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Emergency Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

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1
Q

Acute Bronchiolitis

eti, sxs, dx

A

MCC RSV - fall and winter months

Infants and young children

Sxs:

  • tachypnea
  • respiratory distress
  • wheezing

Dx:

  • nasal washing for RSV culture antigen assay
  • CXR - normal
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2
Q

Acute Bronchiolitis

Tx

A

Hospitalization if

  • O2 Sat < 95-96%
  • < 3mos old
  • RR > 70
  • nasal flaring
  • retractions
  • atelectasis on CXR

Supportive Tx —>

  • humidified O2,
  • antipyretics,
  • B agonist (albuterol),
  • neb racemic epinephrine, and
  • steroids

O2 is only tx to improve

Ribavirin for severe lung or heart dz in IMC pts

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3
Q

Acute Bronchitis

eti, sxs

A

Cough > 5 days; lasts 1-3 wks

MC viral, Bacterial - M catarrhalis

Chronic Lung pt - H influ, S pneumo, M. catarrhales

Sxs:

  • Cough NO fever ( if + then consider PNA)
  • constitutional symptoms less severe than PNA
  • normal VS,
  • no Rales or egophony
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4
Q

Acute Bronchitis

dx, tx

A

CXR if uncertain or persistent symptoms

Tx:

  • Supportive - h2, analgesics, B agonist, cough suppressants
  • Acute exacerbation of chronic bronchitis - more likely to be bacterial
    • empiric 1st line- 2nd gen cephalosporin,
    • 2nd gen macrolide or Bactrim
      • eldery
      • underlying cardiopulmonary dz w/ cough >7-10 d
      • pts who is IMC
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5
Q

Acute Epiglottitis

eti, sxs

A

EMERGENCY - Supraglottic inflammation

airway obstruction d/t H. influenzas type B (Hib)

MC unvaccinated children

Sxs: 3 Ds of epiglottis

  • Dysphagia
  • Drooling
  • Respiratory Distress
  • tripoding
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6
Q

Acute Epiglottitis

dx, tx

A

X ray lateral film - Thumbprint sign

Secure airway - get cultures for H influ

Tx:

  • intubation
  • supportive care
  • Ceftriaxone* Tx as outpatient if stable
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7
Q

Acute Respiratory Distress Syndrome

eti

A

ARDS - respiratory failure characterized by fluid collecting in lungs = no O2

incr permeability of alveolar-capillary membrane -> development of protein rich pulp edema (non cariogenic pulm edema)

can also be d/t critically ill pts or those with significant injuries I.e. sepsis, severe trauma, aspiration of gastric contents, near drowning

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8
Q

ARDS

sxs

A
  • Severe SOB - unable to breath independently w/o ventilator
  • rapid onset of profound dyspnea occurring w/in 12-24 hrs after precipitating event
  • Tachypnea
  • pink frothy sputum crackles
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9
Q

ARDS

dx

A

ABG PaO2 and FIO2 ratio - not responsive to 100% O2

  • mild 200-300
  • mod 100-200
  • severe <100

CXR

  • bilateral infiltrates => white out pattern
  • spares CP angles

Cardiacs Cath of plum artery

  • Pulm cap wedge pressure (PCWP) < 18 mmHg = ARDS
  • if > 18 mmHg - Cardiopulm edema
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10
Q

ARDS

tx

A

Tx underlying cause

PEEP lowest setting to maintain PaO2 > 60 mmHg and keep O2 sat > 90%

often fatal

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11
Q

Asthma eti

A

Chronic, reversible inflammatory airway disease w/ recurrent attacks of breathlessness and wheezing

Sxs:

  • Samter’s triad
    • asthma nasal
    • polyps
    • ASA/NSAID allergy
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12
Q

Asthma sxs

A

SXS: triad of dyspnea, wheezing, cough chest tightness

PE

  • prolonged expiration with wheezing
  • hyperresonance to percussion
  • tachycardia
  • tachypnea
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13
Q

Asthma dx

A
  • PFT - dec FEV1, decr FEV1/FVC ratio
  • Methacholine challenge test >/= 20% dec in FEV1 Bronchodilator test >= 12% incr in FEV1
  • Peak Expiratory Flow Rate used in ED (nl is 400-600) PEFR >15% from initial attempt = response to tx
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14
Q

