Pulmonology Flashcards
1
Q
ABG-Atrial Blood Gas
A
pH 7.35-7.45 PaCO2 35-45 mmHG HCO3- 21-28 mEq/L PaO2 80-100 mmHG anion gap(Na+)-(CL-+HCO3-)=8-16 mEq/L
2
Q
Acidosis
A
pH<7.35
3
Q
Alkalosis
A
pH>7.45
4
Q
Respiratory Acidosis
A
Decreased pH
increased PaCO2
Normal HCO3-
5
Q
Respiratory Alkalosis
A
Increased pH
Decreased PaCO2
Normal HCO3-
6
Q
Metabolic Acidosis
A
Decreased pH
Normal PaCO2
Decreased HCO3-
7
Q
Metabolic Alkalosis
A
Increased pH
Normal PACO2
Increased HCO3-
8
Q
Differential Diagnosis for Cough
A
Asthma COPD Interstitial lung disease Malignancy Chronic pneumonia Pleural effusion GERD Chronic allergic Rhinitis Medication(ACEI-BB)
9
Q
Differential Diagnosis for Dyspnea
A
Flash pulmonary edema PE Anaphylaxis Aspiration Cardiac tamponade/effusion COPD exacerbation vs chronic Acute/chronic pneumonia Respiratory muscle weakness Spontaneous/Tension Pneumonthorax Metabolic Acidosis
10
Q
Differential Diagnosis for Hypoxemia
A
Asthma COPD CHF PE Pneumonia Pneumothorax
11
Q
Differential Diagnosis for Sputum Production
A
Cardiogenic pulmonary edema Acute Pneumonia Bronchitis Lung abscess Bronchiectasis Lung Cancer
12
Q
Differential Diagnosis for Hemoptysis
A
Bronchitis Lung Cancer Bronchiectasis Cryptogenic Pneumonia Tuberculosis
13
Q
Differential Diagnosis for Clubbing
A
Lung Cancer
Interstitial lung disease
Mesothelioma
Cystic fibrosis
14
Q
Chest Xray Systematic approach
A
A-Assess quality B-Bones and soft tissue C-Cardiac Silhouette D-Diaphragm E-Effusions F-Fields and Fissures G-Great vessels H—Hilla and Mediastinum I-Impression
15
Q
Pleural Effusion
A
Fluid that accumulates between pleural layers(OUTSIDE lung tissue)
16
Q
Pulmonary Infiltrate
A
Consolidation
Fluid or material fill the space within the lungs(INside the lungs)
17
Q
Common Causes of pleural effusion
A
Lung cancer-Pneumonia-TB-Trauma-Drug RXN, abestosis, sarcoidosis
18
Q
Common causes of pulmonary infiltrate
A
Pneumonia-pulmonary edema-cystic fibrosis-TB-trauma
19
Q
IV contrast use for CT
A
Evaluate cancer in Liver, kidneys and brain
Better evaluate blood vessels, vascular soft tissues, organs and tumors
20
Q
Iodine contrast dye adverse rxn
A
Vomiting, resp symptoms, pain, urticaria, burning, allergy
Ask about Hf of RXN, Iodine allergy, Diabetes, Vascular disease, RENAL DYSFUNCTION
21
Q
VQ scan
A
Scan that uses radioactive material to examine airflow and blood flow-DIagnose PE especially for pregnant or before lobe resection in lung cancer
22
Q
D-Dimer
A
HIgh sensitivity
Low Specificity
23
Q
Pulmonary angiogram
A
Used to visualize large PE, aid in direct thrombosis, Identify sites of bleeding to place coils
24
Q
Indications for pulmonary function tests
A
Pre-op veal
Evaluate sign/symptoms (cough, SOB, DOE, wheezing, hypoxemia, hypercapnea, crackles)
Abnormal CXR/CT
MOnitor-Occupational exposure-respirator use-pulmonary rehab
Screening at risk Pt
25
Obstructive lung disease causes
```
Alph 1 anti trypsin deficiency
Asthma
Bronchiectasis
Bronchiolitis obliterans
COPD
Cystic fibrosis
Early Silicosis
```
26
Restrictive Lung disease causes
CHest wall -ankylosing spondylitis
Kyphosis
Morbid obesity
Scoliosis
Drugs-Amiodarone, methotrexate, Nitrofurantin
Interstitial lung disease-asbestosis, berylliosis, eosinophilia pneumonia
Neuromuscular-ALS, Gillian Barre, Muscular dystrophy
27
Contraindications for PFT
Recent chest pain or MI
