Respiratory Flashcards
Diagnosis of asthma
Diagnosis of asthma
- PFTs/spirometry to assess bronchodilator response-> no response-> methacoline challenge test
- Nocturnal or early morning peak expiratory flow rates measurement–for those with nocturnal symptoms only
Alternative approach: 2-4 wks treatment with inhaled glucocorticoids-> improved condition-> asthma diagnosed
Asthma and comorbid GERD
Comorbid GERD is usually present in pts with asthma-›microaspiration of gastric contents-> 1 vagal tone and bronchial reactivity-> exacerbates asthma symptoms-> sore throat, morning hoarseness, 1 cough only at night, 1 need of albuterol inhaler after meals may not be associated with typical GERD sims+ symptoms- 1 risk with obesity > Rx: PPl improve asthma symptoms and peak expiratory flow rates in asthma
Treatment of asthma exacerbation
Mild to moderate exacerbation: exygen and inhaled short acting beta 2 adrenergic agonists (SAGA
usually respond? il no response-> systeric corticosteraids
Severe exacerbation: SABAs+ ipratropium nebulizer» systemic corticosteroids ( oral/IV - takes se hour to show effect) -> no improvement after one hour of therapy-> one time dosing with IV
magnesium sulfate (bronchodilation) -> signs of respiratory failure > admit to ICU with endotrach
intubation
ABG in Asthma & PE
Respiratory Alkalosis
ABG in COPD
Respiratory acidosis
Anterior mediastinal masses
4Ts
terrible lymphoma,
thyroid,
thymoma,
teratogenic tumors
Anti GBM antibody (goodpasture disease)
Immune mediated IGg type 2 hypersensitivity reaction. can lead to proliferative GN and renal failure. poor prognosis
TTX: plasmapheresis, cyclophosphamide, steroids.
ARDS berlin criteria
1) acute onset <1 week 2)
bilateral involvement 3)
pulmonary edeam not casued by fluid overload or CHF( PCWP <18) 3)
abnormal Pa02/ Fi02
ratio <200)
ARDS casues
1) sepsis 2) aspiration of gastric contents 3) severe trauma, pancreatitis, burns, 4) drug overdose
5) intracranial HT 6)
cardiopulmonary bypass
Arrythmia thats common in
patients with COPD is?
MAT, treated by managing
COPD not by giving antiarrythmic drugs.
Best mechanical ventilation method for COPD pt?
Bipap
Causes of Bronchiectasis:
1) reccurent infections (allergic bronchopulmonary asperigillosis is a risk factor)
2) Cystic fibrosis
3) primary cillary dyskinesia (kartegner syndrome)
4) autoimmune disease (RA, SLE)
5)Humoral immunodeficienev
Causes of exudative Pleural effusion
1) malginancy
2) viral,bacterial infection (TB)
3) PE
4) collagen vascular disease
Causes of transudative
Pleural effusion
1) CHF
2)atelectasis
3)PE
4) peritoneal dyalisis
5) nephrotic syndrome
6)hypoalbuminemia
7) cirhosis
Classical CXR findings in silicosis
egg shell calcifications, localized and nodular peribronchial fibrosis
classical CXR findings of asbestosis
linear opacities, pleural plaques, barbell bodies on
biopsy
clinical manifestations of sarcoidosis
1) Constitutinal symptoms (fever, weight loss, anorexia)
2) CNS involvement ( Optic nerve, facial nerve palsy, peripheral neuropathy, papilledema)
3) Eyes (anterior Uveitis, posterior
Uveitis, conjunctivits)
4)Lungs ( dry cough, dyspnea)
5) Cardiac ( arrythmias, conduction disturbances)
6)MSS (arthitis, arthralgia)
7)Skin (erythema nodosum, subcutanous nodules,)
Comorbidites associated with Asthma?
1) GERD 2) OSA 3) Sinus disease
4) Obesity 5) Vocal cord dysfunction
Complications of COPD
1) Acute exacerbations
2) polycythemia 3) cor pulmonale
COPD risk factors and causes:
1) Smoking 2) Chronic asthma
3) A-1 antitrypsin deficiency
4) environmental factors (2nd hand smoke)
CXR findings of pulmonary embolism
hampton & westmark signs
DDX of finger clubbing
1) LUNG (ILD, CF, lung ca., sarcoidosis) 2) CHF, bacterial endocarditis 3) IBD 4) liver cirhoisis 5) primary billary cirhosis
definition of sarcodiosis
is a chronic systemic disease characterizied with Non caseating granulomas, commonly found in african american women under 40 yr of age, mostly asymptomatic
difference between
Panlobular and centrilobular emphysema
Centrilobular:
1) MC type,
in smokers
2) involves emphysema proximal Acini
3) common in upper lobes
Panlobular:
1) MC in a1 antitrypsin deficiency
2) involves distal and proximal acini
3)common in lung Base
Drug that treats CF
Ivacaftor (CFTR regulator)
ECG finding of Pulmonary
embolism
S1Q3T3
Eosinophilic Granulomatosis with polyangitis (churg strauss)
Granulomatous vasculitis
common in asthma patients,
has high P-ANCA levels
genetic mutation of cystic
fibrosis
CFTR gene, autosomal
recessive, seventh chromosome.
gold standard diagnostic test for ILD
HRCT
Good pasture disease has
high levels of which antibody
PANCA
Granulomatosis with polyangitis (Wegner granulomatosis )
is a necrotizing
granulmatous vasculitis, affects kidneys and lung,
GOLD STANDARD for diganosis is tissue biopsy. has high C- ANCA level
how to treat samters triad?
