Pulmonology Review FINAL Flashcards
What can be given as prevention of bronchiolitis?
Palivizmab during first year of life for children < 29 weeks or immunodeficiency
What antibiotics can be given for patients with epiglottitis?
What can be given as prevention to all close contacts?
-Ceftriaxone or Cefotaxime
-Rifampin and the Hib vaccine
What shape is Strep Pneumo?
Gram positive diplococci
What shape is Staph Aureus?
Gram positive cocci in clusters
Two common causes of hospital-acquired PNA?
Pseudomonas and MRSA (Staph Aureus)
Aspiration PNA Treatment
Ampicillin-Sulbactam or Amoxicillin-Clavulanate
Treatment for PNA
-CAP Outpatient
-CAP Inpatient
Outpatient: Macrolides (Azithromycin) or Doxycycline
Inpatient: Ceftriaxone + Macrolide or Doxycycline
HAP PNA (Pseudomonas Infection Risk) Treatment
-Piperacillin/Tazobactam or Cefepime + Aminoglycoside (Gentamicin) OR Fluoroquinolone (Levofloxacin, Moxifloxacin)
With HAP, what should you add if Legionella is suspected?
If MRSA is suspected?
Legionella: Levofloxacin or Azithromycin
MRSA: Vancomycin or Linezolid
Explain PNA vaccination rules
-PCV13: 4 doses (2, 4, 6, 12-15 months of age)
-PPSV23: adults 65 years or older
-If patient had no prior vaccination, give one dose of PCV13 then 8 weeks later one dose of PPSV23.
-Pregnancy is ok!
MCC of acute bronchiolitis?
RSV
Histoplasmosis is an AIDS-defining illness if CD4 <
CD4 < 150
PCP Pneumonia is the most common opportunistic infection in HIV, especially if CD4 <
CD4 < 200
Symptoms of PCP PNA
What labs are shown?
What does CXR show?
-Dyspnea on exertion, fever, nonproductive cough, oxygen desaturation on ambulation
Increased LDH and beta-D-glucan
diffuse bilateral interstitial infiltrates
PCP Treatment
Bactrim x 21 days
If HIV+, add Prednisone if hypoxic
What is the difference between Costochondritis and Tietze Syndrome?
Both have reproducible chest wall tenderness (MC involving 3rd, 4th, and 5th sternocostal joints)
-Tietze Syndrome has palpable edema, whereas Costochondritis does not.
Etiologies of a Pleural Effusion
-Transudate
-Exudate
-Transudate: CHF MCC, Nephrotic syndrome, Cirrhosis (due to increased hydrostatic pressure or decreased oncotic pressure)
-Exudate: any infection or inflammation. Pulmonary embolism, malignancy (due to increased vascular permeability)
What is the best XR view and what does it show for a pleural effusion?
Lateral decubitus films: blunting of the costophrenic angles (menisci sign)
Light’s Criteria for a pleural effusion
-An exudate is present if any of these 3 present:
–serum protein > 0.5
–serum LDH > 0.6
–LDH > 2/3 upper limit of normal LDH
With a primary spontaneous pneumothorax (PSP), who does it affect most commonly, and what is the pathophysiology behind it?
-No underlying lung disease, tall thin men 20-40 years old, smokers
-Apical sub pleural blebs rupture
Pneumothorax Types
-PSP
-SSP
-Traumatic
-Tension
-Catamenial
-PSP: atraumatic and idiopathic
-SSP: underlying lung disease
-Traumatic: iatrogenic (CPR, PEEP ventilation, MVA, subclavian line placement)
-Tension: positive air pressure pushes the trachea, great vessels, and heart to contralateral side
-Catamenial: occurs during menstruation
Pneumothorax Treatments
-Small PSP < 3 cm from chest wall
-Large PSP > 3 cm from chest wall
-Stable SSP
-Tension
-Small: observation and supplemental oxygen
-Large: Needle or catheter aspiration vs. chest tube or catheter thoracostomy
-Stable SSP: Chest tube or catheter thoracostomy + hospitalization
-Tension: Needle aspiration followed by chest tube thoracostomy
Where should the needle be placed for needle thoracostomy?
Between 2nd and 3rd rib, mid-clavicular line
What is seen on exam in a patient with pulmonary hypertension and why?