Recent or untreated pneumothorax
PE in last 3 month
Recent surgery-Eye, chest, lung
28
Pulmonary function test include
Spirometers, Lung volume determination(Body Plethysmography)Diffusion capacity
And frequently an ABG
29
Normal PFT values
Vary with age, sex, race and height
30
Tidal volume
Volume of air moved during a normal breath on quiet respiration
31
Inspirations reserve volume(IRV)
Maximum volume of air inhaled after normal inspiration
32
Expiratory reserve volume (ERV)
Maximum volume of air exhaled after normal exhalation
33
Residual volume(RV)
Volume of air left in lungs after maximal expiration(Calculated)
34
Functional residual capacity(FRC)
Volume of air in lungs at the end of a normal expiration
| RV+ERV=FRC
35
Inspiratory capacity (IC)
Maximum volume of air that can be inhaled
| TV + IRV= IC
36
Vital Capacity (VC)
Maximum volume of air traffic hat can be exhaled after maximal inspiration
IC+ERV=VC
37
Forced Vital Capacity(FVC)
Maximum volume of air that can forcibly exhaled after maximum inspiration
IC+ERV=FVC(forced)
38
Total Lung Capacity (TLC)
Volume of air in lungs after maximal inspiration
VC+RV=TLC
TV+IRV+ERV+RV=TLC
39
Forced Expiratory Volume in 1 second(FEV-1)
Amount of air forcefully exhaled in 1 second
40
FEV1/FVC ratio
FEV1 divided by FVC used to determine restrictive vs obstructive disease
41
Forced Expiratory Flow/Peak Flow(FEF)
Measure of how fast exhalation is
42
Pre and Post bronchodilator Spirometry
Evaluate for reversibility of obstructive disease(Asthma)
| Considered reversible if FEV1 increase by 12 % or 200mL
43
Bronchoprovocation test
To determine if airway hyperreactivity is present-inducing an asthma attack(Methacholine challenge)
44
Normal FEV1/FVC
>70%
45
Restrictive diseases-PFT findings
Reduced TLC, FRC ERV and RV
| INcreased/Normal FEV1/FVC
46
Obstructive disease PFT findings
Increased TLC, ERV, RV
| Reduced FEV1/FVC
47
Severity of Obstructive Lung disease
| GOLD Criteria
Stage I-Mild-FEV1/FVC<70%, FEV1>80%
Stage II- Moderate- FEV1/FVC<70%, FEV1 50-80%
Stage III- Severe- FEV1/FVC <70%, FEV1 30-50%
Stage IV- Very Severe- FEV1/FVC <70%, FEV1 <30%
48
Decreased diffusion Capacity
```
Obstructive(COPD, Cystic FIbrosis)
Parenchyma lung disease(sarcoidosis, asbestosis, interstitial lung disease)
Systemic Disease(Connective tissue disease, Scleroderma, rheumatoid arthritis, Lupus)
```
49
Increased Diffusion Capacity
Exercise
| Polycythemia
50
Pulmonary rehab activities
```
Social activity
Exercise
Nutritional support
Pharmacotherapy
Education on disease process
Smoking Cessation
Psychosocial support
Outcome assessment
```
51
Pneumonia
Acute infection of the pulmonary parenchyma
52
Types of pneumonia
Community acquired
Hospital/nosocomial/ventilator
Aspiration
53
Virulence factors of pneumonia causing bacteria
Strep Pneumonia- produces pro teases that split IgA
| Chlamydia Pneumonia- ciliostatic factor
54
Viral pneumonia
Difficult to determine
RSV, parainfluenza, adenovirus
Flu Aand B- more likely to weaken lungs/immune system for secondary bacterial infection
55
Fungal Pneumonia
Think immunocompromised
Histoplasmosis- Midwest-US travel Hx
Coccidioides app-AZ, CA,NM, TX
Cryptococcus-Found in soil
56
Pneumonia S and Symptoms
```
Cough +/- sputum
Fever
Dyspnea
+/- Pleuritic chest pain
+/- chills
+/-rigor
+/- hemoptysis
```
57
Pneumonia Physical exam
```
Febrile
RR>24
Tachycardia
