Pulmonology Flashcards
What are the diseases that are obstructive in nature?
Asthma
COPD
Bronchiectasis
Bronchiolitis
What are the diseases that are restrictive in nature?
Parenchymal diseases Interstitial diseases Neuromuscular disease Pleural diseases Chest wall abnormalities
What pulmonary diseases that are due to vascular abnormalities?
Pulmonary embolism
Pulmonary AV fistula
Pulmonary hypertension
What necessary diagnostic evaluation in respiratory diseases?
Chest imaging
Sputum analysis
Pulmonary function test (eg. Spirometry)
Bronchoscopy
Smokers cough usually occurs at what time of the day?
Early morning
Asthmatic cough usually occurs at what time of the day?
Midnight or early morning
What should you do to diagnose psychogenic cough?
Preoccupy patient with other activities and see if cough disappear
What is a possible cause for stridor?
Any tracheal or upper way obstruction like FBO, largyngomalacia, etc
Characteristic of a lung abscess sputum?
Foul smelling sputum
What signifies rust-colored and purulent sputum?
Pneumococcal pneumonia
What does pink frothy sputum means?
Pulmonary edema
Characteristics of an uninfected sputum?
Odorless, transparent, whitish gray
Mucoid sputum
Three most common causes of hemoptysis?
Bronchitis
Bronchiectasis
Bronchogenic CA
How much volume of blood can you consider as massive hemoptysis?
100-600 mL/day
Admit patient immediately!
What volume is considered nonmassive hemoptysis?
<100 mL per day
What are the possible causes of hemoptysis?
BATTLE CAMP Bronchiectasis, bronchitis Aspergilloma Tumor TB Lung disease Emboli Coagulathy Autoimmune dse, AVM, alveolar hemorrhage Mitral stenosis Pneumonia
What do you call the sudden onset of dyspnea at night? It is an important symptom of what system?
Paroxysmal nocturnal dyspnea
PND and orthopnea are importantly associated with cardiac dse
What disease/s may exhibit platypnea or difficulty in breathing while sitting up?
Atrial myxoma
(Tumor in atrial chamber)
Relieved by supine position
Most common causes of wheezing?
Asthma
COPD
Congestive Heart Failure (also assoc. with crackles)
Where can you spot central cyanosis? What is the cause? Estimated O2 saturation that central cyanosis appears?
Circumoral area or below the tongue
Decreased arterial oxygenation by intracardiac shunt, diseases that decreases dlco
<85% O2
What is the pathogenesis of peripheral cyanosis?
Sluggish blood flow
Limiting blood flow to periphery or extremities
Where will you auscultate a patient with suspected middle lobe involvement/pathology?
Right anterior chest
Can no longer appreciate middle lobe in the posterior chest
What phases of respiration does wheezing usually heard? How about stridor?
Wheezing expiratory
Stridor inspiratory
(WESI)
Difference between orthopnea in respiratory and in cardiac dses?
Respiratory orthopnea occurs only in exacerbation
In cardiac, it occurs even at rest
What do you call the preferred position of patient with obstructive dse? This position aids them in proper breathing and chest expansion?
Tripod position
Signs of respiratory distress
Supraclavicular amd intercostal retractions
Tachypnea
Nasal flaring
Grunting
Paradoxical respiration ( indrawing of chest in inspiration and expansion during exhalation-reverse in normal)
Usual appearance of COPD patients?
Barrel chest
Smokers sign
Tripod position
Prominent scalene and sternocleidomastoid muscles
Flail chest usually found in what patients?
Trauma patient with multiple rib fractures
What are the chest wall abnormalities that may compromise breathing?
Kyphoscoliosis Pectis excavatum (funnel chest)
Pectus carinatum does not cause respiratory abnormalities
Type of breathing in metabolic acidosis?
Kussmauls breathing (rapid deep breathing)
Type of breathing in which there is apnea between normal or slow breathing?
Common in meningitis.
Biots breathing
Type of breathing in which there is progressive increase and decrease followed by apnea? It occurs when the respiratory center in the medulla loses its sensitivity to fluctuations in CO2 or afferent stimuli
Cheyne-Stokes breathing
What is the pathology behind hypoxemia?
Chronic hypoxemia
Perform chest lag test.
Place both thumbs at the lvl of 10th ribs
Pull skin slightly towards midline
Ask patient to inhale and exhale
Observe for chest lagging by taking note of the disappearance of skin fold line
In what conditions that there is an increased tactile fremitus/vibrations?
Consolidation
In what conditions that there is an decreased tactile fremitus/vibrations?
Fluid in chest (pleural effusion, pneumothorax)
Describe the diaphragmatic movement in emphysema? Phrenic nerve palsy?
Reduced or flattening of the diaphragm because of air trapping
No movement of diaphragm in phrenic nerve palsy
Describe tracheal breath sounds
Harsh, loud, high-pitched, extrathoracic
Inspiratory and expiratory components are equal
Describe bronchial breath sounds
loud, high-pitched, heard at manubrium
expiratory component is louder and longer than inspiratory
Describe bronchovesicular breath sounds?
Equal inspiratory and expiratory components
Heard between first and second scapulae
Describe vesicular breath sounds?
Inspiratory component longer than expiratory
Soft and low-pitched
Describe crackles
Short Discontinuous Nonmusical Usually inspiration Coarser crackles in larger airways Like rubbing your hair Fluid filled (pus or blood)
Describe wheezing
Continuous High pitch Musical Usually expiratory Narrowing of airways
Describe rhonchi
Sonorous
Low pitch
Due to transient mucus plugging in larger airways
Disappears upon expectoration
Describe pleural rub
Grating sound
Best hear in inspiration
Like creaking leather
Describe egophony
Eeee heard as aaaa
May be due to CONSOLIDATION, EFFUSION
Describe whispered petriloquoy
Intensification of whispered words
May be due to CONSOLIDATION
Describe bronchophony
Increased transmisson of spoken words
Where will be the shift of trachea in pleural effusion? Pneumothorax? Atelectasis?
Pleural effusion- contralateral to the affected side
Pneumothorax- contralateral to the affected side
Atelectasis- towards the affected side
Increased local pain distant from anteroposterior compression of the chest indicates?
Fractured rib
What is the volume of pleural effusion before it is detectable in chest xray
> 200-250mL
Lesions in the chest are not percussible if the distance is greater than ___
2-3cm
What ribs are frequently fractured?
3rd to 9th ribs
Pulsus paradoxus is a characteristic of?
Cardiac tamponade
Characteristics of cardiac tamponade?
Becks triad
- jugular venous distension
- hypotension
- muffled heart sounds
Pulsus paradoxus
In chest trauma, what structures need great force to be fractured?
Sternum
1st and 2nd ribs
Associated complications in rib fractures?
Rupture of the aorta Pulmonary contusion Tracheobronchial injury Haemorrhage due to intercostal vessels injury Pneumothorax Hemothorax
Multiple rib fractures Atelectasis Hypoventilation Inadequate cough Pneumonia
In chest trauma, what will you suspect if patient from an VE had localized pain in the chest, pain that worsens with movement and coughing, point tenderness, crepitus, and splinting on respiration
Rib fracture
Primary goal of treating rib fractures
Relief from local pain and intercostal spasm
Pain control
- IV analgesics
- IC nerve block
- intrapleural analgesia
- epidural anaesthesia (most effective)
Provide airway and ventilation through high positive pressure ventilation
Non-circumferential splinting
In chest trauma, there is a paradoxical motion of chest, then we have a
Flail chest (sternal flail chest and ant, lat, pos, flail segments)
What is a closed pneumothorax?
Air in pleural space
100% occurrence in penetrating chest trauma, 10-30% in blunt trauma
Signs and symptoms of closed pneumothorax? What to do in prehospital setting in a closed pneumothorax caused by blunt trauma or spontaneous pneumothorax?
Needle thoracostomy
What is an open pneumothorax?
Sucking/slurping chest wound
Usually caused by penetrating trauma
A to- and fro- motion of air in across the chest wall
Decreased breath sounds in the affected side
Management for open pneumothorax?
Occlusive dressing taped on 3 sides
Chest tube insertion
What is tension pneumothorax? Immediate management?
One way valve
resulting to one way entrance of air towards the chest, trapping air inside. Continuous increased of air in the pleural cavity.
