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Internal Medicine > Respirology > Flashcards

Respirology Flashcards

1
Q

Discuss signs of consolidation

A 
- filling of airspace with fluid, pus, blood or cells
Radiological Signs
- increased opacity obsuring pulmonary vessels
- air bronchogram sign
- silhouette sign
      - RML = right heart border
      - RLL = right hemi-diaphragm
      - Lingula = left heart border
      - LLL = left-hemidiaphragm
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2
Q

Discuss signs of atelectasis

A
  • collapse of alveoli
    Radiological Signs
  • volume loss indicating elevated hemidiaphragm, mediastinal and tracheal shift toward ipsilateral side
  • increased opacity of the collapsed part of lung with straight margin
  • no air bronchogram
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3
Q

Discuss signs of pleural effusion

A
  • increased pleural fluid that may displace the lung
    Radiological Signs
  • blunting of costophrenic angle
  • increased opacity with a meniscus
  • tracheal shift towards contralateral side
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4
Q

Discuss signs of lung mass

A
  • nodule: discrete focal opacity <3cm in diameter, benign 65% of time
  • mass: discrete focal opacity >3cm in diameter, malignant 95% of time
  • benign lesions tend to be small <1cm, have stable size for 2 years, have smooth margins and have diffuse or central calcifications
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5
Q

Discuss signs of pneumothorax

A 
- air in pleural space
Radiological Signs
- air outside of lung
- no vessel marking
- sharply demarcated edge
- tracheal shift to contralateral side
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6
Q

Discuss signs of pulmonary edema

A 
- increased fluid in interstitial space
Radiological Signs
- reticular markings
- Kerley B lines
- bronchial wall thickening
- vascular indistinctness of hila
- vascular redistribution 
- cardiomegaly and bilateral pleural effusion
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7
Q

Discuss findings in the Pulmonary Function Test

A

Flow Volume Loop
- scooped flow volume loop suggest obstructive disease
- peaked flow volume loop suggest restrictive disease
Look at FEV1/FVC, FVC, and TLC
- FEV1/FVC <70% predicted then obstructive or mixed
- TLC <80% then mixed
- FVC >80% and TLC >80% then obstructive
- FEV1/FVC >70% then restrictive or normal
- FVC >80% and TLC >80% then normal
- FVC <80% and TLC <80% then restrictive
Look at DLCO to narrow differential
- normal with DLCO >80% then normal
- normal with DLCO <80% then pulmonary vascular disease, anemia, smoking, early interstitial lung disease
- restrictive with DLCO >80% then chest wall or neuromuscular disease
- restrictive with DLCO <80% then interstitial lung disease
- obstructive with DLCO >80% then asthma, chronic bronchitis
- obstructive with DLCO <80% then emphysema

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8
Q

Discuss the severity by PFT results

A 
Obstructive
- FEV1 >80% mild
- FEV1 50-80% then moderate
- FEV1 30-50 then severe
- FEV1 <30 then very severe
Restrictive
- TLC <80% then mild
- TLC 50-80% then moderate
- TLC <50 then severe
DLCO
- 60-80% then mild
- 40-60% then moderate
- <40% then severe
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9
Q

Discuss the causes of hypoxemia

A

Low FiO2
- low fraction of inspired O2
- normal Aa gradient
- high altitude
Hypoventilation
- Decreased minute ventilation
- normal Aa gradient, corrected with supplemental O2
V/Q Mismatch
- abnormal ventilation to perfusion ratio
- increased Aa gradient, corrected with low to moderate O2 supplementation
- asthma, COPD
- pneumonia
- interstitial lung disease
- pulmonary hypertension or pulmonary embolism
Diffusion Block
- abnormal alveolar capillary interface that decrease gas diffusion
- increased Aa gradient, exercise induced/exacerbated hypoxemia
- pneumonia, pulmonary edema
- interstitial lung disease
Shunt
- right to left shunt when blood passes from right to left side of heart without being oxygenated
- increased Aa gradient, cannot be corrected with O2
- atelectasis
- severe pneumonia, pulmonary edema
- right to left cardiac shunt

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10
Q

Discuss the Aa gradient

A

Aa= [FiO2(Patm-PH2O)-(PaCO2/RQ)] - PaO2
Aa=[150-1.25(PaCo2)]-PaO2
- normal <15mmHg

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11
Q

List the common pathogens for community acquired pneumonia

A 
Typical
- Strep pneumonia
- haemophilus influenza
- moraxella catarrhalis
- enterobacteria including Kliebsiella, E coli
- staph aureus
Atypical
- Chlamydia pneumonia
- Mycoplasma pneumonia
- Legionella pneumonia
Aspiration
- anaerobes
Ventilator Acquired Pneumonia
- pseudomonas aeruginosa
- klebsiella
- acinebacter
- enterobacter
- proteus
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12
Q