Accentuated S2, signs of RHF (increased JVP, peripheral edema, ascites)
Increased pulmonary vascular resistance leads to RVH, increased RV pressure, and RHF eventually
Regarding a PE, explain what S1Q3T3 means
Wide deep S in lead 1, both an isolated Q as well as T wave inversion in Lead III
What is the best initial test to confirm a PE?
What should be done if the patient is pregnant or increased creatinine?
What is the gold standard diagnostic for a PE?
-Helical (spiral) CT angiography
-V/Q scan
-Pulmonary angiography
What is the first-line treatment for a patient who is hemodynamically stable with a PE?
Anticoagulation: Heparin bridge + Warfarin or novel oral anticoagulant (Dabigatran, Rivaroxaban, Apixaban, Edoxaban)
PE Prophylaxis
-Low risk, minor procedures, <40 years old
-Moderate Risk
-Patients undergoing orthopedic or neurosurgery, trauma
-Low risk: early ambulation
-Moderate: compression devices/stockings/venodyne boots
-Ortho/Trauma: LMWH
What are two characteristic findings on CXR with a PE?
Hamptons Hump
Westermark Sign
Who does ARDS occur in?
Critically ill patients, (Gram negative sepsis MC), severe trauma, near drowning, severe pancreatitis, etc.
What is shown on a CXR in someone with ARDS?
-Bilateral diffuse pulmonary infiltrates but spares the costophrenic angles
On right heart catheterization, what is seen with ARDS?
PCWP < 18 mm Hg (no cardiogenic pulmonary edema)
Treatment for ARDS
-Noninvasive or mechanical ventilation + treat underlying cause (CPAP, PEEP, and low tidal volume)
Normal Breath Sounds
-Bronchial:
-Bronchovesicular:
-Vesicular:
-Bronchial: Expiration (longer) > Inspiration
-Bronchovesicular: Expiration = Inspiration
-Vesicular: Inspiration > Expiration
Pathophysiology of Neonatal Respiratory Distress Syndrome
-Insufficient surfactant production by an immature lung.
-Dysfunction of Type 2 Pneumocytes
When are antenatal glucocorticoids given to prevent NRDS?
-If premature delivery expected (between 24-36 weeks)
-By 35 weeks, enough surfactant has been produced in the baby’s lungs
What is the best treatment for meconium aspiration?
Prevention of post-term delivery. There is a high incidence of meconium aspiration if over 41 weeks
What is the pathophysiology of emphysema?
-Alveolar capillary destruction + alveolar wall destruction due to chronic inflammation and decreased protective enzymes. Loss of elastic recoil and increased compliance leads to airway obstruction (air trapping)
What type of emphysema is associated with smoking?
With alpha-1-antitrypsin deficiency?
-Centrilobar (proximal acinar)
-Panacinar (diffuse)
What is unique about the PFT in emphysema vs Chronic Bronchitis?
-in Emphysema, the DLCO is decreased due to loss of elastic recoil
What is shown on CXR in those with emphysema?
Hyperinflation: flattened diaphragms, increased AP diameter, decreased vascular markings, bullae
What is the pathophysiology of chronic bronchitis?
-Chronic inflammation leads to mucus gland hyperplasia, goblet cell mucus production, dysfunctional cilia, and infiltration of neutrophils and CD8+ cells
With chronic bronchitis, what is expected on:
-ECG:
-CBC:
-ABG:
-ECG: cor pulmonale (RVH, right atrial enlargement)
-CBC: increased hemoglobin and hematocrit
-ABG: respiratory acidosis
Regarding symptoms, what is the main symptom of emphysema vs chronic bronchitis?
Emphysema: dyspnea
Chronic Bronchitis: productive cough (at least 3 months in the last 2 consecutive years)
What is the MCC of Bronchiectasis in the US?
Cystic Fibrosis
MC associated viruses related to viral COPD exacerbations?
Rhinovirus
What are two factors that reduce mortality in COPD?
Smoking cessation**
Oxygen therapy
COPD Treatment Categories
Category A:
Category B:
Category C:
Higher Burden:
Category A: SABA as needed
Category B: SABA + LAMA
Category C: LAMA + LABA
Higher Burden: LAMA + LABA or LAMA + LABA + glucocorticoid
Name the Drugs
-SABA
-SAMA
-LABA
-LAMA
-SABA: Albuterol
-SAMA: Ipratropium
-LABA: Salmeterol, Formoterol
-LAMA: Tiotropium
What are common side effects of LAMA and SAMAs?
Anticholingeric: dry mouth, thirst, blurry vision, urinary retention, difficulty swallowing
