Pulmonology, part 2 Flashcards
DDx for acute courgh
Asthma exacerbation Chronic bronchitis COPD exacerbation Common cold CHF exacerbation GERD PNA Postnasal drip syndrome Seasonal allergies Sinusitis
Lab and diagnostic findings of acute bronchitis
Clinical dx
CXR- only if signs of PNA , or in elderly with many comorbidities
Influenza A/B nasal swab if fall/winter and signs of flu
Rapid strep if suspect it based on presentation
Sputum cultures not necessary unless PNA confirmed and concerned it is not community acquired
Mycoplasm serology if cough persists >2-3 wks, also consider risk of bordetella based on s/sx
Meds for acute bronchitis
Symptomatic tx: NSAIDs to improve malaise, Guaifenesin for cough
Albuterol inhaler if wheezing to use 2 puffs every 6 hrs prn while ill
Abx not recommended first line unless elderly pt with acute cough and have had a hospital stay within the past year, type 2 DM, or CHF, or chronic steroid
If pos influenza A or B- Tamiflu 75 mg BID x 5 days
Pathophys of acute bronchiolitis/RSV
Acute inflammation of the bronchioles that is usually caused by a viral infection (usually RSV) and also from parainfluenza, influenza, and adenovirus.
Demographics of acute bronchiolitis/RSV
This condition can occur in people of all ages, but severe sx are usually only in young infants (peak in infants 3-6 mos)
Prognosis of acute bronchiolitis/RSV
Usually self-limited.
Recovery begins with regeneration of bronchiolar epithelium after 3-4 days, however cilia do not regrow for as long as 2 wks
Transmission of acute bronchiolitis/RSV
Spread by contact with resp secretions and highly contagious
RSV starts in Nov and peaks in Jan and Feb
High risk of hospital admit- acute bronchiolitis/RSV
Low birth weight Premature infants Lower socioeconomic group Parental smoking Chronic lung disease Severe congenital dz Age <3 mos Acute resp tract infection in children <5 yo is still the leading cause of mortality
PE findings of acute bronchiolitis/RSV
Infants are fussy with difficulty feeding
Low grade fever <101.5
Increasing rhinorrhea and congestion
Adults- presents as the common cold
After 5 days, RSV in infants progresses to lower tract with cough, dyspnea, wheezing
Lab and diagnostic findings of acute bronchiolitis/RSV
In very ill pts, RSV rapid viral antigen test of nasopharyngeal secretions, ABG, CBC, blood cultures, CXR
Every pt, pulse ox and consider rapid flu testing if s/sx indicate
Only 7% develop secondary bacterial infections
Findings on CXR for acute bronchiolitis/RSV
Flattened diaphragm
Hyperinflation
Atelectasis
Criteria for hosp admission- acute bronchiolitis/RSV
Persistent oxygen saturation <92% in room air before albuterol tx
Markedly elevated RR
Dyspnea with intercostal retractions, resp distress
Chronic lung dz, esp if pt already on oxygen
Congenital heart dz
Age <3 mos when severe dz is most common
Difficulty in feeding and inability to maintain oral hydration <6 mos old
Meds- acute bronchiolitis/RSV
Only oxygen has demonstrably improved the condition of young children with bronchiolitis because it decreases the work of breathing
Albuterol neb tx
If sepsis suspected, IV amp or cefotaxime can be started until BCxs come back
Ribavirin is approved by FDA under certain criteria for hospitalized pts
Presentation of croup
Hoarseness
Seal-like barking cough
Variable degree of resp distress
Morbidity of croup
Secondary to narrowing of the larynx and trachea below the level of the glottis, causing the audible inspiratory stridor
Tx of croup
Mod-severe pts need dexamethasone, and hosp pts get nebulized racemic epi
Prognosis of influenza
In pts without comorbid dz, prognosis of influenza A and B is very good.
Avan flu has only been reported in 630 pts as of June 2013, with 375 deaths and limited to eastern Asia
Incubation period and complications of influenza
Types A, B, and C can lead to serious pulmonary infections, pneumonia and morbidity in those immune compromised
Incubation period ranges from 1-4 days
Shedding of virus continues for 5-10 days
Sx of influenza
HA Fever (usually high) Extreme tiredness Joint aches Runny or stuffy nose Sore throat Aches Coughing Vomiting
Health maintenance for influenza
Prevention is the key
Routine annual flu vaccine for 6 mos or older
PE findings of influenza
Fever Sore throat Myalgias HA Nasal d/c: clear rhinorrhea Weakness and severe fatigue Tachycardia Red, watery eyes
Testing/findings for influenza
Rapid flu detection for influenza A and B
-Sensitivity of 62% and specificity of 98%
Avian flu- hospitalized Swab for H5N1 is available since 2009
CXR if elderly or high-risk to exclude PNA
Tx for influenza
To be effective, must be started within 2 days of onset
If pt critically ill- may be started up to 5 days after onset
Can be dosed as prophylaxis
Oseltamivir 75 mg BID x 5 days
Zanamivir- NOT for those with underlying chronic airway dz
10 mg inhaled through Diskhaler BID x 5 days
Pertussis remains a significant cause of morbidity and mortality in ________
Infants younger than 2 yrs old
Characteristics of pertussis
Inexorable spasms of coughing, with a protracted course
Contagious dz can be spread from coughs or sneezes
Begins with mild cold-like sx
After week or 2 can lead to more serious problems
Can be preventable through vaccine
Stage 1 of pertussis
Catarrhal stage May last 1-2 wks Runny nose Low-grade fever Mild, occasional cough Highly contagious
Stage 2 of pertussis
Paroxysmal stage
Lasts from 1-6 wks; may extend to 10 wks
Fits of numerous, rapid coughs followed by “whoop” sound
Vomiting and exhaustion after coughing fits- called paroxysms
Stage 3 of pertussis
Convalescent stage
Lasts about 2-3 wks
Susceptible to other respiratory infections for many
Recovery is gradual. Coughing lessens but fits of coughing may return
What role does the pleural space play?
