Resp Flashcards
Most common cause of chronic cough and not a smoker?
GERD
Asthma
Post-nasal drip
ACEI
Respiration patterns?
Obstructive:
Prolonged expiration
Asthma, COPD
Kussmaul’s:
Regular deep and fast
Exercise, metabolic acidosis, anxiety
Cheyne-Stroke:
Irregular depth + apneic periods.
Uremia
Most common cause of hemoptysis?
Bronchitis
Most common causes of clubbing?
• Resp:
Lung ca, bronchiectesis, fibrosis, abscess (NOT COPD)
• CVS:
Endocarditis
AV fistula
• GI:
IBD, celiac, cirrhosis
• Endo:
Graves’ disease
Causes of high DLco?
Asthma
Pulmonary hemorrhage
Polycythemia
DDx of cough?
- Airway Irritant:
Smoke, dust, fumes.
Post-nasal drip
Aspiration of GERD, foreign body, secretions - Airway Disease:
Asthma, COPD, bronchitis, bronchiectasis.
Neoplasm or LN
URTI causing post nasal drip - Parenchymal disease:
ILD, pneumonia, lung abscess. - CHF
- ACEI
DDx of hemoptysis?
1. Airway disease: Bronchitis Bronchiectasis Bronchogenic Ca Bronchial carcinoid tumor
- Parenchymal disease:
Pneumonia, TB, lung abscess.
3. Vascular disease: PE High pulmonary venous pressure: LVF / MS Vascular malformation Vasculitis: goodpasture's
Define asthma?
It is a chronic airway inflammatory disease.
Due to airway hyperresponsiveness to triggers/antigens leading to reversible bronchospasm causing obstruction.
What is the pathophysiology of asthma?
Airway obstruction => V/Q mismatch > hypoxemia > hyperventilation > low PaCO2 > high PH + muscle fatigue > hypo ventilation , high PaCO2, low PH.
What is the pathophysiology of asthma?
Airway obstruction => V/Q mismatch > hypoxemia > hyperventilation > low PaCO2 > high PH + muscle fatigue > hypo ventilation , high PaCO2, low PH.
Sx of asthma?
- Nocturnal cough with sputum
- wheeze, chest tightness
- Pulsus paradoxus
What are the triggers of asthma?
- URTI
- Allergen (pet dander, dust, mold)
- Irritant (smoke)
- Drugs (NSAIDs, BB)
- Preservatives (sulphite, MSG)
- Anxiety, exercise, GERD, cold
Signs of poor asthma control (DANGERS)?
Daytime Sx = or > 4x/week Activity reduced Nighttime Sx = or > 1x/week GP visit ER visit Rescue puffer = or > 4x/week School absence
What is The pulmonary function of criteria for diagnosis of asthma?
- Spirometry shows reversible obstruction.
⬇️FEV1/FVC 12% - PEF
⬆️ PEF after bronchodilator
PEF > 60%
Diurnal variation > 8% - Positive methacholine challenge test.
Define COPD?
Progressive, irreversible condition characterized by chronic obstruction with periodic exacerbations.
Subtypes of COPD?
Chronic bronchitis + emphysema
Chronic bronchitis vs emphysema?
Dx
• Chronic bronchitis:
Dx clinically
Productive cough for 3 consecutive mo in 2 successive years.
Due to airway narrowing by mucosal thickening and excess mucus.
• Emphysema
Dx path
Alveolar dilatation and destruction w/o fibrosis, leads to decreased lung recoil.
Low recoil > low expiratory pressure > air trapping > airway collapse.
Types of emphysema?
• Centriacinar:
Bronchioles
Smokers
Upper zone
• Panacinar:
Bronchioles, alveolar duct and sac
a1-anti trypsin
Most important risk factor for COPD?
Smoking
Sx of bronchitis vs emphysema?
Blue bloaters vs pink puffers
- Bronchitis:
- Chronic cough w/ purulent sputum + hemoptysis.
- Cor pulmonale + peripheral edema.
