Pulmonology Flashcards
Is pulmonology what is considered a shunt?
An area of lung that is perfused but has no ventilation
What is cor pulmonale?
Right heart failure due to pulmonary hypertension
*pulmonary htn is usually caused by chronic local hypoxic vasoconstriction due to dz like asthma or chronic bronchitis
Physiologic V:Q mismatch
Low V:Q in lung bases
High V:Q in lung apices
Pathologic V:Q mismatch
Low: asthma, chronic bronchitis, pulmonary edema
High: emphysema, PE, foreign body
Control of respiration
Central receptors in the medulla or peripheral receptors in the carotid bodies and aortic bodies detect increased PaCO2
Phrenic nerve stimulation increases rate and depth of respiration
*peripheral receptors are sensitive to low PaO2 but only if hypoxia is significant
Samter’s triad
Asthma
Nasal polyps
ASA/NSAID allergy
Lung exam findings in asthma
Prolonged expiration with wheezing, decreased breath sounds, and hyperresonance to percussion
Signs of status asthmaticus
Inability to speak in full sentences
AMS
pulsus paradoxus
Cyanosis
Tripod positioning
Silent chest
Tachycardia/tachypenea
Pulsus paradoxus
SBP decreases >10 mmHg with inspiration
Best way to assess asthma exacerbation/severity and monitor asthma
Peak expiratory flow rate (PEFR)
Asthma management in ED
Nebulized SABA q20min x3 then reassess
dc on short course (3-5d) oral corticosteroids
SE of SABAs
Tachycardia, tremor, CNS stimulation, and hypokalemia
SE of antimuscarinics
Thirst dry mouth blurred vision urinary retention dysphasia acute glaucoma BPH
SE of steroids
Immunosuppression Hyperglycemia Fluid retention Osteoporosis Growth delay Psychosis Thinning skin
Thrush-inhaled
DOC long term persistent asthma
Inhaled corticosteroids
MOA cromolyn and nedcromil
Inhibits mast cell and leukotriene mediated degranulation
*helps limit acute response to cold air and exercise
Omalizumab
Anti-IgE antibody
Used in severe uncontrolled asthma
Classification of intermittent asthma
Sx <2x week and <2x a month at night
Treatment of intermittent asthma
SABA prn
Classification of mild persistent asthma
Sx >2d/wk and night sx >2x month
Treatment of mild persistent asthma
Low dose ICS
SABA prn
Classification of moderate persistent asthma
Daily sx and nightly sx >1xweek
Treatment of moderate persistent asthma
Low dose ICS with LABA(especially if night sx are worse)
OR
Increase ICS dose
OR
Add LTRA (especially if allergic or asa induced)
SABA prn
Classification of severe persistent asthma
Sx throughout the day and usually nightly
Treatment of severe persistent asthma
High dose ICS and LABA
Consider omalizumab
When should you try to step down therapy is asthma?
After sx controlled for 3months
Most important risk factor for COPD
Smoking
*15% of smokers develop COPD
COPD in a patient younger than 40 should make you think for this
a-1 antitrypsin deficiency
To dx chronic bronchitis
Productive cough >3m for 2 consecutive years
MC symptom in emphysema
Dyspnea
Signs of cor pulmonale
Peripheral edema and cyanosis
How does COPD affect blood pH?
Chronic bronchitis: respiratory acidosis
Emphysema: resp alkalosis but possible resp acidosis in acute exacerbations
When is anticholinergic therapy contraindicated?
BPH and glaucoma
Increased urinary retention and pupillary dilation
When do you use antibiotic when managing acute exacerbations of COPD?
