Pulmonology Flashcards
1
Q
What is acute bronchiolithis?
A
most often caused by RSV - commonly in fall and winter months
- infants and young children
- tachypnea, respiratory distress, wheezing
- diagnosed by nasal washing for RSV culture and antigen assay; CXR = normal
2
Q
What is the tx for acute bronchiolitis?
A
- hospitalization if O2 saturation < 95-96%, age < 3 months, RR > 70, nasal flaring, retractions, or atelectasis on CXR
- supportive = humidified O2, antipyretics, beta-agonist, nebulized racemic epinephrine, and steroids
- the only treatment demonstrated to improve bronchiolitis is oxygen
- ribavirin is given if severe lung or heart disease and in immunocompromised patients
- palivizumab prophylaxis (once per months for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders)
3
Q
What is acute bronchitis?
A
defined by a cough > 5 days, can last 1-3 weeks
4
Q
What are the organisms causing acute bronchitis?
A
- most common - viral (95%)
- common bacterial = M. catarrhalis
- chronic lung patients: H. influenzae, S. pneumoniae, M. catarrhalis
5
Q
What is the presentation of acute bronchitis?
A
- cough, fever (unusual), constitutional symptoms
- typically less severe than pneumonia, normal vital signs, no rales, no egophony
- obtain CXR if the diagnosis is uncertain or symptoms persist despite conservative treatment
6
Q
What is the treatment for acute bronchitis?
A
symptomatic and supportive - hydration, expectorant, analgesic, B2 agonist, cough suppressant
- corticosteroids if a history of underlying reactive airway disease
- ribavirin if severe lung or heart disease and in immunocompromised patients
- if O2 < 96% on room air the patient should be hospitalized
- antibiotics are indicated in elderly, underlying cardiopulmonary disease, cough > 7-10 days, or immunocompromised
7
Q
What is acute epiglottitis?
A
supraglottic inflammation and obstruction of airway due to infection with Haemophilus influenzae type B (Hib)
- this is a medical emergency
- caused by Hib - usually unvaccinated children (Hib vaccine at 2, 4, 6, 12-15 mo)
8
Q
What are the signs and symptoms of acute epiglottitis?
A
triad positioning = the Ds of epiglottitis
- dysphagia
- drooling
- respiratory distress
9
Q
What is the classic finding on x-ray for epiglottitis?
A
thumbprint sign on x-ray lateral neck film, secure airway then culture for H. flu
10
Q
What is the tx for epiglottitis?
A
involves intubating if necessary, supportive care, ceftriaxone, may treat as an outpatient if stable
11
Q
What is acute respiratory distress syndrome?
A
a type of respiratory failure characterized by fluid collecting in the lungs depriving organs of oxygen
- increase permeability of alveolar-capillary membranes = development of protein-rich pulmonary edema (non-cardiogenic pulmonary edema)
- ARDS can occur in those who are critically ill or who have significant injuries = sepsis (most common), severe trauma, aspiration of gastric contents, near-drowning
12
Q
What are the signs and symptoms of ARDS?
A
severe shortness of breath and often are unable to breath on their own without support from a ventilator
- rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event
- tachypnea, pink frothy sputum, crackles
13
Q
What do radiographs show when a patient has ARDS?
A
air bronchograms and bilaterally fluffy infiltrate
-normal BNP, pulmonary wedge pressure, left ventricle function and echocardiogram
14
Q
What is the tx of ARDS?
A
identifying and managing underlying precipitation and secondary conditions
- tracheal intubation with the lowest level PEEP to maintain PaO2 > 60 mmHg or SaO2 > 90
- ARDS is often fatal, the risk increases with age and severity of illness
15
Q
What is asthma?
A
a chronic, reversible inflammatory airway disease with recurrent attacks of breathlessness and wheezing
16
Q
How do you diagnosis?
A
monitor with peak flow
- spirometry with pre and post-therapy (albuterol inhalation) readings
- decreased FEV1/FVC (75-80%)
- > 10% increase of FEV1 with bronchodilator therapy
17
Q
What would you expect with a FEV1 to FVC ratio <80%?
A
(you would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
-in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
18
Q
What is the tx for mild intermittent asthma?
