Pulmonology Flashcards
1
Q
bronchiectasis
A
- causes: cystic fibrosis, infxn, immunodef, airway obst.
- infxn with airway obstruction or impaired defense/drainage precipitates dzs
- sxs: chronic cough with large amnts mucopurulent, foul smelling sputum, dyspnea (SOB), hemoptysis - mild, self-lmited, recurrent or persistent PNA +/- wt loss
- signs: crackles at lung bases
- dx: high resolution CT (GOLD STANDARD), PFTs (obstructive pattern), CXR (abnl, nonspecific)
- other labs: CBC (anemia)
- tx: abx (acute exacerbations), bronchial hygiene - fluids, chest physiotx, inhaled bronchodilators
2
Q
Acute/Chronic bronchitis
A
- etiology: viruses (most), cannot distinguish acute bronchitis from URTI in first few days
- sxs: cough >5d (+/- sputum), lasts 2-3wks
- chest discomfort
- SOB
- +/- fever
- dx: labs not indicated, unless pneumonia suspected (HR >100, RR >24, T >38C, rales, hypoxemia, mental confusion, or systemic illness)
- CXR
- Tx: abx not recommended since most viral
- sxs based tx: NSAIDs, ASA, tylenol, and/or ipratropium
- abx and cough suppressants not indicated
- cough suppressants: codeine-containing cough meds
- bronchodilators (albuterol)
- abx and cough suppressants not indicated
3
Q
Asthma
A
- characteristics: airway inflammation, airway hyperresponsiveness, reversibleairflow obstruction, may begin at any age, dyspnea common when rapid changes in temp or humidity
- extrinsic: Atopic: produce IgE dt enviro triggers (eczema, hay fever), become asthmatic young
- intrinsic: not related to atopy of enviro factors
- want to see increased FEV1 >12% with albuterol
- can also see decrease in FEV1 >20% with methacholine or histamine challenge
- increase in diffusion capacity of lung for DLCO
4
Q
Asthma characteristics, signs, sxs
A
- Triggers: pollens, house dust, molds, cockroaches, cats, dogs, cold air, viral infxns, tobacco smoke, meds (BB, ASA), exercise
- sxs: SOB, wheezing, chest tightness, cough (occurs in 30 mins to exposure to triggers, sxs worse at night)
- signs: wheezing (inspiration and expiration) is the MC finding
5
Q
Asthma dx and tx
A
- Dx: CXR for first time wheezers, PFTs required to dx, spirometry before and after bronchodilators - increase in FEV1 ro FVC by 12%
- Tx 1:
- SABA for acute attacks (onset 2-5 min, lasts 4-6h
- LABA (salmeterol) for nighttime asthma and exercise induced
- ICS: moderate to severe asthma, use reg to decrease airway hyperresp.
- Tx 2:
- Montekukast: proph for mild exercised induced and control of mild-moderate, allows for reduction in steroid and B2
- Cromolyn sodium: proph before exercise
- Avoid BB in asthmatics
6
Q
Acute asthma exacerbation
A
- sxs: sweating, wheezing, speaking incomplete sentences, tachypnea, paradoxical mvmt of abdomen, use of accessory mm.
- dx: PEFR: low, severe <60
- ABG: increased A-a gradient
- CXR: ro pneumonia, pneumothorax
- tx 1: nebulizer (SABA) or MDI, IV or oral steroids, IV magnesium (prevent bronchospasm)
- complications:
- status asthmaticus: doesnt respond to standard meds
- ARDS: resp mm fatigue
- pneumothorax, atelectasis, pneumomediastinum
7
Q
Asthma classification
A
- Intermittent, mild persistent, moderate persistent, severe persistent
8
Q
COPD
A
- 4th leading cause of death in the United States
- Coexisting bronchitis and emphysema, rarely one or the other by itself
- Leads to chronic respiratoyr acidosis with metabolic alkalosis as compensation
- risk factors and causes:
- Smoking (tobacco), alpha antitrypsin deficiency, enviro factors (second hand smoke), chronic asthma
- MCC acute exacerbation: infxn, noncompliance, cardiac dz
- secondary polycythemia (response to chronic hypoxemia
9
Q
Chronic Bronchitis
A
- excess mucous narrows airways (productive cough), scarring and inflamm -> enlarged glands -> smooth m hyperplasia = obstruction
- sxs: cough, sputum, dyspnea (on exert or rest)
- signs: prolonged forced exp time, exp wheezes, dec. breath sounds, insp crackles, tachypnea, tachycardia, cyanosis, accessory mm use, hyperresonance, signs of cor pulmonale
- dx: chronic cough and sputum >3 mo, at least 2 consec years
- CXR, alpha antitryp levels, ABG
