Pulmonology Flashcards
1
Q
Opacification, consolidation, air bronchograms
A
lobar consolidation= PNA
2
Q
hyperlucent lung fields with flattened diaphragms
A
COPD
3
Q
heart > 50% AP diameter, cephalization, Kerly B lines & interstitial edema”
A
CHF
4
Q
Cavity containing an airfluid level
A
abscess (staph or anaerobes)
5
Q
“Upper lobe cavitation, consolidation +/- hilar adenopathy”
A
TB
6
Q
transudative pleural effusion most likely?
A
CHF, nephrotic, Cirrhotic
7
Q
if exudative pleural effusion w/ low pleural glucose?
A
Rheumatoid Arthritis
8
Q
if exudative pleural effusion w/ high lymphocytes?
A
TB
9
Q
if exudative pleural effusion that is bloody?
A
Malignant or PE
10
Q
If exudative pleural effusion most likely?
A
parapneumonic effusion, TB, empyema, cancer, SLE, RA, Pancreatitis
11
Q
Lights criteria Transduative if?
A
Pleural fluid protein: Serum Protein ratio = ≤ 0.5
Pleural Fluid LDH: serum LDH ratio = ≤ 0.6
Pleural Fluid LDH = < ⅔ the upper limit of normal serum LDH
12
Q
Pleural fluid has ph 7.5, glucose 102, cholesterol 25, protein 4, specific gravity 1.003 what type of fluid is it?
A
Transudative Pleural effusion
13
Q
Pleural fluid has ph 7.34, glucose 45, cholesterol 72, protein 53, specific gravity 1.020 what type of fluid is it?
A
Exudative Pleural effusion
14
Q
Pleural fluid is clear, decreased cell count, low levels of protein, albumin and LDH what type is it?
A
Transudative pleural effusion
15
Q
Pleural fluid is cloudy, increased cell count, high level of protein, albumin, and LDH, what type is it?
A
Exudative Pleural effusion
16
Q
Pt. has SOB, tachypnea, Pleuritc chest pain with hemoptysis and is tachycardic and decreased PO2 what does this pt. have?
A
Pulmonary emoblism
tx: with heparin
pest diagnostic test is pulmonary angiography
17
Q
what is the most common cause of ARDS?
A
Sepsis
other: gastric aspiration, trauma, low perfusion, pancreatitis
18
Q
ARDS pathyphysiology?
A
Tissue damage (pulmonary or extrapulmonary) → release of inflammatory mediators (e.g., interleukin-1) → inflammatory reaction → injury to alveolar capillaries and endothelial cells leading to: Exudation of neutrophils and protein-rich fluid (hyaline membrane) into the alveolar space → diffuse alveolar damage (DAD) to type I and type II pneumocytes → decrease in surfactant → intrapulmonary shunting → late stage: proliferation of type II pneumocytes and infiltration of fibroblasts → progressive interstitial fibrosis
19
Q
Diagnosis of ARDS
A
- ) PaO2/FiO2 < 200 (<300 means acute lung injury)
- ) Bilateral alveolar infiltrates on CXR
- ) PCWP is <18 (means pulmonary edema is noncardiogenic)
20
Q
Tx of ARDS
A
Mechanical ventilation with PEEP
with high RR and low tidal volume
21
Q
Obstructive lung disease
A
COPD (Emphysema, chronic bronchitis) Asthma
22
Q
Restrictive lung disease
A
Interstitial lung dz (sarcoid, silicosis, asbestosis. Structural- super obese, MG/ALS, phrenic nerve paralysis, scoliosis
23
Q
COPD dx?
A
postbronchodilator FEV1/FVC < 0.70
Productive cough >3mo for >2 consecutive yrs= Chronic bronchitis
Emphysema= permanent dilatation of pulmonary air spaces distal to the terminal bronchioles
24
Q
COPD treatment?
A
1st line = ipratropium (SAMA), tiotropium (LAMA), budenside and or fluticasone, PDE4 inhibitor (roflumilast). 2nd line = Beta agonists salmeterol, formoterol (LABA) salbutamol, fenoterol(SABA). 3rd line= Theophylline
25
Indications to start O2 therapy and Why is our goal for SpO2 94-95% instead of 100%?
PaO2 <55 or SpO2<88% at rest. If cor pulmonale, <59
COPDers are chronic CO2 retainers. Hypoxia is
the only drive for respiration.
26
COPD exacerbation criteria?