A
(<2x/week or <2 night/month) - SABA prn
19
Q
What is the tx for mild persistent asthma?
A
(>2x per week or 3-4 night/month) - low dose ICS daily
20
Q
What is the tx for moderate persistent asthma?
A
(daily sx or >1 night/week)
- low dose ICS + LABA daily
- medium dose ICS + LABA daily
21
Q
What is the tx for severe persistent asthma?
A
(sx several times/day + nightly)
- high dose ICS + LABA daily
- high dose ICS + LABA + oral steroids
22
Q
What is the acute treatment for asthma?
A
oxygen, nebulized SABA, ipratropium bromide, and oral steroids
23
Q
What is croup?
A
refers to an infection of the upper airway, which obstructs breathing and causes a characteristic barking cough
24
Q
What are the characteristics of croup?
A
- caused by the parainfluenza virus
- common in children 6 mo - 3 years, fall and early winter months (same time of year as bronchiolitis)
- barking cough and stridor
- steeple sign on PA CXR (narrowing trachea in the subglottic region)
25
What is the tx of croup?
- supportive (air humidifier), antipyretics
| - severe: IV fluids and nebulized racemic epinephrine, steroids
26
What is a foreign body aspiration?
when a foreign body enters the airway and causes choking
- objects can enter the esophagus through the mouth, or enter the trachea through the mouth or nose
- most often food and can be life-threatening, 80% in mainstem or lobar bronchus right > left
- risk factors include institutionalization, advanced age, poor dentition, alcohol, sedative use
27
What is the presentation of foreign body aspiration?
(depends on the location of obstruction)
| -inspiratory stridor (if high in the airway) or wheezing and decreased breath sounds (if low in the airway)
28
What does a CXR show when there is a foreign body aspiration?
(expiratory radiograph) may reveal regional hyperinflation of the affected side
-ABG - necessary for appropriately evaluating ventilation, may be useful for following the progression of respiratory failure when it is of concern
29
What is the tx of foreign body aspiration?
remove foreign body with a bronchoscope
- rigid bronchoscopy preferred in children while flexible is diagnostic and therapeutic in adults
- complications include pneumonia, acute respiratory distress syndrome, asphyxia
30
What is hemoptysis?
coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs
-in other words, it is the airway bleeding
31
What is the presentation of hemoptysis?
- coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs
- bronchial capillaries in the mucosa of the tracheobronchial tree rupture as a result of acute infection (viral or bacterial bronchitis, bronchiectasis, cigarette smoke)
- it can occur when tiny blood vessels that line the lung airways are broken massive hemoptysis can be seen with lung cancers and other serious abnormalities
- vascular engorgement with erosion such as in pulmonary hypertension or masses
32
What are the most common causes of hemoptysis?
- bronchitis (50%): hemoptysis, dry cough, cough with phlegm
- tumor mass (20%): hemoptysis, chest pain, rib pain, tobacco history, weight loss, clubbing
- tuberculosis (8%): hemoptysis, chest pain, sweating
33
How is hemoptysis dx?
- examining the expectoration may help localize the source of bleeding
- cytology (especially when worried about lung cancer)
- fiberoptic bronchoscopy is preferred for CA tissue biopsy, bronchial lavage, or brushing
- rigid bronchoscopy for cases of massive bleeding because of its greater suctioning and airway maintenance capabilities
- high-resolution CT gives a greater positive yield of pathology
34
What is the tx of hemoptysis?
- massive hemoptysis warrants a more aggressive early consultation with a pulmonologist
- ABCs = airway maintenance is vital because the primary mechanism of death is asphyxiation, not exsanguination
35
What are the pearls of hemoptysis?
