Pulmonology Flashcards
Measurement of the volume of air that can be expelled from a maximally inflated lung
Force Vital Capacity (FVC)
measurement of the volume of air that can be exhaled at the end of the 1st second
Forced Expiratory Volume in one second (FEV1)
Auscultation sound described as snoring that may clear with cough: rattling low-pitch rumbling “Secretions”
Rhonchi
Auscultation sound described as high-pitched popping: not cleared by cough: During inspiration
Crackles
Auscultation sound described as whistling louder with expiration 2T narrow airways
Wheezing
Loudest over the anterior neck 2T narrowing of the larynx or trachea. (Upper airway obstruction MC)
Stridor
What is Samster’s Triad?
Asthma, Nasal polyps, and ASA/NSAID allergy
Dx tool used if PFT is non-diagnostic
Bronchoprovocation with________
Bronchoprovocation
Methacholine
Gold Standard for reversible obstruction
Pulmonary Function Test
Best and most objective way to asses asthma exacerbation severity and Tx response
Peak Expiratory Flow Rate
What PEFR % is considered responsive to treatment?
> 15% PEFR (Normal 400-600cc)
Pulse Oximetry indicative of Respiratory Distress
SPO2 <90%
Acute Exacerbation Admission criteria
- PEFR <50%
- <15% initial value (200cc)
- Revisit w/I 3 days of exacerbation
- Post-treatment failure
Acute Asthma exacerbation Discharge criteria
- PEFR >70%
- PEFR >15%
- Adequate F/U w/i 24-72 hrs
Asthma management anticholinergic/muscurinic that Inhibits vagal-mediated bronchoconstriction/ secretions
.
Synergistic B2 agonists and anticholinergics
Ipratropium
1sts Line treatment for acute asthma exacerbations. Most effective and fastest within 2-5 min.
Albuterol or Terbutaline (B2 Agonist short acting)
Anti-inflammatory: All but the mildest exacerbations should be discharged on a short course of these
Prednisone, Methyl prednisone, Prednisolone
Short course= 3-5 days
Long-Term exacerbation medications (Chronic control)
- ICS
- LABA
- Mast Cell Modifiers
- Leukotriene receptor Antagonists (LTRA)
Short-term exacerbation quick relief medications
- SABA
- Anticholinergics
- PO Corticosteroids
Exacerbation treatment that inhibits mast cell and leukotriene mediated degranulation
Inhibits acute phase cold air and exercise response
Mast Cell Modifiers (Cromolyn)
Exacerbation treatment that leukotriene-mediated neutrophil migration, capillary perm., M. contraction
Useful in asthmatics w allergic rhinitis/aspirin induced
LTRA (Montelukast or Zafirlukast)
DOC for long term , persistent chronic maintenance.
Cytokine and inflammation inhibition
ICS (Beclomethasone/ Flunisolide/Triamcinolone
Prevents symptoms especially nocturnal asthma. Used as a combo with ICS: not to be used alone.
LABA (Advair/ Salmeterol/Symbicort)
Step down off LABA should be done if asthma control is maintained _________
> 3 months
Adjunct indicated in severe asthma acts as bronchodilator
IV Magnesium
Analgesic that has sedative and bronchodilator effects
Ketamine
Anti-Ige used in severe uncontrolled asthma
FEV1 <60%
Omalizumab
Bronchodilator that improves respiratory muscle endurance. similar to caffeine.
Toxicity causes arrhythmias/seizures.
Theophylline
Intermittent Asthma severity SABA use and Nighttime awakenings.
< 2x week SABA
< 2x months at Night FEV1> 80
Mild Asthma severity SABA use and Nighttime awakenings. What %?
> 2x week (not daily)
3-4x month at night FEV1> 80%
Moderate Asthma severity SABA use and Nighttime awakenings.
Daily SABA
>1x week (not nightly) FEV1 60-80%
Severe Asthma severity SABA use and Nighttime awakenings.
Several a day SABA
Nightly FEV1 < 60%
Asthma Daily Medication Step 1
SABA PRN
Asthma Daily Medication Step 2
- SABA
- Low ICS or Cromolyn
Asthma Daily Medication Step 3
- SABA
- Low ICS
- LABA or LTRA
Asthma Daily Medication Step 4
- SABA
- Medium ICS
- LABA or LTRA
FEV1/FVC Obstructive pattern
- FEV1/FVC <70%
- FVC >80%
- > 200cc or 15% with SABA (20% if Methacholine)
Disorder with loss of elastic recoil and increased airway resistance. Alpha 1 antitrypsin deficiency genetic link.