Plays an important role in respiration by providing a vacuum in the space keeping the visceral and parietal pleura in close proximity. The small volume of pleural fluid (usually 2-10 mL) serves as a lubricant to facilitate movement of the pleural surfaces against each other
What is a pleural effusion?
An abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption
Causes of pleural effusion
Range from cardiopulmonary disorders to symptomatic inflammatory or malignant diseases requiring urgent evaluation and tx.
Transudative pleural effusion
<30 g protein/L
Pathogenesis and causes of transudate pleural effusion
Increased hydrostatic pressure d/t cardiac failure
Decreased oncotic pressure d/t vena caval obstruction or hypoalbuminemia
Exudative pleural effusion
> 30 g protein/liter
Pathogenesis and causes of exudative pleural effusion
Infections d/t bacterial, including TB, and other organisms
Neoplasm d/t metastatic carcinoma, primary carcinoma of lung, mesothelioma of the pleura
Pulmonary infarction d/t thromboembolic dz
Autoimmune dz d/t rheumatoid dz, SLE
Abdominal dz d/t pancreatitis, subphrenic abscess, Meig’s syndrome
Hx findings of pleural effusion- general
Dyspnea
Cough-mild and nonproductive
CP- usually with exudative
Hx findings of pleural effusion- CHF
Lower ext edema
Orthopnea
PND
Hx findings of pleural effusion d/t TB or lung CA
Night sweats
Hemoptysis
Weight loss
Hx findings of pleural effusion- PNA causing pleural effusion
Acute fever
Purulent sputum production
Pleuritic chest pain
PE of pleural effusion
Dullness to percussion Decreased tactile fremitus Asymmetrical chest expansion Diminished breath sounds Egophany Pleural friction rub CHF- jugular venous distention, S3 gallop, edema Liver dz- jaundice CA- Lymphadenopathy
Work up for pleural effusion
CXR- PA and lateral to detect effusion
Thoracentesis for new and unexpected effusions
-Purulent fluid: empyema
-Milky, opalescent fluid: lymphatic obstruction by cancer or trauma
-Grossly bloody: trauma, cancer, or asbestos related
Nl fluid is clear plasma with pH of 7.6
Hospital tx of pleural effusion
Treat underlying cause
-Indications for urgent drainage of effusions include purulent fluid, pleural fluid with pH < 7.2, loculated effusions, and bacteria on Gram stain
Surgery is required for effusions that cannot be drained adequately by needle or small-bore catheters
Pulmonary artery HTN
A mean pulmonary arterial pressure >25 mm Hg at rest, and is characterized by a progressive and sustained increase in pulmonary vascular resistance that eventually leads to right ventricular failure
What are the MCCs of secondary pulmonary HTN
Cardiac disorders
Pulmonary disorders
Both in combination
Primary pulmonary HTN
Rare
Characterized by elevated pulmonary artery pressure with no apparent cause
Hx pulmonary HTN
Dyspnea upon exertion Fatigue Lethargy Syncope with exertion CP Cough- less common
PE of pulmonary HTN
Intensity of pulmonic component of second heart sound P2
R ventricular heave
A rt-sided 4th heart sound and L parasternal heave
R ventricular failure may be associated with high-pitched systolic murmur of tricuspid regurg, hepatomegaly and edema
RFs of pulmonary HTN
Past hx of heart murmur Hx of pulmonary embolism Heavy alcohol consumption Hepatitis Severe sleep apnea Morbid obesity
Cor pulmonale
An enlargement of the right ventricle due to high blood pressure in the lungs usually caused by chronic lung disease
Workup pulmonary HTN/cor pulmonale
EKG- signs of RV dysfunction Echo- to estimate the pulmonary artery pressure and assess ventricular function CXR If no cardiac dz- PFT Consider spiral chest CT and/or VQ scan CBC CMP PT aPTT ABgs ESR RF ANA
Tx/follow-up of pulmonary HTN/cor pulmonale: general
Tx of the underlying dz. Effective therapy should be instituted in the early stages, before irreversible changes in pulmonary vasculature occur. Afterwards, specific interventional therapy, specific medical therapy, or general supportive therapy
Tx/follow-up of pulmonary HTN/cor pulmonale: atrial septal defect and mitral stenosis
Surgical repair
When is lung transplant a tx for pulmonary HTN?
Reserved for pts with severe primary pulmonary arterial HTN
5 yr suvival post transplant is 50%
