Pulmonology Flashcards
Acute asthma exacerbation basics
Initial home management with short-acting bronchodilators followed by addition of systemic steroids (oral) if symptoms persist. Patients with mild to moderate symptoms can be treated outpatient. Severe (hypoxemia, difficulty speaking, use of accessory muscles, reduced peak flow more than 50 percent of baseline) get emergent care. Example is person with 3 day hx of cough, wheezing and SOB with 20% drop in peak flow from baseline (20 is diagnostic). Viral URIs are common triggers. Antibiotics are only indicated in certain patients with COPD too. Inhaled steroids are not indicated in asthma exacerbation acutely. They are for chronic management of persistent asthma. Long acting beta agonists (salmeterol) is only for chronic management, but only in combo with inhaled steroids.
Step up for asthma management
Step up if necessary. Step down if possible
Step 1 (intermittent asthma)
- SABA PRN
Step 2 (now we’re starting with the persistent asthmas)
- Low dose ICS
Step 3
- Low dose ICS and LABA
- OR medium dose ICS
Step 4
- High dose ICS and LABA
Step 5
- High dose ICS and LABA
- AND consider adding omalizumab for patients with allergies
Step 6
- High dose ICS plus LABA plus oral steroids
- AND consider adding omalizumab for patients with allergies
Screen for lung cancer
Recommended test: CT low dose
Interval: yearly
Age: 55-80
Eligibility
- Patient has at least 30 pack yr smoking history
- AND patient is current smoker or quit in last 15 years
Termination of screening
- age over 80
- patient quit smoking for at least 15 years
- patient has other medical conditions that significantly limit life expectancy or ability/willingness to undergo lung cancer surgery
Positive screening test is noncalcified nodule of at least 4mm on CT or any noncalcified nodule on XR. CT does reduce mortality by more than 20%, but there is a 96% false positive rate.
2 most important predictors of survival in severe COPD
FEV1 less than 40 (number one)
Age
Astham exacerbation during pregnancy
Supplemental O2 - maintain SpO2 over 95 (remember this requirement is only 90 in nonpregnant patients)
Bronchodilators
- nebulized or inhaled albuterol
- inhaled ipratropium
Systemic corticosteroids
- if incomplete response to bronchodilators
- oral preferred (prednisone)
Additional therapy
- MgSO4 or terbutaline if severe
- epinephrine contraindicated
- intubate for respiratory failure
Blood gas during asthma exacerbation
Hyperventilation during asthma exacerbation leads to acute respiratory alkalosis. If you see a respiratory ACIDOSIS in asthma exacerbation (PaCO2 greater than 35 in pregnant peeps and 40 for everyone else) this suggests impending respiratory failure and is an indication for intubation
Note that pregnant patients have chronic respiratory alkalosis (PaCo2 27-32)
ABG shows 7.2pH, paO2 52, paCO2 70 perioperatively in an obese patient with respiratory deterioration
Perioperative hypercapnic hypoxic respiratory failure likely due to underlying OSA.
Elevated baseline serum bicarb (more than 27) would indicate compensation for chronic respiratory acidosis which should lead you to think OHS.
Patients with OSA are at increased risk of perioperative respiratory failure from procedures that involve sedation, NM blocker, opioids or anesthesia. When respiratory failure occurs, it is from hypoventilation and typically presents with hypercapnia and hypoxia.
Features of classic Allergic Bronchopulmonary Aspergillosis
History of asthma, CF
XR with infiltrates (often fleeting)
CT with central bronchiectasis
Diagnostic testing shows
- skin test positive for aspergillus fumigatus
- eosinophilia more than 500
- IgE more than 417
- Specific IgG and IgE for A fumigatus
Clinically, youll see recurrent asthma, fever, lethargy, cough with production of brown mucus plugs (may contain eosinophils and grow aspergillus), occasional hemotpysis, and fleeting infiltrates (transient infiltrates in different parts of the lungs).