RF- smoking/Exposure 90%
COPD (Antitrypsin protects Elastin in lungs)
Abnormal permanent enlargement of the terminal spaces. PE-hyperinflation, Barrel chest, pursed lips.
Respiratory alkalosis (Acidosis in acute exacerbations). Pink and cachectic (
Emphysema
Gold Standard Dx for COPD
PFT/Spirometry
Productive cough >3 mos X 2 consecutive years is hallmark: Chronic inflammation. Rales/rhonchi/wheezing
Cyanosis and cor pulmonale. respiratory acidosis. Increased Hct. Cyanotic & obese
Chronic Bronchitis
Chronic Bronchitis Management
Corticosteroids Oxygen- only that decreases mortality Anticholinergics Albuterol Theophylline
COPD staging
FEV1 >80 Mild
FEV1 50-79% moderate
FEV1 30-50% Severe
FEV1<30% Very Severe
Irreversible bronchial dilation 2t transmural inflammation of bronchi. destruction of muscular/elastic tissues of wall
Recurrent chronic lung infections. Productive cough with foul smelling sputum. MCC of massive hemoptysis.
H. Influenza MCC
Bronchiectasis
Bronchiectasis Dx and Treatment
High Resolution CT
MAC- Clarithromycin + Ethambutol + Corticosteroids
Empiric- Ampicillin, Bactrim, Amoxicillin
(Pseudomonas MC= Fluoroquinolone)
Physiotherapy
Autosomal recessive defective transmembrane Receptor protein prevents Cl- transport out of cell.
Thick mucus buildup in lungs, pancreas, liver, intestines, and reproductive tract.
Cystic Fibrosis
Cystic Fibrosis clinical manifestations
- At birth Ileus
- Pancreatic insufficiency (Decr. ADEK absorption)
- Recurrent Respiratory infections
- Infertility
Cystic Fibrosis Dx and Treatment
Dx- Elevated sweat chloride Test (primary) Twice >60
DNA= Definitive
Tx- B2 Ag, mucolytics, Abx, ADEK vit. and vaccinations
Clinical manifestations include Dry cough, dyspnea, CP: BL Hilar nodes LAD: Erythema Nodosum, Lupus pernio
Anterior uveitis: Cardiomyopathies: Rheumatologic: Noncaseating granulomas.
Sarcoidosis
Chronic multisystemic inflammatory, granulomatous DO 2T exaggerated T cell response–> granulomas
Sarcoidosis
Sarcoidosis Dx and Tx
CT- Ground-glass Opacities and BL Hilar LAD
Tissue Bx= Non-caseating Granulomas
Management- Corticosteroids PO (TOC)
- Methotrexate (if CS refractory)
Chronic progressive interstitial scarring 2T persistent inflammation.
CXR- ground-glass opacities and Honeycombing
Idiopathic Fibrosing Interstitial Pneumonia
No effective treatment- Lung transplant
what is the Lofgren’s syndrome triad for sarcoidosis
Erythema Nodosum
BL Hilar LAD
Polyarthralgias + Fever
Chronic Fibrotic lung disease 2T inhalation of mineral dust.
Pneumoconioses (Environmental Lung Disease)
Inhalation DO, 2T granite/slate/quartz/pottery sandblasting
Silicosis
Inhalation DO, 2T coal: CXR: small upper lobe nodules
Coal Worker’s Pneumoconiosis
Inhalation DO, 2T electronics, ceramics, fluorescent light bulbs.
Berylliosis
Inhalation DO, 2T textile or cotton exposure
Byssinosis
Inhalation DO, 2T destruction/renovation of old buildings, insulation, or ship buildings. Pleural thickening
Asbestosis
Malignant Mesothelioma of the pleura
Asbestosis
Hypersensitivity pneumonitis from nitrogen dioxide gas exposure released from plant matter.
(Chute and base of a Silo) –> bronchiolitis obliterans.
Silo Filler Disease (N95 Mask)
Pneumonitis due to moldy hay exposure.
Farmer’s Lung (Allergic Alveolitis/pneumonitis)
Tumor originating from the pleura due to chronic asbestos exposure. Poor prognosis if malignant.
Pleuritic CP, dyspnea, fever, night-sweats, hemoptysis.
Tx:?
Mesothelioma
TX: resection/radiation/Chemo
Acute inflammation of the costochondral, costosternal, or sternoclavicular joints. Common post viral infx/trauma
Pleuritic CP worse with coughing or certain limbs or Torso. TTP 2nd-5th Costochondral Jx.