Asthma tx

A

Categorization

Mild intermittent - (<2x/wk or < 2n/mo) -

  • SABA PRN

Mild Persistent (>2x/wk or 3-4 n/mo)

  • low dose ICS daily

Mod Persistent - (Daily sx or > 1n/wk)

  • Low dose ICS + LABA Daily Med dose ICS + LABA daily

Severe Persistent (sx sev x / d and nightly)

  • High dose ICS + LABA qd High dose ICS + LABA + PO steroids

Acute exacerbations O2 Neb SABA Ipatropium bromide PO steroids (5-7 days)

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15
Q

Croup

A

Eti:

  • Infection of upper airway - obstructs breathing causing barking cough
  • MCC - parainfluenza virus
  • Children 6mos-3yo, fall - early winter mos

sxs

  • barking cough
  • stridor

dx

  • Steeple sign on PA CXR

tx

  • supportive - air humidifier
  • antipyretics
  • Severe - IV Fluids, neb racemic epi, steroids (Dexamethasone)
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16
Q

Foreign Body Aspiration

A

MC in mainstem or lobar bronchus R>L and d/t food

RFs - institutionalization, advanced age, poor dentition, etoh, sedative use

Sxs: Presentation depends on location of obstruction

  • Inspiratory stridor - high in airway
  • wheezing and decr breath sounds - low in airway

Dx

  • Expiratory CXR - hyperinflation to affected side
  • ABG - eval ventilation

Tx

  • Remove foreign body with bronchoscope
  • Rigid bronchoscopy in children
  • Flexible is diagnostic and therapeutic in adults
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17
Q

Hemoptysis

eti, sxs

A

Coughing up blood - airway bleeding

MCC

  • Bronchitis - hemoptysis, dry cough, cough with phlegm
  • Tumor mass - hemoptysis, chest pain, rib pain, tobacco hx, wt loss, clubbing
  • Tuberculosis - hemptysis, chest pain, sweating

Sxs:

  • blood stained mucus or blood from bronchi, larynx, trachea, or lungs
  • Bronchial capillaries rupture d/t acute infx (viral/bacterial bronchitis, bronchiectasis, cig smoking)
  • Tiny blood vessles broken
  • Vascular engorgement w/ erosions in Pulm HTN or masses
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18
Q

Hemoptysis

dx, tx

A

Dx

  • Cytology
  • Sputum/expectorant examination
  • Fiberoptic bronch - for CA tissue
    • biopsy
    • bronchial lavage
    • brushing
  • Rigid bronch - massive bleeding - better suctioning and airway maintenance capabilities
  • High Res CT - pathophys

Tx

  • massive hemoptysis - aggressive early consult with pulmnologist
  • ABCs - airway maintenance is vital - primary COD d/t aspyhixation
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19
Q

Influenza

A

Viral respiratory infx by orthomyxovirus (three strains A, B, C)

sxs

  • fever, coryza, cough, headache, malaise

Dx

  • rapid antigen test in clinic
  • rapid serology more accurate
  • CXR - bilateral diffuse infiltrates

Tx

  • symptomatic for most
  • antivirals w/in < 48-72 hrs
    • Tamiflu/Oseltamivir or Zanamivir/Relenza for influ A & B
    • hospitalized pts
    • outpt with severe progressive illness
    • high complications risk
      • IMC
      • chronic med conditions
      • >65yo
      • pregnant or 2 wks pp
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20
Q

Lung Cancer

subtypes

A

Two major categories

  1. Small Cell Lung Cancer (SCLC) - 15% and poor prognosis
  2. Non-Small Cell Lung Cancer (NSCLC) - 85%
  • adenocarcinoma​
  • squamous cell carcinoma
  • large cell carcinoma
  • carcinoid tumor

Dx

  • CXR to screen
  • Bronchscopy and biopsy or FNA - gold standard
  • Squamous Cell or SCLC - central mass
  • Adenocarcinoma - peripheral mass
  • LC and Carcinoid - throughout lungs
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21
Q