Needle thoracotomy or chest tube insertion
Signs and symptoms of tension pneumothorax?
Mediastinal/tracheal shift contralaterally
Extreme dyspnea Restless, anxiety, agitation, Jugular venous distension Hypotension Rapid weak pulse Shock (late)
Where to place needle in needle thoracostomy?
Upper border of lower rib
2nd rib
What is hemothorax?
Accumulation of blood in the pleural cavity due to vessel injury (intercostal, great vessels)
Massive hemothorax due to major blood vessels
Usual signs of hemothorax
Dullness at the base during percussion
Hypotension if loss is massive
Rapid weak pulse due to increasing intravascular volume loss
Collapsed neck veins (engorged neck veins in tension pneumothorax)
What is bronchiectasis?
Irreversible airway dilatation that involves the lung in either focal or diffuse manner.
What is the difference between a focal bronchiectasis and diffuse bronchiectasis?
Focal bronchiectasis is dilatation of a LIMITED REGION in the pulmonary parenchyma while diffuse bronchiectasis involves more WIDESPREAD DISTRIBUTION and usually arise from systemic or infectious processes.
Important history for bronchiectasis.
Being sickly as a child
Women
Usually affects older individuals
3 Categories of bronchiectasis.
Cylindrical/tubular
Varicose
Cystic/saccular
Differentiate cylindrical, varicose and cystic/saccular bronchiectasis from each other.
Cylindrical/tubular appear UNIFORMLY DILATED and end abrupty at points where there are mucus plugging.
Varicose appears BEADED
Saccular/Cystic appears in the PERIPHERY and ending at BLIND SACS
Pathology of bronchiectasis
Destructive and inflammatory changes of the medium sized airways
Neutrophils production of ELASTASE and MMPs
Resulting to pools of purulent sputum in dilated airways and increasing vasculatrity
Etiology of focal bronchiectasis
Due to obstruction of airway
EXTRINSIC (lymphadenopathy or enlargement of nearby structures compressing the airway)
INTRINSIC (tumor, FBO, bronchial atresia)
Usual causes of upper lung fields bronchiectasis
Cystic or post radiation fibrosis
Usual causes of middle lung fields bronchiectasis
Mycobacterium avium complex (mac)
Dyskinetic or immotile cilia syndrome
Usual causes of lower lung fields bronchiectasis
Chronic recurrent aspiration pneumonia
Immunodeficiency infections
Fibrotic lung diseases
Possible Infectious causes of bronchiectasis
Adenovirus and rhinovirus (lower respi tract involvement)
Staph aureus, klebsiella, anaerobles (untreated pneumonia)
Bordetella pertussis
TB (major cause worldwide)
Possible genetic causes of bronchiectasis
Cystic fibrosis
Kartagener syndrome
Alpha 1 antitrypsin deficiency
Dyskinetic/immotile syndrome
What is yellow nail syndrome?
Due to hypoplastic lymphatics
Triad of lymph edema, pleural effusion, and yellow nail
Can ABPA lead to bronchiectasis?
Yes
What is the most likely diagnosis?
Persistent productive cough
Production of thick tenacious sputum (cough out sputum in a daily basis)
May sometimes present with hemoptysis
History of repeated purulent respiratory infections as a child
May present myalgia, weight loss, and fatigue
Brochiectasis
What is the expected PE findings in bronchiectasis?
Crackles or wheezing
Clubbing (for chronic hypoxemia)
Acute exacerbations will show:
Increased volume of purulent sputum (important to know baseline production)
Changing nature of sputum
What initial diagnostic evaluation is needed? Expected findings?
More accurate/standard diagnostic tool? Expected findings?
Chest x-ray (tram track lines)
Chest CT scan (signet ring, tree in bud, lack of bronchial tapering, airway dilatation at least 1.5times than adjacent vessels, bronchial wall thickening, cyst-like structure emanating from bronchial wall)
Goals of bronchiectasis treatment
Control of active infection
Improvement of secretion clearance
Bronchial hygiene (hydration and mucolytics)
Removal of bronchiectatic parts
Azithromycin and inhaled corticosteroid may help control the inflammation
Definitive treatment for bronchiectasis
Surgery (esp in refractory cases)
Empiric therapy for bronchiectasis before gram stained guided therapy
Amoxicillin
TMP SMX
Levofloxacin
Primarily suspected organisms for bronchiectasis
P. Aeruginosa
H. Influenzae
What therapy may show significant improvement for CF related bronchiectasis but not for non CF related?
Aerosilizaed recombinant DNAse
Define lung abscess?
Often a complication of pneumonia that results to necrosis and cavitation of the lung parenchyma.
Can be single or multiple
Has high microorganism burden
Common cause of lung abscess
Aspiration
What are the factors and predisposing conditions leading to aspiration and lung abscess?
Esophageal dysmotility Seizure disorders Neurologic condition causing bulbar dysfunction Periodontal diseases Alcoholism
Whwat is rhe difference between a primary lung abscess and secondary lung abscess?
Primary lung abscess is due mostly to aspiration leading to infection of anaerobes. It comprised 80% of lung abscess cases. Secondary lung abscess occur in the presence of underlying pulmonary lesions like tumors and systemic conditions like HIV
Primary-aspiration
Secondary- immunocompromised
List of possible microorganisms that can cause lung abscess
Mycobacteria esp TB
Fungi and other parasites
Staphylococcus aureus
Gram-negative bacilli like klebsiella
Anaerobes
Nocardia and Rhodococcus in immunocompromised
Burkholderia and paragonimus in other countries
This condition refers to infectious thrombophlebitis of the internal jugular vein. It most often develops as a complication of a bacterial sore throat infection in young, otherwise healthy adults. The thrombophlebitis is a serious condition and may lead to further systemic complications such as bacteria in the blood or septic emboli.
It occurs most often when a bacterial (e.g., Fusobacterium necrophorum) throat infection progresses to the formation of a peritonsillar abscess.
Lemierre’s syndrome
Clinical manifestations for lung abscess
Usually with periodontal infection with pyorrhea and gingivitis Fatigue Fever Sputum production Putrid smelling sputum
Diagnostic tests requested for lung abscess
CT scan- preferred
Chest xray
Bronchoscopy - to rule out obstruction
What is daptomycin? Why is not used in pulmonary infection?
Daptomycin disrupts the cell membrane and is rapidly bacteriocidal. It has a broad range of activity against all gram-positive bacteria including methicillin, vancomycin, and linezolid resistant organisms.
It should not be used to treat pulmonary infections because surfactant inhibits its activity.
Treatment for lung abscess
Antibiotics(depending on the type of microorganisms causing the disease)
What are the side effects and risk factor of clindamycin?
When it is usually used? Is it safe for pregnant women?
Common side effects include nausea, diarrhea, rash, and pain at the site of injection.
It increases the risk of hospital-acquired Clostridium difficile colitis about fourfold and thus is only recommended when other antibiotics are not appropriate.Alternative antibiotics may be recommended as a result.
It appears to be generally safe in pregnancy.
Most requested chest xray view?
PA
What chest xray view makes the heart and other structures bigger and bony structures flatter or less angled?
AP
When is AP view requested?
Usually in debilitated, intubated, or stroke patients?
Normal cardiothoracic ratio
Less than 0.50
Most common causative organism for pulmonary infections in HIV patients
Pneumocystis jirovecci/carinii
Greatest risk factor for TB
HIV/immunocompromised
Gold standard test for TB in HIV patients
IGRA
Tuberculin skin test nay be negative in HIV
HIV patients have atypical presentation, may or may not show normal chest xray
Therapy for TB with HIV patients
Anti TB first during the intensive phase then HAART may be introduce during the continuation phase
Do not mix antiretroviral with anti-TB drugs
Normal A-a gradient
5-10 mmHg for you non smoker
This increases as a person ages or if with morbidity
Common opportunistic fungal pathogen for solid or hematopoieric transplant patients.
Invasive aspergillosis
Do not give flowers to leukemia or to the above mentioned patients
What is the difference between opportunistic and endemic pathogens?
Opportunistic -usually normal microbiota or found everywhere
Endemic- found in certain area
Endemic fungal pathogen that can cause pulmonary infections to immunocompetent host and can migrate to brain or disseminated to other parts of the body
Cryptococcus neoformans
If suspecting for candida pulmonary infection, what should be requested since KOH test from sputum is not recommended?