Lung SOunds-Crackles
+/- egophony
+/- tactile fremitis
```
58
Pneumonia Diagnostic findings
CBC- Leukocytosis with a left shift
CXR-Lobar consolidation, interstitial infiltrates,+/-cavitation(based on pathogen) if non-diagnostic consider CT Chest
+/- blood cultures(hospitalized)
Sputum with gram stain and culture
Urinary antigen(ICU-testing legionella and Strep pneumoniae)
Procalcitonin-Distinguish between viral/bacterial
59
Treating CAP outpatient/inpatient
```
Severity(CURB65/PSI)
ABility to maintain oral intake
Compliance
Hx Substance abuse
Mental illness
Cognitive impairments
Living situation
Functional status
```
60
Curb 65
```
Point for
-Confusion
-BUN>20mg/dL
-RR>30
-BP<90/60
-Age>/=65
2 or more points hospitalization
```
61
PSI(Pneumonia Severity Index)
More than 70 points =hospitalization
62
Outpatient Treatment of CAP with otherwise healthy Pt
Macrolide(Azithromycin 500mg, then 4 days of 250mg daily)
| Or Doxycycline
63
Outpatient treatment of CAP with Pt with commorbidities
Commorbidities(Chronic Heart, lung, renal disease, DM, ETOH abuse, malignancy, asplenia or immunosupressed)
Respiratory Fluoroquinolone(Levofloxacin Oral/IV 750 mg qday for 5-7 days or afebrile for 48-72 hrs whichever is longer)
Or
Macrolide and a betalactam
(Azythromycin 500mg and 250mg q day x 4 days)
(Amoxicillin clavulanate ER 2 g q 12 hrs for min of 5 days
64
Treatment of CAP inpatient nonICU
```
Respiratory Fluoroquinolone(Levofloxacin 750 mg qday PO/IV min of 5 days)
Or Anti-pneumoncoccal beta lactate(Ceftriaxone)plus a macrolide(Azyrthomycin 500mg qday x 3 days PO/IV)
```
65
CAP in hospital treatment with concern for MRSA
Add Vancomycin or Linezolid
66
Pneumonia prevention
2 vaccines
Prevnar 13-for Pts>6weeks-can have injection site RXN,fever, decrease appetite, irritability, diarrhea, rash
Pneumovax 23-Age>2yrs, can cause-fever, myalgia, severe local and systemic RXN
67
Who should get pneumonia vaccinations
>65
19-64 with-smoker, Nursing home, heart dis, asthma, COPD, liver dis, DM alcoholic, immunocompromised, CSF leaks, Cochlear implants
68
Bronchitis
Self limiting inflammation of bronchi-Cough>5days(1-3weeks)
69
Bronchitis S and S
Cough>5days up to 3 weeks
+/-sputum
Virus
Rarely Bacterial
70
Viral Causes of Bronchitis
```
Flu A and B
Parainfluenza
Coronavirus(1-3)
Rhinovirus
RSV
Human metapneumovirus
```
71
Rare Bacterial causes of Bronchitis
Mycoplasma pneumonia -kids cough 4-6 weeks
Chlamydia pneumonia-college students Pharyngitis, laryngitis, hoarse voice, low grade fevers
Bordetella pertussis(include if long term cough)-whooping cough, posttussive emesis
72
Bronchitis exam and labs
```
Normal exam
May have wheezes or honcho-clear with cough
CXR-normal
No egophony or vocal fremitus
CBC-normal WBC(may have slight elevation in Lymphocytes)
Rapid flu/PCR/culture
Pertussis PCR
Procalcitonin
```
73
Bronchitis treatment
```
Symptomatic
-NSAIDs, ASA, APAP, Ipratropium
-Cough suppressants
-OTC decongestants/antihistamines/guaifenesin
AVOID ANTIBIOTICS
```
74
Bronchiectasis
Inflamed, easily collapsible airway obstruction resulting in chronic daily cough with viscous sputum
75
Bronchiectasis Epi/patho
```
INcreased risk with increased age
Women>men
Cystic Fibrosis
Infectious insult
Impaired drainage, airway obstruction or defect in host defense
```
76
Pathogen most likely to cause chest cavitation on a CXR
Pseudomonas aerguginosa
