Step 2 Pulm Flashcards
4 etiologies of obstructive pulmonary disease: ABCO
Asthma, Bronchiectasis, Cystic Fibrosis/COPD, Obstruction (tracheal or bronchial)
Magic # for FEV1/FVC ratio? If greater than that #, obstructive or restrictive, if less than,
FEV1/FVC <70% –> Obstructive
FEV1/FVC >70% –> Restrictive
Wheezes occur in?
Asthma, COPD, foreign body inhalation (ie anything that causes airway constriction)
Kid with multiple episodes of croup and URIs w dyspnea associated. Suspect dx?
Asthma
PRN vs. long-term meds for asthma?
PRNs: Acute: short-acting beta agonist/bronchodilator: Albuterol
Long-acting:inhaled corticosteroids, long-acting beta agonist (salmeterol=sustained), PO corticosteroids
ASTHMA meds for acute exacerbation?
Albuterol, Steroids, Theophylline (rare), Humidified O2, Mg (severe exacerbation), Anticholinergics
mild intermittent asthma: day/night sx? FEV1? Meds?
Day/Night: less than 2x/week/ less than 2x/month
FEV1>=80%
Meds: none daily, PRN albuterol (SABA)
mild persistent asthma: day/night sx? FEV1? Meds?
Day/Night: more than 2x/week but not daily / more than than 2x/month
FEV1>=80%
Meds: PRN albuterol (SABA) + low-dose daily ICS
moderate persistent asthma: day/night sx? FEV1? Meds?
Day/Night: daily / more than than 1x/week
FEV1 60-80%
Meds: LABA (salmeterol) + low–to-med-dose daily ICS + SABA (albuterol)
severe persistent asthma: day/night sx? FEV1? Meds?
continuous, frequent
FEV1<=60%
Meds: LABA (salmeterol) + high-dose daily ICS + SABA (albuterol) +/- PO steroids
2 interventions proven to improve survival in COPD pts
- Smoking
2. In more advanced COPD, supplemental O2
What meds may be given in acute COPD exacerbation?
Beta-agonists, anticholinergics (ipratropium or tiotropium), IV corticosteroids, +/- ABX, O2, prevention (smoking prevention, pneumococcal and influenza vaccines)
Restrictive lung dz DDX: lungs AINT compliant
A: alveloar isssues-edema, hemorrhage, pus
I: Interstitial lung dz, Inflammatory (COP, sarcoid), Idopathic pulmonary fibrosis
N: Neuromuscular (myasthenia gravis, phrenic nerve palsy, myopathy)
T: Thoracic wall (kyphoscoliosis, obesity, ascites, pregnancy, ankylosing spondylitis
Meds that cause interstitial lung disease?
amiodarone, busulfan, nitrofurantoin, bleiomycin, radiation, high O2 (PaO2 vents)
Sarcoid features
Sarcoid Dz is GRUELING: Granulomas aRthritis Uveitis Erythema nodosum Lymphadenopathy Interstitial fobrosis Negative TB test Gammaglobulinemia
Lofgren syndrome triad?
Lofgren syndrome is a type of sarcoidosis with arthritis, erythema nodosum, and bilateral hilar lymphadenopathy
Pneumoconiosis with pt who has wored in tole or brake linigns, insulation, construction, or ship building?
Asbestosis: imaging shows linear opacites at lung bases and instertitial fibrosis. calcified plaques are indicitaive of benign pleural disease
Pneumoconiosis with pt who has worked n a coal mine. Imaging shws?
Small nodular opacities in upper lung zones. Complications: massive fibrosis
Pneumoconiosis with pt who has worked in mines or quarries or with glass, pottery. imaging shows
Silicosis: imaging shows small nodular opacities in upper lung zones with EGGSHELL calficications. Increased risk of TB, screen annually
Pneumoconissis with pt who works in aerospace, nuclear, or electronics plants, ceramics, foundries, plating facilities, dental material sites, or dye manufacturing. imaging shows?