Broncheoalveolar lavage
Common infection in solid organ recipients (lung/kidney transplants)”?
CMV pneumonitis
Higher risk if recipient is seronegative and donor is seropositive
Group of pathogens for humoral immunity deficiency? Cellular or cell-mediated immunity deficiency?
Humoral-usually bacterial
Cell mediated-usually viral
_______ is a medical emergency most commonly seen in patients with acute myeloid leukemia. It is characterized by an extremely elevated blast cell count and symptoms of decreased tissue perfusion. The pathophysiology is not well understood, but inadequate delivery of oxygen to the body’s cells is the end result. It is diagnosed when white cell plugs are seen in the microvasculature. The most common symptoms are dyspnea and hypoxia, usually accompanied by visual changes, headaches, dizziness, confusion, somnolence, and coma.
Leukostasis
What laboratory test is specific for inflammation?
Erythrocyte Sedimentation Rate (ESR)
C reactive protein -sensitive acute phase reactants
High values indicate inflammation
What laboratory test is specific for infection?
Procalcitonin
Normal values for esr and crp?
ESR: the normal range is 0-22 mm/hour for men and 0-29 mm/hour for women.
CRP: most people without any underlying health problem have a CRP level less than 3 mg/L and nearly always less than 10 mg/L.
Fungal pneumonias with “halo” in CXR is indicative of? The halo represents surrounding hemorrhage?
Aspergillosis
What live vaccines should not be given to immunocompromised?
Intranasal influenza Yellow fever ORAL polio Varicella zoster MMR Others
What Common prophylaxis to avoid pneumocystis, nocardia, strep pneumoniae, and toxoplasmosis in immunocompromised?
TMP-SMX (cotrimoxazole)
What is the most predominant microflora in the mouth and nasopharynx?
Streptococcus viridans or alpha hemolytic viridan
2/3 to 3/4 of cases of acute respiratory illnesses are caused by what group of microorganisms?
Viruses
what is the common viral etiology for common colds?
rhinoviruses (30-40%)
coronaviruses (105)
RSV (10-15%)
influenza/parainfluenza (5%)
adenovirus (5%)
What are the effective treatments for symptoms of common colds?
topical/oral adrenergic agents for nasal obstruction
first-gen antihistamines and ipatropium bromide for rhinorrhea
first gen antihistamines for sneezing
NSAIDs, acetaminophen and ibuprofen for sore throat
first-gen antihistamines, bronchodilators for cough
what is a common cold?
most common respiratory illness also called acute minor coryzal illness incubation period is around 12 to 72 hrs symptoms are: mild or no fever nasal catarrh cough (dry or productive) hoarseness
most important and common cause of bacterial pharyngitis?
streptococcus pyogenes
group A strep
what are the symptoms of pharyngitis?
itchy/sore throat
fever
pharyngeal inflammation (edema and erythema, vesicles and exudates)
what are the different types of pharyngitis based on etiology?
pharyngitis with common cold
streptococcal pharyngitis
anaerobic pharyngitis/vincents angina/peritonsillitis/peritonsillar abscess (quinsys)
ludwigs angina
Management for pharyngitis with common cold
do not give antibiotics
may resolve within 3-4 days if milder symptoms are present
Characteristics of streptococcal pharyngitis that may differentiate it from other types of pharyngitis? this may used to differentiate it from viral origin
marked oahrngeal pain odynophagia high grade fever patchy gray or yellow exudates in tonsils edema of the uvula cervical lymphadenopathy leukocytosis >12 000/mm3
what are the symptoms of a peritonsillar abscess/vincents angina/anaerobic abscess/quinsy?
purulent exudates foul breath severe pharyngeal pain dysphagia fever medial displacement of the tonsil (kissing tonsils if severe)
severe complication leads to mediastinitis
First line drugs for bacterial pharyngitis?
Pen V or Amoxicillin (for 10 days)
Erythromycin or first-gen cephalosporin for penicillin allergic patients
What is diphtheria?
caused by corynebactrium diphtheriae which produces toxin. It develops a pseudomembrane that continues to obstruct the airways.
What are the symptoms of diphtheria?
pseudomembrane sore throat fever dyspnea myocarditis (cause of death in diphtheria)
What is acute laryngitis?
infection of larynx causing hoarseness or dysphonia
usuall causes are bacteria and viruses. Mycobacterium tb and tumor can cause chronic hoarseness
what is the most common cause of inflammation leading to acute sinusitis?
viral upper respiratory infection
differentiate acute sinusitis from acute rhinitis
acute rhinitis is hypersensitivity reaction characterized by nasal catarrh and watery discharge
while
acute sinusitis is inflammation of the sinuses characterized by pain over the areas of sinuses, purulent nasal discharge, headache and fever
common etiology for bacterila sinusitis?
polymicrobrial
give broad spectrum antibiotics
2 Common etiologic causes for hospitally acquired bacterial infection
pseudomonas and staph aureus
what is epiglottitis?
has a potential for causing abrupt, complete airway obstruction
a fulminant course (6 to 12 hrs)with respiratory obstruction within 30 minutes
what is the common etiology for epiglottitis?
Haemophilus influenza B
what are the symptoms of epiglottitis in children and adutls?
children: toxic, febrile, irritable, sore throat, dysphagia, prefer to sit leaning forward, drooling, inspiratory stridor
adult: less fulminant presentation, 2-3 days of symptoms, severe sore throat, odynophagia, fever
diagnostic preference for epiglottitis
direct flexible fiber optic nasolaryngoscopy
wherein a swollen erythematous epiglottitis is seen
what is acute bronchitis?
inflammation of the tracheobronchial tree
what is the most common comorbid with bronchits?
proctitis or inflammation of the anus and rectum
symptoms for acute bronchits?
may begin with flu-like symptoms
cough (non to productive progression)
burning substernal pain associated with respiration
painful when coughing
there are no signs of consolidation and no opacities in chest xray
what is chronic bronchitis?
a component of COPD
smoker’s cough
productive cough of most days for at least 3 months in 2 consecutive years
usually white phlegm
Common etiologies for CAP
S. pneumoniae H. influenzae M. catarrhalis S. aureus K. pneumoniae
What is atypical pneumonia?
pneumonia that has extrapulmonary signs
may not present cough but CXR is positive for pneumonia
3 Common etiologies for atypical pneumonia?
legionella pneumophilia
mycoplasma pneumoniae
chlamydia pneumonia
best choice of antibiotics for atypical pneumoniae
macrolides (azithromycin, clindamycin, erythromycin)
what is aspiration pneumonia?
pneumonia usually in those who have impaired gag reflex, altered consciousness, stroke, imapired gagand swallowing reflexes
usual etiologies are anaerobes like bacteroides, fusobacterium and peptostrep (gram positive cocci)
common site is middle lobe
what are the 2 important viral proteins in influenzae?
hemagglutinin (entry)
neuraminidase (exit)
what is viral pneumonia? usual etiologies?
viral origin has history of flu CXR shows interstitial infiltrates ABG with hypoxemia scanty sputum
CMV, varicella, SARS,COV, influenza, hantavirus, MERS-COV
what is empyema?
infection of the pleural cavity with presence of pus
management for empyema?
thoracentesis or open surgical drainage
broad spectrum antibiotics
what is lights criteria for pleural fluid?
fluid is exudate if: (any of the ff)
effusion/serum protein is greater than 0.5
effusion/serum LDH is greater than 0.6
effusion LDH level is greater than 2/3 of the upper limit of the lab ref range of serum protein
what is a lung abscess?
a suppurative pulmonary infection with destruction of parenchyma producing one or two large cavities. It involves necrosis of parenchyma.
Etiologies may come from aspiration, periodontal disease, or gingivitis
what are the possible etiologies of lung abscess?