- Crackles + cyanosis
- Prolonged expiration
- Obese - Emphysema:
- Exertional dyspnea
- Pink skin + pursed-lip breathing
- Barrel chest
- Cachectic
Investigations of a bronchitis vs emphysema?
- Bronchitis:
• PFT:
⬇️FEV1, FEV1/FVC, DLco
N TLC
• CXR:
Normal AP diameter
Inc bronchovascular markings
Enlarged heart in Cor pulmonale
- Emphysema:
• PFT:
⬇️ FEV1, FEV/FVC, LDco
⬆️ TLC, RV
• CXR: Inc AP diameter Flat hemidiaphragm ⬇️ bronchovascular markings Bullae
Complications of COPD
- Polycythemia 2ry to hypoxia
- Chronic hypoxemia
- Pulmonary HTN
- Cor pulmonale
- Pneumothorax (Bullae)
How to prolong survival and COPD patients? (3)
Smoking cessation
Vaccination
Home oxygen
What is the importance of home oxygen in COPD?
Prevents cor pulmonale and decreases the mortality if you use > 15 h/day when PaO2
Define acute exacerbation of COPD
Sustained (>24-48 hr) worsening of dyspnea cough or sputum production leading to increased use of medication.
O2 target of acute exacerbation of COPD.
88-92% for CO2 retainers.
Management of acute COPD exacerbation
- ABC
• consider assisted ventilation if ALOC or poor ABG. - O2 target 88-92 in CO2 retainers
- Bronchodilators
• SABA + anticholinergic nebz 3 back-to-back q15min. - Systemic steroids:
• IV or oral - Abx if purulent discharge.
- Simple exacerbation > amoxicillin, 2/3G cephalosporins, TMP/SMX
- Complicated (FEV1 less than 50%, 4 exacerbations/year, IHD, home O2, chronic oral steroids)
Fluoroquinolone or amoxi/clavulanate
Definition of a bronchiectasis
It’s an irreversible dilatation of airways due to destruction of airways from persistently infected mucus.
Part of the airway is affected in bronchiectasis
medium sized airways
What is the most common pathogen in bronchiectasis?
P. Aeruginosa
Then, S. Aureus + H. Influenzae
Pathophysiology of the bronchiectasis (3)?
- Obstruction
Tumor
Foreign body
Thick mucus
2. Post-infection TB Pneumonia Pertussis Measles Aspergillosis
- Impaired defense
Hypo-gamma
CF
Ciliary dysfunction (kartagener’s syndrome)
Sx of bronchiectasis
Chronic cough w/ purulent discharge + hemoptysis
Clubbing
Recurrent pneumonia
Local crackle
Investigations in bronchiectasis
- PFT: obstructive pattern
- CXR: tram tracking (specific)
Parallel lines radiating from the hilum. - HRCT (gold standard)
Signet ring - 100% specific
Dilated the bronchi w/ thick walls. Bronchus > artery. - Sputum Cx + AFB
- Serum Ig
- Sweat chloride for CF
Is the gold standard test for bronchiectasis
HRCT
Shows signet ring sign
What’s sarcoidosis?
If you pathic noninfectious non-caseating granulomatous multisystem disease with lung involvement in 90%.
Sx of sarcoidosis?
Asymptomatic or nonspecific
Extra pulmonary Sx: • CVS: arrhythmia + sudden death • Ophtha: uveitis • Derm: erythema nodosum, papule, lupus • peripheral lymphadenopathy • hepatosplenomegaly
Acute syndromes of sarcoidosis? (2)
1- Lofgren’s syndrome:
Fever, erythema nodosum, bilateral hilar lymphadenopathy, arthralgia.
2- Heerfordt-Waldenstrom:
Fever, parotid enlargement, anterior uveitis, facial palsy.
Dx of sarcoidosis?
Biopsy of lymph node for granulomas
Labs in sarcoidosis?
- CBC > shows cytopenia if spleen or BM involved.
- U&E > hypercalcemia/calciuria from VitD activation by granuloma.
- ECG > for conduction abnormality
- slit-lamp > uveitis.
