/0.8) - PaO2
Pulmonary embolism
Risk factors: Immobilization Malignancy Recent surgery Pregnancy OCP use Smoking Obesity Fractures Prior DVT Severe burns
Presentation:
dyspnea, pleuritic chest pain, cough, hemoptysis (rare)
DVT symptoms (swollen leg)
Abrupt AMS
Dx:
D dimer - r/o DVT/PE in low probability situations
CTA - best test
CXR: Hampton’s Hump - wedge shaped opacification at distal lung fields; usually normal, may have atelectasis, pleural efusions
ABG - elevated A-a gradient
ECG - sinus tach - classic but rare: S1Q3T3
V/Q scan - if can’t use contrast for CTA
-ventilatory defects suggest PNA or other parenchymal lung disease
-perfusion defects suggest PE
Tx:
Unstable - thrombolysis (tPA, streptokinase, urokinase)
Stable - anticoagulation
-state LMWH, heparin or fondaparinux -> warfarin or rivaroxaban, apixaban, edoxaban or dabigatran
Pulmonary hypertension
Causes: PE Valvular disease - MS, MR Left to right shunt COPD (MC) Idiopathic
Presentation: dypsnea, fatigue, CP, cough, syncope
Exam: cyanosis Digital clubbing loud S2 JVD Hepatomegaly
Dx:
ECG - RVH - cor pulmonale
CXR: pulmonary vascular congestion, enlarged RV
ECHO or cath to measure pressure
Tx:
CCB (nifedipine)
endothelin receptor antagonists (ambrisentan, bosentan)
cGMP phosphodiesterase inhibitors (sildenafil, tadalafil)
Prostanoids (ilprost, treprostinil)
Pulmonary edema
Increased pulmonary venous pressure -> fluid leaks from vessels into lung interstitial and airspaces
Causes: Left-sided heart failure MI Valvular disease Arrhythmias ARDS
Features: dyspnea orthopnea paroxysymal noctural dyspnea frothy pink sputum tachycardia \+/- wheezing
Dx:
BNP elevated
ECG: T wave abnormalities or QT prolongation
CXR: diffuse interstitial fluid, cephalization of the vessels, Kerley B lines
Tx: NOLIP
Nitrates - redistribute blood outside pulmonary vasculature, decreased preload
Oxygen - if hypoxemic
Loop diuretics
Inotropic drugs - dobutamine, milrinone (not first line, increased mortality)
Positioning
Pleural effusion
Excess fluid in the pleural space
Presentation: Sob, dyspnea with exertion \+/- pleuritic chest pain Fatigue dullness to percussion (over 300 ml) Decreased breath sounds Decreased tactile fremitus egophony \+/- tracheal deviation
CXR: fluid level or blunting of costophrenic angles
Transudate: CHF, cirrhosis, nephrotic sn
- Pleural to serum protein less than 0.5 - OR-
- Pleural to serum LDH less than 0.6
Exudative: cancer, infection, vasculitis
- Pleural to serum protein >0.5
- Pleural to serum LDH >0.6
Tx: underlying pathology
Thoracentesis, chest tube
Pleurodesis - talc or chemo to scar space
Complications: take off too much fluid too quickly -> reexpansion pulmonary effusion
Pneumothorax
Air in the pleural space
Closed PTX: COPD, TB, blunt trauma, spontaneous (thin tall male)
Open PTX: penetrating trauma, iatrogenic (central line, thoracentesis)
Tension PTX: open with ball valve mechanism, increasing pressure
Small PTX - asx
Tension PTX sxs: Decrease wall movement Decreased breath sounds Increased resonance to percussion Decreased tactile fremitus hypoxemia JVD Decreased blood pressure Tracheal deviation away from side
Tx:
less than 15%: O2 and monitoring
>15% - chest tube
Tension: needle decompression
Recurrent - pleurodesis
Hemothorax
blood in the pleural space
like pleural effusion presentation
Complication: clotting blood -> fibrosis pleural space
Dx: thoracentesis - grossly bloody
Tx: O2, chest tube
Tx underlying cause
CENTOR criteria
Strep pharyngitis
Cough absent +1 Exudates, tonsillar +1 Nodes- tender anterior cervical +1 Temperature +1 under 15 +1 OR over 44 -1
0-1 no treatment no cx
2-3: get cx and treat if positive
