Pulmonology Flashcards
Status asthmaticus
Medical emergency: An extremely severe asthma attack
Severe dyspnea accesory muscle use
Absent lung sounds
DX of asthma
PFTs: Dec FEV1 / FEV
reversed with bronchodialators
Methacholine challenge if normal at time of test
Not for DX but likely to have eosinophilia / allergen skin testing / atopy
FOr excrcise induced asthma with known triggers, you can use :
Cromolyn sulfate
or
Nedocromil
When someone arrives to ED with likely asthma exacerbation, how do you work them up?
Treatment?
What to do after treatment?
If refractory or severe?
When to intubate?
PE BMP (CO2 retention) ABG PEFR (Peak expiratoryy flow rate) CXR (to rule out other causes of dyspnia)
O2
Duonebs (Albuterol / ipratropium)
Corticosteroids
Repeat after initial tx: BMP (CO2 retention) ABG PEFR Sats
If refractory or severe: Racemic Epi nebs SubQ epi IV mag
Intubate if:
Rising CO2 Decreasing pH
absence of lung sounds
In ER, after you treat asthma, what to do with them
after 3 hours of neb tx:
No imp- ICU
Total imp - home
anywhere inbetween gets admitted (steroids and nebs)
Classification of asthma
Intermittent:
<2/wk <2/month
Mild persistant:
>2/wk >2/month
Moderate persisitant:
Daily >1 / wk
*Start seeing drops below 80% of FEV1
Severe
Daily Daily
Treatment for each classification of asthma
Intermittant - SABA
Mild persistant - ICS
Moderate Persistant - LABA OR Leukotriene inhib
Severe persistant - inc ICS dose
Refractory - PO steroids
Stats of COPD
20% of smokers get COPD but 90%of COPDers were smokers
Genetic (alpha 1) and environmental factors influence the disease
Chronic Bronchitis Definition
productive cough >3 months of two consectutive years
Sequllae of COPD
Cliliary loss Inc mucouse Smooth muscle hypertrphy (narrowning) Loss of elasticity *Inc pulmonary htn
RF for COPD
Presentation of COPDer (lots)
Labs
CXR
Smoking (40 Pyear
Age >45
Chronic cough Smoker Cyanosis (blue) Edema / RHF / Clubbing air trapping / barrel chest pursed lips/ prolonged exp Weight loss* accesory muscle use*
Labs -
ABG:
Low 02
high CO2
PFT: dec FEV1, Dec FEV1/FVC
CBC inc RBCs.
RAD/RVH in ECG from core pulmonale
CXR
Flattened diaphragm
translucent lung fliedls
COPDER acronym
an aconym to recall all treatments and goals for COPD patient
C corticosteroids - no change in mortality UNLESS infection
O oxygen (saves life)
P prevention (pneumovax Q5yr, flu shot, smoking cessation) savesl lifes
D dialation
E - skip
R - rehab - excercise - increases tolerance. no change in mortality
Profession of COPD treatments
First line:
SABA
LAMA (ipro / tio)
02 as needed
Steroids - IV or PO depending on severity
Intubate / ventilate
COPD exacerbation
SIgns
Signs: drop in CO2 or inc in cough prod
O2 (dont stress dec in hypoxic drive here)
Duonebs (ipra / alb)
IV steroids (no taper is req for COPD)
ABX if purulent sputum* / if sputum increased.
- amoxicillin
- TMPSMX
- Doxy
- Azithro
VIrchows Triad
Venous Stasis
Hypercoagulable State
Endothelial Damage
RF for PE
Stasis Recent Surgery Hypercoagulable disorder -Cancer -OCP -genetic dx
THere are no valves in deep veins!
WOW
Usually in popliteal or femoral veins
How does even a small clot cause dyspnia in PE?
How are large clots different than small ones on workup?
What will ABG look like on PE?
Small clot will release platelet derived mediators that cause lung wide inflamation - fluid will leak around alveoli.
Larger clots will cause right heart strain
ABG - CO2 can be blown off, but O2 cant exchange.
Low O2, normal CO2
Presentation of PE
SOB
Tachypnia
Tachycardia
Leuritic CP
Clear chest XR*
One leg with larger circumference
Wells Criteria
SCores
Score interpretation - what tests to do
What if cant get CTA?
Helps decide what type of test to do and how to treat it.
Clinical signs and sxs of DVT 3
DVT is first or equally likely 3
HR>100 1.5
Immob / surg in last three days 1.5
Prev DVT/PE 1.5
Hemoptysis 1
Cancer in last 6 months 1
Score interpretation:
4 or under - D dimer
5 or more - CTA
No CTA? (renal dz) get VQ scan
TX of PE
How long for heparin bridge
alternate adv/ disadv
If massive
Heparin to warfarin
or
NOAC (no reversal, BID but no monitoring)
TPA if massive
HIT from heparin
low platelets
7 days of first exposure, 3 days on repeat
draw HIT panel
stop hep, give argatroban
Overview of Transudate vs exudate
Unlateral vs Bilat?
Transudate - dec oncotic P vs inc hydrostatic P
-usu bilateral
Exudate - stuff in space is drawing fluid
-usu unulat
Puleural effusion Presentation Dx Next step for analysis When you can do throacentesis
Presentation
SOB
Pleuritic CP
DX
CXR - blunting of costovertebral angle, (needs 250cc)
Then get recumabnt Xray - will see if loculated.
If free moving and above 1cm from chest wall to fluid level, can do thoracentesis.
Lights criteria
Criteria for analizing thoracentesis fluid. transudate vs exudate
“Fluid comes first”
(Extracted / serum)
it is an exudate IF:
fLDH/sLDH > 0.6
fProt/sProt > 0.5
LDH >2/3 upper limit of normal * (200)
If it is an Exudate, must get Glucose, amylase, Cel count, cultre, gram stain, AFB / TB antigen, RF, CCP, ANA
If loculated and not free flowing on recumbant X ray?
Consult surg for possible VATS vs TPA vs thorocotomy
If CHF and plural effusion….
Skip tap, and diuresis
DDX for Transudate
DDX for Exudate
Transudate Inc hydrostatic -CHF Dec Oncotic -Nephrosis, Cirrhosis, Gastrosis
Exudate
- Malignancy
- PNA
- TB
Screening for lung cancer
Annual low dose CT scan is inidcated for indivuduals who:
Quit less than 15 years prior
55-85
Have a 30pack year hx
If a pulmonary nodule is found:
Next step
If Stable?
If unstable?
Next step - compare old
If no change in two years, it is stable
If Stable? - nothing
If unstable? - serial CT scans to monitor
- Sometimes if it looks bad (size, surface, smoke, self =age - may get bx immediately
Ways of getting BX of lung tissue
Bonchoscopy / EBUS
Percutaneous CT BX
VATS if in the middle
Thoracentisis if effusion
Lung cancer presentation
Fever
hemoptysis
weight loss
ARDS
Overview
Exam
DX (difinitive)
TX
Pulmonary edema caused by increased permiability of capiliarties.
Exam
Pt will be hypoxic
SOB / Cough / Crackles
(looks like CHF with normal heart fucntion)
Difinitive DX - Capilary wedge pressure
TX - PEEP
DDX of ARDS
GNR septicemia
burns
TRALI (transfusion related acute lung injury)
drowning
