Pulmonology Step Up Flashcards
paradoxic movement of abdomen and diaphragm on inspiration
sign of impending respiratory failure i.e. severe acute asthma attack
arterial blood gas findings in acute asthma attack
LOW PaCO2, LOW PaO2
- increased or normal PaCO2 is a sign of resp. mm fatigue or severe airway obstruction (consider mechanical ventilation); increased A-a gradient
PFTs in asthma
decreased expiratory flow rates
decreased FEV1/FVC ratio < 0.75%
increased DLco
in order to dx. asthma, what should the PFT result be after bronchodilator??
FEV1 or FVC should increase by 12% or 200 ml after albuterol (B2-agonist)
methacholine challenge
FEV1 decreases by > 20% after methacholine challenge, this is suggestive of asthma
quickest method of diagnosis of asthma in acute setting
peak expiratory flow rate
first line therapy in acute severe asthma exacerbation
- inhaled short-acting B2 agonist via nebulizer or MDI
- IV steroids - taper when clinical improvement is seen and replace w/ inhaled
- oxygen - SaO2 > 90%
in what situations do you use long-acting B2 agonists (salmeterol) in tx of asthma?
- night-time asthma
- exercise-induced asthma
- severe, persistent asthma
when do you use inhaled corticosteroids in asthma tx?
mild-moderate asthma in addition to short acting B2 agonist
when is montelukast useful for asthma tx?
- prophylaxis of mild exercise induced asthma
- control of mild-moderate disease (lowers need for steroid and bronchodilator requirements)
- severe asthma resistant to max doses of inhaled steroids as last resort before using chronic systemic steroids
when can cromolyn sodium/nedocromil sodium be used?
only for prophylaxis i.e. before exercise in adults; first-line chronic treatment in children
anticholinergic drugs (tiotropium, ipratropium)
useful in pts with heart disease and asthma but they take significant time to achieve max bronchodilation and are only medium potency
FEV1/FVC < 80%, normal TLC and DLco
chronic bronchitis
FEV1/FVC < 80%, increased TLC, decreased DLco
emphysema
features of centrilobular emphysema
smokers, limited to respiratory bronchioles and mostly in upper lung zones
features of panacinar emphysema
a1 antitrypsin deficiency, proximal and distal acini affected, mostly in lung bases
sign specific to COPD
prolonged forced expiratory time (timed full exhalation of vital capacity > 6 seconds)
to diagnose airway obstruction, one must have….
normal or increased TLC
decreased FEV1
definitive diagnostic test in COPD
spirometry
PFTs in COPD
- decreased FEV1 and FEV1/FVC < 0.70
- increased TLC, RV and FRC (air trapping)
- decreased vital capacity
good screening test in obstruction
peak expiratory flow rate – if < 350 L/min, perform PFT
CXR findings in emphysema
hyperinflation, flattened diaphragm, enlarged retrosternal space, small heart size and diminished vascular markings
ABG in COPD
chronic PCO2 retention, decreased PO2
- respiratory acidosis with metabolic alkalosis (compensation)
most important tx. intervention in COPD
smoking cessation - prolongs survival rate
clinical monitoring in pts with COPD
serial FEV1 measurements
pulse oximetry
exercise tolerance
which tx. interventions have been shown to lower mortality in COPD?
smoking cessation
home O2 therapy
mainstay of long-term treatment in COPD
short acting inhaled B2 agonists and inhaled anti-cholinergic drugs (combined they are more efficacious than either alone)
- inhaled steroids may be used as well
what do you give a COPD pt with significant symptoms or recurrent exacerbations?
inhaled corticosteroid (budesonide, fluticasone) AND long-acting bronchodilator (salmeterol, formeterol)
role of theophylline in COPD tx
only for cases of refractory COPD –> lots of side effects and benefit unclear
criteria for continuous or intermittent long term O2 therapy in COPD
- PaO2 < 55 mmHg OR
- O2 sat < 88% at rest or during exercise OR
- PaO2 55-59 mmHg and signs of polycythemia or cor pulmonale
benefit of oxygen therapy in COPD
when used for > 18 hr/day, reduces mortality in pts with COPD by controlling pulmonary HTN and thus, cor pulmonale
which two drugs are added for acute COPD exacerbations?
systemic steroids
antibiotics
pt presents with acute COPD exacerbation, what steps do you take?