10
Q
emphysema etiology and types
A
- elastase (protease) excess and overinflation (elastasereleased from WBCs ingesting lung tissue, normally inhib by alpha antitryp.; tobacco smokeincreases WBCs, inhibits antitryp, increases oxidative stress)
- types:
- centrilobular: MC, smokers, destruction of bronchioles in upper lungs
- Panlobular: pts with alpha antityrp def.; destruction of prox and distal acini (lung bases)
11
Q
emphysema sxs, dx
A
- sxs: productive cough or chest tightness, worse in morning, clear to white sputum, 50yo typical
- dyspnea MC presents at 60yo, wheezing
- signs: tachypnea, DOE, cyanosis, JVD, atrophy of limb musculature, peripheral edema, Barrel chest (2:1 A:P), diffuse or focal wheezing, diminished breath sounds, hyperresonance
- dx: permanent enlargement of airspaces distal to terminal bronchioles dt destruction . of alveolar walls
- decreased DLCO
- PFTs (spirometry): FEV1/FVC <0.75, FEV1 decreased, TLC, residual volume, FRC increased
- Vital capacity decreased: extra air coming in is not useful - becomes dead space
- CXR
12
Q
chronic bronchitis tx
A
- smoking cessation (most important)
- albuterol (long term salmeterol for requent use of SABA)
- anticholinergics (ipratropium)
- combo of B agonist and anticholinergics
- Inhaled corticosteroids (O2 tx): long term hypoxemia leads to HTN and cor pulmonale
- pulmonary rehab: improves exercise tolerance
- IMZ: flue and strep q1y pneumo q5-6y
- surgery: lung resection vs transplant
13
Q
emphysema tx
A
- smoking cessation and home O2 are the only interventions shown to lower mortality
-
steroids and abx for acute exacerbations: increased sputum produciton or change in character or worsening SOB
- not responsive to bronchodilators, IV methylprednisolone if hosp., azithro or levo, O2>90% nasal cannula, NPPV (BiPAP or CPAP), can lead to ARDS
- Criteria for O2: PaO2 55mm Hg, O2 sat <88% (pulse ox) at rest or exercise, PaO2 55-59 + polycythemia or cor pulmonale
- look for nocturnal hypoxemia, give CPAP or O2 as needed
14
Q
COPD staging
A
15
Q
Community acquired PNA
A
- occurs when there is a defect in pulm defense mech (cough reflex, mucociliary clearance, immune response)
- urinary Ag for Strep pneumo helpful screening tool in pts w/ leukopenia, asplenia, alcohol use, chronic liver dz, pleural effusion, ICU
- urinary Ag for Legionella helpful in pts with alc use, travel previous 2 wks, pleural effusion, ICU
- broad spectrum B-lactamase species: enterobacter, klebsiella pneumo, e. coli
16
Q
community acquired PNA (pneumo PNA) in immunocompetent: etiology, RF, sxs
A
- MCC: s. pneumo, H flu, Myco PNA, S aureus, N meningitidis, M catarrhalis, K PNA, other GNR
- viruses: influenza, RSV, adeno, parainfluenza
- Occurs outside hosp or within 48hr of hosp admission
- RF: old, alcoholic, smoker, asthma, COPD
- MCC pulm dz in HIV pts
- sxs: fever, cough (with or without sputum), SOB, sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, HA< abd pain
- signs: fever or hypotherm, tachypnea, tachycardia, O2 desat, insp crackles and bronchial breath sounds, dullness to percussion
17
Q
CAP in immunocompetent: dx
A
- dx:
- imaging:
- CXR (patchy airspace opacities to lobar consolidation with air bronchograms) - not necessary in outpt bc empiric tx is effective, recommended if unusual presentation, hx, or inpt, clearing of opacities can take 6 wk or longer
- CT: more sensitive and specific
- Labs: sputum gram stain (not sensitive or specific for strep pneumo), urinary Ag test for strep pneumo and legionella, rapid Ag test for flu, pre-antibiotic sputum and blood cultures, CBC, CMP, LFTs, bilirubin, ABG in hypoxemic pts, HIV testing, procalcitonin-released by bact toxins and inhibited by viral infxn
- imaging:
18
Q
community acquire PNA in immunocompromised pts
A
- etiology: HIV (ANC <1000), current or recent exposure to myelo or immunosuppressive medications, or pts taking chronic steroids
- dx: sputum induction, BAL (r/o PCP PNA)
19
Q
Nosocomial PNA
A
- Pathogens: s. aureus, K. PNA, E. coli, pseudomonas aeruginosa
- sxs: at >/= 2 of the following: fever, leukcytosis, purulent sputum