Montelukast ( a leukotrine modifier)
hypersensitivity pneumonitis
immune mediated
pneumonitis, by IGg, IGa antibodies. Results in non caseating granulomas & peribronchial mononuclear infiltrates with giant cells.
MANAGMENT: removal of offending agent
idiopathic pulmonary fibrosis
unknown etiology, 50-70yr
old, men, smokers presents with >6months of dry cough & SOB 50% association with finger clubbing
ILD that affect the upper parts of lung
Myobacteruim Settles
Superiorly At Lung
1) TB
2)sarcoidosis
3) silicosis
4)Ankylosing spondylitis
5)Langerhans histocytosis
ILD that affects base of lung
AAPC
1) asbestosis
2)aspiration
3) Pulmonary fibrosis (idiopathic)
4)Collagen vascular disease
Important clincal feature of Bronchiectasis?
chornic cough with LARGE amouts of mucopurluent
FOUL smelling sputum.
Indications for Oxygen therapy in COPD:
1) if Pa02 (55mmhg) OR
02sat <88%
2) if Pa02 (59mmhg) OR 02sat 89% in patients with HF, Cor palmonale
Local invasion forms of lung
cancer?
1) SVC syndrome (5%)
caused by mediastinal tumors
2) phrenic nerve palsy (1%)
3) Reccurent laryngeal nerve palsy (3%)
4) Horner syndrome: invasion of cervial sympthatic plexus
5) Pancost tumor: involvment of C8-T2: causes weakness, numbness in upper extermities. COMMONLY from squamous cancers
6)Malignant pleural effusion (considerd stage 4 cancer )
Lung PFT in ILD
Both FEV1 & FVC are reduced equally, thus FEV1/ FVC ration remains normal or is increased
Main precipitants for COPD exacerbations (organisms)
1) MCC is viral causes
2) strep. pneumonia 3)
H.influenza 4) mycoplasma pneumonia 5) Moraxella catarrhalis
Management of Asthma exacerbations
1) Inhaled b2 agnoist
2)oral steroids or IV 3) IV magnesuim (only used in unresponsive cases to above medications)
4) Supplemental oxygen
5) Antibiotics (ONLY if suspicion of bacterial penumonia is present) 6)
intubation
Managment of Asthma
1) Inhaled B2 agonists
2) Inhaled steroids 3)
Leukotrine modifers (montelukast) 4) Theophyline
Managment of COPD exacerbations
1) FIRST LINE:
Bronchodilators alone or combination of B2 agonists or anticholinergics) 2)
Oral Steroids 3) oxygen 4) antibiotics 5) intubation if refractory
middle mediastinal masses
MACLL morgagni hernia, aneursym, Cyst, lymphoma, lung cancer
most common cardiac finding in patients with Plumonary embolism is
Sinus tachycardia
Most common form of lung cancer?
1) Non small cell 75% (adenocarcioma is most common type) 2) small cell
25%
most common lung cancer in general?
is metz. from breast and
colon
Most common sites of Metz.
LABB 1) liver 2) adrenal in lung cancer
glands 3) brain 4) bone
most likely organism to
cause pneumonia in patients with CF?
Pseudomonas
MX of NSCLC
resection tradiation
MX of SCLC
if limited: combination chemo + radiation if extensive: chemo alone followed by whole brain irradiation if responsive to chemo
Paraneoplastic syndromes of
Lung cancer
SCLC: 1) Inappropriate
ADH 2) ACTH (cushing) 3) eaton lambert syndrome
4) hypercalcemia due to PTH secretion (commonly squamous) 5)
hypercalcemic pulmonary osteoarthropathy squamous & adenocarcinoma)
Risk factors of Lung cancer?
1) smoking 2) asbestos 3)
radon 4) COPD 5) second hand smoke exposure
screening test of lung cancer
low dose CT annually for: 1)
pt. with >30 pack years 2)
stopped smoking less than
15 yr ago 3) older than 55 yrs of age
what is not a determinent of
Resection for lung cancer
size
PFT in restrictive lung disease
DECREASE IN TLC, VC, FRC
PFT vaules in COPD:
INCREASE in TLC, FRC, RV DECREASE in VC, FEV1, FEV1/FVC ratio, peak expiratory flow
positive tests in Sarcodosis
1) tuberculin skin test 2)
ACE enzyme elevation
3) Hypercalcemia and hypercalcuria
posteroir medisatinal masses
neurogenic tumors, esophageal mass, bochadelk hernia, enteric cyst
Pulmonary alveolar protienosis
accumulations of
surfactant like protien and phospholipids.