S. aureus in young patients
Anaerobes (prevotella, bacteroides, fusobacterium) in aspiration patients
M. tuberculosis in tb patients
What are mostly requested diagnostic procedures in respiratory tract infections?
throat swab
sputum gram stain/culture/sensitivity
antigen detection (Legionella, S. pneumo, P. carinii)
AFB for mycobacteria
KOH for fungi
Giemsa Toluidine blue for P. carinii (fungi)
bronchoscopy for nonresolving pneumonia
Describe Strep. pneumoniae in GS
gram-positive (purple)
diplococci
lancet-shaped
DOC: penicillin
Give pneumo vaccine to elderly, health care workers
Describe H. influenzae in GS
gram negative (pink) coccobacilli
DOC: 2nd and 3rd gen cephalosporins, BLIC
Describe Bordetella pertussis
gram-negative coccobacilli does not cause pneumonia (does not go down the lungs) causes whooping cough virulence genes are bvg A and bvg S
DOC: Ilosone (erythromycin estolate) -irritating to the stomach
what are the two phases of whooping cough?
catarrhal phase (most infectious stage) paroxysmal phase (worsening of cough with whooping)
suspected agent if with pneumatocoeles
S. aureus
describe Klebsiella pneumoniae
blood agar shows mucoid colony
common etiology in CAP and HAP
gram negative bacilli
common in alcoholics, diabetics
describe corynebactrium diphtheria
club-shaped appearancee
with metachromatic granules, bacilli lie parellel and acute angles with each other
describe pseudomonas aeruginosa
greenish pigment in agar
fruity smell
common pathogen in necrotizing fasciitis and burn patients
describe acinetobacter baumanii
very infectious
if one patient is infected, it may spread to others within a week
gram-negative
diplococci
intravenous catheters can be the source of infection
found in moist surfaces in the hospital
culture medium for mycoplasma pneumonia
Lowenstein-Jensen medium
has fried egg appearance
atypical cause of pneumonia
suspected pathogen for CAP with risk factor of alcoholism
Anaerobes,
Klebsiella,
Mycobacterium,
Streptococcus pneumoniae
suspected pathogen for CAP with risk factor of aspiration
anaerobes
suspected pathogen for CAP with risk factor of COPD and smoking
Chlamydophila pneumoniae, Haemophiuls influenzae, Legionella, Moraxella catarrhalis, Pseudomonas, gram-neg rods, S. pneumoniae
suspected pathogen for CAP with risk factor of animals or parturient cats
Coxiella burnetti (Q fever)
suspected pathogen for CAP with risk factor of HIV infection (early)
H. influenzae
M. tuberculosis
S. pneumoniae
suspected pathogen for CAP with risk factor of HIV (late)
aspegillus, cryptococcus, H. capsulatum, P. jirovecii, Nocardia
suspected pathogen for CAP with risk factor of hotel or cruise ship
Legionella
suspected pathogen for CAP with risk factor of IVDU
Anaerobes, M. tuberculosis, S. sureus
suspected pathogen for CAP with risk factor of lung abscess
anaerobes, M. tb, S. aureus (MRSA)
suspected pathogen for CAP with risk factor of travel to middle east
MERS-COV
suspected pathogen for CAP with risk factor of travel to Southeast asia or east asia
SARS, or avian influenzae
most common viral cause of pneumonia in pediatric patient less than 2 years of age
rhinovirus and RSV
what is the most common bacterial pathogen in children 3 weeks to 4 years of age with pneumonia?
streptococcus pneumoniae
What is the suspected agent if patient with pneumonia shows lobar pattern in CXR?
bacterial
what is the most sensitive and more specific criterion of pneumonia used by WHO?
Tachypnea
what is the WHO criteria of tachypnea in neonates, how many breaths per min?
> or equal to 60
what is the WHO criteria of tachypnea in 2 to 12 months of age, how many breaths per min?
> or equal to 50
what is the WHO criteria of tachypnea in 1 year old to 5 years old,, how many breaths per min?
> or equal to 40
what is the WHO criteria of tachypnea in children aged 5 years and above, how many breaths per min?
> or equal to 30
What are the usual characteristics/symptoms and signs of children with pneumonia?
fever, tachypnea, wheezing or crackles, nasal flaring, decreased breath sounds, cyanosis, consolidation in chest ultrasound
What criteria can you consider to make the diagnosis of pneumonia less likely?
absence of fever
O2 saturation greater than 94
absence of tachypnea, nasal flaring, and chest wall retractions
When is PCAP A/B considered as the classification of the pneumonia?
when there is no sign of respiratory distress (to differentiate from PCAP C, and D)
no altered CNS functions
none or mild malnutrition, dehydration and comorbid,
mild cxr findings
When is PCAP C considered?
when there are signs of respiratory distress such as head bobbing, cyanosis and IC/subcostal retractions but not yet with grunting and apnea
if with grunting and apnea, considered PCAP D
also with altered CNS and signs of malnutritions and dehydration, and comorbid conditions
Where to admit PCAP C patients? PCAP D?
PCAP C at wards
PCAP D at ICU
When to say that deyhdration is mild?
thirsty
increased pulse rate
decreased urine output
normal PE
When to say that deyhdration is moderate?
tachycardia, sunken eyes and fontanels. little of no urine output dry mucous membrane, delayed capillary refill >2s cool and pale
When to say that deyhdration is severe?
rapid and weak pulses no urine output very sunken eyeballs and fontanels no tears delayed capillary refill >2s cold and mottled skin
what are the essential diagnostic aids to request in suspected pneumonia?
Pulse oximetry for O2 saturation Gram stain and culture of sputum Chest Xray PA and lateral Chest ultrasound C reactive protein procalcitonin CBC ABG if severe (migh indicate metabolic acidosis) serum sodium for hyponatremia
What is the predictive marker for mortality in pneumonia?
pH in ABG
In the management of bacterial pneumonia, when can you do switch therapy?
when parenteral antibiotics has been gicen for at least 24 hrs
At least afebrile for last 8 hrs without antipyretics
Responsive to current antibiotic therapy
Able to feed without vomiting or diarrhea
Without any pulmonary or extrapulmonary signs
What are the 4 series of changes/phases of pathogenesis seen at least in lobar type pneumonia?
edema (proteinaceous exudates) red hepatization (rbcs are extavasating, bacterial proliferation, neutrophil influx) gray hepatization (sign of containmment of infection, no more extravasating erythrocyte) resoliution (macrophage is dominant)
What are the most common manifestations of pneumonia in adults?
tachypnea
tachycardia
fever
at least one abnormal chest findings (crackles, wheeze, diminished breath sounds, rhonchi)
what are the features of moderate risk CAP?
altered mental state suspected aspiration decompensated comorbids unstable vital signs CXR may show multilobar inflitrates, pleural effusion, abscess
what are the features of high risk CAP?
any of criteria under moderate risk CAP plus:
severe sepsis and septic shock
need for mechanical ventilation
need for ICU admission
what are the features of low risk CAP?
stable vital signs
no altered mental state
no suspected aspiration
no or stable comorbids
can be managed as outpatient
What diagnostic testing should be requested next if the pneumonia is non-resolving?
request for invasive procedures to get samples directly from the lung parenchyma
- transtracheal biopsy
- transthoracic biopsy
- bronchoalveolar lavage
- protected brush specimen
What is CURB-65?
Confusion Urea (BUN) > or equal 7mmol/L Respiratory rate > 30breaths/min Blood pressure <90/60 65- age
interpretation:
0-1: outpatient
2 points: admit patient
> or equal to 3: ICU admission
What category risk of CAP does Legionella and Anaerobes cause?
moderate to high risk
What category risk of CAP does Staph aureus and Pseudomonas aeruginosa?
high risk
Duration of treatment for P. aeruginosa in CAP?
14-21 days
Duration of treatment formycoplasma and chalmydophila in CAP?
10-14 days
Duration of treatment for Legionella in CAP?
14-21 days (10 days if azalides are used)
Duration of treatment for MRSA/MSSA CAP?
7-21 days for MRSA (28 days if with bacteremia
7-14 days for MSSA (28 days if with bacteremia)
Duration of treatment for most bacterial pneumonias aside from specific causes?
usually around 5-7 days
What is the discharge criteria for CAP admission?
stable vital signs with >90 O2 saturation and functioning GI tract
what does bacteriologically confirmed PTB means?
diagnosed as TB through smear positive or culture positive or rapid diagnostic test positive (Xpert MTB/Rif)
What does clinically diagnosed PTB means?
negative in DSSM and culture but highly suggestive of TB according to symptoms and radiologic findings.
Also, when patient is high risk like HIV/AIDS positive
still treated as TB
What does new case TB means?
Patient never had TB treatment before or had treatment but only less than 1 month
What does retreatment case TB means?
Patient treated previously treated with TB drugs for at least 1 month
What does relapse TB case means?