77
Significant risk factor for Pseudomonas aeruginosa caused pneumonia
Hx of structural lung disease
78
Significant risk factor for MRSA
Use of H-2 blocker
| Also pneumonia after Recent completion of antibiotics think MRSA
79
Bronchiectasis Etiology
```
Foreign body aspiration/airway obstruction
Defective host defense
Cystic fibrosis
Rheumatic diseases
Dyskinesia cilia
Pulmonary infections
Smoking
```
80
Bronchiectasis Clinical features
```
A daily cough
Productive mucopurulent sputum
Lasts months to years
Dyspnea
Wheezing
Pleuritic chest pain
```
81
Bronchiectasis physical exam
Crackles
Wheezing
+/- clubbing
82
Bronchiectasis Diagnostic findings
Chest CT-Diagnostic study of choice
CXR-linear atelectasis with dilated thickened airways
CBC
Immunoglobulin quantitation
Swear chloride test/mutation analysis for CF
Sputum smear
PFT-Obstructive impairment, decreased or normal FVC, Low FEV1, Low FEV1/FVC
83
Treatment of Bronchiectasis
Treat underlying cause(rare)
Acute exacerbation-Oral antibiotics(no sputum start Fluoroquinolone otherwise treatbased on culture) x 14 days
Hospitalize if RR>25, Hypotensive, Temp>38, Hypoxemia
Chronic-Mucolytic agents, airway clearance(chest physiotherapy), suppressive antibiotics, SUrgery(lung resection), Lung transplant
84
Lung abscess
Necrosis of the pulmonary parenchyma caused by microbial infection(Necrotizing Pneumonia)
85
Acute Lung Abscess
Less than1 month
86
Chronic Lung abscess
Greater than 1 month
87
Lung Abscess Primary Cause
ASpiration
88
Lung abscess secondary cause
Neoplasm
| Systemic Disease that compromises immune defenses(HIV, Organ transplant)
89
Lung abscess Patho
Often anaerobic
ASpiration- typical source is gingiva(poor dentition)
Bacteria not cleared normally(substance abuse or anesthesia)
Pneumonia develops
Tissue necrosis starts 7-14days later
90
Lung abscess bacteria
```
Anaerobes
-Peptostreptoccus
-prevotella
-Bacteroides
-Fusobacterium
Nonanerobes
-Strep milleri
-Staph Aureus
-Klebsiella
-Gram neg bacilli
-Strep Pyogenes
-H influenza
-Legionella
-Pseudomonas aeruginosa(immunocompromised)
```
91
Lung abscess clinical features
```
Indolent over weeks to months
Fever
Cough+/- sputum
Putrid/sour tasting sputum
NIght sweats
WEight loss
Anemia
Hemoptysis
Pleurisy
```
92
Lung ABscess clinical features
Chest X-ray-Infiltrate with cavity
| Chest CT- determine location
93
Lung abscess treatment
Anaerobic
Beta lactam-beta-lactamase inhibitor(Ampicillin-sulbactam 3 g IV q 6hrs
Carbapenem(Imipenem)
Typically 3 weeks or until CXR shows small stable residual lesion
94
Pertussis aka Whooping cough eti/patho
INfants less than 12 months(can be fatal)
Gram negative coccobacillus-Bordetella pertussis
Transmitted by respiratory droplets
HUman reservoir
INcubation 1-3 weeks(10 days)
Adheres to ciliated epithelium then proliferates and disseminates, localized to epithelium only
95
3 stages of pertussis
Catarrhal
Paroxysmal
Convalescent
96
Catarrhal Phase
7-10 days
Indistinguishable from a viral URI
Gradually becomes more severe as it enters paroxysmal phase
97
Paroxysmal Phase
1-6 weeks up to 10
Cough increases over 1-2 weeks, plateaus for 2-3 and gradually decreases
Paroxysmal cough(burst of numerous coughs with one inspiration)
Long inspiratory gap with High pitched Whoop
Posttussive emesis
Sputum +/- purple to
98
Convalescent Phase
Paroxysms less common