- dx: CXR, blood cultures x2, CBC and CMP, sputum culture and gram stain (not sensitive or specific), ABG, thoracentesis if effusion, procalcitonin
20
Q
pneumocystis pneumonia
A
- pneumocystis jirovecii - caused by fungus found in lungs of mammals
- MC opportunistic infxn in HIV/AIDS
- sxs: fever, SOB, nonproductive cough, exam findings disproportionate to imaging showing diffuse interstitial infiltraties, fatigue, weakness, weight loss
- dx: CXR (definitive): diffuse or perihilar infiltrates, reticular interstitial PNA or airspace dz that mimics pulm edema (5-10%) normal CXR, absent pleural effusions)
- sputum wright-giemsa stain or DFA (direct fluorescence Ab) - definitive in 50-80%
- BAL - definitive in 95%
- CD4 <200 - if AIDS
- ABG; hypoxia, hypocapnia, reduced DLCO
- increased LDH but nonsepcific, serum B-glucan is more sensitive and specific, WBC low
- tx: Bactrim, add steroids if PaO2 <79 or A-a gradient >35 if given in 72h, dapson if sulfa allergy, all pts with CD4 <200 should undergo proph
21
Q
PNA tx: outpatient, smokers, and inpatient (non-ICU)
A
- Outpt: 5 djays minimum or until pt afebrile x48-72h
- pathogens: S pnemo, M pneumo, C pneumo, flu virus
- Previously healthy, no recent abx: macrolide (clarithro or azithro x4d), doxy
- At risk for drug resistance (old, comorbid, immunosuppress, exposure to child in daycare): respiratory FQ (moxiflox), macrolide plus B lactam
- Smokers: Cefdinir
- Inpt, non-ICU:
- Pathogens: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
- First line: Resp FQ (IV levo), or IV cipro
- If at risk for pseudomonas: IV macrolide plus IV B lactam (HD ampicillin or Ceoftaxime or ceftriaxone)
22
Q
PNA tx: hospitalized or ICU pts
A
- Duration: 5d minimum or until pt afebrile x48-72h
- ICU: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
- Previously healthy: Azithro or resp FQ (moxi or levo) plus cefotaxime, ceftriaxone, or UNASYN
- if B lactam allergy: FQ plus Aztreonam
- pts at risk for drug resistance: Antipneumococcal and antipseudomonal B lactam: Zosyn, cefepime, imipenem or meropenem PLUS:
- cipro or levo, OR, antipneumo B-lactam (cefotaxime, ceftriaxone, UNASYN) PLUS Aminoglyc (gent, tobra, amikacin) PLUS Azithro or resp FQ
- If at risk for MRSA: add vanco or linezolid
23
Q
PNA tx: nosocomial PNA
A
- previously healthy: ceftriaxone, moxi, levo, cipro, UNASYN, Zosyn, or ertapenem
- at risk for drug resistance: one agent from each:
- Antipseudomonal
- Cefepime, Impenem, Zosyn, or aztreonam (if PCN allergy)
- Second antipseudomonal
- Levo, cipro, gent, tobra, or amikacin
- MRSA coverage
- vanco or linezolid
- Antipseudomonal
24
Q
When to admit for PNA
A
- CURB-65 Score
- confusion
- uremia
- resp rate
- blood pressure
- age >65
- <1 = no hosp
- 1-2 = hosp (maybe ICU)
- 3+ = definite ICU admit
25
Pulmonary neoplasm
* Risk factors: **cigarette smoking** (\>85%) increased risk with increasing pack yrs
* *Adenocarcinoma = lowest association of smoking*
* Asbestos
* Radon
* COPD
* Metastatic dz: **brain, bone, adrenal glands, liver**
26
Small cell lung cancer
* 25%
* Sxs: **recurrent PNA, anorexia, weight loss, weakness, cough**
* Associated sxs: **superior vena cava syndrome** (facial fullness, edema, dilated veins over ant chest, arms, face, JVD, phrenic nerve palsy, recurrent laryngeal nerve palsy (hoarseness), **Horner syndrome** (unilateral facial anihdrosis, ptosis, miosis), malignant pleural effusion, **Eaton-Lambert syndrome** (similar to myasthenia gravis)
* Dx: **CXR** (not for screening), **CT chest** (staging), **bx** (histologic type), cytologic exam of sputum (central tumors), fiberoptic bronchoscope (central dz), PET scan, transthoracic bx (peripheral dz), mediastinoscopy (advanced dz)
* Tx: **chemo and radiation**
* if dz is extensive, **chemo only** and then radiation if it is responsive to chemo
* Prognosis:
* Limited: **10-13% 5y survival**
* Exstensive: 1-3% 5y survival
* Staging: limited = confined to CHEST and supraclavicular nodes (not cervical or axillary); extensive = outside chest and supraclavicular nodes
27
Non-small cell lung cancer