Costochondritis
Acute inflammation of the costochondral, costosternal, or sternoclavicular joints. Common post viral infx/trauma
Positive palpable edema/swelling, heat, and erythema
Tietze Syndrome
Abnormal accumulation of fluid in the pleural space. Decreased fremitus, BS, and dullness on percussion
Lights criteria= > 0.5 protein, >0.6 LDH, <7.2 pH, < 40 glucose
Exudative Pleural effusion
MCC of Transudate Pleural Effusion > 90%
CHF
Nephrotic Syndrome, Cirrhosis, hypoalbuminemia
MCC of Exudative Pleural effusion
Infection/Inflammation
Malignancy
Positive Menisci sign means
Blunting of the costophrenic angles
DX for Pleural effusion is best done with a CXR positioned how?
Lateral decubitus on the affected side down
Pleural Effusion treatment
Thoracentesis= GS (exudative inject Streptokinase)
Pleurodesis= Malignant/Chronic (Talc/Doxy to obliterate)
Primary pneumothorax includes
Trauma (No underlying Lung disease)
Secondary Pneumothorax includes
PTX 2T Underlying Lung Disease (COPD/Asthma)
PTX during menstruation due to ectopic endometrial tissue in the pleura?
Catamenial Pneumothorax
Tension pneumothorax TRIAD
JVD, Pulsus Paradoxus, and hypotension
Management of small primary spontaneous PTX
What is the percentage/measurement?
Observe at least 6 hours then repeat CXR
(Resolves w/I 10 days w O2 absorbs 3-4x faster)
<15-20% or = 2-3 cm between chest wall and lung
Tension PTX Tx?
Needle Aspiration- 2nd ICS MCL–> Chest tube
Pulmonary nodule: Mediastinal Tumor MC
Thymoma
Malignant Pulmonary nodule presentation
- Irregular
- speculated
- Rapid growing (Double in 4mos)
- Cavitary with thickened walls
Nodule < 5% probability of malignance in <50 yoa patient w/o smoking Hx. Tx?
Otherwise >5% and smoker >50 yoa?
Observation
Dx- Needle aspiration or bronchoscopy Tx- Resection
Pulmonary Nodule that May secrete serotonin, ACTH, ADH, melanocyte stimulating hormone. MC < 60 YOA
Diarrhea (serotonin), Flushing, and Tachychardia 2T A-H1 and Incr. Bradykinin
Bronchial Carcinoid Tumor
Pink to purple well vascularized central tumor in bronchoscopy =
Tx
Bronchial Carcinoid Tumor
Excision Sx
MCC of cancer death in Men and women. MCC smoking
Greatest tendency to METS to brain, bone, liver, LAD
Bronchogenic Carcinoma
Bronchogenic Carcinomas include
NSCC- Adenocarcinoma, Squamous cell, Large cell
Small Cell Carcinoma (Oat Cell)-
Metastasizes early: Central and aggressive: Mets at presentation–> Chemotherapy is TOC
Central, Cabronado, Chemotherapy,
Hyponatremia and SIADH
Small Cell Carcinoma
Centrally located, cavitary lesions, Calcinosis, Pancoast tumor (CCCP). Treatment?
Hemoptysis and maybe picked up on sputum cytology
Squamous Cell
TOC= Surgical Resection
MC type of NSCC in smokers, women and non-smokers
35%.
Peripheral with voluminous sputum production
NSCC- Adenocarcinoma
Most aggressive and 2nd MC NSCC?
Large Cell Carcinoma (Anaplastic)
Shoulder pain, cervical cranial sympathetic compression (_____) syndrome, atrophy of hand arm m.,
+ superior sulcus tumor
Pancoast Tumor Syndrome
Horner’s Syndrome includes
Anhidrosis, Ptosis, and miosis
Dyspnea, Pleuritic CP (70%), hemoptysis, MC post-op with sudden tachypnea? Lung auscultation ML normal
Pulmonary Embolism
PE MC symptom and MC sign
Symptom is Dyspnea
Sign- Tachypnea
Pulmonary Embolism ordered if high suspicion and negative CT/or VQ scan: Dx Gold standard
Pulmonary Angiography
Best initial test for suspected Pulmonary Embolism
Helical CT scan
If CT scan contraindicated then use
VQ scan (Low Probability use only)
Most Common ECG changes in PE
Tachycardia and nonspecific ST/T changes
Most specific ECG changes for PE
S1Q3T3
Pulmonary Embolism management Hemodynamically stable? If ____ treatment is CI?