4-5: tx empirically
Tx: b-lactam abx - PCN, amox
Ludwig angina
cellulitis of floor of mouth, extending into submandibular area
Causes:
dental ifnection
polymicrobial - GAS, staph, Bacteroides
Tx: abx
I&D
protect airway
Peritonsillar abscess
Infection between the tonsil and pharyngeal constrictors
Causes: strep, S. aureus, Bacteroides
Presentation:
Fever, severe sore throat, muffled “hot potato” Voice
Tonsil or uvula deflection to the opposite side
Trismus (lockjaw)
Drooling
Tx: needle aspiration, I&D, abx
Mononucleosis
EBV
Presentation Fatigue 3-6 mo Sore throat malaise LAD - posterior cervical Splenomegaly Fever Tonsillar exudates
Labs: heterophil Ab - monospot EBV serology elevated LFTs Hemolytic anemia (rare) thrombocytopenia (rare)
Tx: supportive
no noncontact supports x3 weeks
no contact sports x4 weeks
Viral influenza
Presentation: arthralgias, myalgias (severe) nasal congestion cough V/D high fevers LAD
Lab: rapid swab
Tx: zanamivir or oseltamivir within 48 hr of sxs
ppx: vaccine - takes 2-4 weeks to kick in
Sinusitis
associated with allergic rhinitis, barotrauma, viral infection, prolonged NG tube, asthma
Bacterial causes: S. pneumo, H flu, Moraxella catarrhalis
Rare spread to CNS -> meningitis
Chronic - over 3 mo - obstruction (polyps, deviated septum) or anaerobic infection
Presentation: purulent nasal discharge maxillary toothache tendernes of affected sinus foul smell
Tx: nasal irrigation analgesics oral decongestants intranasal steroids amox-clav, doxy, levofloxacin
DM - mucormycosis
severe/chronic - get CT sinuses
Acute bronchitis
features:
Cough lasting longer than five days - often productive +/- purulent sputum
usually not associated with fever
Dx: sputum cx not recommended
CXR r/o PNA (fever, abnl V/S, abnl lung exam)
Tx: supportive, usually viral
Causes of pneumonia in neonates
GBS
E. coli
Causes of pneumonia in under 5 yo
RSV
S. pneumo
S. aureus
Causes of pneumonia in 5-20 yo
S. pneumo
Mycoplasma pneumoniae
Chalmydophilla pneumoniae
Causes of pneumonia in >20 yo
S. pneumo Mycoplasma penumoniae Chlamydophila pneumoniae Haemophilus influenzae Influenza virus Legionella pneumophila (+ diarrhea)
Causes of pneumonia in ederly
S. pneumo
Haemophilus influenzae
S. aureas
Typical pneumonia presentation, pathogens, empiric tx
presentation: Fever Cough Sputum production SOB
CXR: lobar consolidation
Pathogens:
S. pneumo
H flu
S. aureus
Tx: B-lactams
Atypical pneumonia presentation, pathogens, empiric tx
Presentation: Prolonged illness Dry cough Headache Fatigue
CXR: interstitial infiltrates
Pathogens: Mycoplasma pneumoniae Chlamydophila pneumoniae Legionella pneumophilia Chlamydophila psittaci
Tx: macrolides, fluoroquinolones
Empiric treatment for neonates with CAP
hospitalize
ampicillin + gentamicin
or
vancomycin + gentamicin
empiric treatment for children with CAP
often outpt tx
amox or amox-clav for typical
azithromycin for atypical or pcn allergy
Outpatient treatment of CAP in otherwise healthy individual with no antibiotics in last 3 mo
Azithromycin or doxycycline alone
Outpatient treatment of CAP in patient who received antibiotics in the last three months or has chronic medical problems (DM, lung dz, immunosuppression)
b-lactam - amox or cefuroxime PLUS macrolide (azith)
OR
Respiratory fluoroquinolone - levo or moxi
Inpatient treatment for CAP
B-lactam PLUS macrolide - ceftriaxone + azithromycin
Respiratory fluoroquinolone
ICU treatment for CAP
b-lactam PLUS macrolide or respiratory fluoroquinolone
Pneumococcal vaccine
PCV-13 - conjugate - 4 doses before 2 yo
PPSV-23 - polysaccharide
19-64 yo: smoker, alcoholic, chronic heart, lung, liver disease, DM