- PFT: obstructive or restrictive or normal
- CXR > lymphadenopathy + nodular opacities
Staging in sarcoidosis?
- Depends on CXR
• Stage 0
Normal CXR
• Stage 1
Bilateral hilar lymphadenopathy +/- paratracheal.
• Stage 2
Bilateral hilar lymphadenopathy + Diffuse ILD
• Stage 3
ILD only
• Stage 4
Fibrosis (Honeycombing)
Rx of sarcoidosis?
85% of stage 1 resolves
50% of stage 2 resolves
Steroids for symptoms + organ involvement.
Define hypersensitivity pneumonitis?
It is a non-IgG mediated poorly formed granuloma and lymphocytic in for inflammation of the lung parenchyma caused by sensitization to inhaled agents.
Types of hypersensitivity pneumonitis and causative organism?
- Farmer’s lung = thermophilic actinomycetes
- Bird breeder = response to bird IgA.
- Humidifier + sauna takers = Aurobasidium
Presentation of hypersensitivity pneumonitis (acute + chronic)
Acute (4-6 hr):
Chills + fever
Cough + dyspnea
CXR: diffuse infiltrates
Chronic: Dyspnea + cough Weight loss PFT: progressively restrictive. CXR: upper lobe reticulonodular pattern
Type of immune response in acute vs chronic hypersensitivity pneumonitis?
Acute = type III (immune complex)
Chronic = Type IV (cell mediated, delayed hypersensitivity)
Rx of hypersensitivity pneumonitis?
Avoidance of further exposure
Systemic steroids
Who is at risk of asbestosis pneumoconiosis?
Workers in insulations Shipyards constructions Pipe fitters Plumbers
What is this doses pneumoconiosis?
Slowly progressive diffuse interstitial fibrosis induced by asbestos fibers after 10-20 yr exposure.
Sx of Asbestosis pneumoconiosis.
Paroxysmal non-productive cough with fine end-respiratory crackles
CXR finding of asbestosis pneumoconiosis.
Lower love reticulonodular pattern
+/- Honeycomb
Plural + diaphragmatic plaques and calcification.
Pathology in asbestosis?
Ferruginous bodies:
Yellow brown rod shaped structures.
Represent asbestos fibers in macrophages
Complication of asbestosis
Bronchogenic carcinoma
Lung cancer in smokers
Define pulmonary hypertension
A mean pulmonary arterial pressure > 25mmHg at rest + > 30 with exercise.
Or pulmonary artery pressure > 40 mmHg at rest.
WHO classification of pulmonary HTN?
- Pulmonary arterial HTN
- PHTN due to left heart
- PHTN due to lung dz
- Chronic thromboembolic PHTN
- Others.
Causes of arterial PHTN?
Idiopathic
Collagen vascular (SLE, RA, scleroderma)
Porto-PHTN
Pulmonary capillary hemangiomatosis
Systemic-pulmonary shunt
Pulmonary vaso-occlusive Dz
SCA
HIV
Schistosomiasis
Drugs + toxins
Epidemiology of idiopathic PHT?
Young females 36 yr
Associated with anorexic drugs, amphetamine or cocaine use
Sx of idiopathic PHTN?
- Dyspnea, chest pain, syncope
2. RV heave, reynaud’s
Dx idiopathic PHTN?
- CXR: enlarged central pulmonary arteries + RV enlargement.
- 2D echo > RV pressure.
- CT angio to R/O PE
- Cardiac cath > direct measurement of pulmo artery pressure.
What is pulmonary embolism
It’s a clot in the pulmonary arterial tree with subsequence:
- increase in pulmonary vascular resistance
- V/Q mismatch
- reduced pulmonary blood flow.
What is the most common source of pulmonary emboli?
Proximal leg thrombi (popliteal, femoral, iliac veins)
Risk factors for PE?
