Pulmonology

Question 1

bronchiectasis

Answer 1

• 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

Question 2

Acute/Chronic bronchitis

Answer 2

• 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)

Question 3

Asthma

Answer 3

• 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

Question 4

Asthma characteristics, signs, sxs

Answer 4

• 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

Question 5

Asthma dx and tx

Answer 5

• 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

Question 6

Acute asthma exacerbation

Answer 6

• 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

Question 7

Asthma classification

Answer 7

• Intermittent, mild persistent, moderate persistent, severe persistent

Question 8

COPD

Answer 8

• 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

Question 9

Chronic Bronchitis

Answer 9

• 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

Question 10

emphysema etiology and types

Answer 10

• 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)

Question 11

emphysema sxs, dx

Answer 11

• 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

Question 12

chronic bronchitis tx

Answer 12

• 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

Question 13

emphysema tx

Answer 13

• 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

Question 14

COPD staging

Answer 14

Question 15

Community acquired PNA

Answer 15

• 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

Question 16

community acquired PNA (pneumo PNA) in immunocompetent: etiology, RF, sxs

Answer 16

• 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

Question 17

CAP in immunocompetent: dx

Answer 17

• 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

Question 18

community acquire PNA in immunocompromised pts

Answer 18

• 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)

Question 19

Nosocomial PNA

Answer 19

• 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

Question 20

pneumocystis pneumonia

Answer 20

• 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

Question 21

PNA tx: outpatient, smokers, and inpatient (non-ICU)

Answer 21

• 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)

Question 22

PNA tx: hospitalized or ICU pts

Answer 22

• 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

Question 23

PNA tx: nosocomial PNA

Answer 23

• 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

Question 24

When to admit for PNA

Answer 24

• CURB-65 Score
  
  • 1. confusion
  • 2. uremia
  • 3. resp rate
  • 4. blood pressure
  • 5. age >65
• <1 = no hosp
• 1-2 = hosp (maybe ICU)
• 3+ = definite ICU admit

Question 25

Pulmonary neoplasm

Answer 25

• 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

Question 26

Small cell lung cancer

Answer 26

• 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

Question 27

Non-small cell lung cancer

Answer 27

• 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

Question 28

lung cancer screening

Answer 28

• 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

Question 29

Obestiy hypoventilation (pickwickian) syndorme

Answer 29

• 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

Question 30

Carcinoid Tumor

Answer 30

• 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

Question 31

Solitary Pulmonary Nodules

Answer 31

• 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%)

Question 32

Sarcoidosis

Answer 32

• 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

Question 33

sarcoidosis staging

Answer 33

• 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

Question 34

idiopathic pulmonary fibrosis

Answer 34

• 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

Question 35

pneumoconiosis

Answer 35

• coal worker’s, asbestos, silicosis, berylliosis

Question 36

coal worker’s pneumoconiosis

Answer 36

• 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

Question 37

asbestosis

Answer 37

• 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

Question 38

silicosis

Answer 38

• 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

Question 39

berylliosis

Answer 39

• 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

Question 40

pulmonary hypertension

Answer 40

• 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

Question 41

cor pulmonale

Answer 41

• 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)