| Cough resolves over 2-3 weeks
99
Atypical presentation of pertussis in young infants
Feeding difficulties
Apnea
Cyanosis
100
Pertussis complications
Bacterial pneumonia MC in kids, MC cause of death
101
Diagnostic tests for Pertussis
CBC w/diff-Leukocytosis with lymphocytosis(degree of lymphocytosis parallels severity) Lymphocytosis even though bacterial cause due to only infecting epithelium
CXR-may have subtle changes
Have high index of suspicion
Clinical case definition
Confirmatory tests(Culture, PCR, serology)
102
CLinical case def of pertussis
```
Cough illness >2 weeks
Plus one of
-Paroxysms of cough
-Inspiratory whoop
-posttussive emesis w/o other causes
```
103
Pertussis bacterial culture
Gold standard-nasopharyngeal secretion swab x 10 sec
104
Pertussis PCR
Vary results
| Posterior nasopharyngeal swab
105
Pertussis Serology
Anti bodies detected in 1-2 weeks of symptoms
Most reliable to compare acute to convalescent-not practical clinically
Better to test single time 2 weeks post onset for IgG, high tiger.2 years after vaccine supports infection
106
Diagnosing Pertussis
```
Clinical case def
Confirm with tests
<2 weeks:culture and PCR
>2 weeks: PCR and serology
>4 weeks:serology only
```
107
Pertussis treatment
Best to treat during catarrhal phase up to 3 weeks of cough
-most contagious
-decreases severity
Treat if symptoms <3-4 weeks
INfants and pregnant treat <6 weeks
Health care workers treat <8 weeks
Macrolides(azythromycin 500 mgx1 then 250 mg qday x 4 days)
TMP-SMX(Bactrim)DS BID x 14 days(not for pregnant or nursing)
108
Pertussis Pt education
Describe disease
Pharmacotherapy
Fluids, rest Isolation
Public health(prophylaxis and reportable)
109
Pertussis prophylaxis
Close contacts
High risks of severe complications
Use full course of ABx
Watch for 21 days
110
Pertussis isolation
No school or healthcare work for 5 days of treatment or 21 days of symptoms
Public health will determine
111
Seasonal influenza transmission
Large droplets-coughing or talking
Shedding highest 1/2-1 day after exposure
INcubation 1-4 days
112
Influenza CLinical presentation
Systemic-Fever myalgias, headache, malaise
Upper resp-Sore throat, nose congestion
Lower resp-Cough
Will have both upper and lower resp tracts involved
Physical exam-Hyperemia, +/-cervical adenopathy
Abrupt onset of systemic and resp symptoms
Gradual improvement over 2-5 days to a week
113
Influenza complications
MC- Pneumonia-(Primary viral pneumonia, more severe persistence high Fever and other s and s)(Secondary-bacterial pneumonia MC, Strep and then staph)
114
INfluenza Clinical def
Influenza like illness(ILI)
-Affects both upper and lower resp tracts
-Signs of systemic illness(fever>100, headache, myalgia, weakness)
-Not attributed to other causes
Confirmation needed for high risk Pt
115
Influenza confirmation
Needed for High risk Pt and severe case/complications
116
Diagnostic testing for Influenza
Rapid antigen testing(In clinic)
Reverse transcriptase PCR(send out)
VIral culture(not useful in clinic)
117
Influenza treatment
Neuraminidase inhibitors
-Oseltamivir-tamiflu 75 mg BID x 5 days-
-Side effects- N/V/D
Shortens duration of influenza symptoms 1-3 days if given with in 24-36 hrs
118
Influenza prophylaxis treatment
Oseltamivir 75 mg x7 days for high risk Pts who have been vaccinated
X 14 days for high risk Pt who have not been vaccinated prior
