Pulmonology (Current) Flashcards
Risk factors for Sarcoidosis
- African American
- Females
- Northern Europeans
Symptoms of Sarcoidosis
- Dry (nonproductive) cough
- Skin: erythema nodosum, lupus pernio
- Parotid gland enlargement
- Anterior Uveitis
- Restrictive cardiomyopathy
- Diabetes Insipidus
What is Lofgren Syndrome in regards to sarcoidosis?
-Erythema nodosum + bilateral hilar LAD + polyarthralgias with fever
Best initial test and what does it show for sarcoidosis
-Bilateral hilar LAD on CXR
What kind of pattern is on a PFT for Sarcoidosis?
Restrictive pattern: normal or increased FEV1/FVC, normal or decreased FVC
What is the most accurate diagnostic for sarcoidosis?
Tissue Biopsy: noncaseating granulomas
What is one other lab that is significant in sarcoidosis?
Increased ACE levels
If the patient is symptomatic and has sarcoidosis, what is the first line treatment?
Oral corticosteroids
What is a pleural effusion?
Abnormal accumulation of fluid in the pleural space
Physical exam findings of a pleural effusion
- Dullness to percussion
- Decreased fremitus
- Decreased breath sounds
- Dyspnea, pleuritic chest pain, cough
Lateral decubitus chest radiographs are the best type of radiographs to get to evaluate for a pleural effusion. What do you see?
Blunting of the costophrenic angles (meniscus sign)
What is the gold standard diagnostic for pleural effusion?
Thoracocentesis
What are the factors of Light’s Criteria? If any of the three are present, it is an exudate cause?
- Pleural fluid protein: serum protein > 0.5
- Pleural fluid LDH: serum LDH > 0.6
- Pleural fluid LDH: > 2/3 of the upper limit of normal LDH
When do you perform a chest tube for the fluid drainage?
If empyema (pleural fluid pH < 7.2, glucose < 40, or positive gram stain) -May inject with streptokinase to facilitate breakup of loculations
Symptoms of a pneumothorax
- Hyperresonance to percussion
- Decreased fremitus
- Decreased breath sounds over affected area
- Unequal respiratory expansion
Initial test of choice for a pneumothorax
Chest radiograph (expiratory upright view preferred)
- Companion lines
- Decreased peripheral markings
Primary spontaneous pneumothorax:
Secondary spontaneous pneumothorax:
Tension pneumothorax:
Traumatic pneumothorax:
Primary: no underlying lung disease
Secondary: underlying lung disease
Tension: positive air pressure pushes trachea and heart to contralateral side
Traumatic: Car accident, subclavian line placement
Stable secondary spontaneous pneumothorax treatment
Chest tube or catheter thoracotomy + hospitalization
Tension Pneumothorax treatment
-Needle aspiration followed by chest tube thoracostomy
Patient education following a pneumothorax
-Avoid pressure changes for a minimum of 2 weeks (high altitudes, smoking, scuba diving, etc.)
Strongest risk factor for sleep apnea
Obesity
First line diagnostic test for sleep apnea
In-laboratory polysomnography (15 or more events per hour)
Treatment for sleep apnea
- Behavioral changes including weight loss, no alcohol, changes in sleep positioning
- CPAP (mainstay)
- Tracheostomy is definitive treatment
What is the first-line in prevention of meconium aspiration?
Prevention of post-term delivery (> 41 weeks) via labor induction and prevention of fetal hypoxia
What is pulmonary hypertension defined as?
Elevated mean arterial pressure > 20 mmHg with a pulmonary vascular resistance > 3 Wood units
What is on physical exam of a patient with pulmonary hypertension?
- Accentuated S2
- Signs of right heart failure: increased JVP, peripheral edema, ascites
- Pulmonary regurgitation, right ventricular heave
- Dyspnea, fatigue, chest pain, weakness
On a chest radiograph for pulmonary hypertension, you see enlarged pulmonary arteries and signs of right sided heart failure. However, what is the definitive diagnostic for pulmonary HTN?
-Right heart catheterization: elevated pulmonary artery pressure, RV pressure
On a CBC for pulmonary HTN, what is seen?
Polycythemia (high # of RBC)
Increased hematocrit
If primary pulmonary HTN (idiopathic in cause), what is the treatment?
- Vasoreactivity trial with Nitric Oxide, IV Adenosine, or CCB
- -If vasoreactive: CCB first line
- -Prostacyclins (Iloprost)
- -PD5-inhibitors (Tadalafi)
What is the definitive treatment for pulmonary HTN?