Change in sputum, increasing dyspnea, increased cough
27
COPD exacerbation tx
O2 to 90%, albuterol/ipratropium nebs, PO or IV
| corticosteroids, FQ or macrolide ABX,
28
show to improve COPD mortality
1. ) Quitting smoking (can decr rate of FEV1 decline
| 2. ) Continuous O2 therapy >18hrs/day
29
Important vaccinations for COPD?
Influenza shot yearly
Pneumococcal: reduces the incidence of community-acquired pneumonia and invasive pneumococcal diseases
Age 19-64 years: Administer PPSV23.
Age ≥ 65 years
Vaccinated: Administer PPSV23 (should be at least 5 years after the previous PPSV23 dose and at least 1 year after PCV13).
Not vaccinated or unknown vaccination history: Administer PCV13 followed by PPSV23
Immunocompetent patients: Administer PPSV23 after 1 year.
Individuals with immunocompromising conditions, cerebrospinal leaks, or cochlear implants: Administer PPSV23 after 8 weeks.
30
new clubbing in finger and toes in COPDer and swelling and pain in joints and long bones, what is the next best step and what is it?
Next best step is CXR
| most likely hypertrophic osteoarthropathy associated with NSCLC
31
Asthma exacerbation what do you do?
tx w/ inhaled albuterol and PO/IV
steroids.
Watch peak flow rates and blood gas. PCO2 should be low. (initially have ↓ PCO2 and respiratory alkalosis (↑ pH) due to tachypnea) Normalizing (rising) PCO2 means impending respiratory failure INTUBATE.
32
Asthma
If pt has sxs twice a week and PFTs are normal
Treatment?
Albuterol only
33
Asthma
If pt has sxs 4x a week, night cough 2x a month and
PFTs are normal
Treatment?
Albuterol + inhaled CS
34
Asthma
If pt has sxs daily, night cough 2x a week and FEV1 is
60-80%
Treatment?
Albuterol + inhaled CS + long-acting beta-ag (salmeterol)
35
Asthma
If pt has sxs daily, night cough 4x a week and FEV1 is <60%
Treatment?
Albuterol + inhaled CS + salmeterol + montelukast and oral steroids
36
1cm nodues in upper lobes w/
| eggshell calcifications.
Silicosis. Get yearly TB test!.
| Give INH for 9mo if >10mm
37
Reticulonodular process in
lower lobes w/ pleural
plaques.
Asbestosis. Most common cancer associated is
broncogenic carcinoma, but increases risk
for mesothelioma
38
• Patchy lower lobe infiltrates,
| thermophilic actinomyces.
Hypersensitivity Pneumonitis =
| “farmer’s lung”
39
```
Hilar lymphadenopathy, ↑ACE
erythema nodosum.
with hypercalcemia
who to refer too?
Dx? Tx?
```
Sarcoidosis
2/2 ↑ macrophages making vitD
Ophthalmology uveitis conjunctivitis in 25%
Dx by biopsy. Tx w/ steroids
40
pulmonary nodule with popcorn calcification
hamartoma (most common benign pulm nodule)
41
pulmonary nodule with concentric calcification
old granuloma
42
Pt < 40, <3cm, well circumscribed pulm nodule most likely has a benign or malignant nodule?
Benign pulmonary nodule
| Tx w/ CXR or CT scans q2mo to look for growth
43
Pt is elderly smoker, old, If >3cm, if eccentric
| calcification of pulmonary nodule, is nodule more likely to be benign or malignant?
Malignant pulmonary nodule
| Do open lung bx and remove the nodule
44
Patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated PNA or lung
collapse and is a non smoker what is the MC cancer
Adenocarcinoma. Occurs in scars of old PNA
Peripheral lung cancer. Mets to liver, bone, brain and adrenals
Exudative effusion with high hyaluronidase
45
Patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated PNA or lung
collapse and has kidney stones,
constipation and malaise low PTH +
central lung mass: what do they have?
Squamous cell carcinoma. (central lung cancer)
Paraneoplastic syndrome 2/2 secretion
of PTH-rP. Low PO4, High Ca
46
Patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated PNA or lung
collapse and has shoulder pain, ptosis,
constricted pupil, and facial edema?
Superior Sulcus Syndrome from Small
| cell carcinoma. Also a central lung cancer.
47
Patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated PNA or lung
collapse and has ptosis better after 1
minute of upward gaze?
Lambert Eaton Syndrome from small
| cell carcinoma. Ab to pre-syn Ca chan
48
Patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated PNA or lung
collapse and is Old smoker presenting w/ Na = 125,
moist mucus membranes, no JVD?
SIADH from small cell carcinoma.
Produces Euvolemic hyponatremia.