- increased sputum
- change in sputum quality
- CXR evidence of infection
(Azithromycin has anti-inflammatory properties)
Irreversible bronchial dilation of bronchi due to infection
Bronchiectasis
MC pathogenic cause of bronchiectasis
H flu
Pseudomonas if cystic fibrosis pt
MC cause of massive hemoptysis
Bronchiectasis
*acute bronchitis and lung ca MC causes of hemoptysis overall
Thx of mycobacterium avium complex
Clarithromycin and ethambutol
Describe Aspergillosis sputum
Thick brown
Tx of aspergillosis
Corticosteroids and itraconazole
Inheritance pattern for CF
Autosomal recessive
Presentation of CF
Meconium lieus at birth
FTT/bulky pale stools from pancreatic insufficiency
Bronchiectasis/chronic sinusitis
Cholinergic drug used to induce perspiration on sweat chloride test
Pilocarpine
Definitive test for cystic fibrosis
DNA analysis
Pathophysiology of sarcoidosis
Exaggerated T cell response leads to granuloma formation
Common manifestation of sarcoidosis
Pulmonary-dry cough, sob, cup
LAD-hilar
Skin-erythema nodosum, lupus pernio, rash, parotid enlargement
Visual-anterior uveitis/blurred vision
*b symptoms, joint pain, Bell’s palsy, and myocardial involvement also possible
Describe the pathognomicc skin finding of sarcoidosis
Lupus pernio: violaceous raised discoloration on face (resembles frost bite)
Noncaseating granulomas, Hilar LAD and eggshell nodal calcifications should make you think of
Sarcoidosis
Management of sarcoidosis
Observation for most (spontaneous remission in 2yr 40%)
Steroids then methotrexate if worsening or bad sxs
Hydroxychloroquine for skin lesions
Classic presentation of sarcoid
Young or with resp and constitutional sxs, blurred vision and erythema nodosum
Löfgren syndrome
Common presentation of sarcoidosis in Northern Europeans
- Erythema nodosum
- Bilateral hilar LAD
- Polyarthralgias and fever
Associated with good prognosis and spontaneous remission
Histological findings of sarcoid
Noncaseating granulomas
And
Langerhans giant cells containing asteroid bodies or schaumann bodies
How does idiopathic pulmonary fibrosis usually present?
Gradual onset of dyspnea and nonproductive cough in 40-50yo male
Diffuse reticular opacities/honeycombing and ground glass opacities should make you think
Idiopathic pulmonary fibrosis
Management of idiopathic pulmonary fibrosis
No effective treatment
Lung transplant is the only cure
Professions associated with pneumoconiosis
Mining and quarry work: silicosis Coal or carbon mining: black lung Electronic & aerospace: berylliosis Textile industry: byssinosis Ship building, pipe fitting and renovation: asbestosis
Parrot fever is caused by
Chlamydophila psittaci
How do you differentiate costochondritis from Tietze syndrome?
Costochrondritis: no edema
Tietze syndrome: edema
Etiology of transudative pleural effusion
CHF (MC), nephrotic syndrome,, cirrhosis, hydpoalbuminemia, atelectasis, and sometimes PE
Etiology of exudative fluid
Infection, inflammation, and sometimes PE
Test for small pleural effusions
Lateral decubitus films
Lights criteria
Presence of any of these indicates exudative effusion
- pleural protein:serum protein ration >0.5
- pleural LDH:serum LDH >0.6
- pleural LDH >2/3 ULN
Tx of pleural effusion
Diuretics
Thoracentesis
Chest tube
Pleurodesis
Common pathogens that cause empyema
Staph aureus
Strep pneumo
S. Pyogenes
H flu
Describe a cystic fibrosis diet
Fat soluble vitamins (ADEK)
Pancreatic enzymes
High protein
High calorie
Sometimes zinc or iron
2 ways to get toxoplasmosis
Eating undercooked meat and changing kitty litter
TB treatment regimen for pregnant women
Isoniazid, rifampin, and ethambutol
Streptomycin is C/I and pyrazinamide safety is undetermined so only use if dealing with resistance
What is catamenial pneumothorax?
Pneumothorax occurring during mensuration due to ectopic endometrial tissue in pleura
Management of pneumothorax
Observation if small (<20%) and no severe symptoms - repeat CXR in 6hr to confirm no progression
Chest tube placement/thoracostomy
Needle aspiration followed by chest tube if tension pneumothorax
Rare neuroemdocrine tumor of enterochromaffin cells which secrete serotonin, ACTH, ADH, and melanocytes stimulating hormone
Carcinoid tumors
MC in GI system but 2nd MC in lungs
Where does lung cancer like to metastasize to?