- the most common presentation of acute or mild hemoptysis is bronchitis
- older smokers with hemoptysis lung cancer must be ruled out with HIGH - RESOLUTION CT of the chest
- NEGATIVE CXRs DO NOT RULE OUT LUNG CANCER
36
What is influenza?
a viral respiratory infection caused by orthomyxovirus resulting in fevers, coryza, cough, headache, and malaise
-three strains exist: A, B, and C
37
Who should receive an annual influenza vaccine?
everyone > 6 months
-avoid vaccination: severe egg allergy, previous reaction, Guillain-Barre syndrome (GBS) within 6 weeks of previous vaccination, GBS in the past 6 weeks, < 6 months old, avoid FluMist in patient with asthma
38
How is influenza dx?
rapid antigen test in the clinic, rapid serology test more accurate
-CXR in primary influenza pneumonia will show bilateral diffuse infiltrates
39
What is the tx of influenza?
symptomatic (for most) or with antivirals = ideally < 48 hours - tamiflu (oseltamivi), inhaled relenza (zanamivir), IV rapivab (peramivir), and oral baloxavir (Xofluza)
- zanamivir and oseltamivir both treat influenza A and B = (think Dr. "OZ" treats the flu)
- indications for antiviral treatment: hospitalized, outpatient with severe/progressive illness, an outpatient at high risk for complications (immunocompromised, pt with chronic medical conditions, > 65 yo, pregnant women/ 2 weeks postpartum)
40
What are the two categories of lung cancer?
- small cell lung cancer (SCLC), about 15% of cases (poor prognosis)
- non-small cell lung cancer (NSCLC), about 85% of cases, four subtypes include adenocarcinoma, squamous cell carcinoma, large cell carcinoma and carcinoid tumor
41
What are the characteristics of small cell carcinoma?
15% of cases
- 99% smokers; doesn't respond to surgery; metastases common at presentation
- central location, very aggressive
- associated with paraneoplastic syndromes; Cushing's, SIADH
42
What is the tx of small cell carcinoma?
can't have surgery, need chemo
| -associated manifestations: SVC syndrome, pancoast tumor, horner's syndrome, carcinoid syndrome
43
What are the characteristics of non-small carcinoma?
85%
- adenocarcinoma (35-40%): MOST COMMON, peripheral mass; smoking/asbestos exposure; thrombophlebitis
- squamous cell (central mass 25-35%): presents with hemoptysis, central location, hypercalcemia, elevated PTHrp
- large cell (5%): rarely responds to surgery; periphery location, gynecomastia
- carcinoid tumor (1-2%): lack glandular and squamous differentiation
44
What is the tx of non-small cell?
stage 1-2 = surgery
stage 3 = chemo
stage 4 = palliative
45
What is carcinoid tumors?
GI tract cancer metastasized to lung (CA of appendix = MC; appendix - liver - lung)
- presentation: hemoptysis, cough, focal wheezing, recurrent pneumonia
- carcinoid syndrome = cutaneous flushing, diarrhea, wheezing, hypotension (telltale sign)
- adenoma = MC type of carcinoid tumor (slow-growing, rare)
- Dx: bronchoscopy - pink/purple central lesion, well-vascularized; elevated 5-HIAA
- treatment is with surgery
46
What is a pulmonary nodules?
< 3 cm is a nodule (coin lesion) > 3 cm = mass
47
What are the steps to deal with pulmonary nodule?
1. incidental finding on CXR
2. send for CT
3. if suspicious (depending on radiographic findings below) will need a biopsy
- ill-defined lobular or spiculated suggests cancer
4. if not suspicious < 1 cm it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr
- calcification, smooth well-defined edges, suggests benign disease
48
What is pertussis?
whooping cough (pertussis) is a highly contagious respiratory tract infection marked by a severe hacking cough followed by a high-pitched intake of breath that sounds like a whoop
49
What are the characteristics of pertussis?
gram-negative bacteria Bordetella pertussis - high contagious
- consider in adults with cough > 2 weeks, patients < 2 year old
- catarrhal stage: cold-like symptoms, poor feeding, and sleeping
- paroxysmal stage: high-pitched "inspiratory whoop"
- convalescent stage: residual cough (100 days)
50
How is pertussis dx?
by a nasopharyngeal swab of nasopharyngeal secretions - culture
51
What is the tx for pertussis?
macrolide (clarithromycin/azithromycin); supportive care with steroids/beta2 agonists
- vaccination: 5 doses - 2, 4, 5, 15-18 mo, 4-6 years (DTap)
- 11-18 yo = 1 dose Tdap
- expectant mother should get Tdap during each pregnancy, usually at 27-36 weeks
52
What is a pleural effusion?
accumulation of excess fluid between the layers of the pleura outside the lungs (pleural space)
-presents with dyspnea, and a vague discomfort or sharp pain that worsens during inspiration
53
How do you differentiate between exudate and transudate with pleurocentesis?