Discuss the pathophysiology and complications of pneumonia

A

Pathophysiology
- pathogen enter respiratory tract through direct inhalation, aspiration, direct spread from upper respiratory tract, or hematogenous spread
- pathogen colonize and proliferate
- immune system cause inflammation and migration of neutrophils into air space
Complications
- pleural effusion which can be transudate or exudate (empyema)
- lung abscess
- pneumatocele
- necrotizing pneumonia
- right heart failure
- dehydration

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13
Q

Discuss the presentation and investigations for pneumonia

A 
Presentation
- productive cough with colored sputum
- SOB
- pleuritic chest pain
- fever, chills
- dullness to percussion
- increased tactile fremitus
- crackles and decreased air entry
- increased whispered pectoriloquy
- egophany
Investigations
- CBC, electrolytes, BUN, blood glucose and blood gas
- Chest x-ray
       - bronchopneumonia: diffuse patchy consolidation with multiple foci of isolated consolidation
       - lobar pneumonia: localized continuous consolidation of distinct region
       - intersitial pneumonia: reticular nodular pattern with increased lung markings throughout
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14
Q

Discuss the indications for hospitalization for pneumonia

A 
Pneumonia Severity index
- class 1 and 2 as outpatient
- class 3 treated in observation or short hospitalization
- class 4 and 5 as inpatient
CURB65
- Confusion
- Urea >7
- Respiratory Rate >30
- BP <90 or <60
- Age >65
- <=1 can be treated as outpatient, 2 as inpatient, >=3 in ICU
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15
Q

Discuss antibiotic choice for inpatient pneumonia

A

Choice
- Ceftriaxone 1g IV Q24H + Azithromycin 500mg IV Q24 if
- severely ill with HR>125 or hypotension <90, tachypnea >30 or hypoxic <90%
- allergy to quinolone
- received quinolone within last 3 months
- Otherwise Levofloxacin 750mg PO Q24H
Switch from IV to PO
- hemodynamically stable
- clinical improvement
- ability to tolerate PO
- normal functioning GI tract
Stepping Down Ceftriaxone + Azithromycin
- Cefuroxime 500mg PO Q12H +/- Azithromycin 250-500mg PO Q24H
- Levofloxacin 750mg PO Q24H
Duration
- discontinue if patient afebrile for 2-3 days and have <=1 of the CAP associated signs of instability
- temperature >37.8
- HR >100
- Systolic BP <90
- RR >24
- O2 Sat <90% on room air or PaO2 <60
- Altered mental status
- 5 days for patients that are not immune compromised or do not have structural lung disease
- 7 days for patients who are moderately immune compromised or structural lung disease
- 10 days for slow clinical response or significant immune compromised

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16
Q

Discuss signs and investigations for pleural effusion

A

Presentation
- possibly asymptomatic
- SOB
- asymmetric chest expansion
- dullness to percussion, decreased tactile fremitus
- decreased air entry
Investigation
- Chest x-ray
- Thoracocentesis (if >1cm of fluid on lateral decubitus x-ray)
- appearence of pleural fluid
- cell count and differential
- biochemistry: LDH, protein, glucose, pH, albumin
- gram stain, acid fast stain, culture
- cytology

17
Q

Discuss the Light’s criteria for transudative vs exudative pleural effusion

A

Exudative if any of the following

  • pleural fluid protein/serum protein >0.5
  • pleural fluid LDH/serum LDH >0.6
  • pleural fluid LDH >2/3 upper normal limit of serum LDH
18
Q

Discuss the differential for transudative vs exudative effusion

A 
Transudative
- CHF
- nephrotic syndrome
- hypoalbumin (liver failure)
Exudative
- infection
- malignancy
- pulmonary embolism
19
Q

Differentiate between para-pneumonic effusion and empyema

A

Parapneumonic effusion is pleural effusion related to pneumonia abscess or bronchiectasis

  • can progress to empyema
  • Pleural fluid >=7.2 in parapneumonic
  • glucose >=3.33
  • LDH <1000
  • Gram stain negative
  • No frank pus
20
Q

Discuss the pathophysiology of Asthma

A
  • variable airflow limitation and airway hyperresonsiveness represented by exaggerated contractile response of the airway to variety of stimuli
  • atopic march: eczema, food allergies, environmental allergies
    - strongest predictor for development
21
Q

