Respirology Flashcards
Diagnosis of ashtma on PFTs
PFTs showing obstructive lung disease =↓ FEV1/FVC <0.8
o Reversible (↑FEV1 improves >12% with b-agonists)
o Inducible with Methacoline: Done if FEV1/FVC is initially normal (FEV1 decreases 20% with methacholine)
It’s called reactive airway disease until recurrent presentations
Patient with daytime symtoms < 2 /wk, nocturnal symptoms < 2 / month, FEV1 > 80%. Asthma stage and tx?
Intermitent. Rescue SABA
Patient with daytime symtoms < 1 /day, nocturnal symptoms > 2 / month, FEV1 > 80%. Asthma stage and tx?
Mild persistent. Rescue SABA + low dose ICS*
- Could be replaced with Leukotriene Antagonist (e.g. Motelukast) or theophyline
Patient with daytime symtoms > 1 /day, nocturnal symptoms > 1 / week, FEV1 60-80%. Asthma stage and tx?
Moderate persistent. Rescue SABA + low dose ICS + LABA
ICS could be replaced with Leukotriene Antagonist (e.g. Motelukast)
Patient with daytime symtoms > 1 /day, nocturnal symptoms frequent, FEV1 < 60%. Asthma stage and tx?
Severe persistent. SABA + high dose ICS + LABA
ICS could be replaced with Leukotriene Antagonist (e.g. Motelukast)
Patient with severe persistent daytime and nocturnal symptoms. Asthma stage and tx?
Refractory. SABA + high dose ICS + LABA + PO steroids
But PO steroids should be avoided. Try anti IgE (omalizumab) if IgE related asthma.
ICS are interchangeable with…
LTA – Leukotrien receptor antagonis (e.g., montelukast)
Patient with asthma exacerbation + silent chest
Medical emergency that might need intubation
Rescue treatment for asthma exacerbation
racemic epinephrine, subcutaneous epinephrine, magnesium, nebulizer
Asthma exacerbation treatment
O2 for SATO2 > 92%
Short acting b-agonist: Neb/MDI (metered-dose inhaler)
Short acting anticholinergic: Neb/MDI
Steroids: methylprednisolone 125mg IV / prednisone 40-60 mg PO
Ambulatory tx after asthma exacerbation
B-agonist MDI + prednisone 1-2 mg/kg x 5 days
Types of emphysema
centriacinar (smokers) and panacinar (a1 antitrypsin deficiency)
Clinical characteristics of Emphysema:
- CO2 retention, no hypoxemia, ↑AP dyameter, prolong exhalation, dypnea, minimal cough
- Pink puffers
- Hypoxemia, pulmonary hypertension, CHF, edema, productive cough
- Blue bloaters
Dx?
Chronic Bronquitis
Tx COPD
- SABA (albuterol)
- SABA + long acting muscarinic antagonist – LAMA (tiotropium)
- SABA + LAMA + LABA (salmeterol)
- SABA + LAMA + LABA + ICS
- SABA + LAMA + LABA + ICS + Phosphodiesterase 4 inhibitors – PDE4-i (theophylline)
- SABA + LAMA + LABA + ICS + PDE4-i + steroids
Chronic treatment of COPD
- C: corticosteroids. ICS /Prednisone PO / methylprednisolone IV
- O: oxygen if SAT < 88% or PaO2 < 55. Goal, keep SAT 88-92%
- P: prevention. Influenza and Pneumococcal vaccines, and smoking cessation (first line)
- D: dilators: SABA, LABA, PO (e.g., PDE4-i, theophylin)
- E: experimental (surgery)
- R: rehab
Oxygen and prevention impruve survival
What prolongs survival in COPD?
Oxygen, vaccination and smoke cessation
Anthonisen classification
COPD exacerbation: Wheezing/SOB, Cough, Sputum production. I worse than III
Anthonisen I or II - - >AB
AB in COPD exacerbation
Amoxicillin-clavulanic acid (first line), doxycycline, azithromycin (do an ECG first to measure QT)
Bx modalities in lung cancer.
Large proximal lesions?
EBUS (Endobronchial ultrasound), e.g., Squamous cell carcinoma
Bx modalities in lung cancer.
Lesion in periphery?