Patient was previously cured from TB (DSSM neg and culture neg after treatment completion) but ha recurrence of TB after some time
What does treatment after failure case in TB means?
Patient was treated with TB drugs but still smear positive after 5 months or later of treatment
what does lost to follow-up cases mean in TB?
patient was previosly treated with TB drugs but was lost to follow up for about 2 months or more
what does previous treatment outcome unknown?
previosuly treated with TB with outcome unknown not documented
What does MDR TB means?
TB that is resistant to atleast both rifampicin and isoniazid
What does XDR TB means?
resistant to fluoroquinolones at at least one of second-line injectable drugs
what is considered as positive induration in tuberculin skin test?
> 10mm induration
what is tuberculin skin test?
screening toll for TB infection in children
results are based on induration/whealing of skin test
should not be used alone in diagnosis of TB
what is DSSM?
used to have definitive diagnosis of TB
monitor progress of antibiotic therapy
confirm cure from antibiotic therapy
two adequate sputum specimens should be submitted
What are the 4 first line drugs in TB therapy?
HRZE Isoniazid Rifamipicin Pyrazinamide Ethambutol
Who are included in Category I TB treatment regimen? what is the recommended regimen?
new cases of PTB and EPTB (either bacteriologically or clinically confirmed)
2HRZE, 4HR
(can include ethambutol in 4HR if suspected to be in highly resistant area)
Who are included in Category Ia TB treatment regimen? what is the recommended regimen?
new case of EPTB with involvement of CNS, bones or joints
2HRZE, 10HR
Who are included in Category II TB treatment regimen? what is the recommended regimen?
previously treated drug-susceptible PTB or EPTB such as cases of relapse, treatment after failure, lost to follow-up, treatment outcome unknown
2HRZES and 1 HRZE, 5HRE
Who are included in Category IIa TB treatment regimen? what is the recommended regimen?
previously treated drug-susceptible EPTB with involvement of CNS, bones, or joints
2HRZES and 1HRZE, 9HRE
Who are included in drug-resistant TB treatment regimen? what is the recommended regimen?
those who are found to be drug-resistant in standard regimen drug-resistant (SRDR) and XDR
individualized based on previous treatment
Define COPD
characterized by airflow obstruction
irreversible and progressive disease with progression of breathlessness (ask for progression of breathlessness)
composed of chronic bronchitis and emphysema
diagnosed either by spirometry or CT scan/histology (emphysema)
highly link with smoking
disease of the old (35 years beyond)
p
Define chronic bronchitis
a component of COPD
characterized by airflow obstruction with chronic productive cough everyday for 3 months more in 2 consecutive years
diagnosed through spirometry and presence of productive sputum
linked with smoking
Define emphysema
a component of COPD
characterized by airflow obstruction due to abnormal increase in size of alveoli/airspace brought by progressive destructiob of alveolar tissue
highly linked with smoking
diagnosed through CT scan or histology
What symptoms could differentiate breathlessness with respiratory origin from breathlessness with cardiac origin?
breathlessness with cardiac origin usually presents with:
orthopnea/PND
chest pain
palpitations
cardiac pe abnormalities
risk factors for CV disease like hypertension, diabetes, and obesity
anemia may also cause breathlessness, check for Hgb
What are the usual causes of pulmonary/airway obstruction?
most likely COPD and asthma
may also consider other diseases like stricture tumour compression obliterative bronchiolitis pulmonary edema
How to differentiate COPD from asthma?
Asthma is reversible while COPD is irreversible. Affter inhalation of short acting b2 agonists, check spirometry again and see if FEV1/FVC improves. If it improves, most likely it is asthma.
Improvement in FEV1 of greater or equal to 15% of baseline value or 400mL
asthma also presents with cough more frequent at night and early morning, with wheezing
How does COPD cause airflow obstruction?
COPD causes airway inflammation and loss of alveoli and lung parenchyma that causes airflow obstruction
What is the histological characteristics of airway in chronic bronchitis?
Airways in chronic bronchitis are inflamed and scarred.
Many mucus-producing goblet cells replacing the respiratory epithelium
thickened airway walls with increased luminal secretions
INFLAMED SCARRED GOBLET CELLS THICKENED WALLS INCREASED SECRETIONS SMOOTH MUSCLE SPASMS
How does loss of elastic recoil in emphysema causes airflow obstruction?
Elastic recoil contributes to positive intrathoracic pressure that is required to push air out of the lungs to the environment.
Loss of elastic recoil in emphysema leads to loss of positive intrathoracic pressure. Air cannot go out. Therefore, there is air trapping leading to hyperinflation. Thus, obstructive in nature.
Assessment of severity of airflow obstruction is based on what parameter in spirometry? How is it classified?
FEV1
Mild if 50-80% of predicted
Moderate if 30-49% of predicted
Severe if <30% of predicted
What is the histological characteristics of lung parenchyma in emphysema?
DESTROYED LUNG PARENCHYMA
BLACK STAINING
MULTIPLE HOLES IN CT SCAN
BULLAE IN CT SCAN
these result to loss of elastic recoil
How should you interpret results of CXR in COPD patients?
CXR in COPD patients should show:
- increased aeration (increased lucency)
- upper border of liver should be at top of 5th ICS midclavicular line
- flattened diaphragm
- increased spaces between ribs
also notice for other abnormalities like tumor, vascularities, pneumothorax, pleural effusion
What are the main goals in COPD management?
- Minimize progression of the disease, delaying or preventing further disability.
- Relieve symptoms
Cannot treat the damaged done because it is irreversible
What treatment should be advised to minimize or prevent progression of disease in COPD?
stop the inciting trigger
STOP SMOKING
What treatment relieves COPD symptoms like breathlessness?
SMOKING CESSATION
PULMONARY REHABILITATION
DRUGS (may help like SABA, LABA, CORTICOSTEROIDS, ANTI-MUSCARINIC)
What is pulmonary rehabilitation? When it is usually advised? What are its benefits?
pulmonary rehab is a 6-12 weeks of physical exercise, disease education, psychological and social interventions. It is run by multidisciplinary teams
advise usually for COPD and post lung surgery patients
benefits are:
reduced breathlessness
improve exercise capacity
improve health-related quality of life
What pharmacologic drugs can be prescribed to COPD patients?
SABA (SALBUTAMOL) can help prior to exercise rehab; may help reduce breathlessness
ANTI-MUSCARINICS (IPATROPIUM)
LABA (SALMETROL, EFORMOTEROL) for moderate and severe COPD
LONG-ACTING ANTIMUSCARINICS (TIOTROPIUM)
XANTHINES (not clearly studied but may help)
What important symptoms are usually related to lung cancer?
weight loss
hemoptysis
smoking (but can also be found in non smokers)
How to calculate for pack years of cigarette?
(cigarettes per day/20) times number of years smoked
What is the relationship between risk of lung cancr and pack years of cigarettes?
there is 70% increase risk of lung cancer for every 10 pack years smoke
those who do not smoke has less than 1% risk
What are possible effects/disease can tobacco smoking brought to your respiratory system?
COPD
lung cancer
laryngeal cancer
mouth cancer (for tobacco chewers)
what can you do reduce withdrawal symptoms of a heavy smoker who is trying to quit smoking?
Prescribe nicotine patches (15mg) to be applied at day at removed at night
nicotine however may have side effects like chest pain and blood pressure changes
chewing gum
what the six forms of nicotine that can be prescribed for smoking cessation?
transdermal patch chewing gum lozenge inhalator nasal spray sublingual tablet
What is/are the alternatives for nicotine replacement?
Bupropion (amfebutamone) -an antidepressant
common side effect is insomnia or dry mouth
can trigger seizures (should not be given to those with seizure history)
What are the 5 A’s used by health professionals to brief quit smoking intervention?
ask advise assess assist arrange
what are common features of exacerbation of COPD?
worsening breathlessness
change in sputum colour (in bronchiectasis, it’s increasing amount of sputum volume)
Define acute exacerbation of COPD
It is a sustained worsening of the symptoms from the stable state like:
-increased cough, breathlessness and sputum production
-change in sputum color
which is:
-more than usual day to day variations
-acute in onset (pneumonia usually has sub-acute presentation)
-may require a change in treatment
how to differentiate CRP levels when differentiating COPD exacerbations and pneumonia?
Both have elevated CRP levels but pneumonia has way higher CRP (187mg/L) level compared to COPD which only has arounf 54 mg/L
What is CRP? what is its relevance?
