Pulmonology Flashcards
What is the next best step after diagnosis of chronic cough with no use of ACEi?
- CXR
Most common cause of chronic cough in an immunocompetent, non-smoker
- PND
- Asthma
- GERD
What is a cough variant asthma?
cough with hyperactive airway
worse at night or on waking
What is the major risk factor for asthma?
Atopy
Most common allergens to trigger asthma ___
Dermatophagoides species (dust mites(
Evidence of Variable expiratory airflow limitation
- FEV1/FVC ratio (<0.7)
- FEV1 that increases by >12% and at least 200mL from baseline post bronchodilator
- Reduced FEV1 that increases >12% (and by at least 200mL) after 4 weeks on steroid trial
- Decrease in FEV1 by 20% with methacoline or histamine
What is the most accurate test for asthma?
Pulmonary function test or spirometry (decrease in FEV1 to FVC ration)
What is the most accurate test in asymptomatic patients suspected of asthma?
- Methacoline / Histamine stimulation test
In patients with asthma presenting with clinical urgency, what will you do?
- Empiric treatment with ICS and as needed SABA
Conditions in which asthma is considered partly controlled
- > /1 per year exacerbation
- > 2x per week daytime symptoms
- > 2x/week need for reliever
- <80% lung function
- With limitation of activity
- Nigh awakening
[Asthma: Controller and Reliever]
Step 1
Controller: Low dose ICS-Formoterol
Budesonide+Formoterol
Reliever: low dose ICS + formoterol
[Asthma: Controller and Reliever]
Step 2
Daily low dose ICS or as needed low dose ICS-formoterol
Reliever: low dose ICS-Formoterol
[Asthma: Controller and Reliever]
Step 3
Controller: Low dose ICS-LABA
Reliever: As needed ICS formoterol
[Asthma: Controller and Reliever]
Step 4
Controller: medium dose ICS-LABA
Reliever: As needed ICS formoterol
[Asthma: Controller and Reliever]
Step 1
Controller: High dose ICS-LABA
reliever: low dose ICS-formoterl
What is the most effective and first line drug for patients with persistent asthma?
ICS
___ is an IgG against IgE. It decreases the activation and release of mast cells
Omalizumab
What is the first line drug for acute severe asthma?
SABA
What are the drugs safe in pregnancy?
- SABA
- ICS
- Theophylline
[Diagnosis]
smoker, worsening shortness of breath, dyspnea at rest, barrel-shaped chest, faint expiratory wheezes
COPD
What is the best initial test for COPD
CXR
Most accurate test: Pulmonary function test
Best diagnostic test: ABG
What muscles helps the COPD patient breath when he assumes a tripod position
- SCM
- Scalene
- Intercostal muscles
What is the cut off for FEV1/FVC ratio in patients with COPD
<0.7
[Diagnose]
40/M non-smoker with
COPD
CXR: bullae at the bases of the lungs
Alpha 1 antitrypsin deficiency
A narrow loop in spirometry suggests a ___ (obstructive/restrictive) lung pattern
Restrictive = decrease volume
A short loop in spirometry suggests a ___ (obstructive/restrictive) lung pattern
Obstructive = decrease airflow
[GOLD Classification based on post FEV1 test]
FEV1 50 to <80% predicted
Moderate = GOLD 2
[GOLD Classification based on post FEV1 test]
FEV1 30 to <50% predicted
Severe = GOLD 3 = 50 + 30
note: 50 + 30% = 80%
GOLD 2 = 50 to 80%
What stage of COPD will you start pulmonary rehab?
GOLD B
What is the DOC for GOLD A?
- Bronchodilator
What are the vaccines required for patients with COPD
- Flu
2. Pneumo
[Modified Medical Research Council Dyspnea Scale]
Shortness of breath walking on level ground or up a slight hill
Grade 1
[Modified Medical Research Council Dyspnea Scale]
Walks slower than people of similar age due to breathlessness or has to stop tp rest when walking at own pace
Grade 2 = slow
[Modified Medical Research Council Dyspnea Scale]
stops to rest after walking 100m or after walking few minutes on level ground
Grade 3 = 100m
[Modified Medical Research Council Dyspnea Scale]
too breathless to leave the house or breathless with ADLs
Grade 4
[Pharma: COPD]
PDE4 inhibitor used for moderate to severe exacerbations
Roflumilast
What are the 3 interventions that demonstrate influence to the natural history in COPD?
- Smoking cessation
- O2 therapy
- Lung volume reduction
When will you start supplemental oxygen therapy in COPD patients?