- CXR - R/O infection etc
- inhaled short acting B2 agonist and anticholinergic
- IV steroids (methylprednisolone)
- antibiotics - azithromycin or levofloxacin
- supplemental oxygen
- non-invasive positive pressure ventilation
first line drugs in COPD
anticholinergic agents - ipratropium bromide, tiotropium (given via MDI)
- can add B2 agonists if needed (but not first line bc many pts also have heart disease)
- inhaled corticosteroids are not routinely used in chronic COPD (unless combined with LABA)
best predictor of survival in COPD
FEV1 - if < 25%, pts usually dyspneic at rest
which vaccinations should COPD pts routinely get?
pneumococcal every 5 years
influenza yearly
H.influenza if not previously vaccinated
diagnostic study of choice in bronchiectasis
high resolution CT scan
- signet ring bronchi diameter > accompanying artery
CXR findings in bronchiectasis
- tram-tracking of bronchi away from hilum
- 1-2 cm cysts
- nonspecific findings - linear atelectasis, increased markings
main treatment approach to bronchiectasis
- inhaled bronchodilators
- chest physiotherapy
- antibiotics for acute exacerbations
limited small cell lung cancer
confined to chest and supraclavicular nodes (not cervical or axillary nodes) –> extensive is outside the chest and SC nodes
paraneoplastic syndromes seen in SCLC?
SIADH, ectopic ACTH secretion, Eaton-Lambert syndrome
paraneoplastic syndromes in squamous cell ca. of lung
PTHrP secretion, hypertrophic pulmonary osteoarthropathy
most impt study for diagnosis of lung cancer
CXR - but should NOT be used as a screening tool
study used for staging of lung cancer
CT with contrast - can show local/distant mets as well as mediastinal LAD
role of cytological exam of sputum in diagnosing lung cancer
can only detect CENTRAL lesions - same goes for fibreoptic bronchoscopy
how do you get a definitive diagnosis of lung cancer?
confirmation of pathology with transthoracic needle biopsy
which diagnostic test would be useful for identifying pts with advanced dz who would not benefit from surgical resection?
mediastinoscopy - direct visualization of superior mediastinum
best tx. option for NSLC
surgery with radiation as adjunctive therapy
who should NOT receive surgery for lung cancer?
- small cell lung cancer
2. NSCLC pts with mets outside the chest
best tx. option for limited SCLC
chemotherapy plus radiation
best tx. option for extensive SCLC
chemotherapy alone initially
if pt responds, prophylactic radiation to decrease incidence of mets and prolong survival
factors that favor malignancy in a solitary pulmonary nodule
age > 50 yrs smoker or previous smoker size > 3.0 cm and steadily growing irregular or speculated borders stippled or eccentric calcifications
criteria for dx. exudative effusion
one of the following: LDH effusion > 200 IU/ml LDH pleural/serum > 0.6 protein pleural/serum > 0.5 - none of these can be positive for transudate
pleural fluid w/ elevated amylase
esophageal rupture, pancreatitis, malignancy
exudative effusion that is primarily lymphocytic
suspect TB and do a pleural biopsy
pleural fluid with a pH < 7.2
parapneumonic effusion or empyema
first test to do if you suspect a pleural effusion
CXR - PA view, lateral view and lateral decubitus films
minimum criteria for performing a thoracentesis in pleural effusion
at least 10 mm thick effusion on lateral internal decubitus CXR –if not, risk of pneumothorax is too high
what do you look for in thoracentesis fluid?
chemistry - glucose, protein, LDH, pH
cytology
cell count - CBC w/ differential
culture - gram stain
Tx. of transudative effusions
diuretics, sodium restriction
therapeutic thoracentesis - if lots of fluid causing dyspnea
Tx. of uncomplicated parapneumonic effusion
antibiotics alone
Tx. of complicated parapneumonic effusion
chest tube drainage
intrapleural injection of thrombolytic agents
antibiotics
after which procedures should you obtain a CXR? (3)
transthoracic needle aspiration
thoracentesis
central line placement
primary spontaneous PTX
occurs in otherwise healthy individuals (usually tall, lean young men) due to spontaneous rupture of subpleural blebs at the apex of the lungs
physical exam signs seen in spontaneous PTX
decreased breath sounds on affected side
hyperresonance over chest
decreased/absent tacile fremitus
mediastinal shift toward PTX
confirmatory diagnostic test for spontaneous PTX
CXR - shows visceral pleural line
first tx. for spontaneous PTX
supplemental oxygen
Tx of spontaneous PTX in symptomatic pt
supplemental oxygen
chest tube insertion
what is next best step if you suspect a tension PTX in a pt?