Berylliosis: imaging shows diffuse infiltrates; hilar adenopathy. Requires chronic corticosteroid tx
To increase oxygenation for pt on a vent, increase what 2 settings?
Increase FiO2 or increase PEEP
To increase ventillation for pt on a vent, increase what 2 settings?
Increase respiratory rate or tidal volume
In hypoxemia, check what with ABG?
A-a gradient. If normal. is PaCO2 increased? Yes..hypoventilation, No, decrease FiO2
If A-a gradient is abnormal, is PaO2 correctible with O2, if yes: V/Q mismatch
If no: right-to-left shunt
Common triggers for ARDS
sepsis, pna, aspiration, multiple blood transfusions, inhaled or ingested toxins, trauma
Criteria for ARDS diagnosis
- Acute onset <1 week
- PaO2/FiO2 ratio <=300 with PEEP/CPAP>+5 cm H2O
- B/l pulmonary infiltrates
- Respiratory failure not completely explained by heart failure
Goal oxygenation in ARDS
PaO2>=55 mm Hg or SaO2>=88%
Mechanical ventilation in ARDS, use what settings?
low tidal volumes (4-6 cc/kg of ideal body weight) to minimize ventillator-associated lung injury
Mean pulmonary arterial pressure in pulm HTN?
> 25 mm Hg (nl=15 mm Hg)
Etiologies for pulm HTN?
Left heart failure, mitral valve disease, increased resistance in the pulmonary veins, including hypoxic vasoconstriction
Pt w lung nodule, from ohio river valley. Dx?
histoplasmosis
Which lung cancers have central lesions?
Sentral lesions: Squamous cell carcinoma and Small cell carcinoma
If lung nodule is 2 cm in 34 yo, next step?
Watch it and re-XR. likely benign if pt is less than 35, lesion less than 2 cm, if lesion is central, uniform or popcorn calcification.
When should you intubate?
As a rough rule of thumb, think about intubation in any patient whose CO2 is greater than 50 mm Hg or whose O2 is less than 50 mm Hg, especially if the pH in either situation is less than 7.30 while the patient is breathing room air. Usually, unless the patient is crashing rapidly, a trial of oxygen by nasal cannula, face mask, or Bi-PAP (biphasic positive airway pressure) is given first. If it does not work or if the patient becomes too tired (use of accessory muscles is a good clue to the work of breathing), intubate. Clinical correlation is always required; patients with chronic lung disease may be asymptomatic at lab value levels that seem to defy reason. Alternatively, lab values may look great, but if the patient is becoming tired from increased work of breathing or is significantly altered (e.g., Glasgow Coma Scale <8), intubation may be needed.
Difference btwn typical and atypical PNA on P and T?
Typical Pneumonia Atypical Pneumonia
Prodrome Short (<2 days) Long (>3 days)
Fever High (>102°F) Low (<102°F)
Age >40 yr <40 yr
CXR One distinct lobe involved
Diffuse or multilobe involvement
Bug Streptococcus pneumoniae
Many (Haemophilus, Mycoplasma, Chlamydia spp.)
Antibiotic∗ Ceftriaxone, broad-spectrum Macrolides (e.g., azithromycin), doxycycline, or certain fluoroquinolones (e.g., levofloxacin, moxifloxacin)
Pt w COPD and PNA. Which bugs?
COPD: think of Haemophilus influenzae, Moraxella sp.
0-12 month old w PNA. Virus?
RSV
2-5 yo w PNA. Virus?
Croup/parainfluenza
4 main types of non-small cell carcinoma?
- adenocarcinoma: Most common lung cancer in nonsmokers and overall. Glandular pattern on histology.
- Squamous cell carcinoma: Hilar mass that arises from the bronchus. cavitates. PTHrP. Keratin Pearls
- Large cell carcinoma. Highly anaplastic. poor prognssis. Pleiomorphic giant cells. Can secrete b-hCG
- Bronchial carcinoid tumor: Good prognsis. Occasionally w carcinoid syndrome. Nests of neuroendocrine cells; chromogranin A+
CV associations w . adenocarcinoma?
migratory thrombophlebitis
Nonbacterial verrucous endocarditis
Hypertrophic pulmonary osteoarthropathy assc’d w what lug cancer histology?