- pO2 <55 or Sat 88%
2. pO2 <60 or sat 90 if with signs of pulmonary hypertension or heart failure
[COPD: Initial Therapy for]
Group A
Bronchodilator
[COPD: Initial Therapy for]
Group B
- Long acting bronchodilator
2. LABA/LAMA
[COPD: Initial Therapy for]
Group C
LAMA
[COPD: Initial Therapy for]
Group D
LAMA or
LAMA + LABA or
ICS + LABA
What are the drugs used for smoking cessation?
- Nicotine
- Bupropion
- Varenicline
Indications for NIPPV
- Respiratory acidosis (PCO2 >/ 45mmHg and pH /< 7.35
- Severe dyspnea with muscle fatigue
- Persistent hypoxemia despite oxygenation
Low risk CAP Criteria
VS are not:
- RR >/ 30
- HR >/ 125
- Temp <36 or >40 degC
- SBP <90
- DBP <60
Not altered mental status, no suspected aspiration, no unstable co-morbids, CXR not multilobar, pleural eff, or abscess
Moderate risk CAP
VS are:
- RR >/ 30
- HR >/ 125
- Temp <36 or >40 degC
- SBP <90
- DBP <60
Withaltered mental status, no suspected aspiration, no unstable co-morbids, CXR not multilobar, pleural eff, or abscess
no severe sepsis and septic shock, no need for mech vent
What are the components of CURB-65?
Confusion
U - BUN >30
RR >/30
BP SBP >90 DBP<60
65 years old or older
Remember 30 BUN 30 RR 30 DBP 30 + 30 = 60 SBP 30 x 3 = 90
Based on CURB-65, what is the mortality rate if the patient has a score of 2
13%
Supervised outpatient/brief inpatient
Based on CURB-65, what is the mortality rate if the patient has a score of 3
17%
Hospitalize
Based on CURB-65, what is the mortality rate if the patient has a score of 4
41.5%
ICU
what are the etiologies in low risk pneumonia?
S. pneumonia C. pneumonae H. influenzae Enterics M. catarrhalis M. pneumonia
SCHEMM
What are the possible etiologies for moderate risk pneumonia?
S. pneumonia C. pneumonae H. influenzae Enterics M. catarrhalis M. pneumonia
SCHEMM
+ Legionella pneumophila
What are the possible etiologies for high risk pneumonia?
S. pneumonia C. pneumonae H. influenzae Enterics M. catarrhalis M. pneumonia SCHEMM
Legionella pneumophila
P. aeruginosa
S. aureus
[Possible etiology: pneumonia]
What are you atypical causes of pneumonia
- Mycoplasma
- Chlamydia
- Legionella
[Possible etiology: pneumonia]
stay in hotel or on cruise ship in previous 2 weeks
Legionella
[Possible etiology: pneumonia]
patient with stroke, dementia, decreased consciousness
Anaerobes, gram negative enterics
[Possible etiology: pneumonia]
recent antibiotic uses, malnutrition, steroid use, bronchiectasis
Pseudomonas
What is the best initial test for pneumonia?
CXR
Biomarkers:
CRP - for treatment failure or worsening disease
Procalcitonin - distinguish bacterial from viral
[Pharma: Pneumonia]
Low Risk, no co-morbids
- DOC: Amoxicillin
- Azithromycin
- Clarithromycin
[Pharma: Pneumonia]
Low ris, stable co-morbids
- Co-amoxiclav + Sultamicillin OR
2. Cefuroxime +/- Extended macrolides
[Pharma: Pneumonia]
moderate risk
- Ampicilin-Sulbactam, Ceftriaxone, Ertapenem + (Levofloxacin Moxifloxacin)
OR
- Ampicilin-Sulbactam, Ceftriaxone, Ertapenem + Azithromycin
[Pharma: Pneumonia]
high risk, no risk for Pseudomonas
- BLIC, Cephalosporin, Carbapenem + Azithromycin or Clarithromycin
OR
- BLIC, Cephalosporin, Carbapenem + Levofloxacin or Moxifloxacin
[Pharma: Pneumonia]
high risk, with risk for Pseudomonas
- Piperacillin-Tazobactam, Meropenem, Imipenem-Cilastatin + Azithromycin or Clarithromycin
+ gentamicin or amikacin
OR
- BLIC, Cephalosporin or carbapenem + IV Ciprofloxacin or IV levofloxacin
[Pharma: Pneumonia]
high risk, with risk for Pseudomonas, MRSA SUSPECTED
Add Vancomycin, Linezolid or Clindamycin
- Piperacillin-Tazobactam, Meropenem, Imipenem-Cilastatin + Azithromycin or Clarithromycin
+ gentamicin or amikacin
OR
- BLIC, Cephalosporin or carbapenem + IV Ciprofloxacin or IV levofloxacin
[Response to Pneumonia Treatment]
Fever is expected to resolve after ___ week
1 week
[Response to Pneumonia Treatment]
chest pain and sputum production should substantially reduce after ___ weeks
4 weeks
[Response to Pneumonia Treatment]
cough and breathlessness should have substantially reduced after ___ weeks
6 weeks
[Response to Pneumonia Treatment]
Most symptoms should have resolved, but fatigue may still be present after ___ months
3 months
[Response to Pneumonia Treatment]
most people will feel back to normal after ___ months
6 months
What is the first evidence that suggests response to treatment?
