Pulmonology Flashcards
ABG-Atrial Blood Gas
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
Acidosis
pH<7.35
Alkalosis
pH>7.45
Respiratory Acidosis
Decreased pH
increased PaCO2
Normal HCO3-
Respiratory Alkalosis
Increased pH
Decreased PaCO2
Normal HCO3-
Metabolic Acidosis
Decreased pH
Normal PaCO2
Decreased HCO3-
Metabolic Alkalosis
Increased pH
Normal PACO2
Increased HCO3-
Differential Diagnosis for Cough
Asthma COPD Interstitial lung disease Malignancy Chronic pneumonia Pleural effusion GERD Chronic allergic Rhinitis Medication(ACEI-BB)
Differential Diagnosis for Dyspnea
Flash pulmonary edema PE Anaphylaxis Aspiration Cardiac tamponade/effusion COPD exacerbation vs chronic Acute/chronic pneumonia Respiratory muscle weakness Spontaneous/Tension Pneumonthorax Metabolic Acidosis
Differential Diagnosis for Hypoxemia
Asthma COPD CHF PE Pneumonia Pneumothorax
Differential Diagnosis for Sputum Production
Cardiogenic pulmonary edema Acute Pneumonia Bronchitis Lung abscess Bronchiectasis Lung Cancer
Differential Diagnosis for Hemoptysis
Bronchitis Lung Cancer Bronchiectasis Cryptogenic Pneumonia Tuberculosis
Differential Diagnosis for Clubbing
Lung Cancer
Interstitial lung disease
Mesothelioma
Cystic fibrosis
Chest Xray Systematic approach
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
Pleural Effusion
Fluid that accumulates between pleural layers(OUTSIDE lung tissue)
Pulmonary Infiltrate
Consolidation
Fluid or material fill the space within the lungs(INside the lungs)
Common Causes of pleural effusion
Lung cancer-Pneumonia-TB-Trauma-Drug RXN, abestosis, sarcoidosis
Common causes of pulmonary infiltrate
Pneumonia-pulmonary edema-cystic fibrosis-TB-trauma
IV contrast use for CT
Evaluate cancer in Liver, kidneys and brain
Better evaluate blood vessels, vascular soft tissues, organs and tumors
Iodine contrast dye adverse rxn
Vomiting, resp symptoms, pain, urticaria, burning, allergy
Ask about Hf of RXN, Iodine allergy, Diabetes, Vascular disease, RENAL DYSFUNCTION
VQ scan
Scan that uses radioactive material to examine airflow and blood flow-DIagnose PE especially for pregnant or before lobe resection in lung cancer
D-Dimer
HIgh sensitivity
Low Specificity
Pulmonary angiogram
Used to visualize large PE, aid in direct thrombosis, Identify sites of bleeding to place coils
Indications for pulmonary function tests
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
Obstructive lung disease causes
Alph 1 anti trypsin deficiency Asthma Bronchiectasis Bronchiolitis obliterans COPD Cystic fibrosis Early Silicosis
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
Contraindications for PFT
Recent chest pain or MI
Recent or untreated pneumothorax
PE in last 3 month
Recent surgery-Eye, chest, lung
Pulmonary function test include
Spirometers, Lung volume determination(Body Plethysmography)Diffusion capacity
And frequently an ABG
Normal PFT values
Vary with age, sex, race and height
Tidal volume
Volume of air moved during a normal breath on quiet respiration
Inspirations reserve volume(IRV)
Maximum volume of air inhaled after normal inspiration
Expiratory reserve volume (ERV)
Maximum volume of air exhaled after normal exhalation
Residual volume(RV)
Volume of air left in lungs after maximal expiration(Calculated)
Functional residual capacity(FRC)
Volume of air in lungs at the end of a normal expiration
RV+ERV=FRC
Inspiratory capacity (IC)
Maximum volume of air that can be inhaled
TV + IRV= IC
Vital Capacity (VC)
Maximum volume of air traffic hat can be exhaled after maximal inspiration
IC+ERV=VC
Forced Vital Capacity(FVC)
Maximum volume of air that can forcibly exhaled after maximum inspiration
IC+ERV=FVC(forced)
Total Lung Capacity (TLC)
Volume of air in lungs after maximal inspiration
VC+RV=TLC
TV+IRV+ERV+RV=TLC
Forced Expiratory Volume in 1 second(FEV-1)
Amount of air forcefully exhaled in 1 second
FEV1/FVC ratio
FEV1 divided by FVC used to determine restrictive vs obstructive disease
Forced Expiratory Flow/Peak Flow(FEF)
Measure of how fast exhalation is
Pre and Post bronchodilator Spirometry
Evaluate for reversibility of obstructive disease(Asthma)
Considered reversible if FEV1 increase by 12 % or 200mL
Bronchoprovocation test
To determine if airway hyperreactivity is present-inducing an asthma attack(Methacholine challenge)
Normal FEV1/FVC
> 70%
Restrictive diseases-PFT findings
Reduced TLC, FRC ERV and RV
INcreased/Normal FEV1/FVC
Obstructive disease PFT findings
Increased TLC, ERV, RV
Reduced FEV1/FVC
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%
Decreased diffusion Capacity
Obstructive(COPD, Cystic FIbrosis) Parenchyma lung disease(sarcoidosis, asbestosis, interstitial lung disease) Systemic Disease(Connective tissue disease, Scleroderma, rheumatoid arthritis, Lupus)
Increased Diffusion Capacity
Exercise
Polycythemia
Pulmonary rehab activities
Social activity Exercise Nutritional support Pharmacotherapy Education on disease process Smoking Cessation Psychosocial support Outcome assessment
Pneumonia
Acute infection of the pulmonary parenchyma
Types of pneumonia
Community acquired
Hospital/nosocomial/ventilator
Aspiration
Virulence factors of pneumonia causing bacteria
Strep Pneumonia- produces pro teases that split IgA
Chlamydia Pneumonia- ciliostatic factor
Viral pneumonia
Difficult to determine
RSV, parainfluenza, adenovirus
Flu Aand B- more likely to weaken lungs/immune system for secondary bacterial infection
Fungal Pneumonia
Think immunocompromised
Histoplasmosis- Midwest-US travel Hx
