Respiratory Flashcards
Asthma?
Start with Symbicort PRN and up to 8 puffs a day as a scheduled or PRN medication (can be used as a rescue medication).
Asthma - needs ICS to improve. LABA now first line. SABA not so much.
COPD Tx?
Start with a LAMA - often Spiriva, can move to a LAMA/ LABA combo and then add on a ICS if needed
3 pillars of CAP Dx?
Evidence of infection (fever/ malaise)
Sx localized to the respiratory system (cough/ sputum)
Chest imaging (infiltrates)
When should you get a gram stain and culture in CAP
Inpatients, severe, empiric MRSA pseudomonas tx, or risk of HCAP.
Should you get blood cultures on a patient with CAP?
Not routinely, no
Prediction of severity of pneumonia?
PSI or CURB-65, with evidence for PSI
Should this patient with CAP go to the ICU?
IDSA 2007 major criteria or 3 minor warrants ICU admission
Tx for CAP for outpatients?
Outpatient, for no comorbidities - Amoxicillin 1g TID, or Doxycycline 100mg BID, AZT is not so strongly recommended
Comorbidities: combo Amox/clav + macrolide or quinolone (moxiflox/levoflox)
Inpatients without risk of MRSA/pseumonas tx?
Ceftriaxone or quinolone
No need to add on add on anaerobic coverage for aspiration pneumonia unless lung abscess/ very severe
CAP with positive for flu - still give antibiotics?
Yes, usually a co-infection.
Bronchiectasis managment?
Get a sputum sample, and start empiric abx
Treat lung abcess with?
21-48 days of Amox-clav or other beta lactam - inhibitor combos or penems?
Empyema tx?
Thoracentesis or chest tube drainage need to control the source and IV abx - 3rd gen cephalosporins +metronidazole
Risk factors for lung CA?
Smoking (duration more important than amount)
Occupational exposures
Genetic predisposition
Radiation exposure
Types of Lung CA?
Small cell Pancoast (location in the upper part of the lung) NSLC: - Adenocarcinoma - Squamous cell - Large Cell
Features of Adenocarcinoma?
Not necessarily related to smoking
Diffuse and might be more peripheral
Subtype in bronchioles - might present as an unrelenting pneumonia
Female
Squamous cell CA features?
Hilar findings more like a cavitary lung lesion
Associated with smoked
Small cell features?
Very aggressive, lots of Mets, smokers centrally located
Can measure chromogranin - this is a neuroendocrine tumour
Carcinoids of the lung?
Like pre-small cell CA, endobrachial can be removed easily
Common Mets location for Lung CA?
Liver, brain, bone, adrenals
Pancoast lung ca presentation?
More likely to show SVC occlusion symptoms (edema of the neck) and hoarseness and dysphagia (recurrent laryngeal, esophagus), horner’s syndrome , brachial plexus involvement, horner’s syndrome
What is paraneoplastic syndrome?
The effect of the cancer on the immune system or hormonal signalling
- SIADH
- Etopic Cushing
- Neurological (MG, Eaton- Lambert, dementia)
- Hypercoagulation
- Hypercalcemia
Horner’s syndrome?
Mitosis (constriction), ptosis, and anhidrosis (no face sweat)
Pemberton sign?
SVC occlusion, raise arm above the head, face turns bright red
Screening for Lung CA
Low dose CT - 3 consecutive years then stop
Over 55-74, with 30 pack year, who smoke or quit less than 15 years ago
Diagnosis pathway:
https://www.cancercareontario.ca/en/pathway-maps/lung-cancer
CXR findings suspicious for lung CA
Nodule - less than 3cm
Mass - more than 3cm
Both can be indicative for lung CA (the bigger the more concerning)
Pleural effusion
Hilar and mediastinal adenopathy
Elevated hemidiaphragm
Questions to ask if suspicious of lung CA
COPD, Pulmonary fibrosis, radiation exposures, past CA, family history, TB
Can think of like this:
Constitutional Sx, Metastatic sx, Local sx and risk factor
*Also drug coverage.
Try to r/out PE/ ACS
Cancer performance status measure?
ECOG
Hamman’s sign?
A crunching, rasping sound in time with heart beat - heart beating against the air filled mediastinum.
Hamman syndrome - pneumomediastinum after excessive pressure such as childbirth, asthma, valsalva
Airway sizes and adventitious sounds
Wheezes (smaller), Ronchi (medium), Stridor (large airway)
Legionella?
Dyspnea, cough, diarrhea - order an legionella urinary antigen disease.
Milliary TB
Acute, severe TB
Causes of Pulmonary HTN?
Group 1 (directly on vasculature): Idiopathic, Genetic, drugs, HIV, sickle cell disease, Porto pulmonary, connective tissue disease Tx: with pulmonary vasodilators
Group 2 (more pressure): Left heart failure, valvular disease, Congenital heart disease
Group 3 (hypoxia): COPD, interstitial lung disease, sleep apnea (increases risk factors),
Group 4 (obstructive): PE/VTE, malignancy can cause this too, chronic thromboembolic pulmonary hypertension
Group 5: misc weird stuff
Criteria for pulmonary hypertension
Mean pulmonary artery pressure of >20mmHg
Measure the Right ventricular systolic pressure >40mmHg (echo) and then follow up with a right heart catheter to get the mean PAP, PVR >3 and PCWP <15
Work up for Pulmonary Hypertension
Should test for HIV, examine joints, ANA/RF/anti-CCP, ECHO (and treat any heart disease), give O2, work up for sleep apnea, get a V/Q scan (for pulmonary embolism)
If all negative become concerned for pulmonary arterial hypertension- need right heart cath. Check Pulmonary capillary wedge pressure (should be less than 15mmHg)
Treatment of Pulmonary arterial HTN
1) phosphodiesterase 5
2) endothelin antagonists
3) prostacyclin agonists
One of the first signs of diabetic kidney disease?
High urine protein, long before there is a Cr rise, this counts as chronic kidney disease