- Resolution of fever within a week
2. Decreasing WBC within 2 to 4 days
[Diagnosis]
Fever, cough, chest pain, discolored phelgm, foul smelling sputum
Lung abscess
Initial test: CXR
Most accurate: Chest CT
Most frequently affected side if the lung with lung abscess
Right lung
Tx: IV Clindamycin or IV Beta lactam with BLIC
What is the CD4 count to suspect PCP pneumonia?
<200
What is the CXR findings in PCP pneumonia?
near normal to diffuse bilateral infiltrate to large cysts or blebs
What is the DOC for PCP pneumonia
- TMP/SMX
- Adjunct steroid therapy if with PaO2 <70 mmHg or A-a gradient >35
Tx: 21 days
[Diagnose]
50F CHF DOB
Mild respiratory distress, absent breath sounds and dullness to percussion at the base of the lung
Dx: Pleural effusion
Initial test: CXR PA Lat
Most accurate: UTZ guided thora
Measure the serum and pleural fluid protein gradient
What are the indications for performing an initial thoracentesis?
- > 10mm thick pleural effusion of lateral decubitus CXR
- With CHF
- Asymmetric, chest, pain, fever
A trial of diuresis to alleviate pleural effusion will last for ___ days
3 days.
then if it persists, do a thoracentesis
What are the findings of an exudative pleural effusion?
- PF/Serum protein > 0.5
- PF/Serum LDH > 0.6
- PF LDH > 2/3 upper normal serum limit
Most common cause of pleural effusion ____
LV heart failure
What is the most common cause of exudative pleural effusion in many parts of the world?
TB
What is the 2nd most common cause of exudative effusion
Malignancy
If patient is clinically transudative, but criteria is exudative, what will you checK?
Check difference between serum-PF protein.
If gradient >31g/dL, effusion is transudative
If the pleural fluid has a glucose of <60 mg/dL, consider
- Malignancy
- Bacterial infections
- Rheumatoid Arthritis
In cases of pleural effusion, when will you do a more invasive procedure?
- Loculated pleural fluid
- Pleural fluid pH <7.20
- Pleural fluid glucose <60mg/dL
- Positive gram stain or culture of the pleural fluid
- Presence of gross pus in the pleural space
When will you remove the CTT in patients warranting CTT drainage?
Drainage rate of 50mL/day
[Chylothorax vs Pseudochylothorax]
Milky gross appearance
TAG >400
Chylomicrons present
Chylothorax
if TAG <50mg/dL, its not chylothorax
Conditions that can cause pseudochylothorax
- TB
- RA
- Inadequately treated empyema
- Chronic exudative effusion from almost any cause
Rupture of which part of the lungs frequently cause spontaneous pneumothorax?
Apical bleb
[Diagnosis]
DOB, pleuritic chest pain
Decreased breathsounds, hyperresonance, absent fremitus, hypoxia and hypercapnia on ABG
Pneumothorax
What are the agents used in Pleurodesis?
- Talc
2. Tetracycline
Most common cancer associated with asbestos exposure
Lung cancer
[Diagnose: CXR findings]
Calcified pleural plaques
Asbestosis
[Diagnose: CXR findings]
egg-shell calcification
Silicosis
[Diagnose: CXR findings]
nodules along septal line
Berylliosis
[Diagnose: CXR findings]
Diffuse infiltrates; hilar adenopathy
Byssinosis
due to cotton
[Diagnose: CXR findings]
Progressive fibrosis
coal workers pneumoconiosis
coal exposure
What is the most common daytime symptom in OSA?
excessive sleepiness
What is the gold standard for diagnosis of OSAHS?
Overnight polysomnogram (PSG)
Apnea in OSA is defined as ___
- Cessation of airflow >10s
2. Persistent respiratory effort (obstructive) OR absence of respiratory effort (central)
Hypopnea is defined as ____
- > 30% reduction in airflow for at least 10s during sleep
2. >3% desaturation or an arousal
How will you treat OSA?
- Weight loss
2. CPAP
How will you treat central sleep apnea?
- avoid alcohol and sedatives
2. Acetazolamide
What is the most common complaint in patients with OSA?
Snoring