Discuss the symptoms and diagnosis of asthma

A

Signs and Symptoms
- Wheezing
- Cough
- Dyspnea
- Reduce air entry on auscultation
Diagnosis
- obstrutive pattern on spirometry
- Children 6-11 have FEV1/FVC <0.8 and increased FEV1 post-bronchodilator >=12%
- Adults have FEV1/FVC <0.75 and increase in FEV1 post-bronchodilator by >=12% and >=200mL
- scooped flow volume curve
- high residual volume RV/TLC >0.35
- methacholine challenge where have >20% drop in FEV1 with <4mg/mL of methacholine
- FEV1 drop of >10% at 80% of maximum HR

22
Q

Discuss possible triggers for asthma exacerbation

A
  • Allergens exposure
  • Respiratory infection
  • Cigarettes
  • Animal dander
  • Dust mites
  • cold/dry air
  • exercise or emotional factors
  • B Blockers/ASA/NSAIDs
23
Q

Discuss the management of asthma

A
  • Environmental control
  • Education
  • Action plan
    Medication
  • Short-Acting Bronchodilator on demand for very mild
  • Inhaled Corticosteroid for maintenance therapy for mild asthma (symptoms 3x per week)
    - leukotriene receptor antagonist second line
    - start at low dose and progress
  • Long acting bronchodilator used as third line add on
    - must be on ICS if using LABA
    - if less than 12 then increase ICS before
  • Third line to add LTRA
  • Fourth line prednisone
24
Q

Discuss the characteristics of good asthma control

A
  • Daytime Symptoms <4x/week
  • Nighttime symptoms <1x/week
  • Normal physical activity
  • Infrequent and mild exacerbation
  • No absences due to asthma
  • Need for SABA <4dose/week
  • FEV1 >=90% best
  • sputum eosinophils <2-3%
25
Q

Discuss the pathophysiology and symptoms of COPD

A

Pathophysiology
- airflow limitation caused by inflammatory response to inhaled toxins
Signs and Symptoms
- Productive cough
- Dyspnea
- Decreased breath sounds
- Wheezes
- Prolonged expiratory phase of breathing
Investigations
- PFT: FEV1/FVC <0.7 with no improvement with bronchodilator
- Spirometry increased FRC, RV and decreased VT
- CXR: hyperinflation of lung with flattended diaphragm

26
Q

Discuss the Triggers and Signs of COPD exacerbation

A 
Triggers
- Respiratory infection
- Environmental pollution
- pulmonary embolism
- comorbid respiratory or cardiac condition
Signs
- Change in amount or color/purulence of sputum
- More short of breath
- change in mood
- Fatigue
27
Q

Discuss the MRC dyspnea scale of symptoms and impairement of lung function

A

Normal
- MRC 1 dyspnea only with strenuous exercise
- Normal spirometry
Mild
- MRC 2 dyspnea when hurring on level ground or walking up hill
- FEV1 >80% predicted and FEV1/FVC <0.7
Moderate
- MRC 3 walk slower than people because of breathlessness or has to stop for breath
- MRC 4 stop for breath after walking 100m
- 50% <= FEV1 < 80% predicted
- FEV1/FVC <0.7
Severe
- MRC 5 too breathless to leave house or breathless with dressing
- 30%

28
Q

Discuss the management of COPD

A 
Education
- inhaler
- action plan
Smoking Cessation
- most important intervention to slow lung decline
Exercise or Pulmonary Rehabilitation
- All patients should exercise
Vaccination
- influenza
- Pneumovax <65 or Prevnar >65
Pharmcotherapy
- Mild: SABA prn
- Moderate: SABA and LABA/LAAC prn
- Severe (>1 AECOPD/year): Long acting anticholinergic + ICS/LABA + SABA prn
Oxygen
- severe hypoxemia (PaO2 <55mmHg or SaO2 <88%)
- PaO2 <59mmHg or SpO2 <89% with evidence of right heart failure or cor pulmonale or erytrhocytosis (Hct >55%)
Surgery
- lung volume reduction surgery
Lung Transplant
- FEV1 <25%
- PaCO2 >55
- pulmonary hypertension
29
Q

Discuss the indications for hospitalization for AECOPD

A

Hospitalized if any of the following

  • inadequate response to outpatient emergency department management
  • marked increase in dyspnea
  • severe underlying COPD, FEV1 <50%
  • inability to eat or sleep
  • new cyanosis or worsening hypoxemia
  • Acute respiratory acidosis
  • Change in mental status
  • Insufficient home support
  • High risk comorbidities
30
Q