- Stasis:
Immobilization
Obesity
Venous insufficiency - Endothelial damage = post-op / trauma
3. Hypercoagulable state: Malignancy + Ca Rx Estrogen administration (OCP, HRT) Pregnancy + postpartum Nephrotic syndrome Hx of DVT/PE (personal or family) Coagulopathies: Factor V Leiden Antithrombin/ protein C/S deficiency Antiphospholipid antibody syndrome
What is Wells’ criteria and what is it used for?
Used to predict PE.
Risk factors: • DVT signs = 3 points • immobilization or surgery in 4wks = 1.5 • Hx PE/DVT = 1.5 • HR > 100 = 1.5 • Hemoptysis = 1.0 • Ca = 1.0
Clinical probability:
Low (0-2)
Intermediate (3-6)
High > 6
How to evaluate suspected PE?
- Low probability:
D-dimer (+ve) -> CT (+ve) = PE
D-dimer (-ve) -> No PE - High probability:
CT (+ve) -> PE
CT (-ve) -> Not PE
Rx of PE
- Admit
- O2 + pain management
- Acute anticoagulant: SC LMWH or IV heparin ASAP.
- interventional thrombolytic.
- IV thrombolytic for massive PE
- IVC filter for recent DVT + absolute # to anyicoagulant.
Duration of long-term anticoagulation for PE patient
- Reversible cause of PE (surgery, trauma, pregnancy): 3-6 mo
- Unprovoked PE: 6 mo
- Non reversible (Ca, anti phospholipid): indefinite
Types of pulmonary vasculitis?
Wegener’s granulomatosis
Churg-Strauss syndrome
Goodpasture’s disease
Define Wegener’s vs Churg-Strauss vs Goodpasture’s?
- Wegener’s:
Vasculitis of medium to small arteries with necrotizing granulomatous lesions. - Chrug-Strauss:
Allergic rhinitis, asthma, eosinophila - Goodpasture’s:
Alveolar hemorrhage and granulonephritis 2ry to anti-GMB antibodies that cross-react with basement membrane of kidney and lung.
Dx of Wegener’s vs chrug-Strauss vs Goodpasture’s
- Wegener’s
CXR: nodules + cavities
c-ANCA - Chrug-Strauss:
Eosinophilia + p-ANCA - Goodpasture’s:
CXR: alveolar infiltrates (hemorrhage)
ELISA with anti-GMB
Linear staining on immunofluorescent
What is the most common collagen vascular disease affecting the lung?
Scleroderma
Types oh for pleural effusions
Transudative + exudative
How to distinguish transudative vs exudative effusions?
Modified Light’s Ceiteria
- Plural/serum protein: > 0.5
- Plural/serum LDH: > 0.6
- Plural LDH: > 0.45 upper limit of serum LDH
One or more = exudative
Pathophysiology of transudative vs exudative pleural effusions
- Trans:
Increased formation and absorption of plural fluid. - Exudate:
Increased permeability of pleural capillaries or lymphatic system.
Causes of transudative vs exudative pleural effusions
- Trans:
CHF
Nephrotic syndrome + cirrhosis
Peritoneal dialysis + hypothyroidism + CF - Exudate:
- Infections: bacterial pneumonia + TB
- Ca
- Inflammatory: collagen vascular disease + PE
- Intra-abdominal: subphrenic abscess
- Intra-thoracic: perforated esophagus
- Trauma.
Simple vs complicated pleural effusion
- Simple:
PH > 7.1
LDH 2.2 - Complicated:
PH 1/2 serum
Glucose
What is pneumothorax?
Air in the pleural space that rises intra-pleural pressure and causes partial lung deflation
Causes of pneumothorax
Trauma Iatrogenic (central cath, mechanical ventilation) Spontaneous: 1ry > healthy tall young males. 2ry > emphysema + lung cancer
Sx of tension pneumothorax
- Severe respiratory distress
- Tracheal deviation to contralateral side
- High JVP
- Hypotension
Sx. Of pneumothorax
Dyspnea + pleuritic chest pain
Tracheal deviation
Low tactile/vocal fremitus
Hyperresonance
Rx of pneumothorax
Small:
- resolves continuously
- 100% O2
- intercostal tube.
Large:
- chest tube w/ underwater seal +/- suction