Non-small cell
Peripheral neuropathy, subacute cerebellar degeneration, myasthenia assc’d with what lung cancer?
small cell carcinoma
Hypercoaguability assc’d with what lung cancer?
Adenocarcinoma
Lung cancer mets in LABBs?
Liver, Adrenals, Bone, Brain
Lights criteria?
Pleural protein/Serum protein>0.5
Pleural LDH/Serum LDH>0.6
Pleural Fluid LDH: More than 2/3 the upper limit of normal serum LDH
*Effusion is exudative if any of the above are met
Causes of Exudative Effusion
Think leaky capillaries. Malignancy, TB, bacterial or viral infection, PE w infarct, and pancreatitis
Causes of Transudative Effusion
Think of intact cappilaries. CHF, Liver or kidney disease, and protein-losing enteropathy
Normalizing PCO2 in a patient w a asthma exacerbation may indicate?
Impending respiratory failure
Treatment for acute asthma and COPD exacerbation?
B-agonists, PO steroids, (anticholinergics and ABX for COPD)
PD of sarcoidosis?
Dyspnea, Increased ACE, Hypercalcemia, lateral hilar lymphadenopaty on CXR, noncaseating granulomas
PFTs of obstructive pulmonary dz?
FEV1/FVC<0.7
PFTs of restrictive pulmonary dz?
FEV1/FVC>=0.7, Decreased TLC
Honeycomb pattern on CXR. DT?
Diffuse Interstitial Pulmonary Fibrosis. Tx=Supportive care, antifibrotic agents may also help
Tx for SVC syndrome?
Radiation
What is the typical acid-base disorder in PE?
Respiratory alkalosis w hypoxia and hypercarbia
NSCLC associated with hypercalcemia?
squamous cell carcinoma
SIADH + Lung Ca. Dx?
SCLC
LEMS is assc’d with what lung ca?
SCLC
Lung cancers assc’d w cigarette exposure
SCLC, SCC
What characteristics favor dz of carcinoma in pt with an isolated pulmonary nodule?
> 2 cm. Age >45ish. Tobacco hx. New or larger lesions. Absence of calcification or irregular calcification. Irregular margins
ARDS characteristics?
hypoxemia. Pulmonary edema w normal PCWP (~12).
Sequelae of asbestos exposure.
Bronchogenic carcinoma. pulmonary fibrosis. Pleural plaques or mass (latter is mesothelioma)
Increased risk of what infxn w silicosis?
TB
Classic CXR for pulmonary edema?
Cardiomegaly, prominent pulmonary vessels, Kerley B lines, Bat’s wing appearance of hilar shadow, perivascular and peribronchial cuffing
Causes of hypoxemia?
R-L Shunt Hypoventilation Low inspired FiO2 Diffusion defect V/Q mismatch
CXR radiography for PE
Hampton hump refers to a dome-shaped, pleural-based opacification in the lung most commonly due to pulmonary embolism and lung infarction (it can also result from other causes of pulmonary infarction (e.g. vascular occlusion due to angioinvasive aspergillosis). While a pulmonary embolism is expected to result in a wedge-shaped infarction, the expected apex of this infarction may be spared because of collateral supply from the bronchial arterial circulation, leading to the characteristic rounded appearance of a Hampton hump.
Asthma PFT findings: FEV1, FVC, TLC
FEV1 decreased, FVC normal, TLC increased DURING exacerbation. PFTs are normal btween asthma exacerbations
First-line diagnostic test for confirmation of the diagnosis in patients ≥ 5 years of age.
Shows signs of obstructive lung disease with increased airway resistance → ↓ FEV1, ↓ Tiffeneau index (FEV1/FVC ratio)
Obstruction is reversible with bronchodilators → diagnostic confirmation via post-bronchodilator test
Dec
Of the following, which is the strongest predisposing factor for asthma in this 4 month-old? 2nd hand smoke exposure, diet, having old carpets, family history, living in urban area?
Family History