* Etiology: **SCC**, adeno, large cell, bronchoalveolar cell
* sxs: cough, hemoptysis, obstruction, wheezing, **pancoast syndrome** (superior sulcus tumor - shoulder pain, radiates down arm, pain and upper extremity weakness dt brachial plexus invasion, horner syndrome)
* associated sxs: paraneoplastic syndromes (SIADH, ectopic ACTH, PTH-like secretion, hypertrophic pulm osteoarthropathy)
* dx: CXR (pleural effusion) - always perform bx for intrathoracic lymphadenopathy
* tx: surgery = best option (if met outside chest, not candidate; may recur after surgery)
* Radiation: important adjunct, chemotherapy has an uncertain benefit
* staging: primary TNM staging
28
lung cancer screening
* annual screening for lung cancer with low-dose CT 55-80yo w/ 30 pack/yr hx and currently smoke or quit within past 15yrs
* discontinue screening once person stops for 15yrs or develops health prob that substantially limits life expectancy
29
Obestiy hypoventilation (pickwickian) syndorme
* severely overweight ppl fail to breathe rapidly or deeply enough resulting in low blood O2 and high CO2 levels
* may result in OSA, eventual heart failure sxs (leg swelling0
* clinical features: **obestiy (BMI \>30)**
* tx: **weight loss, cpap**
30
Carcinoid Tumor
* tryptophan is converted from vitB3 (niacin) to serotonin by tumor = niacin def
* MC site: **appendix,** but can be found in a variety of locations (small bowel, rectum, bronchus, kidney, pancreas); most begin in small bowel and appendix - go to liver and then become sxatic because spreads to heart and lung (R heart valve)
* M=F, \<60yo
* sxs: cough, hemoptysis, focal wheezing, recurrent PNA, pellagra (dermatitis, dementia, diarrhea)
* dx: fiberoptic bronchoscopy (pink or purple tumor in central airway), CT scan to localize and follow growth, octreotide scintigraphy
* tx: surgical excision, if sxatic, resistant to radiation and chemo
* complications: bleeding, airway obstruction
* prognosis: favorable
31
Solitary Pulmonary Nodules
* single, isolated, less than 3cm, well-circumscribed nodule or "coin lesion" with no associated mediastinal or hilar lymph node involvement (determines if malignant)
* RF for malignancy: age 30+, smokers, more cigs per day, prior malig
* sxs: asxatic (incidental on CXR)
* dx: **review old imaging studies** (compare with prior studies, estimate doubling time)
* **CT chest** for any suspicious SPN, flexible bronchoscopy (central lesions), transthoracic fine needle bx (FNA) - determines if malignant, PET scan
* tx: see tx based on probability of malig below
* prognosis: significant risk of malignancy (10-68%)
32
Sarcoidosis
* chronic systemic granulomatous dz - noncaseating granulomas, often multiple organ systems; lungs mostly involved
* Etiology: unkown, most often occurs in AAs especially F, 75% cases occur \<40yo
* sxs: **malaise, fever, wt loss,** dry cough, DOE, **arthralgias,** arthritis, bone lesions, **erythema nodosum****, ant uveitis,** post uveitis, conjunctivitis, arrhythmias, heart block, sudden death, CN VII (bell's palsy), optic nerve dysfn, papilledema, periph neuropathy
* dx: **bilateral hilar adenopathy**, **ACE** elevated, **hypercalciuria, hypercalcemia**, PFTs (dec VC/TLC, dec DLCO, inc FEV1/FVC)
* definitive dx: **transbronchial bx** (must see noncaseating granulomas - not dx by itself)
* tx: most resolve spontaneously in 2y, no tx
* **systemic (PO) steroids:** if sxatic, active lung dz, PFT deterioration, conduction disturbances, severe skin or eye involvement, methotrexate if refractory
* prognosis: good for most pts
33
sarcoidosis staging
* **Honeycombing**: scarred shrunken lung; air space dilated, firbous scarring in interstitium; associated with a poor prognosis
* Stage 1: bilateral hilar adenopathy WITHOUT parenchymal infiltrates
* Stage 2: hilar adenopathy WITH parenchymal infiltrates
* Stage 3: NO hilar adenopathy + **diffuse parenchymal infiltrates**
* Stage 4: pulmonary fibrosis with honeycombing + firbocystic parenchymal changes
34
idiopathic pulmonary fibrosis
* etiology: unkown, more common in **male smokers**