CRP is an acute phase protein which means its plasma concentrations increase by at least 25% during inflammatory conditions such as infection and autoimmune disease
Values >100mg/L
-bacterial infection
Values >10 mg/L
-clinically significant inflammation cause by infection and inflammatory conditions such as rheumatoid arthritis
Management for acute exacerbations of COPD?
acute oxygen therapy
nebulized SABA as bronchodilators
oral corticosteroids to decrease inflammation
antibiotics if with infections
What bacteria most likely cause COPD exacerbation?
H. influenzae
Moraxella catarrhalis
S. pneumoniae
What are the structural changes happens to the airway when there is anaphylaxis?
laryngeal edema
bronchoconstriction
vasodilation (leading to hypotension)
Why is it important to check for history of drug allergies?
A precaution to prevent anaphylaxis or other hypersentivity issues
What are first line drugs to immediately manage anaphylaxis?
intramuscular adrenaline/epinephrine
intravenous histamine
intravenous hydrocortisone
What is the value of PaO2 to say that the patient is in respiratory failure?
PaO2 below 8 kPa
What id henderson hasselbach equation?
(H+) + (HCO3-) -> (H2CO3) -> (H2O) + (CO2) and vice versa
What possible differential diagnosis can cause type II respiratory failure?
type 2 RF is hypercarbia
Ddx: severe COPD (due to fatigue of chest wall muscles, and other respiratory muscles) severe lung disease neurological muscular chest wall disease
How can you differentiate severe COPD from other differential dx of type 2 RF?
check for wheezing, lung hyperinflation andother COPD symptoms through spirometry, etc.
For neurological, muscular, and other chest wall disease, check through physical examination and neurological examination, and glasgow coma scale
why is is oxygen therapy must be cautiously administered to a patient with possible diagnosis of COPD who are at risk of CO2 rentention?
Patient with severe COPD has chronic CO2 retention which repeats the cycle of hypoventilation and hypercarbia. This desensitizes the respiratory center which is supposedly sensitive to CO2. In other words, the chemosenstive area becomes desensitized to changes in cO2 and highly relies to weaker stimulus like hypoxia.
In this case, hypoxia should supposedly trigger an increase in ventilation , however, if you administer O2 with high percentage, hypoxia will be corrected thus, removing the stimulus for ventilation. This further worsens the respiratory failure.
but even though oxygen treatment is difficult in this case, it is essnetial to treat hypoxia. Ventilatory support may be needed in this treatment.
Cite some indications for invasive ventilation?
- those who are severely unwell with imminent respiratory arrest
- severely impaired consciousness
- patients who cannot protect their airways and clear secretions
what are the complications of non-invasive ventilation?
aspiration in patients with reduced conscioussness
pneumothorax
gastrointestinal distension and perforation
what are the clinical features of hypercapnia?
bounding pulse
flapping tremor
confusion
(this is due to toxic effects on the brain and circulation)
what is the most common cause of type 2 RF?
severe COPD and acute exacerbations of COPD
but may type 2 RF may also be caused by neurological, muscular, and chest wall disease
what is does scooped expiratory flow in the flow volume loop means?
scooped expiratory flow means prolonged expiration suggestive of obstructive disease
what is the normal range of A-a gradient?
5 to 15 mmHg
this increases if there is hypoxemia
except hypoventilation and high altitude
Why is bronchoscopy not really used for diagnosis of cancer in an investigated pulmonary nodule?
it is because bronchoscopy will not reach peripheral lesions and will mislabel 10% of central cancers by finding non specific inflammatory changes.
Biopsy either US guided or open lung biopsy is more accurate than bronchosocpy
what CXR view is needed to visualize pleural effusions?
plain PA then lateral decubitus view
How does COPD lead to right heart dysfunction?
loss of pulmonary arterioles and capillaries as part og pathology of emphysema
pulmonary arterial vasoconstrictions secondary to hypoxia
increased viscosity og blood caused by polycythemia as a compensatory mechanism for hypoxia
What respiratory diseases may lead to cor pulmonale?
COPD especially chronic bronchitis
interstital lung disease
pulmonary fibrosis
In cor pulmonale, how can you assess further on the pulmonary arteries and right heart?
2d-echo and doppler echo
Right heart catherization
ECG
How does hypoxia cause polycythemia?
chronic hypoxia increases erythropoietin levels leading to blood cell formation in the bone marrow.
What respiratory consequence can polycythemia cause?
pulmonary hypertension due to high blood viscosity
it also increases systemic consequences like stroke and PE-DVT
What is cor pulmonale?
often referred as pulmonary heart disease or pulmonary hypertensive heart disease that causes rv hypertrophy and RV dilatation that may lead to Right-sided Heart failure
What usually causes Acute cor pulmonale?
massive embolus usually cause acute cor pulmonale where RV dilatation without hypertrophy occurs in the right side of the heart
What is the ptahophysiolgy of cor pulmonale?
it is primarily cause by changes in the pulmonary vasculature and/or the lung parenchyma that are sufficient to cause pulmonary hypertension leading to right sided heart failure
What diseases of the pulmonary parenchyma leads to cor pulmonale?
COPD Interstitial fibrosis Pneumoconiocosis Bronchiectasis (TB or recurrent pneumonia) Cystic fibrosis
What diseases of the pulmonary vasculature leads to cor pulmonale?
pulmonary thromboembolism
primary pulmonary hypertension
pulmonary arteritis (Wegeners granulomatosis)
tumor microembolism
drug- toxin- radiation- induced vascular obstruction
what diseases of the chest wall leads to cor pulmonale?
kyphoscoliosis
marked obesity or picwickian syndrome
neuromuscular disease
what physiological disorders leads to pulmonary vasoconstriction leading to pulmonary hypertension?
metabolic acidosis hypoxemia chronic altitude sickness idiopathic alveolar hypoventilation obstruction to major airways
what is pickwickian syndrome?
it also called as obesity hypoventilation syndrome, a condition in which severely overweight people fail to breathe rapidly or deeply enough resulting to low oxygen levels and carbon dioxide retention
Why is it necessary to request PET scan in a suspected cancer (lung cancer) with lympahdenopathy?
nodal metastasis has a poor prognosis in cancer therapy. Although lymphadenopathy usually accompanies cancer, it may be caused by other disease. It should be confirmed if the lymphadenopathy is a cancer metastatis and tocheck that is to request for PET scan.
what is the most common cause of lymphadenopathy in left supraclavicular area or the virchows node?
usually cause by stomach cancer metastasis
Other left sided lympahdenopathies ddx are:
-other abdominal and pelvic malignancies (stomach, pancreas, ovaries, prostate)
-left side lung cancer
-lymphoma
If it is right side supraclavicular nodes, most likely it is caused by:
- lung cancer metastasis
- mediastinal cancer
- esophageal cancer
- lymphoma
other: TB
What diagnostic investigations should be performed to make a histological diagnosis of cancer?
Fine needle aspiration
Ultrasound-guided biopsy
Fiberoptic bronchoscopy (if it is in the lung)
CT guided biopsy
what is pleural mesothelioma?
- malignant tumor arising from the pleura
- commonly associated with asbestos exposure
- may show signs of shortness of breath, pleural rub or pleural effusion
- mean survival from diagnosis is 8 to 14 months
what pulmonary conditions are associated with asbestos exposure?
pleural plaques
asbestosis (inflammation and fibrosis of the lung parenchyma dues to asbestos fibers in the lungs)
lung cancer
pleural mesothelioma
Why is careful pleural test necessary for a patient with suspected mesothelioma?
any pleural intervention with suspected mesothelioma may seed mesothelioma to other parts of the chest, that is why careful intervention is needed.
Thus, number of invasive procedures in the pleural cavity should be minimized if possible.