Over 65, CSF leak, asplenic, cochlear implant, or immunocompromised
Pneumocystis jirovecii (PCP)
Immunocompromised
- HIV CD4 less than 200
- Chronic glucocorticoid use
Slow progression to respiratory failure
CXR: diffuse, B/L interstitial infiltrates
Elevated LDH
Sputum with Pneumocystis on stain
Tx:
21 days of TMP-SMX (IV or PO) or Pentamidine (IV) or Primaquine (PO) + clindamycin (IV or PO)
steroids if pO2 less than 70 on room air or A-a gradient greater than 35
Primary tuberculosis
Local infection in the lung
Fever
+/- cough and chest pain
LAD
Forms granulomas with central caseous necrosis (Ghon focus)
Ghon complex: Ghon focus + hilar LAD
10% untreated -> PNA or disseminated TB
90% -> latent
Reactivation of tuberculosis
5-10% with latent TB
Risk: Recent primary infection Immunosuppression DM Kidney disease Older age HIV TNF-a inhibitors
Lung apices
Features: Fever Night sweats Weight-loss Cough and hemoptysis
Disseminated involves: bones, CNS, GI, GU
Diagnosis of TB
Sputum x3 8 hours apart
- Acid fast stain
- AFB cx - takes 4-6 weeks, needed for susceptibility
TB NAAT - rapid, but no susceptibility info
TB screening
PPD
Interfereon gamma release assay
-quantiferon TB- GOLD
-T-spot
Evaluates release of IFN-gamma by T cells presented with M. tuberulosis antigens
positive result - previous immune response to TB
Immunosuppression -> unreliable results
PPD positive criteria
5 mm: HIV, close contact with TB, CXR suggestive of TB, immunosuppression
10 mm: homeless, IV drug use, prison, health care, immigrants from endemic areas, DM, HD, kids under 4
15 mm: always considered positive (low risk individuals)
Treatment of active vs latent TB
Latent:
Isoniazid daily x 9 mo OR Rifapentine + isoniazid q1 wk x3 mo
Active:
2 months of RIPE then 4 mo of Rifampin + isoniazid
RIPE: Rifampin Isoniazid + B6 Pyrazinamide Ethambutol
Acute respiratory distress syndrome
Respiratory failure following a severe acute injury to lung
-sepsis, trauma, aspiration
Features: Acute dyspnea and respiratory decompensation Cyanosis Tachypnea Wheezing, rales, Rhonchi
Dx:
ABG: respiratory alkalosis
Wedge pressure less than 18 (if pulm edema w/ CHF over 20)
PaO2:FiO2 less than 200 (under 100 severe)
CXR: diffuse pulmonary densities
Tx:
Admit ICU - supportive care and treat underlying cause
Mechanical ventilation with low tidal volumes (minimize injury) and adequate PEEP (recruit collapse alveoli)
Conservative fluids - goal CVP 4-6 mmHg
Furosemide and albumin to prevent pulmonary edema
Prone positioning - improves oxygenation (not survival)
Minimize O2 consumption:
- prevent fever
- minimize anxiety and pain
- limit respiratory muscle use- paralytics
Transfuse blood only if Hgb below 7 - transfusion may increase risk of death in ARDS patient
Oxygen delivery methods
NC - 24-40% FiO2 (FiO2 increases 3% every 1L/min up to 6 L/min)
Face mask- 50-60% FiO2
Non-rebreather - 60-95% FiO2
CPAP -> 80% FiO2
Mechanical vent up to 100% FiO2
Prevention of post operative atelectasis
Incentivive spirometry
Early postop ambulation
Upper airway suctioning
Bronchoscopic suctioning
Intubation
Pre-oxygenate - 100% O2 several minutes
Pretreat
- Lidocaine for increased ICP
- Fentanyl for pain
- Atropine for secretions, prevent bradycardia
Induction agents:
Sedatives: etomidate, propofol, midazolam, ketamine
Paralytics: succinylcholine, rocuronium
Cricoid pressure (Sellick technique)
Placement: Watch tube pass vocal cords -Check end tidal CO2 -look for bilateral lung expansions -listen for air sounds in stomach -CXR for positioning
Complications: tube misplacement, aspiration, dental injuries
Tracheostomy if ET tube in place for few weeks