Risk factors for solitary pulmonary nodules
AB 2S 2C 1) age >60 2)
Borders: irregular 3) Smoking
4) size: >2cm has 50% chance of malignancy 5)
Calcification: malignant if eccentric and asymmetrical
6) change in size: if rapid more likely to be malignant
Risk factors of Lung cancer?
1) smoking 2) asbestos 3)
radon 4 COPD 5) second hand smoke exposure
Sarcoidosis findings on chest XR
bilateral hilar adenopathy is a hallmark finding.
screening test of lung cancer
low dose CT annually for: 1)
pt. with >30 pack years 2)
stopped smoking less than
15 yr ago 3) older than 55 yrs of age
Signs of COPD:
INSEPCTION: 1) cyanosis 2)
use of accessory muscles
3) prolonged expiratory phase with pursed lips
PALPATION: 4) tachypneia 5) tachycardia PERCUSSION:
6) hyperressonance
AUSCULTATION: 7)
inspiratory crackles 8)
expiratory wheeze 9)
decreased breath sounds.
*** in advanced disease signs of COR PULMONALE
Treatment of Bronchiectasis
1) MAINLY antibitoics 2)
hydration 3) physiotherapy
4) inhaled bronchodilators (rarely)
Treatment of choice in sarcoidosis
if asymptomatic = nothing
if symptomatic = Steroids
are treatment of choice, if refractory to steroids after 6 months try methorexate
Treatment of COPD:
1) SMOKING CASSATION is the most important.
2) oxygen therapy 3)
inhaled anti cholinergics ( ipratropuim bromide, tiotropium) 4) inhaled beta 2 agonists 5) combination of both (anticholinergics and B2 agonist) 6)
Inhaled corticosteroids
IN COMBINATION with B2 agnoist (NEVER ALONE
7) theophyline (narrow theraputic index (IN
REFRACTORY CASES)
8) Phosphodiestrase
What is pulmonary langerhan cell histocytosis
a chronic interstial pneumonia caused by abnormal proliferation of histocytes. 90% in smokers
What is samters triad?
Combination of asthma, aspirin sensitivity and nasal polyps
what is the cause of samters triad?
Leukotrine overproduction
What is the most frequent non cardiac cause of pulsus paradoxes
COPD & ASTHMA
what organ systems does cystic fibrosis affect?
1) RS
2) GI (exocrine pancrease, intestines)
3) Fertility (gentourinary system)
what should patiens
with pulmonary alveolar
protienosis NOT be given
steroids because there at increased risk of infections
what type of hypersensitivity response is Asthma?
type 1 IGE mediated
What’s the A-a gradiant in
Pulmonary embolism
elevated due to V/Q mismatch
what’s the gold standard
for Dx of pulmonary hypertension
Right heart catheterization
whats the defenitive
diagnositc test in sarcoidosis
transbronchial biopsy
whats the gold standard for
Pulmonary embolism ?
Pulmonary angiography
whats the hallmark
diganositic finding of ILD?
desaturation more than 4% with ambulation
when is surgical resection of
Lung ca C/I
1) Bilatera 2) metz. 3) malignant pleural effusion
when is thoracocentisis not done in Pleural effusion?
1) if fluid is lobulated
2) if <10ml
3) if pt. has CHF – try duretics first.
When to measure A1 antitrypsin level?
in patients with family history
of premature COPD (<45yr) or in nonsmokers presenting with emphysema
which anticoagulants can
be taken in patients with
GFR
1) warfrain
2) Unfractinated low heprain
3) apixiban
which race is CF comonly in?
caucasians
treatment of Pulmonary alveolar protienosis
1) lung lavage 2) granulocyte stimulating factor
vitamin deficiency in CF
AKED vits. 1) vit. A = night blindness 2) Vit. K = coagulopathy 3) Vit, E = ataxia, hemolysis 4) Vit. D = rickets
what drugs should be avoided in Samters triad?
NSAIDS, like aspirin
What finding on HRCT indicated poor pronosis and end stage lung disease?
Honey coomb pattern
What is an indication that pleural effusion could be due to RA?
if pleural glucose is <60 Low ph
High LDH and cell count
Exudative pleural effusion
What is GOLD staging for
COPD?
measures severity of
COPD according to FEV1
1)>80% = Mild dz
2) 80-50% =moderate
3) 50-30% = severe
4) <30% = very severe
What is Lights Criteria
used to diagnose Exudative pleural effusion. (HAS TO HAVE AT LEAST ONE)
1)Pleural Protien/ Serum
protien = >0.5
2) Pleural LDH/ Serum LDH = >0.6
3) LDH >2/3rd of upper normal limit of serum LDH