CT-guided percutaneous Bx, e.g., Adenocarcinoma
Bx modalities in lung cancer.
In the lung
VATS (video-assisted thorascopic surgery)
Patient age > 55, quitted smoking <15 years ago, with spiculated nodule > 2 cm. Next step?
Resection of the lesion
Pleural effusion, thoracocentesis positive for malignancy. Stage of disease?
IV (metastasic)
Fever, weight loss, hemoptysis and negative CxR for cancer. Next step?
Rule out paraneoplastic syndrome before assuming there is no lung CA.
Fever, weight loss, hemoptysis and positive CxR for cancer. Next step?
CT scan
Pulmonary mass confirmed with CT scan. Next step?
Bx, PET-CT (stage), and PFTs
Lung cancer screening. How and to whom?
Screening with Low dose CT-scan yearly
• Age 55-80
• 30 pack/year history
• Quitted smoking less than 15 years ago
CxR no sensitive or specific, so not recommended!!
Pulmonary node definition
Lesion < 3 cm. If > 3 cm, it’s called mass
Characteristics of a pulmonary node suggestive of cancer
Size > 2cm, spiculated, positive smoking Hx, age > 70
Pulmonary node not suggestive of cancer
Size < 8mm, Smooth surface, calcified, no smoking Hx, age < 45
Pulmonary node on CxR, next step?
Look old films first!!
Pulmonary node without changes compared to previous films. Next step?
No further action needed (not even follow-up)
New pulmonary or changing pulmonary node. Next step?
Compare patient’s risks fx and nodule characteristics
• Low risk: serial CTs
• High risk: Bx
Lung cancer treated only with chemo/radiotherapy and never with Sx?
Small cell lung cancer
SCLC vs NSCL, which one is more common?
SCLC (10-15%); NSCLC (85-90%)
Horner’s syndrome
Miosis, anhidrosis, ptosis. Associated with Pancoast tumor
Tx of SCLC
Chemo + rad, no matter the stage
Smoking Hx, lung cancer of central location, ADH-SIADH. Dx?
SCLC
Smoking Hx, lung cancer of central location, ACTH-Cushing. Dx?
SCLC
No smoking Hx, lung cancer of peripheral location, no paraneoplastic syndrome
Adenocarcinoma
Smoking history, lung lesions with salt and pepper histology on microscope. Dx and Next step?
Carcinoid lung cancer (Serotonin paraneoplastic syndrome: flushing, diarrhea, wheezing)
Urinary 5 HIAA.
Smoking Hx, lung cancer of central location, hipercalcemia. Dx?
Squamous cell lung cancer. Paraneoplastic syndrome (hyper PTH)
Causes of pleural effusion (transudate)
CHF, nephrotic syndrome, cirrhosis, pulmonary embolism
Causes of pleural effusion (exudate)
Malignancy, TB, pneumonia
Most common cause of exudative pleural effusion
TB is the most common cause worldwide. Pneumonia (PNA), malignancy, and CHF are the most common in the US
Pleural Effusion of < 1 cm. Next step?
Observation
Loculated pleural effusion. Next step?
Thoracostomy, if it doesn’t work, thoracotomy
Pleural effusion, > 1 cm, not loculated. Next step?
Is it CHF? If so, diuresis and observe. If it fails or isn’t CHF, then tap
Pleural effussion is determined to be transudate. Next step?
Treat cause
Light’s criteria
- LDHf > 2/3 upper limit of normal
- LDHf/LDHs > 0.6
- Proteins f/Proteins s > 0.5
At least one –> Exudate
None of them –> transudate
Tests to run on a pleural effusion
Tube 1: cell count with differential - PMN: Pneumonia - Lymph: TB or malignancy - RBC: Hemothorax or CA Tube 2: cytology (malignancy) Tube 3: Glucose, pH, total proteins and LDH (light’s criteria), ADA (TB), triglycerides (chylothorax) Tube 4: gram stain and culture
Virchow’s triad?
o Venostasis (e.g., hospitalized, POP, inmobiliztion, car rides, no physical activity)
o Endothelial injury (e.g., POP, trauma, HTN, smoking, cath)
o Hypercoagulative state (e.g., contraceptives, malignancy, pregnancy, coagulopathies)