IF UFH or SQ LMWH
PO Warfarin or Novel Oral AC (Apix/Rivax/Edox-aban
CI-AC/unsuccessful= IVC Filter
Pulmonary Embolism management Hemodynamically un-stable?
Thrombolytic Tx (Strepto/Uro-Kinase or Alteplase) [Preferred over embolectomy]
Embolectomy Tx- If thrombolytic CI
Antidote for Coumadin is?
Vitamin K (Extrinsic II, VII, IX, X) [Monitor INR 2-3]
Antidote for LMWH is ?
Protamine Sulfate (Intrinsic) [CI: in renal failure]
Lower Risk of HIT (HIT incr. with UFH and monitor PTT 1.5-2.5)
Must be overlapped with Heparin for at least 5 days?
Coumadin
PE prophylaxis
Early Ambulation
Elastic stockings/Pneumatic compressions
LMWH
PERC criteria
< 50 yoa
Pulse <100
O2 sat >95%
No prior PE
Pulmonary Hypertension Mean Pulmonary Arterial Pressure?
> 25mmHg (normal= <20 mmHg or 30mmHg during ex.)
MCC of primary Pulmonary HTN?
idiopathic MC in middle aged or young women
MCC of secondary Pulmonary HTN?
COPD
Sleep apnea, PE, Metabolic
Pulmonary HTN DX and Tx?
Dx- Right Sided heart catheterization GS
CBC= Policythemia and Incr. Hct
Tx- Nitric Oxide, Adenosine, CCBs
Secondary- Tx COPD with O2
MCC and 2nd MCC of Community Acquired Pneumonia
(CXR=Lobar): “Rusty Blood Tinged”
COPD and Cystic Fibrosis
Strep Pneumonia
H. Influenza 2nd MCC
MCC of Atypical Pneumonia. (CXR=Diffuse and Patchy)
Military recruits and college
Mycoplasma Pneumoniae (Walking)
Related to contaminated water supplies.
“Currant-Jelly”
increased LFTs, hyponatremia, NVD, anorexia
Legionella (Urine Testing Ag PCR)
Pneumonia Often seen after a viral illness:
Hematogenous spread in IVDU, immunoincomp, elderly
Staphylococcus Aureus
Pneumonia seen in aspirators, alcoholics, and assoc with cavitary lesions
Klebsiella (Aspiration = Anaerobes)
Seen in Cystic Fibrosis, Immuno comp., HIV, transplant
Pseudomonas Aeruginosa
MC viral Pneumonia in infants and children
RSV and Parainfluenza
MC viral pneumonia in adults
Influenza
MC Pneumonia in Transplants and Aids
CMV
MC pneumonia with fungal or parasites immunocompromised patient
Pneumocystis Jirovecii
CAP Pneumonia Tx
Macrolide (Azithromycin) or Doxycycline 1st Line (Out-Pt)
B-LactamAmoxicillin-Clavunate/Amp-sulbactam + Macrolide Azithromycin (In-Pt) or Doxy or FQ (Levo)
CAP in ICU
B-LactamAmoxicillin-Clavunate/Amp-sulbactam + Macrolide Azithromycin (In-Pt) or
FQ (Levo) + B-Lactam
HAP Tx Pseudomonas? MRSA? Legionella
Pseudomonas- FQ (Levo) + B-Lactam
MRSA- Linezolid + Vancomycin
FQ (Levo) + Azithromycin
Pneumococcal Vaccines
PCV13= 13 Ag used in childhood
PPSV23= 23 MC serotypes >2-64 w chronic dz
for >65 yoa
Chronic Lung infection leading to granuloma formation.
Inhalation of airborne droplets.
night sweats, fevers/chills, weight-loss, anorexia, fatigue
Tuberculosis
Outcome of infection leads to caseating granulomas.
Become PPD positive 2-4 weeks post infx.