Lung Cancer - Adenocarcinoma

A

35-40% of cases

MC type of bronchogenic carcinoma

non-smoker w/ incidental finding and small peripheral lesion

22
Q

Lung Cancer - Squamous Cell Carcinoma

A

25-35% of cases

Bronchial in origin and centrally located mass

MC in smokers

likely to have hemoptysis, central bronchus solitary tumor

23
Q

Lung Cancer - Large Cell

A

rare 5%

rapid doubling time

rarely response to surgery

24
Q

Lung Cancer - Carinoid

A

1-2%

tumor that produces excess serotonin (niacin B3 deficiency)

Pink purple leasion in the central airway

resistant to chemo/radiation

surgical excision

25
Q

Lung Cancer - SCLC

A

15%

Highly aggressive

always occurs in smokers

rapidly growing, mets by dx

cannot be tx with sx, needs chemo/XRT

a/w

  • ACTH and ADH - hyponatremia and hypercalcemia
  • Lambert-Eaton myasthenic syndrome - muscle weakness of limbs d/t ACTH/ADH
  • SVC syndrome
  • Horner syndrome
26
Q

Horner’s Syndrome (Lungs CA)

A

Cervical sympathetic chain

  1. unilateral facial anhidrosis (no sweating)
  2. ptosis
  3. miosis
27
Q

Pancoast Syndrome

A

A/w Squamous Cell Carcinoma

tumor at lung apex

crushes brachial plexus + cervical sympathetic chain

  • Shoulder pain
  • UE weakness
  • Horner’s syndrome
28
Q

SVC Syndrome

A

a/w SCLC

obstruction of SVC by tumor resulting in

  • facial fullness
  • JVD
  • dilated veins in anterior chest
    *
29
Q

Screening for Lung Cancer

A

USPSTF

  • annual Lung CA screenign with low dose CT
  • 55-80 yo
  • 30 pack year hx
  • current smokers or
  • quit within last 15 years

Incidental finding on CXR

  • send for CT
  • if suspicious - need bx
    • Ill defined borders, lobular or spiculated = cancer
  • If not suspicious < 1cm
    • monitor q 3mos, 6 mos, yearly for two years
    • calcifications, smooth, well defined edges = benign
30
Q

Lung Cancer

Treatment

A

NSCLC

Stage 1-2 = sx

Stage 3 = chemo then surgery

Stage 4 = palliative

SCLC

chemo only

can’t be tx with sx

31
Q

Pertussis

eti, sxs

A

Whooping cough - severe hacking cough followed by high pitched intake of breath (sounds like whoop)

Gram neg bacteria = Bordetalla pertusis

Consider in adults with cough > 2 wks, patients < 2yo

  1. catarrhal stage - cold like sxs, poor feeding, sleeping
  2. Paroxysmla stage - high pitched inspiratory whoop
  3. Convalescent stage - residual cough (100 days)
32
Q

Pertussis

dx, tx

A

Nasopharyngeal swab of secretions and culture

Tx - with Macrolide (clarithomycin/azithromycin)

supportive care w/ steroids + B2 agonists

vaccinations

  • 5 doses - 2, 4, 6, 15-18mos, 4-6 yrs (DTap)
  • 11-18 yo = 1 dose Tday
  • Expectant mothers Tdap each pregnancy at 27-36 wks
33
Q

Pleural Effusion

A

Accumulation of excess fluids in pleura space

Sxs

  • dyspnea
  • vague discomfort or sharp pain that worsens during inspiration

Dx

Determine whether pleurocentesis

  • exudative (infection, malignancy, immune) or
  • transudative (transient changes in hydrostatic pressure - cirrhosis, CHF, nephrotic syndrome, ascites, hypoalbuminemia

Lateral decubitis CXR

  • Isolated L Pleural effusion = exudative
  • R sided = transudative

Chest CT

US

Thoracentesis - gold std and tx

34
Q

Light’s Criteria

A

Pleurocentesis to determine if Pleural fluid is exudative:

  1. Pleural fluid protein / serum protein >0.5
  2. Pleural fluid LDH / Serum LDH >0.6
  3. Pleural fluid LDH > 2/3

Exudative - infection, malignancy, immune,

MCC - pna, CA, PE, TB

35
Q

Pleuritic Chest Pain

A

Inflammation of tissues that line lungs and chest cavity (pleura)

sudden, intensely sharp , stabing, burning pain in chest when inhaling and exhaling

exacerbated by deep breathing, coughing, sneezing, or laughing

MCC - PNA, pericarditis, pericardial effusion, pancreatitis

36
Q

Pneumonia - Bacterial

A

S pneumo

Sxs

  • fever, dyspnea, cough
  • tachycardia, tachypnea
  • +/- sputum

Dx

  • Patchy, segmental lobar, multilobar consolidation
  • Blood cultures x 2
  • Sputum gram stain

tx

  • outpatient - doxy, macrolides
  • inpt - ceftriaxone + azithromycin/resp FQs
37
Q

PNA - Viral

A

Adults - Flu MC

Kids - RSV

quick onset

Dx

  • CXR - bilateral interstitial infiltrates
  • rapid antigen testing for flu
  • RSV nasal swab
  • cold agglutinin titer negative

Tx

  • Flu with Tamiflu (A & B) if sxs < 48hrs onset
  • symptomatic tx = B2 agonists, fluids, rest
38
Q

PNA - Fungal

A

Common in IMC pts (AIDS, steroid use, organ transplant)

Coccidiodes (valley fever)

  • non remitting cough/bronchitis non responsive to conventional tx
  • Fungal inhalation in Western States
  • Dx with ELISA for IgM and IgG
  • Tx with fluconazole/itraconazole

Pulmonary aspergillosis - health immune systems

  • fluconazole/itraconazole

Cryptococcus - soil, disseminate and a menintitis

  • LP for meningitis
  • Tx with amp B

Histoplasmosis - apical pulmonary lesions resembling cavitary TB, worsening cough and dyspnea, progression to disabling respiratory dysfx

  • bird or bat droppings - Mississippi Ohio River Valley
  • Signs - mediastinal or hilar LAD (sarcoid)
  • tx with amp B

HIV - PJP (Pneumocystis jiroveci)

Common in HIV pts with CD4 count < 200

  • CXR - diffuse interstitial or bilateral perihilar infiltrates
  • dx - bronchoalveolar lavage PCR, labs, HIV tests, low O2 despite supplemental oxygen
  • Tx with bactrim and steroids
39
Q

Curb-65 Score

A

Hospitalization for Pneumonia Severity

  • Confusion
  • Urea > 7
  • RR > 30
  • BP < 90/60
  • Age > 65yo

0-1 = low risk

2 = probable admission vs close outpt mgmt

3-5 = admission & manage as severe

40
Q

Pneumothorax

A

Collapsed lung caused by accumulation of air in pleural space

Spontaneous vs traumatic

  • primary - abs of underlying dz (tall, thin, male age 10-30 at greater risk)
  • Secondary - presence of underlying dz (COPD, asthma, CF, ILD)

SXS:

  • Acute onset ipsilateral chest pain and dyspnea - decreased tactile fremitus
  • deviated trachea
  • hyperresonance
  • Diminished breath sounds

Tx - depends on size

  • small < 15% of diameter of hemithorax - resolves spontaneously w/o chest tube placement
  • large > 15% diameter & symptomatic - chest tube placement
  • Serial CXR q 24 hrs until resolve
41
Q

Tension PTX

A

penetrating injury -> air in pleural space increasing and unable to escape

Mediastinal shift to contralateral side and impaired ventilation

CXR = pleural air

ABG = hypoxemia

medical emergency - large bore needles to allow air out of chest

Chest tube for decompression

42
Q

Pulmonary Embolism

eti, sxs

A

blockage in one of pulmonary arteries in lungs

MCC - deep veins of LEs

RF:

  • Virchow’s Triad
    • Hypercoagulable state (sx, CA, OCP, preg, smoking, long bone fracture)
    • Venous stasis
    • Epithelial injury

Sxs

  • Dyspnea MC
  • pleuritic chest pain
  • Tachycardia –> EKG with S1Q3T3, non spec ST waves
  • Tachypnea
43
Q

Well’s Criteria

A
44
Q

Pulmonary Embolism

dx

A

Dx - Well’s score assess probability of PE

  • Spiral CT - best initial test
  • Pulm angiography - gold standard
  • CXR - Westermark sign or Hampton Hump (Triangular or rounded pleural base ) BUT NORMAL