do NOT get CXR –> immediate decompression is needed w/ large bore needle or chest tube
how do you perform chest decompression in tension PTX?
insert large bore needle in 2nd or 3rd IC space in midclavicular line
which drugs are linked to interstitial lung disease?
amiodarone busulfan nitrofurantoin bleomycin phenytoin penicillamine
what should you do if a pt comes in with digital clubbing?
obtain a CXR - there is likely underlying lung disease
best diagnostic test for interstitial lung disease
high resolution CT scan
CXR findings in interstitial lung disease
reticular or reticulonodular (ground glass) appearance
PFTs in interstitial lung disease
decreased lung compliace = increased/normal FEV1/FVC
decreased lung volumes
decreased DLco
“honeycomb” lung
scarred, shrunken lung - end-stage finding with poor prognosis (airspaces are dilated and there are fibrous scars in interstitium)
MC clinical features in idiopathic pulmonary fibrosis
progressive exercise intolerance
cough and dyspnea
coarse crackles on auscultation
digital clubbin
definitive diagnosis of idiopathic pulmonary fibrosis
open lung biopsy - must exclude other causes of ILD
Tx. of IPF
steroids + azathioprine/cyclophosphamide ] only about 20% of pts will respond to this therapy (best prognostic indicator)
ultimately, need lung transplant
Lofgren’s syndrome
acute sarcoid syndrome w/ fever, erythema nodosum, bilateral hilar LAD and arthritis
Heerfordt Waldenstroms syndrome
acute sarcoid syndrome w/ fever, parotid enlargement, uveitis and facial palsy
definitive dx. of sarcoidosis
transbronchial biopsy showing non-caseating granulomas (in context of clinical picture)
CXR finding in sarcoidosis
bilateral hilar adenopathy
lab findings in sarcoidosis
- elevated ACE level in serum
- hypercalciuria/hypercalcemia
- skin anergy
- PFTs showing restrictive pattern
what type of exam should all pts suspected of having sarcoidosis have?
opthalmologic - 25% of cases have uveitis/conjunctivitis
Tx. of choice in sarcoidosis
systemic steroids - high dose for 2 months, followed by 3 months of dose tapering
which conditions in sarcoid MUST be treated with steroids?
uveitis
CNS involvement
hypercalcemia
what drug can be used in sarcoidosis pts with progressive disease refractory to steroids?
methotrexate
chronic interstitial pneumonia caused by abnormal proliferation of histocytes
Histiocytosis X
gold standard for dx. of Wegener’s granulomatosis
tissue biopsy
- but if pt is positive for c-ANCA, likelihood of disease is high
pt with asthma presents with pulmonary infiltrates, rash and eosinophillia
churg-strauss syndrome
antibody assoc. with Churg-Strauss
perinuclear ANCA (p-ANCA)
what is needed to consider diagnosis of asbestosis?
history of exposure - shipyard, foundries, mining, insulation, boilers, brake liners
CXR findings in asbestosis
pleural plaques, calcifications at level of diaphragm and diffuse interstitial fibrosis mainly in lower lobes
dx. of asbestosis
history of exposure, clinical findings - impt
definitive = lung biopsy showing barbell-shaped asbestos fibers
tx. of asbestosis
none available - stop smoking!
CXR findings in silicosis
eggshell calcifications (rare) hyaline nodules (1-10 mm) mostly in upper lobes
what infectious disease is silicosis associated with and what should these pts do?