Fluid restrict +/- 3% saline in <112
49
Patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated PNA or lung
collapse and CXR showing peripheral cavitation and
CT showing distant mets?
Large Cell Carcinoma
50
Pt. presents with chronic sinusitis with painful nasopharyngeal ulcerations, with cough with hematuria (glomerulonephritis) and necrotizing vasculitis of small arteries
What is it?
Granulomatosis with polyangiitis
| Wegener's granulomatosis
51
what is the most common complaint of Granulomatosis with polyangiitis
upper respiratory manifestations
52
What lab marker is highly sensitive for Granulomatosis with polyangiitis?
PR3-anca/C- anca (cystoplasmic antineutrophil cytoplasmic antibodies) (anti-proteinase 3)
53
what would urine studies show with someone with granulomatosis with polyangiitis
Hematuria, proteinuria, RBC casts, nephritic sediment
54
How do you confirm the diagnosis of granulomatosis with polyangiitsi?
Need biopsy of tissue
55
Treatment for Granulomatosis with polyangiitis?
Mild: Glucocorticoids + methotrexate
| Moderate to severe disease: glucocorticoids + (cyclophosphamide or rituximab)
56
Centrilobular emphysema
smokers; upper lobe
57
Panlobular emphysema
α1-antitrypsin deficiency; lower lobe
58
Patients with COPD who are < 60 years of age, have no smoking history, and/or have basilar-predominant COPD what is the most likely diagnosis?.
α1-antitrypsin deficiency
| Liver biopsy in patients with AATD: PAS-positive, spherical inclusion bodies in periportal hepatocytes
59
Bronchietasis
is an irreversible and abnormal dilation in the bronchial tree that is generally caused by cycles of bronchial inflammation in addition to mucous plugging and progressive airway destruction
Causes: pulm infec, CF, PCD, ABPA
60
Bronchietasis clinical features
Chronic productive cough (lasting months to years) with copious mucopurulent sputum ; the following may be heard on auscultation:
Crackles
Wheezing
61
High-resolution computer tomography (HRCT): confirmatory test
Dilated bronchi with thickened walls; possible signet-ring appearance; tram track lines
Cysts, especially at bronchial ends in lower lobes, and honeycombing
Bronchietasis
62
Medications for acute asthma excerbations
To remember the meds for asthma exacerbations, think ASTHMA: Albuterol, Steroids, Theophylline (rare), Humidified O2, Magnesium (severe exacerbations), Anticholinergics.
63
Hypersensitivity pneumonitis
Hypersensitivity pneumonitis (or extrinsic allergic alveolitis) is a hypersensitivity reaction following exposure to environmental allergens. It is associated with inflammatory interstitial lung disease. Occupational groups affected by hypersensitivity pneumonitis are most commonly exposed to birds, hay, or certain reactive chemical species.
64
Pt. has a recurrent 'common cold' with an irritating cough and fever may indicate what?
Hypersensitivity pneumonitis
Dx. positive serologies, IgG antibodies are found during an allergic reaction!
tx: antigen avoidance, steroid therapy
65
Pt. Dyspnea upon exertion and cough with sputum working in sandblasting; mining; construction; glass manufacturing; working in foundries has what?
Silicosis
66
Caplan syndrome
pneumoconiosis (silicosis or asbestosis) with intrapulmonary nodules in combination with rheumatoid arthritis
67
Complications of Silicosis
Increased risk of TB
| Lung cancer
68
pt. comes with cough, sob, clubbing of fingers working in the manufacture or demolition of ships, plumbing, roofing, insulation, heat-resistant clothing, and brake lining
Asbestos
69
Complication of asbestos
Mesothelioma
70
pt. worked in shipyard presents with SOB, non pleuritic chest pain, fever of several weeks, weight loss; what does he have?
Mesothelioma
| dx: pleurocentesis, CXR, calretinin
71
what is the most common malignancy associated with asbestosis?
bronchogenic carcinoma,
72
Clinically features of Sarcoidosis
Features of sarcoidosis are GRUELING: Granulomas, aRthritis, Uveitis, Erythema nodosum, Lymphadenopathy, Interstitial fibrosis, Negative TB test, and Gammaglobulinemia.
73
lofgren syndrome
Fever with Migratory polyarthritis
Erythema nodosum
Bilateral hilar lymphadenopathy
a form of sarcoidosis
74
Labs of sarcoidosis
Increased esr, crp,
increased calcium
increase ACE
75
Biopsy of sarcoidosis
Non-caseating granulomas, giant cells
76
70 yo white male with Chronic rhinitis/sinusitis with thick purulent/bloody discharge
Treatment-resistant pneumonia
Glomerulonephritis, has what?