VQ scans - old school

ABG = respiratory alkalosis 2/2 hyperventilation => resp acidosis

D-Dimer only if LOW suspicion - RULE OUT

45
Q

Pulmonary Embolism

tx

A

Hemodynamically stable

  1. Anticoags
    • Warfarin - 3 mos bridge with heparin 3-5 days
      • INR range 2-3
    • Heparin - acute phase with followed by factor Xa inhibitors Rivaroxaban or PO Direct Thrombin Inhibitors Dabigatran
  • Minimal antigoag for 3 mos w/ reversible RFs
  • if unprovoked - 6 mos then reeval
  • If two eps unprovoked - long term anticoag
  1. IVC filter - stable pt who can’t take anticoags or unsuccessful

UNSTABLE

  1. Thrombolectomy - if unstable or massive PE
46
Q

Respiratory Syncytial Virus

A

MCC LRTI in children - get by age 3

leading cause of PNA and bronchiolitis

sxs

  • Rhinorrhea
  • wheezing/coughing that persists for months
  • low grade fever
  • nasal flaring/retractions
  • nail bed cyanosis

Tx

  • hospitalization if
    • tachypnea w/ feeding difficulties
    • visible retractions
    • O2 Sat <95%
  • Supportive care
    • albuterol via neb
    • antipyretics
    • humidified O2
    • Steroids (controversial)
    • Resolves in 5-7 days

Vaccines for children with lung issues or premature –> synagis prophylaxis (palivizumab) 1x/m for 5 mos in Nov

47
Q

Tuberculosis

eti, sxs

A

Mycobacterium tuberculosis

RF - endemic area, IMC (HIV), recent immigrants (<5yo), prisoners, health care workers

transmission - inhalation of aerosolized droplets

Sxs:

  • fatigue, productive cough, bloody sputum
  • night sweats, wt loss, post tussive rales
48
Q

Tuberculosis

Screening

A

PPD - Tb skin test

Mantoux Test Rules - tests positive if

  • >5mm at high risk, fibrotic changes on CXR, IMC HIV/Drugs, steroids/TNF antagonist daily, or close contact w/ infectious TB
  • > 10mm in pts < 4yo, and risk factors = health care facilities, IVD, recent immigrants with high prevalence, renal insufficiency, prison, homeless shelter, bypass surgery
  • > 15mm if no other risk factor
49
Q

Tuberculosis

Dx

A
  • Sputum for AFB smears - have to be 3 AFB negatives
  • NAAT - quicker dx
  • CXR - cavitary lesions, infiltrates, ghon complexes in apex of lungs
  • Bx - caseating granulomas
    • miliary TB = spread outside lungs => vertebral column (Pott disease)
50
Q

Tuberculosis

tx

A

Empiric tx

PPD + & CXR negative - latent TB => Isoniazid 9 mos +B6 for neuropathy

PPD + & CXR positive - active TB => quad therapy (RIPE)

  • Rifampin - red orange urine, hepatitis
  • Isoniazid - perip neuropathy (B6 pyridoxine 25-50mg/day)
  • Pyrazinamide - hyperuricemia (gout)
  • Ethambutol - optic neuritis (eye changes), red green blindedness

Need two negative AFB smears and cultures to stop therapy

Prophy isoniazid for household members - for 1 year

dc therapy if transaminases > 3-5 x ULN

51
Q

Shortness of Breath

A

RR > 25 or < 10

O2 Sat < 92%

usu in older adults

weak respiratory effort

Hypercapnia - elevated CO2 on ABG

DDx

  • Asthma
  • COPD
  • CHF

Tx

  • HFNC or rebreathing mask 100% O2
  • Albuterol for asthma and COPD
  • Lasix for CHF
  • BiPAP for respiratory difficulty and low O2 sat
  • Intubation for severe cases
52
Q

SOB

Pearls

A

VS addressed first

SOB - initial tx is O2

R/o Pulm and cardio etis

CXRs, CBC, CMP, BNP, Trop, EKG on all patients

ABGs - resp is functioning

Emergency Medicine (13 decks)

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