TB - should get yearly PPDs; if > 10 mm, 9 months isoniazid tx
Caplan syndrome
rheumatoid nodules in periphery of lung in pts with RA and coexisting pneumoconiosis
dx. of berylliosis
beryllium lymphocyte proliferation test (blood test)
tx. of berylliosis
glucocorticoids
hypersensitivity pneumonitis (extrinsic allergic alveolitis)
inhalation of antigenic agent to alveolar level induces immune-mediated pneumonitis (i.e. moldy hay, avian droppings, air conditioners, compost)
hallmark finding in hypersensitivity pneumonitis
presence of serum IgG and IgA to inhaled antigen
diagnosis of goodpasture’s syndrome
tissue biopsy
anti-GBM ab’s on serology
Tx. of goodpasture’s syndrome
plasmapheresis
cyclophosphamide
steroids
pulmonary alveolar proteinosis
accumulation of surfactant-like protein and phospholipids in the alveoli
CXR findings in pulmonary alveolar proteinosis
ground glass appearance w/ bilateral alveolar infiltrates (resembling a bat shape)
definitive dx. test for pulmonary alveolar proteinosis
lung biopsy
Tx. of pulmonary alveolar proteinosis
lung lavage
new therapy - GCSF
general criteria used to define acute respiratory failure
- hypoxia - PaO2 < 60 mmHg
2. hypercapnia - PaCO2 > 50 mmHg
hypoxemic respiratory failure
low PaO2 with low/normal PaCO2 - present when O2 sat. is < 90% despite FiO2 > 0.6
hypercarbic (ventilatory) respiratory failure
failure of alveolar ventilation due to either a decrease in minute ventilation or an increase in dead space leading to CO2 retention
ventilation is monitored by…
PaCO2
- to decrease PaCO2 one must either increase RR or Tidal Volume
oxygenation is monitered by…
O2 sat. or PaO2
- to decrease PaO2 one must either decrease FiO2 or PEEP
ventilation, but no perfusion
V/Q mismatch
perfusion, but no ventilation
intrapulmonary shunting
- venous blood is shunted into arterial circulation w/o being oxygenated
features of V/Q mismatch respiratory failure
hypoxia w/o hypercapnia
- responsive to supplemental oxygen
in what scenario is the Aa gradient normal in a setting of hypoxia?
hypoventilation
low inspired PaO2
indication for NPPV
conscious patients with impending respiratory failure in an attempt to avoid intubation/mechanical ventilation
success rates for NPPV (BIPAP, CPAP) are greatest for…
hypercarbic respiratory failure (esp. COPD pts)
who is at highest risk of ARDS?
pts with sepsis or septic shock
pathophysiology of ARDS
massive intrapulmonary shunting secondary to widespread atelectasis, collapse of alveoli and surfactant dysfunction secondary to neutrophil activation, elevated alveolar mb permeability and pulmonary edema
clinical features in ARDS
- dyspnea, tachypnea, tachycardia
- progressive hypoxemia - not responsive to supplemental O2
- high peak airway pressures due to stiff, noncompliant lungs
classic clinical criteria for diagnosing ARDS
- hypoxemia refractory to O2; ratio of PaO2/FiO2 < 200
- bilateral diffuse pulmonary infiltrates on CXR
- no evidence of CHF: PCWP < 18 mmHg
PCWP
pulmonary capillary wedge pressure - reflect left heart filling pressures –> indirect marker of intravascular volume status
tx of ARDS
- supplemental O2
- mechanical ventilation w/ PEEP
- fluid management - want PCWP bw 12-15
- treat underlying cause
general indications for mechanical ventilation
- sig. respiratory distress/arrest
- impaired or reduced level of consciousness
- metabolic acidosis
- respiratory mm. fatigue
- sig. hypoxemia (PaO2 < 70) or sig. hypercapnia (PaCO2 > 50)
- respiratory acidosis (pH < 7.2) with hypercapnia
swan-ganz catheter findings in ARDS
normal CO, normal PCWP
increased pulmonary artery pressure
acceptable ranges of gas values in mechanical ventilation
PaO2 50-60
PaCO2 40-50
pH 7.35-7.50
assisted controlled ventilation
ventilator delivers breath of predetermined TV when pt initiates breathing AND if pt does not initiate a breath, ventilator takes over at a predetermined rate
synchronous intermittent mandatory ventilation
patient can breathe on their own above the mandatory set rate; ventilator breaths are synchronized with patient inspiratory effort so the two do not occur at the same time; if no breath initiated by patient, the mandatory breath is delivered by ventilator
continous positive airway pressure
positive pressure is delivered continuously (0-20 cmH20) by ventilator, but not volume breaths are delivered i.e. pt breathes on his/her own
pressure-support ventilation
used mostly during weaning; pressure is delivered with an initiated breathe to assist breathing
how do you confirm proper endotracheal tube placement?
listen for bilateral breath sounds
check postintubation CXR - tip of ET tube should be 3-5 cm above carina
difference between PEEP and CPAP
PEEP - during mechanical ventilation
CPAP - during spontaneous breathing
side effects of high levels of PEEP
- barotrauma - pneumothorax
2. low CO due to decreased VR
can a patient still aspirate with an ET tube?
yes
preferred agents for sedation in mechanical ventilation
benzodiazepines
- opiods for analgesia
what should you do if pt is mechnically ventilated for > 2 weeks?