Why was the biopsy performed under CT guidance in a patient suspected with mesothelioma?
mesothelioma tends to affect patches of the pleura and therefore blind biopsy may miss disease and may need to be repeated. CT guidance increases the chance of making positive diagnosis and should reduce the number of pleural interventions required
Explain WHO analgesic ladder
Patient in pain should receive regular analgesia with additional drugs if pain is uncontrolled:
Step 1: regular simple analgesia (paracetamol)
Step 2: Add mild opioid analgesia (codeine)
Step 3: Use stronger opiate (morphine)
Step 4: Increase dose of opiates until pain is relieve
Adjuvant drugs such as NSAIDs or drugs to suppress nerve pain can be added to any step.
what causes hoarse voice?
laryngeal or vocal cord lesions
- laryngitis (viral infection, smoking, acid reflux)
- voice overuse
- inhaled steroids
- vocal cord nodules
- laryngeal carcinoma
damage to recurrent laryngeal nerves
- lung cancer
- thyroid surgery
- thyroid cancer
- dissection of the thoracic aorta
etc
How do secondary lung metastasis differ from primary lung cancer?
primary lung cancer is usually isolated while secondary metastasis have a cannonball appearance in CXR
What is pancoast’s tumour?
tumours in the lung apex which infiltrates the lower brachial plexus causing the symptoms of muscle arm wasting and pain
What are the significance of pulmonary function tests PFTs?
- to know the nature if restrictive or obstructive
- to assess disease severity
- post-treatment evaluation of lung function
What is methacholine challenge test?
can be used to test bronchial hyperreactivity
normal range of TLC values
80-120% of predicted
normal range of RV
75-120% of predicted
FEV1/FVC ratio
80% above
normal DLCO
75-120%
FEV1
80-120% predicted
Another parameter to detect obstructive lung disease aside from FEV1/FVC ratio. It detects obstructive disease earlier.
FEF (forced expiratory flow)
What is the expected results of PFTs in a patients with interstitial lung disease? heart failure?
restrictive nature
lowered DLCO
same with heart failure
What is the expected results of PFTs in a patients with emphysema?
obstructive nature
decreased DLCO
Increased DLCO may be seen in what conditions?
pulmonary hemorrhage
goodpasture’s syndrome
What is Goodpasture’s syndrome?
it is a group of diseases that affect the lungs and kidneys. It is an autoimmune disorder that attacks the basement membrane. Also called as anti-glomerular basement membrane disease. Diagnosis is through antigen-antibody testing.
What does scooped expiratory flow volume loop means?
scooped expiratory flow volume loop means that the person has obstructive disease.
What is the normal value of A-a gradient?
5-15 mmHg
What is parapneumonic effusion?
pleural effusion usually caused by bacterial pneumonia
If it complicates to empyema, it needs immediate chest tube drainage rather than antibiotics alone
What are some indications for intubation?
upper airway injury (burns, laryngeal edema, trauma)
airway compromise
neurological depression
loss of protective reflex (gag and cough reflex)
What prompts the need of mechanical ventilation?
usually different types of RF
if with metabolic acidosis and hypercapnia and cannot support spontaneous ventilation by itself
What are the most important laboratory tests in the evaluation of respiratory compromise?
ABG measurement to see the status of blood gases wheter hypoxemic or hypercapnic or ph level derangements
What does pleural effusion with lymphocytic predominance suggest?
Tuberculosis
What does pleural effusion with hemorrhagic characteristic indicates?
can be: mesothelioma lung or breast cancer pulmonary thromboembolism trauma
what are the possible risk factors for lung cancer?
- smoking (1st)
- radon (2nd most common; from uranium decay)
- asbestos (asbestosis, mesothelioma)
- arsenic in water (found in ground water from mining, industrial and arsenic pesticides
- genetic predisposition (p53)
- occupational exposures (arsenic, cobalt, chromium, cadmium, asbestos)
- ionizing radiation
what are the two most common types of lung cancer?
adenocarcinoma (most common)
bronchogenic carcinoma
What are the characteristics of lung adenocarcinoma?
- cancer of lung gland cells (glandular)
- usually found in periphery
- more common in women
- most common types in patients who are NON SMOKER
- has mucinous and non-mucinous subtypes
- metastasize widely
What are the characteristics of lung large cell carcinoma?
- is more like an adenocarcinoma that is poorly differentiated
- poorly differentiated adenocarcinoma
- large cells without cytoplasmic differentiation
- more common peripherally
What are the characteristics of lung/bronchogenic squamous cell carcinoma?
- squamous dysplasia from columnar epithelium of the airways
- centrally located
- slow growing
- can be shown in bronchogenic washing or cytological examination of sputum
- associated with hypercalcemia
What are the characteristics of small cell carcinoma of the lung?
- usually centrally located
- fast growing
- early metastasis commonly to brain, liver, adrenal glands, and bone
- associated with eaton-lambert syndrome, paraneoplastic syndrome, inappopriate ADH secretion
- SVC syndrome
What are some systemic effects of paraneoplastic syndrome?
Hypercalcemia Cushing syndrome SIADHS Eaton-Lambert syndrome Pulmonary hypertrophic osteoarthropathy Anemia DIC
What is the most common site for metastasis for primary lung cancer?
- Liver
- Bone marrow
- Adrenal glands
- Brain
Why is pet scan not used to diagnose metastasis to the brain? what is the alternative diagnostic tool?
brain also uses a lot of glucose which will diffusely light up in PET scan. Thus, brain MRI is used to diagnoses metastasis in the brain.
What diagnostic tools are used for staging of cancer?
CT scan
PET scan
or combination which is the FDG-PET
What does limited disease means in cancer?
It means that cancer only invades the lung, hilar, and mediastinal lymph nodes
without invasion of the organs
What does extensive disease means in cancer?
means that cancer metastasized to other organs
What is the advantage of radiation therapy over chemotherapy?
radiation treatment kills rapidly dividing cells locally through ionizing radiation, it has no systemic effects compared to chemotherapy
what are the disadvantages or complications of radiotherapy in lung cancer treatment?
may have the following complications: skin reactions mucositis hoarseness of voice hypothyroidism low blood counts lung fibrosis heart complications secondary cancer brought by radiation dysphagia is there is stenosing
what is neoadjucvant therapy?
radiation before surgery to shrink tumor
surgery
radiation or chemotherapy after surgery to eliminate remaining cancer cells
What is an external beam radiation therapy or EBRT?
it delivers high doses of radiation to lung cancer cells from OUTSIDE of the body. It directs to the tumor.
What id High dose rate (HDR) Brachytherapy?
Internal radiation
it delivers high doses of radiation from implants placed close to or inside the tumors of the body
-usually used by gynecologist for endometrial and cervical cancer
what are the advantages of ERBT?
it targets the tumor directly while minimizing damage to healthy cells
does not carry standard surgical risks like bleeding, blood clot, post-operative pain
*this is not given to stage 4 cancer which has already diffuse cancer
What is chemotherapy?
it uses drug treatment to kill fast growing cancer cells examples are: Capecitabine (Xeloda) Doxurubicin Oxaliplatin Paclitaxel
Its effects are systemic in nature which also affects fast growing normal cells like GI epithelial cells and hair cells
why is there a need for repeated doses or cycles of chemotherapy?
chemotherapy only kills a fraction of cancer cells that is why repeated doses are needed to prevent exponential growth of cancer cells.
what is targeted therapy for lung cancer?
it is a kind of personalized treatment for those who have mutations in the tyrosine kinase domain of EFGR
Phenotype most likely eligible for this treatment are those who are: non-smoker, female, east-asian, adenocarcinoma
What is the mechanism of avastatin for cancer therapy?
used to block neovascularization in cancer cells
What are the target genes in targeted therapy for lung cancer?
EFGR
HER1 (increases neovascularization through VEGF and MMP)
Give examples of Tyrosine Kinase inhibitor used for treatment of lung cancer with TK mutations?
Gefitinib (Iressa)
Erlotinib (Tarceva) -side effect is rash (the more rash, the more effective is the therapy)
Afatinib
What is immunotherapy?
it is the latest discovered treatment for cancer. Immunotherapy drugs can block tumor cells from deactivating T-cells.
What are some complications of chemotherapy?
alopecia anemia diarrhea extravasation leukopenia nausea and vomiting stomatitis thrombocytopenia
What pharyngeal arches give rise to multiple muscles and cartilage structures in the oropharynx and larynx? what pharyngeal arch degenerates?
4th and 6th give rise to structures related to respiration
5th pharyngeal arch degenerates
Laryn, trachea, and lung bud is an outpouching of the ____?
esophagus
What is the sensory and motor innervation of the diaphragm?
C3, 4, 5 keep the diaphragm alive
345 is the phrenic nerve
What are the 4 parts that made up the diaphragm?
