Pulmonology Flashcards
What are the best tests during an asthma exacerbation?
Peak expiratory flow
ABG - inc PCO2
Severity can be quantified by the decrease in PEF compared to baseline and the A-a gradient
Normal or high CO2 means patient is not compensating/not hyperventilating which indicates impending respiratory failure
Indications for O2 in COPD
PaO2 < 55 or sat < 88%
IF R heart failure or PV or pulmonary HTN … then PaO2 < 60 or sat < 90%
What medication delays progression of COPD?
Nothing
When would you use theophylline or roflumilast?
last resort to avoid having to use oral steroids when patient is not controlled w/ SABA + LABA + LAMA and inhaled steroid
ABPA Findings and Tx
- brown flecked sputum
- transient infiltrates on CXR
- eosinophilia in serum, IgE
TX = oral steroids not inhaled if severe, itraconazole if recurrent episodes
Sweat Test Pos for CF
If > 60 mEq/ L
4 Common Microbes on Sputum Cx in CF
1 - non-typable H flu
2- staph aureus
3- pseudomonas
4- burkholderia
Inpatient v. Outpatient Tx of CAP
Outpatient - azithromycin OR doxy
Outpatient if co-morbidities or abx in last 3 mo - levofloxacin or moxifloxicin
Inpatient - levofloxacin/moxi OR cetriaxone + azithromycin
CURB65
Reason for Admission in Pneumonia (if 2+)
- confusion
- uremia
- resp distress
- BP (hypotension)
- > 65 yo
Tx HAP
Def - after 48 hrs in hospital or if discharged < 90 days ago
Cover E coli and Pseudo
- piperacillin tazo
- imipenem or meropenem
- cefepime or ceftazidime
Tx of VAP
Purulent secretions + fever/WBC on vent
3 DRUG COMBO
1 (anti-pseudo) - cefepime. pip-tazo, imipenem
2- (anti-pseudo) - gentamicin/amikacin OR cipro/levo
3- (MRSA) - vanco or linezolid
Pneumonia Vaccination
Normally in 65 + yo (13 then 23 6-12 months later)
If given before age 65 because underlying lung, liver, kidney disease then give second dose 5 yrs after first
PCP (findings, tx, ppx, allergy options)
Findings - Inc LDH, patchy bilateral infiltrates, cx BAL
Tx - bactrim + steroids if A-a gradient > 35 or PO2 < 70
Other Tx Options (allergies) -
- clindamycin and primaquine
- Pentamidine
PPX - bactrim once CD4 < 200 (can stop if increases above 200 again)
- can use atovaquone or dapsone if allergy
**dapsone and primaquine also cause hemolysis in G6PD
Tb Testing
IGRA = PPD (sensitivity)
IGRA - one visit; no cross reaction w/ vaccine
If either is positive … get CXR
Pos PPD
- 5 cm if HIV, steroid use, close contact w/ active tb, organ transplant, calcification on CXR
- 10 cm if immigrant, prisoner, healthcare worker, close contact w/ latent tb, heme malignancy, CM, alcoholic
- 15 cm no risk factors
Tb Tx Considerations
RIPE 2 mo, RI 4 mo if active (pos CXR)
9 mo isoniazid or 12 wks isoniazid + rifampetine if inactive (neg CXR)
All cause hepatotoxicity (stop if LFTs 3-5X ULN)
Give pyridoxine w/ isoniazid
How do you treat MAC?
Azithromycin (same as PPX)
+ rifampin and ethambutol
Drugs that can cause pulmonary fibrosis (7)
bleomycin
busulifan
amiodarone
methysergide
nitrofurantoin
cyclophosphamide
methotrexate
What 2 meds can dec rate of progression in idiopathic pulmonary fibrosis?
Pirfenidone - anti fibrotic, inhibits collagen synthesis
Nintedanib - tyrosine kinase inhibitor, blocks growth factors and fibroblasts
What is the most common CXR finding in PE? What is the most common EKG finding in PE?
CXR - atelectasis
EKG - sinus tachycardia, non-specific ST changes
How do you treat PE?
Enoxaparin (LMW heparin) –> bridge to warfarin
or NOAC if hemodynamically stable (rivaroxaban, apixaban, edoxaban, dabigatran)
Indications for IVC Filter
Contraindication to anti-coagulation (CNS bleed)
Recurrent emboli while therapeutic A/C
RV dysfunction so bad that next embolus no matter how small would be fatal
NOAC Reversal Agents
Andexanet alfa - for rivaroxaban, apixaban, edoxaban
Idarucizumab - for dabigatran
Warfarin Reversal Agent
Prothrombin complex concentrate
When do you thrombolytics for PE?
If unstable (systolic < 90 and tachycardia)
When do you use direct-acting inhibitors?
HIT (heparin induced thrombocytopenia)
Ex) argatroban
Heart Sounds in Pulmonary HTN
wide splitting of P2
loud P2
may have pulmonic or tricuspid insufficiency
Drug Classes for Idiopathic Pulmonary HTN
prostacyclin analogues - epoprostenol, teprostinil, iloprost (-PROST)
endothelin antagonists - bosentan (- ENTAN)
PDE inhibitors - sildenafil
cGMP stimulator - riociguat
Ca channel blockers
ARDS Dx and Tx
Dx - Po2/FIO2 < 300 (more severe if < 100), bilateral white out, not due to CHF (normal wedge pressure)
Tx - PEEP so that you can have lower FIO2 (oxygen is toxic) + low tidal volume (6 mL per kg)