Granulomatosis with polyangiitis
77
pt. presents with cough exertional SOB worked as welder or automobile industry
Aluminosis (aluminum dust)
78
pt. presents with cough exertional SOB work as coal miner
Anthracosis
79
pt. presents with cough exertional SOB worked metal workers
beryllium
80
SCLC
Central location, Smokers
81
NSCLC: adenocarcinoma
peripheral location
| Most common type of lung cancer overall and in women and non-smokers
82
NSCLC: Squamous Cell Carcinoma
Central airways, Smokers
| ↑ Parathyroid hormone-related protein (PTHrP) leads to hypercalcemia (See Hypercalcemia of malignancy)
83
Pneumothorax features
P-THORAX: Pleuritic pain, Tracheal deviation, Hyperresonance, Onset sudden, Reduced breath sounds (and dyspnea), Absent fremitus, X-rays show collapse.
84
Pulmonary effusion with low glucose count causes?
Think MEAT to memorize causes of pulmonary effusion with decreased glucose content: M = Malignancy, E = Empyema, A = Arthritis (rheumatoid pleurisy), T = Tuberculosis!
85
pseudochylothorax
A chronic, exudative effusion that is enriched with cholesterol and characterized by cholesterol crystal formation. Has a milky appearance, similar to that of a true chylothorax. Common causes include chronic pneumothorax, tuberculous pleurisy, rheumatoid pleurisy, and empyema.
86
chylothorax,
Lymphatic fluid from the thoracic duct (chyle) in the pleural cavity. Chyle is a cloudy milky fluid with high concentrations of lipids (↑ triglycerides, cholesterol, chylomicrons, and fat-soluble vitamins).
87
Contraindications of beta 2 agonists
Hypersensitivy
Use with caution in patients with the following conditions:
Hyperthyroidism
Glaucoma: especially contraindicated in narrow-angle glaucoma
Diabetes
Hypokalemia
Seizures
Cardiovascular disease (e.g., heart failure, hypertension, arrhythmias, coronary artery disease)
88
Indications of Beta 2 agonists
Bronchial asthma: mediates spasmolysis of the bronchi
COPD: mediates spasmolysis of the bronchi
Preterm/undesired contractions in obstetrics: mediates tocolysis
Hyperkalemia: drives K+ intracellularly
89
Beta 2 agonists side effects
Cardiac: arrhythmias; tachycardia
1. β1-mediated cardiac stimulation (no absolute β2 selectivity); 2. reflex tachycardia after β2-mediated vasodilation
Central nervous system/muscular: tremor
Electrolytes
Hyperglycemia--β2-mediated stimulation in the liver → elevated cAMP levels → increased glycogenolysis
Hypokalemia-->β2-mediated stimulation of Na+/K+-ATPase → intracellular K+ shift
90
Long-acting beta agonists (LABA)
Formoterol
| Salmeterol
91
Short-acting beta agonists (SABA)
Albuterol
Terbutaline
Pirbuterol
Levalbuterol
92
Beta 2 adrenergic agonists do what?
Relaxes bronchial smooth muscle
93
Hypercapnic respiratory failure
↑ PaCO2 and ↓ PaO2
94
Hypoxemic respiratory failure
↓ PaO2
95
Increased tactile fremitus
Dull to Percussion
Coarse Crackles
PNA
96
Decreased/absent tactile fremitus
Hyperresonant to percussion
Decreased/absent breathe sounds
Pneumothorax
97
Increased tactile fremitus
Dullness ot percussion
Fine or coarse crackles
Pulmonary edema
98
Decreased Tactile fremitus
Dullness to percussion
Decreased breathe sounds
Pleural effusion
99
Approach to Massive hemoptysis
1. Dependent positioning if side of bleeding can be identified
2. Secure airway (intubation)
3. Stabilize cardiovascular function (IV fluids/transfusion)
4. Stop bleeding (correct coagulopathy, flexible bronchoscopy with balloon tamponade, arteriography with embolization if other measures fail)
A chest x-ray, to determine the underlying pa
100
Ataxic breathing
irregular breathing in rhythm and depth
| due to brain damage
101
Cheyne-Stokes breathing
alternating periods of deep breathing followed by apnea
102
3 C's of Central Sleep Apnea
The 3 C’s of Central sleep apnea are Congestive heart failure, CNS trauma or toxicity, and Cheyne-Stokes breathing.
103
Central Sleep apnea
Breathing-related sleep disorder characterized by repetitive cessation or decrease of respiratory effort during sleep due to impaired function of the respiratory center. Airway obstruction is absent.