Brain
Bone
Liver
Lymph nodes
Adrenal glands
Describe different types of lung cancer
- non-small cell
1. adenocarcinoma MS, often peripherally located and associated with gynecomastia
2. squamous cell central located and associated with cavitary lesions, hemoptysis, hypercalcemia and pancoast syndrome
3. Large cell/anaplastic carcinoma is very aggressive - small/oat cell which Mets early and is associated with SVC syndrome, SIADH/hypernatremia, Cushing syndrome, and lambert Eaton syndrome
Describe pancoast syndrome
Tumors at superior sulcus cause
- Shoulder pain
- horner syndrome (miosis, ptosis, and anhydrosis due to cervical cranial sympathetic compression)
- atrophy of hand/arm muscles
*assoicated with squamous cell lung carcinoma
Management of lung cancer
Non-small cell: surgical resection, especially if isolated to chest
Small/oat cell: chemo with or without radiation (because this type of Ca Mets early)
Expected CXR findings for PE
Normal CXR in setting of hypoxia highly suspicious for PE
Classic findings of westermark sign or Hampton’s hump are rare
Management of PE
Initiate heparin therapy for 2-3d followed by 3mo warfarin or NOAC therapy
IVE filter if anticoag therapy C/I or unsuccessful
Thrombolytic tx or embolectomy only if hemodynamically unstable and no C/Is
PERC rule
Pulmonary Embolism Rule our Criteria
- age <50
- pulse <100
- O2 sat >95%
- no hx PE
- no recent surg/trauma
- no hemoptysis
- no exogenous estrogen use
- no unilateral leg swelling
Normal mean pulmonary arterial pressure
<20
Who gets primary idiopathic pulmonary htn?
Middle aged or young women
Tx of pulmonary htn
CCB if vasoreactive
Phosphodieterase-5-inhibitors if not
*O2 only therapy to decrease mortality
Infection associated with bird/bat dropping in Mississippi & Ohio river valley
Histoplasmosis
Hospital acquired/nosocomial pneumonia
Occurs >48hrafter hospital admission
Labs to dx legionella
Urine antigen
*hyponatremia and elevated LFTs often seen
Atypical pneumonia with GI symptoms should made you consider this
Legionella
Describe pneumonococcal vaccines
PVC 13 - 4 doses at 2, 4, 6, and 12-15mo
PPSV23 given time 2 yo at least 8wk after completing PCV13, adults>65, and people with chronic dz
Diagnosis of TB
Gold standard:AFB sputum cultures
CXR: May show CASEATING granulomas, Ghon’s complex, or Ranke’s complex
Quantiferon assay
Tx of active TB
4 drugs (RIPE or RIPS) for 2mo Rifampin Isoniazid Pyrazinamide Ethambutol or Streptomycin
Then continue isoniazid and rifampin for another 4mo or 3mo after negative sputum culture
What should you give with isoniazid to prevent peripheral neuropathy?
Pyridoxine (B6)
Treatment of latent TB
Isoniazid and B6 for 9mo 12mo if HIV)
Pertussis/whooping cough is caused by
Bordetella pertussis
Diagnosis of pertussis
Nasal swab for PCR
CBC may show profound lymphocytosis
Treatment of pertussis
Supportive (O2, nebulizers, ventilation prn)
Macrolides to decrease contagiousness and for exposed contacts (Bactrim 2nd line)
Tx of epiglottis
Supportive/intubation if needed
Dexamethasone for edema
Ceftriaxone or cefotaxime
RSV causes
Acute bronchiolitis
Laryngotracheitis(croup) is most commonly caused by
Parainfluenza
Tx of croup
Cool humidifier
Hydration
Dexamethasone
(Nebulized epinephrine and hospitalization is moderate to severe)
How do you differentiate ARDS from pulmonary edema with pulm capillary wedge pressure?
ARDS <18mmHg
Pul edema >18mmHg
Biggest risk factor for sleep apnea
Obesity
Evaluation of sleep apnea
Polysonogram (>15event/hr is diagnostic)
Check CBC for polycythemia
Epsworth sleepiness scale
What type of abn breathing pattern do you see with hypercapnia?
Cheyenne-stokes
Cyclic breathing pattern with gradual decrease in rate followed by 10-15 sec apnea
What type of abn breathing pattern do you see with opioid use of damage to the medulla oblongata?
Biot’s breathing
Quick if shallow breaths with periods of apnea
What type of abn breathing pattern do you see with metabolic acidosis?
Kussmaul’s respirations
Deep rapid continuous respirations
Normal values to know for acid base disorders
pH 7.35-7.45
Pco2 35-45
HCO3 22-26
AG 10-12