Coccidioides app-AZ, CA,NM, TX
Cryptococcus-Found in soil
Pneumonia S and Symptoms
Cough +/- sputum Fever Dyspnea \+/- Pleuritic chest pain \+/- chills \+/-rigor \+/- hemoptysis
Pneumonia Physical exam
Febrile RR>24 Tachycardia Lung SOunds-Crackles \+/- egophony \+/- tactile fremitis
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
Treating CAP outpatient/inpatient
Severity(CURB65/PSI) ABility to maintain oral intake Compliance Hx Substance abuse Mental illness Cognitive impairments Living situation Functional status
Curb 65
Point for -Confusion -BUN>20mg/dL -RR>30 -BP<90/60 -Age>/=65 2 or more points hospitalization
PSI(Pneumonia Severity Index)
More than 70 points =hospitalization
Outpatient Treatment of CAP with otherwise healthy Pt
Macrolide(Azithromycin 500mg, then 4 days of 250mg daily)
Or Doxycycline
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
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)
CAP in hospital treatment with concern for MRSA
Add Vancomycin or Linezolid
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
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
Bronchitis
Self limiting inflammation of bronchi-Cough>5days(1-3weeks)
Bronchitis S and S
Cough>5days up to 3 weeks
+/-sputum
Virus
Rarely Bacterial
Viral Causes of Bronchitis
Flu A and B Parainfluenza Coronavirus(1-3) Rhinovirus RSV Human metapneumovirus
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
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
Bronchitis treatment
Symptomatic -NSAIDs, ASA, APAP, Ipratropium -Cough suppressants -OTC decongestants/antihistamines/guaifenesin AVOID ANTIBIOTICS
Bronchiectasis
Inflamed, easily collapsible airway obstruction resulting in chronic daily cough with viscous sputum
Bronchiectasis Epi/patho
INcreased risk with increased age Women>men Cystic Fibrosis Infectious insult Impaired drainage, airway obstruction or defect in host defense
Pathogen most likely to cause chest cavitation on a CXR
Pseudomonas aerguginosa
Significant risk factor for Pseudomonas aeruginosa caused pneumonia
Hx of structural lung disease
Significant risk factor for MRSA
Use of H-2 blocker
Also pneumonia after Recent completion of antibiotics think MRSA
Bronchiectasis Etiology
Foreign body aspiration/airway obstruction Defective host defense Cystic fibrosis Rheumatic diseases Dyskinesia cilia Pulmonary infections Smoking
Bronchiectasis Clinical features
A daily cough Productive mucopurulent sputum Lasts months to years Dyspnea Wheezing Pleuritic chest pain
Bronchiectasis physical exam
Crackles
Wheezing
+/- clubbing
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
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
Lung abscess
Necrosis of the pulmonary parenchyma caused by microbial infection(Necrotizing Pneumonia)
Acute Lung Abscess
Less than1 month
Chronic Lung abscess
Greater than 1 month
Lung Abscess Primary Cause
ASpiration
Lung abscess secondary cause
Neoplasm
Systemic Disease that compromises immune defenses(HIV, Organ transplant)
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
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)
Lung abscess clinical features
Indolent over weeks to months Fever Cough+/- sputum Putrid/sour tasting sputum NIght sweats WEight loss Anemia Hemoptysis Pleurisy
Lung ABscess clinical features
Chest X-ray-Infiltrate with cavity
Chest CT- determine location
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
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
3 stages of pertussis
Catarrhal
Paroxysmal
Convalescent
Catarrhal Phase
7-10 days
Indistinguishable from a viral URI
Gradually becomes more severe as it enters paroxysmal phase
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
Convalescent Phase
Paroxysms less common
Cough resolves over 2-3 weeks
Atypical presentation of pertussis in young infants
Feeding difficulties
Apnea
Cyanosis
Pertussis complications
Bacterial pneumonia MC in kids, MC cause of death
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)
CLinical case def of pertussis
Cough illness >2 weeks Plus one of -Paroxysms of cough -Inspiratory whoop -posttussive emesis w/o other causes
Pertussis bacterial culture
Gold standard-nasopharyngeal secretion swab x 10 sec
Pertussis PCR
Vary results
Posterior nasopharyngeal swab
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
Diagnosing Pertussis
Clinical case def Confirm with tests <2 weeks:culture and PCR >2 weeks: PCR and serology >4 weeks:serology only
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)
Pertussis Pt education
Describe disease
Pharmacotherapy
Fluids, rest Isolation
Public health(prophylaxis and reportable)
Pertussis prophylaxis
Close contacts
High risks of severe complications
Use full course of ABx
Watch for 21 days
Pertussis isolation
No school or healthcare work for 5 days of treatment or 21 days of symptoms
Public health will determine
Seasonal influenza transmission
Large droplets-coughing or talking
Shedding highest 1/2-1 day after exposure
INcubation 1-4 days
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
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)
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
Influenza confirmation
Needed for High risk Pt and severe case/complications
Diagnostic testing for Influenza
Rapid antigen testing(In clinic)
Reverse transcriptase PCR(send out)
VIral culture(not useful in clinic)
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
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