- determine if the pleural fluid is exudative by meeting at least one of the light's criteria (increased protein, increased LDH)
- pleural fluid protein/serum protein >0.5
- pleural fluid LDH/serum LDH >0.6
- pleural fluid LDH >2/3
54
What is transudate pleural effusion?
transient - from changes in hydrostatic pressure: cirrhosis, CHF, nephrotic syndrome, ascites, hypoalbuminemia
55
What is exudative pleural effusion?
protein ratio increase, LDH increase: infection, malignancy, immune; MC cause = pneumonia, cancer, PE, TB
56
How do you dx a pleural effusion?
lateral decubitus CXR, chest CT, U/S
- thoracentesis is the gold standard
- PE shows decreased tactile fremitus and dullness to percussion in pleural effusion
- Isolated left-sided pleural effusion likely exudative
- right-sided = transudative
57
What is the tx of pleural effusion?
throacocentesis
-effusions that are chronic or recurrent and causing symptoms can be treated with pleurodesis (pleural space is artificially obliterated) or by intermittent drainage with an indwelling catheter
58
What is pleuritic chest pain?
caused by inflammation of the tissues that line the lungs and chest cavity (pleura)
59
What are the characteristics of pleuritic chest pain?
- characterized by sudden and intensely sharp, stabbing, or burning pain in the chest when inhaling and exhaling
- It is exacerbated by deep breathing, coughing, sneezing, or laughing
- common causes include pneumonia, pericarditis, pericardial effusion, pancreatitis
60
What is viral pneumonia?
adults - flu = MC; kids = RSV, comes on fast
- Dx: CXR = bacterial interstitial infiltrates; rapid antigen testing for flu, RSV nasal swab, cold agglutinin titer negative
- tx: flu with Tamiflu (A and B) if sx's began < 48 hours; symptomatic tx = beta 2 agonists, fluids, rest
61
What is bacterial pneumonia?
fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum
- Dx: patchy, segmental lobar, multipolar consolidation; blood cultures x 2, sputum gram stain
- tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs
62
What is fungal pneumonia?
common in immunocompromised patients (AIDs, steroid use, organ transplant)
- coccidioides (valley fever): non-remitting cough/bronchitis non-responsive to conventional tx
- fungal inhalation in western states; test with EIA for IgM and IgG
- tx: fluconazole/itraconazole
- Pulmonary aspergillosis: usually those with healthy immune systems
- tx: fluconazole/itraconazole
- Cryptococcus: found in soil; can disseminate and a meningitis
- lumbar puncture
- tx: amphotericin B
- histoplasma capsulate: pulmonary lesions that are apical and resemble cavitary TB; worsening cough and dyspnea, progression to disabling respiratory; no dissemination
- bird or bat droppings (caves, zoo, bird); Mississippi Ohio river valley
- signs: mediastinal or hilar LAD (looks like sarcoid)
- tx: amphotercin B
63
What is PJP?
HIV: pneumocystis jiroveci
- common in HIV patient with CD4 count < 200
- CXR: diffuse interstitial or bilateral perihilar infiltrates
- Dx: bronchoalveolar lavage PCR, labs, HIV test; low O2 sat despite supplemental oxygen
- tx: bactrim and steroids; pentamidine for allergy
- prophylaxis for high risk patients with CD4 < 200 = daily bactrim
64
What is CURB-65 score for pneumonia severity?
estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment
- confusion; urea>7;RR>30, systolic BP <90 mmHg or diastolic BP <60 mmHg, age >65
- 0-1 = low risk, consider home tx
- 2 = probable admission vs close outpatient management
- 3-5 admission, manage as severe
65
What is a pneumothorax?
a collapsed lung caused by an accumulation of air in pleural space
-presents with acute onset ipsilateral chest pain and dyspnea with decreased tactile fremitus, deviated trachea, hyper resonance, diminished breath sounds
66
What is primary and secondary pneumothrorax?
can be spontaneous or traumatic
- primary: occurs in absence of underlying disease (tall, thin males age 10-30 at greatest risk)
- secondary: in present of underlying disease (COPD, asthma, cystic fibrosis, interstitial lung disease)
67
What is a tension pneumothorax?
penetrating injury - air in pleural space increasing and unable to escape
- a mediastinal shift to the contralateral side and impaired ventilation
- CXR = pleural air; ABG shows hypoxemia
68
What is the tx for a pneumothorax?