tracheostomy - to decrease risk of tracheomalacia (softening of tracheal cartilage)
definition of pulmonary HTN
- mean pulmonary arterial pressure > 25 mmHg at rest or > 30 mmHg with exercise
- systolic pulm. aa presure > 40 mmHg at rest
main clinical features of pulmonary HTN
dyspnea, chest pain and syncope on exertion
physical exam findings in pulmonary HTN
loud pulmonic cpt of S2 (P2) and subtle lift of sternum (sign of RV dilatation)
gold standard for diagnosing pulmonary HTN
right heart catheterization
- can be estimated using Doppler 2D echo
ECHO changes in pulmonary HTN
dilated pulmonary artery
dilated/hypertrophy of RA and RV
abnormal mvt of IV septum
vasodilator trial in pulmonary HTN
give pt. inhaled NO, IV adenosine and oral CCBs under hemodynamic monitoring to predict response before initiating long-term tx
tx. of primary pulmonary HTN
- CCBs - nifedipine, diltiazem
- vasodilators - sildenafil, bosentan, epoprostenol
- anticoagulation w/ warfarin
- lung transplantation
what should you think of if a patient with long bone fracture develops dyspnea, mental status change and petechiae?
fat embolism
when can you make the diagnosis of PE w/o further testing?
when patient has symptoms of PE and a DVT is found
which situations can essentially R/O PE?
- low probability V/Q scan (or normal helical scan)
- negative pulmonary angiogram
- negative D-dimers and low clinical suspicion
ABG levels in PE
not diagnostic -> respiratory alkalosis (low PaO2, low PaCO2)
- elevated Aa gradient
when should you perform a duplex venous ultrasound of lower extremities?
- if you suspect DVT
2. if you suspect PE and spiral CT cannot be done or is inconclusive
initial diagnostic study of choice for PE?
helical CT scan
normal V/Q scan
virtually R/O PE
high probability V/Q scan
high sensitivity for PE - tx. pt with heparin
if you have low or intermediate probability V/W scan
need further testing –> duplex USG, spiral CT or pulmonary angiography to confirm
what do you do if dx. of PE is clinically unlikely? (decision rule score < 4)
D-dimer test
- if normal: can R/O PE, no tx
- if positive: do a CT Scan
what do you do if dx. of PE is clinically likely (decision rule score > 4)?
spiral CT
- if no PE (no tx) or if PE (tx)
- if inconclusive or cannot be done -> do leg USG (if DVT, tx; if no DVT - do V/Q scan or pulm. angiogram)
gold standard for diagnosis of PE?
pulmonary angiogram
main tx. strategy for PE
- supplemental O2
- heparin - LMWH } start immediately based on clinical suspicion
- oral warfarin - long term
contraindications for heparin
active bleeding
heparin induced thrombocytopenia
uncontrolled HTN
recent stroke
warfarin tx for PE
start with heparin, continue for 3-6 months depending on risk factors; want INR between 2-3
which conditions warrant an INR between 2.5-3.5
prosthetic mechanical heart valves
prophylaxis of recurrent MI
antiphospholipid syndrome
when should you consider thrombolysis in PE management?
not routinely used; consider in:
- pts with massive PE and hemodynamically unstable
- pts w/ evidence of RHF/cardiogenic shock
indications for using an IVC filter in PE management
- contraindication to anticoagulation
- complication of current anticoagulation
- failure of adequate anticoagulation
- pt w/ low pulmonary reserve who is at high risk of death from PE
where do aspirated contents usually end up?
lower segment of Right UPPER lobe
upper segment of RIGHT lower lobe
what antibiotics do you give if you suspect aspiration pneumonia?
penicillin G or clindamycin
how do you prevent aspiration in high risk patients?
keep head of bed elevated
nasogastric tube placement to decompress stomach
definition of massive hemoptysis
> 600 ml of blood in 24 hrs
MCC of massive hemoptysis
bronchiectasis
bleeding diathesis
what diagnostic studies should be done in a pt w/ hemoptysis?
CXR
bronchoscopy
CT scan of chest
causes of low DLco
emphysema sarcoidosis interstitial fibrosis pulmonary vascular disease anemia
causes of high DLco
asthma obesity intracardiac L-R shunt exercise pulmonary hemorrhage
normal V/Q ratio
- 8
- if higher, indicates inadequate perfusion of adequately ventilated lung