* sxs: gradual onset of progressive dyspnea, nonproductive cough, constitutional sxs - clubbing, insp crackles
* dx: CT (progressive fibrosis over several years), CXR (diffuse patchy fibrosis with pleural based honeycombing or ground glass; may be normal), PFTs (restrictive pattern, dec lung volume with NL to inc FEV1/FVC ratio), exclude other cause of ILD
* tx: **no effective treatment,** \>70% do not respond and experience gradual respiratory failure, supplemental O2, steroids with or without cyclophosphamide, lung transplant
* prognosis: variable, but mean survival is 3-7y after first dx
35
pneumoconiosis
* coal worker's, asbestos, silicosis, berylliosis
36
coal worker's pneumoconiosis
* inhalation of coal dust (carbon + silica), nodular opacities at upper lung fields), coal mining
* sxs: simple (no respiratory disability), complicated (fibrosis - restrictive lung dz)
* dx: FEV1 dec, + ANA, nonspecific
* tx: progressive massive fibrosis
37
asbestosis
* diffuse interstitial fibrosis caused by inhalation of asbestos fibers (**lower lobes)**, inhalation, demolition, construction, \>90% have lung involvement, highest incidence in north american black F and north european whites
* sxs: insidious development (\>15-20y) post-exposure, nonspecific ILD findings
* dx: clinical dx, hx of exposure to asbestos - CXR (pleural plaques, hazy infiltrates, and bilateral linear opacities), bx (asbestos bodies)
* tx: no specific tx, **stop smoking**
* prognosis: increased risk of **bronchogenic carcinoma** (smoking synergistic) and **malignant mesothelioma**
38
silicosis
* localized and nodular peribronchial fibrosis (**upper lobes)**
* sources: mining, stone cutting, glass manufacturing
* sxs: exertional dyspnea (MC), cough with sputum production
* signs: restrictive pulm fn findings
* dx: CXR (**egg shell calcification** of enlarged hilar lymph nodes)
* tx: removal from exposure to silica
* prognosis: increased risk of tuberculosis, progressive fibrosis
39
berylliosis
* high technology fields: aerospace, nuclear power, ceramics, foundries, tool and die manufacturing
* sxs: acute (diffuse pneumonitis by massive exposure to beryllium), chronic (similar to sarcoidosis with granulomas, skin lesions, and hypercalcemia)
* dx: beryllium lymphocyte proliferation test
* tx: **chronic glucocorticoid tx** for both acute/chronic, **glucocorticoid tx** for both acute/chronic
40
pulmonary hypertension
* mean **pulm arterial pressure greater than 25mmHg** at rest or 30mmHg during exercise
* young or middle-aged F
* cause: unkown, abnl increase in pulm arterial resistance - thickening of pulmonary arterial walls, pulm HTN in absence of disease of heart or lung; dx of exclusion
* sxs: **DOE, fatigue, CP** (exertional), syncope (exertional)
* signs: loud pulmonic P2 sound, subtle lift of sternum, **JVD**, hepatomegaly, **ascites, peripheral edema**
* dx: EKG **R ventricular hypertrophy,** R axis deviation and R atrial abnlity, echo **dilated pulmonary artery,** dilation and hypertrophy of RA/RV, abnl mvmt of IV septum, **R heart cath = GOLD STANDARD** (inc PA pressure), CXR clear lungs, enlarged RV, central pulm arteries, "**peripheral pruning of large pulm arteries"**, PFTs restrictive, ABGs, V/Q scan (PE vs PPH)
* tx: **IV prostacyclins** (epoprostenol) and CCB (lower pulm vasc resistance), anticoag with warf dt venous stasis, physical inactivity, risk of thrombosis, lung transplant
* prognosis: poor, mean survival 2-3y from dx
41
cor pulmonale
* R ventricular hypertrophy with eventual RV failure, resulting from pulm HTN, secondary to pulm dz, MC secondary to **COPD**
* other causes: recurrent PE, ILD, asthma, CF, OSA, pneumoconiosis
* sxs: dec exercise tolerance (**DOE)**
* signs: parasternal lift, cyanosis, clubbing, JVD, hepatomegaly, ascites, peripheral edema, polycythemia (if COPD present)
* dx: CXR (**enlarged RA, RV, and pulm arteries,** EKG RA deviation, **P pulmonale** (peaked P waves), R vent hypertrophy
* tx: tx underlying pulm disorder, use **diuretic** tx cautiously, patient may be preload dependent, apply continuous **long-term O2** tx if hypoxic, digoxin (if coexistent LV failure)