- small - <15% diameter of hemithorax will resolve spontaneously without the need for chest tube placement
- large - >15% diameter and symptomatic pneumothoraces require chest tube placement
- serial CXR every 24 hours until resolved
- tension pneumothorax is a medical emergency
- large bore needles to allow the air out of the chest; chest tube for decompression
69
What is a pulmonary embolism?
a blockage in one of the pulmonary arteries in the lungs
- more than 90% originate from cots in the deep veins of the lower extremities
- presents with dyspnea (most common) and pleuritic chest pain
- R/F: Virchow's triad = hyper coagulable state, trauma, venostasis (surgery, cancer, oral contraceptives, pregnancy, smoking long bone fractures/fate emboli)
- homan's sign: (Dorsiflexion of the foot causes pain in calf) indicative of deep vein thrombosis
- EKG: TACHYCARDIA (most common), S1Q3T3 (rare), non-specific ST wave changes
70
How is a pulmonary embolism dx?
Well's score is used to assess the probability of pulmonary embolism
- spiral CT = initial method of identifying
- pulmonary angiography = gold standard definitive
- CXR: Westermark sign or Hampton hump (triangular or rounded pleural base infiltrate adjacent to hilum)
- VQ scans are "old school" = perfusion defects with normal ventilation (normal VQ rules out PE; abnormal - non-specific)
- venous duplex ultrasound of lower extremities (normal test does not exclude PE)
- ABG = respiratory alkalosis secondary to hyperventilation
- d-dimer
71
What is the tx of a pulmonary embolism?
heparin is the anticoagulant of choice fo the acute phase with factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban) and oral direct thrombin inhibitors (dabigatran) thereafter
- warfarin for patients in whom factor Xa or direct thrombin inhibitors are no available and for patients with severe renal insufficiency (target INR range 2.0-3.0)
- duration of treatment: minimum of anticoagulation 3 months with reversible risk factor
- unprovoked: anticoagulation recommended for at least 6 months then reevaluate
- two episodes unprovoked, long term with anticoagulation
72
What is respiratory syncytial virus?
MC cause of lower respiratory tract infection in children worldwide - virtually all get it by age 3; the leading cause of pneumonia and bronchiolitis
- rhinorrhea, wheezing/coughing that persists for months, low-grade fever, nasal flaring/retractions, nail bed cyanosis
- diagnosed with nasal washing, RSV antigen test; CXR can show diffuse infiltrates
73
What is the tx for respiratory syncytial virus?
indications for hospitalization = tachypnea with feeding difficulties, visible retractions, oxygen desaturation < 95-96%
- supportive measures include albuterol via nebulizer, antipyretics and humidified oxygen, steroids (controversial), resolves in 5-7 days
- vaccine for children with lung issues or born premature/immunocompromised at birth should get Synagis prophylaxis (palivizumab) = once per month for five months beginning in November
74
What is the presentation of shortness of breath?
- most common diagnoses among older adult patients
- a complaint of acute shortness of breath/respiratory distress
- respiratory rate >25 or <10
- oxygen saturation of less than 92%
- lungs maintain homeostasis with respect to gas exchange and acid-base status
- changes in oxygenation can lead to SOB
75
What are the most common causes of shortness of breath?
- asthma
- chronic obstruction pulmonary disease
- CHF
76
What are the other causes of shortness of breath?
- pneumonia
- pneumothorax
- pulmonary embolus
- pleural effusion
- pregnancy
- metabolic acidosis
- aspirin poisoning
- renal failure
77
What are the DDX of shortness of breath?
foreign body aspiration, interstitial lung disease, obesity, pulmonary hypertension, sarcoidosis, TB, anemia, cardimyopathy, pericarditis, epiglottis, GAD, myasthenia gravid, fracture rib, sudden blood loss
78
How is shortness of breath dx?