Not contagious
Chronic (Latent) Tuberculosis
Reactivation of TB with waning immune defenses: MC localized at apex/upper lobes w cavitary lesions
Patients are contagious
Secondary Reactivation TB
Outcome of initial TB infection. Rapidly progressive. Patients are contagious
Primary TB
Extra pulmonary TB if in Vertebrae=_____
if in LAD = ________
Pott’s Disease (Vertebrae TB)
Scrofula (LAD)
TB PPD screening mm size
> /= 5mm: HIV, TB Pt contact, CXR TB
> /= 10mm: High risk contact
> /= 15mm: everyone else
TB DX studies
Acid Fast Smear sputum Cx X 3 days- yearly for active
CXR- exclude Active (+) PPD and Screen yearly active
Interferon Gamma Release Essay- Not BCG Vax affected
Active TB Tx
RIPE X2 mos (Active 6 mos)
Rifampin- Orange secretions
Isoniazid- Peripheral Neuropathy (Pyridoxine B6)
Pyrazinamide- Rash (photosensitive)
Ethambutol- Optic neuritis (Color blind)
Streptomycin- ototoxicity (aminoglycoside)
Latent TB Tx
INH + Pyridoxine 9 mos
HIV= INH + Pyridoxine X12 mos
MCC pathogen of Laryngotracheitis (Croup)
Parainfluenza virus Type 1
MCC pathogen of Acute Epiglottitis (Supraglottitis)?
Haemophilus Influenza B
MCC pathogen of Pertussis Whooping cough?
Bordetella Pertussis
Highly contagious cough infection. MC in <2yo Manifests in three stages. Resolution may last 6 wks
Coughing fits with inspiratory whooping. DX- Nasal Swab PCR: Lymphocytosis > 50K: DOC for treatment ?
Pertussis (Whooping cough)
Nasal Swab=GS DX
Azithromycin/Erythromycin (Macrolide)
Inflammation MC 2T viral infx of upper airway. Barking cough hoarseness. worse at night. Virus: steeple sign.
Tx? Mild-Mod-Severe
Laryngotracheitis(Croup)
(Racemic Epi) Tx- Mild= Dex, air mist, hydrate: MOD-Sev- Dex- Epi, Dex
Manifestation of Dysphagia, Drooling, and distress 3Ds.
Muffled voice, tripoding, inspiratory stridor. 3mos-6 yo
Dx- Laryngoscopy (cherry red). X-ray- Thumb print sign.
TX?
Acute Epiglottitis (Supraglottitis)
Tx: Supportive Airway is “Mainstay” Ceftriaxone + Dex
Cefotaxime
Pertussis stage where patient is most contagious?
Catarrhal Phase
Pertussis stage with severe cough fits w emesis?
Paroxysmal phase
Pertussis phase with resolution of cough? (up to 6 wks)
Convalescent Phase
Inflammation of tracheal/bronchi: often follow URI. MCC is Adenovirus. Hallmark is cough for 1-3 weeks.
Tx:
Acute Bronchitis
Tx: Symptomatic (ABX= Immunocomp or >7-10 days)
Inflammation of the bronchioles: LRI of the small airways. infants <2 YOA MC affected. –> Resp. Distress
Tx:
Acute Bronchiolitis
Tx: Humid O2, B-Agonist, racemic epi, (Ribavirin- immu)
“No Steroids”
Acute Bronchiolitis MCC
Respiratory Syncytial Virus
Irreversible bronchial dilation 2t transmural inflammation of bronchi. destruction of muscular/elastic tissues of wall
Recurrent chronic lung infections. Productive cough with foul smelling sputum. MCC of massive hemoptysis.
H. Influenza MCC
Bronchiectasis
Abrupt onset of Fever, chills, malaise, Myalgias (Legs/Lumbosacral area), pneumonia, pharyngitis.
Dx: Nasal swab or viral culture
Tx:?
Influenza
Tx: W/I 48 hrs onset= Olseltamivir/Zanamivir
Ribavirin= covers A n B
Recommended population influenza vaccine
> /= 65 yoa (Indicated >6mos
Asthma, COPD, Sickle cell, DM
Influenza contacts
Inflammatory lung injury 2T cytokines. MC developed in critically ill patients (MCC Sepsis). –> acute Resp Failure
dx- catheterization of Pulmonary artery PCWP of ____
“swan-Ganz”
Tx:
Acre Respiratory Distress syndrome
Dx- Capillary wedge pressure <18mm Hg (12-18mmHg)
Tx- Positive end Expiratory Pressure (PEEP) PaO2>55 mmHg
What are the three main components of ARDS
- Severe refractory hypoxemia
- BL Infiltrates on CXR
- Pulmonary edema/CHF absence (PCWP<18 mmHg)
Sleep Apnea 1st Line Dx ?
In-Lab Polysomnography (>/= 15 events/hr)
Tx- CPAP
Acid Base disorders step approach
- pH > 7.45 or < 7.35
- PCo2 Opposite=Resp/ same=Met (35-45)
- HCO3- (22-26)
Anion GAP formula is
AG= Na- (Cl- (+) HCO3-) (10-12 normal)