Once ABPA dx is confirmed, treat with glucocorticoids and itraconazole
Eosinophilc granulomatosis with polyangiitis
Churrgg-strauss. It’s an autoimmune vasculitis.
Difficult to control asthma. Plus, allergic rhinitis with nasal polyps, chronic sinusitis, mononeuropathy multiplex, and skin stuff (granulomas, palpable purpura)
qSOFA
Screening tool in ED for sepsis performed at bedside. 1 point each for:
- RR above 22
- AMS
- SBP at or below 100
Score of 2 and up indicates sepsis.
2 goals of tx for sepsis are IVFs and early antibioitcs. Often broad coverage (Vanc/Cefepime). need to cover for gram positive and negative. Ideally send blood cultures first, but initiation of antibiotics should begin within 1 hr of presentation.
Reccurent pneumonia in an elderly smoker
May be the first manifestation of bronchogenic carcinoma.
- Next best step is CT
- Best dx tool is bronch with bx
Multiple episodes of bacterial pneumonia that respond to antibiotics, often in the same area of the lung. Think bronchial obstruction. Which could be from a mass. Other ddx:
- Carcinoid tumor (younger, nonsmoking)
Causes of nonresolving pneumonia or pulm infiltrates
- Broncogenic carcinoma (old, smoker)
- Bronchoalveolar cell carcinoma
- lymphoma
- eosinophilc PNA
- bronchiolitis obliterans organizing pneumonia (BOOP)
- systemic vasculitis
- pulmonary alveolar proteinosis
- drugs (amiodarone)
ARDS cause
Its a noncardiogenic pulmonary edema that arises from a systemic disease process like sepsis or pancreatitis or from lung injury like inhalation. It’s diffuse pulmonary edema bilaterally.
Fat emobolism syndrome
Potential complication of long bone fracture that can lead to hypoxemia and respiratory distress. Patients will also have altered mental status (neuro stuff) and a petechial rash. CXR with no airspace disease.
Management of pulmonary contusion
First off in the case of contusion vs PE (CXR usually shows an irregular focal opacity for contusion, and patient has pain at the site corresponding to specific site of injury/trauma). Also, hypoxemia/respiratory symptoms may be delayed by 24-48h
Management is supportive care (pulm toilet, supplemental O2 as needed) and pain control. Should be monitored in hospital for 24-48h. Most patients have resolution of symptoms in 3-5d
Pediatric OSA
Usually from adenotonsillar hypertrophy
- Night symptoms
- loud snoring, pauses in breathing, gasping
- enuresis, parasomnias (sleepwalking, night terrors)
- Day symptoms
- inappropriate naps or falling asleep during school
- irritability, inattention, learning problems, behavior problems
- Mouth breathing, nasal sleep
- Complications include
- poor growth (FTT)
- poor school performance
- cardiopulmonary (HTN, structural heart changes)
Management is tonsillectomy and adenoidectomy
Indications for IVC filter placement
Complications of anticoagulation
Contraindication to anticoagulation
Failure of anticoagulation in setting of known DVT/PE
What lab should be checked prior to initiating TPN?
Serum phosphate
TPN puts patients at high risk for hypophosphatemia and is a prominent manifestation of refeeding syndrome (these patients are at risk of seizure, rhabdo, cardiovascular ocmpromise like arrhythmia and HF).
TPN (specifically the dextrose within it) drives phosphate into cells (via increased insulin) to make ATP. This depletes serum phosphate
Causes of hemoptysis
Pulmonary (bronchitis, cancer, bronchiectasis). Acute bronchitis is number 1 cause.
Cardiac (Mitral stenosis/acute pulm edema)
Infection (TB, lung abscess, bacterial PNA, aspergillosis)
Heme (coagulopathy)
Vascular (PE, AVM)
Systemic (granulomatosis with polyangitis, goodpasture)
Other (trauma, cocaine)
When are ABx indicated in a COPD patient?
COPD exacerbation with any of the 2 following:
- Increased sputum purulence
- increased sputum volume
- increased dyspnea
- mechanical ventilation (alone is enough here)