- respiratory rate <10 or >25
- weak respiratory effort
- oxygen saturation <92% on room air or <95% on high concentration oxygen
- hypercapnia (elevated CO2 in ABG)
- decrease level of consciousness
- exhaustion
79
What is the tx of shortness of breath?
- oxygen (high flow nasal canal or rebreathing mask)
- albuterol for asthma and COPD
- lasix for CHF
- BIPAP for respiratory difficulty and low O2 saturations
- Intubation for severe cases
80
What are the pearls of shortness of breath?
- vital signs should be addressed first
- shortness of breath initial treatment is oxygen (nasal, rebreather, etc.)
- must rule out pulmonary and cardiac etiologies
- CXRs, CBC, CMP, BNP, troponin, EKG on all patients
- ABGs can help uncover how the respiratory system is truly functioning
81
What is tuberculosis?
a disease caused by bacteria called mycobacterium tuberculosis (acid-fast bacilli)
82
What are the characteristics of tuberculosis?
- presentation: fatigue, productive cough, night sweats, weight loss, post-tussive rales
- RF: endemic area, immunocompromised (HIV), recent immigrants (<5 y/o), prisoners, healthcare worker
- transmission: inhalation of aerosolized droplets
83
What is the screening for tuberculosis?
tuberculin skin test (TST) or interferon-gamma release assays IGRAs
84
What is the mantoux test rules?
test is positive if induration
- >5 mm at high risk, fibrotic changes on CXR, immunocompromised HIV/drugs, steroids/TNF antagonists daily, or close contact with pt with infectious TB
- >10 mm in patients age <4 or some risk factors = hospital and other healthcare facilities, IVDU, recent immigrants from high prevalence area, renal insufficiency, prison, homeless shelter, diabetes, head/neck cancer, gastrectomy/jejunoileal bypass surgery
- >15 mm if there are no risk factors
85
How do you diagnosis tuberculosis?
sputum for AFB smears and mycobacterium tuberculosis cultures - have to be 3 AFB negative
- NAAT helps diagnosis better and sooner
- CXR: cavitary lesions, infiltrates, ghon complexes in the apex of lungs
- biopsy = creating granulomas
- miltary TB = spread outside lungs = vertebral column: Pott disease; scrofula (TB to cervical lymph nodes)
86
What is the tx of tuberculosis?
start empiric treatment in those who likely have it
- PPD positive + CXR negative: latent TB = isoniazid for 9 months (+B6 to prevent neuropathy)
- PPD positive + CXR positive: active TB = quad therapy (RIPE): rifampin, isoniazid, pyraninamide, ethambutol - all are hepatotoxic
87
What are the side effects of the drugs?
Four drugs x 8 weeks (RIPE) then two drugs x 16 weeks (RI)
- rifampin - red organe urine, hepatitis
- Isoniazid - peripheral neuropahty (B6 = pyridoxine 25-50 mg/day)
- pyrazinamide - hyperuricemia (gout)
- ethambutol - optic neuritis (eye changes), red-green blindness
88
What do patients with TB need to have for treatment cessation?
patients with active TB will need two negative AFB smears and cultures in a row negative for therapy cessation
- prophylaxis for household members = isoniazid for 1 year
- D/C therapy if transaminases > 3-5 x ULN
- Pt's on INH should supplemental Vitamin B6 (pyridoxine 25-50 mg/day) to prevent neuropathy
- monitor serum creatinine, take meds on an empty stomach since can reduce absorption, watch for hepatotoxicity, aware of drug interactions especially with HIV meds
89
What are the ddx for wheezing?
asthma, chronic bronchitis, COPD, carcinoid tumors, RSV, acute bronchiolitis, foreign body aspiration, transfusion reaction, heartburn/dyspepsia, ingestion of toxic substances/ foreign bodies, pulmonary neoplasm, for pulmonate, photosensitivity reaction, food allergies, influenza, pneumonia, emphysema, anaphylaxis