Discuss the in-hospital management of AECOPD

A

Treatment
- target O2 >90%
- albuterol 2.5mg by nebulizer Q1-4H or 4-8 puffs with spacer
- Ipratropium 500mcg nebulizer Q4H or 2-4 puffs
- systemic steroids (prednisone 40mg PO for 5 days)
Non-Invasive Positive Pressure Ventilation
- respiratory distress: tachypnea >25 RR or use of accessory muscles
- respiratory acidosis: pH <7.35 or PaCo2 >45
Antibiotics
- uncomplicated (<65yo, FEV1 >50%, <3 exacerbations a year, no cardiac disease)
- Azithromycin 500mg POx1d then 250mg Q24H for 4d
- Cefuroxime 500mg PO Q12H
- Doxycycline 100mg PO Q12H x1d then 100mg Q24H
- Septra 1 tab PO Q12H
- Complicated (any of above risk factors)
- Levofloxacin 750mg Q24H
- Amox-Clav 875mg Q12H x1d then 100mg Q24H
- Pseudomonas then Cirpofloxacin
- Abx for 5d if mild-mod, 7d for severe

31
Q

List the Common Asthma/COPD Inhalers and their side Effects

A 
SABA (blue)
- Salbutamol (ventolin)
- tachycardia
- arrhythmia
- irritability
- difficulty sleeping
- muscle cramps
LABA (orange)
- formoterol (oxeze)
- salmeterol (serevent)
- same as SABA
ICS (red)
- Fluticasone (flovent)
- Beclomethasone (ovar)
- hoarseness
- sore throat
- thrust
ICS + LABA
- Fluticasone + Salmeterol (Advair - purple)
- Pulmicort + Oxeze (Symbicort - red)
- shaky hands
- tachycardia
- thrush
- sore throat
- hoarse
Short-Acting Anticholinergic
- Ipratropium bromide (atrovent)
- dry mouth
- urinary retention
Long-Activing Anticholinergic
- Tiotropium (spiriva)
- same as SAAC
32
Q

Discuss the presentation and consequences of OSA

A 
Symptoms
- snoring, apnea, choking
- morning headache
- GERD
- poor quality of sleep resulting in daytime sleepiness, impaired memory/concentration and depression
Long-term
- systemic hypertension
- increased risk of stroke or MI
- increased risk of AF or CHF
- increased risk of pulmonary hypertension as have vasopasm of pulmonary arteries from decreased desats
- increased risk of diabetes
- increased risk of depression
- daytime hypercapnia and hypoxemia
33
Q

Discuss the management of OSA

A 
Indications
- symptomatic
- AHD >=15 as incrase cardiovascular risk
- occupation
- presence of comorbid condition
Non-Specific
- weight loss
- avoid substances
- positional therapy (side sleeping)
- avoid sleep deprivation
Nasal continuous Positive Airway Pressure (CPAP)
- 1st line
- continuous blowing of room air into airway splinting it open
- BiPAP for larger adults requiring greater pressure
Surgery
- for underlying anatomical problem
34
Q

Discuss the diagnosis of OSA

A

Must have A or B and C
A: Excessive daytime sleepiness that cannot be explained
B: >=2
- recurrent choking or gasping in sleep
- recurrent awakening from sleep
- daytime fatigue
C: Apnea hypopnea index (apnea + hypopnea/hrs asleep) >5 (mild:6-15/hr, mod:16-30/hr, sev: .30/hr)
- hypopnea is decreased airflow by 50% with decreased O2 sat by >4% or EEG arousal

35
Q

List the definition and risk factors for apnea

A

Apnea: cessation of airflow for >10 seconds or 2 breath cycles
- obstructive: cessation >10s despite respiratory efforts
- central: cessation for >10s with no respiratory effort
Risks for OSA
- male
- older age >45
- obesity, including pregnancy
- increased neck circumference (normal is 17.5 in men and 15.5 in women)
- substances (smoking, alcohol, sedative, opioid)
- medications
- any structural abnormality with airway
- increased mallampati score
- family history

36
Q

Discuss the differential for Chronic Cough

A 
Mechanical
- post-nasal drip
- GERD
Infection
- TB
- pneumonia
Inflammation
- COPD
- Asthma
Medication
- ACE inhibitor
Neoplasm
- Bronchogenic carcinoma
- lung cancer
- lung metatasis
Other
- intersitial lung disease
37
Q

Discuss the investigation for chronic cough

A 
PFT with Methcholine Challenge
- if hx suggest asthma
PPI
- for GERD
Abx
- pneumonia: purulent sputum, systemic signs of infection
Smoking Cessation
Stop ACE Inhibitor
Non of the Above
- CXR
- Normal CXR then 3 week empiric anti-histamine for post-nasal drip
      - if partially effective add nasal glucocorticoid
- CT
- Bronchoscopy
- Cardiac Studies

Internal Medicine (12 decks)

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