SPBD (several parts build the diaphragm)
Septum transversum
pleuroperitoneal folds
body wall
dorsal mesentery of the esophagus
What is the most common TEF-EA type? 2nd most common?
Type C- (esophageal atresisa, distal TEF)
Type A- isolated EA, no TEF
Clinical correlation of Potter syndrome to AF volume and pulmonary development?
Potter syndrome is a kind of renal malformation in utero. With this condition, there is little volume of AF (OLIGOHYDRAMNIOS). Aspiration of AF is essential for lung development and fetal breathing movements. With too little AF, there is underdevelopment of pulmonary structures or PULMONARY HYPOPLASIA.
which side of the body does diaphragmatic hernia occurs? why?
left side
because liver on the right prevents herniation of bowel in the right thorax.
What is the innervation of visceral pleura? parietal pleura?
visceral pleura lacks sensory innervation
parietal pleura is innervated by branches of the INTERCOSTAL and PHRENIC nerves and is highly sensitive to pain but visceral pleura is not
Possible differentials for transudate pleural effusion? exudate?
transudates are usually from SYSTEMIC causes and usually BILATERAL
- CHF
- LIVER CIRRHOSIS
- NEPHROTIC SYNDROME
Exudates are usually from LOCAL causes and usually UNILATERAL
- LUNG INFECTION
- PE
- MALIGNANCY
what structures pierce through the diaphragm and at what levels of the vertebrae?
mnemonic (I 8 10 EGGS AAT 12)
Ivc at T8
EsopaGus vaGus at T10
Aorta, Azygous, Thoracic duct at T12
What are the arrangement of intercostal vessels from superior to inferior? what part of the rib they are located?
VAN (superior to inferior)
located at the INFERIOR BORDER of the rib
Paralysis of diaphragm, what nerve is severe?
ipsilateral paralysis of diaphragm results fromseverement of the PHRENIC NERVE
what is kartagener syndrome?
also called as immotile cilia syndrome or primary ciliary dyskinesia), a defect in the protein dynein prevents cilia from moving proplerly,
This results to impaired clearance of secretions and FREQUENT RESPIRATORY INFECTIONS, as well as INFERTILITY, SITUS INVERSUS OR SITUS AMBIGUUS (HETEROTAXY)
What do you call the alveolar macrophages that phagocytize RBCs in CHF?
HEART FAILURE CELLS
What are the 2 roles of ACE?
- Covert Angiotension I to II
- Breakdown bradykinin
increase bradykinin results to cough and angioedema
ACE inhibitors inhibit ACE, which in turns prevent breakdown of bradykinin, increasing its levels
What is OSA?
OSA occurs when excess body weight, extra pharyngeal tissue, or abnormal anatomy (tonsillar hypertrophy or short mandible) blocks the upper airway passages when the patient is sleeping. The obstruction causes periods of hypoventilation and hypoxia resulting to nocturnal awakenings, poor sleep and daytime somnolence.
Treatment is CPAP
For mechanically ventilated patient, hypoxia (low O2) can be corrected by?
increasing FiO2 or PEEP
For mechanically ventilated patient, hypercarbia can be corrected by?
increasing minute ventilation or tidal volume
Causes of RIGHT-SHIFTED hemoglobin dissociation (or the decrease of affinity of hemoglobin to oxygen leading to GREATER OXYGEN UNLOADING?
BAT ACES increased of the following: BPG (2-3 BPG) Altitude Temperature Acid (decrease in pH) CO2 Exercise Sickle cell
What is the rule of thumb for translating PO2 and SpO2?
40-50-60 PO2 corresponds to 70-80-90% SpO2 respectively
What is the pathology behind CO poisoning? What is the immediate management?
CO binds to hemoglobin 240 times than O2, thus creating an allosteric change in thehemoglobin that prevents the unloading of O2 from other binding sites. This causes a left shift of the curve and results in hypoxemia in CO poisoning.
Treatment: high-flow O2
What is Bosental drug for?
for pulmonary hypertension
Bosentan is antagonist of endothelin. It lowers the PVR by relaxing the blood vessels.
What is the most potent cerebral vasodilator?
CO2
Increased in CO2 decreases cerebral vascular resistance, resulting in increased perfusion and intracranial pressure
Obstructive lung diseases mnemonic ABCDE
Asthma Bronchiectasis Chronic bronchitis Decreased FEV1/FVC ratio Emphysema
What are the common non allergic causes of asthma?
aspirin
exercise
occupational exposure
viral infection
How to tell emphysema in CXR?
hyperlucency
increased ICS
enlarged retrocardiac clear space in lateral CXR
flattened diaphragm
Why is aspirin not given to asthmatics?
Aspirin blocks the cyclooxygenase pathway which favors the leukotriene pathway, exacerbating the roles of leukotriene in asthma pathology. Leukotrienes are potent vasoconstrictor.
What is pulsus paradoxus?
a decrease of blood pressure by 10 mmHg or more during inspiration.
It is seen in cardiac tamponade, asthma, OSA, and croup.
How does asthma exacerbation lead to respiratory failure?
asthma exacerbations are typically associated with respiratory alkalosis from tachypnea. Signs of acidosis (decrease pH and increased PaCO2) suggest impending respiratory failure as the patient’s muscle of respiration become fatigues. This is a potential emergency requiring intubation.
What are the adverse effects associated with supplemental O2 administration in patients with NRDS?
RIB
Retinopathy of prematurity
Intraventricular hemorrhage
Bronchopulmonary dysplasia
What part of the lung does asbestosis usually affects? silcosis and coal? (remember the mnemonic for this)
Asbestosis is from the roof but affects the base (lower lobes).
Silica and coal are from the base (earth) but affects the upper lobes.
What are the causes of hypercalcemia? (CHIMPANZEES)
Calcium excess intake Hyperparathyroidism, Hyperthyroidism Iatrogenic (thiazides) Multuple myeloma Pagets disease of the bone Addisons disease Neoplasms Zollinger Ellison syndrome Excess Vitamin D Excess Vitamin A Sarcoidosis
Pneumoconiosis associations:
Silica –>
lung nodules
eggshell calcification inhilar nodes
TB
Pneumoconiosis associations:
coal workers pneumoconiosis –>
Dust cells (alveolar marcphages with anthracotic pigments)
Pneumoconiosis associations:
Asbestosis –>
Bronchogenic carcinoma
Malignant mesothelioma
Pneumoconiosis associations:
Berylliosis –>
Granulomas mimicking sarcoidosis
Drugs that causes pulmonary fibrosis (mnemonics: Breathing Air Badly from Medications)
Bleomycin
Amiodarone
Busulfan
Methotrexate
Pharmacological management for DVT
Give HEPARIN for 6 days then starting warfarin simultaneously (or before transitioning to warfarin)
Heparin has a faster onset than warfarin, this also decreases the risk of warfarin-induces skin necrosis
What are possible DDx for hypercoagulable states?
FACTOR V LEIDEN ANTITHROMBIN DEFICIENCY PROTEIN C AND S DEFICIENCY DYSFIBRIGENEMIAS ANTIPHOSPHOLIPID SYNDROME IMMOBILITY PREGNANCY ORAL CONTRACEPTIVE USE OBESITY
Types of emboli (mnemonic: FATBAT)
Fat Air Thrombus Bacteria Amniotic fluid Tumor
What structure is the point of interest to differentiate thrombi that form pre- and post-mortem?
Lines of Zahn
-an interdigitating pink (platelets) and red (RBCs) found only in thrombi BEFORE DEATH
What is Cheyne -Stokes respiration?
refer to a cyclic breathing pattern in which a period of apnea is followed by a gradual increase in tidal volume and respiratory rate, then a gradual decrease until the next apneic period.
This occurs when damage to the respiratory center causes a delay between the brain stem’s detection of changes in blood gas levels (afferent response) and the compensatory adjustments in respiration (efferent response)
what are signs and symptoms of hypercalcemia?
stones, bones, abdominal moans, and pyschic groans
Nephrolithiasis
Bone Pains
Constipation or abdominal pain
Altered mental status (psychiatric overtones)
What provides motor innervation to all laryngeal muscles except cricothyroid muscles?
recurrent laryngeal nerve
What is the most common benign lung tumor?
bronchial hamartoma
-they contain islands of mature hyaline cartilage (hamartoma) and presents as well-defined coin lesion with POPCORN CALCIFICATION on CXR