Heart-lung transplant
Acute Respiratory Distress Syndrome develops in who?
Critically ill patients (Gram-negative sepsis)
Severe Trauma
Near Drowning
Severe Pancreatitis
What does chest radiographs for acute respiratory distress syndrome classically show?
-Bilateral diffuse pulmonary infiltrates that spare costophrenic angles
With right heart catheterization, what is diagnostic for ARDS?
Pulmonary capillary wedge pressure < 18 mm Hg
Treatment for ARDS
Noninvasive or mechanical ventilation + treat underlying cause
What is the difference between costochondritis and Tietze Syndrome?
Costochondritis: reproducible chest wall tenderness without palpable edema
Tietze Syndrome: reproducible chest wall tenderness with palpable edema
What is the treatment for costochrondritis and Tietze Syndrome?
NSAIDs
Parrot Fever (Psittacosis) is an infection with _______ that is due to exposure of ______
Chlamydia Psittaci
Infected birds
Treatment for Psittacosis
Tetracyclines
Risk Factors for Berylliosis
-Aerospace, electronics, ceramics, tool and dye manufacturing, jewelry making
What is Berrylium?
Alloyed with nickel, aluminum, and copper so people working in those industries are at increased exposure
Treatment for Berylliosis
Corticosteroids, oxygen
-Methotrexate if corticosteroids fail
Risk factors for Silicosis
-Quarry work, sandblasting with granite, slate, quartz, pottery makers, coal mining
Silicosis greatly increases the risk for _____
Tuberculosis
What is seen on chest radiographs with silicosis
- Multiple, small round nodular opacities primarily in upper lobes
- Eggshell calcifications of hilar and mediastinal nodes
Definitive diagnostic for silicosis
Lung biopsy
What is Caplan Syndrome?
Coal worker’s pneumoconiosis + Rheumatoid Arthritis
What does a chest radiograph for coal worker’s pneumoconiosis show?
Small nodules in upper lung with hyperinflation of lower lobes in obstructive pattern
Treatment for Coal Worker’s Pneumoconiosis
Supportive
Risk factors for a PE
-Virchow’s Triad: hyper coagulability, stasis, intimal damage
Symptoms of a PE
- Tachypnea (most common sign)
- Tachycardia
- Dyspnea (most common symptom)
- Pleuritic chest pain
- Hemoptysis
What is highly suspicious of a PE?
Normal chest xray in the setting of hypoxia
What does an ECG show for a PE?
Nonspecific ST/T changes and sinus tachycardia
-S1Q3T3 (deep wide S in lead I; both isolated Q and T wave inversion in III)
When is a D-dimer helpful in PE?
Only if negative and low suspicion for PE
What is the best initial test to confirm the presence of a PE?
Helical (Spiral) CT angiography
A V/Q scan is performed when patients cannot undergo a CT. Who are these people?
Pregnancy
Increased creatinine
Gold standard and definitive diagnostic for PE
Pulmonary angiography
An IVC filter is indicated in stable 3 patients:
- Anticoagulation contraindicated (recent bleed, bleeding disorder)
- Anticoagulation unsuccessful
- RV dysfunction seen on echocardiogram (next embolus can be fatal)
If the patient is hemodynamically stable, treatment for PE is
-Anticoagulation (first line): Heparin bridge plus Warfarin or novel oral anticoagulant (Dabigatran, Rivaroxaban, Apixaban, Edoxaban)
If the patient is hemodynamically unstable (SBP < 90, acute RV dysfunction), what is the treatment for a PE?
Thrombolysis (LMWH)
Thromectomy or embolectomy
PE prophylaxis is warranted in patients undergoing surgery with prolonged immobilization, pregnant women, or history of DVT/PE. What are the recommendations?
- Early ambulation ( < 40, minor procedures)
- Elastic stockings, compression devices
- LMWH (orthopedic surgery, trauma)
The Wells’ Criteria for DVT. Explain
3 points added for: Clinical signs and symptoms of DVT, PE is #1 diagnosis
1.5 points for: HR > 100, Immobilization at least 3 days or surgery in past 4 weeks, previous DVT or PE
1 point: hemoptysis, malignant with treatment in past 6 months
Low probability: < 2 points = D-dimer
Moderate: 2-6 points = CTA or D-dimer
High: > 6 = CTA
What is the antidote for LMWH and UFH?
Protamine Sulfate
